Conservation of residual renal function

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The common causes of chronic renal failure are listed on Table...!., although the proportional distribution varies with age. With adequate medical management only a few patients will go on to develop endstage renal failure; however, it may be precipitated by critical illness since the chronically insufficient kidney is more sensitive to hypoperfusion injury, more likely to develop acute tubular necrosis, and less likely to recover from an acute insult. The development of acute on chronic renal failure commonly results from multiple small insults, such as a combination of hypovolemia and nephrotoxicity.

HnAqieul teas (ig ^sftWiey dsessef Table 1 Common causes of chronic renal failure

Glomerular and renovascular disease are commonly associated with retention of salt and water leading to edema and hypertension, whereas in tubulointerstitial disease due, for example, to chronic obstruction or interstitial nephritis, the kidney fails to conserve sodium and patients are normotensive. Patients with chronic renal failure cannot compensate for hypovolemia or hypotension and are at risk from a further acute reduction in glomerular filtration rate. The risk is greatest in those with contracted circulations, as found for example in patients with tubulointerstitial disease or nephrotic syndrome and in renal failure associated with liver disease. Therefore fluid status and cardiovascular indices must be assessed in the context of the underlying renal pathology and corrections made rapidly. Finally, the dosages of drugs excreted by the kidneys should be modified in patients with chronic renal failure and, where possible, nephrotoxic drugs should be avoided.

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