Hemodynamic alterations in ischaemic acute renal failure

It is concluded that the condition of 'acute renal failure' starts in the first minutes after restoration of the circulation, following the ischemic period. The aggregation of red blood cells in the renal medulla with the subsequent cessation of medullary blood flow represents an important factor causing both the reduced urinary concentrating ability and the depressed urinary potassium concentration. The persisting medullary ischemia leads to cellular swelling and eventually to cell necrosis, which in turn results in a mechanical obstruction of the tubular lumen in the region of the loops of Henle and the medullary collecting ducts. In contrast, the anuria which is evident weeks after the primary damage, seems to be caused by the release of vasoconstrictor principles, whose origin is unclear, but it seems not to be mediated via the renal nerves, since the same symptoms are found in transplanted kidneys. Therapeutic endeavors using heparin, saline expansion and mannitol to improve the rheological characteristics of the blood seems to be of limited value. Infusion of hyperoncotic albumin during the ischemic period, however, seems to be of some benefit, since glomerular filtration is better preserved. The addition of ATP and magnesium, glucose or adjustment of the acid base status with buffers has not been encouraging in the present models, in which glomerular filtration rate is reduced to only a few percent of control.