Etiology, prognosis, and outcome of post-operative acute renal failure

A Multivariate analysis was done in all patients who developed post operative ARF, during the period 1990-1995 to determine the etiological spectrum and to identify various variables affecting the outcome. Of 140 patients (110 operated at SGPGI and 30 operated outside) 116 underwent elective surgery. The different types of surgery leading to ARF were urosurgery (3.5%), open heart surgery (32.9%), gastrosurgery (16.4%), pancreatic surgery (9.3%), obstetrical surgery (3.6%) and others (2.8%). The incidence of ARF in SGPGI patients was highest in pancreatic surgery group (8.2%) followed by open heart surgery (3%). The different etiological factors responsible for ARF were perioperative hypotension (67.1%), sepsis (63.6%) and exposure to nephrotoxic drugs (29.3%). Sixty-four patients (45.7%) required dialysis. The overall mortality was 45%. The mortality was highest in patients who underwent open heart surgery (89.1%) followed by pancreatic surgery (84.6%). The factors associated with high mortality, other than the type of surgery, were preoperative hypotension (p < 0.05), oliguria (p < 0.01), need for dialysis (p < 0.05) and multiorgan failure (p < 0.001). AM following emergency surgery had poor outcome, though not statistically significant. Perioperative sepsis (p < 0.05) and preoperative use of aminoglycoside (p < 0.05) were significantly higher in patients operated outside SGPGI. This was associated with higher incidence of ARF. Thus we conclude that presence of multiorgan failure, oligoanuria, preoperative hypotension and need far dialysis are poor prognostic markers in ARF following surgery.     

Acute Renal Failure and Mortality After Open-Heart Surgery in Infants

Acute renal failure (ARF) is a major complication in infants who undergo cardiac surgery. The aim of this investigation was to identify possible risk factors for ARF and mortality in this patients group. Out of 64 patients, 21 (32.8%) cases developed acute renal failure and overall mortality rate was 25%. The mortality rate was higher in the infants who developed ARF than those who did not (66.7% and 4.7%, respectively, p < 0.05). Also, ARF was positively correlated with mortality (r:0.70, p < 0.0001). The nonsurvivors had lower mean serum albumin than did the survivors (p < 0.05), and serum albumin level was negatively correlated with mortality (r = ? 0.34, p < 0.05). For the patients with serum albumin level < 3.5 g/dL, the unadjusted odds ratio for mortality was 4.3 (CI 95%:1.05 ? 17.86). Total bypass time and aorta clamping time were significantly longer in the nonsurvivor group than in the survivor group (p < 0.05 for both). In conclusion, the significant risk factors for mortality in these patients were development of ARF, low serum albumin level, and long total bypass and aorta clamping times, which may be predictive of poor prognosis.     

Prognostic Factors in Patients Undergoing Surgery for Severe Necrotizing Pancreatitis

Pancreatic necrosectomy remains an important treatment modality for the management of infected pancreatic necrosis but is associated with significant mortality. The aim of this study was to identify factors associated with mortality following pancreatic necrosectomy. Patients who underwent pancreatic necrosectomy from January 1995 to December 2004 were reviewed. The association between admission, preoperative and postoperative variables, and mortality was assessed using logistic regression analysis. A total of 1248 patients presented with acute pancreatitis, of whom 94 (7.5%) underwent pancreatic necrosectomy (51 men, 43 women). The preoperative median Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) score was 9 (range 2–19). The median cumulative organ dysfunction score was 2 (0–9) preoperatively and 4 (1–11) postoperatively. In all, 23 patients (24.5%) died. Those who died were older than the survivors; the ages (median and range) were 69 years (40–80 years) versus 52 years (19–79 years) (p < 0.05). They also had higher admission APACHE II scores (median and range): 14 (12–19) versus 9 (2–22) (p < 0.001). There were significant associations between preoperative (p < 0.01) and postoperative (p < 0.01) Marshall scores and mortality following pancreatic necrosectomy. The presence of the systemic inflammatory response syndrome (SIRS) during the first 48 hours (p < 0.01) and the time between presentation and necrosectomy (p < 0.01) were independent predictors of survival. Pancreatic necrosectomy is associated with higher mortality in patients with increased APACHE II scores, early persistent SIRS, and unresolved multiorgan dysfunction. Necrosectomy is associated with poorer outcome when performed within 2 weeks of presentation. This study was presented at the 39th annual congress of the European Pancreatic Club, Graz, Austria, July 2005.     

Nosocomial infections in infants and children after cardiac surgery

Objective  To identify the incidence, characteristics and risk factors of nosocomial infections (NIs) in infants and children undergoing open heart surgery, a prospective observational study. Methods  One hundred consecutive infants and children < 2 yrs of age undergoing open heart surgery (OHS) between March 2007 and December 2007 were included in the study. Samples for blood, endotracheal and urine culture were drawn daily during intensive care unit (ICU) stay. Cultures from endotracheal tube, central venous catheter, arterial cannula, chest tube, urinary catheter and other invasive lines were also obtained. Centers for Disease Control and Prevention criteria were used for defining NIs. A number of possible risk factors predisposing to NI were analyzed. Results  32% patients developed NI. The NI rate was 49%. Common NIs were bloodstream infection (19%), respiratory tract infection (17%), catheter site infection (7%) and urinary tract infection (6%). Common pathogens were Acinetobacter (22.5%), Pseudomonas aeruginosa (20.4%), Klebsiella pneumoniae (16.3%) and Staphylococcus aureus (12.2%). Major risk factors for NI were length of ICU stay (p < 0.001), duration of intubation (p < 0.001), reintubation (p < 0.001), duration of central venous catheterization (p = 0.001), preoperative congestive heart failure (p = 0.002), tracheostomy (p = 0.003), duration of preoperative stay (p = 0.01), blood transfusion (p = 0.01), preoperative balloon atrial septostomy (p = 0.02), duration of surgery (p = 0.03), surgical complexity score (p = 0.03) and hypothermia (p = 0.03). The mortality rate was 11% with significant association between NI and death (p = 0.002). Conclusion  NIs develop frequently in infants and children after OHS. This study may serve as a reference point for further development and implementation of interventions aimed at reducing NI rates and improving patient outcome.     

Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer

Background: Most patients presenting with pancreatic cancer are irresectable at the time the diagnosis is made. Therefore, they are in need of palliative treatment that can guarantee minimal morbidity, mortality, and hospital stay. To address this need, we designed a study to test the feasibility of laparoscopic gastroenterostomy and hepaticojejunostomy and to compare their results with those achieved with open techniques. Methods: We performed a case control study of a new concept in laparoscopic palliation based on the findings of preoperative imaging and diagnostic laparoscopy. Laparoscopic side-to-side gastroenterostomy and end-to-side hepaticojejunostomy (Roux-en-Y) were done in irresectable cases. Of 14 patients who underwent laparoscopic palliation, three had a laparoscopic double bypass, seven had a gastroenterostomy, and four underwent staging laparoscopy only. The results were compared with a population of 14 matched patients who had conventional palliative procedures. Results: Postoperative morbidity was 7% vs 43% for laparoscopic and open palliation, respectively (p < 0.05). There were no mortalities in the laparoscopic group, as compared to 29% in the group who had open bypass surgery (p < 0.05). Postoperative hospital stay averaged 9 days in the laparoscopic group and 21 days in the open group (p < 0.06). Operating time tended to be shorter in the laparoscopic group (p < 0.25). Morphine derivatives were necessary for a significantly shorter period after laparoscopic surgery (p < 0.03). Conclusions: Our preliminary experience strongly suggests that laparoscopic palliation can reduce the three major drawbacks of open bypass surgery—i.e., high morbidity, high mortality, and long hospital stay. Received: 24 February 1999/Accepted: 13 May 1999     

Outcome in a post-cardiac surgery population with acute renal failure requiring dialysis: does age make a difference?

BACKGROUND: Acute renal failure (ARF), requiring dialysis (ARF-d), develops in 1-5% of patients undergoing cardiac surgery and is associated with higher in-hospital mortality. Age is one of the known risk factors for the development of ARF. As the ageing population is increasing, the nephrologist will be faced with a large population of elderly patients requiring dialysis following cardiac surgery. The aim of our study was to evaluate the influence of age on and the risk factors for in-hospital mortality. METHODS: Eighty-two patients with ARF following cardiac surgery and requiring dialysis between January 1997 and October 2001 were included. Two groups of patients were studied: the younger population (<70 years, 42 patients, mean age 59+/-10) and an elderly population (>/=70 years, 40 patients, mean age 76+/-4). Severity of disease was evaluated using the SAPS (Simplified Acute Physiology Score), the Liano score and the SHARF (Stuivenberg Hospital Acute Renal Failure) score. RESULTS: Overall mortality in the population with ARF-d was 56.1%. No difference in mortality rate was found between the younger (61.9%) and elderly patient group (50.0%). The two groups were very similar in baseline and procedural characteristics with exception of body weight (P=0.02) and preoperative glomerular filtration rate (P=0.0001). No significant difference was found in the scoring systems between the old and the young (SAPS P=0.52; Liano P=0.96; SHARF T0 P=0.06; SHARF T48 P=0.15). Mortality in the elderly was significantly correlated with hypotension before starting renal replacement therapy (RRT) (P=0.002), mechanical ventilation (P=0.002), presence of multiorgan failure (MOF) (P=0.0001) and higher scores in the severity models (SAPS: P=0.01; Liano: P<0.0001 and SHARF: P<0.0001). CONCLUSION: The outcome in the elderly requiring dialysis due to ARF post-cardiac surgery is comparable with the outcome in a younger population. No significant difference was found in severity of disease between the elderly and the younger. Variables predicting mortality in the elderly are the presence of MOF, mechanical ventilation and hypotension 24 h before starting RRT. These findings indicate that at the time the nephrologist is called for an elderly patient requiring dialysis due to ARF following cardiac surgery, age per se is not a reason to withhold RRT.     

Antioxidant status of children with acute renal failure

The production of free radicals can cause renal injury and play a role in the pathogenesis of acute renal failure (ARF). The indirect markers of reactive oxygen species (ROS) were evaluated in children with ARF and controls. Forty patients with ARF aged 0–10 years were selected. Twenty age- and gender-matched healthy children were included as controls. Plasma malondialdehyde, protein carbonyl, nitrite, copper, ascorbic acid, zinc, and ceruloplasmin levels were estimated in patients with ARF and controls. The plasma malondialdehyde (p < 0.01), copper (p < 0.001), ascorbic acid (p < 0.05), and ceruloplasmin (p < 0.001) levels were significantly raised in ARF patients in comparison with controls. Significantly higher levels of plasma malondialdehyde (p < 0.01), nitrite (p < 0.001), copper (p < 0.001), and ceruloplasmin (p < 0.001) and lower plasma zinc (p < 0.01) were found in ARF nonsurvivors in comparison with survivors. The cutoff levels of plasma nitrite and ceruloplasmin were found to be most accurate in predicting mortality in ARF patients and had maximum sensitivity (100%) and specificity (60.7%) among the parameters studied. In conclusion, the increased levels of oxidants and antioxidants suggest the production of ROS and their possible role in ARF pathogenesis. Plasma nitrite and ceruloplasmin concentrations demonstrated predictive ability in relation to mortality. Financial Support: The study was supported by Departmental Research Grant of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, India.     

Prognosis of acute renal failure in children

Acute renal failure (ARF) is the acute loss of renal function over a period of hours or days. Given the poor prognosis of ARF among children, there is some urgency to identifying more effective prognostic indicators for detecting disease onset. Such indicators would help provide the means of selecting patients who would benefit the most from early aggressive treatment. In this study we assessed the etiologic and prognostic indicators of ARF, including several risk factors such as sepsis, respiratory distress, age, among others, in 300 children who were admitted to the Ali Asghar Children’s Hospital, Tehran, Iran, from 1990 to 2003. Statistical analysis was performed using multiple regression and chi-square methods, and a score to determine the prognosis of ARF in children was developed. Result: Based on the results of this study the three common causes of ARF are acute tubular necrosis (ATN, 38%), acute glumerulonephritis (24%) and hemolytic uremic syndrome (24.1%). The overall mortality rate among our patients was 24.7%, with the highest risk group being those patients suffering from ischemic ATN. In addition, the correlation (p<0.0005) between the etiology and mortality rate was particularly high in patients with ischemic ATN. Mortality was also high (68%) in children younger than 2 years. Multiple regression models revealed that among those factors that significantly differed between the survivors and nonsurvivors, only the necessity of dialysis (p<0.0005), the use of mechanical ventilation (p=0.05) and disseminated intravascular coagulation (p=0.038) can be regarded as independent determinants of ARF prognosis in children.     

Neoadjuvant Chemotherapy and Radiation for Patients with Locally Unresectable Pancreatic Adenocarcinoma: Feasibility, Efficacy, and Survival

Abstract Background We evaluated the feasibility and efficacy of neoadjuvant chemotherapy and radiation for patients with locally unresectable pancreatic cancer. Materials and Methods From October 2000 to August 2006, 245 patients with pancreatic adenocarcinoma underwent surgical exploration at our institution. Of these, 78 patients (32%) had undergone neoadjuvant therapy for initially unresectable disease, whereas the remaining patients (serving as the control group) were explored at presentation (n = 167). All neoadjuvant patients received gemcitabine-based chemotherapy, often in conjunction with docetaxal and capecitabine in a regimen called GTX (81%). Seventy-five percent of neoadjuvant patients also received preoperative abdominal radiation (5,040 rad). Results Neoadjuvant patients were younger than control-group patients (60.8 vs 66.2 years, respectively, p < 0.002). Seventy-six percent of neoadjuvant patients were resected as compared to 83% of control patients (NS). Concomitant vascular resection was required in 76% of neoadjuvant patients but only 20% of NS (p < 0.01). Complications were more frequent in the neoadjuvant group (44.1 vs 30.9%, p < 0.05), and mortality was higher (10.2 vs 2.9%, p < 0.03). Among the neoadjuvant patients, all but one of the deaths were in patients that underwent arterial reconstruction. Mortality for patients undergoing a standard pancreatectomy without vascular resection was 0.8% in this series. Of patients resected, negative margins were achieved in 84.7% of neoadjuvant patients and 72.7% of NS. Within the cohort of neoadjuvant patients, radiation significantly increased the complication rate (13.3 vs 54.6%, p < 0.006), but did not affect median survival (512 vs 729 days, NS). Median survival for patients who received neoadjuvant therapy (503 days) was longer than NS that were found to be unresectable at surgery (192 days, p < 0.001) and equivalent to NS that were resected (498 days). Conclusions Resection rate, margin status, and median survivals were equivalent when neoadjuvant patients were compared to patients considered resectable by traditional criteria, demonstrating equal efficacy. Surgical resection with venous reconstruction following neoadjuvant therapy for patients with locally advanced pancreatic cancer can be performed with acceptable morbidity and mortality. This approach extended the boundaries of surgical resection and greatly increased median survival for the “inoperable” patient with advanced pancreatic cancer. This work was presented at the American Hepato-Pancreato-Biliary Association Conference in Las Vegas, NV, April 2007.     

Renal Dysfunction After Orthotopic Liver Transplantation

Background

Identification of risk factors of acute renal failure (ARF) after orthotopic liver transplantation (OLT) may avoid the development and attenuate the impact on patient outcome. Therefore, the incidence and risk factors of ARF after OLT at Siriraj Hospital were analyzed.

Methods

The study was retrospectively analyzed from the OLT patients at the Siriraj Hospital between January 2002 and December 2009. ARF was defined as an increased in serum creatinine level more than 1.5 times within the first week postoperation compared with the preoperative level.

Results

A total of 81 liver transplant patients were analyzed. The mean age was 52.45 years (range, 22 to 71) and there were 25 women (30.86%) and 56 men (69.14%). Indications for OLT were end-stage liver cirrhosis (n = 43, 53.09%), hepatocellular carcinoma (n = 36, 44.44%), and fulminant hepatic failure (n = 2, 2.47%). Fifty-eight patients (71.60%) developed ARF, and the perioperative mortality of these was 18.97%. The univariate analysis identified the presence of preoperative coagulopathy, prolonged intraoperative hypotension, more blood loss, and postoperative hypotension as the risk factors of ARF. By the multivariate analysis, prolonged intraoperative hypotension more than 30 minutes and presence of postoperative hypotension were the independent risk factors of ARF. During the intraoperative and postoperative periods, ARF group required more blood and blood components transfusion, longer intensive care unit stay, and higher in-hospital mortality. Seven patients (12.07%) in the ARF group required postoperative renal replacement therapy. Four patients (9.52%) developed chronic renal failure, and one of them required long-term hemodialysis.

Conclusions

ARF was a common complication after OLT, which caused increased morbidity and mortality. Although some patients required dialysis, most of them recovered normal renal function. Prolonged intraoperative hypotension and presence of postoperative hypotension were the independent risk factors of ARF after OLT.     

Risk factors for acute respiratory failure in bariatric surgery: data from the Nationwide Inpatient Sample, 2006–2008

BackgroundAcute respiratory failure (ARF) can be a life-threatening postoperative complication after bariatric surgery and is defined as the presence of acute respiratory distress or pulmonary insufficiency. We sought to identify predictors of ARF in patients who underwent bariatric surgery.MethodsUsing the Nationwide Inpatient Sample database, from 2006 to 2008, the clinical data from morbidly obese patients who underwent bariatric surgery were examined. Multivariate regression analysis was performed to identify the independent factors predictive of ARF. The factors examined included patient characteristics, co-morbidities, payer type, teaching status of hospital, surgical techniques (laparoscopic versus open), and type of bariatric operation (gastric bypass versus nongastric bypass).ResultsA total of 304,515 patients underwent bariatric surgery during the 3-year period. The overall ARF rate was 1.35%. The greatest rate of ARF (4.10%) was observed after open gastric bypass surgery. The ARF rate was lower after laparoscopic than after the open surgical technique (.94% versus 3.87%, respectively; P < .01) and after nongastric bypass versus gastric bypass (.82% versus 1.54%, respectively; P < .01). Using multivariate regression analysis, congestive heart failure (adjusted odds ratio [AOR] 5.1), open surgery (AOR 3.3), chronic renal failure (AOR 2.9), gastric bypass (AOR 2.5), peripheral vascular disease (AOR 2.4), male gender (AOR 1.9), age >50 years (AOR 1.8), Medicare payer (AOR 1.8), alcohol abuse (AOR 1.8), chronic lung disease (AOR 1.6), diabetes mellitus (AOR 1.2), and smoking (AOR 1.1) were factors associated with greater rates of ARF. Compared with patients without ARF, patients with ARF had significantly greater in-hospital mortality (5.69% versus .04%, P < .01).ConclusionWe identified multiple risk factors that have an effect on the development of acute respiratory failure after bariatric surgery. Surgeons should consider these factors in surgical decision-making and inform patients of their risk of this potentially life-threatening complication.     

Early Prognostic Factors in Patients with Acute Renal Failure Requiring Dialysis

Purpose. Despite improvements in renal therapy and technology, the mortality rate of patients with acute renal failure (ARF) remains high. Because ARF is a heterogeneous syndrome, occurring in patients with diverse etiologies and comorbid conditions, predicting its outcome is difficult. This study aims to identify early clinical and laboratory prognostic factors, including acute-phase reactants such as C-reactive protein (CRP), fibrinogen, and albumin, in ARF patients requiring dialysis. Material and methods. From June 2002 to March 2004, 61 patients with ARF requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively analyzed. For each patient, the worst values of prognostic variables 24 hr before starting dialysis were prospectively assessed. Results. Oliguria, low plasma fibrinogen levels, hypotension, cardiac disease, and neoplastic disease were statistically significant in predicting hospital mortality. Using Youden's index, the best cut-off value for plasma fibrinogen in predicting mortality was 300 mg/dL with a sensitivity and specificity of 61% and 96%, respectively. Serum CRP and serum albumin were not predictive of hospital mortality. Conclusion. Early prognostic factors in predicting mortality for patients with ARF requiring dialysis identified by multivariate logistic regression were oliguria, low plasma fibrinogen, hypotension, cardiac disease, and neoplastic disease. Serum CRP and albumin were not predictive of hospital mortality, whereas a plasma fibrinogen level ≤300 mg/dL had 61% sensitivity and 96% specificity in predicting mortality.     

Prognosis of acute renal failure in children: a multivariate analysis

Various factors were analyzed in 80 consecutive children under 16 years who had acute renal failure (ARF), for various prognostic factors. Overall mortality was 42.5%, with significantly higher levels seen in hemolytic uremic syndrome (68%, P <0.05) and associated with cardiac surgery (90.9%, P <0.01). Anuria (67.6% vs. 43.5%, P <0.05), need for dialysis (85.3% vs. 56.5%, P <0.05), neurological complications (50% vs. 6.3%, P <0.01), and respiratory complications (35.2% vs. 2.1%, P <0.01) were significantly higher in nonsurvivors than survivors. Multiple regression analysis showed the presence of neurological and respiratory complications to be poor prognostic factors. Received May 2, 1995; received in revised form August 28, 1996; accepted September 13, 1996     

Parathyroidectomy in the Elderly: Do the Benefits Outweigh the Risks?

n = 36) were compared to those from younger patients (< 70 years of age) ( n = 148). Preoperative symptoms of mental impairment, bone disease, and fatigue were more common in elderly patients ( p < 0.05), and nephrolithiasis was more frequent in younger patients ( p < 0.025). Elderly patients presented with more advanced disease, manifested by higher preoperative parathyroid hormone levels (301.9 ± 63.3 vs. 169.2 ± 14.3 pg/ml, p < 0.05). The cure rate (94.4%), morbidity (5.5%), and mortality (0%) in the elderly were indistinguishable from those of their younger cohorts (98%, 1.4%, and 0%, respectively). In conclusion, the more advanced disease seen in the elderly suggests that they are referred for surgery with a higher threshold than younger patients. Although several series of parathyroidectomy in elderly patients have reported high morbidity rates, significant mortality, and long length of stay (LOS), we found that parathyroidectomy in these patients can be performed with high cures, low morbidity, no mortality, short LOS, and high patient satisfaction. These data suggest that the benefits of surgery outweigh its risks and argue for a lower threshold for referral of elderly patients with primary HPT for surgical treatment.     

Prognostic Value of Acute Physiology and Chronic Health Evaluation II and Organ System Failure in Patients with Acute Renal Failure Requiring Dialysis

Background. Despite advances in modern technology of dialysis, prognosis of patients with acute renal failure (ARF) remains poor. To give the clinicians the most useful information, a model that accurately predicts outcome early in the course of ARF is required. However, because ARF is a heterogeneous syndrome and occurs in patients with diverse etiologies and some coexisting diseases, predicting outcome early is hard. The aim of this study is to evaluate prospectively the Acute Physiology and Chronic Health Evaluation (APACHE II) and organ system failure (OSF) models, evaluated prior to dialysis, in predicting hospital mortality. Methods. From June 2002 to March 2004, ARF patients requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively recruited for this study. The worst clinical and laboratory data in the 24 hours before initiation of dialysis were prospectively evaluated, and the patients' APACHE II score and OSF number were assessed. Results. A total of 61 patients (40 male and 21 female) were enrolled, of whom 38 (62.3%) died before discharge. By multivariate logistic regression, the APACHE II score (odds ratio 1.3 per increase in one score; P< 0.001), or OSF number (odds ratio 1.9 per increase in one OSF; P< 0.01) and oliguria (odds ratio 4.2; P = 0.04), were found to be statistically significant prognostic factors for hospital mortality. Mortality increased progressively and significantly as OSF number (chi-square for trend; P = 0.001) or the APACHE II score (chi-square for trend; P< 0.001) increased. By using Youden's index, the best cut-off value for APACHE II was 24, with 63% sensitivity and 96% specificity. The best cut-off value for OSF number was 2, with a sensitivity of 81.6% and a specificity of 60.9%. The areas under the receiver operating characteristic curves for APACHE II and OSF number were 0.847 (95% confidence interval (CI)= 0.752–0.942; P< 0.01) and 0.769 (95% CI = 0.646–892; P< 0.001), respectively, indicating good model discrimination. Conclusions. This study concludes that APACHE II and OSF number measured prior to initiation of dialysis reliably predict outcomes of ARF patients requiring dialysis. The mortality rates increase as the APACHE II score or OSF number increases. For predicting mortality, the APACHE II score ≥ 24 was found to have 63% sensitivity and 96% specificity, and OSF number ≥ 2 had 81.6% sensitivity and 60.9% specificity.     

Influence of renal dysfunction on mortality after cardiac surgery: modifying effect of preoperative renal function

BACKGROUND: Acute renal failure (ARF) requiring dialysis is an independent risk factor of mortality after cardiac surgery; the level of preoperative renal function influences the risk of both postoperative ARF and mortality. The relationship between mild renal dysfunction and mortality, and the modifying effect of baseline renal function on this association, is less clear. METHODS: We studied 31,677 patients undergoing cardiac surgery between 1993 and 2002. We used a logistic regression model to assess the relationship between postoperative renal dysfunction and mortality, while adjusting for preoperative renal function, postoperative ARF requiring dialysis, and other risk factors. RESULTS: The overall postoperative mortality rate was 2.2% (698/31,677). For the entire cohort, a clinically relevant increase in the adjusted risk of mortality occurred beyond 30% decline in postoperative GFR. The mortality rate was 5.9% (N, 292/4986) among patients who developed 30% or greater decline in postoperative GFR not requiring dialysis versus 0.4% (N, 106/26,136) among those with <30% decline (P < 0.001). A significant interaction between preoperative GFR and percent change in postoperative GFR (P < 0.001) indicated that at equivalent degrees of renal dysfunction, the mortality risk was greater at a lower preoperative GFR. ARF requiring dialysis was strongly associated with mortality in the model (odds ratio 4.2; 95% CI 3.1-5.7). CONCLUSION: Renal dysfunction not requiring dialysis is an independent risk factor of mortality after cardiac surgery. A better preoperative GFR attenuates the effect of postoperative renal dysfunction on mortality; this interaction needs to be considered while defining a clinically relevant threshold of ARF.     

Laparoscopic and Open Distal Pancreatic Resection for Benign Pancreatic Disease

The aim of the study is to provide comparisons of the perioperative outcomes between open and laparoscopic distal pancreatic resection (DPR) for benign pancreatic disease. From 2002 and 2005, there were 28 patients (16 open, 12 laparoscopic) with a mean age of 52 who had presumptive diagnoses of benign pancreatic lesions. Pathology was neuroendocrine tumor (nine and five), mucinous cystic neoplasm (three and three), symptomatic pancreatic pseudocyst (two and two), and others (two and two). The mean operative time was 278 vs 212 min (p = 0.05), the estimated blood lost was 609 vs 193 ml (p = 0.01), and the success rate of preoperative intent for splenic preservation was 17 vs 62% (p = 0.08) in the open and laparoscopic groups, respectively. Two patients (16%) were converted to an open procedure. There was no perioperative mortality. The mean hospital stay and total perioperative morbidity were 10.6 vs 6.2 days (p = 0.001) and nine vs two events (p = 0.03) in the open and laparoscopic groups, respectively. Ten of 12 patients (83%) with laparoscopic DPR had adequate oral intake within 72 h post operatively in contrast to 2 of 16 (12.5%) patients in the open DPR group (p = 0.0001). Laparoscopic DPR is technically feasible, safe, and associated with less perioperative morbidity and a shorter hospital stay than open DPR. In centers with the appropriate expertise, laparoscopic DPR should be considered the procedure of choice for putative benign lesions of the pancreatic body and tail. Presented at the AHPBA Spring Meeting, Miami Beach, FL March 9–12, 2006 (oral presentation)     

Antioxidant U74389G Improves Glycerol-Induced Acute Renal Failure without Affecting PPARγ Gene

Oxygen metabolites play an important role in the pathogenesis of myoglobinuric acute renal failure (ARF). Previously, we have reported a down regulation of peroxisome proliferator activated receptor γ (PPARγ) in glycerol-induced ARF, and the induction of PPARγ has been shown to provide renal protection. In this study, we determined the protective influence of U74389G, a hydroxyl radical scavenger in myoglobinuric ARF, and its association with PPARγ-mediated renal protection in the rat. Vascular responses to AII were determined in renal pre-glomerular vessels following the induction of ARF with glycerol (50%, v/v, i.m.). The extent of renal damage and function were assessed with or without pre-treatment with U74389G (10 mg/kg × 21 days). In ARF, AII vasoconstriction was enhanced (97%; p < 0.05), and AII production was doubled. U74389G reduced AII vasoconstriction and production by 42% (p < 0.05) and 40% (p < 0.05), respectively. U74389G reduced proteinuria (85%; p < 0.05), which was four times higher in ARF. Similarly, U74389G enhanced Na⁺ excretion twofold while reducing plasma creatinine (24%; p < 0.05) and BUN (31%; p < 0.05). U74389G attenuated free radical generation in ARF while nitrite excretion was unchanged. In renal pre-glomerular vessel, PPARγ expression, activity, and mRNA were significantly lower in ARF rats; this was unchanged with U74389G treatment. On the other hand, U74389G significantly reduced NFκB protein expression, which was elevated in ARF by 25% (p < 0.05). We suggest that antioxidant U74389G blunted renal injury and improved renal function in glycerol-induced ARF through the reduction of free radical production and/or inhibition of NFκB without affecting PPARγ.     

Cardiac surgery in patients with end-stage renal disease on dialysis

Objectives. Over the past decade, the number of patients on dialysis and with cardiovascular diseases has steadily increased. This retrospective analysis compares the postoperative mortality after cardiac surgery between patients on hemodialysis and peritoneal dialysis. Methods. Between 1998 and 2015, 136 patients with end-stage renal disease initiating dialysis more than one month before surgery underwent cardiac surgery. Demographics, preoperative hemodynamic and biochemical data were collected from the patient records. Vital status and date of death was retrieved from a national register. Results. Hemodialysis was undertaken in 73% and peritoneal dialysis in 22% of patients aged 59.7?±?12.9 years, mean EuroSCORE 8.6%?±?3.5. Isolated coronary artery bypass graft was performed in 46%, isolated valve procedure in 29% and combined procedures in 24% with no significant statistical difference between groups. The 30-day mortality was 14% for hemodialysis patients and 3% for peritoneal dialysis patients (p?=?.056). One-year and 5-year mortality were, 30% and 59% in the hemodialysis group, 30% and 57% in the peritoneal dialysis group (p?=?.975, p?=?.852). Independent predictors of total mortality were age (p?=?.001), diabetes (p =?.017) and active endocarditis (p?=?.012). Conclusion. No statistically significant difference in mortality was found between patients in hemo- or peritoneal dialysis. However, we observed that patients with end-stage renal disease on dialysis have two times higher mortality rate than estimated by EuroSCORE.     

Factors Related to Anastomotic Dehiscence and Mortality After Terminal Stomal Closure in the Management of Patients with Severe Secondary Peritonitis

Introduction  Management of severe secondary peritonitis (SSP) may require intestinal resections and bowel exteriorization due to an unacceptable high risk for anastomotic dehiscence (AD). Bowel exteriorization can be achieved through loop or terminal stomas. There are no studies addressing the fate of these latter. Our aim was to determine factors associated with AD and mortality in patients submitted to restoration of intestinal continuity after creation of terminal stomas as part of their operative management for SSP. Patients and Methods  We analyzed prospectively collected databases on all consecutive patients with SSP submitted to restoration of intestinal continuity after having had terminal ileostomies (TI) or terminal colostomies (TC) as part of their operative management during a 30-month period. Several patient and disease and operative variables were evaluated as factors related to AD and mortality in this group of patients. Univariate statistical comparisons were made using Student’s t test for continuous variables and chi-square test when categorical variables were compared. Multivariate analyses were also performed. Results  A total of 72 male patients and 36 female patients were included in the study; 54 had TI and 54 had TC. Median number of operations performed as part of their management for SSP (prior to stomal closure) was 2 (range, 1–15). A total of 76 (70%) had had diffuse peritonitis, and 39 (36%) required management with an open abdomen (26 of them with a skin-only closure technique). Median time interval between stomal creation and closure was 190 days (range, 14–2,192). Stapled and hand-sewn anastomoses were done in 24 and 84 patients, respectively. AD occurred in 11 patients (10%). Univariate analyses disclosed age ≥50 years (p < 0.05), high American Society of Anesthesiologists (ASA) score (≥3; p < 0.01), history of chronic renal failure (p < 0.04), history of diffuse peritonitis (p < 0.05), management with an open abdomen (p < 0.05), and lower preoperative hemoglobin values (p < 0.05) as risk factors for AD. Only age ≥50 years prevailed after multivariate analyses. A total of seven patients died (6%). Factors associated with mortality were age ≥65 years (p < 0.02), high ASA score (≥3; p < 0.01), preoperative use of total parenteral nutrition (p < 0.02), lower preoperative hemoglobin values (p < 0.05), time interval between stomal creation and closure <3 months (p < 0.01), AD (p < 0.02), and need for reoperation after stomal closure (p < 0.02). After multivariate analyses, time interval between stomal creation and closure <3 months and need for reoperation were the only ones that prevailed as independent risk factors for mortality (p < 0.05). Conclusions  Although several variables were related to AD and mortality, waiting at least >3 months before attempting restoration of intestinal continuity seems to be the best approach and a practical recommendation in this group of challenging patients.