What is the management approach for a patient with impaired renal function exposed to toxins or infections from goats, such as leptospirosis or caprine arthritis-encephalitis virus?

Management of Renal Failure in Patients with Goat-Associated Exposures

Immediate Nephrotoxin Discontinuation

Stop all nephrotoxic medications immediately, as drugs account for 20-25% of AKI cases and each additional nephrotoxin increases AKI risk by 53%. 1, 2

• Discontinue ACE inhibitors and ARBs immediately during the acute phase when GFR is unstable 1, 2
• Stop NSAIDs immediately as they reduce renal perfusion, particularly dangerous when combined with diuretics and ACE inhibitors/ARBs (the "triple whammy") 1, 2
• Discontinue metformin if GFR <30 ml/min/1.73m² and review if GFR 30-44 ml/min/1.73m² 1
• Stop lithium and digoxin due to toxicity risk with reduced renal clearance 1

Infection-Specific Management

For Suspected Leptospirosis or Bacterial Infection

Start broad-spectrum antibiotics immediately while awaiting cultures, as prompt treatment of infections can prevent or ameliorate AKI. 2, 3

• Obtain urine culture and urinalysis before starting antibiotics to guide definitive therapy 3
• Select first-line antibiotics based on local antibiogram patterns with dose adjustment for renal function 3
• Avoid aminoglycosides unless absolutely necessary and use therapeutic drug monitoring if required 1
• Avoid trimethoprim-sulfamethoxazole if creatinine clearance <15 ml/min 1
• Treat for as short a duration as reasonable, generally no longer than 7 days 3

For Caprine Arthritis-Encephalitis Virus (CAEV)

Provide supportive care only, as CAEV-associated renal lesions (interstitial nephritis) have been documented but no specific antiviral therapy exists. 4

• CAEV can cause inflammatory renal injury with interstitial nephritis and thrombotic arteritis leading to renal infarction 4
• The clinical consequence of CAEV-associated renal injury remains unclear, requiring close monitoring 4
• Management focuses on preventing further kidney damage through nephrotoxin avoidance and hemodynamic optimization 1, 2

Volume Status Optimization

Assess and correct volume depletion or overload immediately using aggressive intravenous fluid resuscitation for volume depletion. 2

• Use isotonic crystalloids for volume expansion rather than colloids 1
• Avoid hydroxyethyl starches as they increase AKI incidence and need for renal replacement therapy 1
• Use vasopressors (norepinephrine) in conjunction with fluids for vasomotor shock, titrating to MAP 65-70 mmHg 1
• Monitor hourly urine output with bladder catheter placement in severe cases 2

Critical Monitoring Protocol

Establish intensive monitoring during the acute phase with daily eGFR, serum creatinine, and electrolytes. 2

• Monitor daily to twice daily electrolytes, especially potassium 2
• Monitor therapeutic drug levels for aminoglycosides, calcineurin inhibitors, lithium, and digoxin 1, 2
• Obtain urinalysis and culture if infection is suspected 2
• Perform comprehensive medication reconciliation and adjust doses based on current GFR 2

What NOT to Use

Do not use diuretics (including furosemide) to prevent or treat AKI, as they are ineffective for kidney protection. 1

• Do not use low-dose dopamine as it does not prevent or treat AKI 1
• Do not use recombinant human IGF-1 as it is ineffective 1
• Diuretics should only be used judiciously for managing fluid overload, not for treating AKI itself 1

Infection Control for Dialysis (If Required)

If hemodialysis becomes necessary, use dedicated machines in isolation with full protective gear including waterproof gowns, N95 masks, face shields, and gloves. 5

• Decontaminate spent dialysate with 2% sodium hypochlorite solution 5
• Discard all blood tubing, unspent dialysate concentrate, and sodium bicarbonate cartridge as infectious waste 5
• Disinfect dialysis machine after each session with sodium hypochlorite solution per manufacturer's instructions 5
• Following infection control guidelines prevented hospital-acquired cases even when 30-50% of patients required hemodialysis 5

Common Pitfalls to Avoid

• Never continue ACE inhibitors/ARBs during acute AKI despite the persistent misconception that they are renoprotective 1, 2
• Never use diuretics to "treat" AKI as this is a dangerous misconception despite strong evidence against it 1
• Never combine multiple nephrotoxins as combining 2-3 nephrotoxins more than doubles AKI risk 1, 2
• Never delay essential antibiotics for suspected bacterial infections, as treatment can prevent AKI progression 2, 3
• Never overlook drug-drug interactions such as macrolide antibiotics with statins, which increase rhabdomyolysis risk 1, 2