Oliguric Patients Research Articles

Renal ischaemia, transient glomerular leak and acute renal tubular damage in patients envenomed by Russell's vipers ( Daboia russelii siamensis) in Myanmar

Fifty-two patients who had been bitten by Russell's vipers in Myanmar developed acute renal failure (serum creatinine exceeding 1·3 mg/dL). Thirty-four of them (65%) became oliguric, but the other 18 (35%) maintained a urine output of more than 400 mL/24 h. In oliguric patients, gastrointestinal haemorrhages, renal angle tenderness and conjunctival oedema occurred more commonly, and peak serum creatinine, blood urea nitrogen and the fractional excretion of sodium were significantly higher ( P < 0·01) than in non-oliguric patients, indicating a greater degree of renal damage. Urinary concentrations of β 2 microglobulin and retinol binding protein were raised in most of the patients indicating failure of proximal tubular reabsorption of these proteins, while high urinary N-acetyl glucosaminidase concentrations were consistent with renal tubular damage. Plasma concentrations of active renin were very high, suggesting that renal ischaemia, associated with activation of the renin-angiotensin system, was involved in the development of renal dysfunction.

Spectrum of Hospital-acquired Acute Renal Failure in the Developing Countries— Chandigarh Study

The spectrum of hospital-acquired acute renal failure in the developing countries has not been documented. We undertook a prospective study to define the causes and outcome of hospital acquired acute renal failure as seen at a referral center in North India. Over a one year period, all patients who developed acute elevation in serum creatinine during the hospital stay were studied. One hundred and ninety of 29,503 admitted patients (0.64 per cent) satisfied the criteria for entering into the study. Nephrotoxic drugs (29 per cent), decreased renal perfusion (21 per cent), major surgery (18 per cent) and septicaemia (17 per cent) were the most frequent causes. Acute renal failure was non-oliguric in 52 per cent of patients. Non-oliguric patients had significantly fewer episodes of hyperkalaemia, neurological abnormalities, metabolic acidosis and gastrointestinal bleeding. They required fewer episodes of dialysis (p < 0.001) and had a significantly lower mortality (p < 0.001) compared to the oliguric patients. Other poor prognostic factors included severity of renal insufficiency, high baseline serum creatinine and presence of multiorgan failure. The present study shows that the spectrum of hospital-acquired acute renal failure in the developing countries is quite similar to that of technologically advanced countries, although the pattern of community acquired acute renal failure is vastly different.

Dopamine treatment for severe ovarian hyperstimulation syndrome

Seven oliguric patients with severe ovarian hyperstimulation syndrome following gonadotrophin treatment for in-vitro fertilization or gamete intra-Fallopian transfer, were treated with low doses of dopamine by peripheral infusion. Five patients were pregnant. The rationale for this therapeutic approach was to increase renal blood flow and glomerular filtration. In addition to dopamine, fluid intake was restricted to 500 ml/day and a protein and salt-rich diet was provided in order to increase serum osmolarity. Within 24-48 h from the beginning of the dopamine treatment, the syndrome started to regress in all cases. No adverse maternal or fetal effects occurred. We conclude that dopamine therapy may constitute a major advance towards the management of severe ovarian hyperstimulation syndrome.

Oliguria in Patients with Normal Renal Function

Oliguria is common in critically ill patients and may result from prerenal, renal, and postrenal causes. Oliguria also frequently develops in patients with normal concentrations of blood urea nitrogen and creatinine. Most of these patients do not develop renal failure. The authors prospectively studied 100 patients admitted to the ICU to determine the etiology of oliguria in these patients. Eighteen patients (18%) developed oliguria (less than 0.33 ml.kg-1.h-1 X 2 h). Seven and eleven patients were felt on clinical assessment to be hypovolemic or normovolemic, respectively. Compared with the hypovolemic patients, the normovolemic oliguric patients had significantly lower serum osmolalities (278 +/- 3 vs. 290 +/- 5 mOsm/kg H2O) and serum sodium concentrations (138 +/- 3 vs. 132 +/- 1 mEq/l). In addition, normovolemic patients had significantly higher urine sodium concentrations (83 +/- 12 vs. 13 +/- 2 mEq/l), fractional excretion of sodium (1.14 +/- 0.2 vs. 0.15 +/- 0.03), and renal failure indices (1.5 +/- 0.3 vs. 0.21 +/- 0.04). ADH concentrations in six hypovolemic and six normovolemic patients were increased in both groups but not significantly different. The hypovolemic patients increased their urine output from 17 +/- 2 ml/h to greater than 0.5 ml.kg-1.h-1 following a 500-ml bolus of normal saline. The normovolemic oliguric patients remained oliguric following the saline bolus (13 +/- 2 to 19 +/- 3 ml/h). The authors conclude that oliguria is common in critically ill patients and results from renal hypoperfusion and ADH excess.(ABSTRACT TRUNCATED AT 250 WORDS)

Aminoglycoside toxicity following antibiotic prophylaxis in cardiac surgery

We have reviewed experience with aminoglycosides in cardiac surgical prophylaxis from 1984 to 1989. In the first two years, prospectively randomized trials (517 patients) allowed comparison of tobramycin (three-day course) with a non-toxic antibiotic, teicoplanin. A significant excess rise in serum creatinine was present at the end of the first postoperative week in patients given tobramycin (165 vs 149 patients, 95% CI 3-17 microM. P less than 0.01, which was most marked in ten oliguric patients with trough serum levels over 2 mg/l (95% CI 7-52 microM). However, no patient needed haemodialysis and only one case of possible ototoxicity was identified. During the next three years, of 912 patients given two to three days gentamicin, 29 patients were shown to have potentially toxic serum levels and oliguria. Three individual cases are described, including one of ototoxicity and one of nephrotoxicity neeeding haemodialysis. The hazards of aminoglycoside toxicity are probably small compared with the failure of other antibiotics to cover staphylococci that may later cause wound infection or endocarditis. However, surgeons should probably be advised to check the aminoglycoside level in all patients on the first post-operative day.

Effects of Furosemide on Pulmonary Shunts

In 23 mechanically ventilated anuric (six) or oliguric (17) patients (less than 16 ml/h of urine output) with severe gas exchange abnormality, we investigated the effect of furosemide on intrapulmonary shunt (Qs/QT). Before and after 0.5, 1, and 2 h of IV administration of 200 mg of furosemide, we assessed the intrapulmonary shunt and PaO2 while patients' hemodynamic measurements were monitored. Ventilatory parameters remained constant throughout the study. While the urine output was minimal and no alteration in hemodynamic values was found, the Qs/QT decreased from 27.7 +/- 2.3 percent (mean +/- SEM) at control to 24.3 +/- 2.1 percent (p less than 0.01) at 0.5 h, 21.7 +/- 2.1 percent (p less than 0.001) at 1 h, and 18.1 +/- 1.8 percent (p less than 0.001) at 2 h. The PaO2 showed no significant difference at 0.5 h but rose significantly from 96 +/- 14 to 105 +/- 14 mm Hg (p less than 0.05) and 111 +/- 14 mm Hg (p less than 0.01) at 1 and 2 h, respectively. Since we observed no changes in hemodynamics, we speculate a direct effect of furosemide in the pulmonary vasculature affecting the ventilation-perfusion mismatch and, therefore, the Qs/QT and PaO2.

Use of extracorporeal supportive techniques as additional treatment for septic-induced multiple organ failure patients

We compared retrospectively four similar groups of patients with multiple organ failure (MOF) due to sepsis. All of them were treated initially with conventional therapy, aprotinin as protease inhibitor and vitamin C with allopurinol as possible scavengers of oxygen-free radicals, were also added. After 24 h of no clinical progress, continuous arteriovenous hemofiltration (CAVH), CAVH/dialysis (CAVH/D), and sequential plasmafilter-dialysis with slow continuous hemofiltration (CAVHP/D) were respectively added to groups 2 (n = 14), 3 (n = 6), and 4 (n = 11). Mortality was 87% for group 1, 71% for group 2, 50% for group 3, and 36% for group 4. In the latter we were able to remove possible MOF-inducing mediators from the bloodstream, to give fluids without restriction (even in oliguric patients), and to improve removal of metabolic waste products. It is possible that these extracorporeal supports, associated with conventional therapy, and pharmacologic drugs such as protease inhibitors and possible scavengers of oxygen-free radicals, helped to reduce the mortality rate. We conclude that, although the number of study patients was too small to reach firm conclusions, the good results observed with CAVHP/D suggest clinical trials to assess the efficacy of this technique.

Effects of low-dose dopamine therapy in the oliguric patient with preeclampsia

Central hemodynamic and renal responses to low-dose dopamine (1 to 5 micrograms/kg/min) infusion were studied in six oliguric (less than 0.5 ml/kg/hr) patients with severe preeclampsia. Hemodynamic parameters were measured and renal function tests were done before and during therapy. There was a significant rise in urine output from a mean (+/- SD) of 21 +/- 10 to 43 +/- 23 ml/hr, accompanied by a rise in cardiac output from 6.8 +/- 1.8 to 8.0 +/- 2.3 L/min (p less than or equal to 0.05). There were no significant changes in blood pressure, central venous pressure, or pulmonary capillary wedge pressure. The fractional excretion of sodium, negative free water clearance, and osmolar clearance tended to rise during dopamine therapy. No adverse maternal or fetal effects occurred. We conclude that low-dose dopamine produces a significant increase in urine production with resolution of oliguria in severe preeclampsia.

Sequential plasmafilter-dialysis with slow continuous hemofiltration: additional treatment for sepsis-induced AOSF patients

Five patients with sepsis-induced acute organ system failure were treated by sequential plasmafilterdialysis with slow continuous hemofiltration in addition to conventional therapy. In this way, we were able to associate the possible clearance of mediators and toxic substances achieved by plasmapheresis with an improved clearance of nitrogen waste products, since we added diffusion to the convective effect of hemofiltration. The hypercatabolism was well controlled, and there was a significant improvement in cardiorespiratory parameters at the same time. These patients were retrospectively compared with four conventionally treated patients (100% mortality) and with six others treated by association of conventional therapy and continuous arteriovenous hemodialysis (50% mortality). Despite the small numbers of patients treated and the need of additional studies, our good results (all the patients survived) encourage us to use this approach as an adjunct of conventional therapeutic measures in oliguric and hypercatabolic AOSF patients.

Influence of Haemodialysis Membranes on β&lt;sub&gt;2&lt;/sub&gt;-Microlobulin Kinetics:In Vivo and In Vitro Studies

Amyloidosis of the beta 2-microglobulin (beta 2M) type is a recently recognised complication of dialysis. We studied plasma and ultrafiltrate beta 2M in 36 chronic haemodialysis patients. Long-term dialysis with standard cuprophan membrane in non-oliguric patients and with the AN69 polyacrylonitrile membrane in oliguric patients resulted in lower plasma beta 2M concentrations (means +/- SD, 24.4 +/- 6.6 and 33.0 +/- 8.2 micrograms/ml, respectively) than with cuprophan in oliguric patients (47.0 +/- 13.2 micrograms/ml, P less than 0.01). In acute studies, plasma beta 2M (corrected for haemo-concentration) increased, although not significantly, during cuprophan dialysis (n = 10) from 40.6 +/- 12.2 to 44.8 +/- 7.6 micrograms/ml and decreased during AN69 dialysis (n = 10) from 39.4 +/- 18.0 to 24.3 +/- 7.1 micrograms/ml (P less than 0.02). After 15 min ultrafiltration, beta 2M sieving coefficient in vivo was 0.33 for AN69 but near zero for cuprophan. Total mass transfer of beta 2M across the AN69 membrane during a 4-h dialysis was 142 +/- 45.8 mg (n = 7). AN69, but not cuprophan, membrane fragments incubated in vitro with normal or uraemic plasma exhibited avid [125-I] beta 2M binding (respectively 12.9% vs 0.47% and 6.09% vs 0.06% of total beta 2M bound at 30 min, n = 6, P less than 0.001 for both). No in vitro generation of beta 2M from whole normal or uraemic blood could be demonstrated during incubation with either membrane.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma levels of main granulocyte components during hemodialysis: effects of immunosuppression.

Plasma levels of granulocyte lactoferrin, granulocyte myeloperoxidase and granulocyte elastase in complex with alpha 1-proteinase inhibitor were investigated during hemodialysis in oliguric patients following cadaveric renal transplantation (CRT). The results were compared with those of patients undergoing regular hemodialysis treatment (RDT) using different membrane materials. In RDT patients, plasma lactoferrin levels increased from 61.9 +/- 10.2 to 417.9 +/- 96.7 using dialyzers made of cuprophane. Dialyzers made of polymethyl methacrylate induced an increase of lactoferrin from 166.6 +/- 28.5 to 712.5 +/- 165.9 and dialyzers made of polyacrylonitrile an increase from 122.6 +/- 23.5 to 647.7 +/- 203.6 ng/ml. In CRT patients, in contrast, plasma lactoferrin levels increased from 49.1 +/- 10.9 to 199.6 +/- 45.9 (cuprophane), from 30.1 +/- 6.9 to 252.5 +/- 46.9 (polymethyl methacrylate), and from 43.3 +/- 9.1 to 174.2 +/- 39.3 ng/ml (polyacrylonitrile). On the other hand, the plasma levels of myeloperoxidase and elastase in complex with alpha 1-proteinase inhibitor increased comparably in both groups of patients. Our data suggest that immunosuppression might prevent degranulation of specific granules independently of the used dialyzer membrane material, whereas no effect was observed on two main components of azurophilic granules.

Limited Value of the Fractional Excretion of Sodium Test in the Diagnosis of Acute Renal Failure

The excreted fraction of filtered sodium (FeNa) was examined in 54 patients with acute intrinsic renal failure in whom renal biopsy was performed to determine the morphology of the acute renal disease. In patients with acute tubulointerstitial nephritis oliguric patients had almost constantly elevated FeNa values, whereas in non-oliguric patients with acute tubulointerstitial nephritis this was observed in less than half. The five patients with acute extracapillary glomerulonephritis had an FeNa greater than 1. FeNa values were low, especially in non-oliguric patients who had mild impairment of renal function. The presence of a high FeNa value correlated significantly with severe morphological tubular changes observed on renal biopsy. We conclude that patients with acute tubulointerstitial nephritis cannot be distinguished from those with acute glomerulonephritis by FeNa, as in both types of acute nephritis the FeNa test shows both low and elevated values.

Pharmacology and therapeutic use of low-dose dopamine.

The renal pharmacologic effects of intravenous dopamine in doses of 0.5-3.0 micrograms/kg/min include increases in renal blood flow, glomerular filtration rate, solute excretion, and urine flow. Clinical studies revealed that low-dose dopamine can reverse oliguria, but these studies were poorly controlled, were confounded by the use of other diuretics, had small patient populations, and often did not evaluate mortality or long-term renal function. When used in low doses, side effects are rarely seen. Because of dopamine's effect on hepatic and renal function, changes in drug clearance may occur. Low-dose dopamine may be considered in the early course of oliguric patients; however, specific advantages over other diuretic therapy have not been established.

Effect of haloperidol on dopamine-induced increase in renal blood flow.

Increasing renal blood flow (RBF) by the administration of low-dose dopamine is one mechanism to increase urine output in oliguric patients. This response is mediated in part by stimulation of dopaminergic receptors in the kidney, which could be attenuated by the dopamine blocker haloperidol. We evaluated this interaction by administering both drugs in clinically used doses to six anesthetized mongrel dogs. A dopamine regimen of 2.5 micrograms/kg/min significantly increased RBF along with cardiac output and stroke volume. Simultaneous administration of haloperidol 50 micrograms/kg iv did not influence the ability of low-dose dopamine to increase RBF. Although haloperidol is an antagonist of dopaminergic receptors, the increase in RBF associated with low-dose dopamine is maintained when intravenous haloperidol is concurrently administered to dogs.

Nonoliguric acute renal failure.

Oliguria has been considered a cardinal feature of acute renal failure. However, many recent reports indicate that acute renal failure usually occurs in the setting of well-maintained urine output. Moreover, the nonoliguric state may accompany acute renal failure due to pre- and post-renal azotemia and a variety of renal parenchymal disorders, as well as acute tubular necrosis. Most studies indicate that nonoliguric forms of acute renal failure are associated with less morbidity and mortality than oliguric acute renal failure. Uncontrolled studies also suggest that volume expansion, potent diuretic agents, and renal vasodilators can convert oliguric to nonoliguric acute tubular necrosis if administered early in the course of acute renal failure. However, prospective studies of early intervention in oliguric patients are needed.

Urinary Tract Infection in Oliguric Patients with Chronic Renal Failure

We studied 182 patients with chronic renal failure by urinalysis and urine cultures. Of the patients 27 per cent had significant bacteriuria (more than 105 perml.), 38 per cent had significant pyuria (more than 10 white blood cells per high power field), 19 per cent had urinary tract infection and 7 per cent had symptomatic urinary tract infection. All 12 patients with symptomatic urinary tract infection had significant bacteriuria and 11 had significant pyuria, while 1 had 5 to 10 white blood cells per high power field. Incidences of urinary tract infection differed depending on the primary renal disease (12, 13, 41 and 67 per cent for chronic glomerulonephritis, diabetic nephropathy, polycystic kidney and chronic pyelonephritis, respectively). Among the patients with chronic glomerulonephritis no significant differences were seen in frequencies of bacteriuria and urinary tract infection between male and female patients or between those who did and did not undergo hemodialysis. Also, no significant correlation was seen between bacteriuria and daily urine output but pyuria was significantly more frequent in oliguric patients or those on hemodialysis.

Prognostic Factors in Neonatal Acute Renal Failure

Sixteen infants, 2 to 35 days of age, had acute renal failure, a diagnosis based on serum creatinine concentrations greater than 1.5 mg/dL for at least 24 hours. Eight infants were oliguric (urine flow less than 1.0 mL/kg/h) whereas the remainder were nonoliguric. To determine clinical parameters useful in prognosis, urine flow rate, duration of anuria, peak serum creatinine, urea (BUN) concentration, and nuclide uptake by scintigraphy were correlated with recovery. Nine infants had acute renal failure secondary to perinatal asphyxia, three had acute renal failure as a result of congenital cardiovascular disease, and four had major renal anomalies. Four oliguric patients died: three of renal failure and one of heart failure. All nonoliguric infants survived with mean follow-up serum creatinine concentration of 0.8 +/- 0.5 (SD) mg/dL whereas that of oliguric survivors was 0.6 +/- 0.3 mg/dL. Peak serum creatinine concentration did not differ between those patients who were dying and those recovering. All infants who were dying remained anuric at least four days and revealed no renal uptake of nuclide. Eleven survivors were anuric three days or less, and renal perfusion was detectable by scintigraphy in each case. However, the remaining survivor (with bilateral renal vein thrombosis) recoveredmore » after 15 days of anuria despite nonvisualization of kidneys by scintigraphy. In neonates with ischemic acute renal failure, lack of oliguria and the presence of identifiable renal uptake of nuclide suggest a favorable prognosis.« less

Prognostic Factors in Neonatal Acute Renal Failure

Sixteen infants, 2 to 35 days of age, had acute renal failure, a diagnosis based on serum creatinine concentrations greater than 1.5 mg/dL for at least 24 hours. Eight infants were oliguric (urine flow less than 1.0 mL/kg/h) whereas the remainder were nonoliguric. To determine clinical parameters useful in prognosis, urine flow rate, duration of anuria, peak serum creatinine, urea (BUN) concentration, and nuclide uptake by scintigraphy were correlated with recovery. Nine infants had acute renal failure secondary to perinatal asphyxia, three had acute renal failure as a result of congenital cardiovascular disease, and four had major renal anomalies. Four oliguric patients died: three of renal failure and one of heart failure. All nonoliguric infants survived with mean follow-up serum creatinine concentration of 0.8 +/- 0.5 (SD) mg/dL whereas that of oliguric survivors was 0.6 +/- 0.3 mg/dL. Peak serum creatinine concentration did not differ between those patients who were dying and those recovering. All infants who were dying remained anuric at least four days and revealed no renal uptake of nuclide. Eleven survivors were anuric three days or less, and renal perfusion was detectable by scintigraphy in each case. However, the remaining survivor (with bilateral renal vein thrombosis) recovered after 15 days of anuria despite nonvisualization of kidneys by scintigraphy. In neonates with ischemic acute renal failure, lack of oliguria and the presence of identifiable renal uptake of nuclide suggest a favorable prognosis.

Dopamine and frusemide in oliguric acute renal failure.

Into 24 oliguric patients with acute renal failure (ARF) for whom mannitol and high-dose frusemide had failed to promote a diuresis, dopamine (3 micrograms/kg/min) plus frusemide (10-15 mg/kg/h) were infused for 6-24 h. In 19 of the 24 patients this treatment produced significant increases in diuresis (from 11 +/- 7 to 85 +/- 51 ml/h; p less than 0.001) and natriuresis (from 45 +/- 13 to 88 +/- 22 mEq/1; p less than 0.001), without any significant modification of blood pressure, pulse rate or central venous pressure. 10 of the 24 patients required dialysis: 5 because therapy failed to promote diuresis and the other 5 because of their hypercatabolic state in spite of polyuria. 5 patients died of causes unrelated to ARF. Since all patients who responded were treated within 24 h after the onset of oliguria, it appears to be crucial to administer dopamine and frusemide early, before more severe anatomical and functional damage develops.

Study of alanine aminopeptidase excretion as a test of gentamicin nephrotoxicity.

We studied the urinary excretion of the proximal tubular enzyme alanine aminopeptidase (AAP) by 38 patients who received gentamicin and by 45 similar control patients. AAP excretion by the control patients was highly variable. The pattern of AAP excretion distinguished patients with pre-renal and renal causes for increases in serum creatinine (SCr) but this can be done more simply with the urine to serum creatinine ratio. Peak AAP excretion did not reflect renal damage in oliguric patients and di not identify gentamicin patients with a renal cause for increases in SCr. The level of AAP excretion in the first three days of gentamicin treatment did identify the three patients with renal causes for an increase in SCr and was highest in a patient with symptomatic hypomagnesaemia due to impairment of proximal tubular function. We concluded that study of AAP excretion in normal volunteers receiving three-day courses of aminoglycosides is a valid screening test for nephrotoxicity but that AAP excretion is too non-specific to use in clinical practice.