Management of Acute Kidney Injury with Hypotension and Dehydration
Immediate aggressive fluid resuscitation with isotonic crystalloids is the cornerstone of management for this patient with severe acute kidney injury (GFR 8), hypotension, and dehydration from prolonged PV bleeding.
Initial Assessment and Stabilization
- Vital signs: BP 100/70, HR 98 - indicates relative hypotension with compensatory tachycardia
- Laboratory findings: GFR 8 (severe AKI, previously 90) - indicates acute, severe renal dysfunction
- Clinical presentation: 10 weeks of intermittent PV bleeding with acute dizziness and dehydration
Immediate Interventions
Establish IV access with two large-bore IVs (16-18G)
Begin fluid resuscitation:
- Isotonic crystalloids (normal saline or balanced solutions) at 1-2 L over first hour 1
- Target MAP >65 mmHg and urine output >0.5 mL/kg/hr
- Monitor for signs of fluid overload (crackles, JVD, peripheral edema)
Blood product administration:
- Type and cross for PRBC transfusion
- Maintain hemoglobin >8 g/dL due to ongoing bleeding 2
- Consider fresh frozen plasma if coagulopathy present
Comprehensive AKI Management
Fluid Management Strategy
Initial phase (first 24 hours):
- Aggressive volume resuscitation to restore euvolemia
- Frequent reassessment of volume status every 1-2 hours
- Adjust fluid rate based on clinical response (BP, HR, urine output)
Maintenance phase:
- Once euvolemic, target neutral to slightly negative fluid balance
- Avoid rapid fluid removal (>1.5-2 L/day) to prevent hemodynamic instability 1
Medication Management
Review and discontinue nephrotoxic medications:
Monitor electrolytes closely:
- Check potassium, sodium, bicarbonate, calcium, phosphate every 6-12 hours
- Treat hyperkalemia if present (calcium gluconate, insulin/dextrose, sodium bicarbonate)
Monitoring and Follow-up
- Hourly monitoring of vital signs, urine output, fluid balance
- Laboratory monitoring:
- Serial creatinine, BUN, electrolytes every 6-12 hours
- Daily CBC to monitor bleeding and response to transfusion
- Coagulation studies if bleeding continues
Indications for Renal Replacement Therapy
Consider urgent RRT if any of the following develop despite medical management 2, 1:
- Refractory hyperkalemia (>6.5 mmol/L or ECG changes)
- Severe metabolic acidosis (pH <7.2)
- Volume overload with pulmonary edema unresponsive to diuretics
- Uremic symptoms (encephalopathy, pericarditis)
- Persistent oliguria/anuria despite adequate fluid resuscitation
RRT Modality Selection
- If hemodynamically unstable: Continuous renal replacement therapy (CRRT) at 20-25 mL/kg/hour 1
- If hemodynamically stable: Intermittent hemodialysis with careful attention to avoid intradialytic hypotension 3
Addressing the Underlying Cause
- Gynecological consultation for evaluation and management of PV bleeding
- Consider interventional procedures to stop bleeding (D&C, hysteroscopy, embolization)
- Investigate cause of bleeding (fibroids, polyps, malignancy, coagulopathy)
Special Considerations
- Avoid intradialytic hypotension if RRT is required, as this can worsen kidney injury and reduce chances of renal recovery 3
- Monitor for signs of fluid overload during resuscitation, especially if oliguria persists 4
- Post-AKI follow-up is essential as even one episode of AKI increases risk of developing chronic kidney disease 1
Prognosis and Recovery Assessment
- Monitor for signs of renal recovery:
- Increasing urine output
- Decreasing serum creatinine
- Improved electrolyte balance
- Post-AKI proteinuria should be monitored as it's a valuable risk-stratification tool for recovery assessment 2
This patient requires immediate attention to restore intravascular volume while simultaneously addressing the underlying cause of bleeding. The severe drop in GFR from 90 to 8 indicates a potentially reversible prerenal AKI if treated promptly and appropriately.