INTERVENTIONS IN CLINICAL ACUTE-RENAL-FAILURE - WHAT ARE THE DATA

A variety of therapeutic approaches have been used both to prevent acu te ischemic and nephrotoxic renal injury and to improve renal function and reduce mortality once acute renal failure (ARF) has developed, Un fortunately, there have been few rigorous assessments of the efficacy of these treatment interventions. The reasons for the lack of abundant critical data regarding treatment effects in ARF are several. First, ARF is a functional disorder, It has a spectrum of etiologies, occurs in a variety of clinical settings and varies in severity, Second, sele cted endpoints of treatment success vary and co-morbid factors frequen tly determine outcome, Third, it had been difficult to carry out prosp ective controlled studies in a disorder in which the mortality rate ap proaches 50%, In this review, an effort was made to analyze the availa ble literature with a primary focus on controlled studies to determine significant prophylactic and treatment effects of various interventio ns in ARF, Three endpoints of therapy (change in renal function, chang e in course of azotemia, and change in mortality) were examined for ph armacologic agents, Changes in course of azotemia and mortality were a ssessed in evaluating different dialysis modes, Effect on nitrogen bal ance, change in course of azotemia, and change in mortality were used as endpoints to determine treatment effects of different nutritional r egimens, When weight was given to prospective controlled studies, some insights emerged as to treatment interventions that are most likely t o have beneficial effects in specific settings of ARF. Among pharmacol ogic agents, mannitol appears to have a positive prophylactic effect i n kidney transplantation. There are no other significant beneficial ef fects of diuretics for prophylaxis or as treatment in early or establi shed ARF, Of vasoactive agents, there is a relatively small amount of data suggesting that diltiazem may have a positive prophylactic effect in kidney transplantation, and dopamine possibly is beneficial early in the evolutionary phase of ARF, Atrial natriuretic peptide and calci um channel blockers may have beneficial effects in established disease , No other pharmacologic interventions are supported by substantial da ta. At best, the results are equivocal regarding the use of early and vigorous dialysis in ARF. However, there are recent impressive data in dicating that the use of biocompatible membranes is efficacious in rec overy and survival, There is no clear evidence that one form of nutrit ional therapy has advantages over others, but some level of amino acid supplementation in addition to basic energy replacement is supported by the overall data. (C) 1995 by the National Kidney Foundation, Inc.