Hypophosphatemia in critically ill patients with acute kidney injury on renal replacement therapies
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Hypophosphatemia is a common but often underestimated electrolyte derangement among intensive care unit (ICU) patients. Low phosphate levels can lead to cellular dysfunction with potentially relevant clinical manifestations (e.g., muscle weakness, respiratory failure, lethargy, confusion, arrhythmias). In critically ill patients with severe acute kidney injury (AKI) renal replacement therapies (RRTs) represent a well-known risk factor for hypophosphatemia, especially if the most intensive and prolonged modalities of RRT, such as continuous RRT or prolonged intermittent RRT, are used. Currently, no evidence-based specific guidelines are available for the treatment of hypophosphatemia in the critically ill; however, considering the potentially negative impact of hypophosphatemia on morbidity and mortality, strategies aimed at reducing its incidence and severity should be timely implemented in the ICUs. In the clinical setting of critically ill patients on RRT, the most appropriate strategy could be to anticipate the onset of RRT-related hypophosphatemia by implementing the use of phosphate-containing solutions for RRT through specifically designed protocols. The present review is aimed at summarizing the most relevant evidence concerning epidemiology, prognostic impact, prevention and treatment of hypophosphatemia in critically ill patients with AKI on RRT, with a specific focus on RRT-induced hypophosphatemia.
KeywordsAcute kidney injury Critically ill patients CRRT Hypophosphatemia Phosphate-containing solutions RRT
VP, LZ and SM had the idea for the review, performed the literature search and data analysis, and drafted the work. EF, GR and LT critically revised the work.
Compliance with ethical standards
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
This article does not contain any studies with human participants performed by any of the authors.
- 2.Ronco C, Ricci Z, De Backer D, Kellum JA, Taccone FS, Joannidis M, Pickkers P, Cantaluppi V, Turani F, Saudan P, Bellomo R, Joannes-Boyau O, Antonelli M, Payen D, Prowle JR, Vincent JL (2015) Renal replacement therapy in acute kidney injury: controversy and consensus. Crit Care 19:146CrossRefGoogle Scholar
- 7.VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, O’Connor TZ, Chertow GM, Crowley ST, Choudhury D, Finkel K, Kellum JA, Paganini E, Schein RM, Smith MW, Swanson KM, Thompson BT, Vijayan A, Watnick S, Star RA, Peduzzi P (2008) Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 359:7–20CrossRefGoogle Scholar
- 8.RENAL Replacement Therapy Study Investigators, Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lo S, McArthur C, McGuinness S, Myburgh J, Norton R, Scheinkestel C, Su S (2009) Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 361:1627–1638CrossRefGoogle Scholar
- 14.Park JT, Lee H, Kee YK, Park S, Oh HJ, Han SH, Joo KW, Lim CS, Kim YS, Kang SW, Yoo TH, Kim DK, HICORES Investigators (2016) High-dose versus conventional-dose continuous venovenous hemodiafiltration and patient and kidney survival and cytokine removal in sepsis-associated acute kidney injury: a randomized controlled trial. Am J Kidney Dis 68:599–608CrossRefGoogle Scholar
- 15.Lim C, Tan HK, Kaushik M (2017) Hypophosphatemia in critically ill patients with acute kidney injury treated with hemodialysis is associated with adverse events. Clin Kidney J 10:341–347Google Scholar
- 23.Morabito S, Pistolesi V, Tritapepe L, Vitaliano E, Zeppilli L, Polistena F, Fiaccadori E, Pierucci A (2013) Continuous venovenous hemodiafiltration with a low citrate dose regional anticoagulation protocol and a phosphate-containing solution: effects on acid-base status and phosphate supplementation needs. BMC Nephrol 14:232CrossRefGoogle Scholar
- 25.Pistolesi V, Zeppilli L, Polistena F, Sacco MI, Pierucci A, Tritapepe L, Regolisti G, Fiaccadori E, Morabito S (2017) Preventing continuous renal replacement therapy-induced hypophosphatemia: an extended clinical experience with a phosphate-containing solution in the setting of regional citrate anticoagulation. Blood Purif 44:8–15CrossRefGoogle Scholar
- 28.Jung SY, Kim H, Park S, Jhee JH, Yun HR, Kim H, Kee YK, Yoon CY, Oh HJ, Chang TI, Park JT, Yoo TH, Kang SW, Lee H, Kim DK, Han SH (2016) Electrolyte and mineral disturbances in septic acute kidney injury patients undergoing continuous renal replacement therapy. Medicine (Baltimore) 95:e4542CrossRefGoogle Scholar
- 44.Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group (2012) KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl S2:1–138Google Scholar
- 45.Pistolesi V, Di Napoli A, Fiaccadori E, Zeppilli L, Polistena F, Sacco MI, Regolisti G, Tritapepe L, Pierucci A, Morabito S (2016) Severe acute kidney injury following cardiac surgery: short-term outcomes in patients undergoing continuous renal replacement therapy (CRRT). J Nephrol 29:229–239CrossRefGoogle Scholar
- 47.Schwartz A, Brotfain E, Koyfman L, Kutz R, Gruenbaum SE, Klein M, Zlotnik A (2014) Association between hypophosphatemia and cardiac arrhythmias in the early stage of sepsis: could phosphorus replacement treatment reduce the incidence of arrhythmias? Electrolyte Blood Press 12:19–25CrossRefGoogle Scholar
- 48.Ariyoshi N, Nogi M, Ando A, Watanabe H, Umekawa S (2017) Cardiovascular consequences of hypophosphatemia. Panminerva Med 59:230–240Google Scholar
- 54.Engwerda E, Van den Berg M, Blans M, Bech A, De Boer H (2018) Efficacy and safety of a phosphate replacement strategy for severe hypophosphatemia in the ICU. Neth J Med 76:437–441Google Scholar