Acute Renal Failure in the ICU

The International Consensus Conference in Intensive Care Medicine considering the “Prevention and Management of Acute Renal Failure in the ICU Patient” was held in Montreal, Canada, on 3–4 May 2007. Five questions formulated by scientific advisors were addressed by experts during a 2-day symposium, and a jury summarized the available evidence in response to the following questions:

( 1 ) How can we identify acute renal failure? This question included issues of definitions, outcomes, biomarkers, and risk factors.

( 2 ) What can we do to protect against the development of acute renal failure during routine ICU care? This question addressed the role of fluids and their type, use of vasopressors, and prevention against the nephrotoxicity of different agents including contrast dyes and antibiotics.

( 3 ) Can we prevent acute renal failure from developing in specific disease states? The different diseases included liver failure, lung injury, cardiac surgery, tumor lysis syndrome, rhabdomyolysis, and elevated intraabdominal pressure.

( 4 ) How should we manage a patient who is critically ill who develops acute renal failure? This topic included general management, nutrition, anticoagulation, and dialysate composition.

( 5 ) What is the impact of renal replacement therapy on mortality and recovery? This last question addressed issues regarding filter membranes, timing, dose, and mode of renal replacement therapy. The panel recommended the use of newly described definitions and found the designation “acute kidney insufficiency” (AKI) to be the most appropriate. The jury indicated that AKI significantly contributes to the morbidity and mortality of patients who are critically ill, stressed the importance of adequate volume repletion for prevention of AKI, although correction of fluid deficit will not always prevent renal failure. Indeed, when hemodynamics are considered satisfactory, persistent fluid challenges should be avoided if they do not lead to an improvement in renal function or if oxygenation deteriorates. Risk factors for AKI include age, sepsis, cardiac surgery, infusion of contrast medium, diabetes, rhabdomyolysis, and preexisting renal disease, as well as hypovolemia and shock. Fluid resuscitation with crystalloids is as effective and safe as resuscitation with hypooncotic colloids, but hyperoncotic solutions are not recommended for this purpose because of their renal risk. The panel recommended abandoning the use of low-dose dopamine to improve renal function. In case of kidney failure, renal replacement therapy is a life-sustaining intervention that can provide a bridge to renal recovery. The panel indicated that traditional triggers for this treatment derived from studies in chronic renal failure may not be appropriate for critically ill patients with AKI, and when renal support is indicated because of metabolic derangements, treatment should not be delayed. Characteristics of dialysate composition and temperature can greatly improve the hemodynamic tolerance of intermittent hemodialysis. There is no evidence that the use of intermittent hemodialysis or continuous hemofiltration clearly produce superior renal recovery or survival rates in general ICU patient populations. Our understanding of how to optimally prevent, diagnose, and manage AKI in critical illness requires a great deal of additional research.

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Dernière mise à jour : 07/12/2015