eMedicine Specialties > Nephrology > Acute Kidney Failure

Acute Renal Failure: Follow-up

Author: Mahendra Agraharkar, MD, MBBS, FACP, FASN, Clinical Associate Professor of Medicine, Baylor College of Medicine, President & CEO, Space City Associates of Nephrology
Coauthor(s): Rajiv Gupta, MD, Assistant Professor, Department of Medicine, Texas A & M University Health Science Center; Consulting Staff, Veterans Affairs Medical Center; Biruh T Workeneh, MD, Assistant Professor, Baylor College of Medicine
Contributor Information and Disclosures

Updated: Aug 17, 2009

Follow-up

Further Outpatient Care

  • Always keep in mind that renal recovery in most cases is not complete and the kidneys remain vulnerable to nephrotoxic effects of all therapeutic agents. Therefore, agents with nephrotoxic potential are best avoided.

Prognosis

  • The prognosis of patients with AKI is directly related to the cause of renal failure and, to a great extent, to the duration of renal failure prior to therapeutic intervention. If AKI is defined by a sudden increment of serum creatinine of 0.5-1 mg/dL and is associated with a mild to moderate rise in creatinine, the prognosis tends to be worse. However, even if renal failure is mild, the mortality rate is 30-60%. If these patients need dialytic therapy, the mortality rate is 50-90%.
    • The mortality rate is 31% in patients with normal urine sediment test results and is 74% in patients with abnormal urine sediment test results.
    • The survival rate is nearly 0% among patients with AKI who have an Acute Physiology and Chronic Health Evaluation II (APACHE II) score higher than 40; the survival rate is 40% in patients with APACHE II scores of 10-19.
    • Other prognostic factors include the following:
      • Older age
      • Multiorgan failure (ie, the more organs that fail, the worse the prognosis)
      • Oliguria
      • Hypotension
      • Vasopressor support
      • Number of transfusions
      • Noncavitary surgery
  • Prerenal azotemia due to volume contraction is treated with volume expansion; if left untreated for a prolonged duration, tubular necrosis may result and may not be reversible.
  • Postrenal AKI, if left untreated for a long time, may result in irreversible renal damage. Procedures such as catheter placement, lithotripsy, prostatectomy, stent placement, and percutaneous nephrostomy can help to prevent permanent renal damage.
  • Timely identification of pyelonephritis, proper treatment, and further prevention using prophylactic antibiotics may improve the prognosis, especially in females.
    • Early diagnosis of crescentic glomerulonephritis via renal biopsy and other appropriate tests may enhance early renal recovery because appropriate therapy can be initiated promptly and aggressively.
    • The number of crescents, the type of crescents (ie, cellular vs fibrous), and the serum creatinine level at the time of presentation may dictate prognosis for renal recovery in this subgroup of patients.

Patient Education

  • Educating patients about the nephrotoxic potential of common therapeutic agents is always helpful. A good example is NSAIDs; most patients are unaware of their nephrotoxicity, and their universal availability makes them a constant concern.
  • For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article Acute Kidney Failure.

Miscellaneous

Medicolegal Pitfalls

  • Although AKI potentially is a reversible condition, it can occur in patients with chronic renal failure. Every effort should be made to identify reversibility, even if improvement in renal function is marginal. The best way to identify reversibility is by tracking the rate of deterioration of renal function. If the rate of worsening renal function accelerates, the cause should be sought and treated.
  • Renal recovery is usually observed within the first 2 weeks, and many nephrologists tend to diagnose patients with end-stage (ie, irreversible) renal failure 6-8 weeks after onset of AKI. It is always better to check these patients periodically because some patients may regain renal function much later.

Special Concerns

  • Great controversy exists regarding the timing of dialysis. Dialysis, especially hemodialysis, may delay the recovery of patients with AKI. Most authorities prefer using biocompatible membrane dialyzers for hemodialysis. There seems to be no difference in outcome between the use of intermittent hemodialysis and continuous renal replacement therapy (CRRT), but this is currently under investigation. However, CCRT may have a role in patients who are hemodynamically unstable and who have had prolonged renal failure after a stroke or liver failure. Such patients may not tolerate the rapid shift of fluid and electrolytes caused during conventional hemodialysis. Although not frequently used, peritoneal dialysis can also technically be used in acute cases and probably is tolerated better hemodynamically than conventional hemodialysis.
  • Indications for dialysis in patients with AKI are as follows:
    • Volume expansion that cannot be managed with diuretics
    • Hyperkalemia refractory to medical therapy
    • Correction of severe acid-base disturbances that are refractory to medical therapy
    • Severe azotemia (BUN >80-100)
    • Uremia
 
Acknowledgments

The editors wish to thank Dr. Aruna Agraharkar, MD, FACP, for previous contributions to this article.



More on Acute Renal Failure

Overview: Acute Renal Failure
Differential Diagnoses & Workup: Acute Renal Failure
Treatment & Medication: Acute Renal Failure
Follow-up: Acute Renal Failure
Multimedia: Acute Renal Failure
References
Further Reading
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References

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Keywords

acute renal failure, kidney disease, renal failure, kidney failure, renal disease, acute renal, glomerulonephritis, dialysis renal, oliguria, anuria, hypotension, acute kidney failure, acute tubular necrosis, chronic renal failure, tumor lysis syndrome, ethylene glycol poisoning, vasculitis, intrinsic renal failure, interstitial renal disease, renal dysfunction, renal artery occlusion, urethral stricture, bladder outlet obstruction, prostate enlargement, interstitial nephritis, renovascular disease, bladder cancer, epigastric bruit, diabetic ketoacidosis, pancreatitis, hypercalcemia, prostaglandin inhibition, ischemic tubular necrosis, crescentic glomerulonephritis, postinfective glomerulonephritis, lupus nephritis, hepatitis, vasculitis-associated glomerulonephritides, prostatic hypertrophy

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Contributor Information and Disclosures

Author

Mahendra Agraharkar, MD, MBBS, FACP, FASN, Clinical Associate Professor of Medicine, Baylor College of Medicine, President & CEO, Space City Associates of Nephrology
Mahendra Agraharkar, MD, MBBS, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology, and National Kidney Foundation
Disclosure: South Shore DaVita Dialysis Center  Ownership interest Other

Coauthor(s)

Rajiv Gupta, MD, Assistant Professor, Department of Medicine, Texas A & M University Health Science Center; Consulting Staff, Veterans Affairs Medical Center
Rajiv Gupta, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Biruh T Workeneh, MD, Assistant Professor, Baylor College of Medicine
Biruh T Workeneh, MD is a member of the following medical societies: American Medical Association, American Society of Nephrology, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Laura L Mulloy, DO, FACP, Professor of Medicine, Chief, Section of Nephrology, Hypertension and Transplantation Medicine, Glover/Mealing Eminent Scholar Chair in Immunology, Medical College of Georgia
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine; Interim Chief of Nephrology; Director of Nephrology Training Program; Director, Metabolic Stone Clinic; Director of Outpatient Clinics, Kidney Disease Program, University of Louisville School of Medicine
Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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