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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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High troponin levels in critically ill patients with renal failure and no acute coronary syndrome: incidence and impact on mortality
From CHEST, 10/1/05 by Vijo Poulose

PURPOSE: High cardiac troponin levels are commonly seen in medical intensive care (MICU) patients with renal failure and no clinical evidence of acute coronary syndrome (ACS). We looked at the incidence of elevated troponin levels in this group of patients and the impact on mortality.

METHODS: We prospectively collected data on all MICU patients who met the following criteria:a) Renal failure--defined as serum creatinine > 140 [micro]mol/L (upper limit of reference range) b) No evidence of ACS (anginal pain, acute ST or T changes on ECG). All patients who fell into the study group had a troponin T level done within the first 24 hours of ICU admission. Troponin T levels [greater than or equal to] 0.1 ng/mL were considered as high. Our primary outcome was the 28-day all cause mortality. We also looked at the correlation between the troponin levels and creatinine clearance as calculated from the Cockroft-Gault equation.

RESULTS: Fifty one patients met the study criteria. Twenty two patients (43%) had elevated troponin T levels. Six of these 22 patients died (mortality rate 27%). The mortality rate in the 29 patients with normal troponin levels was 34%. The severity of illness was similar in both groups(using the Logistic Organ Dysfunction Score). The troponin levels poorly correlated with the levels of creatinine clearance (r2 = 0.005).

CONCLUSION: In the absence of ACS, elevated troponin T levels in MICU patients with renal insufficiency do not appear to confer an increased mortality.

CLINICAL IMPLICATIONS: High troponin T levels in this group of patients may not be an important risk factor for death. Larger studies are needed to validate this finding.

DISCLOSURE: Vijo Poulose, None.

Vijo Poulose MBBS * Siau Chuin MBBS Alvin Ng MBBS Chong-Hiok Tan MB, ChB Changi General Hospital, Singapore, Singapore

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