Acute kidney insufficiency

Morin D, Dumas ML, Valette H, Dumas R.Transitory acute kidney insufficiency and insulin-dependent aftertreatment of kala-azar with pentamidine and N-methylglucamine antimony. Archives francaises de pediatrie. 1991 May 48(5) 349-51. 

Clinical manifestation. It includes several syndromes a) pulmotoxic and irritative syndrome - expressed by catarrhal changes on the contact mucosa and respiratory tract, toxic pulmonary oedema b) hemotoxic syndrome - expressed by severe hemolysis of different degrees, in the severe forms - hemolytic shock and anaemia c) hepatal syndrome - characterised by subicterus or icterus, increased liver and bilirubinaemia d) renal syndrome - by oliguria or anuria, pathological deviations in the urine and acute kidney insufficiency. In the extremely severe forms consciousness is disordered. Laboratory blood and urine chemical tests show evidence of phenol metabolites, data for blood damage (increased values of free hemoglobin, reduced number of erythrocytes), positive liver tests etc. 

Very recently examples of rheological studies on blood were published elsewhere [242]. As an example we want to discuss some results of these investigations here. Fig. 4.45 shows the surface tension response after a step-type area change of a pendent drop area by about 10% for 6 serum samples from one and the same patient at different stages of his acute kidney insufficiency [243]. 

Fig. 4.45 Surface tension response of serum from a 46 years old patient admission suffering from an acute kidney insufficiency admission to hospital (), thfir PY (O. Cl), after haemodialysis ( ), polyuria ( ), leaving the hospital ( )...

Figure 12.4. Dynamic surface tensions as a function of log t for various biological liquids x, serum of a 49 years old patient suffering from acute kidney insufficiency A, gastric juice of an 18 years old patient suffering from gastric ulcer brain , liquor of a 13 year old patient suffering from cerebrospinal encephalitis 0 urine of a 49 years old patient suffering from chronic nephritis...

The sterile peritoneal dialysis solutions are infused continuously into the abdominal cavity, bathing the peritoneum, and are then continuously withdrawn. The purpose of peritoneal dialysis is to remove toxic substances from the body or to aid and accelerate the excretion function normal to the kidneys. The process is employed to counteract some forms of drug or chemical toxicity as well as to treat acute renal insufficiency. Peritoneal dialysis solutions contain glucose and have an ionic content similar to normal extracellular fluid. Toxins and metabolites diffuse into the circulating dialysis... 

A healthy 31-year-old man developed acute renal insufficiency 18 hours after inhaling cocaine 5 g. His blood pressure was 150/100 mmHg, his serum creatinine 177 pmol/l, creatine phosphokinase activity 107 U/l, and serum potassium concentration 3.8 mmol/1. The urinary sodium concentration was 30 mmol/1 and there was a trace of protein and 1-2 red blood cells per high-power field. Immunological studies were unremarkable. Ultrasound showed kidneys of normal size with hyperechogenity of the right kidney. Over the next 10 days he recovered spontaneously. 

A prerenal mechanism secondary to the vascular leak syndrome is commonly involved in the pathophysiology of acute renal insufficiency. In addition it has been suggested that a direct intrinsic intrarenal effect of aldesleukin with a higher than expected reduction in glomerular filtration rate or tubular dysfunction (85,89) is involved. Several isolated cases of acute interstitial or tubulointerstitial nephritis with predominant T lymphocjde infiltration of the kidneys (90-92) and the exacerbation of a subchnical IgA glomerulonephritis (93) suggested altered cell-mediated immunity. 

In a retrospective study of 64 patients, mean age 71 years, with acute renal insufficiency associated with an ACE inhibitor, over 85% presented with overt dehydration due to diuretics or gastrointestinal fluid loss (69). Bilateral renal artery stenosis or stenosis in a solitary kidney was documented in 20% of cases. In seven patients dialysis was required, but none became dialysis dependent. After resolution of acute renal insufficiency, the plasma creatinine concentration returned to baseline and renal function was not significantly worsened. Two-year mortality was the highest in a subgroup of patients with pre-existing chronic renal insufficiency. 

Of 207 patients with ischemic stroke, stages III or IV, treated with an intravenous infusion of dextran 40 over 4 days, 9 (4.3%) developed acute renal insufficiency attributable to the dextran. Oliguria occurred after a mean time of 4 (range 3-6) days. The incidence of dextran-induced renal insufficiency was higher in patients with pre-existing impaired kidney function. The high risk of death in the patients who developed renal insufficiency was due to non-renal complications, notably pneumonia and pulmonary embolism (10). 

In a report of two cases of anuric acute renal insufficiency induced by dextran 40, diuresis and renal function were quickly restored to normal after plasmapheresis (12). Renal biopsy showed normal kidneys, except for swelling and vacuolation of renal tubules suggestive of osmotic nephrosis. 

Diltiazem was associated with the development of acute renal insufficiency in a patient being treated for severe retrosternal chest pain who had neither primary kidney disease nor urinary tract obstruction (8,9). 

One renal transplant recipient developed the nephrotic syndrome, with microscopic hematuria and non-ohguric acute renal insufficiency within 15 days after starting foscarnet therapy for cytomegalovirus infection (13). A kidney biopsy showed crystals in aU glomeruh and in the proximal tubules. The crystals consisted of several forms of foscarnet salts. Renal function and proteinuria nevertheless improved progressively, and a second transplant biopsy 8 months after the first one showed... 

The pathophysiology of acute renal insufficiency due to immunoglobulins is probably related to hyperosmolar renal damage, due to sucrose present in 50 ml intravenous formulations (13,43,85-87). Acute renal insufficiency has also been attributed to sucrose in a kidney allograft... 

A 62-year-old woman developed acute renal insufficiency after using topical ketoprofen for 5 days (11). She had several predisposing factors to NSAID-induced acute renal insufficiency, such as advanced age, chronic renal impairment due to polycystic kidney disease, and treatment with an ACE inhibitor and furosemide. 

In a 6-day-old neonate with a solitary hypodysplastic kidney, suspected sepsis, and acute renal insufficiency, venovenous hemodiafiltration with a high-flux membrane was successfully used to treat a 10-fold overdose of vancomycin (115). 

Acute kidney injury can be severe with foscarnet. Some degree of kidney injury has been reported to occur in as many as two-thirds of patients treated with foscarnet and has been a dose-limiting toxicity in 10-20% of cases [51-56]. Despite dose reduction or discontinuation of foscarnet, azotemia typically progresses for at least a few days before resolving. It may be possible to continue foscarnet at reduced doses in some patients with mild azotemia. Foscarnet-induced AKI is usually reversible, although temporary dialysis may be required [57]. Recovery may be slow, particularly in patients with preexisting kidney insufficiency. Elevated serum creatinine concentrations may persist for several months after discontinuation of foscarnet. Foscarnet nephrotoxicity may be also associated with mild proteinuria. Volume expansion with isotonic saline was effective in reducing the incidence of foscarnet nephrotoxicity to 13%, compared to 66% in non-hydrated historical controls, and allowed patients with prior kidney insufficiency to receive foscarnet without further reduction of kidney function [54, 58]. Intermittent, rather than continuous, infusion of foscarnet may also reduce the incidence of nephrotoxicity [52]. 

Although the kidneys continually produce urine, the bladder stores the urine for intermittent elimination. For the initial diagnosis and management of acute circulatory insufficiency, a catheter can be inserted into the bladder for measuring urine output. In contrast to thirst, which is a relatively insensitive indicator of volume depletion, urine output is generally diminished with inadequate fluid administration and increases with appropriate resuscitation. This presumes, of course, that acute renal failure or medications such as diuretics are not altering the expected response. Adults should produce at least 0.5 to 1 mL/kg per hour of urine, whereas children up to 12 years of age should produce at least 1 mL/kg per hour (2 mL/kg per hour if younger than 1 year of age). ... 

Haas M, Spargo BH, Wit EJC, Meehan SM. Etiologies and outcome of acute renal insufficiency in older adults A renal biopsy study of 259 cases. Am J Kidney Dis 2000 35 433 47. 

Historically, reversible acute renal insufficiency occurred frequently in transplant recipients during the first 6 months of cyclosporine therapy. The incidence of chronic kidney disease in nonrenal transplant patients is reported to be from 10% to 83%. " Recent data indicate that the 5-year risk of CKD after transplantation of a nonrenal organ ranges from 7% to 21%, depending on the type of organ transplanted. In addition, the occurrence of CKD in these patients is associated with more than a fourfold increase in the risk of death. 

Acute renal insufficiency usually improves with dose reduction, and treatment of contributing illness or the discontinuation of interacting drugs. Chronic kidney disease is usually irreversible, but progressive toxicity may be limited by discontinuation of cyclosporine therapy or dose reduction, with the continuation of other immunosuppressants (e.g., prednisone or azathioprine). 

Acute Renal Failure By constricting the efferent arteriole, Angll helps to maintain adequate glomerular filtration when renal perfusion pressure is low. Consequently, ACE inhibition can induce acute renal insufficiency in patients with bilateral renal artery stenosis, stenosis of the artery to a single remaining kidney, heart failure, or volume depletion owing to diarrhea or diuretics. Older patients with congestive heart failure are particularly susceptible to ACE inhibitor-induced acute renal failure. However, nearly aU patients who receive appropriate treatment recover renal function without sequelae. 

---