Medical treatment of acute tubular necrosis.

Editorial QJM Medical treatment of acute tubular necrosis Renal function is acutely impaired in about 5% of common, and that the proposed treatments have been available for many years. If 'evidence' were hospital admissions.1 In all instances, the immediate priorities are the same. First, recognition and treat-required, then none would be treated: but then the same goes for calcium in hyperkalaemia, volume ment of life-threatening complications: most notably hyperkalaemia and pulmonary oedema, the latter repletion in those with no blood pressure, and pulling children out of the way of buses. usually iatrogenic. Second, diagnosis and correction of intravascular volume depletion. Two physical signs Shilliday, Quinn and Allison from the renal unit at the Glasgow Royal Infirmary deserve considerable are reliable, excepting in absolute extremis: reduction in the height of the jugular venous pulse, and credit for performing a study that should, perhaps, have been done many years ago:2 a prospective, postural drop in blood pressure, lying and sitting if standing is not prudent. If either of these signs are randomized, placebo-controlled, double-blind study examining the effects of loop diuretics on renal present, then fluid of a nature similar to that lost should be infused rapidly through a large-bore can-recovery, dialysis and death in patients with acute renal failure. Two hundred and seventy-eight oliguric nula placed in a vein in the antecubital fossa, or a catheter inserted using the Seldinger technique into adults with acute renal impairment leading to a serum creatinine of >180 mmol/l were assessed. the femoral vein. The infusion should be monitored closely, and stopped promptly when the jugular Those who recovered following adequate hydration were excluded (25%); as were any with ultrasono-venous pressure has risen and the postural drop disappeared, lest fluid overload and pulmonary graphic evidence of obstruction; any given loop or osmotic diuretics within the previous 12 h (or large oedema ensue. Needless to say, vigorous efforts should then be made to diagnose and treat the doses of loop diuretics within the previous 48 h); and any who refused consent (a further 40%). Ninety-underlying condition: and in those patients without obvious evidence of severe circulatory disturbance, six patients remained, four of whom were subsequently excluded from analysis. All were given particular care must be taken to ensure that cases of obstruction or nephritis are not missed—by urgent dopamine (continuous infusion at a dose of 2 mg/kg/min) and mannitol (100 ml of a 20% solution ultrasound …