Renal failure acute

Acute renal failure (ARP) is broadly defined as a decrease in glomerular filtration rate (GFR) occurring over hours to weeks that is associated with an accumulation of waste products, including urea and creatinine. Clinicians use a combination of the serum creatinine (Sj-j.) value with change in either or urine output (UOP) as the primary criteria for diagnosing ARF. 

A consensus-derived definition and classification system for ARF has been proposed and is being validated (Fig. 75-1). Components of the system include both GFR and UOP plus two clinical outcomes. Definitions of risk of dysfunction, injury to and /aUure of the kidney, loss of function, and end-stage kidney disease are included in the RIFLE acronym. 

The presentation can be subtle and depends on the setting. Outpatients often are not in acute distress hospitalized patients may develop ARF after a catastrophic event. 

Symptoms in the outpatient setting include change in urinary habits, weight gain, or flank pain. Clinicians typically notice symptoms of ARF before they are detected by inpatients. 

Signs include edema, colored or foamy urine, and, in volume-depleted patients, orthostatic hypotension. 

Under normal conditions, GFR is submaximal because adaptive increases in single nephron GFR follow loss of damaged nephrons. Sensitized animal models that mimic risk factors commonly found in patients with drug-induced acute renal failure are advisable. This need should stimulate research in the field of safety pharmacology. The choice of the species, strain, and sex of test animals should take into account physiological and/or pharmacotoxicological specificities. 

Acute renal failure (ARF) is the deterioration of renal failure over a period of hours to days, resulting in the failure to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasis. 

ARF due to toxic or ischemic injury is the clinical syndrome referred to as acute tubular necrosis common disease with high overall mortality (approximately 50%). Little progress has been made in treatment since the advent of dialysis more than 30 years ago, [7]. Table 7.4 summarizes the known risk factors for ARF, which should always be kept in mind during drug development (especially in clinical trials). 

Renal Function—Measurement of effects on urine excretion in saline-loaded rats Renal D5mamics— Measurement of renal blood flow, GFR, and clearance 

Upon completion of the chapter, the reader will be able to  

Assess a patient s kidney function based on clinical presentation, laboratory results, and urinary indices. 

Identify pharmacotherapeutic outcomes and endpoints of therapy in a patient with acute renal failure. 

Apply knowledge of the pathophysiology of acute renal failure to the development of a treatment plan. 

Design a diuretic regimen that considers the pharmacokinetic and pharmacodynamic 

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Inflammatory and immune diseases Autoimmune disease (A,I), asthma (A), osteoarthritis (I), rheumatoid arthritis (I), septic shock (A,I), infections (A,I), familial cold auto-inflammatory syndrome (I), Muckle Wells syndrome (I), chronic infantile neurological cutaneous and articular syndrome/neonatal onset multisystemic inflammatory disease (CINCA/NOMID) (I), Crohn s disease (I), gout (I), acute renal failure (A,l)... 

Renal—hematuria, cystitis, elevated blood urea nitrogen, polyuria, dysuria, oliguria, and acute renal failure in those with impaired renal function... 

HMG-CoA REDUCTASE INHIBITORS AND FlBRIC ACID DERIVATIVES. The antihyperlipidemic drugp, particularly die HMG-CoA reductase inhibitors, have been associated with skeletal muscle effects leading to rhab-domyolysis. Rhabdomyolysis is a very rare condition in which muscle damage results in die release of muscle cell contents into die bloodstream. Rhabdomyolysis may precipitate renal dysfunction or acute renal failure The nurse is alert for unexplained muscle pain, muscle tenderness, or weakness, especially if tiiey are accompanied by malaise or fever. These symptoms should be reported to die primary health care provider because the drug may be discontinued. 

Mannitol (Osmitrol) is used for the promotion of diuresis in the prevention and treatment of the oliguric phase of acute renal failure as well as for the reduction of IOP and the treatment of cerebral edema Urea (Ureaphil) is useful in reducing cerebral edema and in die reduction of IOE Glycerin (Osmoglyn) and isosorbide (Ismotic) are used in the treatment of acute glaucoma and to reduce IOP before and after eye surgery. 

There is a risk of acute renal failure when iodi-nated contrast material that is used for radiological studies is administered with metformin. Metformin therapy is stopped for 48 hours before and after radiological studies using iodinated material. Alcohol, amiloride, digoxin, morphine, procainamide, quini-dine, quinine ranitidine, triamterene, trimethoprim, vancomycin, cimetidine, and furosemide all increase the risk of hypoglycemia. There is an increased risk of lactic acidosis when metformin is administered with the glucocorticoids. 

Human immune globulin intravenous (IGIV) products have been associated with renal impairment, acute renal failure, osmotic nephros s and death. Individuals with a predication to acute renal failure, such as those with preexisting renal disease, diabetes mellitus individuals older than 65 years or patients receiving nephrotoxic drugs should not be given human IGIV products... 

Renal Effects. Hemorrhage of the medullary layer of the kidneys was reported in three persons who died following ingeshon of endosulfan (Terziev et al. 1974). Acute renal failure was a major contributor to the deaths of two individuals who ingested unknown amounts of endosulfan (Blanco-Coronado et al. 1992 Loetal. 1995). In both cases, postmortem examination revealed extensive tubular necrosis. In contrast, no kidney lesions were found in a man who died 4 days after ingesting approximately 260 mg endosulfan/kg (Boereboom et al. 1998). 

There are numerous abnormalities of cysteine metabolism. Cystine, lysine, arginine, and ornithine are excreted in cystine-lysinuria (cystinuria), a defect in renal reabsorption. Apart from cystine calculi, cystinuria is benign. The mixed disulfide of L-cysteine and L-homocysteine (Figure 30-9) excreted by cystinuric patients is more soluble than cystine and reduces formation of cystine calculi. Several metabolic defects result in vitamin Bg-responsive or -unresponsive ho-mocystinurias. Defective carrier-mediated transport of cystine results in cystinosis (cystine storage disease) with deposition of cystine crystals in tissues and early mortality from acute renal failure. Despite... 

Gutch CF, Tomhave WG, Stevens SC. 1965. Acute renal failure due to inhalation of trichloroethylene. AnnlntMed 63 128-134. 

O Brien KL et al. Epidemic of pediatric deaths from acute renal failure caused by diethylene glycol poisoning. Journal of the American Medical Association, 1998, 279(15) 175-78. 

Arnold, P.E., Lumlertgul, D., Burke, T.J. and Schrier, RW. (1985). In vitro vems in vivo mitochrondrial calcium loading in ischaemic acute renal failure. Am. J. Physiol. 248, F845-850. 

Paller, M.S., Hoidal, J.R. and Ferris, T.F. (1984). Oxygen free radicals in ischaemic acute renal failure in the rat. J. Clin. Invest. 74, 1156-1164. 

Acute renal failure, visual deficits, microangiopathic hemolytic anemia, and pre-eclampsia/eclampsia... 

Acute renal failure/microangiopathic hemolytic anemia o Drugs of choice—nicardipine, fenoldopam... 

Besides hypotension, the most frequent adverse reaction to an ACE inhibitor is cough, which may occur in up to 30% of patients. Patients with an ACE inhibitor cough and either clinical signs of heart failure or LVEF less than 40% may be prescribed an ARB.3 Other, less common but more serious adverse effects to ACE inhibitors and ARBs include acute renal failure, hyperkalemia, and angioedema. 

Develop strategies to minimize the occurrence of acute renal failure. 

O Equations to estimate creatinine clearance that incorporate a single creatinine concentration (e.g., Cockcroft-Gault) may underestimate or overestimate kidney function depending on whether acute renal failure is worsening or resolving. 

There is no evidence that supports drug therapy in hastening the recovery period, decreasing length of hospitalization, or improving survival in acute renal failure. 

Loop diuretics are the diuretics of choice for the management of volume overload in acute renal failure. 

Identifying patients at high risk for development of acute renal failure and implementing preventive methods to decrease its occurrence or severity is critical. 

Acute renal failure (ARF) is a potentially life-threatening clinical syndrome that occurs primarily in hospitalized patients and frequently complicates the course of the critically ill. It is characterized by a rapid decrease in glomerular filtration rate (GFR) and the resultant accumulation of nitrogenous waste products (e.g., creatinine and urea nitrogen), with or without a decrease in urine output. A recent consensus statement... 

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