Acute renal failure: treatment

Treatment of acute renal failure is determined by the etiology, form and stage of acute renal failure. As is known, both prerenal and postrenal forms in the process of development are necessarily transformed into a renal form. That is why the treatment of acute renal failure will be successful in the early diagnosis of the disease, determining its cause, as well as the timely initiation of efferent therapy.

Treatment of acute renal failure has the following objectives:

• treatment of the underlying disease, leading to the development of acute renal failure;
• restoration of water-electrolyte balance, as well as correction of acid-base state;
• replacement of kidney function;
• ensuring adequate nutrition;
• treatment of concomitant diseases.

[1], [2], [3], [4], [5]

Indications for hospitalization

All patients with suspicion of acute renal failure or its confirmation are subject to emergency hospitalization in a multidisciplinary hospital where there is a hemodialysis department.

By the time of discharge, polyuria is preserved in patients with normalized indices of the concentration of nitrous metabolites and electrolytes. During the recovery period, patients who have suffered acute renal failure need a long-term outpatient supervision and treatment of a nephrologist at the place of residence for at least 3 months.

Non-pharmacological treatment of acute renal failure

Treatment of acute renal failure should begin with the treatment of the underlying disease that caused it.

Daily assessment is recommended to assess the degree of fluid retention in the patient's body. For a more accurate determination of the degree of hydration, the volume of infusion therapy and indications for it, a catheter is required to be inserted into the central vein. Daily diuresis should also be considered, as well as the patient's blood pressure.

With prerenal acute renal failure, early recovery of BCC and normalization of arterial pressure are necessary.

For treatment of renal acute renal failure caused by various substances of medicinal and non-medicinal nature, as well as certain diseases, detoxification therapy should be started as soon as possible. It is desirable to take into account the molecular weight of toxins that caused acute renal failure and the clearance potential of the efferent therapy (plasmapheresis, hemosorption, hemodiafiltration or hemodialysis) method used, the possibility of the earliest administration of an antidote.

With postrenal acute renal failure, immediate drainage of the urinary tract is needed to restore adequate urine outflow. When choosing tactics for an operative intervention on the kidney in conditions of acute renal failure, before the operation, information on the sufficient function of the contralateral kidney is needed. Patients with a single kidney are not so rare. During the stage of polyuria, which develops, as a rule, after drainage, it is necessary to monitor the fluid balance in the patient's body and the electrolyte composition of the blood. The polyuric stage of acute renal failure may be manifested by hypokalemia.

Medication for acute renal failure

With undisturbed passage through the digestive tract, adequate enteral nutrition is necessary. If it is impossible, the need for protein, fats, carbohydrates, vitamins and minerals is met by intravenous nutrition. Given the severity of glomerular filtration, protein intake is limited to 20-25 g per day. The required caloric intake should be at least 1500 kcal / day. The amount of fluid necessary for the patient before the development of the polyuric stage is determined based on the volume of diuresis for the previous day and an additional 500 ml.

The greatest difficulty in treatment is caused by a combination in the patient of acute renal failure and urosepsis. The combination of two types of intoxication uremic and purulent - significantly complicates the treatment, and significantly worsens the prognosis regarding life and recovery. When treating these patients, it is necessary to use efferent methods of detoxification (hemodiafiltration, plasmapheresis, indirect electrochemical oxidation of blood), selection of antibacterial drugs according to the results of bacteriological analysis of blood and urine, and also their dosing taking into account the actual glomerular filtration.

Treatment of a patient with hemodialysis (or modified hemodialysis) can not serve as a contraindication to the prompt treatment of diseases or complications that led to acute renal failure. Modern capabilities of monitoring the coagulating system of blood and its medicamentous correction allow to avoid the risk of bleeding during operations and in the postoperative period. To carry out efferent therapy, it is desirable to use short-acting anticoagulants, for example, sodium heparin, the excess of which by the end of treatment can be neutralized with an antidote - protamine sulfate; As a coagulant, sodium citrate can also be used. To control the coagulation system of blood, the study of activated partial thromboplastin time and the determination of the amount of fibrinogen in the blood are usually used. The method of determining the time of blood coagulation is not always accurate.

Treatment of acute renal failure even before the development of the polyuric stage requires the appointment of loop diuretics, for example furosemide up to 200-300 mg per day fractional.

To compensate for catabolism, anabolic steroids are prescribed.

In hyperkalemia, intravenous administration of 400 ml of a 5% glucose solution with 8 units of insulin and 10-30 ml of a 10% calcium gluconate solution is indicated. If it is not possible to correct hyperkalemia with conservative methods, the patient is shown to carry out emergency hemodialysis.

Operative treatment of acute renal failure

To replace the kidney function during the oliguria period, you can use any method of blood purification:

• hemodialysis;
• peritoneal dialysis;
• hemofiltration;
• hemodiafiltration;
• low-flux haemodiafiltration.

In case of multiple organ dysfunction, it is better to begin with low-flux hemodiafiltration.

Treatment of acute renal failure: hemodialysis

Indications for hemodialysis or its modification for chronic and acute renal failure are different. In the treatment of acute renal failure, the frequency, duration of the procedure, dialysis load, the amount of filtration and dialysate composition are selected individually at the time of the examination, before each treatment session. Treatment with hemodialysis continues, not allowing an increase in urea in the blood above 30 mmol / l. When resolving acute renal failure, the concentration of blood creatinine begins to decrease earlier than the blood urea concentration, which is regarded as a positive prognostic sign.

Emergency indications for hemodialysis (and its modifications):

• "Uncontrolled" hyperkalemia;
• severe hyperhydration;
• hyperhydration of pulmonary tissue;
• severe uraemic intoxication.

[6], [7]

Planned indications for hemodialysis:

• the urea content in the blood is more than 30 mmol / l and / or the creatinine concentration exceeding 0.5 mmol / l;
• expressed clinical signs of uremic intoxication (such as uremic encephalopathy, uremic gastritis, enterocolitis, gastroenterocolitis);
• hyperhydration;
• marked acidosis;
• hyponatremia;
• rapid (within a few days) an increase in the content of uremic toxins in the blood (daily increase in urea levels exceeding 7 mmol / L and creatinine 0.2-0.3 mmol / L) and / or a decrease in diuresis

With the onset of the stage of polyuria, the need for hemodialysis treatment is eliminated.

Possible contraindications for efferent therapy:

• abhybrinogenemia bleeding;
• unreliable surgical hemostasis;
• parenchymal hemorrhage.

As a vascular access for dialysis treatment use a two-way catheter, installed in one of the central veins (subclavian, vaginal or femoral).

Approximate terms of incapacity for work

Depending on the underlying disease, leading to the development of acute renal failure, the period of incapacity for work can be from 1 to 4 months.

[8], [9], [10], [11],

Further management

It is necessary to recommend to patients to limit physical activity and to keep to a diet with the moderate maintenance of fiber.

Prognosis of acute renal failure

A large number of surviving patients observe complete restoration of kidney function; in 10-15% of cases, the recovery is incomplete: the kidney function is reduced to different degrees.