An evaluation of pharmacological strategies for the prevention and treatment of acute renal failure.

Acute renal failure (ARF) occurs frequently in hospitalised patients, and is associated with significant morbidity and mortality. The most common and generalised forms of acute renal failure are pre-renal conditions and intra-renal acute tubular necrosis (ATN). Pre-renal ARF in its pure state should be entirely reversible by restoring renal perfusion, but in some cases ATN has already occurred. ATN remains a more vexing problem, and is seen most often with hypotension, perioperative or systemic inflammatory stresses, radiocontrast administration, and exposure to nephrotoxins. Among the available pharmacological options for prevention or treatment of ATN, there is a remarkable lack of definitive evidence supporting specific therapy in any setting. Although loop diuretics, mannitol, and dopamine are frequently used for prevention and/or treatment of ATN, clinical studies have failed to prove value. Other drugs with theoretical value, specifically atrial natriuretic peptide analogues, adenosine blockers, and calcium antagonists, have been insufficiently studied to recommend use. Other pharmacological options may arise in the future. Ensuring adequate intravascular fluid volume remains the only approach to managing ATN which can be considered relatively effective and safe. Given the abundant theoretical basis for the prevention and treatment of ATN with drugs, well conducted clinical studies with relevant outcome measures are clearly warranted.