Changes in potassium level and renal function with balanced crystalloid administration in the emergency department

A common reason that often makes clinicians hesitate to use balanced crystalloids in the emergency department is the risk of unexpected hyperkalemia in patients with decreased renal function. In this single-center retrospective cohort study, we compared the change in potassium levels before and after administrating a balanced crystalloid, Plasma Solution A, in patients with normal and decreased renal function. Patients who were administered Plasma Solution A and had an electrolyte follow-up potassium test within 24 hours were included. Decreased renal function was defined as an estimated glomerular filtration rate (eGFR) of less than 90 mL/min/1.73 m2. A total of 1134 patients were included, comprising 376 patients with normal renal function (an eGFR >90 mL/min/1.73 m2) and 758 patients with decreased renal function. In patients with decreased renal function, the mean administered Plasma Solution A volume (mL/kg, mean (SD)) was 34.0 (20.1). The mean administration duration (hr, mean (SD)) was 13.9 (4.7). The eGFR (mL/min/1.73 m2, mean (SD)) increased from 52.6 (24.4) to 68.0 (37.6) (p < 0.05), and the potassium level (mmol/L, mean (SD)) decreased from 4.4 (0.6) to 4.1 (0.6) (p < 0.05). Altogether, we found that the potassium level and renal function may not be worsened in patients with decreased renal function within 24 hours after the intravenous administration of approximately 2 L of a balanced crystalloid in the emergency department.

Potassium; Renal function; Balanced crystalloid; Emergency department

[1] Myburgh JA, Mythen MG. Resuscitation fluids. New England Journal of Medicine. 2013; 369: 1243–1251.

[2] Wilcox CS. Regulation of renal blood flow by plasma chloride. Journal of Clinical Investigation. 1983; 71: 726–35.

[3] Bullivant EM, Wilcox CS, Welch WJ. Intrarenal vasoconstriction during hyperchloremia: role of thromboxane. American Journal of Physiology. 1989; 256: 152–157.

[4] Yunos NM, Bellomo R, Glassford N, Sutcliffe H, Lam Q, Bailey M. Chlorideliberal vs. chloride-restrictive intravenous fluid administration and acute kidney injury: an extended analysis. Intensive Care Medicine. 2015; 41: 257–264.

[5] Raghunathan K, Shaw A, Nathanson B, Sturmer T, Brookhart A, Stefan MS, et al. Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis. Critical Care Medicine. 2014; 42: 1585–1591.

[6] Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Daniel W, et al. Balanced crystalloids versus saline in critically ill adults. New England Journal of Medicine. 2018; 378: 1949

[7] Simon F, Sharon M, Naomi H, Leanlove N, Rinaldo B, Laurent B, et al. Balanced multielectrolyte solution versus saline in critically ill adults. New England Journal of Medicine. 2022; 386: 815–826.

[8] Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, et al. Balanced crystalloids versus saline in noncritically ill adults. New England Journal of Medicine. 2018; 378: 819–828.

[9] Self WH, Semler MW, Wanderer JP, Ehrenfeld JM, Byrne DW, Wang L, et al. Saline versus balanced crystalloids for intravenous fluid therapy in the emergency department: study protocol for a cluster-randomized, multiple-crossover trial. Trials. 2017; 18: 178.

[10] Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: a clinical review. World Journal of Critical Care Medicine. 2016; 5: 235–250.

[11] Shaw AD, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Schermer CR, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% Saline compared to Plasma-Lyte. Annals of Surgery. 2012; 255: 821–829.

[12] McFarlane C, Lee A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement. Anaesthesia. 1994; 49: 779–781.

[13] Young JB, Utter GH, Schermer CR, Galante JM, Phan HH, Yang Y, et al. Saline versus Plasma-Lyte in initial resuscitation of trauma patients: a randomized trial. Annals of Surgery. 2014; 259: 255–262.

[14] Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and Plasma-Lyte (R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Annals of Surgery. 2012; 256: 18–24.

[15] Kim MY, Jeon NY, Hyun SK, Kim HT, Cho WH, Park UJ. The effects of normal saline solution versus hartmann’s solution on the acid-base and electrolytes status and renal function after kidney transplantation. Korean Journal of Transplantation. 2015; 29: 194–199.

[16] Toporek, A. H., Semler, M. W., Self, W. H., Bernald GR, Wang L, Siew ED, et al. Balanced crystalloids versus saline in critically ill adults with hyperkalemia or acute kidney injury: secondary analysis of a clinical trial. American Journal of Respiratory and Critical Care Medicine. 2021: 203: 1322–1325.

[17] Levey AS, Coresh J, Bolton K, Culleton B, Harvey KS, Ikizler TA, et al. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. American Journal of Kidney Diseases. 2002; 39: S1–266.

[18] Levin A, Stevens P.E, Bilous RW, Coresh J, Francisco A, Jong PE, et al. Kidney disease: improving global outcomes (KDIGO) CKD work group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International Supplements. 2012; 3: 1–150

[19] Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Critical Care Medicine. 2021; 49: 1063–1143

[20] Turck D, Bresson JL, Burlingame B, Dean T, Fairweather-Tait S, Heinonen M, et al. Dietary reference values for potassium. EFSA Journal. 2016; 14: 4592

[21] Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. American Journal of Emergency Medicine. 2022; 52: 85–91.