›BUN > 35 mmol/L in context of oliguric AKI
›Diuretic phase fluid strategy
›Aggressive fluid and electrolyte repletion
›Match urine output with IV or oral fluids
›Potassium replacement: IV or oral based on severity
›Sodium monitoring — hyponatremia and hypernatremia both possible
Renal replacement therapy
›Hemodialysis or CRRT selection
›CRRT preferred in hemodynamically unstable patients
›CVVHDF or CVVHF modality
›Continuous filtration avoids large fluid shifts
›Intermittent hemodialysis in hemodynamically stable patients
›3–4 sessions per week if chronic
›Single session if acute hyperkalemia management
›Duration
›Most HFRS AKI is reversible
›Discontinue when urine output recovering and renal function improving
›Ribavirin — not routinely recommended
›Evidence for Hantaan virus (HTNV) in China
›One controlled trial showed reduced mortality (HTNV)
›Dose if used: 33 mg/kg IV loading dose, then 16 mg/kg IV every 6 hours x4 days, then 8 mg/kg IV every 8 hours x6 days
›Total course 10 days
›Ineffective against Puumala virus (PUUV)
›Not recommended for European HFRS
›No FDA or EMA approval for HFRS indication
›Consult infectious disease before use
›Analgesia and antipyresis
›Acetaminophen preferred
›For fever and pain management
›Avoid NSAIDs: nephrotoxic, inhibit platelet function
›Avoid aspirin: platelet dysfunction in thrombocytopenic patient
›Nephrotoxin avoidance
›Avoid aminoglycosides
›Use alternative antibiotics if bacterial coinfection suspected
›Avoid contrast agents for imaging when possible
›Use ultrasound or non-contrast CT first
›Avoid ACE inhibitors and ARBs during AKI
›Hemorrhage management
›Platelet transfusion for active bleeding with platelet < 50 x10^9/L
›Threshold may be higher (< 100 x10^9/L) for invasive procedures
›FFP and cryoprecipitate for DIC with active hemorrhage
›Avoid anticoagulants given hemorrhagic diathesis
›Blood product transfusion
›pRBC for hemoglobin < 70–80 g/L or symptomatic anemia
›Hyperkalemia management (oliguric phase)
›Potassium > 6 mmol/L with ECG changes
›Calcium gluconate 1 g IV over 5–10 minutes (membrane stabilization)
›Sodium bicarbonate 50–100 mmol IV for metabolic acidosis correction
›Insulin 10 units IV + dextrose 50% 50 mL IV
›Kayexalate (sodium polystyrene sulfonate) 15–30 g orally or PR
›Dialysis for refractory hyperkalemia
›Hyponatremia management (febrile phase)
›Mild hyponatremia (Na 130–133 mmol/L): fluid restriction
›Monitor closely — predicts oliguric AKI development
›Severe hyponatremia (Na < 125 mmol/L): hypertonic saline cautiously
›Correct at rate < 10 mmol/L per 24 hours to avoid osmotic demyelination