Oligoanuric Acute Renal Failure Research Articles

Renal artery aneurism and renal autotransplantation: review of surgical technique, preoperative complementary examinations and postoperative follow-up protocol

Introduction: Renal artery aneurysm (RAA) is a rare pathology; however, its incidental diagnosis is increasingly frequent due to the increasing use of imaging techniques. Complex (hilar) RAAs, dependent on the distal renal artery and its branches, constitute a subset of RAAs that present a therapeutic challenge due to their anatomical location and may require extracorporeal arterial repair and autotransplantation. Material and methods: A bibliographic review is carried out to homogenize the management of this pathology, analyzing the indications for surgical treatment, the recommended surgical technique step by step, as well as post-surgical monitoring. Two clinical cases of RAA treated in our center by hand-assisted laparoscopic nephrectomy, ex vivo bench repair and renal autotransplantation are presented. Results: In both cases, a postoperative Doppler ultrasound of the graft was performed 24 hours later, in which a renal graft was observed in the iliac fossa, of normal size and cortical thickness within normality with normal color Doppler signal, and spectral curves without alterations. Both patients presented oligoanuric acute renal failure (injury) during the immediate postoperative period (first 24 hours) with complete resolution at discharge, which occurred on the 11th and 12th postoperative day, respectively. In both patients a diuretic renogram with MAG3 was performed. In case 1, it was performed the third postoperative month and a slightly ectatic right kidney was observed with less perfusion and parenchymal incorporation of the radiotracer, with a reduction in relative renal function (39.47%) and MAG3 clearance (indeterminate renographic pattern). In this patient, a CT scan with the excretory phase was performed simultaneously, in which a grafted right kidney was seen at the level of the right iliac fossa with good contrast elimination in the excretory phase bilaterally and symmetrically. A small non-perfused area is observed in the upper pole. In the second patient, the renogram was performed on the 14th postoperative day, finding the morphofunctional study of the graft within normal parameters without detecting areas of hypoperfusion. The levels of creatinine and glomerular filtration were, respectively, in the first case: 0.86mg/dl and 90.19ml/min/1.73m2 preoperatively and 0.83mg/dl and 90.96ml/min/ 1.73m2 per postoperative month. In the second case, the values were: preoperatively creatinine of 0.66mg/dl and glomerular filtration rate of 97.96ml/min/1.73m2 and 0.81mg/dl and 89ml/min/1.73m2 one month postoperatively. Conclusion: After reviewing the literature, there is no consensus regarding the imaging techniques to be performed after renal autotransplantation and the optimal time frames for performing these for the evaluation of the postoperative graft. There is also no homogeneity in the imaging techniques to be performed in the preoperative assessment. In our experience, open ex vivo surgical repair of complex distal hilar RAAs has been successful with low morbidity and mortality and an acceptable rate of preservation of renal function.

Consecutive episodes of heart and kidney failure in an \u201cotherwise\u201d healthy young man

BackgroundAcute renal failure is a rare occurrence in a patient with an unremarkable past medical history and should always lead to an in depth clinical study. The occurrence in the same healthy young subject, of consecutive episodes of heart failure and of acute renal failure is an even rarer event and should prompt diagnostic tests and restrict the diagnostic hypotheses.Case presentationWe present the case of a 28 year-old man who, while waiting to undergo assessment for a mild chronic kidney disease, was diagnosed with decompensated dilated cardiomyopathy and placed on diuretics and β-blockers. After few weeks he developed a non oligoanuric acute renal failure with a slight elevation of serum calcium. Renal biopsy proved suggestive for renal sarcoidosis; thus the hypothesis of systemic sarcoidosis with cardiac and renal involvement was possible avoiding further delay in initiation of therapy.ConclusionsCardiac sarcoidosis is usually silent but the majority of cases are diagnosed when cardiac symptoms are present in a patient with systemic sarcoidosis. Renal involvement with granulomatous interstitial nephritis is also quite rare and can be an unexpected finding at kidney biopsy. This case highlights the need to evaluate thoroughly clinical problems that do not fit in a specific scenario and emphasizes the importance of performing a kidney biopsy in case of kidney failure of unknown etiology.

Scleroderma renal crisis.

Scleroderma renal crisis (SRC) is characterized by malignant hypertension and oligo-anuric acute renal failure. It occurs in 5% of patients with systemic sclerosis (SSc), particularly in patients with diffuse disease during the first years. SRC is more common in patients receiving corticosteroids, the risk increasing with increasing dose. The disease is sometimes triggered by use of nephrotoxic drugs and/or intravascular volume depletion. Left ventricular insufficiency and hypertensive encephalopathy are typical clinical features. Thrombotic microangiopathy is detected in 43% of cases, and anti-RNA-polymerase III antibodies are present in one-third of patients. Renal biopsy is not necessary if SRC presents classical features. However, biopsy may help to define the prognosis and guide treatment in atypical forms. The prognosis of SRC has greatly improved with the introduction of angiotensin-converting enzyme (ACE) inhibitors. However, the 5-year survival for SSc patients with full SRC remains low (65%). The treatment of SRC relies on aggressive blood pressure control with an ACE inhibitor, combined with other antihypertensive drugs if needed. Dialysis is frequently indicated but can be stopped in about half of patients, mainly those with good blood pressure control. Patients who need dialysis for more than 2 years qualify for renal transplantation.

A Case of Acute Renal Failure Following Ethylene Glycol Intoxication in a Dog

The manuscript describes a clinical case of severe oligoanuric acute renal failure in a young dog following ethylene glycol intoxication. Significant deviations were established in urinary renal markers and blood biochemical parameters: severe azotemia, hypocalcaemia, hyperphosphataemia, hyperkalaemia and metabolic acidosis. The ultrasound renal findings demonstrated increased renal cortex echogenicity the typical for ethylene glycol intoxication, with a characteristic halo sign around the medulla. Electrocardiography showed a progressive decrease in amplitudes of P and R peaks, increased sharp edged repolarisation T wave. The performed symptomatic therapy did not lead to favourable outcome due to delayed intervention by the owner and non-administered antidotal therapy. The histopathological finding was consisted in degeneration, necrosis, desquamation of kidney epithelial cells, dilated tubules and multiple calcium oxalate deposits. The described changes, in our opinion, are relevant and could be used for diagnostics of the studied pathology.

Manifestations rénales de la sclérodermie systémique

Scleroderma renal crisis is characterized by malignant hypertension and oligo-anuric acute renal failure. Scleroderma renal crisis occurs in 2 to 5% of patients with systemic sclerosis, particularly those with diffuse cutaneous systemic sclerosis in the first years of disease evolution. High-dose corticosteroid therapy (> 15 mg/d) is associated with an increased risk of scleroderma renal crisis. Patients present with prominent left heart failure and hypertensive encephalopathy. Renal failure can be associated with moderate proteinuria, without hematuria. Thrombotic microangiopathy is detected in 43% of the cases. Anti-RNA polymerase III antibodies are present in one third of patients with scleroderma renal crisis. In case of renal failure, iatrogenic or functional origin must be investigated, as well as crescentic glomerulonephritis associated with antineutrophil cytoplasm antibodies (ANCA) or thrombotic microangiopathy. Renal biopsy is not necessary to establish the diagnosis in typical forms of scleroderma renal crisis. However, it can help to evaluate the prognosis and it is recommended when clinical presentation of scleroderma renal crisis is unusual. The prognosis of scleroderma renal crisis dramatically improved with the use of angiotensin-converting enzyme (ACE) inhibitors. However, 5-year survival of patients who developed a scleroderma renal crisis is only 65%. The treatment relies on the early control of blood pressure with increasing doses of ACE inhibitors, in association with calcium channel blockers if necessary. In case of severe renal failure and/or hypertension, dialysis can help to quickly control the vascular overload and the blood pressure. Dialysis can be stopped in about half of cases. After 2 years on dialysis, eligible patients should be considered for renal transplantation. The prevention of scleroderma renal crisis lacks consensus. Corticosteroids and/or nephrotoxic drugs should be avoided in patients with diffuse cutaneous systemic sclerosis.

Late Renal Vein Thrombosis Associated With Recurrence of Membranous Nephropathy in a Renal Allograft: A Case Report

Allograft renal vein thrombosis (RVT) is an uncommon but potentially catastrophic complication. Although it usually occurs in the early posttransplant period and is associated with surgical complications or vascular rejection, it may develop later, when it is generally related with a hypercoagulable state. Typical clinical presentation is sudden oligoanuric acute renal failure, and hematuria, with a painful and swollen renal allograft. Confirmation of the diagnosis requires Doppler ultrasound and computed tomography. Herein we have reported a successfully treated case of late RVT that developed in an allograft with recurrent membranous nephropathy associated with the nephrotic syndrome. The patient fully recovered renal graft function a few days after presentation, which was related to anticoagulant therapy. We demonstrated complete recanalization of the venous thrombosis.

Treatment of metformin-associated lactic acidosis with sustained low-efficiency daily dialysis.

Sir, Sustained low-efficiency daily dialysis (SLEDD) is an intermittent prolonged dialysis modality which is increasingly used for the treatment of acute renal failure [1,2], as it combines most of the advantages of both the classic intermittent treatments and the continuous modalities in terms of safety, efficacy, haemodynamic stability and costs. GENIUS® 90 Therapy System (GENIUS) (Fresenius Medical Care, Bad Homburg, Germany) gained interest for application in SLEDD for the treatment of acute renal failure [1,2] as well as of acute drug intoxication [3–6]. No published experience exists about the use of SLEDD in metformin-associated lactic acidosis (MALA). Here we report the case of a 64-year-old diabetic woman who on 12 November 2007 was admitted to the gynaecology unit of our hospital in order to undergo a surgical intervention for the correction of hysterocele, cystocele and enterocele. On 14 November 2007 she underwent colpohysterectomy, McCall culdoplasty, urethrocystopexy and colpoperineoplasty. Her past medical history included mild chronic renal failure (serum creatinine levels were between 1.3 and 1.5 mg/dl), arterial hypertension and type II diabetes mellitus. At the time of admission she was being treated with the following drugs (daily doses): metformin 3000 mg, allopurinol 300 mg, verapamil 120 mg, irbesartan 300 mg and furosemide 25 mg. On 17 November serum creatinine level was 1.4 mg/dl; on 18 November the patient became oliguric, confused and started to be affected by nausea, vomiting, abdominal pain and anorexia. On 19 November serum creatinine level was 5.7 mg/dl and liver enzymes were normal. Irbesartan and metformin therapy were stopped. A renal ultrasound showed normal kidney volume with districtly reduced thickness, a small increase of echogenicity and no hydronephrosis. In the evening, the patient became anuric and presented diffuse oedema, rales at lung bases and tachypnoea. Drowsiness appeared. She was hypoglycaemic at 50 mg/dl; blood pressure was 90/40 mmHg; the serum creatinine level was 7.4 mg/dl. Lactic acidosis was diagnosed: pH 7.16, serum bicarbonate level 11.1 mmol/l, serum lactate level 13.8 mmol/l (normal values: 0.5–1.6 mmol/l). A double lumen 12 F central venous catheter was positioned in the left femoral vein and a 10-h SLEDD session with GENIUS was started. A low-flux polysulfone membrane (F7; surface area 1.6 m2; Fresenius Medical Care, Bad Homburg, Germany) was applied, blood/dialysate flow was set at 120 ml/min and the ultrafiltration rate at 150 ml/h. Anticoagulation of the circuit was obtained with heparin 5000 IU/treatment. Dialysate composition was as follows: calcium, 1.5 mmol/l; magnesium, 0.5 mmol/l; potassium, 3 mmol/l; sodium, 140 mmol/l; bicarbonate, 35 mmol/l; chloride, 111.5 mmol/l; hydrochloric acid, 2.0 mmol/l; glucose, 5.5 mmol/l and citrate, 0.084 mmol/l. At the start of the SLEDD session, blood pressure was 100/50 mmHg and was constant during the treatment. Blood samples were collected every hour for the serum bicarbonate and lactate level measurement. Five hours after the end of the first GENIUS treatment, the patient started a new 8-h SLEDD session with GENIUS (on 20 November), and on 21 November a further 6-h SLEDD session with GENIUS was started 18 h after the end of the second session. Serum bicarbonate and lactate levels are shown in Figure ​Figure1.1. There was a rapid decrease in serum lactate levels and the reciprocal increase in serum bicarbonate levels during the three SLEDD sessions. A complete normalization of acid–base balance and of serum lactate levels with cessation of anuria was observed after three treatments. On 23 November, pH was 7.41, serum bicarbonate levels 24.5 mmol/l and serum lactate levels 1.5 mmol/l. On 29 November the patient was discharged from the hospital with serum creatinine levels of 2.9 mg/dl. After 3 months her serum creatinine levels were back to 1.4 mg/dl. In conclusion, SLEDD with GENIUS is able to offer an adequate and well-tolerated dialysis treatment for the therapy of MALA associated with severe oligoanuric acute renal failure. Fig. 1 Hourly measurements of serum lactate (•) and bicarbonate levels (⧫) during the three sessions of SLEDD with GENIUS. Conflict of interest statement. None declared.

Acute Hemolysis and Oligoanuric Acute Renal Failure Caused by Interrupted

A 38-year-old patient was treated with relapsing pulmonary tuberculosis with reinstitution of rifampicin (RFP) after a medicationfree interval of l8 years. One week after initiation of treatment the patient developed acute severe hemolytic anemia and oligoanuric acute renal failure (ARF) necessitating dialysis. ARF following intermittent or discontinous and interrupted RFP therapy is a relatively infrequent clinical observation. Many pathogenetic mechanisms for the renal failure have been proposed, including intravascular hemolysis with hemoglobinuria and its consequent nephrotoxicity. Interrupted and intermittent therapy with RFP should be avoided and non-compliant patients should be given alternative treatment when possible.

Treatment of acute renal failure caused by renal artery occlusion with renal artery angioplasty

Background: Renovascular disease is a common cause of renal impairment and hypertension, particularly in the older population. Oligoanuric acute renal failure secondary to renal artery occlusion is not well recognized; however, it is potentially reversible if identified and treated. Methods: Five patients presented to our institution with oligoanuric acute renal failure. Each had evidence of vascular disease, and a prerenal insult was identified. They were investigated with renal artery Doppler ultrasound or nuclear imaging before proceeding to percutaneous angioplasty and stent placement. Results: The targeted kidney had relatively well-preserved renal size, and potential viability of the renal tissue was determined by nuclear scanning with parenchymal uptake of tracer. Percutaneous angioplasty and stent placement resulted in brisk reperfusion of the kidney and an immediate diuresis with improvement of renal function, avoiding supportive dialysis after the procedure. Contrast nephrotoxicity was identified in two of the five cases. Conclusion: Renal artery occlusion should be considered as a cause of oliguric acute renal failure, particularly in patients at high risk who present with a sudden deterioration of renal function, with nuclear imaging showing potentially viable renal tissue with relatively well-preserved renal size. Percutaneous revascularization should be considered in this group. © 2002 by the National Kidney Foundation, Inc.

Anuric Acute Renal Failure Caused by Dextran 40 Administration

Dextran 40 is largely used in clinical medicine as a plasma substitute because of its beneficial effects on the microcirculation and antithrombogenic properties. An unusual adverse reaction of dextran administration is oligoanuric acute renal failure. We report two cases of anuric ARF induced by dextran 40. Diuresis and renal function were quickly resumed after plasmapheresis treatment. Renal biopsy revealed normal kidneys except for swelling and vacuolation of renal tubules suggestive of osmotic nephrosis.

A Study of 500 Cases of Acute Renal Failure (1978-1991)

A retrospective study of 500 consecutive cases of acute renal failure (ARF) in a period covering 1978 through 1991 is presented. A total of 316 females and 182 males with an average age of 46.4 years (14 to 84) had a global survival rate of 68%. Oligoanuric ARF was present in 77% of the patients and, except in 13 cases, all were dialyzed with varied techniques. The treatment plan consisted of early and repetitive dialysis, rational use of antibiotics, and parenteral and/or oral nutritional support. The patients have been divided into three main categories according to etiology: gyneco-obstetric, medical, and postsurgical cases, the latter having the poorest survival rate. With regard to ARF post-septic abortion, we strongly believe that a hysterectomy should not be carried out except in the presence of gangrene or proven uterine perforation, as surgery increases the morbomortality rate in these septic patients.

Management of acute renal failure in the critically ill with continuous venovenous hemodiafiltration.

Continuous venovenous hemodiafiltration (CVVHD) has been increasingly utilized for renal replacement therapy in the critically ill. We report details of a prospective study of CVVHD in 12 critically ill patients (7 males, 5 females; mean age 60 years, range 30-72 years; Apache II score mean 27.4, range 21-35) with oligoanuric acute renal failure supported on CVVHD. Vascular access was obtained via double lumen subclavian or femoral cannulae. The mean pretreatment urea was 35.9 mM/L and the mean pretreatment creatinine was 559 microM/L. After 24 h of treatment on CVVHD these fell to a urea mean of 20.3 mM/L and a creatinine mean of 298 microM/L and remained stable at these values for the duration of CVVHD. The mean net ultrafiltrate volume was 551 mL/h, with a urea clearance mean of 26.6 mL/min and a creatinine clearance mean of 23.7 mL/min. There were no complications related to use of the blood pump module or extracorporeal circuit. Excellent hemodynamic stability, control of fluid and electrolyte balance, and azotaemia control were maintained while on CVVHD. Technique survival was 100%. Patient survival was 42%. We conclude that CVVHD is a safe, effective, and durable therapy for the treatment of acute renal failure in the critically ill and that it offers outstanding metabolic control and cardiovascular stability.

Exertional Heat Stroke and Acute Renal Failure in a Young Woman

Strenuous exercise leading to heat stroke is known to cause rhabdomyolysis and acute renal failure in men, but there are no reports of this environmental illness in otherwise healthy women. We report the first case of heat and exercise induced acute renal failure in a young nonacclimated adult female following intense exertion in the Grand Canyon. This individual displayed the typical clinical features of exertional heat stroke including hyperpyrexia, CNS disturbance, rhabdomyolysis, oligoanuric acute renal failure, and disseminated intravascular coagulopathy. The pathophysiology is discussed as well as sexual differences in response to heat and exercise. The specific factors that may have predisposed this young woman to heat stroke from exertion are identified.