fluid management in CKD

Question 1

what are the distributions of fluid in the body and the corresponding litres?

Answer 1

60% of body weight is water = 42L
2/3 of this is intracellular = 28L
1/3 of this is extracellular = 14L
intravascular is 1/4 of extracellular = 3.5L
extravascular is 3/4 of extracellular = 10.5L

Question 2

what are the sources of fluid intake?

Answer 2

food and drinks
IV fluids
transfusions

Question 3

what are the signs of hypovolaemia?

Answer 3

tachycardia 
hypotension
low JVP
reduced skin turgor 
dry tongue 
reduced urine output
reduced weight 
increased creatinine and increased Hb and haematocrit

Question 4

what are the symptoms of hypovolaemia?

Answer 4

thirst

dizziness

Question 5

what are the signs of hypervolaemia?

Answer 5

normal pulse
high or normal BP
high JVP
normal tissue turgor
normal tongue
normal urine output
increased weight 
reduced creatinine and reduced Hb and haematocrtit

Question 6

what are the symptoms of hypervolaemia?

Answer 6

breathlessness

leg oedema

Question 7

how is fluid status assessed?

Answer 7

BP 
pulse
skin turgor
oedema 
JVP assessment
central venous pressure 
pulmonary oedema and pleural effusion seen on CXR
ascites 
vital signs chart, input and output chart, stool chart, weight chart

Question 8

who are the pts at risk of hypovolaemia?

Answer 8

elderly 
ileostomy/colostomy 
short gut syndrome 
bowel obstruction
diuretics

Question 9

who are the pts at risk of hypervolaemia?

Answer 9

AKI
CKD
heart failure
liver failure

Question 10

how is hypovolaemia managed?

Answer 10

• oral fluid
• IV fluid if pts are very ill, diarrhoea and vomiting, high output stoma, elderly with swallowing difficulties
• treat reversible cause

Question 11

what is crystalloid IV fluid?

Answer 11

made of small moleucules which pass through the cell membrane
the IV fluid moves from the intravascular space to the extravascular space
isotonic solution eg 5% dextrose and 0.9% NaCl

Question 12

what is colloid made from?

Answer 12

large molecules which cannot pass through the cell membrane
this means that this IV fluid stays in the intravascular compartment and can expand intravascular volume through drawing fluid into the vessels

Question 13

how is hypervolaemia managed?

Answer 13

diuretics eg furosemide, spironolactone
fluid restriction
treat reversible cause

Question 14

what urine output would you expect with CKD stage 1-4?

Answer 14

normal urine output

Question 15

what urine output would you expect with CKD stage 5?

Answer 15

oligouric or anuric

Question 16

what are the causes of rising creatinine whist managing fluid overload?

Answer 16

• too aggressive treatment with diuretics
• Extravascular hypervolaemia but intravascular hypovolaemia
• Progression of CKD