Acute Renal Failure - the Continuing Challenge

Abstract

Acute potentially reversible renal failure (1, 2) can appear in patients in any branch of medicine, from the psychiatrically ill to women during and after pregnancy; thus it is a condition no doctorabove all no physician can ignore. The grim fact is that even in 1986, once oliguria resistant to cardiac support and volume replacement has set in, the patient has at best only an even chance of surviving. Why is it that despite great advances in almost all forms of treatment which might have improved survival, and the ability to substitute for absent renal function almost indefinitely, the mortality remains so distressingly high? One obvious answer is that acute renal failure is almost always secondary to some other event, and that the nature and severity of these events is so overwhelming that treatment has little effect. Today some of the 'milder' forms of acute renal failure, such as that following septic abortions of mismatched blood transfusions, have almost disappeared from clinical practice in developed countries, and we are left with a residuum of patients whose acute renal failure arises from a variety of circumstances, many of which carry in themselves a poor prognosis. At this point it should be made clear that here we are discussing only the variety of acute uraemia appearing in individuals with previously normal renal function, characterised in many patients by acute tubular necrosis, and normally running a course of several days to a few weeks, oliguria (<500 ml/24 h) (3); and that other causes of acute uraemia with oliguria, such as obstruction or acute glomerulonephritis, are not under consideration even though their early diagnosis by ultrasound or renal biopsy from the group considered here may be a crucial part of the early management of the syndrome of acute uraemia.