Management of acute renal failure

Seek specialist advice and review. (1,2)

• immediate referral is indicated if;
  • suspected acute renal failure (ARF) (acute kidney injury (AKI))
  • ARF superimposed on chronic kidney disease (CKD)
  • newly detected ERF (GFR < 15 mL/min/1.73 m2)

The two most immediate aspects of management are treatment of any hyperkalaemia (danger of arrhythmias) or fluid overload (danger of pulmonary oedema).

The overall management of a patient with acute renal failure is divided into various management objectives:

• treatment of cause of acute renal failure
• management of fluid balance
• management of electrolyte balance
• management of uraemia
• control of acidosis
• general management:
  • constant supervision, dedicated nursing care
  • control of infection - choice of drugs must take into account decreased renal function

Notes:

• pharmacological management:
  • loop diuretics should not routinely be used to treat acute kidney injury
  • loop diuretics should be considered for treating fluid overload or oedema while:
    • an adult, child or young person is awaiting renal replacement therapy, or
    • renal function is recovering in an adult, child or young person not receiving renal replacement therapy
    • low-dose dopamine should not be offered to treat acute kidney injury
• fluid replacement prescriptions should be tailored to the needs of the patient
  • potassium containing solutions (Hartmann's and Ringer's Lactate) should be used cautiously in patients who develop progressive AKI, due to the potential risk of exacerbating hyperkalaemia
• monitoring fluid status
  • important to monitor the patient's volume status throughout the episode of AKI
    • an essential part of patient management in the recovery phase. Patients may develop a polyuric phase during which they are at increased risk of developing a negative fluid balance and electrolyte disturbance including hypernatraemia and hypokalaemia
    • needs to be careful consideration of when to reintroduce medications such as antihypertensives and diuretics

Reference:

1. UK Kidney Association. The UK eCKD Guide. February 2024.
2. NICE. Acute kidney injury: prevention, detection and management. NICE guideline NG148. Published December 2019, last updated October 2024