Treatment of Severe Metabolic Alkalosis with Continuous Renal Replacement Therapy

Abstract

Concomitant severe metabolic alkalosis, hypernatremia, and kidney failure pose a therapeutic challenge. Hemodialysis to correct azotemia and abnormal electrolytes results in rapid correction of serum sodium, bicarbonate, and urea but presents a risk for dialysis disequilibrium and brain edema. We describe a patient with Zollinger-Ellison syndrome with persistent encephalopathy, severe metabolic alkalosis (highest bicarbonate 81 mEq/L), hypernatremia (sodium 157 mEq/L), and kidney failure despite 30 hours of intravenous crystalloids and proton pump inhibitor. We used continuous renal replacement therapy (RRT) with delivered hourly urea clearance of ~3 L/hour (24 hour sustained low efficiency dialysis with regional citrate anticoagulation protocol at blood flow rate 60 ml/min and dialysate flow rate 400 ml/min). To mitigate a pronounced decrease in plasma osmolality while removing urea from this hypernatremic patient, dialysate sodium was set to start at 155 mEq/L then at 150 mEq/L after 6 hours. Serum bicarbonate, urea, and sodium were slowly corrected over 26 hours. This case demonstrates how to regulate and predict the systemic bicarbonate level using single pool kinetic modeling during convective or diffusive RRT. Kinetic modeling provides a valuable tool for systemic blood pH control in future combined use of extracorporeal CO2 removal and continuous RRT systems.

A Rare Case of Severe Metabolic Alkalosis with Unusual Hyperproteinemia Treated with Continuous Renal Replacement Therapy and Regional Citrate Anticoagulation

“…The literature mentioning treatment of metabolic alkalosis using CRRT, and particularly together with RCA, remains scarce [12, 13]. Nevertheless, a number of units use RCA as a default on all continuous or extended dialysis circuits.…”

Hemorrhagic Encephalopathy From Acute Baking Soda Ingestion

“…Hemodialysis can be considered in critically ill patients with renal failure and severe electrolyte derangements that are not responding to fluid and electrolyte repletion. 26 …”

An integrated model using the Taguchi method and artificial neural network to improve artificial kidney solidification parameters

“…Hemodialysis is the treatment process that uses patients’ blood for extracorporeal circulation, thereby improving electrolyte and abnormal pH imbalance and helping patients with uremic symptoms. Hemodialysis is mainly used to treat chronic and acute renal function failure management, which is generally difficult to treat with traditional medicine [12].…”