ESPN 50th Annual Meeting

ESPN 2017


 
Renal Replacement Therapy for Severe Hyperosmolality and AKI
LOAI EID 1 ALAA ABDULAZIZ 1 ALA HABAIBEH 1

1- PEDIATRIC NEPHROLOGY DEPARTMENT, DUBAI HOSPITAL-DHA, DUBAI, UAE
 
Introduction:

Management of AKI & hyperosmolality using conventional renal replacement methods places patient at higher risk of rapid osmolar shifting that leads to major neurological consequences. CRRT provides the ability to control rate of reduction in osmolality by allowing the adjustment of dialysate solution and narrowing osmolar gap between the patient and dialysate. Further, “inefficient” solute clearance will less the rate of pH and osmolar changes over time.

Material and methods:

Case Report

Results:

A 16-kg male child known case of Central Diabetes Insipidus presented unconscious and anuric with septic shock, anemic (Hb 4.8g/l), AKI (BUN 427mg/dl, Creatinine 7.6 mg/dl), severe hypernatremia (Na 216 mmol/l), and a PH of 7.0. Measured osmolality was 593 osmols/l. Patient was resuscitated, incubated and shifted to PICU. “Inefficient” CVVHD was begun at 8 mls/kg/hr (in order to slowly improve the pH) with the use of PrismaSate® with an additional 80 meq/l of NaCl added to give total Na of 200 meq/L of PrismaSate® resulting in a dialysate bath of 550 osmols/l. Patient osmols were recalculated at 3 hrs increments and additional Na in the dialysate was decreased as needed. Based upon patient osmolar changes, additional sodium was adjusted until normal osmols were obtained (Figure). Over 72 hours the child had gradual drop of sodium till reaching 170mmol/l then CVVHD was stopped and patient was shifted to medical treatment of hypernatremia. Over time patient had recovery of osmols, PH, renal and neurological function and continued on medical management.  

Figure

 

Conclusions:

To our best knowledge, this is the first case in literature to have such presentation and manage by this way. The patient presented with severe hyperosmolality and significant metabolic acidosis. A rapid correction of either of these conditions places him at risk for herniation and pontine demyelination. Utilizing a slow approach to osmolar and pH corrections is recommended in the literature to avoid these risky complications. Standard dialysis dosing of 35 mls/kg/hr or 2000 mls/m2/hr will result in significant solute clearance. By making the CVVHD prescription inefficient, one can then do a slow correction of the metabolic acidosis and with manipulation of the sodium bath of the dialysate one can narrow the osmolar gap between the patient and dialysate allowing for slow and continuous correction of the osmolality.