Protecting Renal Blood Flow in the Intensive Care Unit

  • J. A. Kellum
Conference paper


Acute renal failure (ARF) in the intensive care unit (ICU) represents a different spectrum of disease compared to ARF occurring outside the ICU. As much as 95% of ARF in the ICU is secondary to acute tubular necrosis (ATN). Incidence and mortality rates for ARF in and outside the ICU are quite different [1–3]. For example, the incidence of ARF is about 5% outside the ICU and mortality rates are usually < 30%. However, in the ICU, the incidence can be as high as 15% with a mortality rate between 50% and 90%. Severe ARF (defined as requiring dialysis) rarely occurs in isolation, and most often occurs in association with multiple organ failure (MOF) [4]. Ischemia, principally of the renal medulla, is estimated to contribute to 85% of cases of ARF [5], and multiple causes of medullary ischemia have been identified [6]. Most ARF occurs with multiple insults. Common conditions causing or exacerbating medullary ischemia are shown in Table 1. Thus, it seems reasonable that preserving renal blood flow (RBF) should be seen as an imperative for the intensivist. Unfortunately, this goal is easier to espouse than to achieve, and increasing RBF may not always be beneficial.


Acute Renal Failure Atrial Natriuretic Peptide Renal Blood Flow Distal Tubule Renal Medulla 


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  1. 1.
    Hou SH, Bushinsky DA, Wish JB et al (1983) Hospital-acquired renal insufficiency: a prospective study. Am J Med 74: 243–248PubMedCrossRefGoogle Scholar
  2. 2.
    Brivet FG, Kleinknecht DJ, Loirat P et al (1996) Acute renal failure in intensive care units — causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on Acute Renal Failure. Crit Care Med 24: 192–198PubMedCrossRefGoogle Scholar
  3. 3.
    Liano F, Junco E, Pascual J et al (1998) The spectrum of acute renal failure in the intensive care unit compared with that seen in other settings. The Madrid Acute Renal Failure Study Group. Kidney Int [Suppl] 66: S16–S24Google Scholar
  4. 4.
    Tran DD, Oe PL, de Fijter CW et al (1993) Acute renal failure in patients with acute pancreatitis: prevalence, risk factors, and outcome. Nephrol Dial Transplant 8: 1079–1084PubMedGoogle Scholar
  5. 5.
    Thadhani R, Pascual M, Bonventre JV (1996) Acute renal failure. N Engl J Med 334: 1448–1460PubMedCrossRefGoogle Scholar
  6. 6.
    Brezis M, Rosen S (1995) Hypoxia of the renal medulla — its implications for disease. N Engl J Med 332: 647–655PubMedCrossRefGoogle Scholar
  7. 7.
    Adams PL, Adams FF, Bell PD et al (1980) Impaired renal blood flow autoregulation in ischemic acute renal failure. Kidney Int 18: 68–76PubMedCrossRefGoogle Scholar
  8. 8.
    Kelleher SP, Robinette JB, Conger JD (1984) Sympathetic nervous system in the loss of autoregulation in acute renal failure. Am J Physiol 246: F379–F386PubMedGoogle Scholar
  9. 9.
    Bersten AD, Holt AW (1995) Vasoactive drugs and the importance of renal perfusion pressure. New Horiz 3: 650–661PubMedGoogle Scholar
  10. 10.
    Osswald H, Muhlbauer B, Schenk F (1991) Adenosine mediates tubuloglomerular feedback response: an element of metabolic control of kidney function. Kidney Int [Suppl] 32: S128–S131Google Scholar
  11. 11.
    Heyman SN, Fuchs S, Brezis M (1995) The role of medullary ischemia in acute renal failure. New Horiz 3: 597–607PubMedGoogle Scholar
  12. 12.
    Patak RV, Fadem SZ, Lifschitz MD et al (1979) Study of factors which modify the development of norepinephrine-induced acute renal failure in the dog. Kidney Int 15: 227–237PubMedCrossRefGoogle Scholar
  13. 13.
    Banks RO (1988) Vasoconstrictor-induced changes in renal blood flow: role of prostaglandins and histamine. Am J Physiol 254: F470–F476PubMedGoogle Scholar
  14. 14.
    Yang S, Silldorff EP, Pallone TL (1995) Effect of norepinephrine and acetylcholine on outer medullary descending vasa recta. Am J Physiol 269: H710–H716PubMedGoogle Scholar
  15. 15.
    Hoogenberg K, Smit AJ, Girbes AR (1998) Effects of low-dose dopamine on renal and systemic hemodynamics during incremental norepinephrine infusion in healthy volunteers. Crit Care Med 26: 260–265PubMedCrossRefGoogle Scholar
  16. 16.
    Martin C, Papazian L, Perrin G et al (1993) Norepinephrine or dopamine for the treatment of hyperdynamic septic shock? Chest 103: 1826–1831PubMedCrossRefGoogle Scholar
  17. 17.
    Redl-Wenzl EM, Armbruster C, Edelmann G et al (1993) The effects of norepinephrine on hemodynamics and renal function in severe septic shock states. Intensive Care Medicine 19: 151–154PubMedCrossRefGoogle Scholar
  18. 18.
    Conger JD, Robinette JB, Hammond WS (1991) Differences in vascular reactivity in models of ischemic acute renal failure. Kidney Int 39: 1087–1097PubMedCrossRefGoogle Scholar
  19. 19.
    Breslow MJ, Miller CF, Parker SD et al (1987) Effect of vasopressors on organ blood flow during endotoxin shock in pigs. Am J Physiol 252: H291–H300PubMedGoogle Scholar
  20. 20.
    Hussain SNA, Rutledge F, Roussos C et al (1998) Effects of norepinephrine and fluid administration on the selective blood flow distribution in endotoxic shock. J Crit Care 3: 32–42Google Scholar
  21. 21.
    Bellomo R, Kellum JA, Wisniewski SR et al (1999) Effects of norepinephrine on the renal vasculature in normal and endotoxemic dogs. Am J Respir Crit Care Med 159: 1186–1192PubMedGoogle Scholar
  22. 22.
    Zaritsky A, Lotze A, Stull R et al (1988) Steady-state dopamine clearance in critically ill infants and children. Crit Care Med 16: 217–220PubMedCrossRefGoogle Scholar
  23. 23.
    Kellum JA (1997) The use of diuretics and dopamine in acute renal failure: a systematic review of the evidence. Crit Care Med 1: 53–59Google Scholar
  24. 24.
    Seri I, Kone BC, Gullans SR et al (1988) Locally formed dopamine inhibits Na+-K+-ATPase activity in rat renal cortical tubule cells. Am J Physiol 255: F666–F673PubMedGoogle Scholar
  25. 25.
    Heyman SN, Kaminski N, Brezis M (1995) Dopamine increases renal medullary blood flow without improving regional hypoxia. Exp Nephrol 3: 331–337PubMedGoogle Scholar
  26. 26.
    Olsen NV, Hansen JM, Ladefoged SD et al (1990) Renal tubular reabsorption of sodium and water during infusion of low-dose dopamine in normal man. Clin Sci (Colch) 78: 503–507Google Scholar
  27. 27.
    Weisberg LS, Kurnik PB, Kurnik BR (1994) Risk of radiocontrast nephropathy in patients with and without diabetes mellitus. Kidney Int 45: 259–265PubMedCrossRefGoogle Scholar
  28. 28.
    Schnermann J, Todd KM, Briggs JP (1990) Effect of dopamine on the tubuloglomerular feedback mechanism. Am J Physiol 258: F790–F798PubMedGoogle Scholar
  29. 29.
    Dishart MK, Kellum JA (2000) An evaluation of pharmacological strategies for the prevention and treatment of acute renal failure. Drugs 59: 79–91PubMedCrossRefGoogle Scholar
  30. 30.
    Neumayer HH, Wagner K (1987) Prevention of delayed graft function in cadaver kidney transplants by diltiazem: outcome of two prospective, randomized clinical trials. J Cardiovasc Pharmacol 10[Suppl 10]: S170–S177PubMedGoogle Scholar
  31. 31.
    Dawidson I, Rooth P, Fry WR et al (1989) Prevention of acute cyclosporine-induced renal blood flow inhibition and improved immunosuppression with verapamil. Transplantation 48: 575–580PubMedGoogle Scholar
  32. 32.
    Neumayer HH, Kunzendorf U, Schreiber M (1992) Protective effects of diltiazem and the prostazycline analogue iloprost in human renal transplantation. Ren Fail 14: 289–296PubMedCrossRefGoogle Scholar
  33. 33.
    Manara AR, Bolsin S, Monk CR et al (1991) Metoclopramide and renal vascular resistance. Br J Anaesth 66: 129–130PubMedCrossRefGoogle Scholar
  34. 34.
    Felder RA, Blecher M, Calcagno PL et al (1984) Dopamine receptors in the proximal tubule of the rabbit. Am J Physiol 247: F499–F505PubMedGoogle Scholar
  35. 35.
    Hatala R, Dinh TT, Cook DJ (1997) Single daily dosing of aminoglycosides in immunocompromised adults: a systematic review. Clin Infect Dis 24: 810–815PubMedCrossRefGoogle Scholar
  36. 36.
    Prins JM, Buller HR, Kuijper EJ et al (1993) Once versus thrice daily gentamicin in patients with serious infections. Lancet 341: 335–339PubMedCrossRefGoogle Scholar
  37. 37.
    Walsh TJ, Hiemenz JW, Seibel NL et al (1998) Amphotericin B lipid complex for invasive fungal infections: analysis of safety and efficacy in 556 cases. Clin Infect Dis 26: 1383–1396PubMedCrossRefGoogle Scholar
  38. 38.
    Barrett BJ, Carlisle EJ (1993) Metaanalysis of the relative nephrotoxicity of high-and low-osmolality iodinated contrast media. Radiology 188: 171–178PubMedGoogle Scholar

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© Springer-Verlag Italia, Milano 2001

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  • J. A. Kellum

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