Guideline for the management of acute renal failure

Alex M. Davison

Renal Unit, St James's University Hospital, Leeds, UK

In this issue Drs Ronco, Kellum, and Mehta announce the establishment of a group to seek evidence-based practice and consensus on the adequate provision of dialysis for patients with acute renal failure. Their task is daunting, but nonetheless most welcome.

Acute renal failure remains, and will continue to remain, a significant problem for many nephrologists and intensivists. In spite of the many advances in clinical management and technological improvements in equipment, the mortality from this condition stubbornly remains about 50%. The reasons for this are complex but include the fact that many patients are older, have multiple co-morbid conditions, and frequently have more than one organ failure. The introduction of haemodialysis was a major advance in the management of acute renal failure and more recently the introduction of continuous systems has been embraced rapidly and enthusiastically.

There is, however, little sound evidence-based information to justify the widespread switch from intermittent to continuous systems. Can we be sure the improved fluid balance capabilities of continuous systems allowing for almost unlimited fluid replacement (drug infusions and nutrition) is not offset by some adverse effect? The management of chronic renal failure has improved with the introduction of methods of quantifying dialysis dose to provide optimum treatment with currently available equipment. The aims of the Acute Dialysis Quality Initiative (ADQI) in attempting to improve the management of patients with acute renal failure by developing similar methodology is a step in the right direction.

In clinical practice it seems that there has been a change in the patient case mix. Many, who would previously have developed acute renal failure, are now managed by prompt fluid replacement and restoration of adequate circulation such that they do not progress to renal shutdown. Thus, it is becoming less common to manage ‘clean’ acute renal failure and more commonly the clinician is faced with multi-organ failure—any combination of respiratory, cardiac, neurological, hepatic, and gastrointestinal failure with renal failure. Such patients are more frequently managed in the intensive care unit and so it is only proper for the ADQI group to raise this question as to who should manage such patients.

The ADQI group are to be congratulated on their initiative, nephrologists and intensivists will follow their activities with interest, and it is to be hoped that the outcome of their activities will lead to improved patient care.

Editor's note

Please see also Dialysis and Transplantation News by Ronco et al., pp. 1555–1558.

Notes

Correspondence and offprint requests to: Alex Davison, Renal Unit, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK. Back





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