Acute Renal Failure: Diagnostic and Therapeutic Considerations

Abstract

Introduction: The choice of renal replacement therapy modality may affect renal recovery after acute kidney injury. When acute renal failure is so severe as to require renal replacement therapy (RRT) mortality rates are as high as 63%. This review aimed to highlight the updated diagnostic and therapeutic considerations that should be considered during the management of acute renal failure.
Methods: The authors performed a systematic search of the MEDLINE and EMBASE bibliographic databases to identify published studies evaluating acute renal failure. search strategies combined the medical subject heading terms "kidney failure, acute" combined with prognosis (specificity) limited to "humans," "article" and "journal article" for MEDLINE. The authors restricted their search to clinical studies performed in adult populations and published in the English language. The full-text review was independently performed by two reviewers (as above) for the following specific eligibility criteria including observational cohort and/or randomized/quasi-randomized clinical trial (RCT) design. All data were extracted independently with standardized forms with a subsequent discussion of any discrepancies. Data were collected on study characteristics and quality, demographics and baseline characteristics. The data, therefore, are synthesized qualitatively.
Results: A total of 494 citations were identified. After the primary and secondary screening, 15 studies fulfilled all criteria for final analysis (13 articles). The authors found two randomized trials, four prospective cohort studies, and nine retrospective cohort studies. Of these, 13 were published as articles in peer-reviewed journals, and 2 studies were published as abstracts only. Only five had a prospectively assembled control group, four had comparable modes of RRT between the early and late initiation groups, and only three studies accounted for withdrawals/loss to follow-up.
Conclusions: We can conclude that diuretics and dopamine are clearly not helpful and may even be harmful, while volume expansion with saline is unproven but potentially beneficial. The facts are even less clear regarding mannitol in vascular surgery. In other types of surgery, such as coronary artery bypass or biliary surgery, small studies have also been unable to demonstrate a benefit associated with mannitol. Given these considerations, and in the absence of clinical data, diuretics cannot be recommended to prevent acute renal failure.