Table 269-4.

Management of Ischemic and Nephrotoxic Acute Renal Failurea

Management Issue Therapy
REVERSE CAUSATIVE RENAL INSULT
Ischemic ARF Restore systemic hemodynamics and renal perfusion
Nephrotoxic ARF Eliminate nephrotoxins
Consider specific measures (e.g., forced alkaline diuresis,
chelators: see text)
PREVENTION AND TREATMENT OF COMPLICATIONS
Intravascular volume overload Salt (1-2 g/d) and water (usually <1 L/d) restriction
Diuretics (usually loop blockers ± thiazide)
Ultrafiltration or dialysis
Hyponatremia Restriction of enteral free water intake (<1 L/d)
Avoid hypotonic intravenous solutions (including dextrose
solutions)
Hyperkalemia Restriction of dietary K+ intake (usually <40 mmol/d)
Eliminate K+ supplements and K+-sparing diuretics
Potassium-binding ion-exchange resins (e.g., sodium
polystyrene sulphonate)
Glucose (50 mL of 50% dextrose) and insulin (10 units regular)
Sodium bicarbonate (usually 50-100 mmol)
Calcium gluconate (10 mL of 10% solution over 5 min)
Dialysis (with low K+ dialysate)
Metabolic acidosis Restriction of dietary protein (usually 0.6 g/kg per day of high
biologic value)
Sodium bicarbonate (maintain serum bicarbonate >15 mmol/L
or arterial pH >7.2)
Dialysis
Hyperphosphatemia Restriction of dietary phosphate intake (usually <800 mg/d)
Phosphate binding agents (calcium carbonate, aluminum
hydroxide)
Hypocalcemia Calcium carbonate (if symptomatic or if sodium bicarbonate to
be administered)
Calcium gluconate (10-20 mL of 10% solution)
Hypermagnesemia Discontinue Mg2+-containing antacids
Hyperuricemia Treatment usually not necessary [if <890 mmol/L (<15 mg/dL)]
Nutrition Restriction of dietary protein (~0.6 g/kg per day)
Carbohydrate (~100 g/d)
Enteral or parenteral nutrition (if recovery prolonged or patient
very catabolic)
Indications for dialysis Clinical evidence (symptoms or signs) of uremia
Intractable intravascular volume overload
Hyperkalemia or severe acidosis resistant to conservative
measures
?Prophylactic dialysis when urea >100-150 mg/dL or creatinine
>8-10 mg/dL
PRESCRIBING OF MEDICATIONS
Choice of agents Avoid other nephrotoxins, ACE inhibitors, cyclooxygenase
inhibitors, and radiocontrast unless absolute indication and
no alternative agent
Drug dosing Adjust doses and frequency of administration for degree of
renal impairment
a These are general recommendations and must be tailored to needs of individual patients.