3
Acute toxic renal failure

https://doi.org/10.1016/j.bpa.2003.09.007Get rights and content

Abstract

Acute renal failure (ARF) is a common problem in intensive care medicine. Even modest degrees of ARF not requiring dialysis treatment increase the risk of death approximately fivefold. Despite the widespread appreciation of the role of nephrotoxic drugs in their contribution to ARF, these drugs continue to have an ongoing aetiological role. Potentially nephrotoxic drugs include non-steroidal anti-inflammatory drugs, radiocontrast agents, antimicrobial and anaesthetic agents. Endogenous compounds such as myoglobin and haemoglobin may furthermore cause toxic nephropathy. Tubular injury initiated by toxins often results from a combination of acute renal vasoconstriction and direct cellular toxicity due to intracellular accumulation of the toxin, or, alternatively, may be mediated immunologically in case of interstitial nephritis. Patients with reduced renal functional reserve, cardiovascular co-morbidity, diabetes mellitus, and advanced age are at increased risk. Awareness of the range of toxins on the one hand and simple measures such as adequate pre-hydration of the patient and drug monitoring on the other hand may be sufficient to avoid drug-induced ARF or minimize its clinical severity in susceptible patients.

Section snippets

Myoglobinuria

Rhabdomyolysis is the breakdown of striated muscle with release of constitutive components into the extracellular fluid and circulation. One of the key compounds released is myoglobin, an 18.8 kDa oxygen carrier. Normally, myoglobin is loosely bound to plasma globulins and only small amounts reach the urine. When massive amounts of myoglobin are released, the binding capacity of plasma protein is exceeded. Myoglobin is then filtered by the glomeruli and subsequently reaches the tubules.12

Radiocontrast nephropathy

Within the last decade, radiological procedures utilizing contrast media are being widely applied for both diagnostic and treatment purposes. This has resulted in an increasing incidence of renal function impairment caused by the exposure to contrast material—an iatrogenic disorder known as radiocontrast nephropathy (RCN). Acute RCN is the third leading cause of new-onset renal failure in hospitalized patients. RCN is associated with prolonged in-hospital stay, increased morbidity, mortality,

Conclusion

Toxic nephropathy should always be considered as a cause of ARF in surgical patients. Both exo-and endotoxins may be involved. Awareness of the range of toxins and the high-risk clinical settings in which they become important is vital in avoiding toxic ARF and in minimizing its clinical severity. Simple prophylactic measures include therapeutic drug monitoring, avoidance of concomitant use of several potentially nephrotoxic drugs and restoration/maintenance of adequate hydration (Table 3).

Acknowledgements

The author thanks Dirk Kuypers, MD, for his helpful comments and suggestions.

References (92)

  • M.A Perazella et al.

    Are selective COX-2 inhibitors nephrotoxic?

    American Journal of Kidney Diseases

    (2000)
  • H.D Humes

    Aminoglycoside nephrotoxicity

    Kidney International

    (1988)
  • J.M Prins et al.

    Once versus thrice daily gentamicin in patients with serious infections

    Lancet

    (1993)
  • M.A Fisher et al.

    Risk factors for amphotericin B-associated nephrotoxicity

    American Journal of Medicine

    (1989)
  • M.A Perazella

    Crystal-induced acute renal failure

    American Journal of Medicine

    (1999)
  • J.E Heavner

    Toxicity of anaesthetics

    Best Practice Research Clinical Anaesthesiology

    (2003)
  • F.M Reichle et al.

    Halogenated inhalational anesthetics

    Best Practice and Research Clinical Anaesthesiology

    (2003)
  • F Schortgen et al.

    Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study

    Lancet

    (2001)
  • C.A Block et al.

    Prevention of acute renal failure in the critically III

    American Journal of Respiratory and Critical Care Medicine

    (2002)
  • P Carmichael et al.

    Acute renal failure in the surgical setting

    Australian and New Zealand Journal of Surgery

    (2003)
  • P.J Conlon et al.

    Acute renal failure following cardiac surgery?

    Nephrology Dialysis Transplantation

    (1999)
  • P.S Kellerman

    Perioperative care of the renal patient

    Archives Internal Medicine

    (1994)
  • B.K Novis et al.

    Association of preoperative risk factors with postoperative acute renal failure

    Anesthesia and Analgesia

    (1994)
  • G.M Chertow et al.

    Preoperative renal risk stratification

    Circulation

    (1997)
  • E.M Levy et al.

    The effect of acute renal failure on mortality. A cohort analysis

    Journal of the American Medical Association

    (1996)
  • S Bhandari et al.

    Survivors of acute renal failure who do not recover renal function

    Quarterly Journal of Medicine

    (1996)
  • F Linao et al.

    and the Madrid Acute Renal Failure Study Group. Epidemiology of acute renal failure: a prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group

    Kidney International

    (1996)
  • E Vanholder et al.

    Journal of the American Society of Nephrology

    (2000)
  • R.C Woolfson et al.

    Causes of acute renal failure

  • G Bocca et al.

    Compartment syndrome, rhabdomyolysis and risk of acute renal failure as complications of the lithotomy position

    Journal of Nephrology

    (2002)
  • N Kikuno et al.

    Traumatic rhabdomyolysis resulting from continuous compression in the exaggerated lithotomy position for radical perineal prostatectomy

    International Journal of Urology

    (2002)
  • F.C Riess et al.

    Rhabdomyolysis following cardiopulmonary bypass and treatment with enoximone in a patient susceptible to malignant hyperthermia

    Anesthesiology

    (2001)
  • K.A McKenney et al.

    Delayed postoperative rhabdomyolysis in a patient subsequently diagnosed as malignant hyperthermia susceptible

    Anesthesiology

    (2002)
  • G Green

    A fatal case of malignant hyperthermia complicated by generalized compartment syndrome and rhabdomyolysis

    Acta Anaesthesiologica Scandinavica

    (2003)
  • R Baliga et al.

    Oxidant mechanisms in toxic acute renal failure

    Drug Metabolism Reviews

    (1999)
  • M.R Schenk et al.

    Continuous veno-venous hemofiltration for the immediate management of massive rhabdomyolysis after fulminant malignant hyperthermia in a bodybuilder

    Anesthesiology

    (2001)
  • B.H Webster

    Clinical presentation of haemolytic transfusion reactions

    Anaesthesia and Intensive Care

    (1980)
  • O Uzun et al.

    Haemolysis following implantation of duct occlusion coils

    Heart

    (1999)
  • E Nikolsky et al.

    Radiocontrast nephropathy: identifying the high-risk patient and the implications of exacerbating renal function

    Reviews in Cardiovascular Medicine

    (2003)
  • M.R Rudnick et al.

    Contrast media-associated nephrotoxicity

    Seminars in Nephrology

    (1997)
  • M.R Rudnick et al.

    Contrast media-associated nephrotoxicity

    Current Opinion in Nephrology and Hypertension

    (1996)
  • L.J Arend et al.

    Role for intrarenal adenosine in the renal hemodynamic response to contrast media

    Journal of Laboratory and Clinical Medicine

    (1987)
  • B.J Murphy et al.

    nephropathy Journal of the American Society of Nephrology

    (2000)
  • B.M Louis et al.

    Protection from the nephrotoxicity of contrast dye

    Renal Failure

    (1996)
  • C.S McCarthy et al.

    Multiple myeloma and contrast media

    Radiology

    (1992)
  • P Aspelin et al.

    Nephrotoxic effects in high-risk patients undergoing angiography

    New England Journal of Medicine

    (2003)
  • Cited by (56)

    • International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): A human rights case for nephrology

      2015, The Lancet
      Citation Excerpt :

      Some of the recommendations rely on the availability of blood chemistry analysers, which might have little or no availability in resource-limited settings, particularly in those in level 2 and 3 countries. The avoidance of drugs and nephrotoxins that cause AKI138,139 and appropriate dose adjustment of renally cleared or protein-bound drugs140 are essential. Drugs that should be used with caution or avoided include angiotensin-converting-enzyme inhibitors, angiotensin-II receptor blockers, NSAIDs,141–144 aminoglycosides,145,146 amphotericin B,146 contrast media, chemotherapy drugs,147,148 antiretroviral therapy, and calcineurin blockers.

    • Nephrotoxicity and Nephroprotective Potential of African Medicinal Plants

      2014, Toxicological Survey of African Medicinal Plants
    • Selective ET<inf>A</inf> receptor blockade protects against cisplatin-induced acute renal failure in male rats

      2014, European Journal of Pharmacology
      Citation Excerpt :

      Results of the current study demonstrated that acute administration of cisplatin (6 mg/kg) to male rats led to histological alterations of the renal tubular cells. These changes were associated with decline in renal functions, leading to increased concentrations of serum creatinine and blood urea nitrogen, and are in line with previous studies (Evenepoel, 2004; Lameire et al., 2005; Sahu et al., 2013). Furthermore, the findings of the current study point to the presence of oxidative stress and are in accordance with data in previous reports (Antunes et al., 2001; Mora et al., 2003; Sahu et al., 2013; Weijl et al., 1997).

    • Drug induced nephrotoxicity and associated factors a narrative review

      2023, Journal of Medical Pharmaceutical and Allied Sciences
    • Evaluation of Acute Kidney Injuries Among Acutely Intoxicated Patients by RIFLE Classification

      2022, Mansoura Journal of Forensic Medicine and Clinical Toxicology
    View all citing articles on Scopus
    View full text