Fluids in Renal Disorders

Title of Guideline (must include the word Guideline (not protocol, policy,
procedure etc)

Guideline for Management of Fluids in

Children and Young People with known Renal
Disorders

Contact Name and Job Title (author)

Dr Farida Hussain, Consultant Paediatric

Nephrologist
Directorate & Speciality

Family Health; Renal

Date of submission

July 2011
Date on which guideline must be reviewed (this should be one to three years)

July 2014
Explicit definition of patient group to which it applies (e.g. inclusion and
exclusion criteria, diagnosis)

Patients with Renal Disorders

Abstract

This guideline describes Management of Fluids

in Children and Young People with known Renal
Disorders
Key Words

Fluids; Renal
Statement of the evidence base of the guideline has the guideline been peer
reviewed by colleagues?
Evidence base: (1-5)

5: recommended best practise based on the

clinical experience of the guideline developer

Consultation Process

Paediatric Renal Team

Target audience

Staff at Nottingham Childrens Hospital

This guideline has been registered with the Nottingham University Hospital Trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review
date.

Page 1 of 8

Contents
Page
Introduction

Summary of organization

Patients with chronic kidney disease:

Oligo-anuria
Polyuria

Tubulopathies

Nephrogenic diabetes insipidus

Acute renal impairment

Appendix
Composition of fluids
Chronic kidney disease categories
Normal maintenance fluid requirements

Introduction
The aim of this guideline is to provide guidance in management of intravenous fluids in
patients with known renal disease who are nil by mouth (for whatever reason). This includes
patients with chronic renal impairment, acute renal failure and tubulopathies. The commonest
situation where this arises is in the peri-operative time period, but is also applicable if the
patient is nil by mouth for other reasons e.g. unable to tolerate oral fluids due to severe
gastroenteritis.

For ALL patients undergoing surgery, good liaison with the surgeons and
anaesthetists is imperative.

Discussion with the surgeons may limit the length of time that the patient requires to
be nil by mouth (for fluids +/- medicines) which will help with the overall management
of these patients.

Co-ordinate to place the child first on the operating list if possible.

Wherever possible (e.g. routine surgery) the problem should be anticipated and fluids
calculated before the patient is admitted for surgery. This is especially important in
certain groups of patients (e.g. patients with cystinosis) where preparation of the i.v.
fluids need to be checked by pharmacy and can cause delays.
The following is intended to be used as a guideline only. All cases should be
discussed with the consultant paediatric nephrologist on-call.

For all patients, on-going assessment of their clinical state and regular review of weight, along
with regular blood tests are imperative (the frequency of which should be discussed with the
consultant on-call) as this may alter the fluid regime that needs to be prescribed.

Page 2 of 8

Summary of Organisation
Planning for elective procedures
Referral letter from Paediatric nephrology to surgical team (with a copy in the notes). The
surgical team should ensure the relevant anaesthetist is also sent a copy of the letter. The
letter should include:
Current weight
Height
BP
Estimated 24 hour urine output
Current recommended fluid intake (restriction / target)
Current medication
Current electrolyte results

For all procedures:

Pre-op

assessment (by surgical team):

24 hour urine output estimation
current fluid intake (restriction or target)
current medications (inc. mineral supplements)
recent U&E results
liaison w surgeons & anaesthetists (&PICU if necessary)
prescribe fluids if requires pharmacy input

At time of operation:
confirm above details
examine patient paying particular attention to:
O State of hydration
O Weight compare with previous weights
O Height
O Blood pressure
Prescribe fluids if not already done
Post-op monitoring of patient: (frequency to be agreed)
Clinical status
Strict fluid input / output charts
Weight
U&Es - (should include full renal profile: includes HCO3-, Ca and PO4 frequency
decided by consultant
An immediate post-op sample should be sent on all patients
Liaise with surgeons re: when can restart oral / gastrostomy feeds +/- medications

Page 3 of 8

Patients with Chronic Kidney Disease

The management pre, peri, and post-operatively, of ALL of these patients should be
discussed with the paediatric nephrologists on-call, even if the patient is admitted under a
different team (e.g. surgical team).
Depending on the patients diagnosis, and current CKD staging (See appendix), their
management will be different, and an up-to-date knowledge of their current estimated 24 hour
urine output, current fluid requirements and current medications (as outlined in the planning
stage) allows a decision as to which of the following categories to place the patient.

a) Oligo-anuric
These patients usually have severe chronic renal insufficiency
(typically GFR < 15mls/min/1.73m2)
Pre-renal transplant
This is a very specific clinical situation, as the patients need to be well hydrated pre-op.
Please refer to separate renal transplant guidelines
Other situations
If the patient has a set fluid restriction at home (provided that they are not either
dehydrated or fluid overloaded), this can be set as a 24 hour fluid requirement.

Fluid prescription this will depend on recent blood results, but in general 5%
dextrose 0.45% saline is used.

For most oligo/anuric patients, potassium should NOT be added to i.v fluids

Regular monitoring of both clinical and biochemical status is required and fluids
adjusted accordingly. (typically this involves blood test monitoring 12 hourly initially)

If no fluid limits have been set, the patient can be managed safely with a regime of
insensible losses + urine output

Insensible losses are calculated as: 400mls/m2/day).

Body Surface Area calculated using the equation: (ht in cm x wt in kg / 3600).

b) Polyuric patients
These patients may produce large volumes of urine, and are also typically salt-losers, and are
therefore at high risk of dehydration without adequate fluid replacement.
Pre- renal transplant
This is a very specific clinical situation, as the patients need to be well hydrated pre-op
Please refer to separate renal transplant guidelines
Other

situations
Pre-operative calculate current daily fluid intake
Review recent U&Es blood results
Calculate current sodium intake (if on supplements)
Check urinary sodium

Page 4 of 8

Tubulopathies
Fanconi syndrome (e.g. cystinosis)
Cystinosis is an autosomal recessive disorder characterized by defective lysosomal cystine
transport, leading to excessive intracellular cystine accumulation. This affects predominantly
the proximal tubule, leading to a severe Fanconis syndrome (hypophosphataemia,
aminoaciduria, glycosuria and acidosis). They also have a high fluid requirement due to
polyuria.
Pre-op
Calculate the current fluid intake that the patient requires
Calculate daily sodium, potassium and bicarbonate requirements from medications.
Choose appropriate fluid, and calculate how much potassium chloride and sodium
bicarbonate need to be added to each bag.
O Please note that these patients often have very high potassium
requirements.
Addition of potassium to i.v fluid bags is restricted to certain wards
and therefore it may be necessary for the fluids to be made up in
pharmacy these should be written up in advance to avoid any
delays
all calculations should be checked with responsible nurse

Fluids should be commenced as soon as the patient is nil by mouth, and not wait until the
patient is in theatre as there is a risk of dehydration in this time.
Post-op
Fluids continued with
regular clinical review (including repeating patient weight if necessary)
regular blood monitoring ((U&E should be a full renal profile - includes HCO3-, Ca
and PO4 and is typically 8 hourly)
with adjustment to fluids (rate +/- composition) if necessary.

Liaise with surgeons about re-starting medications and using NG tube or gastrostomy (if
patient has one) as soon as possible, as this will aid management.
Nephrogenic Diabetes Insipidus (NDI)
NDI is the inability of the kidney to concentrate urine in response to arginine vasopressin,
leading to polyuria and polydipsia. In contrast to the conditions mentioned already, these
patients produce very dilute urine and hold on to sodium. Patients are normally able to selfregulate their sodium concentration, provided they have access to free water and are able to
tolerate this.
If they are kept nil by mouth, their clinical status can change rapidly and this is reflected in the
level of monitoring suggested for them post-operatively.
Admission to PICU / HDU electively should be considered for all NDI patients who
require to be kept NBM post-operatively
Discussion with the surgeons as to when the earliest time water can be given orally or
via gastrostomy should occur, as this will ease management.
Pre-op
Knowledge of current total daily fluid intake allows calculation of hourly fluid
requirement.
Fluids should be commenced as soon as the patient is nil by mouth

Calculate the normal maintenance volume for 24 hours the patient would receive for
their weight. This volume should be given as 4% dextrose / 0.18% Saline
Then calculate what extra fluid they normally take per day. This volume should be
given as 5% dextrose.

Page 5 of 8

 The 2 fluids should be run simultaneously (i.e. 2 iVAC pumps will be required)

As these patients run the risk of hypernatraemic dehydration, close monitoring is required
including:
Hourly input/ output (weighing nappies is usually sufficient)
Regular weights (up to 6 hourly if NBM)
Regular biochemistry monitoring including BMs (6 hourly initially as long as initial
post-op bloods satisfactory)
Bloods samples should be requested as urgent, and results should be chased up and
entered onto a results flow sheet)
If there is any evidence of worsening hypernatraemia, weight loss or negative fluid
balance discuss with consultant. The ratio of fluids being given may need to change and
the rate of administration may need to be altered (if the rate requires changing, it will usually
involve increasing the rate of 5% dextrose alone)
If there is evidence of hypokalaemia, potassium should be added to the maintenance (4%
dex/0.18% Saline) fluids.
If there is evidence of hyperglycaemia, this should be controlled, as this may drive the urine
output further discuss with consultant if rising BM or BM>15 or glycosuria.
As soon as the patient can tolerate enteral fluids (discuss with surgeon if post-op, to see if
clear fluids allowed as soon as possible) allow them to take water orally / via NG / via
gastrostomy, and reduce the iv fluid rate accordingly (as long as clinically stable)
A decision as to which fluid rate to reduce will depend on factors including: current sodium
and glucose levels.

Patients with Acute Renal Failure +/- Acute Glomerulonephritis

These patients usually present with oliguria or anuric. ALL of these patients should be
referred to paediatric nephrology
Many patients will be given a set fluid restriction by the consultant paediatric
nephrologists on-call
Fluid prescription this will depend on recent blood results, but in general 5%
dextrose 0.45% saline is used.
For most oligo/anuric patients, potassium should NOT be added to i.v fluids

Regular monitoring of both clinical and biochemical status is required and fluids
adjusted accordingly. (typically this involves blood test monitoring 8 12 hourly)
If no fluid limits have been set, the patient can be managed safely with a regime of
insensible losses + urine output
2

Insensible losses are calculated as: 400mls/m /day.

Body Surface Area calculated using the equation: (ht in cm x wt in kg / 3600).

Page 6 of 8

Page 7 of 8

Appendix
Composition of Commonly Used Intravenous Fluids:

Note: 0.45% solution alone is a hypotonic solution and its use is severely restricted.

Chronic Kidney Disease Categories

Normal Maintenance Fluid requirements per 24 hours

100mls/kg for the 1st 10kg
50mls/kg for the 2nd 10kg
20mls/kg thereafter

Insensible Losses
2

These are estimated on the basis of body surface area as 400mls/m /day.
Body Surface Area is estimated using the equation: (height [cm]

x wt [kg] / 3600)

Page 8 of 8