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Causes of acute renal failure (ARF) are summarized. The article focuses on "shock kidneys" as they occur following traumatic or septic shock. There may be low-grade intermittent but persisting endotoxemia in the former together with other factors like rhabdomyolysis, and marked endotoxemia at least for a few hours in the latter. Endotoxin is a prime cause of release of noxious cytokines like tumor necrosis factor-alpha (TNFa). At present, many studies support the evidence for its role in multi-organ failure (MOF). One can account for endotoxemia along with bacterial translocation through the gastrointestinal mucosa if there is transient mesenteric ischemia during shock. Hence, monocyte­macrophages can be stimulated to release their cytokines that predispose to MOF. The cell biology of renal tubular changes in ARF is then briefly discussed in order to mention new therapeutic approaches.

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A total of 52 patients were referred to our center from gynecology and obstetric units in our area with acute renal failure during the last two years. Seven patients were found to have so called syndrome of hemolysis (H), elevated liver enzymes (EL) and low platelets (LP) associated with acute renal failure. The syndrome can easily be confused with other diagnoses like hemolytic uremic syndrome, idiopathic thrombotic thrombocytopenic purpura and disseminated intravascular hemolysis. Six patients had renal biopsies to confirm the diagnosis, while one did not consent for biopsy. Four patients were found to have acute tubular necrosis, one had acute cortical necrosis and one was not enough for interpretation. We conclude that the patients can easily be misdiagnosed if we are not familiar with the diagnosis and that the overall prognosis is good if the patient survives the acute stage.

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We evaluated 215 patients with acute renal failure (ARF) in three centers in Jordan over an 18 months period. Their ages ranged between 12-90 years, and 120 of them were males. Parenchymal renal insult was the commonest cause of ARF as it was seen in 125 patients (58%). Pre-renal azotemia was seen in 60 patients (28%) and acute obstructive uropathy in 30 patients (14%). At presentation, 152 patients (70.7%) were oligo-anuric, while 63 (29.3%) were non-oliguric. Forty patients (18.6%) required dialysis support; 30 of them were in the renal failure group (75%). Thirty-two of the 40 patients were oliguric­aruric. Complete recovery of renal function was achieved in 80% for the whole group, and in 64% of those with parenchymal renal insult. Forty-seven patients (21.9%) died; 35 of them (63.9%) were in the renal group, and 37 patients (78%) were oligo-anuric. Sepsis and cardiac complications were together responsible for almost 75% of the deaths.

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Over a period of six months, 55 patients out of 11,216 (0.49%) admitted to the hospital developed acute renal failure (ARF). The diagnosis of ARF was based on the usual criteria, a sudden rise in blood urea nitrogen and creatinine with or without oliguria. Patients age ranged between 15 and 81 years with a mean of 51.9 years. Renal ischemia (69%) and nephrotoxic drugs (16.3%) were the two main etiologic factors. Among the causes of ischemia, septic shock was the commonest (29%), followed by severe hypotension due to several causes such as hemorrhage, burns, severe diarrhea and cardiogenic shock (25.4%), and ACE inhibitors (10.9%). ARF was associated with an average of 15.8 days stay in hospital versus 5.1 days for the overall hospital admissions. Immediate management of hypotension by intravenous fluid replacement, vasopressor agents and the necessary surgical intervention was appropriately considered. Intravenous frusemide was used for oliguric patients. Intermittent hemodialysis was used in 18 patients and continuous venovenous hemofiltration in six patients. Twelve patients with ARF due to ischemia died, while there were no deaths in the nephrotoxic group (p < 0.05). The overall mortality was (21.8%), which had no correlation with patient age. All non-oliguric patients survived with the mortality being exclusively in the oliguric group.

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To evaluate the approach of physicians to the diagnosis and management of acute renal failure (ARF) in the Kingdom of Saudi Arabia, a questionnaire was mailed to nephrologists, physicians attending to renal failure patients, specialists working in intensive care unit (ICU) and the general physicians in 110 hospitals, which have either an ICU or a dialysis unit. The questions were related to the areas of evaluation, conservative management, dialysis therapy, and prognosis of ARF. There were 135 responses from 76 hospitals (69%); 37 of small size (<150 beds), 21 of medium size (151-400 beds), and 18 of large size (401-1200 beds). There were 69 respondents from the small hospitals, 34 from the medium-sized, and 32 from the large hospitals. According to the respondents, the most encountered ARF patients were in the intensive care units and were most likely due to sepsis and nephrotoxic drugs. There were no differences among the respondents in the areas of initial evaluation, conservative and/or emergency treatment. However, the nephrologists were significantly more willing to follow-up their ARF patients and to carry more specific diagnostic procedures (i.e., renal biopsy) and specific advanced therapeutic procedures (i.e., dialysis), More ARF patients are being treated by continuous renal replacement therapy (CRRT) than intermittent hemodialysis or peritoneal dialysis. The minority of the respondents believed that the prognosis of ARF had not improved much, despite the improvement in diagnosis and therapy. They attributed this to the change in the demographics of ARF, since more ICU and elderly patients are seen in practice. We conclude that nephrologists are indispensable for the management of acute renal failure. More efforts may be needed to recruit nephrologists to hospitals in Saudi Arabia. A local fellowship program may help in this regard. Furthermore, CRRT facilities, at least in the large hospitals, are required.

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