Nonoliguric Acute Renal Failure Research Articles

Acute renal failure secondary to spontaneous acute tumor lysis syndrome in myelofibrosis

A 70-year-old man with myelofibrosis developed nonoliguric acute renal failure in association with acute uric acid nephropathy in the absence of chemotherapy or radiotherapy. The patient had an 18-month history of transfusion-dependent myelofibrosis and moderate chronic renal insufficiency. Admission laboratory findings were remarkable for severe hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia with acute deterioration of renal function, consistent with a diagnosis of acute uric acid nephropathy. Treatment, including hemodialysis and allopurinol administration, resulted in clinical improvement with normalization of serum uric acid concentrations and resolution of acute renal failure. With long-term allopurinol therapy, renal function has remained at his previous baseline, and there has been no transformation to acute leukemia. This case represents a rare instance of acute renal failure related to the occurrence of acute uric acid nephropathy associated with myelofibrosis and emphasizes the importance of early recognition and aggressive management, which can lead to recovery of renal function. © 2001 by the National Kidney Foundation, Inc.

Una causa infrecuente de falla renal aguda e ictericia. Leptospirosis: caso clínico y revisión de la literatura

Leptospirosis, a spirochaete, is a zoonosis of worldwide distribution of which human infection is accidental or recreational. The human is usually an accidental host and person to person transmission is extremely rare. It was first described in 1886 by Weil and its diagnosis has been increasing in the last few decades. We report the case of a 14 year old boy who acquired the infection while swimming in infected water. He presented fever, jaundice, thrombocytopenia, meningitis and acute non-oliguric renal failure with mild hypokaliemia and mild metabolic acidosis. He was treated with penicillin with a satisfactory evolution and without complications. Laboratory tests confirmed leptospirosis serotype icterohaemorragia. Leptospirosis should be suspected in febrile patients with jaundice and renal failure.

Reversible Renal Failure in Paroxysmal Nocturnal Hemoglobinuria

A Chinese patient with paroxysmal nocturnal hemoglobinuria (PNH) developed acute nonoliguric renal failure with intercurrent urinary tract infection and hemolysis. There was no evidence of renal vein thrombosis. Renal biopsy showed features of acute tubular necrosis (ATN) and hemosiderosis. Magnetic resonance imaging (MRI) showed characteristic features of renal hemosiderosis. The patient was stabilized with temporary hemodialysis and intravenous fluid. The renal function fully recovered 3 weeks later. We review the literature and summarize the clinical features of this disease entity. To our knowledge, this case is the first to report such disorder with thorough investigation including concomitant diagnostic MRI imaging and renal biopsy.

Amelioration with vessel dilator of acute tubular necrosis and renal failure established for 2 days.

Seventeen Sprague-Dawley rats had ischemic nonoliguric acute renal failure (ARF) induced by vascular clamping resulting in their preischemic blood urea nitrogen (BUN) and creatinine levels of 16 +/- 1 and 0.56 +/- 0.05 mg/dl to increase to 162 +/- 4 and 8.17 +/- 0.5 mg/dl, P < 0.001, respectively, at day 4 of postischemia. Vessel dilator, a 37-amino-acid cardiac peptide hormone (0.3 microg x kg(-1) x min(-1) ip), decreased the BUN and creatinine levels to 53 +/- 17 mg/dl and 0.98 +/- 0.12 mg/dl (P < 0.001) in another seven animals where ARF had been established for 2 days. Water excretion doubled with ARF and was further augmented by vessel dilator. Transthoracic echocardiography revealed left ventricular dilation as a probable cause of the increase in vessel dilator in the circulation with ARF, and vessel dilator infusion reversed this dilation. At day 6 of ARF, mortality decreased to 14% with vessel dilator from 88% without vessel dilator. Acute tubular necrosis was <5% in the vessel dilator-treated rats compared with 25% to >75% in the placebo-treated ARF animals. We conclude that vessel dilator improves acute tubular necrosis and renal function in established ARF.

Treatment of malarial acute renal failure by hemodialysis.

We studied 112 patients with malarial acute renal failure (ARF) during the period 1991-1997 at Bangkok Hospital for Tropical Diseases (Mahidol University, Bangkok, Thailand). Hemodialysis was performed in 101 (90.2%) of these patients. The mean number of times the patients were hemodialyzed was 6.5 (range = 1-27). Ninety-three (83.0%) patients were oliguric and the remainder were nonoliguric. Patients who had oliguric renal failure required more hemodialyses and had more complications than the nonoliguric patients. The oliguric patients had an eight-fold higher risk of requiring six or more hemodialyses (95% confidence interval = 1.2-53.9, P = 0.0008). The overall mortality rate was 10.7% (12 of 112). Eleven of the patients who died were jaundiced and eight of them had cerebral malaria with a Glasgow Coma Score < or = 8. We conclude that hemodialysis is a useful treatment for oliguric and nonoliguric ARF from severe malaria, particularly when initiated early in the course of the illness.

A Case of Nonoliguric Renal Failure After General Anesthesia with Sevoflurane and Desflurane

A Case of Nonoliguric Renal Failure After General Anesthesia with Sevoflurane and Desflurane

Difficult Airway Management in a Patient with Traumatic Asphyxia

Difficult Airway Management in a Patient with Traumatic Asphyxia

Acute Renal Failure in Recipients of Organ Transplantation and Nontransplantation Patients: Comparison of Characteristics and Mortality

Mortality from acute renal failure in critically ill patients remains in excess of 50% despite decades of improvement in supportive care. It is not known whether replacement of other failing organs by non-renal organ transplantation affects mortality in acute renal failure. We retrospectively reviewed the course of 169 patients with acute renal failure managed at a single university medical center over a 1-year period. Measures of disease severity (need for renal replacement therapy, mechanical ventilation or parenteral nutrition, presence of oliguria and APACHE II scores) and final outcome were compared in 97 patients with acute renal failure who did not receive transplants and 72 patients with acute renal failure who underwent non-renal solid organ transplants. Overall mortality was 50.3% and directly correlated with APACHE II score. Compared to nontransplant patients, transplant recipients were younger, more frequently male, and less often oliguric; but the groups were similar in mean APACHE II scores and need for renal replacement therapy, prolonged mechanical ventilation, and parenteral nutrition. Overall, mortality was significantly lower for transplant patients compared to nontransplant patients (34.7% vs. 61.9%, p < 0.05). In nonoliguric acute renal failure and renal failure not requiring renal replacement therapy, mortality was low and similar in both transplant and nontransplant patients. Compared to nontransplant patients with similar risk factors and similar APACHE II scores, mortality was significantly lower for transplant patients who were oliguric, or who required renal replacement therapy, mechanical ventilation, or parenteral nutrition. Organ transplantation is associated with a survival advantage in acute renal failure when compared to the outcome of critically ill nontransplant patients. The relation between APACHE II scores and survival is altered by transplantation.

Acute Renal Failure in Renal Allograft Recipients and Patients with Native Kidneys

In order to evaluate the role of underlying disease in the high mortality observed in acute renal failure (ARF) and risk factors related to the development of oliguric ARF in renal allograft recipients, two groups were selected: 34 patients with native kidneys, aged 16 and 57 years, and presenting ischemic ARF caused by cardiovascular collapse, with no signs of infection at the time of diagnosis; and 34 renal allograft recipients who developed ARF immediately after transplantation, without rejection. ARF was defined either as 30% increase of basal plasmatic creatinine in patients with native kidneys or non-normalization of plasmatic creatinine at day 5 after transplantation in renal allograft recipients; oliguria as diuresis ≤ 400 mL/24 h. There were no differences in age, male frequency, oliguria presence and duration, need for dialysis, and infection episodes for renal allograft recipients and patients with native kidneys. The development of sepsis (3% and 41%) and death rate (3% and 44%) were higher in patients with native kidneys (p < 0.01). The renal allograft recipients with both oliguric (n = 18) and nonoliguric (n = 16) ARF were evaluated and no difference was observed in the recipient's age, donor's age, cold ischemia time, time elapsed until plasmatic creatinine normalization, donor's plasmatic creatinine or urea, and mean arterial pressure. No differences were observed between the groups regarding frequency of infection episodes during ARF and frequency of death. In conclusion, renal allograft recipients presented a lower death rate and were less susceptible to sepsis. Cold ischemia time, age, and hemodynamic characteristics of the donor did not affect the development of oliguria.

Mechanisms of acute renal failure

Acute renal failure can be defined as an abrupt decline in renal function with a decrease in glomerular filtration rate (GFR) resulting in the retention of nitrogenous waste products. Acute renal failure has conventionally been classified as (a) prerenal failure, denoting a disorder in the systemic circulation that causes renal hypoperfusion. Implicit in the prerenal classification is that the correction of the underlying circulatory disturbance (e.g. by improvement in cardiac function or repletion of volume) restores the GFR. However, prerenal failure is often followed by transition to (b) intrinsic renal failure, where correction of the circulatory impairment does not restore the normal GFR. Intrinsic renal failure generally includes tubular necrosis. (c) Postrenal failure (obstructive) is a third possibility. Some patients with acute renal failure have oliguria (conventionally defined as a urine output of less than 400 ml day ), but others do not. In fact, patients with acute renal failure can be divided approximately equally into oliguric and non-oliguric. The pathogenetic factors appear to be identical in both types but in general are less severe in nonoliguric acute renal failure. Three abnormalities of renal function are present in intrinsic acute renal failure. These are (1) intratubular obstruction, (2) backleak of glomerular filtrate through damaged tubular epithelium, and (3) a primary reduction of GFR as a consequence of the release of vasoactive substances, which alter pressure, flow and filtration coefficient (kf) in the glomerular capillaries. The kidneys have an enormous blood supply. They receive 20–25 % of the cardiac output, but account for only 0.5 % of the body weight. The renal blood supply is typically around 400 ml 100 g 1 min 1 compared with about 70 ml 100 g 1 min 1 for heart and liver. The kidneys also have a very high oxygen consumption, but because of the high blood flow, the arteriovenous oxygen difference across the kidney is small. PO2 decreases from 95 mm Hg in the renal artery, to a value of about 70 mm Hg in the renal venous blood. In view of this it may seem surprising that renal ischaemia and acute renal failure are such major problems. In this article we examine those features of the renal physiology which contribute to the (intrinsic)

Urinary NAG as an early indicator of renal damage in Russell's viper bite envenomation

Urinary N-acetyl-β-D-glucosaminidase (NAG; β-N-acetylglucosaminidase; EC 3.2.1.30), blood urea, serum creatinine and creatinine clearance were measured in 23 patients bitten by Russell's viper ( Daboia russelii siamensis), with systemic envenomation, at different time intervals after the bite during clinical observation for 5 d. Activities of urinary NAG were compared with these indicators of renal function in 3 clinical conditions: non-oliguric acute renal failure (ARF), oliguric ARF not requiring peritoneal dialysis, and oliguric ARF requiring peritoneal dialysis. Cut-off values to identify the 3 conditions were established. When the times of onset of the conditions, indicated by the cut-off values, were compared, urinary NAG was generally found to be the earliest indicator of renal damage. In each type of ARF, the urinary NAG level was abnormal before changes in the values of the other indicators of renal function. It may be possible to predict the types of ARF within 2 h after the bite by measurement of urinary NAG.

Ochratoxin and Kidney Disease in the Human

Ochratoxin A (OTA), produced by several species of Aspergillus and Penicillium, is known for its nephrotoxicity in pigs and rats. Human exposure to this toxin, essentially by consumption of contaminated food and drinks derived from cereals, could be potentially nephrotoxic. There is a paradox between the risk of OTA for human renal disease, due to the wide distribution of this mycotoxin throughout the world, and the rarity of reported cases demonstrating its role in chronic renal disease. Possible OTA-induced acute renal failure was recently reported in Italy after a farmer and his wife worked 8 hours in a granary closed for several months. Renal biopsy in the woman who developed nonoliguric acute renal failure revealed lesions of acute tubular necrosis. A strain of Aspergillus ochraceus producing OTA was isolated from the wheat. Chronic nephrotoxicity due to OTA is probably more usual and makes the diagnosis more difficult. Balkan Endemic Nephropathy, a chronic tubulo-interstitial renal disease, could be due to OTA. Epidemiologic studies showed that in areas where high OTA levels are reached in food and in the blood of the population, there is a high incidence of nephropathy and renal tumours. The demonstration of DNA adducts in kidneys of animals exposed to OTA and similar adducts in renal tissue and tumours from individuals in the endemic region of the Balkan countries highlights a new molecular epidemiological approach. Karyomegalic interstitial nephritis, characterized by karyomegaly in proximal and distal tubular epithelial cells, has been reported in nine patients. Karyomegaly could be due to an environmental toxin that interferes with DNA replication. Involvement of the oxidative pathway in genotoxicity of OTA is known and oxidant stress induces DNA damage. Therefore, karyomegaly could be a histological marker of interstitial nephritis due to OTA. In developing countries where the prevalence of end stage renal failure due to nephropathy of uncertain etiology is high. OTA and probably other mycotoxins could be major environmental factors in the occurrence of renal disease.

Acute tubulointerstitial nephritis in association withYersinia pseudotuberculosis infection

A 4-year-old girl was diagnosed as having acute renal failure due to tubulointerstitial nephritis. The girl presented with remittent fever, vomiting and non-oliguric acute renal failure with sterile pyuria and tubular reabsorptive dysfunction. Ultrasound examination revealed that the kidneys were markedly enlarged with diffuse hyperechogenicity in the cortex when the abnormal renal function was present and were restored in size and echogenicity when the renal function normalised. A diagnosis of Yersinia pseudotuberculosis infection was based on a rise in haemagglutination titres against the organism.

Survival in a Case of Massive Paraquat Ingestion

Serious exposure to the herbicide paraquat usually results in death, either due to gastrointestinal caustic lesions, shock, and acute respiratory distress syndrome or related to the progressive development of pulmonary fibrosis associated with refractory hypoxemia. We report a case of suicidal paraquat ingestion in a 59-year-old man. Most of the indicators of poor prognosis were encountered in this patient. Treatment consisted of early digestive decontamination and hemodialysis, followed by antioxidant therapy, including the administration of deferoxamine (100 mg/kg in 24 h) and a continuous infusion of acetylcysteine (300 mg/kg/d during 3 weeks). The patient only developed a nonoliguric acute renal failure, a mild alteration of liver tests, and an impairment of CO transfer factor without any respiratory complaint. Renal and hepatic disturbances completely resolved within 1 month, whereas CO transfer factor remained altered 14 months later. This observation suggests that early administration of an antioxidant therapy, including deferoxamine and acetylcysteine could be usefully associated with measures that prevent digestive absorption or enhance elimination to limit systemic toxicity in potentially fatal paraquat poisoning.

Effect of the Dialysis Membrane in the Treatment of Patients with Acute Renal Failure

The mortality rate among patients with acute renal failure remains high, and the role of the biocompatibility of the dialysis membrane in the resolution of this disorder is not known. We prospectively studied 72 patients with acute renal failure who required hemodialysis and assigned them to two treatment groups. One group underwent dialysis with the widely used cuprophane dialysis membrane, which activates the complement system and leukocytes, and the other group underwent dialysis with a synthetic polymethyl methacrylate membrane, which has a more limited effect on complement and leukocytes. Scores on the Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) were calculated at the initiation of dialysis. Survival and the recovery of renal function were determined with the use of proportional-hazards and exact logistic-regression analyses. When dialysis was initiated, the patients in the two groups were similar in terms of age, APACHE II scores, the prevalence of oliguria, and biochemical indexes of renal failure. Twenty-three of the 37 patients (62 percent) in the group undergoing dialysis with the polymethyl methacrylate membrane recovered renal function, as compared with 13 of the 35 patients (37 percent) in the group undergoing dialysis with the cuprophane membrane (P = 0.04 after adjustment for the APACHE II score). The median number of dialysis treatments required before the recovery of renal function was 5 in the former group and 17 in the latter group (P = 0.02). Twenty-one patients (57 percent) undergoing dialysis with the polymethyl methacrylate membrane survived, as compared with 13 patients (37 percent) undergoing dialysis with the cuprophane membrane (P = 0.11). Of the 20 patients in each group who initially had nonoliguric acute renal failure, the survival rates were 80 percent with the polymethyl methacrylate membrane and 40 percent with the cuprophane membrane (P = 0.01). Among patients with acute renal failure requiring hemodialysis, the use of the polymethyl methacrylate membrane, as compared with the cuprophane membrane, resulted in improved recovery of renal function.

Glomerular and Tubular Factors in Urine Flow Rates of Acute Renal Failure Patients

Distinguishing between oliguric and nonoliguric acute renal failure (ARF) has clinical relevance. However, there is a paucity of data regarding the pathophysiologic basis for variations in urine flow rates in ARF. This study was designed to determine whether differences in residual levels of glomerular filtration rate (GFR) or differences in tubular reabsorption of filtered solutes and H2O accounted for the variations in urine flow rates among ARF patients. Twenty-five patients with ARF of 3 to 6 days duration having ischemic and nephrotoxic etiologies, increasing serum creatinines of more than 0.7 mg/dL/d, urine sodium concentrations and fractional excretions of sodium (FENa) of more than 20 mEq/L and more than 1%, respectively, 12 hours after stopping diuretics and urine sediments consistent with acute tubular necrosis were studied. Urine and serum collections were made over an 8-hour period to determine creatinine clearance (Ccr), filtered osmolar load, urine to serum creatinine ratio (U/Scr), urine to serum creatinine osmolality (U/Sosm), and FENa. These were compared with urine flow rates. Creatinine clearance was validated as an estimate of GFR in ARF with simultaneous inulin clearances x 12 measurements (r = 0.935, P < 0.001). Residual Ccr was strongly correlated with urine flow rate (r = 0.857, P < 0.001), as was filtered osmolar load (r = 0.810, P < 0.001). However, the latter relationship was totally dependent on Ccr. There was no correlation between U/Scr, U/Sosm, or FENa and urine flow rates. It is concluded that the residual level of GFR is the primary determinant of variations in urine flow rate in patients with ARF.

A Unique Complication of Nonsteroidal Anti-inflammatory Drug Use

We read with great interest the two case reports by McIntire et al 1 on "Acute Flank Pain and Reversible Renal Dysfunction Associated with Nonsteroidal Anti-Inflammatory Drug Use." We also treated a 14-year-old healthy girl who had acute severe bilateral flank pain and nonoliguric acute renal failure. The patient's flank pain and vomiting started 4 days before admission. A diagnosis of possible urinary tract infection was made and amoxicillin therapy was instituted. Her past medical history was unremarkable except for an uncomplicated urinary tract infection 6 years earlier.

Glomerular Alterations in Experimental Oliguric and Nonoliguric Acute Renal Failure

Studies were performed in oliguric and nonoliguric forms of uranyl acetate (UA)-induced and ischemic acute renal failure (ARF) to examine whether a reduction in GFR is correlated with glomerular morphologic alterations. UA-induced nonoliguric and oliguric ARF were induced in rabbits by i.v. injections of 0.9 and 2 mg/kg, respectively. A 60-min renal artery clamping produced nonoliguric ARF in previously uninephrectomized rats, but oliguric ARF in the clamped kidneys of sham-nephrectomized animals. A decline in the whole-kidney CIn rate was more marked in oliguric ARF kidneys of both models than in nonoliguric ARF kidneys. Also, tubular damage was more pronounced in oliguric kidneys when compared with nonoliguric kidneys. Scanning electron microscopic observations revealed glomerular alterations in oliguric and nonoliguric kidneys in both models, evidenced by a flattening and spreading of podocyte cell bodies associated with loss of epithelial foot processes and a reduction in the density and diameter of endothelial fenestrae. There was no significant difference in these glomerular changes between oliguric and nonoliguric kidneys. The findings suggest that less reduction in the whole-kidney GFR in nonoliguric ARF kidneys is ascribed largely to less pronounced tubular damage rather than to less severe glomerular morphologic alterations.

Acute renal failure following physical torture.

Ten cases of acute renal failure (ARF) were seen in the period from July 1990 to August 1991 in the Nephrology Department of the SIMS Hospital, Srinagar. All were males in the age group of 18-28 years and in apparent good health when apprehended by the police. There was alleged history of physical torture of different types. All had been beaten on the buttocks, back and limbs; in addition, 2 cases had been given repeated electric shocks and 1 case put to 'sit-and-stand' exercise for about 3 h. The interval between the first day of torture till they came to our observation varied from 4 to 11 days. The main clinical features at the time of presentation were generalized aches and weakness (10), oligoanuria (9), vomiting (8), hypertension (6), acidosis (10), facial puffiness and pedal edema (6), fever and shivering (3), pulmonary edema (2), stupor (4), and hyperkalemia (5). All the cases had an established ARF (serum creatinine 668-1,997 mumol/l and serum urea 21.8-71.8 mmol/l) when first seen. Muscle enzymes, creatine phosphokinase, lactic dehydrogenase and serum glutamic oxaloacetic transaminase were all significantly raised indicating rhabdomyolysis. All showed evidence of myoglobin casts in urine. Nine had oliguric and 1 had nonoliguric ARF. All except the 1 case with nonoliguric ARF were managed with peritoneal dialysis and/or hemodialysis. All recovered. Early recognition of ARF is important since the main attention in such cases is directed towards the surgical aspect.

Metabolism of calcium and vitamin D3 in patients with acute tubulointerstitial nephritis: a study of 41 patients with nephropathia epidemica.

We studied serum concentrations of calcium, phosphate, intact parathyroid hormone (PTH) and vitamin D3 metabolites in 41 patients with nephropathia epidemica. Thirty-four of the 41 patients had a mild to moderate, mostly nonoliguric acute renal failure (ARF). Hypocalcemia developed in relation to the severity of renal failure, and parathyroid gland response to hypocalcemia was normal. The serum concentration of 1,25-dihydroxyvitamin D3 was lower than normal in patients who developed ARF. Serum phosphate was the most important factor in regulating the serum 1,25(OH)2D3 level, though only mild phosphate retention was seen in the patients. We observed normal or slightly elevated serum phosphate, hypocalcemia accompanied by elevated PTH levels and a decreased serum concentration of 1,25(OH)2D3 in patients with ARF caused by nephropathia epidemica.