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Maintaining fluid balance in patients with chronic kidney disease (CKD) can be challenging and requires close attention to changing clinical conditions that require modifications to therapy. For instance, a patient who is stable on an ACE inhibitor along with a diuretic may be faced with numerous scenarios which could place them at risk for a disruption in renal function, such as volume depletion from a gastrointestinal illness, hot weather, or a hospitalization with no oral intake permitted. Inadequate maintenance of volume may precipitate azotemia or acute kidney injury, and such a patient may be encouraged to increase oral fluid intake, to hold their diuretic or ACE inhibitor, or to have IV fluids and electrolyes administered. However, once the clinical condition returns to normal, a follow-up evaluation is typically necessary to monitor for change in body weight along with other physical signs of volume status. At that point, the reinstitution of maintenance medications (especially diuretics) and reduced fluid intake can prevent the inadvertent onset of volume excess, edema or heart failure.

Conversely, patients with CKD may be faced with scenarios which lead to volume excess, edema or worsening heart failure. These might include withdrawal of a diuretic in clinic, dietary sodium indiscretion, or default administration of IV fluids during an elective surgery. In such situations it might be necessary to add new or increased doses of diuretic and absolute salt restriction (some providers may also feel it necessary to restrict fluids as well). However, when the clinical condition corrects, a reassessment for the need of such intensified therapy with monitoring of the change in body weight along with other physical signs of volume status can avert volume depletion, the precipitation of azotemia, or acute kidney injury.

It is important to recognize that clinical conditions for patients with CKD can be dynamic and changes may not be well tolerated. Regular monitoring is needed with the potential for “back and forth” adjustment in fluid recommendations and medications in order to maintain these patients’ fragile volume status.

The rational clinical examination. Is this patient hypovolemic? McGee S; Abernethy WB 3rd; Simel DL
JAMA 1999 Mar 17;281(11):1022-9

Diarrhoea, vomiting and ACE inhibitors:--an important cause of acute renal failure. Stirling C, Houston J, Robertson S, Boyle J, Allan A, Norrie J, Isles C
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Long-term follow-up of acute renal failure caused by angiotensin converting enzyme inhibitors.Wynckel A, Ebikili B, Melin JP, Randoux C, Lavaud S, Chanard J.
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Last Updated - September 19 2017 18:13:54.

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