Management Of Acute Renal Failure Research Articles

Has mortality from acute renal failure decreased? A systematic review of the literature

Purpose To determine mortality rates in patients with acute renal failure during the past decades. Methods We performed a MEDLINE search using the keywords “acute renal failure” crossed with “outcome,” “mortality,” “ICU,” “critically ill” or “prognosis” in the period from January 1970 to December 2004. Abstracts and full articles were eligible if mortality rates were reported. We also reviewed the bibliographies of available studies for further potentially eligible studies. The dates of the observation period for each study and not the publication dates were considered for the analysis, so the earliest data were from 1956. Results Of 85 articles fulfilling the criteria, 5 were excluded because of duplicate publications using the same database, so that 80 were included in our review with a total of 15 897 patients. Mortality rates in most studies exceeded 30%, and there was no consistent change over time. Conclusion Despite technical progress in the management of acute renal failure over the last 50 years, mortality rates seem to have remained unchanged at around 50%.

Acute Renal Failure Management in the Neonate

After completing this article, readers should be able to: 1. Define the types and delineate the causes of acute renal failure (ARF) in neonates. 2. Describe the laboratory tests and imaging studies used to diagnose ARF. 3. Explain the roles of fluid balance, diuretics, dopamine, and nutrition in the management of neonatal ARF. 4. Describe the approaches to treating hyponatremia, hyperkalemia, calcium-phosphorus perturbations, acidosis, and hypertension in ARF. 5. Review the outcome and prognosis for ARF in neonates. Acute renal failure (ARF) is a very common problem in the neonatal intensive care unit. The newborn kidney has a very low glomerular filtration rate (GFR) that is maintained by a delicate balance between vasoconstrictor and vasodilatory forces. (1) Although sufficient for growth and development under normal conditions, the low GFR of the newborn kidney limits postnatal renal functional adaptation to endogenous and exogenous stresses. (2) This limited response predisposes the newborn to the development of ARF and is even more pronounced in the low birthweight infant (ie, <2,500 g due to preterm birth or intrauterine growth restriction). (3) Given this predisposition, early identification of ARF in the neonate is essential to preserving renal function. The true incidence of neonatal ARF is difficult to ascertain, but studies have reported that 8% to 24% of newborns admitted to the neonatal intensive care unit present with ARF. These percentages are likely an underestimation because many cases of nonoliguric neonatal ARF, which occurs commonly in sick neonates, are excluded. (1) ARF is defined as a sudden decrease in GFR that results in the progressive retention of creatinine and nitrogenous waste products and the inability to regulate fluid and electrolyte homeostasis. The definition of ARF in neonates is less precise because the serum creatinine shortly after birth is a reflection of maternal renal function, usually less than 1.0 mg/dL (88.4 …

The diagnosis of acute renal failure in intensive care: mongrel or pedigree?

Acute renal failure is common in the intensive care unit; it is well recognised that patients who develop acute renal failure have a high mortality rate. While there have been improvements in the management of acute renal failure, the mortality remains high. Acute renal failure is easily diagnosed biochemically and clinically but it is not a single disease entity. It is a syndrome that affects a very heterogeneous population. Studies of acute renal failure and of the impact of renal replacement therapy in intensive care are usually inconclusive, which may be the natural consequence of studying a syndrome. This article focuses on the more uncertain features of acute renal failure, the problems of investigating acute renal failure as a disease and the difficulties of applying the results of a study of a heterogeneous population to the management of individuals.

Perioperative management of renal dysfunction

Neither end-stage nor chronic renal failure are common, but patients with these conditions are significantly more likely to require planned surgical procedures. This contribution discusses the problems that accompany these conditions and strategies to avoid interfering with their treatment or precipitating a deterioration in renal function. It is not always obvious if the renal dysfunction is long-standing or has been precipitated by the surgical problem in patients presenting for emergency surgery who also have renal failure. This review discusses the diagnosis and management of acute renal failure in this setting.

Renal replacement therapy and acute renal failure

Acute renal failure (ARF) is a syndrome that occurs when there is a sudden decline in the glomerular filtration rate. The purpose of this review is to examine new developments and clinical applications of renal replacement therapies including hemodialysis, continuous renal replacement therapy, the bioartificial kidney, and peritoneal dialysis in the management of this complicated syndrome. New developments in hemodialysis include in-line hematocrit monitoring and improved biocompatible dialyzer membranes. While recent studies indicate that increased delivery of dialysis improves the outcome of patients with ARF, the optimal regimen of intermittent dialysis or continuous renal replacement therapy remains to be determined. The bioartificial kidney, combining hemofiltration with a device containing human tubular cells, is currently in clinical trials and represents another alternative in the management of ARF. In peritoneal dialysis, new solutions using icodextrin may improve fluid removal and blood pressure. The optimal choice of renal replacement therapy depends on many factors. Use of new options in renal replacement therapy and early initiation of dialysis may help to improve survival and outcome of patients with ARF.

Letter to the Editor: Management of Acute Renal Failure Due to Russell's Viper Envenomation: An Analysis on the Reported Thai Cases

Russell's viper (RVV) is an important tropical venomous snake. In severe envenomous cases, acute renal failure (ARF) can be seen. Here, the author performs this ministudy to document the management of ARF among reported Thai patients. A literature review on the papers concerning ARF due to RVV in Thailand was performed. Based on this study, hemodialysis and specific antivenom administration shows more favorable outcome than peritoneal dialysis.

Nutritional management of acute renal failure

Acute renal failure (ARF) is associated with fundamental alterations of metabolism and immunocompetence with the induction of a pro-oxidative and proinflammatory state. Thus, the objectives of nutritional therapy include not only conventional goals such as maintaining lean body mass and stimulating immunocompetence and repair functions, but also mitigating the inflammatory state and improving the oxygen radical scavenging system and endothelial functions. Moreover, pre-existing and/or hospital-acquired malnutrition has been identified as an important factor contributing to the persistent high mortality in acutely ill patients with ARF. A nutritional program for a patient with ARF must consider not only the specific metabolic consequences associated with renal failure and with the underlying disease process, but also the profound alterations in nutrient balances induced by replacement therapy. Nutrient requirements thus may differ widely between individual patients and during the course of disease, and nutrition therapy must be coordinated with renal replacement therapy. Whenever possible, enteral nutrition should be provided in patients with ARF because even small amounts of luminal nutrients will help to maintain intestinal function. Nevertheless, in many patients parenteral nutrition, at least supplementary and/or temporarily, will become necessary. Because of the complex alterations in the use of various nutrients and the impaired tolerance to electrolytes and volume load, metabolic complications of nutritional support frequently occur in patients with ARF. Therefore, nutrition therapy must be more closely monitored in patients with ARF than with other diseases.

Acute renal failure in children and infants

This review provides an overview of various topics related to acute renal failure and summarizes the results of recent advancements of particular significance in the care of children with acute renal failure. Over the past two decades, the treatment and prognosis of children with acute renal failure has notably shifted owing to advances in continuous treatment modalities, improvements in vascular access, and increased acknowledgment and understanding of the importance of optimizing nutritional support. After discussing the various causes of acute renal failure in children and infants, this review focuses on recent advancements in the management of acute renal failure, including acute dialysis modalities and continuous renal replacement therapy.

Utilization of continuous renal replacement therapy in a case of feline acute renal failure

AbstractObjective: To introduce and investigate the application, efficacy, and potential clinical complications of a continuous renal replacement therapy (CRRT) in a feline acute renal failure (ARF) patient.Case summary: A domestic short‐haired cat presented for continued management of ARF of a presumed toxic etiology. Severe azotemia and uremic complications had been identified on initial presentation to a local urgent care facility, and the cat had been referred for renal replacement therapy following approximately 9 hours of conservative management. Continuous venovenous hemodiafiltration was performed over an approximately 25‐hour period, and a significant resolution of the cat's uremic derangements was obtained. Major complications included significant hypothermia and a single episode of hypocalcemia associated with utilization of citrate anticoagulation. All complications identified were readily managed. Following hospital discharge, long‐term medical support was not required, and no evidence of significant illness was noted 6 months following therapy.New or unique information provided: CRRT represents a collection of extracorporeal blood purification techniques that utilize extended treatment periods for gradual, physiologically balanced correction of uremic toxicity. These therapies demonstrate significant promise in the treatment of ARF cats with actual or potential hemodynamic compromise, and prior advances in therapeutic administration have made these techniques readily accessible within the intensive care unit setting.

Survey of the Management of Acute Renal Failure in the Critically Ill in England and Wales

Survey of the Management of Acute Renal Failure in the Critically Ill in England and Wales

Evaluation of Kidney Function in Patients with Acute Renal Failure Using High‐Performance Liquid Chromatography: A Case Report

Accurate measurement of glomerular function rate (GFR) in the setting of acute renal failure is difficult to achieve with current clinical methods, such as measuring plasma creatinine concentration and 24-hour urine creatinine clearance. High-performance liquid chromatography was used to measure GFR directly in a critically ill patient with acute renal failure. This approach involved evaluating the elimination kinetics of nonionic contrast material administered intravenously for radiologic imaging. It required no additional patient exposure to radiographic contrast media and enabled caregivers to determine kidney function accurately in the presence of worsening clinical status and delayed changes in plasma creatinine. This and other methods for more accurate measurement of GFR in patients with acute renal failure may provide the foundation for clinical studies that assess the severity and management of acute renal failure.

Acute Peritoneal Dialysis in Eastern Nepal

B.P. Koirala Institute of Health Sciences is the only dialysis center outside the capital city of Nepal. Although the burden of renal failure in Nepal is high, limited resources and dialysis facilities are the major constraint on management of acute renal failure (ARF) and acute dialysis in chronic renal failure (CRF). In the present study, carried out from January 2000 to June 2002, we looked into the prospect of introducing peritoneal dialysis (PD) to the district hospitals for treatment of ARF and acute dialysis in CRF. We designed a form to evaluate the causes of renal failure and the indications for, complications of, and outcomes of dialysis. During this study, junior doctors in our hospitals completed the forms. Resident doctors were trained to do intermittent peritoneal dialysis (IPD) and were responsible for the carrying out the procedure under supervision, together with a staff nurse. A total of 120 patients underwent IPD during the study period, including 66 men and 54 women. The most common indications for acute dialysis in CRF were metabolic acidosis (56%), uremic encephalopathy (45%), and fluid overload (44%). The most common causes of ARF were acute gastroenteritis (20%), sepsis (20%), and septic abortion (16%). Fifteen patients died of sepsis and multi-organ failure. Lack of dialysis facilities in the geographic periphery means that most patients present late in the course of their disease, as evidenced by severe metabolic acidosis and uremic encephalopathy. Peritoneal dialysis is a simple procedure, easily tolerated by the patient and requiring less expertise than hemodialysis does. Moreover, nursing staff, technicians, and doctors can be easily trained in the technique. Despite certain limitations, PD still has much potential and can be successfully accomplished in district hospitals and less accessible areas.

Management of Acute Renal Failure

Management of Acute Renal Failure

Hypotension during intermittent hemodialysis: new insights into an old problem.

The main indication for renal replacement therapy in critically ill patients is ischemic acute tubular necrosis associated with multiple organ failure requiring mechanical ventilation and catecholamine administration. The kind of renal replacement therapy offering the best hemodynamic tolerance remains debated. Intermittent hemodialysis (IHD) is often viewed by many ICU physicians as inducing hemodynamic instability. The application of recent concepts regarding hemodialysis modalities is able to solve part of this old problem [1]. A major problem with IHD is the direct application of chronic hemodialysis concepts in the management of acute renal failure. This approach is responsible for much of the observed hemodynamic instability and can be minimized by thoughtful planning prior to IHD in the critically ill patient.

Update on dialytic management of acute renal failure.

The potential impact of renal replacement therapy on clinical outcomes in acute renal failure (ARF) remains a subject of ongoing investigation and controversy. This article reviews in depth the clinical trials to date that have examined the effect of dialysis-related variables on outcomes of patients with hospital-acquired ARF. In particular, the role of the dialysis modality, dialyzer characteristics, and dosing strategies are discussed. Clinical trials comparing intermittent hemodialysis (HD) to continuous renal replacement therapies (CRRT) have failed to demonstrate a survival difference when adjusting for disease severity. Similarly, studies evaluating dialyzer membrane biocompatibility and flux properties had no impact on survival. Efforts aimed at measuring dialysis adequacy in patients with ARF receiving HD using urea kinetic modeling are hindered by a lack of understanding of solute kinetics in this setting. However, dosing strategies during CRRT are promising. Finally, the application of cell therapy to the successful substitution of renal function shows promise for the future.

On-line Haemodiafiltration in the Management of Acute Renal Failure

Purpose – Patients with acute renal failure (ARF) offer particular challenges in terms of cardiovascular stability during renal replacement therapy. Targets for small solute clearance are unclear, removal of inflammatory mediators is desirable, and biocompatible membranes are essential. This study examined the impact of using on-line haemodiafiltration (HDF), which combines convective and diffusive transport, with replacement fluid being produced “on-line” from reverse-osmosed water. Methods – Clinical outcomes were examined in all patients presenting with ARF. Initially, management of ARF included daily haemodialysis (4 hours with biocompatible membrane). Subsequently, all patients were managed with on-line HDF using the Gambro AK200 Ultra™, daily for 4 hours. In the initial stages of patient management, CVVH was used in the ICU setting throughout the study period. Pre 1 Pre 2 Post 1 Post 2 Alive (total) 4 9 18 29* Dead 10 5 9 11* Alive on chronic HD 5 8 11 3* Results – A comparison was made between the years prior to (Pre-1 and 2) and following (Post-1 and 2) the change to on-line HDF. (* p < 0.001 vs Pre 1/Pre 2). Conclusions – On-line HDF is a modality that combines cardiovascular stability and significant middle molecule clearance. Using on-line HDF in the management of ARF, there were significant improvements in survival and recovery of renal function.

Novel approaches to the treatment of acute renal failure

Acute renal failure (ARF) occurs frequently in hospitalised patients and is associated with significant morbidity and mortality. Many therapeutic strategies have been undertaken both to prevent acute renal injury and, once ARF occurs, to improve renal function and reduce mortality. Among the available pharmacological options, no specific therapy has been shown to alter the course of ARF. This article reviews the efficacy of several strategies in experimental renal disease and raises the possibility that similar interventions might be available to the clinician in the near future for the prevention and management of ARF. The prospect of these novel strategies, together with the ever-increasing understanding of the complex pathophysiology of ARF, offers the promise of effective and more physiological therapeutic interventions in this new millennium.

Update on Dialytic Management of Acute Renal Failure

Update on Dialytic Management of Acute Renal Failure

Early management and prevention of acute renal failure.

Despite major advances in nutritional support, membrane technology and dialytic techniques, the mortality of patients with acute renal failure (ARF) who require dialysis is still almost 50% (1). Increased patient age and co-morbidity confer a poorer prognosis, and the condition is certainly commoner in this patient group. Hence, one study showed that the age-related annual incidence of ARF increased from 17 per million in adults under 50 years to 949 per million in the 80-89 age group (2). Over 60% of cases of ARF ultimately result from renal hypoperfusion and consequent intra-renal ischaemic damage, which leads to acute tubular necrosis (ATN) (3). Ischaemic ARF may thus result from a diversity of systemic and intra-renal circulatory stresses including acute losses of blood and extra-cellular fluids, from low cardiac output states such as following ischaemic or toxic myocardial damage, and even from drug-induced renal perfusion shutdown (ACE inhibitors, non-steroidal anti-inflammatory agents). Many cases of ARF have a multi-factorial aetiology (e.g. post-surgical sepsis with hypovolaemia, hypotension and injudicious antibiotic use), and these patients, who often have other organ failure, fit into the poorer prognostic category. A large number of patients with ischaemic ARF pass through a phase of potentially reversible pre-renal oliguria; early recognition and prompt, appropriate treatment of these pre-renal factors can prevent progression to established ARF, with the genuine prospect of improved patient morbidity and mortality, and this is the main scope of this article. Early diagnosis in other patients with ARF, such as those with acute inflammatory renal disease (e.g. vasculitis) or urinary tract obstruction, will allow appropriate prompt treatment and the possibility for reversal of the ARF. The following account, which is composed of personal experience, that of colleagues, and the literature (1,4), is not intended to provide a comprehensive guide to the management of ARF, but seeks to highlight important common pitfalls and fundamental principles in the recognition and subsequent preventive treatment of these patients.

Animal models of acute tubular necrosis.

The evaluation and management of acute renal failure in the ICU patient remains a formidable task because of the complexity of this condition. Clinical and physiologic assessment and complementing laboratory and imaging tests are currently insufficient to differ between true renal parenchymal damage (acute tubular necrosis; it is important to realize that this term does not necessarily imply widespread injury, because whole organ dysfunction in humans has often been associated with very limited parenchymal cellular necrosis) and prerenal azotemia (decreased renal blood flow with altered glomerular hemodynamics and subsequently diminished glomerular filtration, without significant epithelial cell injury). Moreover, tubular damage and altered glomerular hemodynamics may coexist or lead to each other, and their relative contribution to the evolving renal dysfunction has not been unequivocally established. The limited data regarding the renal pathology of such patients and the scant information about human morphologic and functional correlates further undermine our knowledge about diagnostic and therapeutic approaches to these patients. Advanced techniques are critically needed to establish noninvasively the dynamic status of renal parenchymal microcirculation and the distribution of intrarenal oxygenation and to identify evolving cellular energy depletion and tubular cell damage. A few technologies are potentially promising, such as blood oxygen level dependent magnetic resonance imaging, positron emission tomography, and kidney injury molecule-1 detection in patients' urine. Because of the difficulties in analyzing the pathophysiology in humans, clinicians continue to rely largely on animal models to guide understanding and rationale for the identification of therapeutic targets. Data from such animal studies are complemented by studies in isolated perfused kidneys, isolated tubules, and tubular epithelial cell cultures. In this report, we summarize some concepts of acute tubular necrosis that have evolved as a result of these studies, evaluate available animal models, and underscore controversies regarding experimental acute tubular necrosis.