Acute Renal Failure: Prevention

Prevention of acute kidney failure (ANV) requires attention to reducing individual risk factors. The KDIGO guidelines provide recommendations for the prevention of acute kidney injury (“AKI”) in high-risk patients [see guidelines below]:

  • Discontinuation of all nephrotoxic medications (see below for causes/medications).
  • Maintenance of adequate perfusion pressure.
  • Optimization of volume status (cave: fluid overload).
  • Consideration of advanced functional hemodynamic monitoring.
  • Avoiding hyperglycemia (high blood glucose).
  • Close monitoring of serum creatinine concentration* and urine output to detect oliguria* (=.
  • Consideration of alternatives to radiographic contrast agents

* Low sensitivity

Primary or secondary prevention

  • Survey individual risk: Urinalysis and sonography (ultrasound) of the urinary tract should be performed before surgical procedures or contrast administration to detect obstruction (“occlusion“).
  • Avoid hypotension. There is a U-shaped correlation between systolic blood pressure and likelihood of acute renal failure. Below about 100-110 mmHg, the risk increased exponentially.
  • Prophylaxis of KM-induced nephropathy (English contrast-induced nephropathy, CIN): volume therapy before contrast administration: 0.9% NaCl solution (1 ml/kg/h) at least 6 hours before to 12 hours after contrast administration; this serves to prevent dehydration (dehydration).

Drugs (nephrotoxic: nephrotoxic (damaging to the kidney) drugs/nephrotoxic drugs).

  • ACE inhibitors (benazepril, captopril, cilazapril, enalapril, fosinopril, lisinopril, moexipril, peridopril, quinapril, ramipril, spirapril) and AT1 receptor antagonists (candesartan, eprosartan, irbesartan, losartan, olmesartan, valsartan, telmisartan) (acute: Decrease in glomerular filtration rate (GFR) associated with creatinine increase: ACE inhibitors as well as AT1 receptor antagonists abolish vasoconstriction in the vas efferens, and a decrease in GFR and increase in serum creatinine result. Up to 0.1 to 0.3 mg/dl, this is usually tolerable.However, in the presence of hemodynamically relevant renal artery stenosis (not uncommon in patients with atherosclerosis/arteriosclerosis), GFR becomes markedly angiotensin II-dependent, and administration of an ACE inhibitor or AT1 receptor antagonist may result in acute renal failure (ANV))!
  • Angiotensin receptor neprilysin antagonists (ARNI) – dual drug combination: sacubitril/valsartan.
  • Allopurinol
  • Atypical antipsychotics (olanzapine, quetiapine, risperidone) – elderly patients have approximately 70% increased risk of hospitalization for acute renal failure (ANV) during the first three months of treatment with atypical antipsychotics
  • Antiphlogistic and antipyretic analgesics (non-steroidal anti-inflammatory drugs (NSAID), non-steroidal anti-inflammatory drugs) or non-steroidal anti-inflammatory drugs (NSAID* ) Caution: the combination of a diuretic, an RAS blocker, and an NSAID is associated with a significant risk of acute kidney injury:
    • Acetylsalicylic acid (ASA).
    • Diclofenac
    • Ibuprofen/naproxen
    • Indometacin
    • Metamizole (novaminsulfone) is a pyrazolone derivative and analgesic from the group of non-acidic non-opioid analgesics (highest analgesic and antipyretic activity. Side effects: Circulatory fluctuations, hypersensitivity reactions, and very rarely agranulocytosis.
    • Paracetamol / acetaminophen
    • Phenacetin (phenacetin nephritis)
    • Selective COX-2 inhibitors such as rofecoxib, celecoxib (side effects: decreased sodium and water excretion, blood pressure increase and peripheral edema. This is usually accompanied by hyperkalemia!).
  • Antibiotics
  • Antifungals
  • Chloral hydrate
  • Diuretics
  • Colchicine
  • D-Penicillamine
  • Gold – sodium aurothiomalate, auranofin
  • Hydroxyethyl starch (HES)
  • Immunosuppressants (ciclosporin (cyclosporin A)) – esp. ciprofloxacin plus ciclosporin A.
  • Interferon
  • Colloidal solution with hydroxyl starch
  • Contrast media – Of particular importance here are magnetic resonance imaging (MRI) contrast media containing gadolinium, which can lead to nephrogenic systemic fibrosis (NSF). Particularly affected by NSF are patients with a glomerular filtration rate (GFR) of less than 30 ml/min. [CKD stage 4]; iodine-containing radiographic contrast agents; [require prophylactic irrigation in renal insufficiency]EMA (European Medicines Agency): categorization of GBCAs (gadolinium-based contrast agents) in terms of NSF (nephrogenic systemic fibrosis) risk, based on thermodynamic and kinetic properties:High risk:
    • Gadoversetamide, gadodiamide (linear/non-ionic chelates) gadopentetate dimeglum (linear/ionic chelate).

    Medium risk:

    • Gadofosveset, gadoxetic acid disodium, gadobenate dimeglumine (linear/ionic chelates).

    Low risk

    • Gadoterate meglumine, gadoteridol, gadobutrol (macrocyclic chelates).
  • Lithium
  • Proton pump inhibitors (PPI; acid blockers).
    • “Atherosclerosis Risk in Communities” (ARIC): 10-year PPI use: rate of chronic renal failure in patients on PPI 11.8%, without 8.5%; rate of renal damage: 64%; two pills a day resulted in significantly more frequent damage: 62%
    • Geisinger Health System: observation period 6.2 years; rate of chronic renal failure disease: 17%; rate of renal damage: 31%; two pills a day resulted in significantly more frequent damage: 28%
  • Rast blockers: the combination of a diuretic, an RAS blocker, and an NSAID is associated with a significant risk of acute kidney injury.
  • Tacrolism (macrolide derived from the gram-positive bacterium Streptomyces tsukubaensis. Tacrolimus is used as a drug in the group of immunomodulators or calcineurin inhibitors).
  • Antivirals
  • Cytostatic drugs – carboplatin, cisplatin, cyclophosphamide, gemcitabine, iphosphamide (ifosfamide), methotrexate (MTX), mitomycin C, platinum (cisplatin).

Environmental stress – intoxications (poisonings).

  • Metals (cadmium, lead, mercury, nickel, chromium, uranium).
  • Halogenated hydrocarbons (HFCs; trichloroethene, tetrachloroethene, hexachlorobutadiene, chloroform).
  • Herbicides (paraquat, diquat, chlorinated phenoxyacetic acids).
  • Mycotoxins (ochratoxin A, citrinin, aflatoxin B1).
  • Aliphatic hydrocarbons (2,2,4-trimethylpentane, decalin, unleaded gasoline, mitomycin C).
  • Melamine

Prevention factors (protective factors)

  • Remote ischemic preconditioning (RIP; remote ischemic preconditioning): procedure to condition tissues from damaging stress. The procedure; For this purpose, a blood pressure cuff is placed around the upper arm before the start of anesthesia and inflated three times for five minutes each to 200 mmHg or 50 mmHg above the respective systolic blood pressure.There is a five-minute break between each.Effect: The ischemia and reperfusion thus produced is thought to release mediators into the systemic circulation, which then activate protective mechanisms in vulnerable organs.In the RenalRIPC randomized trial of cardiac surgery patients at very high risk for acute renal failure, 52.5% of patients in the control group experienced acute renal failure (AKI 1-3), compared with 37.5% in the RIP group.