RENAL FAILURE

written by: Stan Macik; article published: year 2008, month 10;

In: Root » Health » Medicine and alternative

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Acute renal failure is a common and serious complication of critical illness which adversely affects the prognosis. The importance of preventing renal failure by rapid and effective resuscitation, as well as the avoidance of nephrotoxic drugs (especially NSAIDs), and control of infection cannot be overemphasized. Shock and sepsis are the most common causes of acute renal failure in the critically ill, but diagnosis of the cause of renal dysfunction is necessary to exclude reversible pathology, especially obstruction.

Oliguria is usually the first indication of renal impairment and immediate attempts should be made to optimize cardiovascular function, particularly by expanding the circulating volume and restoring blood pressure. Restoration of the urine output is a good indicator of successful resuscitation. Evidence now suggests that dopamine is not an effective means of preventing or reversing renal impairment and this agent should not be used for renal protection in sepsis. If these measures fail to reverse oliguria, administration of diuretics such as furosemide (frusemide), or less often mannitol, may be indicated. Currently furosemide infusions are most frequently employed, but mannitol is specifically indicated in rhabdomyolysis. If oliguria persists, it is necessary to reduce fluid intake and review drug doses.

Intermittent haemodialysis has a number of disadvantages in the critically ill. In particular it is frequently complicated by hypotension and it may be difficult to remove sufficient volumes of fluid. Peritoneal dialysis is also frequently unsatisfactory in these patients and is contraindicated in those who have undergone intra-abdominal surgery. The use of continuous veno-venous haemofiltration, usually with dialysis (CVVHD), is therefore preferred and is indicated for fluid overload, electrolyte disturbances (especially hyperkalaemia), severe acidosis and, to a lesser extent, uraemia.

If the underlying problems resolve, renal function almost invariably recovers within a few days to several weeks later.

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