Basic Considerations in Renal Failure 
 
Renal failure can be acute (AKI) or chronic (CKD). In critical care, acute kidney injury is common due to sepsis, shock, nephrotoxic drugs, or multiorgan failure. Proper management is crucial to prevent complications and optimize patient outcomes. 
 
1. Nephrotoxic Drugs 
These are drugs that can damage the kidneys, especially in patients with pre-existing renal impairment. Nurses and medical students should be vigilant. 
 
Common nephrotoxic drugs include: 
NSAIDs (e.g., ibuprofen, naproxen) – reduce renal perfusion. 
Aminoglycosides (e.g., gentamicin, amikacin) – dose-dependent tubular toxicity. 
Vancomycin – can cause tubular necrosis. 
ACE inhibitors / ARBs – can worsen renal function in hypotension or bilateral renal artery stenosis. 
Contrast media – risk of contrast-induced nephropathy. 
Loop diuretics (high doses) – can cause volume depletion if overused. 
Chemotherapy drugs (cisplatin, methotrexate) – direct nephrotoxicity. 
 
Key nursing points: 
Check baseline renal function (creatinine, eGFR). 
Monitor urine output closely (<0.5 mL/kg/hr is concerning in AKI). 
Adjust or avoid nephrotoxic drugs where possible. 
Encourage hydration if not contraindicated. 
 
2. Drug Dose Adjustment in Renal Failure 
 
The kidney is the primary route for excreting many drugs. In renal failure, drugs may accumulate and become toxic. 
 
Key principles: 
Check renal function (creatinine, eGFR, urine output). 
Use renal dosing guidelines for medications like antibiotics, antivirals, and anticoagulants. 
Dialyzable drugs may need supplemental dosing post-dialysis. 
 
Examples of adjustments: 


 
Nursing role: 
Verify renal function before administering drugs. 
Monitor for drug toxicity signs (e.g., confusion, arrhythmias, ototoxicity). 
Raise any queries with pharmacy (allocated pharmacist or medicines information/out of hours cover) or medical team
 
3. Fluid Overload 
 
Renal failure leads to inability to excrete water, causing fluid accumulation. 
 
Clinical signs: 
Peripheral oedema, pulmonary oedema 
Hypertension 
Weight gain 
Jugular venous distension 
Critical care considerations: 
Monitor fluid balance charts rigorously. 
Daily weights. 
Adjust IV fluids and diuretics carefully. 
Consider renal replacement therapy if severe. 
Nursing role: 
Strict input/output monitoring. 
Assess for lung crackles, shortness of breath, oxygen saturation. 
Monitor for fluid overload in sepsis resuscitation or DKA treatment. 
 
4. Hyperkalaemia 
Renal failure often causes potassium retention, which is life-threatening. 
Causes: 
Reduced renal excretion 
Acidosis 
Tissue breakdown (rhabdomyolysis, haemolysis) 
Clinical signs: 
Muscle weakness 
Arrhythmias (peaked T waves on ECG) 
Cardiac arrest in severe cases 
 
Critical care management: 
Follow local Policy however this usually includes: 
Immediate ECG monitoring 
Stabilize cardiac membrane: give IV calcium gluconate (or Calcium resonium if less severe) 
Shift potassium into cells: Insulin + glucose, β2-agonists (monitor for rebound hyperkalaemia) 
Remove potassium: Diuretics (if renal function allows), potassium binders, dialysis 
Address underlying cause

Nursing role: 

Monitor serial potassium and ECGs 
Attach the patient to a cardiac monitor
Alert team for rapidly rising K⁺ 
Ensure no potassium-containing IV fluids or meds are given if elevated serum K levels (remember Hartman’s (Ringer’s lactate) contains Potassium). 
 
Summary Table for Quick Reference 



Key Points: 
Always check renal function before prescribing/administering medications. 
Maintain strict fluid balance in ICU/acutely unwell patients. 
Recognize early signs of electrolyte disturbances. 
Understand indications for dialysis and which medications are dialysable. 
Communicate promptly with the allocated medical team if renal function worsens.