Causes and Prognosis of Nontraumatic Acute Renal Failure Requiring Dialysis in Adult Patients with and without Diabetes

Effects of Korean red ginseng extract on acute renal failure induced by gentamicin and pharmacokinetic changes by metformin in rats

AIM OF THE STUDY

Korean red ginseng is one of the best selling dietary supplements and its individual constituents enhance renal function. Acute renal failure (ARF) is a predisposing complication of diabetes mellitus as a result of combination drug therapy. The combination of antibiotic-antidiabetic drugs can entail toxicities and drug interactions because of the antibiotic resistance in patients with severe bacterial infection. Currently, gentamicin-metformin combination therapy is commonly prescribed for treating bacterial infections and diabetes, even though both drugs are mainly excreted via the kidney. Thus, this study was designed to investigate whether a Korean red ginseng extract (KRG) prevents renal impairment and pharmacokinetic changes by metformin in rats with renal failure induced by gentamicin.

MATERIALS AND METHODS

The in vivo pharmacokinetics and in vitro hepatic/intestinal metabolism of metformin were assessed using control (CON), control with Korean red ginseng extract (KRG-CON), acute renal failure induced by gentamicin (ARF), and ARF with Korean red ginseng (KRG-ARF) rats.

RESULTS AND CONCLUSIONS

Pharmacokinetic changes of metformin did not occur in KRG-ARF rats because KRG reduce the renal accumulation of gentamicin compared to ARF rats. Thus, KRG seemed to prevent acute renal failure induced by gentamicin treatment.

Peroxisome proliferator-activated receptor β/δ agonism protects the kidney against ischemia/reperfusion injury in diabetic rats

Diabetes is an important risk factor for ischemic acute kidney injury, whose pharmacological treatment remains an unmet medical need. The peroxisome proliferator-activated receptor (PPAR) β/δ is highly expressed in the kidney, although its role has not yet been elucidated. Here, we used an in vivo model of renal ischemia/reperfusion (I/R) in streptozotocin-induced diabetic rats (i) to evaluate whether diabetes increases kidney susceptibility to I/R injury and (ii) to investigate the effects of PPARβ/δ activation. The degree of renal injury (1h ischemia/6h reperfusion) was significantly increased in diabetic rats compared with nondiabetic littermates. PPARβ/δ expression was increased after I/R, with the highest levels in diabetic rats. Administration of the selective PPARβ/δ agonist GW0742 attenuated the renal dysfunction, leukocyte infiltration, and formation of interleukin-6 and tumor necrosis factor-α. These effects were accompanied by an increased expression of the suppressor of cytokine signaling (SOCS)-3, which plays a critical role in the cytokine-activated signaling pathway. The beneficial effects of GW0742 were attenuated by the selective PPARβ/δ antagonist GSK0660. Thus, we report herein that PPARβ/δ activation protects the diabetic kidney against I/R injury by a mechanism that may involve changes in renal expression of SOCS-3 resulting in a reduced local inflammatory response.

Acute kidney injury prediction following elective cardiac surgery: AKICS Score

Acute kidney injury (AKI) following cardiac surgery (AKICS) is associated with increased postoperative (post-op) morbidity and mortality. A prognostic score system for AKI would help anticipate patient (pt) treatment. To develop a predictive score (AKICS) for AKI following cardiac surgery, we used a broad definition of AKI, which included perioperative variables. Six hundred three pts undergoing cardiac surgery were prospectively evaluated for AKI defined as serum creatinine above 2.0 mg/dl or an increase of 50% above baseline value. Univariate and multivariate analyses were used to evaluate pre-, intra-, and post-op parameters associated with AKI. The AKICS scoring system was prospectively validated in a new data set of 215 pts with an incidence of AKI of 14%. Variables included in the AKICS score were age greater than 65, pre-op creatinine above 1.2 mg/dl, pre-op capillary glucose above 140 mg/dl, heart failure, combined surgeries, cardiopulmonary bypass time above 2 h, low cardiac output, and low central venous pressure. The AKICS score presented good calibration and discrimination in both the study group and validation data set. The AKICS system that we developed, which incorporates five risk categories, accurately predicts AKI following cardiac surgery.

Risk factors for acute renal failure: inherent and modifiable risks

PURPOSE OF REVIEW

Our purpose is to discuss established risk factors in the development of acute renal failure and briefly overview clinical markers and preventive measures.

RECENT FINDINGS

Findings from the literature support the role of older age, diabetes, underlying renal insufficiency, and heart failure as predisposing factors for acute renal failure. Diabetics with baseline renal insufficiency represent the highest risk subgroup. An association between sepsis, hypovolemia, and acute renal failure is clear. Liver failure, rhabdomyolysis, and open-heart surgery (especially valve replacement) are clinical conditions potentially leading to acute renal failure. Increasing evidence shows that intraabdominal hypertension may contribute to the development of acute renal failure. Radiocontrast and antimicrobial agents are the most common causes of nephrotoxic acute renal failure. In terms of prevention, avoiding nephrotoxins when possible is certainly desirable; fluid therapy is an effective prevention measure in certain clinical circumstances. Supporting cardiac output, mean arterial pressure, and renal perfusion pressure are indicated to reduce the risk for acute renal failure. Nonionic, isoosmolar intravenous contrast should be used in high-risk patients. Although urine output and serum creatinine lack sensitivity and specificity in acute renal failure, they remain the most used parameters in clinical practice.

SUMMARY

There are identified risk factors of acute renal failure. Because acute renal failure is associated with a worsening outcome, particularly if occurring in critical illness and if severe enough to require renal replacement therapy, preventive measures should be part of appropriate management.