CHRONIC RENAL FAILURE WITH FLUID OVERLOAD – PATHWAY Investigations: • FBC--anaemia • PT/PTT, GXM—for dialysis, transfusion • U/E/Cr/HCO3/Glucose—renal fxn, DM • HbA1c if diabetic--DM • Ca/Phosphate/Magnesium—renal osteodystrophy • Fasting iPTH—endocrine compx • LFT • Fasting lipids--hyperlipidaemia • ECG/CXR ) • ABG on room air—metab acidosis ) exclude AMI • CK/CKMB ) • UFEME, Urine c/s Day 2: • If Hb<11 g/dL:

Fe/TIBC Ferritin B12 / folate Stool OB x3

• If Hb<6 g/dL Consider OGD, transfusion, thal workup etc

Nutrition: • Low salt • Low protein 0.8g/kg/day • Low phosphate • Low potassium • DM 1500/1800/2000 kcal Fluids: • 500ml/day (if serum Cr > 400 μmol/L) • 800ml/day (if serum Cr < 400μmol/L) Assessment: • Vital signs • Height/weight • Urine dipstick • Pruritus • Oedema – sites and severity • Compliance with fluid restriction • I/O charting • IV plug • O2 therapy • Urinary catheter if required

Treatment Orders: 1. Diuresis with IV frusemide:

120-240 mg/8hrly (if serum Cr > 400 μmol/L) 80-120 mg/8hrly (if serum Cr < 400μmol/L) If no response, step up to maximum OR infusion at 30 mg/hr Urinary catheter if no urine output > 6hrs

2. Exclude cardiac event

Check baseline ECG If pt has IHD, do CK/CKMB/Trop T Repeat ECG x3

3. Consider acute dialysis/filtration (if hypoxic, severe fluid overload, acidosis, or

hyperkalaemia) PT/PTT, GXM If for dialysis, trace Hep/HIV status.

If results > 6mths, order HBsAg, Anti-HCV, HIV 4. (Day 3) If anaemia workup negative, consider erythropoietin therapy – refer

pharmacist and inform on cost 5. (Day 5) Review CXR: if clear, consider switching to oral frusemide. If well on oral

frusemide, consider discharge 6. Discharge plan:

Fluid restriction Nutritional restriction (decreased protein, potassium, phosphate, calories (if DM)) When to seek medical help: skin turgor, pitting oedema, weakness, fatigue,

muscle cramps, N/V Skin care Identify primary physician, appointments, home care etc.

Referral Plan (Day 2 onwards): • If Cr > 400 μmol/L

Assess ADL (toilet needs, dressing, feeding) If can’t do any one ADL, refer MSW If can do all, refer renal coordinator, vascular surgeon

• If Cr < 400 μmol/L, refer renal coordinator, MSW, vascular surgeon as required • Others: pharmacist, physiotherapist, psychologist etc.