What is the immediate management for acute on top of chronic kidney failure?

From the Guidelines

The immediate management of acute on chronic kidney failure requires prompt identification and treatment of the underlying cause while providing supportive care, with a focus on stopping nephrotoxic medications, ensuring adequate hydration, and correcting electrolyte imbalances, as recommended by the most recent guidelines 1. The management approach should prioritize the patient's overall clinical condition, taking into account the presence of both acute and chronic kidney disease components. Initial steps include:

• Stopping nephrotoxic medications to prevent further kidney damage
• Ensuring adequate hydration while avoiding volume overload, which may require careful fluid status assessment and the use of diuretics like furosemide 40-80mg IV for volume overload or fluid restriction if necessary
• Correcting electrolyte imbalances, particularly hyperkalemia, which may require calcium gluconate 10% 10mL IV, insulin 10 units with dextrose 50% 50mL IV, or sodium bicarbonate 50mEq IV if severe, as suggested by the KDIGO guidelines 1
• Metabolic acidosis may require sodium bicarbonate supplementation
• Close monitoring of renal function, electrolytes, and urine output is essential, with a target urine output of at least 0.5mL/kg/hr
• Nutritional support should be optimized with protein restriction (0.6-0.8g/kg/day) and adequate caloric intake If conservative measures fail, renal replacement therapy (dialysis) should be considered, particularly for refractory hyperkalemia, severe acidosis, uremic symptoms, or volume overload unresponsive to diuretics, with continuous RRT (CRRT) favored over intermittent forms of dialysis for the management of acute renal failure in patients with cardiogenic shock, as recommended by the American Heart Association 1. This comprehensive approach addresses both the acute deterioration and underlying chronic kidney disease, aiming to prevent further kidney damage and associated complications.

From the FDA Drug Label

In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, Furosemide tablets should be discontinued.

The immediate management for acute on top of chronic kidney failure is not directly addressed in the provided drug label. However, it can be inferred that caution is necessary when using furosemide (IV) in patients with severe progressive renal disease.

• The label recommends discontinuing Furosemide tablets if increasing azotemia and oliguria occur during treatment.
• It is also advised that therapy should be initiated in a hospital setting for patients with certain conditions, implying the need for close monitoring. 2

From the Research

Immediate Management for Acute on Top of Chronic Kidney Failure

The immediate management for acute on top of chronic kidney failure involves addressing the underlying causes of the acute deterioration and managing the resulting complications, such as electrolyte imbalances and fluid overload.

• Electrolyte and Acid-Base Disturbances: Acute kidney injury (AKI) is associated with electrolyte and acid-base disturbances such as hyperkalemia, metabolic acidosis, hypocalcemia, and hyperphosphatemia 3. The initiation of dialysis in AKI can efficiently treat these complications.
• Dialysis Modality: The choice of dialysis modality can be made based on their operational characteristics to tailor the therapy according to the clinical scenario 3. Continuous techniques may be particularly useful in these situations as they allow more time for correction and to maintain balance.
• Diuretic Use: Diuretics may be used to favorably modify the disturbances associated with chronic renal failure, such as hypertension, edema, hyperkalemia, and acidosis 4. However, the use of diuretics is not without complications and should be carefully considered.
• Hyperkalemia Management: Hyperkalemia is a major risk of potentially life-threatening cardiac arrhythmic complications in patients with kidney disease 5. Therapeutic interventions aimed at preventing and treating hyperkalemia are essential, including the use of diuretics, potassium exchange resins, and dialysis.
• Limitations of Diuretic Use: The use of diuretics in critically ill patients with acute renal failure was associated with an increased risk of death and nonrecovery of renal function 6. This suggests that diuretics should be used with caution and only when necessary.

Key Considerations

• The management of acute on top of chronic kidney failure requires a comprehensive approach that addresses the underlying causes of the acute deterioration and manages the resulting complications.
• Dialysis may be necessary to efficiently treat electrolyte and acid-base disturbances associated with AKI 3, 7.
• The use of diuretics should be carefully considered, taking into account the potential benefits and risks 4, 6.