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0521779407-02 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 19:18
Acute Renal Failure 53■Cast nephropathy
➣Multiple myeloma
➣Protease inhibitors
➣AcyclovirPost Renal
■See chapter on obstruction
■History, physical, ultrasound, urine chemistries, urine sediment usu-
ally pinpoint cause
management
What to Do First
Stabilize the patient; treat any life-threatening features.
■Thorough history, physical, chart review
➣1. Are there reversible causes?
Rule out volume depletion
Consider central venous monitoring (CVP or Swan-Ganz
catheter)
Consider trial of IV fluids
➣2. Is there obstruction?
Renal ultrasound
➣3. Urine sediment
➣4. Stop all nephrotoxins
➣5. Monitor drug levels if possible, and dose medications for
reduced GFR
specific therapy
Prevention
■Correct extracellular fluid volume deficits
■Avoid nephrotoxins (aminoglycosides, radiocontrast, NSAID), esp in
high-risk patients
➣Prehydration with sodium bicarbonate therapy prior to radio-
contrast may be better than saline, but more data are needed.
➣N-acetylcysteine (NAC) 600 mg po BID before and day of procedure
is low cost and safe, and may help prevent contrast nephropathy.Established ATN
Tight control of blood glucose reduces the need for dialysis.
■No specific therapy for established ATN
➣Renal dose dopamine, fenoldopam, diuretics, mannitol: No con-
clusive experimental evidence these agents are beneficial in
patients with established ATN