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Acute Kidney Failure Overview

The kidneys are a pair of small (about the size of your fist) bean-shaped organs that lie on either side of your spine at just below
your lowest ribs. They filter by-products and toxins from your blood and preserve the balance of bodily fluids and electrolytes.
• The kidneys excrete these compounds with water to make urine.
• They also eliminate excess body water while reabsorbing useful chemicals and allowing waste to pass freely into the
bladder as urine.
• They allow a person to consume a variety of foods, drugs, vitamins and supplements, additives, and excess fluids
without worry that toxic by-products will build up to harmful levels.
• The kidneys regulate the amount of various substances in the blood and the amount of water in the body.
Blood circulates through the kidneys for filtration.
• As the first step in filtration, the blood passes through the glomeruli, complex structures composed of tiny blood vessels
entwined together. Substances present in the blood are selectively filtered across the outer linings of the tiny blood
vessels and excreted with water as urine or reabsorbed into tube-like structures (tubules) for further filtration.
• The tubules continue filtering blood until all appropriate substances are reabsorbed into the blood and all the waste
products are excreted.
• Once urine leaves your kidney, it travels through long, thin tubular ureters to the bladder and out your urethra during
urination.
• The kidneys also help regulate blood pressure and secrete hormones that contribute to red blood cell production.
Kidney failure occurs when the kidneys partly or completely lose their ability to filter water and waste from the blood.
• The build up of toxic substances normally removed from the body by the kidneys can cause dangerous health problems.
• Acute kidney failure (also referred to as renal failure) happens rapidly.
• Mild kidney dysfunction is often called renal insufficiency.
Acute kidney failure occurs in about 5% of people who are hospitalized for any reason. It is even more common in those
receiving intensive care.
Chronic kidney failure results when a disease slowly destroys your kidneys. Destruction occurs over many years, usually with no
symptoms until the late stage of kidney failure. Progression may be so gradual that symptoms may not occur until kidney
function is less than one-tenth of normal.

Acute Kidney Failure Symptoms


The following symptoms may occur with acute kidney failure. Some people have no symptoms, at least in the early stages. The
symptoms may be very subtle.
• Decreased urine production
• Body swelling
• Problems concentrating
• Confusion
• Fatigue
• Lethargy
• Nausea, vomiting
• Diarrhea
• Abdominal pain
• Metallic taste in the mouth
Seizures and coma may occur in very severe acute kidney failure.
Exams and Tests
Many people with acute renal failure notice no symptoms. Even with symptoms, they are nonspecific, meaning they could be
caused by many different conditions. A physical examination typically reveals few, if any, abnormal findings.
Kidney failure is often detected from blood or urine tests. These tests might be ordered because the patient is in the hospital for
another reason, because they don't feel well and can't tell why, or as part of a routine health screening.
• Levels of urea (blood urea nitrogen [BUN]) and creatinine are high in kidney failure of prerenal origin. This is called
azotemia.
• Electrolyte levels in the blood may be abnormally high or low because of improper filtering.
• When the duration and severity of kidney failure is severe, the red blood cell count may be low. This is called anemia.
The amount of urine produced over a period of hours may also be measured for quantity and quality or the amount of wastes
being excreted. When kidney tissue is injured, protein and desirable substances may be inappropriately excreted in the urine. In
some cases, the amount of urine remaining in the bladder after urination will be measured by inserting a catheter (a thin, rubber
tube) that drains the bladder.
• Urine retained in the bladder after urinating suggests postrenal failure, usually due to prostate enlargement in men.
• The urine may be dark, indicating that creatinine and other substances are concentrated.
• The urine will be examined under a microscope to detect signs of specific kidney problems. Some of these signs
include blood, pus, and solid materials called casts.
• Electrolyte levels in the urine may help pinpoint the exact cause of the kidney failure.
If the diagnosis is not certain after laboratory tests, an ultrasound of the kidneys and bladder may be done. These can help reveal
signs of specific causes of kidney failure.
In some cases, tissue samples of the kidneys are taken (biopsy) to find the cause of the renal failure.

Acute Kidney Failure Treatment


Treatment of acute renal failure depends partly on the cause and extent of the failure. The patient should be referred to a kidney
specialist (nephrologist) for care. The first goal is to pinpoint the exact cause of the kidney failure, as that will partly dictate the
treatment. Secondly, the degree to which accumulating wastes and water are affecting the body will impact treatment decisions
about medications and the need for dialysis.

Medical Treatment
Treatment is focused on removing the cause of the kidney failure.
Medications and other products the patient ingests will be reviewed. Any that might harm the kidneys will be eliminated or the
dose reduced.
Other treatments will be offered, with the following goals:
• Correct dehydration - Intravenous fluids, with electrolyte replacement if needed
• Fluid restriction - For those types of kidney failure in which excess fluid is not appropriately eliminated by the kidneys
• Increase blood flow to the kidney - Usually related to improving heart function or increasing blood pressure
• Correct chemical (electrolyte) abnormalities - Keeps other body systems working properly
If the patient's kidneys do not respond to treatment, and adequate kidney function does not return, they will need to undergo
dialysis. Dialysis is done by accessing the blood vessels through the skin (hemodialysis) or by accessing the abdominal cavity
through the lining that encases the abdominal organs (peritoneal dialysis).
• With hemodialysis, the patient is connected to a machine by a tube running from a conduit created surgically between a
large artery and vein. Blood is circulated through the artificial kidney, which removes toxins and wastes. The blood is
then returned to the patient's body.
• Most people require hemodialysis three times per week.
With peritoneal dialysis, wastes and excess water from the bloodstream cross into the abdominal cavity (peritoneal space) and are
eliminated from the body by coursing through a catheter that is surgically implanted (through the skin) into the peritoneal cavity.
Most people with acute kidney failure improve when the cause of the kidney failure is removed or treated and don't require
dialysis. Normal kidney function is usually restored, though in some cases, residual damage only allows partial restoration of the
kidney function. Such patients may not require dialysis but may need medicines to supplement lost kidney function.

Prevention
Yearly physical exams by a healthcare provider include blood tests and urinalysis to monitor kidney and urinary tract health.
Drink enough fluids to keep the kidneys functioning properly.
Avoid taking substances or medications that can poison or damage kidney tissues. Ask a healthcare provider about substances to
avoid.
Persons at risk for chronic kidney disease may need more frequent testing for kidney function and other problems that occur with
declining kidney function. Difficulties urinating or blood in the urine should prompt a visit to your physician as soon as possible.

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Management of Oliguria
Acute oliguric renal failure, especially that acquired in the hospital, is associated with high morbidity and mortality
rates.3 In addition, the costs of caring for patients with acute oliguria are very high.17 A variety of therapies have
shown promise in animal models of acute renal injury.3 However, the results of clinical trials have been less
encouraging. Several reviews have addressed this topic.3,18,19 In a clinical trial, 504 patients with acute renal failure
were randomly assigned to receive anaritide (a synthetic form of atrial natriuretic peptide) or placebo.20 Twenty-four
percent of the patients had oliguria at the time of enrollment. The primary end point of the study was dialysis-free
survival for 21 days after treatment. Anaritide had no apparent benefit in the patients without oliguria. Among the
patients with oliguria, dialysis-free survival was 27 percent in the group receiving anaritide, as compared with 8
percent in the group receiving placebo (P = 0.008). These results led to a follow-up study designed to enroll 250
patients with oliguric acute tubular necrosis. But this trial was discontinued after 210 patients had been randomly
assigned to treatment, because it failed to demonstrate any benefit from the administration of anaritide.
Conversion from oliguria to a nonoliguric state has been considered beneficial.20 This has been the rationale for
using diuretics or dopamine, a selective renal vasodilator that causes natriuresis, in patients with acute oliguria.21,22
The potential benefits of conversion to a nonoliguric state include less stringent restrictions on salt and water intake,
a decreased requirement for dialysis, and perhaps an improved prognosis.21
Although there is considerable controversy about the benefits of conversion to a nonoliguric state, some
recommendations can be made. First, it is important to identify patients at risk for iatrogenic renal failure.23 Second,
patients should be rapidly evaluated to rule out prerenal or postrenal causes of oliguria, and nephrotoxic drugs should
be discontinued when possible. Third, a fluid challenge may be appropriate in patients with oliguria who do not have
a volume overload. The amount of fluid administered must be determined on an individual basis. Although the use of
diuretics is controversial, if there is an inadequate response to the fluid challenge, the administration of a loop
diuretic should be considered. Since the window of opportunity may be narrow, we suggest an initial intravenous
infusion of 100 to 200 mg of furosemide. Some authors have recommended the use of a furosemide drip in a dose of
10 to 40 mg per hour.21 If urinary output fails to increase within one to two hours, the dose may be doubled, and a
thiazide diuretic added. However, large doses of intravenous furosemide for prolonged periods may cause hearing
loss. The therapy should be discontinued if there is no response. If there is a response, serial measurements and
monitoring of volume status, hemodynamics, and electrolytes are crucial.
The benefit of dopamine therapy (1 to 3 µg per kilogram of body weight per minute) in patients with acute renal
injury is controversial.22 In selected cases in which dopamine is used, a diuretic response may be evident within the
first six hours of therapy. If urinary output does not increase within this time, the therapy should be discontinued.24
Dialysis
Once the presence of intrinsic renal failure has been established, therapeutic interventions are confined to supportive
care and the institution of dialysis in an effort to normalize extracellular volume and electrolyte concentrations and to
control hyperkalemia and metabolic acidosis. The appropriate frequency and duration of dialysis for acute renal
failure have not been determined. Guidelines and standards need to be developed for the use of dialysis in patients
with acute renal failure.25
It has been suggested that hypotension occurring during treatment with intermittent dialysis may perpetuate the renal
injury and prolong the "repair" of tubular cells, which in turn may increase the risk of morbidity and mortality. It has
been proposed that continuous renal-replacement therapy offers the benefit of slow and controlled ultrafiltration with
a marked decrease in the frequency and duration of hypotensive episodes.26 Continuous renal-replacement therapy
should be used in patients whose condition is unstable and who are prone to hypotensive events.27 The selection of
dialysis membranes may also be important in patients with acute renal failure. Cellulose membranes may activate
complement and lead to the mobilization of leukocytes, with untoward effects on the patient. Recent reports suggest
that the use of biocompatible membranes in patients with acute renal failure is associated with better outcomes,
including a decreased incidence of infection, than cellulose membranes.28,29 In a multicenter study of 153 patients
with acute renal failure undergoing dialysis with biocompatible or bioincompatible membranes, dialysis with
biocompatible membranes resulted in significantly better survival (57 percent, vs. 46 percent) and recovery of renal
function (64 percent, vs. 43 percent).29
Protein and Energy Intake
Besides the maintenance of a fluid and electrolyte balance, adequate protein and caloric intake is essential in patients
with acute oliguria. Protein catabolism can be substantial (200 to 250 g per day) in patients with acute renal
failure,30,31,32 particularly those with shock, sepsis, or rhabdomyolysis. Increased protein degradation may accelerate
the rate of increase in the concentrations of potassium, hydrogen ion, and phosphorus in patients with oliguria. A
negative nitrogen balance may lead to malnutrition, with impaired immune function and an increased risk of
morbidity and mortality. Aggressive nutritional therapy should be instituted early in patients with acute renal failure.
In many instances, total parenteral nutrition is required. Increased caloric intake should be provided, with the use of
a combined carbohydrate and fat regimen.
The NEW ENGLAND JOURNAL of MEDICINE (Saulo Klahr, M.D., and Steven B. Miller, M.D.)