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Monitor renal function and potassium especially with impaired renal function. If volume depleted, first rehydrate before commencing ACE-inhibitor. ACE-inhibitor are contraindicated in: Hyperkalaemia known allergy to ACE-inhibitor 328Standard Treatment Guidelines
Begin with low dosage of ACE-inhibitor and titrate up ensuring blood pressure remains in normal range and no side effects are present, up to the maximum dose or until the proteinuria disappears –whichever comes first. Pharmacological Treatment Adults C: Enalapril 10–20 mg (PO) 12 hourly. HyperlipidaemiaIf hyperlipidaemia is a co-existent risk factor manage according to section Diabetes mellitus In diabetics, optimise control according to section 9.6: Diabetes mellitus type 2, in adults Avoid oral hypoglycaemics if GFR is < 60 because of the risk of lactic acidosis with metformin and prolonged hypoglycaemia with long acting sulphonylureas. Hypertension Treat if present. See Section 20.7: HypertensionCurrent evidence does not support stricter blood pressure control targets for the majority of patients with CKD [IA]. CKD patients with albuminuria may benefit from tighter control with a target of < 130/80 [IIA]. Fluid overload Treat fluid overload if present and refer. Adults B:Furosemide 40–80mg slow I.V or oral, 12 hourly. If poor response, repeat after 1 hour. Do not give I.V fluids –use heparin lock or similar I.V access. Note: Exclude heart failure in patients with persistent pedal oedema. Referral to nephrologist All cases of suspected chronic kidney disease stages 3–5 for assessment and planning All children All cases of CKD with: ohaematuria, oproteinuria oraised blood urea or creatinine initially for assessment and planning Uncontrolled hypertension/fluid overload CKD associated with hyperlipidaemia No resolution of proteinuria with ACE-I therapy Note: Patients who might qualify for dialysis and transplantation or who have complications should be referred early to ensure improved outcome and survival on dialysis, i.e. as soon as GFR drops below 30 mL/min/1.73 m2, or as soon as diagnosis is made/suspected 329Standard Treatment Guidelines329
21.2 ACUTE RENAL FAILURE (ARF) Is an abrupt or rapid decline in renal filtration function This is (usually) reversible kidney failure, most commonly as a result of: dehydration and fluid loss drugs/toxins, urinary tract obstruction, and acute glomerulonephritis in older children Diagnostic Criteria Oedema Oluguria/anuria Convulsions in children Investigations Serum electrolytes, Urea and Creatinine tests Ultrasound Urinalysis Non-Pharmacological TreatmentGive oxygen, and nurse in semi-Fowlers’ position if patient has respiratory distress. Stop intake of all salt and potassium containing foods and fluids Restrict fluid intake to 10 mL/kg/day daily plus visible fluid losses Pharmacological TreatmentAdults If diastolic blood pressure is greater than 100 mmHgor systolic blood pressure is above 150 mmHg: C: Amlodipine (PO) 5 mg as a single dose.