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Renal failure

Renal failure is the condition where the kidneys fail to function properly. Physiologically, renal failure is described as a decrease in the glomerular filtration rate. Clinically, this manifests in an elevated serum creatinine. more...

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It can broadly be divided into two categories: acute renal failure and chronic renal failure.

Chronic renal failure (CRF) develops slowly and gives few symptoms initially. It can be the complication of a large number of kidney diseases, such as IgA nephritis, glomerulonephritis, chronic pyelonephritis and urinary retention. End-stage renal failure (ESRF) is the ultimate consequence, in which case dialysis is generally required while a donor for renal transplant is found.
Acute renal failure (ARF) is, as the name implies, a rapidly progressive loss of renal function, generally characterised by oliguria (decreased urine production, quantified as less than 400 to 500 mL/day in adults, less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants), body water and body fluids disturbances and electrolyte derangement. An underlying cause must be identified to arrest the progress, and dialysis may be necessary to bridge the time gap required for treating these underlying causes.

Acute renal failure can present on top of (i.e. in addition to) chronic renal failure. This is called acute-on-chronic renal failure (AoCRF). The acute part of AoCRF may be reversible and the aim of treatment, like in ARF, is to return the patient to their baseline renal function, which is typically measured by serum creatinine. AoCRF, like ARF, can be difficult to distinguish from chronic renal failure, if the patient has not been followed by a physician and no baseline (i.e. past) blood work is available for comparison.

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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

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