Patients at obvious risk of ARF are usually easy identified and include those with existing renal impairment or those who have had prolonged episodes of renal hypoperfusion or sepsis, or who have been exposed to large doses of nephrotoxic drugs. However, there are many patients with serum creatinine concentrations in the upper range of normal who have 'concealed' impairment of renal function and who are susceptible to minor renal insults. These include small patients (low muscle mass), diabetics, and hypertensives. The reason for their exquisite sensitivity is the non-linear relationship between renal function and serum creatinine concentration. Serum creatinine rises above the upper level of laboratory normal ranges only after some 50 per cent of glomeruli fail ( Fig, 1).
Fig. 1 The relationship between glomerular filtration rate and serum creatinine.
There are a number of risk factors which are potentially avoidable or to which exposure can be substantially reduced. Nephrotoxic agents
The use of drugs with known nephrotoxic effects should be avoided where possible. However, there may be situations in which an assessment of the relative risks is in favor of a potentially nephrotoxic agent, for example use of an aminoglycoside in the management of Gram-negative septicemia.
When nephrotoxic agents are used care should be taken to minimize adverse effects by monitoring drug levels. In addition, toxicity may be reduced by adopting an optimal dosing regimen. For example, nephrotoxicity of aminoglycosides may be reduced by once daily administration ( .H.a.t.a!a...eL..a.L 1996) and close monitoring of trough concentrations. A different formulation, such as use of liposomal amphotericin B, may reduce nephrotoxicity.
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