Pre-renal → renal acute kidney failure: On the basis of your explanation, what drugs are you going to use and how will they help to improve the clinical situation?
Based on studies that have investigated efficacy and patient survival prioritise the drugs you would use.
Clinically he is hypotensive (88/60) tachycardic 100/min, cyanotic and has a raised JVP at 5cm.
- First thing: treat acute CHF first then manage the diabetes
- - If no venous pooling; i.e. if pre-renal failure is through dehydration, put in saline IV and replenish fluids so not hypertensive and tachycardic. Don't know evidence but physiology of it speaks for itself
- - in this case there is raised JVP, so not so much volume loss, rather we need to increase heart function
- ACE inhibitors: used in this case even when patient is hypotensive
- - 26% risk reduction of complication with for CHF
- - improves cardiac function by reducing congestion/afterload (improve cardiac contractility, natriuresis and diuresis)
Frusemide: to promote diuresis and reduce the acute pulmonary oedema
- Simvastatin Scandinavian study: 2223 patients were assigned placebo and 2221 were assigned simvastatin treatment for a mean period of 5.4 years. There was a 30% relative reduction in the risk of death with simvastatin treatment.
- - Plus other diabetes targeted interventions; diet, exercise, other glycemic controlling/anti-diabetic drugs (not metformin which is contraindicated in renal disease)
Evidence base suggests that in general, in diabetics the higher the BP, the higher the mortality rate.