Management of acute renal failure: new perspectives

Despite major developments in medicine, surgery, and intensive care, acute renal failure (ARF) still remains a common problem affecting approximately 5% of all general hospital patients. Mortality of all forms of ARF continues to be greater than 50%, and this percentage has not decreased significantly over the last 30 years. There are multiple factors, which may explain the persistence of such high mortality; the most important of these is probably the evolution of the disease spectrum underlying the development of ARF. At present, ARF is more often observed in older or more complex patients frequently in association with multiorgan system failure. The annual cost of managing ARF is staggering. This article reviews several of the new strategies and approaches that have been developed to aid in the management and prevention of ARF. For example, the use of biocompatible membranes has been proven to positively influence the course of ARF, which necessitates renal replacement therapy. Although continuous renal replacement therapy has a theoretical advantage compared with intermittent hemodialysis in critically ill and hemodynamically unstable patients, there are no well-controlled clinical studies to support a beneficial effect on mortality. There is, however, good evidence that calcium channel blockers play a positive role in the management of ARF, especially that associated with cadaveric kidney transplantation. Vasoactive agents, such as dopamine, may have the advantage of increasing the urine output in patients with oliguric ARF; however, their efficacy in otherwise altering the course of ARF is not well substantiated. Finally, growth factors and atrial natriuretic peptide appear to have the potential for accelerating renal recovery and decreasing morbidity and mortality from this commonly encountered medical problem. Prospective randomized clinical studies are the key to many of the dilemmas encountered with ARF.