Acute Renal Failure And Sepsis

The

new england journal

of

medicine

review article

mechanisms of disease

Acute Renal Failure and Sepsis
Robert W. Schrier, M.D., and Wei Wang, M.D.

cute renal failure occurs inapproximately 19 percent of patients with moderate sepsis, 23 percent with severe sepsis, and 51 percent with septic shock when blood cultures are positive (Tables 1 and 2).1,2 A progressiveincrease in the acute respiratory distress syndrome also occurs with moderate and severe sepsis and septic shock. In the United States, an estimated 700,000 cases of sepsis occur each year, resulting inmore than 210,000 deaths; this number accounts for 10 percent of all deaths annually and exceeds the number of deaths due to myocardial infarction.3 The combination of acute renal failure and sepsis isassociated with a 70 percent mortality, as compared with a 45 percent mortality among patients with acute renal failure alone. Thus, the combination of sepsis and acute renal failure constitutes aparticularly serious medical problem in the United States.4 Substantial progress has been made toward understanding the mechanisms whereby sepsis is associated with a high incidence of acute renalfailure. Moreover, recently identified clinical interventions may be able to decrease the occurrence of acute renal failure and sepsis and the high associated mortality. The cytokine-mediated inductionof nitric oxide synthesis that occurs in sepsis decreases systemic vascular resistance.5 This arterial vasodilatation predisposes patients with sepsis to acute renal failure, the need for mechanicalventilation, and ultimately, increased mortality. In this article, we review the effects of nitric oxide–mediated arterial vasodilatation on resistance to exogenous pressors and hypotension (Fig. 1),and we discuss the use of arginine vasopressin in patients with septic shock. We also review the effects of increased plasma concentrations of several endogenous vasoconstrictor hormones, including...