Quality assurance in the treatment of acute renal failure

Abstract

Despite a plethora of information regarding what is or isn’t adequate dialysis prescription for end stage renal failure [1-3] there is an amazing paucity of information regarding what is adequate treatment for acute renal failure. Similarly, quality assessment for the dialytic treatment of relatively stable patients with ESRD can be reasonably distilled down to simple mortality [4], an approach which is not easily applicable to acutely ill patients whose mortality risk is already very high and in whom acute renal failure may be an incidental, supplemental insult. Thus, it is still commonly believed that acutely ill patients die with renal failure and not from renal failure. In agreement with this concept, a recent NIH sponsored conference has suggested that outcome parameters for patients with acute renal failure should be stratified into several levels; by the length of stay, both in the ICU and in the hospital; by the number who recover renal function; by the amount of renal function recovered and, finally, the percentage survival in terms of discharge from the ICU and the hospital [5]. Clearly, considering the initial poor survival of acutely ill patients even before developing ARF, and considering the variability of etiologies and comorbidities, it is exceedingly difficult to obtain such stratified outcome parameters from the experience of a single medical institution. Thus, the same aforementioned NIH conference concluded that evidence based guidelines for the treatment of acute renal failure must be obtained from multicenter trials that use standardized criteria for management and outcomes. Nonetheless, even in the context of a multicenter trial, problems in interpretation of results remain. As convincingly argued by Bellomo and Boyce, the geographical variability in survival rates, the need for large numbers of patients (≤ 160) and the differing expertise of the treating physicians present seemingly insurmountable problems [6].