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]
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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 |
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Acarbose |
50-200 mg tds |
avoid |
avoid |
avoid |
3 |
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Aciclovir |
5-15 mg/kg/q8h |
100% q12h |
100% q24h |
50% q24h |
1,3 |
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Allopurinol |
300 mg daily |
50% |
50% |
25% |
3 |
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Amantadine |
100 mg q12-24h |
100% q48h |
100% q72h |
100% q7days |
1,2 |
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Amikacin |
15 mg/kg/q24h |
50% q24h, ML |
50% q48h, ML |
caution, ML |
1,2,3 |
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Amoxycillin |
250-500mg q8h |
100% q8h |
100% q12H |
100% q24h |
2,6 |
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Amoxycillin & Clavulanic acid |
875/125mg bd |
100% |
100% |
100 % q24h |
2 |
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Ampicillin |
0.5-2 g q6h |
100% q8h |
100% q12h |
100% q12-24h |
1 |
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Amisulpride |
50-1200 mg daily |
50% |
33% |
caution |
6 |
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Azithromycin |
0.25-1 g daily |
100% |
100% |
100% |
2,9 |
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Aztreonam |
2 g q8h |
75% |
50% |
25% |
1,2 |
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Benzylpenicillin |
0.6-2.4 g q4-6h |
75% |
75% |
20-50% ( max.
ESRD 3.6g/d) |
1,2,3 |
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Captopril |
25-50 mg q8h |
75% q12h |
50% q12h |
50% q24h |
3 |
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Caspofungin |
35-70 mg/day |
100% |
100% |
100% |
2,9 |
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Cefepime |
1-2 g q8-12h |
100% q12h |
50% q12h |
25-50% q24h |
2,6 |
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Cefotaxime |
1-2 g q6-8h |
100% q8h |
100% q12h |
100% q24h |
1,2 |
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Ceftazidime |
1-2 g q8h |
100% q12h |
100% q24h |
50% q24h |
2 |
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Ceftriaxone |
1-2 g q24h |
100% q24h |
100% q24h |
100% q24h |
2 |
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Cephalexin |
500 mg q6h |
100% q6h |
100% q6h |
100% q8-12h |
2 |
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Cephalothin |
0.5-2 g q6h |
100% q6h |
100% q8h |
100% q12h |
2 |
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Cephazolin |
1-2 g q8h |
100% q12h |
100% q12h |
100% q24h |
1,2 |
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Ciprofloxacin po |
500-750 mg q12h |
q12-24h |
q24h |
q24h |
1,2 |
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Ciprofloxacin iv |
400 mg q8-12h |
q12-24h |
q24h |
q24h |
1,2,4 |
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Cisapride |
5-15 mg/bd-qid |
100% |
100% |
50% |
3,9 |
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Clarithromycin |
250-500 mg q12h |
100% q12h |
50% q12h |
50% q12h |
2 |
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Clindamycin |
150-600 mg q6-8h |
100% |
100% |
100% |
1,2 |
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Codeine |
30-60 mg q4-6h |
75% |
75% |
50% |
3 |
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Colchicine |
MD: 0.5-1 mg/day |
100% |
50% |
25% |
3 |
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Colistin |
1.25-2.5mg/kg/ q12h |
100% q24h |
100% q24h |
100% q36h |
2,9 |
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Danaparoid |
SC or IVI |
100% |
50% |
25% |
10 |
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Dicloxacillin |
0.5-2 g q4-6h |
100% q6h |
100% q6h |
100% q12h |
2 |
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Didanosine |
100-300 mg q12h |
100% q24h |
100% q24h |
50% q24h |
1 |
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Digoxin |
0.25-0.5 mg q24h |
50% q24h, ML |
25% q24h, ML |
10-25% q48h, ML |
3 |
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Enoxaparin |
Tx: 1 mg/kg bd |
100% q12h |
100% q24h |
100% q24h |
8,9 |
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Erythromycin |
500mg-1g q6h |
100% |
100% |
50% |
1,2 |
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Ethambutol |
15 mg/kg/q24h |
100% q24h |
100% q36h |
100% q48h |
1,2 |
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Famciclovir |
125-500 mg q8-12h |
100% q12h |
50% q24h |
50% q48h |
1,2 |
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Flecainide |
50-100mg q12h |
50% |
50% |
50% |
4 |
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Flucloxacillin |
0.5-2 g q4-6h |
100% q6h |
100% q6h |
100% q12h |
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Fluconazole |
100-800 mg q24h |
50% |
50% |
50% |
1,2 |
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Flucytosine |
37.5-50 mg/kg/q6h |
100% q12h |
100% q24h |
100% q24-48h |
1,2,53 |
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Foscarnet (ID) |
60 mg/kg/q8h |
Use product |
nomogram to |
calculate dose |
1,2 |
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Foscarnet (MD) |
90-120 mg/kg/d |
Use product |
nomogram to |
calculate dose |
1,2 |
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Fusidic acid |
500mg q8-12h |
100% |
100% |
100% |
1,6 |
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Gabapentin |
400 mg tds |
300 mg bd |
300 mg daily |
300 mg q48h |
6 |
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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 |
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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 |
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Gentamicin |
3-5 mg/kg/q24h |
See Aminoglycoside Dosing Guidelines page |
1,2 |
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Hexamine |
0.5-1 g q12h |
avoid |
avoid |
avoid |
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Imipenem |
0.5 g q6h - 1 g q8h |
50% q8h |
50% q12h |
50% q12h |
1,3 |
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Isoniazid |
5 mg/kg/day
(max 300 mg/day) |
100% |
100% |
100% |
2,9 |
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Itraconazole |
100-200 mg q12h orally |
100% |
100% |
50% orally
do not use IVI |
1,2,3 |
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Ketoconazole |
200-400 mg daily |
100% |
100% |
100% |
1,2 |
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Lamivudine |
Up to 150 mg bd |
150 mg daily |
100 mg daily |
25-50 mg daily |
1,2 |
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Lamotrigine |
100-500 mg q12h |
75% |
75% |
100mg daily |
2,9 |
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Levetiracetam |
500-1500 mg q12h |
250-750 mg q12h |
250-500 mg q12h |
500 mg -1 g q24h |
3 |
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Linezolid |
600 mg q12h |
100% |
100% |
100% |
6 |
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Lisinopril |
5-10 mg q24h |
75% |
50% |
25-50% |
1 |
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Lithium |
0.9-1.2 g/ day |
75%, ML |
50%, ML |
25-50%, ML |
1 |
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Meropenem |
0.5-2 g q8h |
100% q12h |
50% q12h |
50% q24h |
3 |
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Methyldopa |
250-500 mg tds |
100% q8h |
100% q12h |
100% q12-24h |
3 |
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Metformin |
0.5-1 g q8-24h |
25% caution |
avoid |
avoid |
9 |
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Metoclopramide |
10mg qid |
75% |
75% |
50% |
3 |
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Metronidazole |
500 mg (IVI) q6-12h |
100% |
100% |
50% |
3,9 |
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Morphine |
20-25 mg q4h |
75% |
75% |
50% |
3 |
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Moxifloxacin |
400 mg daily |
100% |
100% |
100% |
1,2 |
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Mycophenolate |
1-1.5 g bd |
100% |
Up to 1 g bd |
Up to 1 g bd |
3 |
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Nitrofurantoin |
50-100 mg daily |
avoid |
avoid |
avoid |
2,9 |
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Norfloxacin |
400 mg q12h |
100% q12h |
100% q24h |
100% q24h |
6 |
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Omeprazole |
20-60 mg daily |
100% |
100% |
100% |
1,2 |
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Pamidronate |
30-90mg each 3-4 weeks |
100% |
100% |
Only urgent use; rate 20mg/hr |
9 |
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Paroxetine |
20-60 mg daily |
75% |
50% |
50% |
3 |
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Pentamidine |
4 mg/kg/q24h |
100% q24h |
100% q24h |
100% q24-36h |
2 |
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Pyrazinamide |
25 mg/kg/day (max 2.5 g) |
100% |
100% |
100% |
1,2 |
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Ranitidine |
50 mg iv q6-8h
(150-300 po bd-daily) |
50% |
50% |
25% |
6 |
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Rifabutin |
150-600 mg/day |
100% |
50% |
50% |
1,2 |
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Rifampicin |
150-600 mg/day |
100% |
100% |
50-100% |
3 |
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Roxithromycin |
150 mg q12h |
100% |
100% |
100% |
2,9 |
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Sotalol |
160 mg q12h |
100% q24h |
100% q48h |
100% q72h |
1,2 |
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Stavudine |
40 mg q12h |
50% q12h |
50% q24h |
No data |
2 |
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Teicoplanin |
6 mg/kg/day |
Q48h |
q48h |
q72h |
3,6 |
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Terbinafine |
250 mg/day |
50% |
50% |
50% |
1 |
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Tetracycline |
250-500 mg q6h |
100% q12h |
100% q24h |
avoid |
1,2 |
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Ticarcillin/Clav. |
3.1 g q4-8h |
100% q6-8h |
100% q8-12h |
50-100% q12h |
2 |
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Tobramycin |
3-5 mg/kg/q24h |
50% q24h, ML |
50% q48h, ML |
Caution, ML |
1 |
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Topiramate |
200mg q12h |
50% |
50% |
25% |
1,2 |
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Tramadol |
50-100 mg q4-6h |
100% |
100% q12h |
avoid |
3 |
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Tranexamic acid |
25 mg/kg q6-8h |
50% |
25% |
10% |
1,2,3 |
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Trimethoprim/ Sulfamethoxazole |
160/800 mg q12h |
50-100% |
50% |
50% q24h, ML |
2,6 |
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Valaciclovir |
0.5-1.5 g q6-12h |
100% q8-12h |
100% q12-24h |
50-100% q24h |
3 |
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Valganciclovir-Treatment/ ID |
900 mg bd |
450mg bd- daily |
450mg every 2 days |
Use IVI ganciclovir |
6 |
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Valganciclovir-Prophylaxis/ MD |
900 mg daily |
450mg /day |
450mg twice a week |
Use po valaciclovir |
6 |
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Vancomycin |
500 mg q6-12h |
See Vancomycin Dosing Guidelines page |
6 |
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Venlafaxine |
75-375 mg daily |
50% |
50% |
50% |
3 |
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Vigabatrin |
1-2 g bd |
25% |
25% |
25% |
6 |
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Voriconazole (po) |
200-400 mg q12h |
100% |
100% |
100% |
1 |
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Voriconazole (iv) |
3-6 mg/kg/q12h |
avoid |
avoid |
avoid |
3 |
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Zalcitabine |
0.75 mg q8h |
0.75 mg q12h |
0.75 mg q12h |
0.75 mg q24h |
2,9 |
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Zidovudine |
200 mg q8h |
200 mg q8h |
200 mg q8h |
100 mg q8h |
2,9 |
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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
