Renal failure, acute pathophysiology

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

The pathophysiology, clinical manifestations, diagnosis, and treatment of acute renal failure and chronic kidney disease (CKD) or end-stage renal disease are discussed in Chaps. 75 and 76, respectively. 

Rossen B, Steiness I. The pathophysiology of acute renal failure after chlorprothixene overdosage. Acta Med Scand 1981 209(6) 525-7. 

De Vriese AS, Robbrecht DL, Vanholder RC, Vogelaers DP, Lameire NH. Rifampicin-associated acute renal failure pathophysiologic, immunologic, and clinical features. Am J Kidney Dis 1998 31(1) 108-15. 

Traditionally, when searching for the etiology of AKI, the clinician s will subdivides the potential causes of a sudden decline of GFR into one of three general pathophysiologic processes pre renal failure, intrarenal failure or post renal failure [1]. Recently, Miet et al [ 52] in discussing drug-induce acute kidney injury detailed two additional mechanisms that need to be considered in addition to those outlined in Table 2. 

Lieberthal W, Levinsky NG. Acute renal failure. In The kidney physiology and pathophysiology. Seldin W, Giebish G (editors). Raven Press, New York 1992 p 3181-3225. 

Stein JH, Gottschall J, Osgood RW, Ferris TF Pathophysiology of a nephrotoxic model of acute renal failure. Kidney Int 8 27-41, 1975... 

Llach F, Felsenfeld AJ, Haussler MR.The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. N Engl J Med 1981 305 117-123. 

Bames JL, McDowell EM, McNeil JS, et al. 1980. Studies on the pathophysiology of acute renal failure. V. Effect of chronic saline loading on the progression of proximal tubular injury and functional impairment following administration of mercuric chloride in the rat. Vichows Arch B 32 233-260. 

Figure 45-1 i Pathogenesis of ischemic acute renal failure. Hypoxic insults cause vascular responses and tubular damage. (From Bonventre Weinberg JM. Recent advances in the pathophysiology of ischemic acute renal failure. J Am Soc Nephrol 2003 14 2199-210.)... 

Bonventre JV, Weinberg JM. Recent advances in the pathophysiology of ischemic acute renal failure. J Am Soc Nephrol 2003 14 2199-210. 

Table 2. Classification of various drugs based on pathophysiologic categories of acute renal failure.

Ischemic, nephrotoxic, and septic rodent models of acute renal injury were developed to study mechanisms of acute renal failure. Decreasing renal blood flow is critical in the pathophysiology of ARF in humans. Ischemic and other animal models are used to reproduce the morphological features of human disease. 

There are bilateral and unilateral models of ischemic ARF. The bilateral model is used more often because it is more similar to the pathophysiology of the syndrome of acute renal failure in humans and the most likely to yield clinically relevant information. Moreover, uninephrectomy immediately before renal artery occlusion may offer protection from this insult [21, 22]. 

Studies of the pathophysiology of acute renal failure has classically considered both tubular and vascular mechanisms [227,228]. In vitro techniques isolating either the vascular or tubular components have been developed. For example, the use of isolated proximal tubules in suspension or in culture allows the study of tubular mechanisms of injury in the absence of vascular factors [229] [230]. There are both in vitro and in vivo models to study vascular injury in the kidney. In vitro models include the study of vascular smooth muscle cells or endothelial cells in culture. In this section, the in vivo methods to evaluate the renal micro-circulation will be discussed. This is of relevance as many nephrotoxins exert their deleterious effects through pharmacologic actions on the resistance vasculature with parenchymal injury occurring as a consequence of ischemia. In clinical practice nephrotoxins may cause prerenal azotemia as a result of increased renal vascular resistance. Nephrotoxins that cause acute renal failure on a vascular basis include prostaglandin inhibitors e.g. aspirin, non-steroidal anti-... 

Kribben A, Edelstein CL, Schrier RW Pathophysiology of acute renal failure. J.Nephrol. 12 SuppI 2 S142-S151, 1999... 

Thurau K, Mason J, Gstraunthaler G Experimental acute renal failure. In The Kidney Phyaology and Pathophysiology. Edited by Seldin DW, Giebisch G. New Yoik, Raven Press, 1985, pp 1885-1899. 

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