Fluid management

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Acute Kidney Injury is common in COVID 19 and associated with an increased risk of death. Causes may include: hypovolaemia, haemodynamic changes, viral infection leading directly to kidney tubular injury, thrombotic vascular processes, glomerular pathology or rhabdomyolysis.

Maintaining euvolaemia is critical to reduce incidence of AKI and relies on regular and accurate assessment of fluid balance.

Insensible losses may be high, especially with fever and high respiratory rate.


Aim to achieve and maintain optimal fluid status (euvolaemia) in all patients.

  • If there is volume depletion (hypovolaemia), and fluid needs cannot be met orally or enterally, give patients intravenous fluids as part of a protocol to restore and maintain optimal fluid status.
  • Monitor renal function every 24-28 hours when unwell
  • Ensure patients have an intravenous fluid management plan that is reviewed daily
  • Base choice of fluids on biochemistry results and fluid status

Consider reviewing medication than can cause or worsen AKI

  • Consider stopping usual diuretics if euvolamic with high insensible losses
  • Withhold medication that can cause or worsen AKI, unless essential
  • See below for ACEi/ARB advice

Avoid fluid boluses if normotensive

See NICE guidance here.

ACE Inhibitors (ACEi) and Angiotensin Receptor Blockers (ARBs)

Continue ACEi and ARBs in those with: 

  • Hypertension
  • Post MI LV dysfunction
  • Ischaemic Heart Disease
  • Heart failure with reduced ejection fraction

Consider withholding ACEi and ARBs in other patients while unwell