1. This document outlines the treatment plan and pathway for a patient presenting with chronic renal failure and fluid overload. 2. The plan involves diuresis with IV frusemide to reduce fluid, investigations to assess renal function and exclude other issues, and consideration of acute dialysis for severe cases. 3. Additional orders include monitoring for anemia, adjusting nutrition based on renal function, restricting fluid and protein intake, and making referrals to other services based on renal function and abilities.

1. CHRONIC RENAL FAILURE WITH FLUID OVERLOAD – PATHWAY Treatment Orders:
1. Diuresis with IV frusemide:
Investigations: 120-240 mg/8hrly (if serum Cr > 400 μmol/L)
• FBC--anaemia 80-120 mg/8hrly (if serum Cr < 400μmol/L)
• PT/PTT, GXM—for dialysis, transfusion If no response, step up to maximum OR infusion at 30 mg/hr
• U/E/Cr/HCO3/Glucose—renal fxn, DM Urinary catheter if no urine output > 6hrs
• HbA1c if diabetic--DM
• Ca/Phosphate/Magnesium—renal osteodystrophy 2. Exclude cardiac event
• Fasting iPTH—endocrine compx Check baseline ECG
• LFT If pt has IHD, do CK/CKMB/Trop T
Repeat ECG x3
• Fasting lipids--hyperlipidaemia
• ECG/CXR )
3. Consider acute dialysis/filtration (if hypoxic, severe fluid overload, acidosis, or
• ABG on room air—metab acidosis ) exclude AMI hyperkalaemia)
• CK/CKMB ) PT/PTT, GXM
• UFEME, Urine c/s If for dialysis, trace Hep/HIV status.
If results > 6mths, order HBsAg, Anti-HCV, HIV
Day 2: 4. (Day 3) If anaemia workup negative, consider erythropoietin therapy – refer
• If Hb<11 g/dL: pharmacist and inform on cost
Fe/TIBC
Ferritin 5. (Day 5) Review CXR: if clear, consider switching to oral frusemide. If well on oral
B12 / folate frusemide, consider discharge
Stool OB x3
• If Hb<6 g/dL 6. Discharge plan:
Consider OGD, transfusion, thal workup etc Fluid restriction
Nutritional restriction (decreased protein, potassium, phosphate, calories (if DM))
Nutrition: When to seek medical help: skin turgor, pitting oedema, weakness, fatigue,
• Low salt muscle cramps, N/V
• Low protein 0.8g/kg/day Skin care
• Low phosphate Identify primary physician, appointments, home care etc.
• Low potassium
• DM 1500/1800/2000 kcal Referral Plan (Day 2 onwards):
• If Cr > 400 μmol/L
Fluids: Assess ADL (toilet needs, dressing, feeding)
• 500ml/day (if serum Cr > 400 μmol/L) If can’t do any one ADL, refer MSW
• 800ml/day (if serum Cr < 400μmol/L) 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.
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