Table 1.
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.