Renal failure in acute pancreatitis. Timing of dialysis and surgery.

Despite the progress in intensive care treatment the ongoing systemic inflammatory response syndrome (SIRS) in patients with severe pancreatitis (SP) and renal failure (RF) is associated with high mortality. The aim of this lecture is to outline the knowledge drawn from literature and personal experience and to re-evaluate the management strategy of SP patients whose clinical course is complicated with impairment of the renal function. INCIDENCE, RISK FACTORS AND OUTCOME: Impaired renal function can be observed in 14-43% of patients with SP mostly in combination with other organ system failure. SIRS is the main culprit in the pathologic process. Extent of necrosis does not correlate with derangement of the renal function, however, infection is a serious risk factor. Mortality reaches 71-84% in patients with SP and RF, which requires dialysis. Risk factors highly associated with RF and detrimental outcomes in SP patients are advancing age, prior chronic disease, cardiovascular and pulmonary failure, mechanical ventilation, hypotension, oliguria, coma, and jaundice. SP is associated with increased bowel permeability, impaired visceral perfusion, retroperitoneal oedema and increased intraabdominal pressure, which can directly affect the renal function as consequence of the acute abdominal compartment syndrome (AACS). TREATMENT: Early aggressive resuscitation including isovolemic hemodilution with dextran 60, venovenouse hemofiltration, early enteral nutrition and antibiotic prophylaxis are of extreme importance. Surgery is indicated in SP with evidence of the RF when clinical course deteriorates despite intensive care, especially if infection is present and/or AACS develops. CONCLUSION: RF in the patients with SP reflects the severity of SIRS. Improvement of the visceral perfusion is the goal of resuscitation. Surgery is indicated in case of failed conservative treatment and may be successfully combined with hemodialysis.