Management of acute renal failure

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In this condition, patient develops either oliguria (passage of less than 400 ml of urine / 24 hrs) or anuria (passage of urine less than 100 ml / 24 hrs).

Causes

Pre Renal

  • Postpartum haemorrhage.
  • Shock.
  • Burn.
  • Dehydration.
  • Sepsis.
  • Low output cardiac failure.

Renal

  • Acute tubular necrosis.
  • Acute cortical necrosis (hypertension, pregnancy).
  • Acute interstitial nephritis (drugs e.g “kushta” infection).
  • Acute glomerulonephritis.
  • Vasculitis.
  • Acute polynephritis.

Post Renal

Obstructive uropathy (prostate cancer, cervical cancer).

Symptoms

Anuria/ oliguria are main complaints.

Patient may present with hiccups, dyspnoea, vomiting, confusion, loss of consciousness or fits, uraemic smell.

Signs

  • Oliguria, vomiting, confusion & GIT bleed.
  • Signs of fluid overload (oedema, dyspnoea, and cough, raised JVP).
  • Signs of volume depletion (hypotension, dehydration).

Investigations

  • CBC will indicate anemia that is partly dilutional & increased TLC if infection is present.
  • Urinalysis will show casts.
  • Serum Urea & Serum Creatinine will be raised.
  • Serum electrolytes may show a raised K+, decreased Na+, decreased Ca++, & raised PO4++.
  • Renal USG for obstructive lesions.

Treatment

1   Catheterize the patient to measure urinary output.

2-  If there is evidence of fluid overload, Inj. Mannitol:  200 ml of 20 % Mannitol is given I/V within 20 min.  If urinary output increases in one hour, a second dose is given.  If there is no response, then discontinue Mannitol.  N.B.: -Before using Mannitol, make sure that patient does not have CCF.

3   If there is no increase in urinary output in 6 hrs, then Inj. Lasix 500 mg in 500 ml of 5% distilled water I/V within 1-2 hrs.  If patient does not show improvement after 6 hrs of above therapy, then dialysis is indicated.

4       Symptomatic Treatment

(a)    For Acidosis:  100 ml NaHCO3 is given.

(b)   For Hyperkalemia:  10-20 ml of Inj. Ca gluconate OR

Infusion of 200 ml in 10% glucose with 16 units of plain insulin.

(c)   In case of bleeding:  Packed cell volume is given.  Avoid whole blood transfusion.

(d)  Inj. Maxolon is given for nausea / vomiting.

While treating the patient, over infusion is avoided by monitoring the JVP & auscultation of the chest (basal crepts).

Sepsis

Give antibiotics after C&S.  Titrate the dose according to S/Creatinine & GFR values.

Further Management

  • Relieve the obstruction if present (stone, prostate).
  • Give cimetidine to avoid bleeding from stress ulcers.
  • Provide a diet rich in calories and high quality proteins (2000 to 4000 Cal/day).

Indication for Urgent Dialysis

  • Serum K+ level persistently high (76 mmol/L) Acidosis (pH<7.2)
  • Pulmonary oedema.
  • Pericarditis & cardiac tamponade.
  • High catabolic state with rapid progression.