Highlight: as identified by RIFLE (risk, injury, failure, loss, end-stage) criteria (242), and that the effect of renal deterioration is quite detrimental to the elderly individual. Initial evaluation must include such fundamental steps as performance of a physical examination that may reveal an occluded urinary catheter causing an enlarged bladder. Hypovolemia, both absolute, as in severe dehydration, and relative, as in sepsis, must be aggressively corrected with appropriate fluid and blood products; invasive monitoring is warranted in this population of patients with compromised reserve. Dosage adjustment of potentially nephrotoxic medications is mandatory, using assessment of GFR as a guide. Antimicrobials such as cephalosporins and aminoglycosides, nonsteroidal anti-inflammatory medications, certain chemotherapeutic medications, and angiotensin-converting enzyme inhibitors are common offenders (243). Loop diuretics, mannitol, and natriuretic peptides have largely been demonstrated to be of no use in preventing incipient acute renal failure that may seem to be starting (244). The role of N-acetylcysteine and bicarbonate to minimize the deleterious effect of radiocontrast medium on renal function in critically ill individuals remains controversial, but it should generally be used in any elderly patient receiving contrast (245,246,247). Beyond awareness of medications that impact renal function, there is the effect of age-related diminished renal function on drug metabolism and excretion (248). Recall that common indicators of renal function, BUN and Scr, although appearing normal in the elderly, may mask a compromised GFR, risking medication-induced complications if this fact is overlooked. Early nephrology consultation is encouraged when RIFLE criteria suggest compromised renal function; similarly, a critical care pharmacologist can assist in clarifying renal-active medication issues in these complex patients.
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