|Year : 2001 | Volume
| Issue : 4 | Page : 538-549
|Recommended Standards for Acute Renal Failure, Pre-dialysis Chronic Renal Failure and General Nephrology
Ibrahim Hassan Fahal
Consultant Physician and Nephrologist, Oldchurch Hospital, Romford, Essex, United Kingdom
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|How to cite this article:|
Fahal IH. Recommended Standards for Acute Renal Failure, Pre-dialysis Chronic Renal Failure and General Nephrology. Saudi J Kidney Dis Transpl 2001;12:538-49
A = Evidence from at least one properly performed randomized controlled trial (quality of evidence Ib) or meta-analysis of several controlled trials (quality of evidence Ia).
|How to cite this URL:|
Fahal IH. Recommended Standards for Acute Renal Failure, Pre-dialysis Chronic Renal Failure and General Nephrology. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2020 Jan 19];12:538-49. Available from: http://www.sjkdt.org/text.asp?2001/12/4/538/33796
B = Well-conducted clinical studies, but no randomized clinical trials; evidence may be extensive but essentially descriptive (evidence levels IIa, IIb, III).
C = Evidence (level IV) obtained from expert committee reports or opinions, and/or clinical experience of respected authorities. This grading indicates an absence of directly applicable studies of good quality.
Acute renal failure (ARF)  is the condition in which a patient, usually with no known previous renal impairment, develops acutely failing renal function, with an increase, more or less rapid, of urea, creatinine, hydrogen ion, potassium and other renally excreted substances in the blood over hours or days. There are many causes of this condition, which may very simply be broken down into:
a). Medical conditions (reaction to drugs, gross electrolyte disturbance, glomerulonephritis, infection etc). Renovascular disease has become increasingly recognized as a common cause of renal failure, particularly in the elderly and above all in patients receiving angiotensin-converting enzyme inhibitors. Renal atheroembolism has also been noted with increasing frequency.
b). Multiple trauma such as industrial or road accidents or burns, civil or military violence etc.
c). Surgical interventions, especially when complicated by sepsis.
d). Obstetric accidents, which are rare in developed countries; it must be noted however that the few cases that still occur are often severely ill.
e). Obstruction of the urinary tract, often acutely on a background of more chronic obstruction.
Recovery of renal function can be expected in the majority of patients with ARF from causes listed above, within a few days to a few weeks, but only if the patient survives the many vicissitudes of ARF and is aged less than 50 years. In some medical conditions, and in patients over 50 years of age, an increasing proportion have some preceding renal functional impairment in excess of that expected for age. These patients may fail to recover function or recover very limited function, such that they require long-term dialysis, or only achieve partial recovery, though able to stop dialysis treatment. The proportion of patients surviving but not achieving independence from dialysis appears to be increasing  acute irreversible renal failure. 
A conservative estimate of the number of patients with ARF is that 70 per million population/year require dialysis for this condition.  No good data exist for those who become uremic and need a specialist opinion but do not require or do not receive dialysis; probably about another 130 per million population/year fall into this group. There is in addition substantial underreferral of patients in ARF, as judged by hospital laboratory data.  ARF becomes more common with age, the highest incidence being in 90 year olds, but the largest absolute numbers occur in late middle age and early old age.
Within any hospital catchment area, the number of cases of ARF per year will vary with the presence of other specialist services, for example cardiothoracic surgery or oncology. The case-mix of patients has changed greatly during the past decades,  together with a notable rise in the average age of those referred (now 60-65 years).
Some patients who present as acute emergencies with uremia, and appear initially to have acute reversible renal failure, are subsequently found to have an acute deterioration of renal function superimposed on chronic irreversible renal failure, or chronic irreversible renal failure itself and remain on dialysis after 90 days. 
Types of acute renal failure
Two types of ARF should be distinguished: Isolated failure of the kidneys alone. ARF in which the kidneys are the sole organs involved, other organ systems functioning normally, at least to begin with. Multiple organ failure. ARF as part of a severe illness, infection or trauma in which other organ function is compromised.
The case-mix in different districts will contain different proportions of these two types of renal failure, and will vary according to local clinical activity, e.g., the presence of a trauma unit, a bone marrow transplant unit, liver or cardiothoracic surgery service. Respiratory insufficiency is the most common associated organ failure, but up to four or five other organ systems may fail simultaneously.
Where should patients be managed?
This raises controversial issues, and will depend to some extent upon what high dependency unit (HDU) facilities are available on the renal ward. ARF affecting only the kidneys varies in severity, but can in the majority of cases be managed appropriately in renal wards, which usually have the facilities of an HDU. Some patients with mild respiratory impairment (e.g. from fluid overload, which can be corrected) can be managed in a renal ward with HDU facilities, by techniques such as continuous positive air pressure (CPAP). In general, however, patients with other organ failure besides the kidney should be managed in an intensive care unit (ICU).
If managed in the renal ward or unit, it is inappropriate for patients with ARF to be managed in the same setting as long-term dialysis patients, which carries many disadvantages, e.g. a requirement that these acutely ill patients be dialyzed according to schedule rather than according to need; a special area for those in ARF needs to be designated.
For any patient in ARF, full support services, including access to specialist interpretation of renal biopsies and a variety of imaging techniques, microbiology etc, are needed.
By contrast, patients with multiple organ failure require multi-disciplinary management within a suitably equipped and staffed ICU. This will often require transfer of the patient, which should be carried out in a timely fashion supervised by an experienced and properly equipped transfer team  in accord with the recommendations of the report of the working group on guidelines on admission to and discharge from ICUs and HDUs. 
Patients with failure of the kidneys and one or more other organs normally should be managed in a high dependency or intensive care unit. (C)
When should therapy begin?
There are no absolute rules as to when treatment for renal failure should begin, but it is better to begin treatment apparently too soon than too late. Thus, when it is obvious that ARF is established, dialysis should be started before complications occur.
A common practice is to start renal failure treatment when the blood urea exceeds 3050 mmol/L, but this depends also upon the rate of rise and clinical setting. Indications for emergency treatment include hyperkalemia (plasma K + >6.5 mmol/L), pulmonary edema as a result of fluid overload, acidosis leading to circulatory compromise, and gross symptoms of general uremia.
Management techniques and site
ARF involving only the kidneys can be managed by a variety of techniques in the renal ward. Regular intermittent hemodialysis is the commonest mode of management, but continuous filtration techniques may be used, although they are not available in many renal wards on a 24hour basis. Peritoneal dialysis is still used in the occasional patient whose tissue breakdown is not severe (non-catabolic).
A full range of treatment modalities for ARF involving only the kidneys should be available in the renal ward or ARF treatment area. Facilities appropriate to a HDU should be available in addition.
ARF in the critically ill associated with multiple organ failure, or other organ failure, must of necessity be managed in an ICU. Dialysis and filtration as part of multiple organ support should be carried out using biocompatible membranes for the dialytic technique since controlled trials have demonstrated increased survival , even though the benefit of this approach has been challenged. ,
Although increased survival has not been demonstrated compared with conventional hemodialysis,  treatment will most often be by continuous hemofiltration using a veno-venous blood circuit and a blood pump, but other techniques may be used according to individual needs and local skills such as pump-less arteriovenous hemofiltration or (in carefully selected patients, and in children), peritoneal dialysis. The important point is that access to a range of techniques, including intermittent and continuous therapy, should be available in the ICU for these complex and very ill patients.
Biocompatible (polyacrylamide, polysulphone) membranes should be used for renal replacement therapy of patients with ARF as part of multiple organ failure. Whilst pumped veno-venous continuous hemofiltration will most often be used, other modalities of treatment should be available in the ICU. (A)
Those in charge of the patients in ICUs in hospitals without an in-house physician /nephrologist should have had appropriate training and experience to allow them to manage such patients' medical, surgical, nutritional and pharmacological needs with skill and confidence, and have defined formal links to a local renal unit for advice on the telephone and a visit or visits from a nephrologist. ICUs that treat only a handful of such patients each year should not have to manage them unaided.
In hospitals with both a renal unit and an ICU, patients with multiple organ failure including ARF should be managed jointly by intensive care physicians and nephrologists. At an appropriate time, if they recover other organ functions, they may be able to transfer to the renal ward if necessary.
In hospitals with an ICU but no renal unit, if those units see more than about 20 patients with ARF per year, the intensive care medical staff, especially at consultant level, will need to have had training in the medical aspects of ARF. (C)
Units likely to see 10-15 or fewer patients with ARF per year should normally transfer such patients to an appropriate nearby ICU with renal back-up. (C)
All ICUs without in-house access to a renal unit should have formal links with their nearest renal unit for advice and consultation, and that advice and consultation should be sought for all critically ill patients one of whose components is renal failure. This commitment has workload and staff implications for renal units. (C)
These are difficult to set because the casemix of patients may influence outcome, e.g. the presence of a very active oncology, bone marrow transplantation, cardiothoracic surgery or hepatology unit supplying the unit with patients. Age, perhaps surprisingly, has little effect in many series on outcome compared with other acute medical problems such as sepsis. 
Despite many attempts ,,, no clinical or biochemical index has been developed so far that can predict individual outcome reliably enough to be useful, though repeated measurements with time may improve prediction.  All such patients require treatment based upon their individual disease process, clinical condition and response to treatment.
Survival to discharge in patients with any type of ARF affecting the kidneys alone should be more than 90%.
In patients with combined renal and respiratory failure (dialyzed and ventilated), 40-50% should survive until discharge. (B)
At least 5-10% should survive until discharge if a third organ system fails and this state persist for more than three days. (B)
All patients whose kidneys fail in the course of multiple organ failure should have replacement therapy if other active treatment is to continue, although it may in some cases be appropriate to withdraw dialysis along with other support at a later date. (B)
Death in the presence of ARF in patients below the age of about 50 years is rarely the direct result of the renal failure itself but from some aspect of the circumstances leading to the multiple organ failure.
The survivors of ARF usually will have no need of further dialysis if aged less than 55 years. However, over this age an increasing proportion either fail to recover renal function and continue on dialysis past 90 days 2 or have underlying renal disease (especially renovascular disease), so what appears at onset to be an episode of ARF turns out to be an acute presentation of endstage renal disease. These patients present not only major problems of clinical management and rehabilitation but extra costs, which have not yet been accurately defined.
Patients not requiring dialysis
Referral or consultation on patients with electrolyte problems and acute uremia who do not require dialysis forms a major part of the work of renal units, and has cost and personnel implications. For convenience, a blood urea over 30 mmol/l and/or plasma creatinine greater than 300 µmol/l should act as a definition of such patients, who respond with return of renal function towards normal with management of electrolyte and other problems, e.g. urinary tract obstruction, which is particularly common in elderly men. 
The numbers of patients presenting in acute uremia but not requiring dialysis should be recorded and audited.
Items for Audit
For audit of acute renal failure the following data should be recorded:
Number of patients requiring temporary support for ARF.
Causes of the acute uremia (including how many were in fact acute-on-chronic renal failure, i.e. requiring dialysis at 90 days). Number of organ systems failing and APACHE II (Acute Physiological and Chronic Health Evaluation) score at admission, start of dialysis and day seven. Site of management.
Technique of renal replacement therapy used.
Outcome: Percentage leaving the ITU alive: with renal function remaining in need of dialysis support.
Percentage discharged from hospital.
Percentage surviving 6 or 12 months after onset.
| Recommended Standards for Chronic Renal Failure (pre-dialysis)|| |
Progressive renal insufficiency
Patients with progressive renal insufficiency need careful follow-up and monitoring in an attempt to slow progression of the renal failure when possible, to prevent complications and to prepare patients physically and mentally for the appropriate renal replacement therapy.
Early referral of such patients to a nephrologist with facilities for full assessment, including diagnostic imaging, specialized renal histopathology, dietetics and urology, is indicated but it is not always practiced in the UK at present. As an approximate guide, any patient with a plasma creatinine in excess of 150 µmol/l or whose plasma creatinine is rising rapidly (> 50 µmol/l in 1-2 weeks) should be referred for assessment. Some will turn out to have reversible or controllable causes of renal failure (e.g. urinary tract obstruction, renovascular disease or hypertension); their prompt identification and treatment has clear clinical and financial advantages.
Patients with greater degrees of renal failure (e.g. plasma creatinine > 300 µmol/l) have a lower potential for reversal or amelioration of renal failure, but blood pressure control and diet have much to offer. There are advantages also in following these patients with progressive renal failure in a separate low clearance clinic, in which their renal failure is managed and they are educated about modes of renal replacement treatment that can be provided.
All patients who appear to have progressive renal insufficiency and a plasma creatinine above 150 umol/l and/or rapidly rising plasma creatinine concentrations should be referred to a nephrology service for assessment and follow-up. (B)
Blood pressure control
As control of systemic hypertension is so far the only intervention (other than treatment of the primary disease) that has been demonstrated in controlled trials to slow the progression of chronic renal failure (CRF),  optimal blood pressure control is essential. Angiotensin-converting enzyme (ACE) inhibitors have been shown in prospective controlled trials to slow the decline of renal function in patients with chronic renal insufficiency,  especially diabetic patients.  The position with regard to other antihypertensive agents such as calcium channel blockers remains unclear, but the various treatments given in the Modification of Diet in Renal Disease (MDRD) study  suggest that this could be a general effect of hypotensive therapy and not specific to ACE inhibitors.
Because of all the problems associated with interpretation of hospital clinic blood pressures, and possible future need to measure blood pressure on dialysis, there are obvious advantages in teaching patients to take their own blood pressures and bring the results to the clinic. The standard method using a mercury manometer and auscultation over an artery can prove difficult, so methods with a direct read-out may be needed. It should be noted that the only such machine approved by the Blood Pressure Subcommittee of the British Cardiac Society is an oscillotonometric method, using machines of the Omron TM series.
Target blood pressures for all patients should be: Age < 60-BP < 140/90 mm Hg (Korotkoff V if auscultation is used) Age > 60-BP < 160/90 mm Hg (Korotkoff V if auscultation is used). For certain diabetic patients these figures may need to be lower. (A)
Diet and biochemical control
Optimal control of protein, calcium and phosphate intake, immunoreactive parathormone (iPTH) and metabolic acidosis is important and may have an impact on morbidity, and possibly on the progression of renal disease.
Each patient should be assessed by a renal dietitian at regular intervals to optimize mineral, protein, fat and total calorie intakes. Although symptomatic benefit can be achieved, the role of protein intake in determining rapidity of decline in renal function remains controversial, despite several prospective controlled trials. ,,,,, The input of dietetic nursing and medical time required to achieve any putative benefit must also be taken into consideration; at the moment few units in the UK practice dietary restriction of protein in patients with a glomerular filtration rate < 25 ml/min (plasma creatinine approximately 350 µmol/l depending on age, sex and body size). This policy conflicts with the advice arising from the MDRD study in the United States , and with meta-analyses of trials.
Protein intake is, in any case, restricted spontaneously to approximately 0.6-0.7 g/kg/24 h by uremic patients not receiving any dietary advice,  although the quality of the protein selected may not be optimal, or the caloric intake, adequate. An intake of 0.8-1.0 g protein/kg/24 h biased in favor of first class protein seems best until further evidence accumulates. If protein restriction is practiced it must be supplemented with an adequate increase in energy intake (> 35 g/kg ideal body weight/24 h), and supervised carefully by a trained renal dietitian. Thus, at the moment no standards can be recommended in this contentious and very important area.
Very low protein diets (0.2-0.5 g/kg/24 h), although possibly effective in some well supervised patients with very low renal function,  are poorly complied with in practice, may lead to negative nitrogen balance and hence to increased morbidity, and are not recommended.
Control of serum bicarbonate within naormal levels is advocated below. This may involve the administration of doses of bicarbonate that result in volume expansion and hypertension. The 'trade off' of these two goals has to be assessed for each individual.
Target ranges for:
Serum calcium 2.2-2.7 mmol/l (corrected for serum albumin)
Serum phosphate 0.8-1.5 mmol/l Bicarbonate within local normal limits. (B)
The influence of lipid concentrations on the evolution of renal failure in humans is equivocal. At the moment, we do not make any recommendations for desired concentrations of plasma cholesterol, beyond those that would be applied to a population of individuals not in renal failure. When further data have accumulated it should be possible to make recommendations in this area.
There is considerable controversy about the early management of bone disease in adult patients with CRF. Some maintain that vitamin D in the form of calcitriol or l a-hydroxycholecalciferol should be started in small doses at a very early stage, when the plasma creatinine is only 250-300 µmol/l. Baker et al  and Hamdy et al  provide controlled evidence in favour of this; others use this drug much later in the course of the disease. The serum alkaline phosphatase is an insensitive index of bone disease in this setting, a normal level providing little information and a raised level suggesting that disease of some severity is already present. Thus the measurement of serum iPTH by an intact hormone assay is necessary. Some recommend that the serum parathormone concentrations should be maintained at normal or nearly normal levels throughout; others are less aggressive.
Serum alkaline phosphatase should be monitored at each visit and maintained within normal limits.
Serum iPTH should be maintained at two, or at most three, times the upper limit of normal (130-210 pg/ml). (A)
As their renal failure worsens, patients become more and more anemic. Despite a growing body of data demonstrating that the use of erythropoietin (EPO) significantly improves quality of life in patients with advanced renal failure before they go on to dialysis,  including at least one prospective controlled trial,  EPO has been little used in this group of patients in the United Kingdom probably because of its high cost.
At the moment we are unable to set standards for target hemoglobin concentrations in pre-dialysis renal failure, but the influence on timing of entry on to dialysis treatment, with all its associated costs, may be affected by the hemoglobin level. However, no cost effectiveness data are yet available.
Beginning regular dialysis
The great majority of patients reaching end-stage renal failure will be treated by some form of dialysis in the first instance, although a minority may receive a renal transplant (especially from a living donor) without any prior dialysis. The optimum time to start dialysis for each patient remains controversial.  However, all are agreed that delay in reaching dialysis beyond readily acceptable indices leads to a higher early mortality, ,,, and to higher per patient costs.  Some of this late treatment remains the result of late referral to the renal unit, , and can only be addressed by education of community health professionals.
The problem remains of how to decide when dialysis should begin in patients already known and attending a low clearance clinic. Urea kinetic modeling may be of use in this context  since plasma concentrations of urea and creatinine may mislead, especially in elderly and malnourished patients. The suggestion has been made that dialysis should be started at a point at which the weekly small solute removal (Kt/V) falls to that regarded as optimal for a patient on dialysis. This corresponds to a weekly Kt/V of about 2.2 and implies starting small amounts of dialysis at a level of native creatinine clearance of about 15 ml/min and gradually increasing this as residual renal function falls away. If implemented, such a policy of 'early start/gradual increment' would have major organizational and financial implications. At the moment no recommendations can be made in this important field until more data are available.
Items for Audit
Audit of patients in chronic renal failure should include collection of the following data:
Patients joining the low clearance clinic Serum creatinine at time of first referral Number requiring immediate dialysis Patients attending the low clearance clinic Distribution and % of patients achieving target levels for:
Blood pressure, serum calcium, phosphate and bicarbonate, serum iPTH
| Recommended Standards for General Nephrology|| |
The early diagnosis and prompt treatment of a number of renal diseases (e.g. reflux nephropathy, diabetes mellitus and hypertensive nephropathy) may prevent renal failure obviate the need for renal replacement therapy and reduce comorbidity in those requiring treatment for end stage renal failure, which in turn improves prognosis. Only encouragement of referral or joint management through communication with colleagues in general hospitals and family practice can achieve this.
Clear recommendations for referral of patients with symptoms or signs of possible renal disease have yet to be worked out, though the Scottish Intercollegiate Guidelines Network (SIGN) has published documents recommending management strategies for patients found to have proteinuria and/or haematuria. ,
In addition to patients with major renal syndromes - chronic (repeated plasma creatinine > 150 g/mol/l) or acute renal failure, acute glomerulonephritis or a nephrotic syndrome, or recurrent renal stones - general practitioners and consultant general physicians or specialists in other areas of medicine should be encouraged to refer for nephrology assessment in the following clinical settings:
Abnormalities on urinalysis (proteinuria, hematuria) and/or raised plasma creatinine (> 150 umol/l) concentrations without apparent cause, with or without clinical complaints. Persistent microhematuria even if renal function is normal, particularly if the patient is under 40-45 years of age or there is associated proteinuria and/or hypertension (Older patients with isolated hematuria of any dimension should be referred to a urological hematuria clinic).
Frank hematuria in patients under 40-45 years of age. Persistent proteinuria with normal renal function, especially if accompanied by hematuria. Refractory hypertension associated with abnormal urinalysis and/or elevated plasma creatinine concentration. Patients with known polycystic kidney disease, even if renal function is normal, and their close relatives should they require counseling. Patients with urinary tract infections in some circumstances*
Diabetics with clinically evident proteinuria, even with normal renal function. Pregnant women with known renal disease. (B)
* With hypertension; infection with unusual organisms (eg Proteus, Klebsiella); in adult males; during pregnancy Patients with infections and symptoms of voiding dysfunction may be referred to either a renal or a urological clinic.
Renal units must have access to a full range of support services, including all modes of imaging, histopathology, microbiology social services, dietetic services and occupational therapy. Many services will be required on occasion outside normal working hours.
Liaison with colleagues
The nephrologist will need to co-operate on a daily basis with many colleagues, both in a consultative capacity for renal problems arising in patients under their care, and also in asking their help in specialist problems in patients with renal disease under their own care.
The nephrologist will be involved also in co-operating with community services, especially in the care of elderly patients with or without renal failure or on dialysis.
The care of the majority of patients with ongoing renal disease, especially those with renal failure (plasma creatinine > 300-400 umol/l), should be in a special low clearance clinic. (B)
The care of patients with diabetes mellitus presents particular problems of management, such as the care of the feet and eyes, but there is hope for prevention. There is evidence from a controlled trial that the degree of control of diabetes may postpone or prevent renal damage, but this must be maintained at a level very close to that at which hypoglycemic episodes become common. There is evidence that the use of angiotensin-converting enzyme inhibitors may prevent diabetic nephropathy or slow its progression.
Care of patients with diabetes and renal disease, especially those with renal failure, should be through joint diabetic/renal specialist management. (B)
Systemic immunological disorders
The kidney may be involved in a variety of systemic immunological disorders such as vasculitis and systemic lupus erythematosus, sometimes at onset but also sometimes late in the disease, by which time the patient is already under observation and treatment. There is much advantage in liaison with colleagues likely to encounter such patients, especially rheumatologists, and in having joint clinics at which these patients can be reviewed.
Renal biopsy performance and interpretation is an important part of the practice of general nephrology. In terms of diagnostic and prognostic utility, where the biopsy is performed and who performs it are less important than who interprets it. At the moment we cannot suggest standards for the various methods of renal biopsy, including mechanical methods such as the Biopty TM gun.
In some hospitals, radiologists will perform the renal biopsies, but it is important that specialist registrars in nephrology receive instruction and practice in doing renal biopsies. Less experienced staff, such as senior house officers, should not normally be involved in performing biopsies.
Renal biopsy interpretation is a highly specialized component of histopathology. It should be performed only by, or under the supervision of a specialist renal pathologist participating in appropriate audit, quality assurance and continuing medical education activities in pathology. In some renal units this will mean sending the biopsy specimen elsewhere for interpretation.
The laboratory should be accredited for histopathology and have on site facilities for electron microscopy and immunohistological staining of the biopsy specimens, which are essential for the interpretation of many specimens. Reporting times should be such that appropriate and timely intervention can be achieved clinically.
For quality control and medical education, regular joint clinico-pathological meetings should take place.
Interpretation of renal biopsies should take place in a suitably equipped and staffed specialist histopathology laboratory. This may mean sending the biopsy to another hospital for processing and assessment. (B)
Items for Audit
There are few audit measures in general nephrology that permit evaluation of the service, other than general audit such as waiting times for, and in, outpatients or for ward admission, cancellation of interventions,
lengths of hospital stay etc. We suggest the following points for audit of renal biopsy:
Number of renal biopsies done per year
Number of individuals performing biopsy during the period of analysis
Success rate in obtaining adequate tissue (>10 glomeruli/section) at first attempt Clinical complication rate and nature (bleeding, symptomatic A-V aneurysm etc) in uremic and non-uremic subjects.
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Ibrahim Hassan Fahal
Consultant Physician and Nephrologist, Oldchurch Hospital, Romford, Essex
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