management of acute renal failure

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Seek specialist advice and review.

  • immediate referral is indicated if (1)
    • 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


  • pharmacological management (3):
    • 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



Last reviewed 03/2021