Acute Renal Failure in the Intensive Therapy Unit PDF
Preview Acute Renal Failure in the Intensive Therapy Unit
Current Concepts in Critical Care Already published in the Series: . Shock and the Adult Respiratory Distress Syndrome Edited by W. Kox and D. Bihari Imaging and Labelling Techniques in the Critically TIl Edited by W. Kox, J. Boultbee and R. Donaldson - - - - - - c , c b \) David Bihari and Guy Neild (eds.) Acute Renal Failure in the Intensive Therapy Unit With 63 Figures Springer-Verlag London Berlin Heidelberg N ew York Paris Tokyo Hong Kong David Bihari, MA, MRCP Director of Intensive Care Services, Department of Intensive Care, Guy's Hospital, St Thomas St, London SEl 9RT, UK Guy Neild, MD, FRCP Senior Lecturer in Nephrology, Department of Renal Medicine, Institute of Urology, UCMSM, St Philip's Hospital, Sheffield St, London WC2A 2EX, UK [SBN-13: 978-1-4471-1752-0 e-[SBN-13: 978-1-4471-1750-6 00[: 10.1007/978-1-4471-1750-6 British Library Cataloguing in Publication Data Acute renal failure in the intensive therapy unit. 1. Man. Kidneys. Acute Failure & Chronic Renal Failure I. Bihari, David, 1954-- II. Neild, Guy, 1948- II. Series 616.6/14 ISBN-13: 978-1-4471-1752-0 Library of Congress Cataloging-in-Publication Data Acute renal failure in the intensive therapy unitlDavid Bihari and Guy Neild (eds.). p. cm. - (Current concepts in critical care) Based on workshop held in Avignon, France in Sept., 1988, sponsored by Fisons PLC. Includes bibliographical references. ISBN-13: 978-1-4471-1752-0 1. Acute renal failure - Congresses. 2. Critical care medicine - Congresses. I. Bihari, David, 1954-- . II. Neild, Guy, 1948--. III. Fisons Limited. IV. Series [DNLM: 1. Critical Care - methods - congresses. 2. Intensive Care Units - congresses. 3. Kidl1ey Failure, Acute - therapy - congresses. WJ 342 A18955 1988] RC918.R4A345 1990 616.6/14 - dc20 DNLMlDLC for Library of Congress 89--21930 eIP Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. © Springer-Verlag Berlin Heidelberg 1990 Softcover reprint of the hardcover 1st edition 1990 The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Filmset by Wilmaset, Birkenhead, Wirral Printed by The Alden Press, Osney Mead, Oxford, UK 2128/3916-593210 Printed on acid-free paper This book is dedicated to the memory of Dr. Paul Noone - a gifted and valued colleague who is sorely missed Preface There is, today, some concern within the medical community that whilst there has been an enormous proliferation of meetings and publications in various fields of clinical investigation, this has not been accompanied to the same extent by any great benefit for patients. Thus, whilst doctors and clinical scientists meet around the world and discuss what they consider to be the important issues, little of this erudition is translated directly into improvements in care, and patients continue to die from their underlying disease. This may sound a little cynical but is particularly true of patients who develop acute renal failure in the Intensive Therapy Unit. It is often said of these patients that rates of survival have not substantially challged over the last 40 years. Some would say that one of the great achievements of modern-day surgical practice and peri-operative care has been the reduction in prevalence of acute renal failure associated with biliary, aortic and ·cardiac surgery. Renal "protection" (volume loading, mannitol, low dose dopamine, loop diuretics) in the Intensive Therapy U nit remains a contentious issue but has obviously contributed in some way to the falling prevalence in these cases. Other than volume loading, it has been difficult to judge the efficacy of the available strategies, particu larly in the more complicated patients with sepsis or trauma and other organ failure. Whilst the incidence of acute renal failure is indeed probably falling, and the spectrum of cases undoubtedly changing from the young and previously healthy to the elderly, infected and chronically diseased, renal replacement therapy is one of the most rapidly evolving aspects of intensive care. Yet, it continues to be fraught with difficulties, not least in the nomenclature and abbreviations (PD, HD, CAVH, CVVH, CAVHD, CVVHD, CUPID) used to describe the techniques available. Physicians who attend in the Intensive Therapy Unit have three specific "gut" feelings about patients who develop renal failure: first, it is a bad thing and is best prevented. Second, it is better to have patients passing some urine than no urine at all since fluid balance is easier and the patient tends not to die from pulmonary oedema nor hyperkalaemia. For this reason, many physicians would attempt to convert oliguric a~ute renal failure into the polyuric form by the administration of large doses of frusemide together with low- viii Preface dose dopamine and mannitol. Finally, it would seem that these patients require some sort of aggressive nutritional support and they should receive dialysis (or whatever) so that this can be achieved. Whilst no-one would seriously question the first principle, there are few data to support the second and third suppositions. Yet, their practice remains ubiquitous in the Intensive Care Unit and, as usual in medicine, the development and strength of expression of an opinion concerning the efficacy of a treatment directly reflects the absence of any convincing objective data, one way or another. So often, ex cathedra statements are made concerning the importance of mannitol, low-dose dopamine or branched-chain amino acids as if there was a mass of evidence to justify their use routinely. For these reasons, we were convinced that the subject "Acute Renal Failure in the Intensive Therapy Unit" required an extensive and lengthy airing in the setting of a small closed workshop of invited experts. At the same time, we were somewhat hesitant of convening such a meeting. Again, our concern centred upon the possible conclusions of such a workshop and whether any worthwhile contribu tion could be made in terms of understanding the pathogenesis of the condition and improving patient care. There are many standard texts available on acute renal failure and there have been a number of excellent editorials published recently in leading journals. There are regular large symposia in North America and Europe at which new data can be presented. We did not want to produce another set of ex cathedra statements to confuse busy clinicians. Nevertheless, the quest for some sort of "consensus" amongst nephrologists and specialists in intensive care from around the world was thought to be unusual enough to deserve support. Our hope was that it might lead to some new ideas and a different perspective on pathogenesis, preven tion and treatment. Thus, with some trepidation, we convened a workshop in Avignon, France in September 1988, most kindly sponsored by Fisons PLC, UK and organized by Mr Philip White, Fisons PLC. This book is the direct result of that meeting and contains much of the thought and discussion that went on in Avignon. Original research papers pertinent to the subject are mixed with reviews of specific issues. As usual, a publication of this nature can never hope to be definitive but reflects the interests of the editors and their contribu tors. Inevitably, there has been some duplication of content but each group of authors contributes their own perspective to a difficult subject. Whilst the reader has to judge for himself, we believe that the group has achieved a clear expression of both the conventional and some novel ideas regarding pathogenesis and management. They have highlighted those areas of which little is known and which require further investigation. What about the patients - will they benefit from this corporate endeavour? Sadly, in the short term, probably not! What is apparent is that there are no magic solutions to the problem of established acute renal failure in the Intensive Therapy Unit. But if we have stimulated the reader to .think about the problem and the Preface ix questions which inevitably arise from that thought, we do the subject a service and sooner or later, the patient will benefit. London David Bihari March 1989 Guy Neild Contents List of Contributors....... .... .......... .... ..................... ...... .... xv SECTION I: Definitions and Epidemiology 1 Acute Renal Failure in the ITU: The Nephrologist's View J. S. Cameron.......................................................... 3 2 Epidemiology of Acute Renal Failure in France Today D. Kleinknecht ...................................................... '" 13 3 Acute Renal Failure and Sepsis: A Microbiologist's View P. Noone ................................................................ 23 4 Acute Renal Failure at a Crossroads K. Solez and L. C. Racusen ........................ .......... ...... 35 5 Acute Renal Failure in Old Age J. F. Macias ........................................... ....... ........... 41 SECTION II: Some Aspects of Renal Physiology 6 Cortical and Juxtamedullary Glomerular Blood Flow After Temporary Ischaemia M. Steinhausen, M. Fretschner, E. Gulbins and N. Parekh 47 7 Are Atrial Pressures Involved in the Regulation of Sodium and Water Balance? Studies in Conscious Animals G. Kaczmarczyk, E. Schmidt, K. Falke and H. W. Reinhardt....................................................... 59 SECTION III: Pathogenesis of Acute Renal Failure in the Intensive Therapy Unit 8 Endothelial and Mesangial Cell Dysfunction in Acute Renal Failure G. H. Neild............................................................. 77 xii Contents 9 Role of the Medulla in Acute Renal Failure P. H. Epstein, M. Brezis and S. Rosen ........................ ;. 91 10 Ischaemic Acute Renal Failure in an Intact Animal Model P. 1. Ratcliffe, Z. H. Endre,l. D. Tange and 1. G. G. Ledingham.................................................. 103 11 Eicosanoids and Acute Renal Failure A. Schieppati and G. Remuzzi..................................... 115 12 Disturbances in Renal Function Associated with Hepatic Dysfunction 1. M. Lopez-Novoa................................................... 131 13 A Review of Mediators and the Hepatorenal Syndrome K. Moore, V. Parsons, P. Ward and R. Williams ............. 143 14 Drug-Induced Acute Renal Failure A. L. Linton............................................................ 157 15 Nature of Postischaemic Renal Injury Following Aortic or Cardiac Surgery B. D. Myers............................................................ 167 16 Acute Renal Failure in Sepsis A. L. Linton............................................................ 181 SECTION IV: Clinical Features of Acute Renal Failure in the Intensive Therapy Unit 17 Strategies in Management of Acute Renal Failure in the Intensive Therapy Unit R. W. Schrier, W. T. Abraham and 1. Hensen................. 193 18 Acute Renal Failure and Crush Injury O. S. Better............................................................. 215 19 Renal Function After Open Heart Surgery H. M. Koning and 1. A. Leusink.................................. 223 20 Acute Renal Failure Following Heart and Heart-Lung Transplantation M. E. Rogerson, G. H. Neild and F. D. Thompson ......... 235 21 Bleeding in Acute Renal Failure K. Andrassy............................................................. 243 22 Mechanisms of Uraemic Enc~phalopathy A. l. Arieff and C. L. Fraser....................................... 255
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