Dialysis in Critically Ill Patients with Hypokalemia: A Challenge to Beat by Adjusting Potassium Bath in Dialysate

Acute renal injury (ARI) is common in critically ill patients and frequently makes renal replacement therapy necessary. Low serum potassium level is associated with arrhythmias and mortality in critically ill patients. Adjusting dialysate �uid potassium to higher level helps preventing post hemodialysis hypokalemia. Objective: To establish role of high potassium dialysate in management of hypokalemia in critically ill patients undergoing renal replacement therapy for ARI. Methods: We did a pilot study and performed a cohort on critically ill patients who developed acute renal injury and required renal replacement therapy for acute indications. We designed two groups each consisting 50 patients. Control group underwent hemodialysis with conventional dialysate. For interventional group, we added potassium bath of 3.0meq/l. Pre and post hemodialysis serum potassium levels were measured results mentioned in the form of bar chart. Results: For intervention group mean pre and post hemodialysis serum potassium levels were 3.43±0.36mg/dl and 4.45±5.00mg/dl respectively with no statistically signi�cant difference in pre and post hemodialysis potassium (p=0.156). While, for control group mean pre and post hemodialysis serum potassium levels were 3.69±0.38mg/dl and 2.97±0.29mg/dl respectively. Difference in pre-post mean serum potassium in control group was statistically signi�cant (p<0.001). Furthermore, three patients in control group developed atrial �brillation in which hypokalemia was con�rmed by laboratory testing. Conclusions: Acute dialysis in critical care on hypokalemic patients can be performed safely by adjusting potassium bath in dialysate.


Original Article
Critical illness is a challenging condition that affects multiple organ systems in life-threatening as well as organthreatening manner.Kidney involvement occurs in critical illness with various clinical manifestations, of which acute kidney injury and electrolyte imbalance are two commonly encountered disorders [1,2].The whole of the homeostatic mechanism is altered during critical illness and there is a surge of stress hormones including corticosteroids, sympathetic system hormones, and renin-angiotensin axis hormones [3].Circulatory collapse and low blood pressure in intensive care unit (ICU) patients is a direct stimulator for renin-angiotensin release [4].This angiotensin rich milieu cause aldosterone release [5].The altered hormonal taste of the body during critical illness is one among the other Dialysis in Critically Ill Patients with Hypokalemia: A Challenge to Beat by Adjusting Potassium Bath in Dialysate was the frequent lab abnormality that was increasing potentially fatal arrhythmia in 10].Hypokalemia in patients admitted to the emergency department with ARI was associated with adverse outcomes [11].Dyskalemia at the time of hospital admission in patients with ARI increases one-year mortality [12].Life-threatening cardiac arrhythmias related to hypokalemia are one of the causes of increased mortality [13].ARI with hypokalemia when required dialysis in ICU patients offers a challenge to intensivists since dialysis worsens hypokalemia and hence the chances of related lifethreatening arrhythmia.We examined the effect of high potassium dialysis on the serum potassium level of critically ill patients undergoing renal replacement therapy for acute indications and compared the results with dialysis under similar conditions with conventional dialysate.High potassium dialysis was found helpful in preventing postdialysis hypokalemia.

M E T H O D S
It was a prospective cohort study of a single center conducted from May 2021 to April 2022 after approval from the ethical as well as research board of the hospital (Ref: App # 0637-2021LNH-ERC, April 27-2021).Data were collected by non-probability consecutive sampling technique in which we included critically ill patients requiring renal replacement therapy for acute indications.We included only those patients were included for whom written consent was obtained after a detailed explanation of the rationale and methods of the study.The study was performed at Liaquat National Hospital Karachi.Data were collected from the nephrology ICU and medical ICU.The author performed a pilot study at the same center to estimate sample size.With a con dence interval (ci) of 95% and power of error (d) = 80%, the open epi software for sample size calculation for comparing two means was used.The initial computed sample size was too small so to enhance the strength of the study, a total of 100 patients were included in the subsequent full study and divided into two groups as control vs intervention (50 in each group).All patients in both groups were undergoing hemodialysis for acute indications only.Chronic kidney disease and maintenance dialysis were considered as exclusion criteria.All patients had low serum potassium levels prehemodialysis (less than 3.5mg/dl).Hemodialysis prescription was similar for all patients in the two groups and was consisting high ux polysulphone dialyzer with a surface area of 1.8m2, blood ow rate of 300ml/mint, dialysate ow rate of 500ml/mint, bicarbonate solution of 36mmol/dl.However, potassium concentration was adjusted for 2 groups in the acidic part of dialysate.The control group had hemodialysis with conventional dialysate

PJHS VOL. 5 Issue. 3 March 2024
Copyright © Published by Crosslinks International Publishers 90 uid with a potassium concentration of 2.0meq/liter (5.49gm).In comparison, the intervention group had a dialysate potassium of 3.0meq/liter A specialized proforma was designed to collect data.Information regarding the patient's biography, admission diagnosis, indication for hemodialysis, and serum potassium level pre and post-hemodialysis recorded.2ml blood was taken from patients each time (pre and post-hemodialysis) by trained staff to measure serum potassium levels in both groups and the sample was analyzed on Cobas 501.Dialysate potassium was manually adjusted to 3.0meq/l by adding a 3.0meq/l potassium bath to the acidic solution of dialysate uid for the intervention group only.Data were analyzed using SPSS version 25.0.Qualitative variables were presented as frequency and percentages.Quantitative variables reported as Mean±SD.Paired t-test was applied to nd the mean differences.Exclusion criteria were strictly followed to avoid any confounding effect.

R E S U L T S
In this study, mean age of participants was 53.20 ± 17.48 years.Out of 100 patients, 52% were male and 48% were female.42% of patients had septicemia as their admission diagnosis, 38% had complicated viral fever, 3% of patients had acute interstitial nephritis, 3% of patients had upper gastrointestinal bleeding, 3% of patients had acute pulmonary edema with severe metabolic acidosis.Other patients had diagnoses of hyper tensive failure, community-acquired pneumonia, uremia, drug toxicity, lupus nephritis, and multiple myeloma with cast nephropathy.51% of patients had DM, 65% had HTN, and 20% had ischemic heart disease as their co-morbid disease.All patients were undergoing hemodialysis for acute indication.In the study population indication for dialysis was consisting metabolic acidosis in 42% of patients, uremia in 38% of patients, and toxic ingestion in 20% of patients.

Indication for Hemodialysis
In the present study, we enrolled ICU patients with critical illness.All patients had low or low normal pre-hemodialysis serum potassium (potassium <3.5 mEq/dl) and required urgent hemodialysis for acute indications.Acute renal injury is frequently seen complication in patients in the ICU setting and is associated with high mortality.ARI is seen in were managed by immediate discontinuation of dialytic treatment.In one patient atrial brillation was observed within half an hour of completion of dialytic treatment and hypokalemia was again con rmed in this case by serum testing for potassium level.This patient was managed with intravenous potassium replacement.Fortunately, all patients survived with timely appropriate action.While in the intervention group, we safely acute dialysis in ill patients with low/low normal serum potassium by adjusting the potassium bath without any complication.

S et al., DOI: https
The detailed descriptive characteristics of participants are shown in table 1. ://doi.org/10.54393/pjhs.v5i03.1334Hypokalemia Management in Critically Ill Dialysis Patients

Table 1 :
Descriptive Characteristics of Participants.