Box 81 Causes of acute renal failure

• New onset chronic renal failure - 13%

• Glomerulonephritis 3%

• Acute tubulo-interstitial nephritis 2%

intensive care admissions have acute renal failure and 2-5% hospitalised patients develop it; 30% patients with acute renal failure will need renal replacement therapy.

The kidney is especially vulnerable to injury resulting from hypoperfusion and/or critical illness. A study by Hou et al. in 1993 looked at all patients admitted to medicine and surgery in their hospital over a 6-month period (excluding those with renal failure). Patients were screened during their stay for worsening of renal function: 5% of these patients developed renal insufficiency - 42% because of hypoperfusion (of these hypotension 41%, major cardiac dysfunction 30%, and sepsis 19%). Major surgery accounted for 18%, contrast media 12%, aminoglycoside administration 7%, and miscellaneous causes 21% (for example, obstruction). The severity of renal insufficiency as judged by serum creatinine was the most important indicator of a poor prognosis. The overall mortality rate was 25% - but this rose to 64% in those patients with an increase in creatinine of 265 |imol litre-1 (318 mg dl-1) or more.

Mortality is especially high in acute renal failure in those patients who have had a myocardial infarction or stroke, have oliguria, sepsis, are male, elderly, or are mechanically ventilated. Patients at risk of acute renal failure can be identified, and hypoperfusion and obstruction can be treated early, so it is likely that a proportion of mortality from acute renal failure is preventable. The reality is that much hypoperfusion is left untreated for several hours and incorrect treatment leads to further deterioration, causing irreversible renal failure.

It is imperative that early effective action is taken to prevent permanent renal failure as soon as renal function becomes compromised.

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