Table 1.

Practical ideas for increasing dialysis surge capacity

Fluid restriction500–750 ml/d (approximately 10 ml/kg per day)
Potassium resinsSodium 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 therapiesOral 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 blockadeLoop 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 HDLimit 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 recipe1 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 considerationsDialysate 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 considerationsEffluent 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.