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.