Table Of ContentCurrent 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
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© 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
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Product Liability: The publisher can give no guarantee for information about drug
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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
