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A review of the pathophysiology, causes and prognosis of acute renal failure in the elderly

Abstract

This paper reviews some of the pathophysiological, causal and prognostic aspects of acute renal failure (ARF) in the elderly patient.

In the discussion on the factors predisposing the aged kidney to acute insults, the hypothesis is advanced that impairment of the autoregulatory capacity of renal blood flow and glomerular filtration rate plays a major role in the pathophysiology of ARF in the elderly patient.

Recent data suggest that the relative increase of elderly patients in the overall population of patients with ARF can only partly be explained by the absolute increase of aged people.

The major causes of ARF in the elderly are discussed. They show the same spectrum of etiologies of ARF as younger patients but within that spectrum, a significantly higher incidence of acute prerenal failure, iatrogenic hemodynamically-mediated ARF, renal vascular syndromes, glomerulonephritis, and post-ischemic acute tubular necrosis is observed. As far as the severity of the prognosis of ARF in the elderly is concerned, the review of published data does not allow definite conclusions on this subject. The main reason is the lack of information in a form that allows an easy and meaningful comparison. The adoption of scoring systems like the APACHE II system should overcome these problems.

At present, the supposition that old age by itself is a bad prognostic factor in the outcome of ARF is dubious and it is certainly not strong enough to deny individual elderly patients with ARF the opportunity of aggressive therapy.

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References

  1. LindemanRD. Overview: Renal physiology and pathophysiology of aging. Am J Kidney Dis 1990; 16: 275–82.

    Google Scholar 

  2. Anderson S, Brenner BM. Effects of aging on the renal glomerulus. Am J Med 1986; 80: 435–42.

    Google Scholar 

  3. Anderson S, Brenner, BM. The aging kidney: structure, function, mechanisms, and therapeutic implications. J Am Geriatr Soc 1987; 35: 590–3.

    Google Scholar 

  4. Euans DW. Renal function in the elderly. AFP 1988; 38: 147–50.

    Google Scholar 

  5. Meyer BR. Renal function in aging. J Am Geriatr Soc 1989; 37: 791–800.

    Google Scholar 

  6. Levi M, Rowe JW. Aging and the kidney. In: Schier RW, Gottochalk CW, editors. Diseases of the kidney. Boston: Little Brown, 1988: 2657–82.

    Google Scholar 

  7. Kaplan C, Pasternack B, Shah H, Gallo G. Age-related incidence of sclerotic glomeruli in human kidneys. Am J Pathol 1975; 80: 227–34.

    Google Scholar 

  8. Kappel B, Olsen S. Cortical interstitial tissue and sclerosed glomeruh in the normal human kidney, related to age and sex. Virchows Arch [A] 1980; 387: 271–7.

    Google Scholar 

  9. Takazakura E, Wasabu W, Handa A, et al. Intrarenal vascular changes with age and disease. Kidney Int 1972; 2: 224–30.

    Google Scholar 

  10. Brenner BM, Meyer TW, Hostetter TH. Dietary protein intake and the progressive nature of renal disease. The role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging; renal ablation, and intrinsic renal disease. N Engl J Med 1982; 307: 652–9.

    Google Scholar 

  11. Kasiske BL. Relationship between vascular disease and age-associated changes in the human kidney. Kidney Int 1987; 31: 1153–9.

    Google Scholar 

  12. Davies DF, Shock NW. Age changes in glomerular filtration rate, effective renal plasma flow, and tubular excretory capacity in adult males. J Clin Invest 1950; 29: 496–507.

    Google Scholar 

  13. Rowe JW, Andres RA, Tobin JD, Norris AH, Shock NW. The effect of age on creatinine clearance in men: A cross-sectional and longitudinal study. J Gerontol 1976; 31: 155–63.

    Google Scholar 

  14. Lindeman RD, Tobin JD, Shock NW. Association between blood pressure and the rate of decline in renal function with age. Kidney Int 1984; 26: 861–8.

    Google Scholar 

  15. Lindeman RD, Tobin JD, Shock NW. Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 1985; 33: 278–85.

    Google Scholar 

  16. Shipton EA. The peri-operative care of the geriatric patient. S Afr Med J 1983; 63: 855–60.

    Google Scholar 

  17. Navar LG. Renal autoregulation: Perspectives from whole kidney and single nephron studies. Am J Physiol 1978; 234: 357–61.

    Google Scholar 

  18. Hall JE, Guyton AC, Jackson TE, Coleman TG, Lohmeier E, Trippodo NC. Control of glomerular filtration rate by the renin-angiotensin system. Am J Physiol 1977; 233: 366–72.

    Google Scholar 

  19. Schuermann J, Briggs JP, Weber PC. Tubuloglomerular feedback, prostaglandins, and angiotensin in the autoregulation of glomerular filtration rate. Kidney Int 1984; 25: 53–64.

    Google Scholar 

  20. Yoshioka T, Yared A, Kon V, Ichikawa I. Impaired preservation of GFR during hypotension in preexistent renal hypoperfusion. Am J Physiol 1989; 256: 314–20.

    Google Scholar 

  21. Persson PB, Ehnike H, Nafz B, Kirchheim HR. Sympathetic modulation of renal autoregulation by carotid occlusion in conscious dogs. Am J Physiol 1990; 258: 364–70.

    Google Scholar 

  22. Patrono C, Dunn MJ. The clinical significance of inhibition of renal prostaglandin synthesis. Kidney Int 1987; 32:1–12.

    Google Scholar 

  23. Coulie P, Deplaen JF, Van Ypersele De Strihou C. Captopril induced acute reversible renal failure. Nephron 1983; 35: 108–11.

    Google Scholar 

  24. Hricik DE, Browning PJ, Kopelman R, et al. Captopril induced functional renal insufficiency in patients with bilateral renal artery stenosis or renal artery stenosis in a solitary kidney. N Engl J Med 1983; 308: 373–6.

    Google Scholar 

  25. Jackson B, Matthews PG, McGrath BP, Johnston CI. Angiotensin converting enzyme inhibition in renovascular hypertension: frequency of reversible renal failure [letter]. Lancet 1984; 1: 225–6.

    Google Scholar 

  26. Mujais SK, Fouad FM, Textor SC, et al. Transient renal dysfunction during initial inhibition of converting enzyme in congestive heart failure. Br Heart J 1984; 52: 63–71.

    Google Scholar 

  27. Packer M, Lee WH, Kessler PD. Preservation of glomerular filtration rate in human heart failure by activation of the renin-angiotensin system. Circulation 1986; 74: 766–74.

    Google Scholar 

  28. Menconi M, Taylor L, Martin B, Polgar P. A review: prostaglandins, aging, and blood vessels. J Am Geriatr Soc 1987; 35: 239–47.

    Google Scholar 

  29. Kent RS, Kitchell BB, Shand DG, Whorton AR. The ability of vascular tissue to produce prostacyclin decreases with age. Prostaglandins 1988; 21: 483–90.

    Google Scholar 

  30. Duchin KL, Peterson LN, Burke TJ. Effect of furosemide on renal autoregulation. Kidney Int 1977; 12: 379–86.

    Google Scholar 

  31. Wright FS, Schnermann J. Interference with feedback control of glomerular filtration rate by furosemide, triflocin, and cyanide. J Clin Invest 1974; 53: 1695–1708.

    Google Scholar 

  32. Zager RA, Alpers CE. Effects of aging on expression of ischemic acute renal failure in rats. Lab Invest 1989; 61: 290–4.

    Google Scholar 

  33. Lameire N, Mathys E, Vanholder R, De Keyser K, Pauwels W, Nachtergaele H, et al. Causes and prognosis of acute renal failure in elderly patients. Nephrol Dial Transplant 1987; 2: 316–22.

    Google Scholar 

  34. Pascual J, Orofino L, Liano F, et al. Incidence and prognosis of acute renal failure in older patients. J Am Geriatr Soc 1990; 38: 25–30.

    Google Scholar 

  35. Rodgers H, Stanilgand JR, Lipkin GW, Turney JH. Acute renal failure: a study of elderly patients. Age Ageing 1986; 19: 36–42.

    Google Scholar 

  36. Abreo K, Moorthy AV, Osborne M. Changing patterns and outcome of acute renal failure requiring hemodialysis. Arch Intern Med 1986; 146: 1338–41.

    Google Scholar 

  37. Bullock ML, Umen AJ, Finkelskin M, Keane WIT. The assessment of risk factors in 462 patients with acute renal failure. Am J Kidney Dis 1985; 5: 97–103.

    Google Scholar 

  38. Maher ER, Robinson KN, Scoble JE, Farrimond JG, Browne DRG, Sweny P, et al. Prognosis of critically-ill patients with acute renal failure: APACHE 11 score and other predictive factors. Q J Med 1989; 269: 857–66.

    Google Scholar 

  39. Lien J, Chan V. Risk factors influencing survival in acute renal failure treated by hemodialysis. Arch Intern Med 1985; 145: 2067–9.

    Google Scholar 

  40. Seggie JL, Milne FJ, Meyyes AM, Hayward A, Kark A. Acute renal failure — 10-year experience of the Johannesburg hospital renal unit. Afr Med J 1987; 72: 827–30.

    Google Scholar 

  41. Rosenfeld JB, Shohat J, Grosskopf I, Boner G. Acute renal failure: a disease of the elderly? Adv Nephrol 1987; 16: 159–68.

    Google Scholar 

  42. Corwin HL, Teplick RS, Schreiber MJ, F NG LST, Bonventre JV, Cogging CH. Prediction of outcome in acute renal failure. Am J Nephrol 1987; 7: 8–12.

    Google Scholar 

  43. Gornick CC, Kjellstrand CM. Acute renal failure complicating aortic aneurysm surgery. Nephron 1983; 35: 145–57.

    Google Scholar 

  44. Berisa F, Beaman M, Adu D, McGonigle RJS, Michael J, Downing R, et al. Prognostic factors in acute renal failure following aortic aneurysm surgery. Q J Med 1990; 279: 689–98.

    Google Scholar 

  45. McInnes EG, Levy DW, Chaudhuri MD, Bhan GL. Renal failure in the elderly. Q J Med 1987; 243: 583–8.

    Google Scholar 

  46. Clive DM, Stoff JS. Renal syndromes associated with nonsteroidal anti-inflammatory drugs. N Engl J Med 1984; 310: 563–72.

    Google Scholar 

  47. Lamy PP. Renal effects of nonsteroidal anti-inflammatory drugs: Heightened risk to the elderly? J Am Geriatr Soc 1986; 34: 361–7.

    Google Scholar 

  48. Stillman MT, Schlesinger PA. Nonsteroidal anti-inflammatory drug nephrotoxicity. Should we be concerned? Arch Intern Med 1990; 150:268–70.

    Google Scholar 

  49. Blackshear JL, Napier JS, Davidman M, Stillman MT. Renal complications of nonsteroidal antiinflammatory drugs. Identification and monitoring of those at risk. Semin Arthritis Rheum 1985; 14: 163–75.

    Google Scholar 

  50. Whelton A, Stout RL, Spiman PS, Klassen DK. Renal effects of Ibuprofen, Piroxicam, and Sulindac in patients with asymptomatic renal failure. Ann Intern Med 1990; 122: 568–76.

    Google Scholar 

  51. Murray MD, Brater DC. Adverse effects of nonsteroidal anti-inflammatory drugs on renal function. Ann Intern Med 1990; 112: 559–60.

    Google Scholar 

  52. Kleinknecht D, Landais P, Goldfarb B. Pathophysiology and clinical aspects of drug-induced tubular necrosis in man. Contrib Nephrol 1987; 55: 145–58.

    Google Scholar 

  53. Murray MD, Brater DC, Tierney WM, Hui SL, McDonald CJ. Ibuprofen-associated renal impairment in a large general internal medicine practice. Am J Med Sci 1990; 299: 222–9.

    Google Scholar 

  54. Hollenberg NK. Medical therapy of renovascular hypertension. Efficacy and safety of captopril in 269 patients. Cardiovasc Rev Rep 1983; 4: 852–76.

    Google Scholar 

  55. Franklin SS, Smith RD. A comparison of enalapril plus hydrochlorothiazide with standard triple therapy in renovascular hypertension. Nephron 1986; 44 (suppl 1): 735–825.

    Google Scholar 

  56. Jackson B, McGrath BP, Matthews PG, Wong C, Johnston CI. Differential renal function during angiotensin converting enzyme inhibition in renovascular hypertension. Hypertension 1986; 8: 650–4.

    Google Scholar 

  57. Jacobson HR. Ischemic renal disease: an overlooked clinical entity? Kidney Int 1988; 34: 729–43.

    Google Scholar 

  58. Weitz Z, Gafter U, Chagnac A, Levi J. Cholesterol emboli in atherosclerotic patients: reports of four cases occurring spontaneously or complicating angioplasty and aortorenal bypass. J Am Geriatr Soc 1987; 35: 357–9.

    Google Scholar 

  59. Gore I, Collins DP. Spontaneous atheromatous embolization. Review of the literature and a report of 16 additional cases. Am J Clin Pathol 1960; 33: 416–26.

    Google Scholar 

  60. Smith MC, Ghose MK, Henry AR. The clinical spectrum of renal cholesterol embolization. Am J Med 1981; 71: 174–80.

    Google Scholar 

  61. Ebert TH, McClushey RT. Case records of the Massachussets General Hospital. N Engl J Med 1986; 315: 308–15.

    Google Scholar 

  62. Gaines PA, Cumberland DC, Kennedy A, Welsh CL, Moorhead P, Rutley MS. Cholesterol embolization: a lethal complication of vascular catheterization. Lancet 1988; 1: 168–70.

    Google Scholar 

  63. Lonni YGW, Matsumoto KK, Lecky JW. Postarotographic cholesterol (atheromatous) embolization. Radiology 1969; 93: 63–5.

    Google Scholar 

  64. Ramirez G, O'Neill WM, Lambert R, Bloomer HA. Cholestrol embolization, a complication of angiography. Arch Intern Med 1978; 138: 1430–2.

    Google Scholar 

  65. Rosansky SJ, Deschamps EG. Multiple cholesterol emboli syndrome after angiography. Am J Med Sci 1984; 288: 45–8.

    Google Scholar 

  66. Kealy WF. Atheroembolism. J Clin Pathol 1978; 31: 948–88.

    Google Scholar 

  67. Preston RA, Stemmer CL, Materson BJ, Perez-Stable E, Pardo V. Renal biopsy in patients 65 years of age or older. An analysis of the results of 334 biopsies. J Am Geriatr Soc 1990; 38: 669–74.

    Google Scholar 

  68. Kassirer JP. Atheroembolic renal disease. N Engl J Med 1969; 280: 812–8.

    Google Scholar 

  69. Meyrier A, Buchet P, Simon P, Fernet M, Rainfray M, Callard P. Atheromatous renal disease. Am J Med 1988; 85: 139–46.

    Google Scholar 

  70. Dumazer P, Modesto A, Bonafe JL, Ton That H, Suc JM. Les embolies rénales de cholestérol: á propos de 6 observations. Nephrologie 1988; 9: 67–72.

    Google Scholar 

  71. Hammerschmidt DE, Greenberg CS, Yamada O, Craddock PR, Jacob HS. Cholesterol and atheroma lipids activiate complement and stimulate granulocytes. J Lab Clin Med 1981; 98: 68–77.

    Google Scholar 

  72. Cosio FG, Zager RA, Sharma HM. Atheroembolic renal disease causes hypocomplementaemia. Lancet 1985; 2: 118–21.

    Google Scholar 

  73. Bruns FJ, Segel DP, Adler S. Control of cholestrol emoblization by discontinuation of anticoagulant therapy. Am J Med Sci 1978; 275: 105–7.

    Google Scholar 

  74. Groeninx Van Zoelen C, Kroon C, Hulst SGT. Cholesterol emboli. Neth J Med 1983; 127: 1902–5.

    Google Scholar 

  75. Rosansky SJ. Multiple cholesterol emboli syndrome. South Med J 1982; 75: 677–80.

    Google Scholar 

  76. McGowan JA, Greenberg A. Cholesterol athero-embolic renal disease. Am J Nephrol 1986; 6: 135–8.

    Google Scholar 

  77. Siemons L, van den Heuvel P, Parizel G, Buyssens N, De Broe ME, Cuykens JJ. Peritoneal dialysis in acute renal failure due to cholesterol embolization: two cases of recovery of renal function and extended survival. Clin Nephrol 1987: 28: 205–8.

    Google Scholar 

  78. Kumar R, Hill CM, McGeown MG. Acute renal failure in the elderly. Lancet 1973; 1: 90–1.

    Google Scholar 

  79. Rodgers H, Stanilgand JR, Lipkin GW, Turney JH. Acute renal failure: a study of elderly patients. Age Ageing 1990; 19: 36: 36–42.

    Google Scholar 

  80. Moorthy AV, Zimmerman SW. Renal disease in the elderly: clinicopathologic analysis of renal disease in 115 elderly patients. Clin Nephrol 1977; 14: 223–9.

    Google Scholar 

  81. Kingswood JC, Banks RA, Tribe CR, et al. Renal biopsy in the elderly: clinicopathological correlations in 143 patients. Clin Nephrol 1984; 22: 183–7.

    Google Scholar 

  82. Potvliege FR, De Roy G, Dupuis F. Necropsy study on glomerulonephritis in the elderly. J Clin Pathol 1975; 28: 891–4.

    Google Scholar 

  83. Diaz-Buxo JA, Donadio JV Jr. Complications of percutancous renal biopsy: an analysis of 1,000 consecutive biopsies. Clin Nephrol 1975; 4: 223–7.

    Google Scholar 

  84. Chung HM, Kluge R, Schrier RW, Anderson RJ. Clinical assessment of extracelluar fluid volume in hyponatremia. Am J Med 1987; 83: 905–8.

    Google Scholar 

  85. Miller TR, Anderson RJ, Linas SL, et al. Urinary diagnostic indices in acute renal failure: a prospective study. Ann Intern Med 1978; 89: 47–50.

    Google Scholar 

  86. Espinel CH, Gregory AW. Differential diagnosis of acute renal failure. Clin Nephrol 1980; 13: 73–7.

    Google Scholar 

  87. Pru C, Kjellstrand CM. The FENa test is of no prognostic value in acute renal failure. Nephron 1984; 36: 20–3.

    Google Scholar 

  88. Diamond JR, Yoburn DC. Nonoliguric acute renal failure associated with a low fractional excretion of sodium. Ann Intern Med 1982; 96: 597–600.

    Google Scholar 

  89. Beaman M, Turney JH, Rodger RSC, Mc Gonigle RSJ, Adu D, Michael J. Changing pattern of acute renal failure. Q J Med 1987; 237: 15–23.

    Google Scholar 

  90. Butkus DE. Persistent high mortality in acute renal failure. Arch Intern Med 1983; 143: 209–12.

    Google Scholar 

  91. Swann RC, Merril JP. The clinical course of acute renal failure. 1953; 32: 215–92.

    Google Scholar 

  92. Kiley JE, Powers SR, Beebe RT. Acute renal failure. Eighty cases of renal tubular necrosis. N Engl J Med 1960; 262: 481–6.

    Google Scholar 

  93. Alwall N. Therapeutic and diagnostic problems in severe renal failure. Copenhagen: Scandinavian University Books, 1963.

    Google Scholar 

  94. Balslov IT, Jorgensen HE. A survey of 499 patients with acute anuric renal insufficiency. Causes, treatment, complications and mortality. Am J Med 1963; 34: 753–64.

    Google Scholar 

  95. Stott RB, Cameron JS, Ogg CS, Bewick M. Why the persistently high mortality in acute renal failure? Lancet 1972; 2: 75–8.

    Google Scholar 

  96. Kennedy AC, Burton JA, Luke RG. Factors affecting the prognosis in acute renal failure. Q J Med 1973; 42: 73–86.

    Google Scholar 

  97. Kleinknecht D, Ganeval D. Preventive hemodialysis in acute renal failure: its effects on mortality and morbility. In: Friedman EA, Eliahou HE, editors. Proceedings of the conference on acute renal failure. Washington DC: Dhew Pub (NIH), 1973 N74-608: 165.

  98. McMurray SD, Luft FC, Maxwell DR. Prevailing patterns and predictor variables in patients with acute tubular necrosis. Arch Intern Med 1978, 138: 950–5.

    Google Scholar 

  99. Werb R, Linton AL. Etiology, diagnosis, treatment and prognosis of acute renal failure in an intensive care unit. In: Chapman A, editor. Acute renal failure. Edinburgh: Churchill Livinstone, 1980: 34.

    Google Scholar 

  100. Manis T, Heneghan W, Charles G, et al. Acute renal failure in a municipal hospital. In: Eliahou HE, editor. Acute Renal Failure. London: John Libbey, 1982: 129–31.

    Google Scholar 

  101. Cioffi WG, Ashikaga T, Gamelli RL. Probability of surviving post-operative renal failure. Ann Surg 1984; 205–10.

  102. Routh GS, Briggs JD, Moore JG, et al. Survival from acute renal failure with and without multiple organ dysfunction.Postgrad Med J 1980; 56: 244–7.

    Google Scholar 

  103. Wheeler DC, Feehally J, Walls J. High risk acute renal failure. Q J Med 1986; 234: 977–84.

    Google Scholar 

  104. Hou SH, Bushinsky DA, Wish JB, Cohen JJ, Harrington JT. Hospital-acquired renal insufficiency: a prospective study. Am J Med 1983; 74: 243–8.

    Google Scholar 

  105. Bluemle LW, Webster GD, Elkinton JR. Acute tubular necrosis. Analysis of one hundred cases with respect to mortality, complications and treatment with and without dialysis. Arch Intern Med 1959; 104: 180–97.

    Google Scholar 

  106. Back SM, Makabali GG, Shoemaker WC. Clinical determinants of survival from postoperative renal failure. Surgery 1975; 140: 685–9.

    Google Scholar 

  107. Minuth AN, Terrell JB, Suki WN. Acute renal failure a study of the course and prognosis of 104 patients and the role of furosemide. Am J Med Sci 1976; 271: 317–24.

    Google Scholar 

  108. Kjellstrand CM, Gornick C, Davin T. Recovery from acute renal failure. Clin Exp Dial Apheresis 1981; 5: 143–62.

    Google Scholar 

  109. Rasmussen HH, Pitt EA, Ibels LS, McNeil DR. Prediction of outcome in acute renal failure by discriminant analysis of clinical variables. Arch Intern Med 1985; 145: 2015–8.

    Google Scholar 

  110. Lohr JW, Mc Farlane MJ, Grantham JJ: A clinical index to predict survival in acute renal failure patients requiring dialysis. Am J Kidney Dis 1988; 11: 254–9.

    Google Scholar 

  111. Liano F, Garcia-Martin F, Gallego A, Orte L, Temel JL, Marcen R, et al. Easy and early prognosis in acute tubular necrosis: a forward analysis of 228 cases. Nephron 1989; 51: 307–13.

    Google Scholar 

  112. Lange HW, Heppli DM, Brown, DC. Survival of patients with acute renal failure requiring dialysis after open heart surgery: early prognostic indicators. Am Heart J 1987; 113: 1138–43.

    Google Scholar 

  113. Rasmussen HH, Ibels LS. Acute renal failure multivariate analysis of causes and risk factors. Am J Med 1982; 73: 211–8.

    Google Scholar 

  114. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system for acutely ill patients. Crit Care Med 1985; 13: 818–29.

    Google Scholar 

  115. Wu AW, Rubin HR, Rosen MJ. Are elderly people less responsive to intensive care? J Am Geriatr Soc 1990; 38: 621–7.

    Google Scholar 

  116. Smithies MN, Cameron JS. Can we predict outcome in acute renal failure? Nephron 1989; 51: 297–300.

    Google Scholar 

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Lameire, N., Verspeelt, J., Vanholder, R. et al. A review of the pathophysiology, causes and prognosis of acute renal failure in the elderly. Geriatric Nephrol Urol 1, 77–91 (1991). https://doi.org/10.1007/BF00577143

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Key words

  • Actual renal failure: Pathophysiology
  • acute renal failure: Etiology
  • acute renal failure: Prognosis