CURRENT Essentials of Critical Care.pdf

Chapter 14 Renal Disorders 215■■Renal Failure, PreventionEssential Concepts• Acute renal insufficiency associated with increased ICU mortality,but limited studies on renal failure prevention• Limited data available in certain settings: cardiovascular surgery,sepsis, contrast-induced nephropathy, cirrhosis associatedrenal dysfunction• Acute tubular necrosis (ATN) and prerenal azotemia most commoncauses of renal impairment• Use of nephrotoxic agents sometimes unavoidable: amphotericin,aminoglycosides, radiographic contrast• Clinical use of renal dose dopamine and diuretics of unprovenbenefit• Albumin infusion costly and has limited role• Atrial natriuretic peptide restricted to clinical trialsEssentials of Management• Avoid use of nephrotoxic agents, if possible• Minimize toxicity exposure: once-daily aminoglycoside dosing,liposomal amphotericin B infusions, nonionic contrast agents• Maintain adequate renal perfusion with volume expansion; colloidversus crystalloid replacement remains controversial• Avoid diuretics unless volume overloaded; exception may bemannitol use in myoglobinuria after volume resuscitation• Premedication with N-acetylcysteine protects from contrastnephropathy; fenoldopam also appears to reduce this nephropathy• Albumin in conjunction with antibiotics reduced renal impairmentand mortality in cirrhosis associated spontaneous bacterialperitonitis• Splanchnic vasoconstrictors and TIPS have led to some reversalof hepatorenal syndrome although mortality remains high• Selenium replacement promising in sepsis■ PearlIn the face of life-threatening hypoxemia secondary to pulmonaryedema, aggressive diuresis takes precedence even in the setting ofworsening renal function, as the availability of renal replacement therapiesmakes “sacrificing” the kidneys an acceptable therapeutic option.ReferenceBlock CA et al: Prevention of acute renal failure in the critically ill. Am JRespir Crit Care Med 2002;165:320. [PMID: 11818313]