Prevention of acute renal failure in the critically ill

Although ARF is an independent predictor of mortality in the critically ill, there is a striking paucity of studies that have examined the prevention of ARF in the critically ill, and to date, no intervention has been shown in a large, randomized clinical trial to prevent renal failure in critically ill patients. One caveat is that some of the negative studies were small and may have lacked sufficient power to detect clinically significant benefit. We have made a number of treatment recommendations, many of which are necessarily based only on small studies or extrapolation from studies done in non-critically ill patients. The development of more exacting guidelines for the prevention of ARF must await the completion of additional controlled studies in critically ill patients. Unfortunately, some initially promising agents, such as human insulin-like growth factor, failed to benefit patients with ARF (33), and it remains uncertain whether other new therapies, such as fenoldopam (a specific DA-1 receptor agonist), endothelin antagonists, or adhesion molecule antagonists will prove effective in the prevention of ARF. It is also possible that a combination of treatment strategies will enhance our ability to prevent the development of ARF.