Management of acute renal failure
Journal
Macedonian Journal of Anesthesia
Date Issued
2020
Author(s)
DOI
2545-4366
Abstract
In multiple clinical settings, Acute Kidney Injury (AKI) is a frequent condition. AKI increases
the short and long-term mortality rate. Although the condition has become more widely
recognized, yet there is still lack of definitions and increased number of studies has appeared
examining AKI across many different clinical settings. Detailed medical history and physical
examination are the key in determining the etiology of AKI and timeline of the progress. The
fundamental principles in management of AKI are to treat the underlying cause, optimizing fluid
balance and hemodynamics, correct electrolytes and eliminate or adjust the dose of nephrotoxic
drugs. Therefore, optimizing hemodynamics and correction of volume depletion will minimize
continuation of kidney injury and will improve recovery, preventing any chronic impairment
of the kidney. However, there are no guidelines for improving hemodynamics and optimizing
volume status for kidney protection. International guidelines for management of sepsis and septic
shock recommend a goal-directed therapy (GDT). Acute Dialysis Quality Initiative has proposed
a new fluid resuscitation strategy consisting of four phases: rescue, optimization, stabilization
and de-escalation phases. Liberal fluid administration is allowed in the rescue phase; in the optimization phase, where the patient is hemodynamically stable, percutaneous fluid management
is required with the aim to maintain hemodynamic stability; in the stabilization phase, when the
patient is stable, equal or negative fluid balance is preferred; and in last de-escalation phase, all
excessive fluid should be removed.
the short and long-term mortality rate. Although the condition has become more widely
recognized, yet there is still lack of definitions and increased number of studies has appeared
examining AKI across many different clinical settings. Detailed medical history and physical
examination are the key in determining the etiology of AKI and timeline of the progress. The
fundamental principles in management of AKI are to treat the underlying cause, optimizing fluid
balance and hemodynamics, correct electrolytes and eliminate or adjust the dose of nephrotoxic
drugs. Therefore, optimizing hemodynamics and correction of volume depletion will minimize
continuation of kidney injury and will improve recovery, preventing any chronic impairment
of the kidney. However, there are no guidelines for improving hemodynamics and optimizing
volume status for kidney protection. International guidelines for management of sepsis and septic
shock recommend a goal-directed therapy (GDT). Acute Dialysis Quality Initiative has proposed
a new fluid resuscitation strategy consisting of four phases: rescue, optimization, stabilization
and de-escalation phases. Liberal fluid administration is allowed in the rescue phase; in the optimization phase, where the patient is hemodynamically stable, percutaneous fluid management
is required with the aim to maintain hemodynamic stability; in the stabilization phase, when the
patient is stable, equal or negative fluid balance is preferred; and in last de-escalation phase, all
excessive fluid should be removed.
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