Occurrence Of Acute Renal Failure Research Articles

Continuous haemofiltration and haemodiafiltration for acute renal failure in severely burned patients

Among 970 burned patients admitted between April 1987 and September 1994, 16 (1.6 per cent) presented acute renal failure requiring dialytic support and were treated by continuous renal replacement therapy as first-line modality. Their mean burned surface area was 58.0±5.7 per cent. Acute renal failure mainly occurred in the second week following admission in relation to sepsis and nephrotoxic drugs. Four types of continuous renal replacement therapy were performed: continuous arteriovenous haemofiltration and haemodiafiltration (CAVH and CAVHDF) and continuous venovenous haemofiltration and haemodiafiltration (CVVH and CVVHDF). Compared to 33 critically ill patients without burns also treated for acute renal failure by continuous haemofiltration or haemodiafiltration during the same period, the mean duration of therapy was longer for the burned patients (24.2±9.4 vs. 5.3±0.8 days). Although mean urine outputs and ultrafiltration rates were similar for both groups, fluid administration was higher for burned patients (8.2±0.7 vs. 3.3±0.2 l/day). Total weight loss during therapy was significantly greater in burned patients (12.6±3.6 vs. 6.8±1.0 kg), in relation to longer treatment period. Bleeding complications were more frequent in burned patients (56 vs. 15 per cent). Mortality rates were similar in both groups (82 vs. 82 per cent). In conclusion, when aggressive initial fluid resuscitation is applied following burn injury, the occurrence of acute renal failure is low, delayed and multifactorial. Since they are haemodynamically well tolerated and provide a good metabolic and volaemic control, continuous renal replacement therapies appear to be useful modalities for burned patients with acute renal failure. However, as bleeding complications are more frequent, careful monitoring is necessary.

Rhabdomyolysis Due to Hyperosmolarity Leading to Acute Renal Failure

Authors present the case of a 37-year-old man admitted to the emergency room of Universidade Federal de São Paulo-Escola Paulista de Medicina, with hyperosmolar coma, following progressive muscle discomfort and loss of renal function, with further need of dialysis therapy. Initial laboratory evaluation showed marked hyperglycemia, hypernatremia, hyperosmolarity, and high levels of creatinine. In the evolution he presented an elevation of creatinophosphokinase levels in parallel with increasing levels of urea and creatinine. Urinalyses showed progressive increase in proteinuria and hematuria. A muscle biopsy was performed and confirmed the presence of muscular necrosis. The purpose of this paper is to emphasize hyperosmolarity as a newly described cause of rhabdomyolysis. The authors point out its multifactorial physiopathology and also stress the relatively common occurrence of acute renal failure (ARF) following an episode of rhabdomyolysis, and the poor prognosis that this complication represents.

Cholesterol atheromatous embolism: an increasingly recognized cause of acute renal failure

Cholesterol atheromatous embolism is a systemic disease resulting from cholesterol crystal embolization to many organs, including the kidney. Vascular surgery, vascular radiology investigations and anticoagulation have been identified as inciting factors. Fifteen patients with extensive atherosclerosis, presenting with simultaneous occurrence of acute renal failure and peripheral ischaemic changes were diagnosed as having acute renal failure due to cholesterol atheromatous embolism. The patients, 12 men and three women, had an average age of 65 years. In one patient, spontaneous occurrence of the disease was observed. An inciting factor was identified in 14 patients: aortography in 10, aortic surgery in two, and thrombolysis in two. Clinical course of acute renal failure was quite variable. Four patients required dialysis; 11 were conservatively managed. All patients had concomitant skin lesions, including digital mottling, cyanosis and gangrene of the toes, and livedo reticularis of the lower limb and abdomen. Eosinophilia was the most common laboratory abnormality. The diagnosis of cholesterol atheromatous embolism was confirmed by tissue examination in eight; in three it was based on the finding of retinal cholesterol emboli; in four patients it was made on clinical grounds. Seven patients died within 36 months. Death was most commonly from cardiac causes. Since the population at risk for cholesterol embolism is growing and the disease is iatrogenic in origin, we should expect to detect cholesterol embolism with greater frequency as cause of acute renal failure in the future.

Prognostic factors in acute renal failure due to sepsis. Results of a prospective multicentre study

Background. Sepsis is a major cause of acute renal failure in hospital patients, but its incidence and the associated prognostic factors have rarely been assessed prospectively by multivariate analysis. Methods. We conducted a prospective 6-month study in 20 multidisciplinary intensive care units to assess the prognosis of patients hospitalized with acute renal failure due to sepsis. Sepsis syndrome and septic shock were defined according to the criteria of the Society of Critical Care Medicine Consensus Conference. Severity scoring indexes (SAPS, APACHE II, and organ system failure (OSF)) were measured on ICU admission and on inclusion. The end-point was hospital mortality. Results. Acute renal failure had a septic origin in 157 patients (Group 1), comprising 68 with septic shock and 89 with sepsis syndrome, and did not result from infection in 188 patients (Group 2). Patients with septic acute renal failure were older (mean age: 62.2 versus 57.9 years, P<0.02) and had on inclusion a higher SAPS (19.3 versus 16.1, P<0.001), APACHE II (29.6 versus 24.3, P<0.001), and OSF (2.07 versus 1.52, P< 0.001) than patients with non-septic acute renal failure. They had a higher need for mechanical ventilation (69.1% versus 47.3%, P<0.001), and acute renal failure was more often delayed during the ICU stay than was present on admission (47.7% versus 32.4% respectively, P<0.005). Hospital mortality was higher in patients with septic acute renal failure (74.5%) than in those whose renal failure did not result from sepsis (45.2%, P<0.001). Mortality was influenced by the presence of a septic shock (79.4%) or of a sepsis syndrome on inclusion (70.8%). Using a stepwise logistic regression model, sepsis was an independent predictor of hospital mortality (OR, 2.51; 95% CI, 1.44-4.39) as well as a delayed occurrence of acute renal failure, oliguria, an altered previous health status, hospitalization prior to ICU, need for mechanical

Acute renal failure in intensive care units--causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on Acute Renal Failure.

To assess the causes, the prognostic factors, and the outcome of patients with severe acute renal failure. Prospective, multicenter study. Twenty French multidisciplinary intensive care units (ICUs). All patients with severe acute renal failure were prospectively enrolled in the study for a 6-month period. Severe acute renal failure was defined by the following criteria: a) a serum creatinine concentration of > or = 3.5 mg/dL ( > or = 310 mumol/L) and/or a blood urea nitrogen concentration of > or = 100 mg/dL ( > or = 36 mmol/L); or b) an increase in blood urea nitrogen or serum creatinine concentration, such that the concentration is 100% above the baseline value in patients with previous chronic renal insufficiency (serum creatinine concentration of > 1.8 mg/dL [ > 150 mumol/L]), excluding those patients with a basal serum creatinine concentration of > 3.4 mg/dL ( > 300 mumol/L). None. Age, sex, previous health status and preexisting organ dysfunction, and type and origin of acute renal failure were recorded. The Simplified Acute Physiology Score, the Acute Physiology and Chronic Health Evaluation (APACHE II) score, and the number of Organ System Failures were calculated on ICU day 1 and at the time of inclusion in the study. Prognostic factors were determined by univariate methods and stepwise logistic regression analysis. There were 360 patients in the study; 217 patients were admitted to the study at the time of ICU admission and 143 patients were admitted to the study after ICU admission. Only 41% of these patients were in good health 3 months before ICU entry. The reason for admission was medical in 78% of cases. The type of acute renal failure was prerenal (n = 16), renal (n = 282), or postrenal (n = 17). Renal replacement therapy was used in 174 patients. Two hundred ten (58%) patients died during the hospital stay. Using stepwide logistic regression, seven variables were predictive of death. These variables were advanced age, altered previous health status, hospitalization before ICU admission, delayed occurrence of acute renal failure, sepsis, oliguria, and severity of illness as assessed at the time of study inclusion by Simplified Acute Physiology Score, APACHE II, or Organ System Failure. The hospital mortality rate of patients with severe acute renal failure in patients requiring intensive care remains high. In order to compare patient groups in further trials concerning acute renal failure, recorded characteristics of the population should include age, previous health status, disease characteristics (initial or delayed acute renal failure, oliguria, sepsis), and the severity of the illness as assessed by physiologic scoring systems recorded at the time of study inclusion.

What dialysis dose should be provided in acute renal failure? A review.

Increased dialysis dose has been shown to improve morbidity and survival in chronic hemodialysis patients. Despite improvement in care and technological aspects of renal replacement therapy, mortality rates of acute renal failure (ARF) have remained essentially unchanged for over two decades, exceeding 50% in most studies. The occurrence of ARF in older patients with more complicated medical and surgical conditions has contributed to this lack of outcome amelioration, and death of ARF patients is now more frequently caused by underlying disease than ARF itself. A recent prospective survey at this institution found a mortality rate of 79.1% among a total of 363 ARF medical and surgical intensive care unit patients, with a mean age near 60 years and a mean admission APACHE II score of over 20, who were treated by intermittent hemodialysis and continuous renal replacement therapy (CRRT). Nonsurvivors had a mean of over four failed systems, in addition to the renal failure, compared with survivors who had less than four. The standards for dialysis adequacy in ARF are not currently defined. Increased catabolism seen in ARF patients in the intensive care unit may justify large dialysis dose delivery. An apparent influence of delivered dialysis dose on the outcome of ARF intensive care unit patients has been recently observed at our institution. Compared with nonsurvivors, survivors had received significantly higher dialysis dose, as assessed by Kt/V and urea reduction ratio. In ARF patients, the discrepancy between delivered versus prescribed dialysis dose may be particularly important and contributed to by the following: reduced blood flow rate and dialysis time consequent to patient intolerance; lower dialyzer in vivo clearances, particularly in heparin-free dialysis; blood recirculation when using temporary vascular access; and postdialysis urea rebound. Prolonging the course of renal failure is one of the risks attributed to frequent dialysis; hypotension and ultrafiltration combined with a deficient renal autoregulation can result in further renal damage. The detrimental effects of bioincompatible membranes have been demonstrated with an induced-delay of renal function recovery. A recent study has reported benefits of biocompatible membranes in terms of potential for renal recovery and maintenance of urine output during dialytic support when compared with bioincompatible membranes. CRRT offers many advantages over intermittent hemodialysis for ARF intensive care unit patients: better hemodynamic tolerance, avoidance of solute rebound, and removal of serum sepsis mediators. However, CRRT have not yet been firmly shown to improve survival rates. Recently, urea kinetics have been used to estimate dialysis dose provided by CRRT.(ABSTRACT TRUNCATED AT 400 WORDS)

Continuous renal replacement therapy for critically ill patients: an update.

Despite continuous progress in intensive care during the last decades, the outcome of critically ill patients in whom acute renal failure (ARF) develops is still poor. This outcome may be explained partially by the frequent occurrence of ARF as part of multiple organ systems failure (MOSF). In this complex and unstable patient population, the provision of adequate renal support with either intermittent hemodialysis or peritoneal dialysis may pose major problems. Continuous renal replacement therapy (CRRT) is now increasingly accepted as the preferred treatment modality in the management of ARF in these patients. The technique offers adequate control of biochemistry and fluid balance in hemodynamically unstable patients, thereby enabling aggressive nutritional and inotropic support without the risk of exacerbating azotemia or fluid overload. In addition, experimental and clinical data suggest that CRRT may have a beneficial influence on hemodynamics and gas exchange in patients with septic shock and (nonrenal) MOSF, independent of an impact on fluid balance. We review both technical and clinical aspects of various continuous therapies, including their impact on serum drug levels and nutrient balance. In addition, an attempt is made to clarify the possible beneficial role of CRRT in reducing patient morbidity and mortality in the ICU.

Failure to isolate verotoxin producing Escherichia coli from patients of haemolytic uremic syndrome.

Haemolytic Uremic Syndrome (HUS) been defined as the simultaneous occurrence of acute renal failure in children with haemolytic anemia and thrombocytopenia. This clinical condition that has been recognized is an important cause of acute renal failure in children.

Protection from acute renal failure.

The occurrence of acute renal failure (ARF), defined as an acute impairment of renal function resulting in the accumulation of nitrogenous waste which cannot be reversed by altering extrarenal factors, is frequent in contemporary medicine. In a recent prospective study, 4.9% of 2216 in-hospital patients developed some degree of ARF, and in some particular clinical situations, such as intensive care medicine or following cardiovascular surgery, the percentage of patients presenting with ARF may be as high as 50% (1,2). ARF is a major problem in clinical medicine not only because of its frequency but also because it represents a major cause of morbidity and mortality (1). Thus, the development of effective means to protect the kidneys against ischemic or nephrotoxic insults is very important in order to decrease the incidence of ARF and its related complications.

Renal Failure Following Contrast Injection for Computerized Tomography

ACUTE renal failure after injection of contrast dye is a rare but well-known complication of intravenous urography and angiography. 1-3 Many physicians are not aware that the latest indication for routine use of contrast dye is computerized tomography (CT), where contrast media may demonstrate lesions not visualized without the dye. We report the occurrence of acute renal failure after injection of contrast media during CT scanning; to our knowledge, this is the first such report. Report of Cases Case 1. — A 72-year-old woman had a left sphenoid ridge meningioma diagnosed by CT scan without use of contrast media in 1974. The tumor was considered inoperable because of its location and her medical condition. In October 1976, she was admitted to the hospital because of increasing but mild confusion, staring spells, and the sudden appearance of right arm paralysis on the day prior to admission. Her medical history was complicated

Acute Uric Acid Nephropathy

The occurrence of acute renal failure in association with hyperuricemia and hyperuricosuria is well recognized in patients with leukemia and lymphoma. In the January issue of theArchives(137:97-99, 1977), Crittenden and Ackerman reported the development of hyperuricemic acute renal failure in a patient with disseminated carcinoma. The pathogenesis of this type of renal failure, often referred to as acute uric acid nephropathy, is not known. However, it is known that the concentration of uric acid increases progressively along the tubule as a result of the reabsorption of water and that uric acid is only sparingly soluble at the acidic pH that is often characteristic of luminal fluid within the distal nephron. Thus, several authors1,2have suggested that these events may facilitate the precipitation of uric acid crystals within the collecting duct system when urinary uric acid excretion is increased. Such crystalline deposits may then decrease renal function by a

Differential Diagnosis and Treatment of Oliguria in Post-Traumatic and Postoperative Patients

The occurrence of acute renal failure in the critically ill patient is an all too frequent occurrence. When postoperative oliguria occurs, it is important to differentiate between postrenal, prerenal, and acute renal failure. An understanding of the basic renal physiology and its alteration by drugs and disease will facilitate an early diagnosis and proper therapy.

Changes in renal concentrating ability associated with major surgical procedures.

THE occurrence of acute renal failure after major surgery has centered attention on the effects of an operative procedure on renal function. Although data are available concerning the effects of anesthesia, operation and the postoperative state on urine formation, renal hemodynamics, water diuresis and electrolyte excretion,1 2 3 4 5 6 7 8 there is little information about the effect of major surgical procedures on renal concentrating ability. It has been suggested that measurement of concentrating ability is useful in differentiating postoperative oliguria due to dehydration from oliguria due to acute tubular necrosis.9 , 10 Concentrating ability is known to decrease transiently in normal subjects during hypotension11 or heavy . . .