Guidelines on the Management and

Investigation of Acute Renal Failure

Renal Unit
Royal Hospital for Sick Children
Yorkhill Division

Please note: The following guidelines have not been assessed using the AGREE
(Appraisal of Guidelines for Research and Evaluation) criteria. This will take place
at the next guideline review.

Acute Renal Failure

Author: Renal Clinicians Group
Date of Review: Jan 2012

Version: 1.0
Authorised by: Dr J Beattie
Q-Pulse Ref: YOR-REN-008

Page 1 of 6
Issue Date: Jan 2011

Contents

Page Number(s)

1. Introduction
2. Definition
3. Aetiology
4. Clinical Assessments 3
5. Investigations
6. Urinary Electrolytes in Renal Failure
7. Management of Acute Renal Failure
7.1 Fluid Management
7.2 Electrolyte Abnormalities
7.2.1 Hyponatraemia
7.2.2 Hypernatraemia
7.2.3 Hyperkalaemia
7.2.4 Hypocalcaemia
7.2.5 Hyperphosphataemia
7.2.6 Hypophosphataemia
8. Acid-Based Disorders
9. Nutrition
10. Hypertension
11. Future Guideline Development

2
2
2
3
4
4
4-5
5
5
5
6
6
6
6
7
7
7-8
8

1. Introduction
The following guideline has been developed by clinicians within the Renal Unit at
Yorkhill. This document is intended for use by clinicians in the Management and
Investigation of Acute Renal Failure. For further information, contact a clinician within the
Renal Unit.

2. Definition of Acute Renal Failure

Oliguria - Urine Output: - < 300ml/m2/day or 0.5ml/kg/hr

Anuria - Urine Output: - <1ml/kg/day
Hyperkalaemia - K >6.0 mmol/L on 2 separate occasions
Clinical Fluid Overload
Oedema
Triple rhythm
Hypertension

3. Aetiology
Pre-Renal

Intrinsic Renal

Post-Renal

Hypovolaemia
Peripheral vasodilatation
Impaired Cardiac Output
Renal Vessel occlusion
Drugs
Hepatorenal Syndrome
Increased intraabdominal
pressure

Circulatory Insufficiency
Nephrotoxins
Renal Disease
Myo/haemoglobinuria
Tumour infiltrate
Intratubular obstruction
Latrogenic Factors

Posterior Urethral Valves

Blocked Catheter
Neurogenic Bladder
Traum
Calculi

Acute Renal Failure

Author: Renal Clinicians Group
Date of Review: Jan 2012

Version: 1.0
Authorised by: Dr J Beattie
Q-Pulse Ref: YOR-REN-008

Page 2 of 6
Issue Date: Jan 2011

4.Clinical Assessment of Acute Renal Failure

Patient Weight Required

Daily
Urine Output
Hydration Status
Blood Biochemistry and FBC

Blood Pressure
Neurological Examination
Bruising/Bleeding
Cardiorespiratory Examination
Drug History

Group and Save

Urinalysis
Urinary Sodium, Osmolality
Microscopy for casts
Culture and sensitivity
Renal Ultrasound

Serum for toxicology/ drug

evels
Hepatitis screen,
E. Coli Antibody
Stool culture
AXR
MCUG
Isotope scan
XR left wrist and hand (signs
Of ROD in acute on chronic)
Opthalmology opinion

5. Investigations

U&Es, LFTs and CRP

Uric acid
Magnesium
Glucose
Osmolality
FBC Blood film
Coagulation Screen

Consider the following on clinical grounds

Parathyroid hormone (if acute
on chronic suspected)
C3
ASO titre, anti DNAse B
Antinuclear antibodies/ antiDNA binding
Anti-GBM antibodies
ANCA (anti neutrophil
cytoplasmic antibody)
Blood culture

Acute Renal Failure

Author: Renal Clinicians Group
Date of Review: Jan 2012

Version: 1.0
Authorised by: Dr J Beattie
Q-Pulse Ref: YOR-REN-008

Page 3 of 6
Issue Date: Jan 2011

6. Urinary Electrolytes in Acute Renal Failure

Urine
Output
Uosm
(mosm)
(newborn)
UNa
(mmol/L)
(newborn)
FENa (%)
(newborn)
Lab
studies

Pre - renal
Oliguria

Intrinsic
Oliguria - Polyuria

Post renal
Variable

>500
(>350)
<10
(3119)
<1
(<2.5)

<300
(<300)
>40
(6335)
>2
(>3)

<350
(<300)
>40

Increased
Urea
Lower
Creatinine

Hypocalcaemia
Hyperphosphataemia
Creatinine increases
by 45 130
mmol/L/day

Hyponatraemia
Hyperkalaemia
Hyperchloraemic
Acidosis

<2
(<3)

7. Management of Acute Renal Failure

7.1 Fluid Management

Correction of Hypovolaemia
Fluid Overload:
o Frusemide 2 - 10mg/kg bolus
o Fluid restriction
o Minimalise drug infusion volumes

Accurate input/output
Daily weight
Dialysis
Beware Polyuria

Aim is to maintain isovolaemia erring on the side of minimal fluid overload.

As a rule of thumb fluid therapy should equal insensible fluid losses plus output (urine,
vomiting, drain losses, diarrhoea etc).
Insensible Fluid Losses
1-10 kg
10-20Kg
>20Kg

Acute Renal Failure

Author: Renal Clinicians Group
Date of Review: Jan 2012

25ml/kg
12.5ml/Kg
5ml/Kg

Version: 1.0
Authorised by: Dr J Beattie
Q-Pulse Ref: YOR-REN-008

Page 4 of 6
Issue Date: Jan 2011

8. AcidBase Disorders
These are invariably acidosis and are often mixed respiratory and metabolic especially in
the intensive care setting. Treatment is generally only indicated if there is associated
hyperkalaemia or if the acidosis is profound.
Treatment of Acid-Based Disorders
Base Deficit (mmol) = Base Excess x Weight/3
Replace half of the deficit initially
Sodium Bicarbonate is hypertonic with a risk of CNS complications or
hypernatraemia and is only effective with adequate ventilation.
Rapid correction of acidosis may cause hypocalcaemia and tetany or seizures
Therefore rapid correction to be avoided

9. Nutrition in Acute Renal Failure

Acute renal failure is a hypercatabolic state and requires aggressive nutritional support.
Unlike adults there is no indication for dietary protein restriction, which should be
delivered in amino acids or protein of high biological value. The majority of calories
should however be delivered as carbohydrates.

Calories 1400 kcal/m2/day

Protein 0.6g/kg/day (1.5g if dialysed)
Intralipid - medium chain triglycerides
Folate and Vitamin supplementation

10. Hypertension in Acute Renal Failure

May relate solely to salt and water overload and therefore in the presence
of oligo/anuria and in the absence of hypovolaemia an initial trial of
diuretic therapy is justified.
For further details of the management and investigation of hypertension see
appropriate protocol.

Acute Renal Failure

Author: Renal Clinicians Group
Date of Review: Jan 2012

Version: 1.0
Authorised by: Dr J Beattie
Q-Pulse Ref: YOR-REN-008

Page 5 of 6
Issue Date: Jan 2011

Drug therapy for the emergency treatment of hypertension is outlined below.

Agent
Labetalol

Dose
1-5 mg/kg/hr

Onset
3-5 min

Nifedipine

0.25-0.5 mg/kg

sublingual

Nitrogylcerin

1-10 ug/kg/min
as IV infusion

Instant

Sodium
Nitroprusside

0.5-8 ug/kg/min
as IV infusion

Phentolamine

Clonidine
Hydralazine

Frusemide

Diazoxide

Action
Alpha & beta
Blocker
5-10 min Ca
channel
blocker
Direct
vasodilator

Complications
Hypoglycaemia
Well tolerated
Headache,
nausea,
Syncope
Tachycardia,
bradycardia

Instant

Direct
vasodilator

Thiocyanate
poisoning

0.1mg/kg stat
5-50ug/kg/min
IVI
2-6 ug/kg

5-10 min

Alpha blocker

~10 min

0.2 to 15
mg/dose IV
bolus
4-6ug/kg/min
IVI
1-3mg/kg over
15min
0.1-1mg/kg/hr
IVI
5 mg/kg (max
300) IV bolus

5-10 min

Central alpha 2
Agonist
Direct
vasodilator

Tachycardia,
vomiting
arrythmias
Depression
Rebound
Headache,
vomiting,
tachycardia

3-5 min

Diuretic

Volume depletion
Electrolyte abn

Direct
vasodilator

Hyperglycaemia
Nausea &
vomiting

11. Future Guideline Development

Should any aspect of this guideline change before the planned review in
February 2007 (i.e. new technology or procedural change) then this guideline
should be updated accordingly.
Future review of this guideline should make use of the AGREE document to
ensure that up-to-date evidence and best clinical practice has been used to
inform this guideline. For further information on guideline development, contact
the Multi-Professional Clinical Practice Group.

Acute Renal Failure

Author: Renal Clinicians Group
Date of Review: Jan 2012

Version: 1.0
Authorised by: Dr J Beattie
Q-Pulse Ref: YOR-REN-008

Page 6 of 6
Issue Date: Jan 2011