Nephrology Book

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Acute Renal Failure Management

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  1. Management: Volume Status
    1. Normal Volume Status
      1. Limit Fluid Intake to Urine Output + 300-500 ml/day
      2. Limit Sodium Intake to 2 grams per day
    2. Volume Overloaded
      1. Limit Fluid intake to less than Urine Output
      2. Limit Sodium Intake to less than 2 grams per day
      3. Consider Loop Diuretic
      4. Consider Dialysis
    3. Volume Depleted
      1. First: Restore Volume with Isotonic saline
      2. Next: Limit Intake to Urine Output + 300-500 ml/day
      3. Limit sodium intake to 2 grams per day
  2. Management: Potassium
    1. Hyperkalemia
      1. Look for potassium source
      2. Eliminate parenteral potassium
      3. Reduce Dietary Potassium intake <50 meq per day
      4. Consider potassium binding resin (Kayexalate)
      5. Aggressive management if Serum Potassium >6 mEq/L
        1. See Hyperkalemia
        2. Consider dialysis
    2. Normokalemia
      1. Limit Potassium intake to 50 meq per day
  3. Management: Acid-Base Status
    1. Acidemia
      1. Look for cause of acidosis (See Arterial Blood Gas)
      2. Reduce protein intake to 0.6 g/kg/day
      3. Aggressive management if pH <7.2 or bicarbonate <15
        1. Consider oral bicarbonate or
        2. Consider isotonic IV bicarbonate
        3. Consider dialysis
    2. Normal pH
      1. Limit protein intake to 0.8 g/kg/day
  4. Nutritional Intake
    1. Maintain 30-50 KCal/Kg/day
  5. Management: Uremia
    1. Absent
      1. Limit protein intake to 0.9 g/kg/day
    2. Present
      1. Reduce protein to 0.6 g/kg/day
      2. Check for Gastrointestinal Bleeding
      3. See Dialysis indications below
  6. Management: Dialysis Indications
    1. Blood Urea Nitrogen >100 mg/dl
    2. Serum Creatinine >10
    3. Uremic Signs (e.g. Pericarditis, Encephalopathy)
    4. Significant bleeding
    5. Refractory severe Metabolic Acidosis (pH <7.20)
    6. Refractory severe Hyperkalemia (potassium >6.0)
    7. Volume Overload
  7. Management: Medications
    1. Assess medications for toxicity
      1. Check drug levels
      2. Adjust dosages for Renal Function
    2. Stop Nephrotoxic Drugs
      1. NSAIDs
      2. ACE Inhibitors
      3. Aminoglycosides
      4. Avoid repeating Radiocontrast Material
      5. Avoid high dose Diuretics in critically ill patients
        1. Avoid Diuretics in relatively resistant patients
        2. Associated with higher mortality
        3. Discourages prior strategy to overcome oliguria
        4. Mehta (2002) JAMA 288:2547
      6. Dopamine does not drop ARF risk in critically ill
        1. Kellum (2001) Crit Care Med 29:1526

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