Preferential use of balanced crystalloids such as lactated Ringer vs saline solution results in reduced risk for major adverse kidney events (MAKEs), according to new findings from a real-world study.
Balanced crystalloids and normal 0.9% saline solution are common options for intravenous isotonic crystalloid infusion. Both are widely available and low cost. But emerging research suggests clinical outcomes may differ between solutions.
In the study, investigators implemented an intervention of preferred prescription of balanced crystalloid solution on arrival to 22 hospitals in a large US health care system. Along with clinician education, revised standard and disease-specific electronic health record (EHR) order sets prompted clinicians to replace normal saline with lactated Ringer when not contraindicated. EHR alerts were suppressed if a patient’s serum sodium level was less than 125 mmol/dL, serum potassium was greater than 6 mmol/dL, or the patient was at risk for elevated intracranial pressure.
Among 148,423 hospitalized adults, the proportion of total fluids received as lactated Ringer (vs saline) increased from 28% in the first week to 75% in the last week of the intervention, Joseph Bledsoe, MD, of Intermountain Medical Center, Murray, Utah, and colleagues reported in JAMA Network Open. The absolute risk for MAKEs significantly decreased 2.2% after the intervention. MAKEs comprised all-cause mortality, new persistent kidney dysfunction (creatinine increase of 200% or more from baseline), and initiation of renal replacement therapy within 30 days.
Patients with sepsis had a large 10.1% absolute risk reduction in the composite MAKEs outcome, the investigators reported. Medical inpatients and emergency department patients not admitted to the hospital had statistically significant reductions in the risk for MAKEs, whereas surgery patients did not.
Dr Bledsoe’s team concluded that they hope implementation studies like this one may “accelerate the capability of clinicians and systems to embed best practice in routine medical work.”
In an accompanying editorial, Matthew W. Semler, MD, MSc, of Vanderbilt University Medical Center, Nashville, Tennessee, lauded the study on lactated Ringer vs saline. “Bledsoe and colleagues provide an excellent example of how a large, integrated health system can break the inertia of ‘the way we’ve always done it’ and effectively implement the slightly better of two available therapies, at scale.”
Dr Semler noted that balanced crystalloids appear to be at least as safe as saline for patients with hyperkalemia, acute kidney injury, end stage kidney disease (ESKD), cirrhosis, diabetic ketoacidosis, and hypochloremia. In this study, patients with baseline ESKD were not included in analyses for new persistent kidney dysfunction and renal replacement therapy.
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Bledsoe J, Peltan ID, Bunnell RJ, et al. Order substitutions and education for balanced crystalloid solution use in an integrated health care system and association with major adverse kidney events. JAMA Netw Open. Published May 2, 2022. doi:10.1001/jamanetworkopen.2022.10046
Semler MW. Intravenous fluids — a test case for learning health systems. JAMA Netw Open. Published May 3, 2022. doi:10.1001/jamanetworkopen.2022.10054