A Simple and Early Prognostic Index for Acute Renal Failure Patients Requiring Renal Replacement Therapy

Recent advances in technology have not substantially changed the high mortality rate associated with acute renal failure (ARF). To obtain a simple, valid prognostic index, we retrospectively evaluated the relative importance of demographic data, causes (acute insults) of renal failure, and comorbid clinical conditions for the outcome in 102 ARF patients who received renal replacement therapy with an overall mortality rate of 65% (66 of 102). There were no significant differences between survivors and nonsurvivors in age and gender. Mortality according to acute insults was similar to that of the whole population studied. Of the 10 clinical conditions at the time of the first renal replacement therapy, mechanical ventilation (p = 0.0002), cardiac failure (p = 0.0006), hepatic failure (p = 0.003), central nervous system dysfunction (p = 0.005), and oliguria (p = 0.04) were found to be significantly related to mortality by univariate analysis. Furthermore, multivariate analysis demonstrated that only mechanical ventilation, cardiac failure, and hepatic failure were significant risk factors. Survival was directly related to the number of significant variables in univariate analysis: zero, 89% (8 of 9); one, 62% (21 of 34); two, 19% (5 of 27); three, 10% (2 of 20); four, 0% (0 of 8); five, 0% (0 of 4). This simple and early prognostic index, derived from the assessment of clinical conditions which were easily de-termined at the patient's bedside, could be useful for outcome prediction in ARF patients requiring renal replacement therapy.     

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.     

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.     

Outcomes of Acute Renal Failure Patients Requiring Intermittent Hemodialysis

The published studies on the prognosis of patients requiring intermittent hemodialysis (IHD) are scarce and have some conflicts. In this study, we retrospectively analyzed our data on ARF patients who were treated with IHD. A total of 192 (female: 85, 44.3%; male: 107, 55.7%) patients were included in the study. The mean age was 56.3 ± 17.1 years. In all, 48.9% of the patients were older than 60 years. The mean number of IHD sessions was 7.8 ± 8.0 per patient; 12.4% was due to prerenal causes, 76.8% was due to intrarenal causes, and 10.8% was due to postrenal causes. The leading indication of the IHD was uremic symptoms (46.8%). With the exclusion of hypertension, 72.4% of the patients had at least one systemic comorbidity. After treatment, 75.5% of the patients recovered, in contrast to 9.4% of patients who were transferred to chronic renal replacement programs and 15.1% who died during IHD period. Pre-dialytic serum creatinine (p?=?0.003) and albumin levels (p?=?0.016), total IHD session number per patient (p?=?0.003), and age (p?=?0.034) were the parameters that were related to high mortality in statistical analysis. Mortality was higher if the leading indication of IHD was biochemical disturbances (p?=?0.013). Diabetes mellitus did not influence mortality. Consequently, predialytic serum creatinine and albumin levels may be very important predictors of mortality. Patients in high-risk groups (older age, female sex, and low pre-dialytic creatinine and albumin levels) should be considered to be treated with slow continuous renal replacement methods.     

Is the Choice of Membrane Important for Patients with Acute Renal Failure Requiring Hemodialysis?

Abstract: It has recently been reported that patients with acute renal failure requiring hemodialysis have an improved recovery of renal function and a higher survival rate when the dialysis treatments are performed with a biocompatible membrane rather than a bioincompatible membrane. Our data, obtained in 57 patients with acute renal failure, do not support these findings since neither the mortality nor the required number of dialysis sessions could be influenced by using a biocompatible membrane.
The survival rate was similar in both groups (64 versus 72%), and renal function was regained in both groups after 6 dialysis sessions. We conclude that when reviewing the literature as well as other factors, the underlying clinical condition or the skill of the physicians is probably more important than the theoretical superiority of biocompatible membranes.     

Peritoneal Dialysis in Acute Renal Failure

The definition of adequate dialysis in acute renal failure (ARF) is complex and involves the time of referral to dialysis, dose, and dialytic method. Nephrologist experience with a specific procedure and the availability of different dialysis modalities play an important role in these choices. There is no consensus in literature on the best method or ideal dialysis dose in ARF.

Peritoneal dialysis (PD) is used less and less in ARF patients, and is being replaced by continuous venovenous therapies. However, it should not be discarded as a worthless therapeutic option for ARF patients. PD offers several advantages over hemodialysis, such as its technical simplicity, excellent cardiovascular tolerance, absence of an extracorporeal circuit, lack of bleeding risk, and low risk of hydro-electrolyte imbalance. PD also has some limitations, though: it needs an intact peritoneal cavity, carries risks of peritoneal infection and protein losses, and has an overall lower effectiveness. Because daily solute clearance is lower with PD than with daily HD, there have been concerns that PD cannot control uremia in ARF patients. Controversies exist concerning its use in patients with severe hypercatabolism; in these cases, daily hemodialysis or continuous venovenous therapy have been preferred.

There is little literature on PD in ARF patients, and what exists does not address fundamental parameters such as adequate quantification of dialysis and patient catabolism. Given these limitations, there is a pressing need to re-evaluate the adequacy of PD in ARF using accepted standards. Therefore, new studies should be undertaken to resolve these problems.     

Hemodynamics and Survival of Patients with Acute Renal Failure Treated by Continuous Dialysis with Two Synthetic Membranes

Synthetic membranes are not identical and have specific interactions that may be harmful or beneficial. We have investigated the incidence of hypotension and the outcome of acute renal failure (ARF) in ventilated patients treated by continuous venovenous dialysis with 2 different synthetic membranes. In Study 1, the mean arterial pressure (MAP) and systemic vascular resistance (SVR) were monitored during the first 12 min of dialysis with polyacrylonitrile (PAN). In Study 2, the MAP and survival rates were compared in patients randomly assigned to either PAN or polysulfone. No subjects were receiving angiotensin converting enzyme inhibitors. In Study 1, the MAP decreased due to a reduction in the SVR during the first 6 min of dialysis but returned to the baseline value by 12 min in 22 patients during 27 dialysis treatments. In Study 2, the MAP was lower than the baseline value at 6 min during 233 dialysis treatments in 133 patients randomly assigned to PAN or polysulfone membranes (PAN group, 81.5 ± 15 to 78.7 ± 15.6 mm Hg, p =0.001; and polysulfone group, 81.3 ± 15.4 to 80.0 ± 15.7 mm Hg, p =0.06). Severe reductions in the MAP were seen during 13.2% of the PAN and 7.2% of the polysulfone treatments (χ², p =NS). The age, APACHE II score, MAP, inotrope requirement, and primary diagnosis did not differ according to membrane material in a total of 197 consecutive patients (PAN, n =97; polysulfone, n =100). Patient survival was 29% (PAN) and 27% (polysulfone). In multivariate analysis, APACHE II score, inotrope requirement, and liver failure were significant determinants of survival. In conclusion, PAN and polysulfone membranes were not different with respect to hypotensive reactions or survival in critically ill patients undergoing continuous venovenous hemodialysis.     

Adequacy Indices for Dialysis in Acute Renal Failure: Kinetic Modeling

Many aspects of the management of renal replacement therapy in acute renal failure (ARF), including the appropriate assessment of dialysis adequacy, remain unresolved, because ARF patients often are not in a metabolic steady state. The aim of this study was to evaluate a system of adequacy indices for dialysis in ARF patients using urea and creatinine kinetic modeling. Kinetic modeling was performed for two different fictitious patients (A and B) with characteristics described by the average parameters for two patient groups and for two blood purification treatments: sustained low efficiency daily dialysis (SLEDD) in Patient A and continuous venovenous hemofiltration (CVVH) in Patient B, based on data from a clinical report. Urea and creatinine generation rates were estimated according to the clinical data on the solute concentrations in blood. Then, using estimated generation rates, two hypothetical treatments were simulated, CVVH in Patient A and SLEDD in Patient B. KT/V, fractional solute removal (FSR) and equivalent renal clearance (EKR) were calculated according to the definitions developed for metabolically unstable patients. CVVH appeared as being more effective than SLEDD because KT/V, FSR, and EKR were higher for CVVH than SLEDD in Patients A and B. Creatinine KT/V, FSR, and EKR were lower and well correlated to the respective indices for urea. Urea and creatinine generation rates were overestimated more than twice in Patient A and by 30–40% in Patient B if calculated assuming the metabolically stable state than if estimated by kinetic modeling. Adequacy indices and solute generation rates for ARF patients should be estimated using the definition for unsteady metabolic state. EKR and FSR were higher for urea and creatinine with CVVH than with SLEDD, because of higher K·T and minimized compartmental effects for CVVH.     

Mortality in Elderly Patients with Acute Renal Failure

In a retrospective study, we identified 55 elderly patients with acute renal failure (ARF) admitted to our hospital during an 8-year period from 1985 to 1993. Information about the etiology, complications, laboratory data, and treatment course were obtained from the clinical history. Of the 200 patients with ARF admitted to the hospital during this period, 28% were patients more than 60 years old (41 male and 14 female) with an average age of 68.5 ± 7 years. The main causes of ARF were sepsis, volume depletion, low cardiac output, arterial hypotension, nephrotoxicity by antibiotics, and obstructive uropathy. The global mortality of elderly patients with ARF was 53%. The mortality rate of the different types of the ARF were: prerenal 35%, intrinsic 64% (oliguric 76%, nonoliguric 50%), and postrenal 40%. Mortality as a result of sepsis occurred in 18 patients (62%), by cardiovascular disease in 4 patients (13%), by acute respiratory failure in 2 patients (7%), and by other causes in 5 patients (18%). In the cases of sepsis, Pseudomonas was detected in 7 cases (39%), Escherichia coli in 2 cases (11%), Gram-negative nonspecific in 3 cases (17%), Klebsiella in 1 case (5%), and in 5 cases (16%), the hemoculture was negative. The patient survival rate was 47% (26 of 55 patients). Of these patients, 19 recovered their normal renal function (73%), but 7 patients remained with renal failure (27%). In conclusion, the global mortality in the elderly patients without considering the types of ARF was 53%. The oliguric form had the highest mortality rate with 76%. The main causes for mortality were sepsis with 62%, cardiovascular disease with 13%, and other causes 18%.     

腹膜透析治疗小儿心脏手术后并发急性肾功能衰竭

目的总结腹膜透析（PD）治疗小儿心脏手术后并发急性肾功能衰竭（ARF）的临床经验。方法27例ARF患者，年龄3个月～12岁（4．20±3．58岁）；体重4．2～30．0kg（12．35±7．65kg）。因心脏手术后发生ARF进行PD。动态监测血气分析、电解质、血清肌酐（Cr）、尿素氮（BUN）、平均动脉压（MAP）和中心静脉压（CVP）的变化。结果PD后5d Cr、BUN与PD前比较明显下降（P〈0．01），血钾、血钠、碳酸氢根（HCO3^-）恢复正常。术后死亡8例（29．6％），死于低心排血量3例，感染并发多器官功能衰竭3例，恶性心律失常1例，肺动脉高压危象1例。发生并发症9例（33．3％），其中管周漏液3例，腹膜炎3例，透析管堵塞3例（其中感染堵塞1例、大网膜堵塞2例）。结论小儿心脏手术后ARF早期行PD疗效肯定、安全，操作方便，可降低死亡率。     

Prognostic Indexes and Mortality in Critically 111 Patients with Acute Renal Failure Treated with Different Dialytic Techniques

The objective of this study was to compare the evolution of patients with acute renal failure (ARF) treated conservatively or with different dialytic techniques in an intensive care unit (ICU). From June 1992 to November 1994, 1087 consecutive patients were admitted in our ICU. Two hundred and twenty of these presented with ARF, and were divided into three groups: group I (control group): 156 patients with ARF who did not receive substitutive techniques; group II: 21 patients under intermittent hemodialysis (IHD) or peritoneal dialysis (PD); group III: 43 patients under continuous hemodiafiltration (CHDF). The studied variables were age, etiology of renal failure, requirement of dialysis, type of dialysis, length of ICU and hospital stay, and renal function outcome. APACHE II and SAPS scores were recorded on admission and analyzed for hospital mortality. Chi-square test and the analysis of variance were used for the statistical analysis. Results are presented as mean ± SD. A p value below 0.05 was considered statistically significant. Although etiology of ARF was multifactorial, we found a high frequency of ARF due to sepsis (56.8%), hypoperfusion (58.7%), and acute tubular necrosis (62.5%). Sepsis and heart failure were clinical conditions associated to a greater mortality. We did not find any statistical difference between the two dialyzed groups for all the studied variables, nor between the three groups regarding APACHE II and hospital stay. Significant differences were found between dialyzed and non-dialyzedpatients respect to age, group I: 64.1 ± 13.6, group II: 56.4 ± 19.7, and group III: 56.0 ± 14.1 fp < 0.001), creatinine peak serum levels, group I: 260 ± 130, group II: 494 ± 209, and group III: 441 ± 170 μmol/L (p < 0.0001), and mortality, group 1:46.9%, group II: 66.7%, and group III: 76.2% (p < 0.002). SAPS score showed differences between the control group and the CHDF group 13.9 ± 4.8 and 16.4 ± 5.4 (p < 0.007), respectively. The use of dialytic techniques in critically ill ARF patients is associated with greater mortality. Prognostic indexes on admission did not correctly classify our patients with ARF. Continuous hemodiafiltration does not involve greater mortality or length of stay as compared to conventional dialysis.     

Prophylaxis of Acute Renal Failure in Patients with Rhabdomyolysis

Patients that develop rhabdomyolysis of different causes are at high risk of acute renal failure. Efforts to minimize this risk include volume repletion, treatment with mannitol, and urinary alkalinization as soon as possible after muscle injury. This is a retrospective analysis (from January 1, 1992, to December 31, 1995) of therapeutic response to prophylactic treatment in patients with rhabdomyolysis admitted to an intensive care unit (ICU). The diagnosis of rhabdomyolysis was based on creatinine kinase (CK) level (>500 Ul/L) and the criteria for prophylaxis were: time elapsed between muscle injury to ICU admission < 48 h and serum creatinine < 3 mg/dL. Fifteen patients were treated with the association of saline, mannitol, and sodium bicarbonate (S+M+B group) and 9 patients received only saline (S group). Serum creatinine at admission was similar in both groups: 1.6 ± 0.6 mg/dL in the S+M+B group and 1.5 ± 0.6 mg/dL in the S group (p > 0.05). Maximum serum CK measured was 3351 ± 1693 μ/L in the S+M+B group and 1747 ± 2345 IU/L in the S group (p < 0.05). However the measurement of CK was earlier in S+M+B patients (1.7 vs 2.7 days after rhabdomyolysis). APACHE II scores were 16.9 ± 7.4 and 13.4 ± 4.9 in the S+M+MB and S groups, respectively (p > 0.05). Despite the treatment protocol the serum levels of creatinine had similar behavior and reached normal levels in all patients in 2 or 3 days. The saline infusion during the first 60 h on the ICU was 206 mL/h in the S group and 204 mL/h in S+M+B (p > 0.05). Mannitol dose was 56 g/day, and bicarbonate 225 mEq/day during 4.7 days. Our data show that progression to established renal failure can be totally avoided with prophylactic treatment, and that once appropriate saline expansion is provided, the association of mannitol and bicarbonate seems to be unnecessary.     

终末期肾病并发急性左心衰应用序贯透析联合BiPAP治疗的临床研究

目的:观察序贯透析(SD)联合双水平气道正压通气(Bi PAP)治疗终末期肾病(ESRD)并发急性左心衰的可行性,以期为ESRD并发急性左心衰的患者提供新的、经济的、安全的治疗思路和方法。方法:选择2013年1月~2014年10月在东莞市清溪医院住院的ESRD并发急性左心衰患者60例为研究对象,随机分成:SD联合Bi PAP治疗观察组和连续肾脏替代疗法(CRRT)对照组,每组30例。比较两组肾功能相关临床指标、血气分析指标以及临床疗效。结果:治疗后两组血尿素氮(BUN)、血肌酐(Scr)肾功能指标,钾(K+)、钙(Ca2+)、磷(P3-)均出现显著减低(P<0.05和P<0.01),两组对上述指标的减低作用差异无统计学意义(P>0.05)。治疗后两组氧分压(Pa O2)、二氧化碳分压(Pa CO2)均得到显著改善(P<0.05和P<0.01),但观察组的改善作用优于对照组(P<0.05)。对照组透析时间为(64.32±12.96)h,显著高于观察组的(51.36±7.92)h,P<0.05。观察组的临床治疗有效率为96.7%(29/30),对照组为93.3%(28/30),两组之间差异无统计学意义(P>0.05)。对照组所用费用约为(9 274.5±814.6)元,显著高于观察组的(7 116.2±658.4)元,P<0.01。结论:SD联合Bi PAP治疗ESRD并发急性左心衰临床疗效与CRRT治疗差异无统计学意义,但联合治疗对于患者缺氧的纠正作用优于CRRT治疗,而且联合治疗操作简单,费用大幅减低,有利于基层医院的推广使用。     

婴幼儿心脏术后急性肾衰竭腹膜透析的护理

对12例心脏术后急性肾衰竭婴幼儿行腹膜透析治疗,结果9例肾功能完全恢复正常,3例死于心功能衰竭.提出保持透析管路通畅,准确记录出入量,做好婴幼儿保暖、透析液体保温及病情观察是护理的关键.