Treatment

Nonpharmacologic Therapy

The kidney is unable to adjust to abrupt changes in sodium intake in patients with severe CKD. Therefore, patients should be advised to refrain from adding salt to their diet, but should not restrict sodium intake. Changes in sodium intake should occur slowly over a period of several days to allow adequate time for the kidney to adjust urinary sodium content. Sodium restriction produces a negative sodium balance, which causes fluid excretion to restore sodium balance. The resulting volume contraction can decrease perfusion of the kidney and hasten the decline in GFR. Saline-containing IV solutions should be used cautiously in patients with CKD because the salt load may precipitate volume overload.

Fluid restriction is generally unnecessary as long as sodium intake is controlled. The thirst mechanism remains intact in CKD to maintain total body water and plasma osmolality near normal levels. Fluid intake should be maintained at the rate of urine output to replace urine losses, usually fixed at approximately 2 L/day as urine concentrating ability is lost. Significant increases in free water intake orally or IV can precipitate volume overload and hyponatremia. Patients with stage 5 CKD require RRT to maintain normal volume status. Fluid intake is often limited in patients receiving hemodialysis to prevent fluid overload between dialysis sessions.

Pharmacologic Therapy

Diuretic therapy is often necessary to prevent volume overload in patients with CKD in those who still produce urine. Loop diuretics are most frequently used to increase sodium and water excretion. Thiazide diuretics are ineffective when used alone in

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patients with a GFR less than 30 mL/min/1.73 m . ' As CKD progresses, higher doses, as much as 80 to 1,000 mg/day of furosemide, or continuous infusion of loop diuretics may be needed, or combination therapy with loop and thiazide diuretics to

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increase sodium and water excretion. ' Outcome Evaluation

Monitor edema after initiation of diuretic therapy. Monitor fluid intake to ensure obligatory losses are being met and avoid dehydration. If adequate diuresis is not attained with a single agent, consider combination therapy with another diuretic.

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