Internal Medicine

P1: SBT

0521779407-02 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 19:18

54 Acute Renal Failure

Indications for Dialysis

■Life-threatening hyperkalemia

■Hypervolemia

■Metabolic acidosis unresponsive to conservative management

■Prevention of symptoms of uremia (Confusion, nausea/vomiting,

pericardial rub), severe azotemia (BUN>120–130)

Type of dialysis

■Hemodialysis often used in hemodynamically stable patients

■Continuous therapies (eg, continuous venovenous hemofiltration)

and peritoneal dialysis are used in selected cases.

follow-up

■Usually necessary to hospitalize patient

■Assess volume status, need for dialysis daily

complications and prognosis

Complications

■Volume overload

➣Restrict Na+, water (<1.0 L/d) loop diuretics may be beneficial

➣Lasix 40 mg IV. If no response, use high dose or constant drip.

➣Complications of loop diuretics: ototoxicity

➣Dialysis if respiratory compromise and no response to diuretics

■Hyperkalemia: potentially life-threatening

➣Mild hyperkalemia (5.5–6.4)

Restrict dietary K+. Stop ACE inhibitors and K-sparing diuretics.

Kayexalate

➣Severe (>6.5), or symptomatic with EKG changes

Temporizing measures until dialysis initiated:

Sodium bicarbonate

Side effect: sodium load (volume overload)

Calcium gluconate IV

D50 and insulin

Side effect: hypoglycemia

■Metabolic acidosis

➣Most advocate maintaining pH >7.2, serum bicarbonate >12, but

optimum pH not known.

➣Limit protein intake

➣Sodium bicarbonate po or IV

Complications: sodium load, volume overload

■Hypocalcemia

➣No treatment unless symptomatic