Acute Renal Failure

From Alice Springs ICU 2009

 

Policy on Management of Patients with acute renal impairment

 

Acute Renal Failure

 

Pre Renal Failure

The body will try to preserve salt and water and the urinary sodium and urine output will be low.

 

Intrinsic Renal Failure

Intrinsic disease of the kidney means the body will not be able to control the loss of solute or water. If in high output state need to chase the urine output with fluid of a similar content to that being passed e.g. in resolving ATN the urine has about the same composition as N/2 Saline.

 

Post Renal Failure

The kidney must be unobstructed as soon as possible to restore function.

 

Management of Impending Renal Failure

1) Catheterize the patient if no urine. Urgent imaging of the kidney to make sure no obstruction

2) Restore intravascular volume

Assessment of fluid status:

Clinical best measured in response to fluid challenge.

•         Blood Pressure and heart rate

•         Skin temperature differential from proximal to distal or core to peripheral temperature gradient

•         Urine output

•         Jugular Venous Pressure

•         Postural hypotension and differing pulse pressure on respiration

•         Conscious state

•         May require central venous pressure monitoring, invasive arterial monitoring and if poor left ventricle an assessment of cardiac output

 

Check urinary sodium if <20 think about pre renal failure and if patient not in pulmonary oedema consider fluid bolus (N/Saline, Hartmann's or a colloid) 5-10mls/kg more careful fluid increments if severe cardiac disease.

 

 

3) Restore perfusion pressure: maintain the patients usual blood pressure

4) Consider frusemide to increase urine flow.  Must maintain intravascular volume if frusemide used (chase UO if not fluid overloaded) as making the intravascular volume of the patient low will cause further renal impairment. The dose of frusemide will depend on the creatinine, a common dose is 40mg followed by a 10-40mg/h infusion. This is discontinued if no improvement in urine output after 4 hours. The urine chase should be with 0.45% Saline if UO excessive or to maintain the correct intravascular volume. Aim for UO between 100-200mls/h. Watch potassium as this will require replacement if urine flow is achieved.

 

5) Make sure that nephrotoxic drugs are not used.

 

6) If radiographic dye is to be used pre treat with N acetylcysteine or sodium bicarbonate (consultant to decide)

 

7) Adjust all other drugs to the correct dose for that degree of renal impairment. (See Appendix 1 Drug Doses in Renal Impairment)

 

8) Avoid secondary insult by having poor perfusion with:

a)     Low blood pressure

b)    Low intravascular volume

c)     High renal venous pressures e.g. high intra abdominal pressures

 

Adjust fluid administration according to urine output if patient remains oliguric despite treatment or dialysis should be started.

Feeds should be renal based feeds. This is less important if dialysis is instituted.

 

Dialysis will be required for

1)     Fluid overload

2)     Hyperkalaemic

3)     Acidosis

4)     Symptomatic uraemia

5)     Removal of drugs if overdose has occurred

 

 

 

 

 

 

Radiographic Dye policy

 

Pre treat all patients with a creatinine of >1.1mg/dl (>100umol/L)

 

Oral N acetylcysteine 1

Used only in those patients where it can be started 24hours prior to the scan and oral absorption is likely to be good.

600mg bd for 4 doses commencing 24hours prior to IV contrast.

With N/Saline hydration started 4 hours prior to scan and continued 24hours after.Caution with patients with poor left ventricular function.

 

Intravenous N acetylcysteine 2

150mg/kg in 500mls N/Saline over 30 minutes prior to scan

then 50mg/kg in 500mls over 4 hours

Caution with patients with poor left ventricular function

15% of patients will have hypersensitivity reactions.

 

Intravenous Bicarbonate solution 3

Add 150mls of 8.4% sodium bicarbonate solution to 850mls of 5% Dextrose solution. Run at 3.5mls/kg/h for 1 hour prior to scan then at 1.2mls/kg for 6hours post scan.

Please monitor BSL in diabetic patients while infusion rates changing.

 

 

References:

 

1. Tepel et al Prevention of radiographic contrast agent induced reduction in renal function by N acetylcysteine NEJM 343: 180-184,2000

2. Birck R et al Acetylcysteine for prevention of contrast nephropathy: metanalysis. Lancet. 2003; 362:598-603

3. Merten,G et al Prevention of Contrast Induced Nephropathy With Sodium Bicarbonate, JAMA, May 19, 2004-Vol 291,No.19.

 

 

 

 

 

 

 

Appendix 1

Cockcroft-Gault formula
CLcr (mL/min) = (140 - age) x Ideal weight (kg) [x 0.85 for women]

0.814 x Scr (micromol/L) ...

If ideal weight is not easily calculated, the actual weight is usually satisfactory except in the morbidly obese.
Ideal weight (males) = 50 kg + 0.9 kg/each cm over 152 cm .......[use 45.5 kg for females]

 

 

 

 

 

 

 

 

Drug

Dose for normal
GFR
> 50 mL/min

GFR
26-50 mL/min

GFR
10-25 mL/min
[CVVHD]

GFR
< 10 mL/min
[Hemo/CAPD]

Rf

 

Acarbose

50-200 mg tds

avoid

avoid

avoid

3

 

Aciclovir

5-15 mg/kg/q8h

100% q12h

100% q24h

50% q24h

1,3

 

Allopurinol

300 mg daily

50%

50%

25%

3

 

Amantadine

100 mg q12-24h

100% q48h

100% q72h

100% q7days

1,2

 

Amikacin

15 mg/kg/q24h

50% q24h, ML

50% q48h, ML

caution, ML

1,2,3

 

Amoxycillin

250-500mg q8h

100% q8h

100% q12H

100% q24h

2,6

 

Amoxycillin & Clavulanic acid

875/125mg bd

100%

100%

100 % q24h

2

 

Ampicillin

0.5-2 g q6h

100% q8h

100% q12h

100% q12-24h

1

 

Amisulpride

50-1200 mg daily

50%

33%

caution

6

 

Azithromycin

0.25-1 g daily

100%

100%

100%

2,9

 

Aztreonam

2 g q8h

75%

50%

25%

1,2

 

Benzylpenicillin

0.6-2.4 g q4-6h

75%

75%

20-50% ( max.
ESRD 3.6g/d)

1,2,3

 

Captopril

25-50 mg q8h

75% q12h

50% q12h

50% q24h

3

 

Caspofungin

35-70 mg/day

100%

100%

100%

2,9

 

Cefepime

1-2 g q8-12h

100% q12h

50% q12h

25-50% q24h

2,6

 

Cefotaxime

1-2 g q6-8h

100% q8h

100% q12h

100% q24h

1,2

 

Ceftazidime

1-2 g q8h

100% q12h

100% q24h

50% q24h

2

 

Ceftriaxone

1-2 g q24h

100% q24h

100% q24h

100% q24h

2

 

Cephalexin

500 mg q6h

100% q6h

100% q6h

100% q8-12h

2

 

Cephalothin

0.5-2 g q6h

100% q6h

100% q8h

100% q12h

2

 

Cephazolin

1-2 g q8h

100% q12h

100% q12h

100% q24h

1,2

 

Ciprofloxacin po

500-750 mg q12h

q12-24h

q24h

q24h

1,2

 

Ciprofloxacin iv

400 mg q8-12h

q12-24h

q24h

q24h

1,2,4

 

Cisapride

5-15 mg/bd-qid

100%

100%

50%

3,9

 

Clarithromycin

250-500 mg q12h

100% q12h

50% q12h

50% q12h

2

 

Clindamycin

150-600 mg q6-8h

100%

100%

100%

1,2

 

Codeine

30-60 mg q4-6h

75%

75%

50%

3

 

Colchicine

MD: 0.5-1 mg/day

100%

50%

25%

3

 

Colistin

1.25-2.5mg/kg/ q12h

100% q24h

100% q24h

100% q36h

2,9

 

 

 

 

 

 

 

 

Danaparoid

SC or IVI

100%

50%

25%

10

 

Dicloxacillin

0.5-2 g q4-6h

100% q6h

100% q6h

100% q12h

2

 

Didanosine

100-300 mg q12h

100% q24h

100% q24h

50% q24h

1

 

Digoxin

0.25-0.5 mg q24h

50% q24h, ML

25% q24h, ML

10-25% q48h, ML

3

 

Enoxaparin

Tx: 1 mg/kg bd

100% q12h

100% q24h

100% q24h

8,9

 

Erythromycin

500mg-1g q6h

100%

100%

50%

1,2

 

Ethambutol

15 mg/kg/q24h

100% q24h

100% q36h

100% q48h

1,2

 

Famciclovir

125-500 mg q8-12h

100% q12h

50% q24h

50% q48h

1,2

 

Flecainide

50-100mg q12h

50%

50%

50%

4

 

Flucloxacillin

0.5-2 g q4-6h

100% q6h

100% q6h

100% q12h

 

 

Fluconazole

100-800 mg q24h

50%

50%

50%

1,2

 

Flucytosine

37.5-50 mg/kg/q6h

100% q12h

100% q24h

100% q24-48h

1,2,53

 

Foscarnet (ID)

60 mg/kg/q8h

Use product

nomogram to

calculate dose

1,2

 

Foscarnet (MD)

90-120 mg/kg/d

Use product

nomogram to

calculate dose

1,2

 

Fusidic acid

500mg q8-12h

100%

100%

100%

1,6

 

Gabapentin

400 mg tds

300 mg bd

300 mg daily

300 mg q48h

6

 

Ganciclovir iv-ID

2.5-5 mg/kg/q12h

2.5 mg/kg/q24h

1.25 mg/kg/q24h

1.25 mg/kg 3x/wk

3

 

Ganciclovir iv-MD

2.5-5 mg/kg/q24h

1.25 mg/kg/q24h

0.625 mg/kg/q24h

0.625 mg/kg 3x/wk

1,6

 

Gentamicin

3-5 mg/kg/q24h

See Aminoglycoside Dosing Guidelines page

1,2

 

Hexamine

0.5-1 g q12h

avoid

avoid

avoid

 

 

Imipenem

0.5 g q6h - 1 g q8h

50% q8h

50% q12h

50% q12h

1,3

 

Isoniazid

5 mg/kg/day
(max 300 mg/day)

100%

100%

100%

2,9

 

Itraconazole

100-200 mg q12h orally

100%

100%

50% orally
do not use IVI

1,2,3

 

Ketoconazole

200-400 mg daily

100%

100%

100%

1,2

 

Lamivudine

Up to 150 mg bd

150 mg daily

100 mg daily

25-50 mg daily

1,2

 

Lamotrigine

100-500 mg q12h

75%

75%

100mg daily

2,9

 

Levetiracetam

500-1500 mg q12h

250-750 mg q12h

250-500 mg q12h

500 mg -1 g q24h

3

 

Linezolid

600 mg q12h

100%

100%

100%

6

 

Lisinopril

5-10 mg q24h

75%

50%

25-50%

1

 

Lithium

0.9-1.2 g/ day

75%, ML

50%, ML

25-50%, ML

1

 

Meropenem

0.5-2 g q8h

100% q12h

50% q12h

50% q24h

3

 

Methyldopa

250-500 mg tds

100% q8h

100% q12h

100% q12-24h

3

 

Metformin

0.5-1 g q8-24h

25% caution

avoid

avoid

9

 

Metoclopramide

10mg qid

75%

75%

50%

3

 

Metronidazole

500 mg (IVI) q6-12h

100%

100%

50%

3,9

 

Morphine

20-25 mg q4h

75%

75%

50%

3

 

Moxifloxacin

400 mg daily

100%

100%

100%

1,2

 

Mycophenolate

1-1.5 g bd

100%

Up to 1 g bd

Up to 1 g bd

3

 

Nitrofurantoin

50-100 mg daily

avoid

avoid

avoid

2,9

 

Norfloxacin

400 mg q12h

100% q12h

100% q24h

100% q24h

6

 

Omeprazole

20-60 mg daily

100%

100%

100%

1,2

 

Pamidronate

30-90mg each 3-4 weeks

100%

100%

Only urgent use; rate 20mg/hr

9

 

Paroxetine

20-60 mg daily

75%

50%

50%

3

 

Pentamidine

4 mg/kg/q24h

100% q24h

100% q24h

100% q24-36h

2

 

Pyrazinamide

25 mg/kg/day (max 2.5 g)

100%

100%

100%

1,2

 

Ranitidine

50 mg iv q6-8h
(150-300 po bd-daily)

50%

50%

25%

6

 

Rifabutin

150-600 mg/day

100%

50%

50%

1,2

 

Rifampicin

150-600 mg/day

100%

100%

50-100%

3

 

Roxithromycin

150 mg q12h

100%

100%

100%

2,9

 

Sotalol

160 mg q12h

100% q24h

100% q48h

100% q72h

1,2

 

Stavudine

40 mg q12h

50% q12h

50% q24h

No data

2

 

Teicoplanin

6 mg/kg/day

Q48h

q48h

q72h

3,6

 

Terbinafine

250 mg/day

50%

50%

50%

1

 

Tetracycline

250-500 mg q6h

100% q12h

100% q24h

avoid

1,2

 

Ticarcillin/Clav.

3.1 g q4-8h

100% q6-8h

100% q8-12h

50-100% q12h

2

 

Tobramycin

3-5 mg/kg/q24h

50% q24h, ML

50% q48h, ML

Caution, ML

1

 

Topiramate

200mg q12h

50%

50%

25%

1,2

 

Tramadol

50-100 mg q4-6h

100%

100% q12h

avoid

3

 

Tranexamic acid

25 mg/kg q6-8h

50%

25%

10%

1,2,3

 

Trimethoprim/ Sulfamethoxazole

160/800 mg q12h

50-100%

50%

50% q24h, ML

2,6

 

Valaciclovir

0.5-1.5 g q6-12h

100% q8-12h

100% q12-24h

50-100% q24h

3

 

Valganciclovir-Treatment/ ID

900 mg bd

450mg bd- daily

450mg every 2 days

Use IVI ganciclovir

6

 

Valganciclovir-Prophylaxis/ MD

900 mg daily

450mg /day

450mg twice a week

Use po valaciclovir

6

Vancomycin

500 mg q6-12h

See Vancomycin Dosing Guidelines page

6

 

 

 

Venlafaxine

75-375 mg daily

50%

50%

50%

3

 

Vigabatrin

1-2 g bd

25%

25%

25%

6

 

Voriconazole (po)

200-400 mg q12h

100%

100%

100%

1

 

Voriconazole (iv)

3-6 mg/kg/q12h

avoid

avoid

avoid

3

 

Zalcitabine

0.75 mg q8h

0.75 mg q12h

0.75 mg q12h

0.75 mg q24h

2,9

 

Zidovudine

200 mg q8h

200 mg q8h

200 mg q8h

100 mg q8h

2,9

 

References (Rf): (1) The Sanford Guide to Antimicrobial Therapy, 34th ed, 2004; (2) Antibiotic Guidelines, Therapeutic Guidelines 2003; (3) Drug prescribing in renal failure, 4th ed, 1999; (4) JAntimicChemother 1994;33:795-801; (5) Knoben, Handbook of Clinical Drug Data 1993; (6) Manufacturer's Product information; (7) Brater, Drug use in renal disease, 1983; (8) RPA Pharmacy Bulletin, 11/97; (9) Australian Medicines Handbook 2004; (10) RPA Clinical Pharmacists Manual 4th ed, 2004.
Abbreviations: ML = measure levels to dose; ID = induction dose; MD = maintenance dose; LD = loading dose; CVVHD = continuous veno-venous haemodialysis; HEMO = haemodialysis; CAPD = continuous ambulatory peritoneal dialysis.
Caution: Considerable care has been taken to ensure that the above recommendations are accurate, but the user is advised to check doses carefully. The CLcr formula is not accurate in patients with rapidly changing renal function.
Prepared by: Zachariah Matthews, PharmD, Department of Pharmacy, Royal Prince Alfred Hospital.
Edited by: Ceridwen Jones, Department of Pharmacy, Royal Prince Alfred Hospital.
Reviewed: 6th revision, January 2005

 


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