Therapy

• resuscitate the patient ^a using crystalloids ^a
• relieve any outflow obstruction   ^a

• but even if critically ill, avoid immediate routine right heart catheterisation ^b  

• Monitor fluid status carefully (e.g. clinical assessment, weight, fluid charts, invasive monitoring) and restrict water and sodium as necessary ^d
• Review medication:
  • avoid potential nephrotoxins (e.g. NSAIDS, aminoglycosides) ^d
  • adjust doses of other medications to account for renal insufficiency ^d
  • regular electrolytes, urea, creatinine: watch for hyperkalaemia ^d
• Regular electrolytes, urea, creatinine: watch for hyperkalaemia ^d

• diuretics
  • high-dose loop diuretics e.g. frusemide
    • Loading dose 120 - 240 mg frusemide , followed by an infusion of 20 mg/h
    • If unable to give as infusion, give 120 mg over one hour every 6 h
    • Reduce dose if creatinine falling
    • Titrate dose to urine output
• mannitol  
  single dose of 100 mL of 20% solution, in patients where the underlying problem is uncorrected hypovolaemia ^c  
• inotropic agents 
  • norepinephrine ^c  (started if systolic blood pressure < 90 mmHg; 0.5 µg/kg/min with increments of 0.3 - 0.6 µg/kg/min to maintain systolic bp >120/80) 

There is no clear benefit from dopamine ^a  (low-dose: 1 - 3 µg/kg/min)   

Common indications include ^d

• hyperkalaemia refractory to treatment
• severe or worsening metabolic acidosis
• volume overload 
• uraemic pericarditis or encephalopathy

There is no clear benefit from using

• anaritide
• essential amino acids