Acute renal failure medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

Acute renal failure may be reversible if treated promptly and appropriately. Resuscitation to normotension and a normal cardiac output is key. The main interventions are monitoring fluid intake and output as closely as possible; insertion of a urinary catheter is useful for monitoring urine output as well as relieving possible bladder outlet obstruction, such as with an enlarged prostate. In the absence of fluid overload, administering intravenous fluids is typically the first step to improve renal function. Fluid administration may be monitored with the use of a central venous catheter to avoid over- or under-replacement of fluid. If the cause is obstruction of the urinary tract, relief of the obstruction (with a nephrostomy or urinary catheter) may be necessary. Metabolic acidosis and hyperkalemia, the two most serious biochemical manifestations of acute renal failure, may require medical treatment with sodium bicarbonate administration and antihyperkalemic measures, unless dialysis is required.

Should hypotension prove a persistent problem in the fluid replete patient, inotropes such as norepinephrine and/or dobutamine may be given to improve cardiac output and hence renal perfusion. While a useful pressor, there is no evidence to suggest that dopamine is of any specific benefit,[1] and at least a suggestion of possible harm. A Swan-Ganz catheter may be used, to measure pulmonary artery occlusion pressure to provide a guide to left atrial pressure (and thus left heart function) as a target for inotropic support.

The use of diuretics such as furosemide, while widespread and sometimes convenient in ameliorating fluid overload, does not reduce the risk of complications and death.[2] In practice, diuretics may simply mask things, making it more difficult to judge the adequacy of resuscitation.

References

  1. Holmes CL, Walley KR (2003). "Bad medicine: low-dose dopamine in the ICU". Chest. 123 (4): 1266–75. PMID 12684320. doi:10.1378/chest.123.4.1266. 
  2. Uchino S, Doig GS, Bellomo R; et al. (2004). "Diuretics and mortality in acute renal failure". Crit. Care Med. 32 (8): 1669–77. PMID 15286542. doi:10.1097/01.CCM.0000132892.51063.2F. 

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