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      Prevention of Acute Renal Failure in the Critically Ill


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          Acute renal failure (ARF) is a common and important complication of critical illness and many interventions have been proposed to prevent it. The pathogenesis of acute renal failure during critical illness is poorly understood. Animal models are based on the induction of renal ischemia and do not reflect the dominance of sepsis as a cause of ARF in the clinical arena. Although biological rationale exists for several interventions, none have been shown to be effective in large randomized double-blind multicentre trials. The only interventions with close to level I evidence are confined to the attenuation of radiocontrast nephropathy. The effect on such interventions is, however, of limited clinical relevance to critically ill patients. The maintenance of adequate intravascular filling, cardiac output and renal perfusion pressure and the avoidance of hypoxemia, marked anemia and nephrotoxins remain the only justifiable interventions at this time.

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          Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis.

          In patients with cirrhosis and spontaneous bacterial peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. We randomly assigned 126 patients with cirrhosis and spontaneous bacterial peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in dosages that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. In patients with cirrhosis and spontaneous bacterial peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone.
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            Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents.

            Injections of radiocontrast agents are a frequent cause of acute decreases in renal function, occurring most often in patients with chronic renal insufficiency and diabetes mellitus. We prospectively studied 78 patients with chronic renal insufficiency (mean [+/- SD] serum creatinine concentration, 2.1 +/- 0.6 mg per deciliter [186 +/- 53 mumol per liter]) who underwent cardiac angiography. The patients were randomly assigned to receive 0.45 percent saline alone for 12 hours before and 12 hours after angiography, saline plus mannitol, or saline plus furosemide. The mannitol and furosemide were given just before angiography. Serum creatinine was measured before and for 48 hours after angiography, and urine was collected for 24 hours after angiography. An acute radiocontrast-induced decrease in renal function was defined as an increase in the base-line serum creatinine concentration of at least 0.5 mg per deciliter (44 mumol per liter) within 48 hours after the injection of radiocontrast agents. Twenty of the 78 patients (26 percent) had an increase in the serum creatinine concentration of at least 0.5 mg per deciliter after angiography. Among the 28 patients in the saline group, 3 (11 percent) had such an increase in serum creatinine, as compared with 7 of 25 in the mannitol group (28 percent) and 10 of 25 in the furosemide group (40 percent) (P = 0.05). The mean increase in serum creatinine 48 hours after angiography was significantly greater in the furosemide group (P = 0.01) than in the saline group. In patients with chronic renal insufficiency who are undergoing cardiac angiography, hydration with 0.45 percent saline provides better protection against acute decreases in renal function induced by radiocontrast agents than does hydration with 0.45 percent saline plus mannitol or furosemide.
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              Epidemiology, management, and outcome of severe acute renal failure of critical illness in Australia.

              To study the epidemiology, style of management, and outcome of intensive care patients with acute renal failure requiring replacement therapy in Australia. Prospective epidemiologic study. Australian adult intensive care units providing acute renal replacement therapy. Adult intensive care patients with acute renal failure treated with renal replacement therapy. Demographic and clinical data collection for 3 months. A standardized data collection form for each case of severe acute renal failure was used to collect demographic, biochemical, clinical, and outcome data. Severe acute renal failure affected 299 patients (approximately eight cases per 100,000 adults per year). Among these patients, 99 (33.1%) had impaired baseline renal function, 238 (79.6%) needed mechanical ventilation, and 232 (77.6%) needed continuous vasoactive drug administration. Critical care physicians controlled patient care and renal replacement therapy in 289 cases (96.7%). Critical care nurses performed such therapy alone in 288 (96.3%) cases. Continuous renal replacement therapy was used in 292 (97.7%) patients. There was no nephrological input in 173 (57.8%) cases. Predicted mortality rates were 52.1% by Simplified Acute Physiology Score II, 49.5% by Acute Physiology and Chronic Health Evaluation II score, and 51.9% by an acute renal failure-specific score. Actual mortality rate was 46.8%. Only 25 (15.7%) patients were dialysis-dependent at hospital discharge. Of these patients, 20 (80%) had premorbid chronic impairment of renal function. In Australia, critical care physicians and nurses manage severe acute renal failure with limited consultative nephrological input. Renal replacement therapy is continuous and outcomes are satisfactory. Our findings support the view that this approach to management of severe acute renal failure is safe.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                January 2003
                17 November 2004
                : 93
                : 1
                : c13-c20
                aDivisione di Nefrologia, Ospedale San Bortolo, Vicenza, Italy; bDepartment of Intensive Care and Department of Medicine (Melbourne University), Austin and Repatriation Medical Centre, Melbourne, Vic., Australia
                66646 Nephron Clin Pract 2003;93:c13–c20
                © 2003 S. Karger AG, Basel

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                Page count
                Tables: 1, References: 54, Pages: 1
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                Minireview: Current Practice

                Cardiovascular Medicine,Nephrology
                Dopamine,Prostaglandins,Thyroxine,Sepsis,Radiocontrast,Diuretics,Acute kidney failure


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