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Therapeutic hypernatremia management during continuous renal replacement therapy with elevated intracranial pressures and respiratory failure

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Abstract

Cerebral edema and elevated intracranial pressure (ICP) are common complications of acute brain injury. Hypertonic solutions are routinely used in acute brain injury as effective osmotic agents to lower ICP by increasing the extracellular fluid tonicity. Acute kidney injury in a patient with traumatic brain injury and elevated ICP requiring renal replacement therapy represents a significant therapeutic challenge due to an increased risk of cerebral edema associated with intermittent conventional hemodialysis. Therefore, continuous renal replacement therapy (CRRT) has emerged as the preferred modality of therapy in this patient population. We present our current treatment approach, with demonstrative case vignette illustrations, utilizing hypertonic saline protocols (3% sodium-chloride or, with coexisting severe combined metabolic and respiratory acidosis, with 4.2% sodium-bicarbonate) in conjunction with the CRRT platform, to induce controlled hypernatremia of approximately 155 mEq/L in hemodynamically unstable patients with acute kidney injury and elevated ICP due to acute brain injury. Rationale, mechanism of activation, benefits and potential pitfalls of the therapy are reviewed. The impact of hypertonic citrate solution during regional citrate anticoagulation is specifically discussed. Maintaining plasma hypertonicity in the setting of increased ICP and acute kidney injury could prevent the worsening of ICP during renal replacement therapy by minimizing the osmotic gradient across the blood-brain barrier and maximizing cardiovascular stability.

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  • 06 May 2019

    The authors would like to report an error in the formula describing the correction factor for the protein content in the serum/plasma.

Abbreviations

ABI:

acute brain injury

AKI:

acute kidney injury

BUN:

blood urea nitrogen

CRRT:

continuous renal replacement therapy

ICP:

intracranial pressure

ICU:

intensive care unit

Na+ :

sodium

RRT:

Renal replacement therapy

CRRT:

Continuous renal replacement therapy

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Acknowledgements

Parts of this projects has been presented in poster format at the 2018 Annual Dialysis Conference, March 3-6, 2018, Orlando, FL and at the 14th International Conference on Continuous Renal Replacement Therapies, Feb 25-28, 2009, San Diego, CA (Blood Purif 2009; 27:271-305). Case vignette #1 was observed at the University of Mississippi Medical Center, while Drs. Fülöp, Koch, and Zsom were serving on the faculty of the Department of Medicine. Drs. Rafael D. Rodríguez and Jorge O. Chabrier-Rosello are current Nephrology trainee at the Department of Medicine, Medical University of South Carolina, SC (Class of 2019).

We sincerely appreciated the assistance of Mr. Attila Lénárt-Muszka during editing and grammar review.

Author information

Authors and Affiliations

  1. Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA

    Tibor Fülöp, Rafael D. Rodríguez & Jorge O. Chabrier-Rosello

  2. Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA

    Tibor Fülöp

  3. Fresenius Medical Care Hungary Kft, Cegléd, Hungary

    Lajos Zsom

  4. Department of Medicine – Division of Nephrology, Thomas Jefferson University, Philadelphia, PA, USA

    Mehrdad Hamrahian

  5. Medicover GmbH, Berlin, Germany

    Christian A. Koch

  6. Carl von Ossietzky University of Oldenburg, Oldenburg, Germany

    Christian A. Koch

  7. Technical University of Dresden, Dresden, Germany

    Christian A. Koch

  8. University of Tennessee Health Science Center, Memphis, TN, USA

    Christian A. Koch

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  1. Tibor Fülöp
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  2. Lajos Zsom
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  3. Rafael D. Rodríguez
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  4. Jorge O. Chabrier-Rosello
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  5. Mehrdad Hamrahian
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  6. Christian A. Koch
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Correspondence to Tibor Fülöp or Christian A. Koch.

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Conflict of interest

Dr. Zsom is a current employee of Fresenius Medical Care (FMC) Hungary and Dr. Fülöp is a former employee of FMC Hungary. Dr. Fülöp is a current employee of the United States Veterans Health Administration. However, the views and opinions expressed herewith do not reflect the official views or opinion or endorsed by the FMC Hungary or the United States Veteran Health Administrations. None of the other authors declares a conflict of interest with this article.

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Implication for health policy/practice/research/medical education

Cerebral edema and elevated intracranial pressure represent a significant management challenge in those with co-existing acute brain and kidney injury. When artificial renal support is required, continuous renal replacement therapy is the preferred modality for these critically ill patients. Herewith, we demonstrate our approaches to administer hypertonic saline solution along with commercially available replacement fluid when conducting continuous veno-venous hemofiltration or hemodialysis, to circumvent the development or progression of elevated intracranial pressure in a patient with brain injury requiring renal replacement therapy.

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Fülöp, T., Zsom, L., Rodríguez, R.D. et al. Therapeutic hypernatremia management during continuous renal replacement therapy with elevated intracranial pressures and respiratory failure. Rev Endocr Metab Disord 20, 65–75 (2019). https://doi.org/10.1007/s11154-019-09483-2

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