Management Of Acute Renal Failure Research Articles

4. Management of Acute Renal Failure

4. Management of Acute Renal Failure

On the Mechanisms Underlying Poisoning-Induced Rhabdomyolysis and Acute Renal Failure

ABSTRACTThe clinical syndrome of rhabdomyolysis is caused by injury of skeletal muscles resulting in release of intracellular muscle constituents. Drug poisoning is one of the causes of severe rhabdomyolysis. Severe electrolyte disorders and acute renal failure may occur in rhabdomyolysis, leading to life-threatening situations. Early initiation of renal replacement therapy can help improve outcome.In the present retrospective study, medical records of 181 patients suspected of rhabdomyolysis from Loghman-Hakim Hospital in the period of 2004 to 2005 were reviewed. A creatinine phosphokinase (CPK) value of greater than five times normal (≥975 IU/L) was the basis for confirmation of a rhabdomyolysis diagnosis. An increased serum creatinine level of more than 30% was the basis for acute renal failure diagnosis.Out of 156 patients, 100 were male with an age range of 13 to 78 years. One hundred and two (92%) patients had CPK >975 U/L, and 36 patients (28.6%) had a 30% or more increase in their creatinine level during their admission days. Mean fluid intake was the same in patients with renal failure and those without renal failure. In 8.3% of the cases, multiple drug poisoning was observed. The most common compound overdose associated with rhabdomyolysis was opium.It is concluded that fluid therapy alone is not adequate in the management of acute renal failure in rhabdomyolysis. Therefore, other etiological factors are involved that remain to be elucidated by further studies.

Shortened Hemofilter Survival Time due to Lipid Infusion in Continuous Renal Replacement Therapy

Background: Continuous renal replacement therapy is widely used for the treatment of critically ill patients with acute renal failure in critical care units. The survival time of the extracorporeal circuit is an important factor in providing renal replacement therapy. Despite rigorous efforts to maintain hemofilter patency, clinicians are occasionally faced with an unexplained short circuit survival time. Methods: We present a critically ill patient undergoing continuous venovenous hemofiltration with regional citrate anticoagulation for management of acute renal failure in the context of sepsis. Once the patient was started on lipid infusion as part of total parenteral nutrition, we observed a shortened circuit survival due to premature hemofilter failure necessitating frequent changes of the hemofilter. The known potential causes for this phenomenon were ruled out. Results: Evaluation revealed grossly lipemic serum associated with severe hypertriglyceridemia. Discontinuation of the lipid infusion was followed by a rapid return of circuit survival time to its baseline. Evaluation of the hemofilter by electron microscopy revealed that the rapid blockage of the hollow fibers was caused by lipid microparticles and fibrin deposits. Conclusion: Since total parenteral nutrition is commonly administered to malnourished and hypercatabolic critically ill patients on continuous renal replacement therapy, we suggest that intravenous lipid therapy might be a previously unreported and unappreciated remediable cause of premature hemofilter failure.

Successful management of acute renal failure with a vaginal pessary: a case report

Persistent uterine prolapse with secondary acute renal failure is a very uncommon event. We report the case of a 77-year-old woman with a 5-year history of uterine prolapse. She was referred to our gynecologic oncology service for 3rd degree uterine prolapse and was found to have bilateral hydronephrosis and acute renal insufficiency. The patient was fitted for a pessary to manage the uterine prolapse, which resulted in resolution of her hydronephrosis and renal insufficiency. Prompt assessment with nephrology consultation and pessary placement for patients with 3rd degree genital prolapse is imperative to ensure that irreversible renal complications do not manifest themselves.

Current structure and organization for renal patient assistance in Italy

Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) has compiled a national census of Renal Units (RU) existing in the twenty Italian regions related to the year 2004. An on-line questionnaire including 158 items explored structural and human resources, organization aspects, activities and epidemiological data in SIN, 2004. The census identified 363 public RU, 303 satellite Dialysis Centres (DC) and 295 private DC totalling 961 DC [16.4 per million population (pmp)]. The inpatient renal beds were 2742 (47 pmp). Renal and dialysis activity was performed by 3728 physicians (64 pmp), of whom 2964 (80%) were nephrologists. There was no permanent medical assistance in 41% of satellite DC. There were 1802 renal admissions pmp and 99 renal biopsies pmp. The management of acute renal failure (13 456 cases; 230 pmp) represented a relevant proportion of the activities conducted in public RU. In 2004 there were 9858 new cases of end-stage kidney disease requiring renal replacement therapy (RRT) (169 pmp). On 31 December 2004, 60 058 patients were on RRT (1027 pmp), 43 293 of which (740 pmp) were on dialysis and 16 765 (287 pmp) with renal graft. This census of the Italian RU and DC in 2004 provides decision makers and healthcare stakeholders with detailed data for benchmarking and has financial implications for the public health system. Similar analyses may be conducted in other countries permitting standardization of medical and cost-related aspects of renal care.

Acute renal failure in pediatrics

Acute renal failure is the generic term for an abrupt and sustained decrease in renal function resulting in retention of nitrogenous and non nitrogenous waste product. This may results in life threatening consequences including volume overload, hyperkalemia, and metabolic acidosis. Acute renal failure is both common and carries high mortality rate, but as it is often preventable, identification of patients at risk and and appropriate management are crucial. This review summarized the most recent information on definition, epidemiology, clinical causes and management of acute renal failure in pediatric patients.

Urological management of indinavir-associated acute renal failure in HIV-positive patients

Indinavir, a protease inhibitor that is commonly used to treat HIV infection, may cause crystal formation within the renal tubules when urine pH is above 3.5. Crystallization in the urine may lead to intrarenal crystal deposition and acute renal failure (ARF). To establish the beneficial urological management of acute renal failure caused by indinavir treatment of HIV/AIDS patients. Five HIV positive patients (four men, one woman) with a mean age of 32 years (range 28-36 years) were referred to our Department of Urology from an AIDS outpatient Clinic, because of the development of postrenal acute renal failure with continuously elevated creatinine and urea plasma levels after indinavir therapy. Among the initial therapeutic maneuvers, indinavir administration was interrupted for 1 week while bilateral double-J ureteral stents were inserted in all the HIV/AIDS patients, during the first 24-72 h to secure upper-tract drainage. Concurrently urine has been acidified by oral administration of the amino acid L: -methionine and oral fluid intake was increased. All the patients responded well to the treatment and their renal function was effortlessly restored to normal within a few days. HIV-positive patients receiving indinavir therapy might be complicated by acute renal failure, mainly due to intrarenal crystal deposition (tubules) or urolithiasis (postrenal obstruction). This adverse effect may simply manage by the discontinuation of indinavir administration, urine acidification, as well as the possible early insertion of bilateral double-J ureteral stents.

Could Uric Acid Have a Role in Acute Renal Failure?

Acute renal failure (ARF), induced by either toxins or ischemia, is associated with significant morbidity. The pathogenesis of ARF is complex and is characterized by renal vasoconstriction and oxidative stress in association with tubular and microvascular injury and interstitial inflammation. In many situations, ARF is associated with a rise in serum uric acid as a result of both increased generation and decreased excretion. Although it is widely recognized that markedly elevated levels of uric acid can cause ARF via supersaturation within the tubules with crystallization and intrarenal obstruction ("acute urate nephropathy"), the possibility that uric acid may affect renal outcomes at concentrations that do not lead to tubular obstruction have not been considered. This article reviews both the salutary and the adverse effects of uric acid on biologic processes and presents the hypothesis that hyperuricemia, particularly if chronic and marked, likely represents a true risk factor for ARF. Hyperuricemia also may account for the paradoxic lack of benefit of diuretics in the management of ARF. It is suggested that studies are needed to investigate the role of chronic hyperuricemia on renal outcomes after acute tubular injury.

The Role of Continuous Renal Replacement Therapy in the Treatment of Poisoning

Extracorporeal elimination of drugs and toxins is a critical component in the management of poisonings, though specific techniques and indications remain a matter of debate. Conventional hemodialysis is frequently the treatment of choice because of its widespread availability and proven effectiveness for certain drugs and toxins. With the increased availability of continuous renal replacement therapy (CRRT) modalities, there is yet another therapeutic option, but one that has yet to find a definitive role in this field. The continuous nature of these therapies is attractive for the management of acute renal failure, but the relatively slower clearance rates as compared to conventional hemodialysis is a distinct drawback in patients with acute xenobiotic-induced toxicity. There are abundant case reports as well as a few small case series in the medical literature documenting the use of CRRT, but specific techniques and the clinical outcomes vary considerably. Therefore one cannot draw definitive conclusions regarding benefit. Some patients, particularly those who are hemodynamically unstable and are not candidates for conventional hemodialysis, may warrant a trial of CRRT. However, at the present time, routine use for the treatment of poisoning is not supported. Controlled trials to better clarify its role would be beneficial, though such studies would be extremely difficult to conduct in this field. We believe that the intelligent application of extracorporeal modalities requires a thorough knowledge of drug pharmacokinetics, of the techniques utilized, and a skeptical analysis of the available literature.

Evidence based practice guidelines for the nutritional management of chronic kidney disease

The purpose of these guidelines is to provide dietitians in Australia and New Zealand with a summary of evidence based clinical guidelines related to the dietetic management of adult patients with chronic kidney disease. The patient target group is any adult patient fulfilling the definition and diagnostic criteria of Chronic Kidney Disease (CKD), excluding those with nephrotic syndrome. These guidelines by definition also exclude acute renal failure and transplantation. The clinical questions were as follows: • At what level of glomerular filtration rate (GFR) should patients be referred to the dietitian in order to maximise nutritional intervention opportunities? • Which specific measures best reflect nutritional status or change in nutritional status in CKD? • What are the goals of nutrition intervention for CKD? • What is (are) the appropriate nutritional intervention(s) to optimise nutritional status in CKD and prevent malnutrition? • What is the optimal method of implementation and follow up to ensure nutritional status is maintained or improved? These guidelines are meant to serve as a general framework for handling patients with particular health problems. It may not always be appropriate to use these guidelines to manage clients because individual circumstances may vary. The independent skill and judgement of the health care provider must always dictate treatment decisions. These guidelines for practice are provided with the express understanding that they do not establish or specify particular standards of care, whether legal, medical or other. 1

Utilizing audit to evaluate improvements in continuous veno‐venous haemofiltration practices in intensive therapy unit

Continuous veno-venous haemofiltration (CVVH) is used regularly in the management of acute renal failure in intensive therapy unit (ITU). A three-staged approach was undertaken involving two audits of practice to improve CVVH record keeping in a 15-bedded cardiac ITU. An initial baseline audit identified a number of areas for improvement in practice. The areas for improvement were implemented then a second audit was repeated. The improvements and practice changes included the dissemination of audit findings to the multidisciplinary team, redesigning the prescription chart to a more user-friendly format and the development of a competency-based CVVH workbook. This nurse-led project demonstrated how positive outcomes and improvements could be achieved with record keeping across the multidisciplinary ITU team.

Implementing a standardized safety procedure for continuous renal replacement therapy solutions

Acute renal failure has been estimated to occur in about 15% of hospitalized patients in the United States.[1][1] The management of acute renal failure is complex and multimodal.[2][2],[3][3] One method frequently used to treat these patients with acute renal failure is continuous renal replacement

Management of acute renal failure in the newborn

Acute renal failure is common in the neonatal period. It is usually manifest by abnormal biochemistry and decreased urine output (<1 ml/kg/h), but non-oliguric renal failure is also common. A detailed understanding of the common pathophysiological mechanisms is rarely needed but an understanding of the common aetiologies (pre-renal, renal and post-renal) will enable the clinician to approach the problem in a logical manner. A standard approach to fluid and electrolyte management is described, along with a practical approach to the investigation and management of renal failure. A working understanding of the principles of peritoneal dialysis is important and a brief overview of the role of haemodialysis in neonatal renal failure is provided.

Page kidney: successful radiological management of acute renal failure

Sir, Page kidney is the external compression of a kidney. The condition is usually caused by a subcapsular haematoma, associated with high blood pressure and occasional renal failure, as described by Irwin Page in an animal model with cellophane papers wrapped round the kidney in 1939 and, subsequently, clinically in 1955 [1,2]. The present case illustrates, in a patient with a single functioning kidney, the successful management of a spontaneous subcapsular haematoma that was causing both acute renal failure and hypertension. A 36-year-old female presented with a left-sided loin pain. At the age of 2 years she had undergone right nephrectomy for a Wilm’s tumour and left-sided lower lobectomy for pulmonary metastatic disease, followed by chemotherapy and radiotherapy. Six months before presentation, following her first pregnancy, she was diagnosed with dilated cardiomyopathy, for which she was given candesartan, carvedilol and warfarin. She was in pain, with tenderness over the left costovertebral angle. Her blood pressure was 94/57 mmHg. Investigation showed INR 2.7, C-reactive protein 20 mg/l and serum creatinine 136mmol/l. An ultrasound scan revealed a mixed reflective collection, adjacent to the postero-lateral aspect of her left kidney. Spectral Doppler analysis of the segmental arteries within the kidney showed a high-resistance pattern with complete loss of normal diastolic flow; but the renal vein was patent. A non-contrast computed tomography (CT) scan confirmed the finding of a subcapsular haematoma (Figure 1). In the following 48 h she became hypertensive, oliguric and her serum creatinine rose to 508mmol/l. Drainage was arranged. After reversal of anticoagulation, an 8F pigtail catheter was inserted percutaneously into the haematoma under ultrasound guidance and 100 ml sero-sanguineous fluid was drained. Ultrasound after 24 h showed a reduction in size

Practice patterns in the management of acute renal failure in the critically ill patient: an international survey

Several controversies have developed over acute renal failure (ARF) definition and treatment: which approach to patient care is most desirable and which form of renal replacement therapy (RRT) should be applied is an everyday matter of debate. There is also disagreement on clinical practice for RRT including the best timing to start, vascular access, anti-coagulation, membranes, equipment and finally, if continuous or intermittent techniques should be preferred. In this lack of harmony, the epidemiology of ARF has recently displayed an outbreak of cases in the intensive care units and nephrologists and intensivists are now called to work together in the case of such a syndrome. We report on the responses of 560 contributors, mostly coming from Europe, to a questionnaire submitted during the third International Course on Critical Care Nephrology held in Vicenza, Italy in June 2004. The questionnaire was divided into several sections concerning demographic and medical information, definition of ARF, practice of RRT, current opinions about clinical advantages and problems related to different RRTs and modalities, and beliefs on alternative indications to extracorporeal treatments. More then 200 different definitions of ARF and about 90 RRT start criteria were reported. Oliguria and RIFLE (an acronym classifying ARF in different levels of severity: Risk of renal dysfunction; Injury to the kidney; Failure of kidney function; Loss of kidney function; End-stage kidney disease.) were the most frequent criteria used to define ARF. In 10% of centres all forms of renal replacement techniques are available, and in 70% of cases two or more different techniques are available: absolute analysis of different techniques showed that continuous renal replacement therapies are utilized by 511 specialists (91%), intermittent haemodialysis by 387 (69%) and sustained low efficiency dialysis by 136 (24%). Treatment prescription showed significant differences among specialists, 60% of intensivists being uncertain on RRT dose prescription compared to 40% of nephrologists (P = 0.002). The most frequently selected dosage was '35 ml/kg/h' for urea (25%) and creatinine targets (26%), and '2-3 l/h' for the septic dose (25%). Of the participants, 90% said that they used RRT for non-renal indications, 60% although responders admitted the lack of scientific evidence as a limiting factor to its use. New classifications such as RIFLE criteria might improve well-known uncertainty about ARF definition. Different RRT techniques are available in most centres, but a general lack of treatment dose standardization is noted by our survey. Non-renal indications to RRT still need to find a definitive role in routine practice.

Consensus development in acute renal failure: the Acute Dialysis Quality Initiative

Although acute renal failure is both common and highly lethal in the intensive care unit, our understanding of the epidemiology and pathophysiology of acute renal failure is limited, and treatment for acute renal failure is extremely variable around the world. The general lack of consensus with regard to definitions, prevention, and treatment of acute renal failure has limited progress in this field. Consensus in acute renal failure requires establishing a framework in which intensivists, nephrologists, pharmacologists, and others who care for critically ill patients with or at risk for acute renal failure can reach consensus and develop evidence-based practice guidelines. The Acute Dialysis Quality Initiative seeks to provide an objective, dispassionate distillation of the literature and description of the current state of practice of dialysis and related therapies as they are applied to acutely ill patients. The purposes of Acute Dialysis Quality Initiative are first, to develop a consensus of opinion, with evidence where possible, on best practice; and second, to articulate a research agenda to focus on important unanswered questions. Broad consensus in the diagnosis and management of acute renal failure and in the use of blood purification in nonrenal critical illness is achievable. Standardization of definitions, practice, and research methodology is urgently needed, and specific proposals have been made by an international, interdisciplinary group.

The Outcome of Acute Renal Failure in the Intensive Care Unit According to RIFLE: Model Application, Sensitivity, and Predictability

The definition, classification, and choice of management of acute renal failure (ARF) in the setting of the intensive care unit (ICU) remain subjects of debate. To improve our approach to ARF in the ICU setting, we retrospectively applied the new classification of ARF put forward by the Acute Dialysis Quality Initiative group, RIFLE (acronym indicating Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal failure), to evaluate its sensitivity and specificity to predict renal and patient outcomes. RIFLE classification was applied to 183 patients with ARF admitted to the ICU (2002 to 2003) at the Northern General Hospital, Sheffield, UK. Patients were divided into 4 groups according to percentage of decrease in glomerular filtration rate from baseline. The risk group included 60 patients; injury group, 56 patients; failure group, 43 patients; and control group, 24 patients. Demographic, biochemical, hematologic, clinical, and long-term health status were studied and compared in the 4 groups. An attempt was made to evaluate, by means of logistic regression analysis and receiver operator characteristic curve analysis, the predictive value of RIFLE classification for mortality in the ICU. The failure group showed the worst parameters with regard to Acute Physiology and Chronic Health Evaluation (APACHE) II score, pH, lowest and highest mean arterial pressures, and Glasgow Coma Scale (P < 0.001). Mortality rate in the ICU (1 month) was significantly greater in the failure group compared with all groups (32 of 43 patients [74.4%]; P < 0.001) and, again, 6-month mortality rate (37 of 43 patients [86%]; P < 0.001). Receiver operator characteristic curve analysis showed that Simplified Acute Physiology Score (SAPS) II was more sensitive than APACHE II score for prediction of patient death in the risk and injury groups compared with the failure and control groups (risk group: SAPS II, 0.8 +/- 0.06; P < 0.001; APACHE II, 0.63 +/- 0.07; P = 0.14; injury group: SAPS II, 0.76 +/- 0.08; P < 0.001; APACHE II, 0.72 +/- 0.07; P = 0.006). RIFLE classification can improve the ability of such older and established ICU scoring systems as APACHE II and SAPS II in predicting outcome of ICU patients with ARF.

Acute renal failure in pregnancy

To provide an evidence-based, up-to-date review of the literature regarding the assessment and management of acute renal failure that may affect women during pregnancy and the postpartum period. A review of the current literature was performed. Acute renal failure is a rare complication of pregnancy but is associated with significant morbidity and mortality. Management requires knowledge of the renal physiologic changes occurring in pregnancy and the relevant diagnoses, both pregnancy-specific and those that may coincidentally occur with pregnancy. In addition, fetal effects must be taken into consideration. Ideal care for women with acute renal failure in pregnancy or postpartum requires a multidisciplinary approach that may include maternal-fetal medicine, critical care medicine, nephrology, and neonatology specialists.

Peritoneal dialysis in the management of acute renal failure in 5 dogs with leptospirosis

AbstractObjective: To describe the use of peritoneal dialysis (PD) in the management of 5 dogs with acute renal failure (ARF) caused by leptospirosis.Case Series Summary: All dogs were treated for leptospirosis with intravenous (IV) fluids and ampicillin prior to PD. Median age of dogs was 5 years (range 2–6 years). All dogs had positive titers for Leptospira bratislava. Median duration of PD was 4 days (range 3–16 days). PD resulted in a decrease in azotemia in all dogs. Median serum blood urea nitrogen at the start of PD was 192 mg/dL (range 140–235 mg/dL) and at the end of PD was 63 mg/dL (range 48–139 mg/dL). Median serum creatinine at the start of PD and the end was 12.8 mg/dL (range 7.7–16.9 mg/dL) and 3.4 mg/dL (range 1.4–11.1 mg/dL), respectively. Complications identified during PD included hypokalemia (n=3, 60%), hypoalbuminemia (n=2, 40%), hypomagnesemia (n=1, 20%), pelvic limb edema (n=2, 40%), central nervous system signs (n=2, 40%), dialysate retention (n=1, 20%), and leakage from the catheter site (n=1, 20%). Peritonitis was not identified in any of the dogs. Four dogs (80%) survived to discharge from the hospital. PD was effective for management of uremia in dogs with ARF caused by leptospirosis.

Neonatal Peritoneal Dialysis

After completing this article, readers should be able to: 1. List the indications for peritoneal dialysis (PD) in neonates. 2. Delineate neonates who are poor candidates for PD. 3. Review the parameters of the PD prescription. 4. Review special nutrition considerations for neonates who are undergoing PD. 5. Review potential complications of PD in neonates. Peritoneal dialysis (PD) is generally considered the optimal dialysis modality for neonates. PD allows for the slow removal of fluid and solutes while avoiding hemodynamic instability. It is technically simple and, when necessary, can be performed continuously in the neonate hospitalized in the neonatal intensive care unit. In this review, we discuss the salient features of neonatal PD, including the rationale and indications for PD, its advantages and disadvantages, the PD prescription, nutritional considerations for the neonate undergoing PD, and the management of peritonitis. ### Rationale and Indications for Dialysis in Neonates Acute renal failure is common, occurring in as many as 23% of neonates hospitalized in neonatal intensive care units. There are excellent reviews in the literature that discuss the causes, pathophysiology, and medical management of acute renal failure in the neonate (see Acute Renal Failure Management in the Neonate in this issue of NeoReviews ). A partial list of the causes of acute renal failure in neonates is provided in Table 1. | Prerenal | || | | | Intrinsic | | | | Postrenal | | | Table 1. Causes of Acute Renal Failure The decision to initiate dialysis typically is necessitated by recalcitrant electrolyte abnormalities, worsening uremia, fluid overload, persistent acid-base abnormalities, …