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Acute renal failure

Acute renal failure (ARF) is a rapid loss of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney. Depending on the severity and duration of the renal dysfunction, this accumulation is accompanied by metabolic disturbances, such as metabolic acidosis (acidification of the blood) and hyperkalaemia (elevated potassium levels), changes in body fluid balance, and effects on many other organ systems. more...

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It can be characterised by oliguria or anuria (decrease or cessation of urine production), although nonoliguric ARF may occur. It is a serious disease and treated as a medical emergency.

Causes

Renal failure, whether chronic or acute, is usually categorised according to pre-renal, renal and post-renal causes:

  • Pre-renal (causes in the blood supply):
    • hypotension (decreased blood supply), usually from shock or dehydration and fluid loss, heart attack
    • vascular problems, such as atheroembolic disease and renal vein thrombosis (which in part may be secondary to loss of coagulation factors due to renal dysfunction)
  • Renal (damage to the kidney itself):
    • infection
    • toxins or medication (e.g. some NSAIDs, aminoglycoside antibiotics, amphotericin B, iodinated contrast, lithium)
    • rhabdomyolysis (breakdown of muscle tissue) - the resultant release of myoglobin in the blood affects the kidney; it can be caused by injury (especially crush injury and extensive blunt trauma), statins, MDMA (ecstasy) and some other drugs
    • hemolysis (breakdown of red blood cells) - the hemoglobin damages the tubules; it may be caused by various conditions such as sickle-cell disease, and lupus erythematosus
    • multiple myeloma, either due to hypercalcemia or "cast nephropathy" (multiple myeloma can also cause chronic renal failure by a different mechanism)
    • Acute glomerulonephritis which may due to a variety of causes, such as anti glomerular basement membrane disease/Goodpasture's syndrome, Wegener's granulomatosis or acute lupus nephritis with systemic lupus erythematosus
  • Post-renal (causes in the urinary tract):
    • urinary retention (as a side-effect of medication or due to benign prostatic hypertrophy, kidney stones)
    • pyelonephritis
    • obstruction due to abdominal malignancy (e.g. ovarian cancer, colorectal cancer)

Diagnosis

Renal failure is generally diagnosed either when creatinine or blood urea nitrogen tests are markedly elevated in an ill patient, especially when oliguria is present. Previous measurements of renal function may offer comparison, which is especially important if a patient is known to have chronic renal failure as well. If the cause is not apparent, a large amount of blood tests and examination of a urine specimen is typically performed to elucidate the cause of acute renal failure, medical ultrasonography of the renal tract is essential to rule out obstruction of the urinary tract.

Consensus criteria for the diagnosis of ARF are:

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Daily hemodialysis improves survival in acute renal failure in the ICU
From CHEST, 6/1/05 by Boban Thomas

To the Editor:

In the excellent special report by Dr. Vincent on evidence-based medicine in the ICU, no mention was made about the beneficial effect of daily hemodialysis (DH) in patients with acute renal failure (ARF). Schiffl and colleagues (1) and Bonventre (2) have demonstrated that a regime of DH was superior to alternate-day hemodialysis (ADH) in this cohort of patients who typically have a high mortality. (1,2) Better uremic control, fewer hypotensive episodes, and more rapid resolution of ARF was noted in the DH group. Notably, among those patients with a normal urinary output at enrollment, 73% in the ADH group and only 21% in the DH group became oliguric. This could be related to the fewer hypotensive episodes in the DH group. Better uremic control and improved volume status could have contributed to the improved survival as well. This study, along with another study by Ronco and colleagues, (3) call for intensive renal replacement therapy in the form of DII or continuous venovenous hemofiltration in all patients in the ICU with ARF.

Boban Thomas, MD, FCCP

Francisco Munoz, MD

Hospital Fernando Fonseca

Lisbon, Portugal

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml).

Correspondence to: Boban Thomas, MD, FCCP, Hospital Fernando Fonseca, Av Almirante Gago Coutinho, Lisbon 1700-029, Portugal; e-mail: boban_thomas@lycos.com

REFERENCES

(1) Schiffl H, Lang SM, Fischer R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med 2002; 346:305-310

(2) Bonventre JV. Daily hemodialysis: will treatment each day improve the outcome in patients with acute renal failure? N Engl J Med 2002; 346:362-364

(3) Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous hemofiltration on outcomes of acute renal failure: a prospective randomized trial. Lancet 2000; 356:26-30

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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