Clinical Acute Renal Failure Research Articles

Risk prediction of acute kidney injury in cardiac surgery and prevention using aminophylline

The incidence of acute kidney injury (AKI) after cardiac surgery remains high. The nonspecific adenosine receptor antagonist aminophylline has been shown to confer benefit in experimental and clinical acute renal failure (ARF) due to ischemia, contrast media, and various nephrotoxic agents. We conducted a prospective open label trial to assess the effectiveness of aminophylline for prevention of renal impairment after cardiac surgery. One hundred and thirty-eight patients undergoing cardiac surgery were risk stratified as per Cleveland score to assess for prediction of AKI. Sixty-three patients received a bolus aminophylline of 5 mg/kg and a subsequent continuous infusion of 0.25 mg/kg/h for up to 72 h, while 75 patients received usual postoperative care. Serum creatinine concentrations were measured preoperatively and daily until day 5 after surgery and the glomerular filtration rate estimated using Cockcroft and Gault formula. Hourly urine output was recorded and patients assigned to respective RIFLE stage of AKI. Cleveland score ≥6 was associated with higher incidence of AKI: I and F (P<0.005). Number needed to treat, an insight into the clinical relevance of a specific treatment, is 8. These results suggest that the perioperative use of aminophylline infusion is associated with lower incidence of deterioration in renal function following cardiac surgery in high-risk patients.

Administered mesenchymal stem cells enhance recovery from ischemia/reperfusion-induced acute renal failure in rats

Adult stem cells are promising for the development of novel therapies in regenerative medicine. Acute renal failure (ARF) remains a frequent clinical complication, associated with an unacceptably high mortality rate, in large part due to the ineffectiveness of currently available therapies. The aim of this study was, therefore, to evaluate the therapeutic effectiveness of bone marrow-derived mesenchymal stem cells in a rat model of ischemia/reperfusion (I/R) ARF. We used a common I/R model in rats to induce ARF by clamping both renal pedicles for 40 minutes. Mesenchymal stem cells were iron-dextran-labeled for in vivo tracking studies by magnetic resonance imaging (MRI) and kidneys were imaged for mesenchymal stem cells immediately after infusion and at day 3 after ARF. Renal injury was scored on day 3 and cells were additionally tracked by Prussian blue staining. We show in I/R-induced ARF in rats, modeling the most common form of clinical ARF, that infusion of mesenchymal stem cells enhances recovery of renal function. Mesenchymal stem cells were found to be located in the kidney cortex after injection, as demonstrated by MRI. Mesenchymal stem cells-treated animals had both significantly better renal function on days 2 and 3 and better injury scores at day 3 after ARF. Histologically, mesenchymal stem cells were predominantly located in glomerular capillaries, while tubules showed no iron labeling, indicating absent tubular transdifferentiation. We conclude that the highly renoprotective capacity of mesenchymal stem cells opens the possibility for a cell-based paradigm shift in the treatment of I/R ARF.

Poly(ADP-ribose) polymerase-mediated cell injury in acute renal failure

Acute Renal Failure (ARF) is the most costly kidney disease in hospitalized patients and remains as a serious problem in clinical medicine. The mortality rate among ARF patients remains around 50% and no pharmaceutical agents are currently available to improve its clinical outcome. Although several successful therapeutic approaches have been developed in animal models of the disease, translation of the results to clinical ARF remains elusive. Understanding the cellular and molecular mechanisms of vascular and tubular dysfunction in ARF is important for developing acceptable therapeutic interventions. Following an ischemic episode, cells of the affected nephron undergo necrotic and/or apoptotic cell death. Necrotic cell death is widely considered to be a futile process that cannot be modulated by pharmacological means as opposed to apoptosis. However, recent reports from various laboratories including ours indicate that inhibition or absence of poly(ADP)-ribose polymerase (PARP), one of the molecules involved in cell death, provides remarkable protection in disease models such as stroke, myocardial infarction and renal ischemia which are characterized predominantly by necrotic type of cell death. Overactivation of PARP in conditions such as ischemic renal injury leads to cellular depletion of its substrate NAD + and consequently ATP. The severely compromised cellular energetic state induces acute cell injury and diminishes renal functions. PARP activation also enhances the expression of proinflammatory agents and adhesion molecules in ischemic kidneys. Pharmacological inhibition and gene ablation of PARP-1 decreased energy depletion, inflammatory response and improved renal functions in the setting renal ischemia/reperfusion injury. The biochemical pathways and the cellular and molecular mechanisms mediated by PARP-1 activation in eliciting the energy depletion and inflammatory responses in ischemic kidney are not fully elucidated. Dissecting the molecular mechanisms by which PARP activation contributes to oxidant-induced cell death will provide new strategies to interfere in those pathways to modulate cell death in renal ischemia. The current review evaluates the experimental evidences in animal and cell culture models implicating PARP as a pathophysiological modulator of acute renal failure with particular emphasis on ischemic renal injury.

Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population

Most epidemiological studies evaluating the association between nonsteroidal anti-inflammatory drugs (NSAIDs) and acute renal failure (ARF) found an increased risk for developing ARF while taking NSAIDs. Despite these studies, little is known about the effect of dose and duration of therapy, risk of individual NSAIDs, comorbidity, or concomitant use of other nephrotoxic drugs. This is a nested case-control study using the General Practice Research Database from the United Kingdom. Participants were 386,916 patients aged 50 to 84 years on January 1, 1997, and free of known cancer, renal disorder, cirrhosis, or systemic connective tissue disease. After validation of cases identified from this cohort, 103 patients were confirmed as idiopathic cases of ARF and compared with 5,000 controls frequency matched by age and sex. Current users of NSAIDs had a relative risk (RR) for ARF of 3.2 (95% confidence interval [CI], 1.8 to 5.8), and the risk declined after treatment was discontinued. Increased risk was present with both short- and long-term therapy and was slightly greater among users of high doses. History of heart failure (HF), hypertension, diabetes, and hospitalizations and consultant visits in the previous year were all associated with a greater risk for ARF. There was a suggestion of a modification of the effect of NSAIDs in patients with hypertension and those with HF. Use of selected cardiovascular drugs was associated with a 5-fold increase in risk for ARF. Diuretics presented the greatest risk. Risk increased with concomitant use of NSAIDs and diuretics (RR, 11.6; 95% CI, 4.2 to 32.2) and NSAIDs and calcium channel blockers (RR, 7.8; 95% CI, 3.0 to 20.5). NSAID users had a 3-fold greater risk for developing a first-ever diagnosis of clinical ARF compared with non-NSAID users in the general population. NSAIDs should be used with special caution in patients with hypertension and/or HF.

Administered mesenchymal stem cells protect against ischemic acute renal failure through differentiation-independent mechanisms

Severe acute renal failure (ARF) remains a common, largely treatment-resistant clinical problem with disturbingly high mortality rates. Therefore, we tested whether administration of multipotent mesenchymal stem cells (MSC) to anesthetized rats with ischemia-reperfusion-induced ARF (40-min bilateral renal pedicle clamping) could improve the outcome through amelioration of inflammatory, vascular, and apoptotic/necrotic manifestations of ischemic kidney injury. Accordingly, intracarotid administration of MSC (approximately 10(6)/animal) either immediately or 24 h after renal ischemia resulted in significantly improved renal function, higher proliferative and lower apoptotic indexes, as well as lower renal injury and unchanged leukocyte infiltration scores. Such renoprotection was not obtained with syngeneic fibroblasts. Using in vivo two-photon laser confocal microscopy, fluorescence-labeled MSC were detected early after injection in glomeruli, and low numbers attached at microvasculature sites. However, within 3 days of administration, none of the administered MSC had differentiated into a tubular or endothelial cell phenotype. At 24 h after injury, expression of proinflammatory cytokines IL-1beta, TNF-alpha, IFN-gamma, and inducible nitric oxide synthase was significantly reduced and that of anti-inflammatory IL-10 and bFGF, TGF-alpha, and Bcl-2 was highly upregulated in treated kidneys. We conclude that the early, highly significant renoprotection obtained with MSC is of considerable therapeutic promise for the cell-based management of clinical ARF. The beneficial effects of MSC are primarily mediated via complex paracrine actions and not by their differentiation into target cells, which, as such, appears to be a more protracted response that may become important in late-stage organ repair.

Clinical Acute Renal Failure: Diagnosis and Management

Acute renal failure (ARF) is frequently encountered in the hospitalized setting. In this article, we discuss the etiology, pathogenesis, preventative therapies, and renal replacement strategies in patients with acute tubular necrosis, the most common form of hospitalized ARF.

Differential effects of human atrial natriuretic peptide and furosemide on glomerular filtration rate and renal oxygen consumption in humans

Imbalance in the renal medullary oxygen supply/demand relationship can cause hypoxic medullary damage and ischemic acute renal failure. Human atrial natriuretic peptide (h-ANP) increases glomerular filtration rate in clinical acute renal failure. This would increase renal oxygen consumption due to increased tubular load of sodium. Loop diuretics are commonly used in acute renal failure. Data on the effects of loop diuretics on glomerular filtration rate and renal oxygen consumption in humans are, however, controversial. We evaluated the effects of h-ANP and furosemide on renal oxygen consumption, glomerular filtration rate, and renal hemodynamics in humans. Prospective two-agent interventional study in a university hospital cardiothoracic ICU. Nineteen uncomplicated, mechanically ventilated postcardiac surgery patients with normal renal function. h-ANP (25 and 50 ng/kg per minute, n=10) or furosemide (0.5 mg/kg per hour, n=9). Renal plasma flow and glomerular filtration rate were measured using the infusion clearance technique for (51)Cr-labeled EDTA and paraaminohippurate, corrected for by renal extraction of PAH. h-ANP increased glomerular filtration rate, renal filtration fraction, fractional excretion of sodium, and urine flow. This was accompanied by an increase in tubular sodium reabsorption (9%) and renal oxygen consumption (26%). Furosemide infusion caused a 10- and 15-fold increase in urine flow and fractional excretion of sodium, respectively, accompanied by a decrease in tubular sodium reabsorption (-28%), renal oxygen consumption (-23%), glomerular filtration rate and filtration fraction (-12% and -7%, respectively). The filtered load of sodium is an important determinant of renal oxygen consumption. h-ANP improves glomerular filtration rate but does not have energy-conserving tubular effects. In contrast, furosemide decreases tubular sodium reabsorption and renal oxygen consumption and thus has the potential to improve the oxygen supply/demand relationship in clinical ischemic acute renal failure.

Proximal tubular cytochrome c efflux: Determinant, and potential marker, of mitochondrial injury

Cytochrome c (cyt c) is released from mitochondria after tissue injury, but little is known of its subsequent fate. This study was undertaken to ascertain: (1) does cyt c readily gain access to the extracellular space; (2) if so, what are some determinants of this process; and (3) might cyt c release be a potentially useful marker of in vivo tissue damage. Isolated mouse proximal tubules (PT) were subjected to site 1 (rotenone; Rot), site 2 (antimycin A, AA), or site 3 (hypoxic) respiratory chain blockade (+/- 2 mmol/L glycine, to prevent plasma membrane disruption/cell death). Alternatively, oxidant injury was imposed (Fe(2+) or cholesterol oxidase). Extra- and intracellular cyt c levels were quantified by Western blot. Plasma or urine cyt c levels were also determined after rhabdomyolysis or ischemic acute renal failure (ARF) (in mice), or clinical ARF. AA, Rot, and hypoxia caused variable degrees of PT cyt c release (AA >> rot approximately hypoxia), but at most, <20% of total cell content was involved. In contrast, Fe(2+) evoked approximately 65% cyt c efflux, and cholesterol oxidation caused approximately 100% cyt c release. Glycine did not block cyt c efflux, dissociating this process from plasma membrane disruption/necrotic cell death. After rhabdomyolysis, plasma cyt c levels rose and correlated with the severity of ARF (r, 0.93 vs. BUNs). Cyt c was detected in urine after both experimental and clinical ARF. Cell cyt c release is dependent on the site and the type of mitochondrial injury sustained. Oxidative injury, in general, and cholesterol oxidation, in particular, seem particularly relevant in this regard. After mitochondrial release, cyt c traverses plasma membranes, eventuating in the extracellular space. The data suggest that plasma and/or urine cyt c appearance might function as a clinically useful in vivo marker of mitochondrial stress and the tissue injury sustained.

Single injection of naked plasmid encoding hepatocyte growth factor prevents cell death and ameliorates acute renal failure in mice.

Hepatocyte growth factor (HGF) is a pleiotrophic factor that plays an important role in tissue repair and regeneration after injury. The expression of both HGF and its c-met receptor genes is rapidly upregulated after acute renal injury induced by folic acid. In this study, the role of exogenous HGF in preventing acute renal failure by systemic administration of naked plasmid containing human HGF cDNA driven under the cytomegalovirus promoter (pCMV-HGF) was examined in mice. Intravenous injection of pCMV-HGF plasmid produced substantial levels of human HGF protein in mouse kidneys. Simultaneous injection of HGF plasmid DNA significantly ameliorated renal dysfunctions and accelerated recovery from the acute injury induced by folic acid. Of interest, preadministration of HGF plasmid 24 h before folic acid injection dramatically protected renal epithelial cells from both apoptotic and necrotic death and preserved the structural and functional integrity of renal tubules. Expression of HGF transgene activated protein kinase B/Akt kinase and preserved prosurvival Bcl-xL protein expression in vivo. These results indicate that a single, intravenous injection of naked plasmid containing HGF gene not only promotes renal regeneration after injury but also protects tubular epithelial cells from the initial injury and cell death in the first place. These data suggest that HGF gene therapy may provide a new avenue for exploring a novel therapeutic strategy for clinical acute renal failure.

A trial of thyroxine in acute renal failure

A trial of thyroxine in acute renal failure. Acute renal failure (ARF) remains a serious medical problem with a high mortality rate. Efforts to shorten the course of ARF might reduce this mortality. Since thyroxine has been shown in experimental models to shorten the course of ARF, we designed a trial to determine if a defined course of thyroxine would alter the course or change the mortality of clinical ARF. A prospective, randomized, placebo-controlled, double-blind trial of thyroxine was carried out in patients with ARF. End points were the percentage requiring dialysis, the percentage recovering renal function, time to recovery, and mortality. Fifty-nine patients were randomized to receive either thyroxine or placebo. The groups were well matched in terms of basal and entry creatinines, age, sex, APACHE II scores at entry, and percentage oliguric. Baseline thyroid functions, including T3, T4, rT3, and thyroid stimulating hormone (TSH) levels, were equal between the two groups and typical of patients with euthyroid sick syndrome. Thyroxine resulted in a progressive and sustained suppression of TSH levels in the treated group, but had no effect on any measure of ARF severity. Mortality was higher in the thyroxine group than the control group (43 vs. 13%) and correlated with suppression of TSH. In contrast to the beneficial effects seen in experimental ARF, thyroxine has no effect on the course of clinical ARF and could have a negative effect on outcome through prolonged suppression of TSH. Critically ill euthyroid sick patients should not be replaced with thyroid hormone.

Endotoxemia, Renal Hypoperfusion, and Fever: Interactive Risk Factors for Aminoglycoside and Sepsis-Associated Acute Renal Failure

Sepsis and aminoglycoside administration remain leading causes of clinical acute renal failure (ARF). In recent years, a number of experimental studies from different laboratories have indicated that specific components of the septic state, most notably fever, endotoxemia, and renal hypoperfusion, can interact to induce synergistic renal damage, acting in concert to produce acute tubular necrosis and ARF. If sepsis-associated ARF has a multifactorial basis, then a number of interventions directed at one or more of its etiologic components could confer protection. In this brief review, evidence to support these pathophysiological and therapeutic considerations are presented.

A clinicopathological study of 17 cases recovered from acute tubular necrosis

Renal biopsy specimens of 17 cases recovered from clinical acute renal failure (ARF) and subsequent pathological acute tubular necrosis (ATN) were analyzed clinicopathologically. The cases were divided into two groups: 11 patients who underwent hemodialysis (HD group) and 6 patients who did not need hemodialysis (non-HD group). The varied histopathological findings were assessed by scoring as parameters and were compared between the two groups and with severity of the clinical conditions as well. Among the histopathological parameters, tubulorrhexis and cell infiltration, mainly composed of lymphocytes, in the interstitium as well as in the tubules were significantly marked in the HD group, while other parameters such as necrosis, flattening, vacuolization and regeneration of the tubular epithelial cells and presence of casts were not necessarily significant. Tubulorrhexis were supposed to reflect the severity of the attack factors on the kidney which had caused ARF and subsequent ATN, and to have caused in turn prolongation of the recovery of the impaired renal function. Cell infiltration, which was divided into 4 types according to the corresponding conditions, might probably have affected the prolonged recovery in the HD group. In 8 cases which could be followed up for 2 years, non showed aggravation of the renal function.

Experimental studies on the elevation of urinary enzyme activities and its pathogenesis in acute renal failure

The urinary activities of N-acetyl-beta-D-glucosaminidase (NAG), gamma-glutamyl transpeptidase (gamma-GTP) and alanine aminopeptidase (AAP) are known to elevate markedly in initial phase of clinical acute renal failure (ARF). This study was performed to clarify the pathophysiological mechanism of the activation of these enzymes using experimental postischemic reperfusion ARF in rats. The relation between the levels of the lysosomal enzymes and lipid peroxidation induced by oxidant stress in these animal models was the main focus of this study. Renal ischemia was made by clamping renal artery for 30 minutes to create a complete ischemia and reflow. Catheterized urine was collected to measure changes of the activities of NAG. gamma-GTP and AAP from 60 to 480 minutes after reperfusion of the kidney. The activities of renal tissue glutathione peroxidase (GSH-Px), NAG and gamma-GTP, and the values of renal contents of glutathione (GSH) and malondialdehyde (MDA) were measured in each sample. It is already known that GSH redox cycle plays an important role in removing various hydroperoxides induced by oxidant stress, generating oxidated GSH from GSH in scavenging process. In order to confirm if GSH plays an important role in intrinsic anti-oxidant system in this model, buthionine sulfoximine (BSO) which is gamma-glutamylcysteine synthetase inhibitor, was administered intraperitoneally to decrease renal GSH contents before the procedure renal ischemia. The following results were obtained; 1) urinary activities of NAG, gamma-GTP and AAP were elevated markedly in GSH depleted rats compared with controls, 2) renal tissue activities of NAG were higher in BSO administered rats than controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial natriuretic peptide and dopamine in a rat model of ischemic acute renal failure

Atrial natriuretic peptide (ANP) has been shown to reverse experimental models of ischemic acute renal failure (ARF). However, infusion of ANP has been associated with systemic hypotension making its use in clinical ARF impractical. Therefore, in this investigation, dopamine (D) was combined with intravenous (i.v.) atriopeptin III (AP III) to determine if this regimen was effective in reversing ARF while preventing systemic hypotension and maintaining renal blood flow (RBF). Four groups of Munich-Wistar rats were studied. Group 1, sham-ARF; Group 2, renal artery (RA) clamp (55 min) followed by i.v. saline; Group 3, RA clamp followed by i.v. AP III-D; and Group 4, RA clamp followed by i.v. D only. All infusions were begun after RA clamp release and continued for four hour. Mean arterial pressure in Group 3 rats given AP III-D were similar to that in Group 2, slightly less than that in Groups 1 and 4 (P less than 0.05), but consistently greater than 100 mm Hg during the four hour infusion. RBF in Group 3 was elevated above the level in Group 1 at P less than 0.05. Glomerular filtration rate (GFR), depressed by 52% in Group 2, was corrected to control (sham-ARF) levels in Group 3. In Group 4 there was a small but significant increase in GFR compared to Group 2 (P less than 0.05), but it remained less than that in sham-ARF or AP III-D treated ARF rats (P less than 0.01). Urine flow rate and urine sodium excretion rate were more than sixfold higher in Group 3 than any other group.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathophysiological aspects of experimental and clinical acute renal failure.

SummaryIn this paper, the 4 major pathogenetic mechanisms of acute renal failure, arc critically reviewed. It is highly probable that in the ischemic models, both tubular obstruction and tubular back leakage play a dominant role; on the other hand, in the nephrotoxic models, hemodynamic intrarenal changes as preglomerular vasoconstriction and/or changes in Kfare more important, especially in the early initiation phase of these models. The tubular lesions occurring in established ARF, lead to failure of urinary concentration and decrease in tubular sodium reabsorption and are reflected in changes in urinary composition.The urinary parameters, especially fractional excretion of sodium (FENa) and renal failure index (RFI) can be used in the differential diagnosis between prerenal and renal failure. However, in clinical ARF where tubular obstruction plays a major role, both the FENa and RFI can be low.

急性腎不全犬の体液分布と電解質,浸透圧に関する実験的研究

Experimental ischemic acute renal failure was made in 20 dogs by occulusion of the renal artery for one and half or two hours. Other 6 dogs were used for the control values of the distribution of the body water. 20 dogs. were raised under controlled intravenous infusion, and electrolytes, ureaN, osmotic pressure in both plasma and urine were measured for three days, and they were devided into two groups after three days according to the volume of the urine; 11 dogs, showing almost anuric (less than 2ml/kg/day)-anuric group, and 9 dogs getting urinary output more than 5ml/kg/day (average 20ml/kg/day)-urinary group.Total body water (TBW), extracellular water (ECW), intracellular water (ICW), interstitial water (ISW) and circulating plasma volume (PV) were measured with NAAP, 35S-Na2SO4 and 131I-RISA.Results were as follows:1. In the anuric group, there was no difference in TBW and distribution of body water from control values.2. In the urinary group, TBW, ICW and U/P ratio of osmotic pressure and ureaN markedly decreased.3. Pottasium, ureaN, osmotic pressure and total protein in the plasma increased in both groups, especially in the anuric group.4. K/Na ratio of the urine in the urinary group, which is said to indicate the activity of aldosterone was not increased as proposed.5. In the diuretic stage of the clinical acute renal failure, the water for massive urinary output surpassing fluid intake may be from the intracellular fluid compartment.

The renal lesion associated with hemoglobinemia. I. Its production and functional evolution in the rat.

A method is presented for the production of a reproducible and reversible renal lesion in the rat by the intravenous injection of a relatively small amount of homologous hemoglobin (40 mg/100 g body weight). Production of the lesion is dependent on prior water deprivation and its severity is related to the degree of dehydration. Ether anesthesia, at the time of hemoglobin injection, predisposes to a severe and reproducible functional defect in the dehydrated rat. In contrast, injection of hemoglobin during pentobarbital anesthesia results in a significant lesion only sporadically. The functional evolution of the lesion has been characterized by inulin clearance measurements. Functional impairment occurs abruptly, within 1 hr after hemoglobin injection, and persists unchanged over the ensuing several hours. Some increase in inulin clearance rate is usually observed at 24 hr after injection, but severe functional impairment persists. Between 24 and 72 hr, a considerable increase in inulin clearance rate occurs, so that only moderate restriction of excretory function is present at the latter time. A further moderate increase in inulin clearance rate is apparent at 7 days after hemoglobin injection, but some reduction in function. persisted in all rats studied at this time. Hemoglobinuria is slight or inapparent in animals manifesting the most marked depression of excretory function, indicating that a severe renal lesion may exist in the absence of visible urinary pigment. Hemoglobinemia is evanescent at the dosage used in this study. These observations suggest that clinical acute renal failure secondary to hemoglobinemia may readily go unrecognized and that this may be a more frequent association than is now appreciated.