Continuous Renal Replacement Therapy Dosing in the Severely Underweight: A Case Report

Guidelines recommend that patients treated with continuous renal replacement therapy be delivered an effluent dose of 20 to 25 mL/kg/h. There is debate, especially at the extremes of body mass index, as to whether actual or ideal body weight (IBW) should be used in these dose calculations. A middle-aged woman with severe anorexia presented with 48 hours of altered mental status. Laboratory tests showed severe metabolic acidosis necessitating intubation, which was ultimately found to be due to nonprescribed use of metformin for weight loss. The patient became anuric and was initiated on continuous venovenous hemodialysis. Due to refractory acidosis, the modality was converted to continuous venovenous hemodiafiltration by adding postfilter hypertonic bicarbonate solution. Based on changes in sodium and bicarbonate levels over 4 hours with hypertonic bicarbonate solution, we were able to calculate an "effective" volume of distribution for this severely underweight patient. Our calculations suggest that IBW gives a better approximation of effective volume of distribution than actual body weight in a severely underweight woman. Inadequate effluent flow rate calculated based on actual rather than IBW may lead to insufficient correction of metabolic derangements in extremely underweight patients.