Treatment of acute renal failure

Acute renal failure is a life threatening illness whose mortality has remained high since the introduction of hemodialysis 25 years ago, despite advances in supportive care. Acute renal failure is an extremely morbid and costly disorder with a significant proportion of patients progressing to end-stage renal disease requiring dialysis. To the nephrologist, acute renal failure remains an extremely frustrating disease, because the pathophysiology is not well understood and the limited therapeutic options force the nephrologist to sit on the sidelines and wait for renal function to return. For example, dialysis remains the only FDA-approved treatment for acute renal failure, but dialysis may also cause renal injury that prolongs renal failure. The purpose of this perspective is to understand the results of the recent, largely negative, clinical trials in view of recent advances in the epidemiology of ARF. This review will also discuss diagnostic tools, strategies for improved design of clinical trials, and other therapeutic interventions that will be needed to properly treat acute renal failure in the 21st century.     

Mannital induced acute renal failure

14 cases of mannitol-induced acute renal failure were reported. The dosage of mannitol used varied widely. In all cases serum Na+, HCO3- were decreased, K+ and BUN increased significantly. Serum osmolality was measured in 5 cases. The osmolal gap was increased greatly, 77.4mOsm/kg. H2O in average. The increase of osmolal gap may play an important role in acute renal failure by causing intensive renal vasocontraction. Monitoring of serum osmolality or osmolal gap can help to prevent mannitol intoxication. The decrease of serum Na+ may be a warning sign of increased osmolal gap. Hemodialysis is the best way for the treatment of mannitol-induced acute renal failure.     

Prevention of acute renal failure

Acute renal failure (ARF) induced by therapeutic agents that are nephrotoxic (e.g., gentamicin, cisplatin, amphotericin, and nonsteroidal anti-inflammatory drugs) or hypotension associated with anesthesia and surgery unfortunately occur with some regularity in small animal practice. Several clinical conditions have been identified that can increase the risk of hospital-acquired ARF in dogs. Recognition of these risk factors allows the clinician to assess the risk/benefit ratio for various drugs and/or procedures. Additionally, initiating protective measures and increasing the monitoring of renal function in those patients that require potentially harmful treatment may decrease the incidence of hospital-acquired ARF.     

Outcomes in acute renal failure

OBJECTIVE: To compare, using decision analytic techniques, maternal and fetal risk and benefits of three strategies for the management of preterm labour after 32 weeks. These strategies are empiric tocolysis, no tocolysis, or amniocentesis for fetal maturity testing. DATA SOURCES: Published medical literature provided the probabilities, including those for tocolysis efficacy, maternal and neonatal outcomes, and steroid efficacy. DATA: Synthesis Separate decision trees were created for hypothetical cohorts of patients presenting with preterm labour at 32, 34, and 36 weeks of gestation to compare strategies. The primary outcome was the total number of expected adverse maternal and neonatal events for each strategy at each gestational age. RESULTS: At 32 weeks tocolysis yielded the lowest total number of adverse maternal and neonatal events. At 34 weeks, both tocolysis and no tocolysis yielded similar overall outcomes. At 36 weeks most clinical outcomes were good regardless of strategy. CONCLUSIONS: This analysis supports the empiric use of tocolytics at 32 weeks. At 34 weeks, either tocolysis or no tocolysis appear to be reasonable alternatives. At 36 weeks no tocolysis is probably preferred. This analysis also suggests that amniocentesis should not be employed in the management of preterm labour at these gestational ages.     

Orthostatic acute renal failure in a renal transplant

Complications due to ureteric obstruction are an occasional cause for renal transplant dysfunction. Here we report an unusual case of orthostatic renal failure in a renal transplant recipient. Our patient had the previously reported predisposing risk factors including: female sex, obesity, and lax abdominal musculature. It is important to recognize this unusual complication of renal transplantation early in order to preserve long-term graft function.     

The Tenckhoff catheter in acute renal failure

The results of a retrospective study of routine measurement of haemoglobin at the examination of one-year-old children at Gr?land mother and child clinic during 1989-91 showed that 37% of the children had anaemia. There was no difference between immigrants and the European population. There was no correlation between anaemia and sex in either of the population groups. This may imply that routine haemoglobin measurement should be generally introduced as part of the regular control of one-year-old children.     

Pathophysiology of experimental nonoliguric acute renal failure

We have identified an integral membrane protein of 145 kD (estimated by SDS-PAGE) of rat liver nuclear envelopes that binds to WGA. We obtained peptide sequence from purified p145 and cloned and sequenced several cDNA clones and one genomic clone. The relative molecular mass of p145 calculated from its complete, cDNA deduced primary structure is 120.7 kD. Antibodies raised against a synthetic peptide represented in p145 reacted monospecifically with p145. In indirect immunofluorescence these antibodies gave punctate staining of the nuclear envelope. Immunogold EM showed specific decoration of the nuclear pores. Thus p145 is an integral membrane protein located specifically in the "pore membrane" domain of the nuclear envelope. To indicate this specific location, and based on its calculated relative molecular mass, the protein is termed POM 121 (pore membrane protein of 121 kD). The 1,199-residue-long primary structure shows a hydrophobic region (residues 29-72) that is likely to form one (or two adjacent) transmembrane segment(s). The bulk of the protein (residues 73-1199) is predicted to be exposed not on the cisternal side but on the pore side of the pore membrane. It contains 36 consensus sites for various kinases. However, its most striking feature is a repetitive pentapeptide motif XFXFG that has also been shown to occur in several nucleoporins. This nucleoporin-like domain of POM 121 is proposed to function in anchoring components of the nuclear pore complex to the pore membrane.     

Oxidant mechanisms in toxic acute renal failure

Setting up a puppy training program is one of the most important services veterinarians can offer. Puppy socialization classes aim not only to socialize the puppies so that they learn to interact well with children, adults, and other dogs, but also to teach basic obedience exercises. The classes build a strong bond between puppy, owner, and veterinary clinic. This article covers the techniques used, the structure of the classes, and outlines benefits for the dog, owner, veterinarian, and community.     

Mechanisms for oliguria in acute renal failure

Equations previously developed to describe the enterohepatic circulation of the major biliary bile acids in man (Gastroenterology 67:887, 1974) were modified in order to predict the effect on biliary bile acid composition and pattern of amino acid conjugation after prototypic perturbations of the enterohepatic circulation in man. For the steroid moiety, the effects of bile acid feeding, increased recycling frequency, decreased intestinal conservation, and increased dehydroxylation were simulated. For the glycine or taurine moiety, the effect of increased deconjugation or preferential loss of one of the amino acid moieties was simulated. For the steroid moiety, the steady state biliary bile acid composition reflects the balance between input and conservation for each bile acid. Similarly, the distribution of bile acids between glycine and taurine conjugates reflects the balance between conjugation and conservation for each amino acid moiety. Because these values may vary widely and independently, analysis of biliary bile acid composition in terms of the steroid moiety or the glycine-taurine ratio per se cannot be used to infer the relative rates of input or conjugation.