Acute renal failure mannitol

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. 

Osmotic diuretics such as mannitol act on the proximal tubule and, in particular, the descending limb of the Loop of Henle — portions of the tubule permeable to water. These drugs are freely filtered at the glomerulus, but not reabsorbed therefore, the drug remains in the tubular filtrate, increasing the osmolarity of this fluid. This increase in osmolarity keeps the water within the tubule, causing water diuresis. Because they primarily affect water and not sodium, the net effect is a reduction in total body water content more than cation content. Osmotic diuretics are poorly absorbed and must be administered intravenously. These drugs may be used to treat patients in acute renal failure and with dialysis disequilibrium syndrome. The latter disorder is caused by the excessively rapid removal of solutes from the extracellular fluid by hemodialysis. 

As their name suggests, osmotic diuretics such as mannitol (Osmitrol), isosorbide (Ismotic), and glycerin (Osmoglyn) draw fluid from the tissues of the body through principles of osmosis. Osmotic diuretics are typically given to treat or prevent acute renal failure (kidney failure). They may also be used to relieve intracranial pressure (swelling of the brain) in cases of head injury or hydrocephalus. 

VIsweswaran P, Massin EK, DuboseTD Jr. Mannitol-induced acute renal failure. J Am Soc Nephrol. 1997 154 1985-1987... 

Better OS, Rubinstein i, Winaver JM, Knochel JP. Mannitol therapy revisited (1940-1997). Kidney int 1997 51 886-894. Goldwasser P, Fotino S. Acute renal failure following massive mannitol infusion Appropriate response of tubuloglomerular feedback Arch intern Med 1984 144 2214-2216. 

Whelan TV, Bacon ME, Madden M, Patel TG, Handy R. Acute renal failure associated with mannitol intoxication. Arch Intern Med 1984 144 2053-2055. 

Horgen KJ, OttavianoYL, Watson AJ. Acute renal failure due to mannitol intoxication. Am J Nephrol 1989 9 106-109. 

Rello J,Trigner C, Sanchez JM, Net A. Acute renal failure following massive mannitol infusion. Nephron 1989 53 377-378. Weaver A, Sica DA. Mannitol-induced acute renal failure. Nephron 1987 45 233-235. 

Dormer HR, Sondheimer JH, Cadnapaphornchai P. Mannitol-induced acute renal failure. Medicine 1990 69(3) 153-159. Mansbach AB, Madden SC, Latta H. Light and electron microscopic changes in proximal tubules of rats after administration of glucose, mannitol, suctose or dextran. Lab Invest 1962 11 421-432. 

Therapeutically, mannitol administered parenterally is used as an osmotic diuretic, as a diagnostic agent for kidney function, as an adjunct in the treatment of acute renal failure, and as an agent to reduce intracranial pressure, treat cerebral edema, and reduce intraocular pressure. Given orally, mannitol is not absorbed significantly from the GI tract, but in large doses it can cause osmotic diarrhea see Section 14. 

When renal function is compromised, treatment involves the use of drugs to increase RBF, glomerular filtration rate (GFR) and urine output. In equine patients with acute renal failure (ARF), furosemide (frusemide), dopamine and mannitol (Table 10.1) are the most common drugs utilized Qose-Cunilleras Hinchcliff 1999). 

Mannitol Osmotic diuretic Increases effective circulating volume and RBF May increase GFR May help to flush away debris that may obstruct the tubules May scavenge oxygen radicals Constant i.v. infusion required May induce hyperosmolality High doses may precipitate acute renal failure... 

Mannitol is widely distributed in nature and occurs in the exudates of many plants. It has about half the sweetness of sucrose. Clinically, mannitol is administered intravenously as an osmotic diuretic in patients with acute renal failure. It is not metabolized appreciably, is filtered by the glomerulus, and is not reabsorbed by the tubules hence, it is excreted in urine (Chapter 39). The nonreabsorbable solute holds water, limits back-diffusion, and thus maintains urine volume in the presence of decreased glomerular function. Intravenous mannitol is also used to relieve an increase in pressure and in volume of cerebrospinal fluid. 

There have been reports of oUgiuic acute renal failure with high doses (>200 mg/day) of the osmotic diuretic mannitol, which responded to hemodialysis [28-... 

Dorman HR, Sondheimer JH, Cadnapaphornchai P. Mannitol-induced acute renal failure. Medicine 1990 69(3) 153-159. 

Initial treatment of the acute renal failure consists of intravascular volume repletion and restoration of the blood pressure. Treatment with mannitol, alkalin-... 

Mannitol (e.g., Resectisol) Osmotically inhibits sodium and water reabsorption, initially increases plasma vol -ume and blood pressure. Acute renal failure, acute closed angle glaucoma, brain edema, to remove overdoses of some drugs. Headache, nausea, vomiting, chills, dizziness, polydipsia, lethargy, confusion, and chest pain. 

A report describes mannitol-induced acute renal failure in a diabetic patient taking losartan. 

A case of acute renal failure has been reported in a woman who underwent retinal sui eiy, which occurred after the postoperative use of a total of 2 g of acetazolamide, 80 g of mannitol and 700 mg of ketoprofen. There appear to be no other similar case reports, but note that loop diuretics , (p.949) are known to increase the risk of NSAID-induced acute renal failure. 

Initial treatment of the acute kidney injury consists of intravascular volume repletion and restoration of the blood pressure. Treatment with mannitol, alkaliniza-tion of the urine and diuretics have all been tried with variable success [110, 111, 122,127]. Clearly, supportive care and dialytic intervention when necessary are crucial to allow for adequate recovery. Hemodialysis may be more effective than peritoneal dialysis in highly catabolic patients with rhabdomyolysis-induced renal failure. 

Provide vigorous intravenous hydration and, if needed, osmotic diuresis with mannitol (see p 464) to maintain urine output and reduce the risk of acute hemoglobinuric renal failure. 

If ICP monitoring is performed, rapid and abrapt increases of intracranial pressure can be directly addressed by the infusion of mannitol, for example, or the application of ranitidine. In most patients, however, the management of raised intracranial pressure has to be performed without actual information on its severity. Thus, general rules are followed, such as elevation of the head of the bed to 30 degrees, sedation, minimal stimulation or the administration of mannitol three times a day. Mannitol has been shown to improve survival in a group of patients with acute liver failure (Canalese et al., 1982). If renal failure accomplishes acute liver failure, however, a paradoxical effect can occur with mannitol treatment as serum osmolality increases and volume overload may occur. Therefore plasma osmolality must be checked at least twice a day to assure that it remains <320 mos-mol/1 (Poison and Lee, 2005 Rinella and Sanyal, 2006). 

These include mannitol and sorbitol which act mainly in the proximal tubules to prevent reabsorption of water. These polyhydric alcohols cannot be absorbed and therefore bind a corresponding volume of water. Since body cells lack transport mechanisms for these substances (structure on p.175), they also cannot be absorbed through the intestinal epithelium and thus need to be given by intravenous infusion. The result of osmotic diuresis is a large volume of dilute urine, as in decompensated diabetes melli-tus. Osmotic diuretics are indicated in the prophylaxis of renal hypovolemic failure, the mobilization of brain edema, and the treatment of acute glaucoma attacks (p. 346). 

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