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Fluid restriction 500–750 ml/d (approximately 10 ml/kg per day) Potassium resins Sodium polystyrene sulfonate Patiromer: 8.4 g daily; at weekly intervals can be increased or decreased by 8.4 g/d up to a maximum of 25.2 g/d Sodium zirconium cyclosilicate: 10 g three times daily for 48 h Oral non–potassium-containing alkali therapies Oral sodium bicarbonate available as tablet or as baking soda: 7.7 mEq HCO3 per 650 mg tablet 29 mEq HCO3 per 1/2 teaspoon baking soda Sodium citrate-citric acid solution: 5 mEq HCO3 per 5 ml solution Total nephron blockade Loop diuretic + carbonic anhydrase inhibitor + thiazide diuretic + mineralocorticoid receptor inhibitor (other strategies exist) In the setting of significant kidney impairment, consider using: Furosemide 200 mg intravenously every 6 hours + acetazolamide 250 mg by mouth every 8 hours + metolazone 10 mg by mouth twice a day + spironolactone 100 mg by mouth twice a day Intermittent HD Limit dialysis treatment duration to 3 hours for most treatments Limit dialysate flow rate (daily) to 600 ml/min Use twice-weekly dialysis, with proposed schedules: Monday–Thursday; Tuesday–Friday; and Wednesday–Saturday CRRT replacement fluid recipe 1 L 0.9% NaCl with KCl as needed +1 L D5W with 150 mEq NaHCO3 +1 L 0.9% NaCl with 1 g MgCl2 +1 L 0.9% NaCl with 1 g CaCl2 =4 L (153 mEq/L Na, 37.5 mEq/L HCO3, 2.6 mmol/L Mg, and 2.25 mmol/L Ca) SLED technical and logistic considerations Dialysate flow rate (QD) 100–200 ml/min Blood flow rate (QB) 200 ml/min Treatment duration 8–12 h (evenings, using HD machines at night) Treatment delivered daily or alternate days depending on patient need ICU nurse monitors machine and records details of treatment like CRRT If no contraindications, systemic anticoagulation with unfractionated heparin to target activated partial thromboplastin time drawn peripherally to be 1.5 times control Dialysate jugs should last the entire treatment PIRRT technical and logistic considerations Effluent rate of 40–50 ml/kg per hour Treatment duration 8–12 h Treatment delivered daily or alternate days depending on patient need ICU nurse monitors machine and records details of treatment like CRRT Traditionally, anticoagulation not required but given the reports of the procoagulant nature of the COVID-19 syndrome, systemic anticoagulation with heparin may be necessary Replacement fluid and/or dialysate used should be precisely calculated to not waste fluid HD, hemodialysis; CRRT, continuous RRT; SLED, sustained, low-efficiency dialysis; PIRRT, prolonged intermittent RRT; ICU, intensive care unit; QD, dialysate flow rate; QB, blood flow rate; D5W, 5% dextrose in water.
In this issue
COVID-19 and the Inpatient Dialysis Unit
