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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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The impact of renal dysfunction in outpatients with systolic heart failure
From CHEST, 10/1/05 by Jun R. Chiong

PURPOSE: Renal function is an underappreciated prognostic factor in heart failure (HF), and renal insufficiency is commonly viewed as a relative contraindication for some proven efficacious therapies. It is unclear whether ACE inhibitors, aldosterone antagonists and beta-blockers exert similar benefits in patients with kidney disease as these patients are infrequently enrolled in HF trials.

METHODS: We analyzed data from a prospective cohort of heart failure patients followed in a specialty clinic. Renal insufficiency was defined as creatinine clearance <60 mL/min using the Cockcroft-Gault equation. Our hypothesis was that renal insufficiency was an independent predictor of outcome as measured by hospitalizations.

RESULTS: In our database of 167 outpatients, 71 (42%) had creatinine clearances calculated at > 60 mL/min (Group 1; mean creatinine clearance of 81.6 mL/min); 96 (58%) had creatinine clearances calculated < 60 mL/min (Group 2; mean creatinine clearance of 39.7 mL/min). There was no difference in the presence of co-morbidities including hypertension, diabetes, and hyperlipidemia. Group 2 patients were older (71 [+ or -] 17 versus 60 [+ or -] 9 years) and had more atrial fibrillation (32% vs. 18%; p = 0.043). The log of pro-brain natriuretic peptide (pro-BNP) level was higher in Group 2 (7.6 + 1.5 vs. 6.7 + 1.5; p<0.0001). The two Groups were similar regarding the etiology of heart failure (52% ischemic in Group 1; 57% in Group 2; p=NS), and advanced heart failure NYHA III/IV (61% in Group 1; 62% in Group 2; p = NS). Patients in both groups received identical therapy, except statin therapy (61% in Group 1; 41% in Group 2; p = 0.011). All cause hospitalization rate for Group 2 was greater compared to Group 1 patients (1.6 vs. 1.2 admissions per patient; p<0.05).

CONCLUSION: Despite similarities in therapies, co-morbidities, NYHA functional class and etiology of heart failure, patients with renal dysfunction with systolic heart failure had a greater all cause hospitalization rate than patients with preserved renal function.

CLINICAL IMPLICATIONS: Abnormal renal function is prevalent in patients with systolic heart failure and is an independent prognostic factor for hospitalization.

DISCLOSURE: Jun Chiong, None.

Jun R. Chiong MD * Binu Jacob MD Robert F. Percy MD Hector P. Sanchez MD Anabel C. Castro MD Alan B. Miller MD University of Florida, Jacksonville, FL

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