Predictive value of bedside effective renal plasma flow for renal recovery in severe acute renal failure

Single injection, single blood sample, effective renal plasma flow (ERPF) estimated by 131I-orthoiodohippurate can be performed accurately and conveniently without urine collection at the bedside. The purpose of this study was to determine if ERPF early in the course of severe acute renal failure (ARF) predicts recovery of renal function in hemodynamically stable patients. Over 18 months, ERPF was determined in 33 such patients with ARF in whom an etiologic diagnosis could be established. Eight patients died within 2 months of onset and while on dialysis, did not have an autopsy, and were not considered further. Six patients (Group A) either remained on dialysis after at least 6 months follow-up or had irreversible renal disease at autopsy. In Group B (19 patients, 13 of whom were dialyzed), serum creatinine returned to less than 2.0 mg/dL (n = 16) or was decreasing without dialysis. Peak serum creatinine (Group A 11.2 +/- 1.4; Group B 10.1 +/- 1.3 mg/dL) did not differ between groups. Oliguria was present in 75% of Group A patients and in 25% of Group B patients. Initial ERPFs differed (p less than 0.001) between Group A (90 +/- 11) and Group B (204 +/- 20 mL/min). Initial ERPF was greater than 125 mL/min in 15 Group B patients but in no Group A patients; the false-positive rate was 21% and the false-negative rate was 0%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Beneficial Effect of Intrarenal Verapamil in Human Acute Renal Failure

Cellular Ca²⁺ influx during the reperfusion period after an ischemic insult has been proposed to be a crucial pathogenetic factor in the development of experimental acute renal failure (ARF). The present study, therefore, examined the potential beneficial effect of intrarenal verapamil, a calcium entry blocking agent, on ARF in patients. Twelve patients were enrolled in the study. Six ARF patients (experimental group)—ARF caused by malaria (4 patients) and leptospirosis (2 patients)—had a catheter placed in their renal artery; verapamil was infused at 100 μg/minfor 3 h and intravenous furosemide, 0.8 mg/kg/h x 24 h was also administered. Another six ARF patients (control group)—ARF caused by malaria (5 patients) and leptospirosis (1 patient)—were treated with intravenous furosemide alone. Baseline renal function was comparable in both groups; GFR (3.16 ± 3.24 vs 0.7 ± 1.5 mL/min, NS), serum creatinine (S_cr), (9.1 ± 2.1 vs 11.3 ± 2.2 mg/dL, NS), and urine volume (V) (41.79 ± 4.77vs 34.54 ± 13.52 mL/h, NS), were comparable in the experimental and control groups. Twenty-four hours posttreatment, the increment of GFR (9.66 ±4.25 vs 1.32 ± 0.50mL/min, P <. 02) and V (181.8 ± 61.7vs 79 ± 18mL/h, P <. 04), were significantly greater in the experimental group as compared to the control group. The course of ARF was also shorter in the experimental group (6.5 ±2.1 vs 13 ± 1.1 days, P <. 05), who also required less dialysis. Thus, combination of a renal arterial infusion of verapamil and intravenous furosemide significantly improves the renal function in tropical ARF as compared to intravenous furosemide alone.     

Significance of the Renal Functional Reserve in Reflux Nephropathy: An Evaluation According to the Degree of Glomerular Damage

Objective. In the treatment of progressive reflux nephropathy (RN), the therapeutic benefit and prognosis of the renal function in RN patients appears to be influenced by the degree of renal functional reserve. We designed this study to determine the presence and characteristics of the renal functional reserve in RN patients. Materials and Methods. In the 35 RN patients with renal scars (19 males; mean age 16.1 years), an exogenous renal clearance test was performed to measure the glomerular filtration rate (GFR) and the effective renal plasma flow (ERPF). In the second half of this test, the renal functional reserve was estimated by measuring the GFR and ERPF during low-dose dopamine infusion. These measurements were then compared with the glomerular size, which had been previously determined by a renal biopsy. Results. Among the patients with a normal glomerular size (?2SD to +2SD), the GFR markedly increased after low-dose dopamine infusion (from 112.15 ± 52.51 to 182.07 ± 69.95mL/min, p < 0.0001), whereas an increase in ERPF was not significant. Among the patients with an enlarged glomerular size (+2SD to +4SD), the GFR and ERPF increased significantly over the baseline values (from 54.60 ± 32.90 to 114.00 ± 65.48 mL/min, p = 0.0076; from 281.01 ± 152.54 to 622.43 ± 392.73 mL/min, p = 0.0155, respectively). Among the patients with an extremely enlarged glomerular size (>+4SD), both the GFR and ERPF remained almost completely unchanged. Conclusion. The renal functional reserve was present even among progressive RN patients with a glomerular size ranging between +2SD and +4SD.     

The Renal Safety Profile of Fluvastatin: Results of a Pooled Analysis

A pooled analysis was designed to evaluate the effects of fluvastatin on the kidney, in terms of renal adverse events, laboratory abnormalities, and renal function over time. An analysis of adverse events was performed on data from 30 completed clinical trials of fluvastatin in 11,815 patients. An analysis of renal function was also performed on data from patients who participated in long-term studies >6 months in treatment duration. Creatinine clearance was calculated using the Cockcroft-Gault formula. Mean creatinine clearance values were in the normal to near-normal range at baseline. Changes in creatinine clearance and serum creatinine from baseline were similar in fluvastatin-treated patients and placebo-treated patients. In the all-fluvastatin group, mean creatinine clearance (±standard deviation) increased from 87.8 (±42.8) mL/min at baseline to 89.4 (±41.2) mL/min at endpoint. In the placebo group, mean creatinine clearance (± standard deviation) increased from 87.7 (± 43.9) mL/min at baseline to 88.7 (±41.4) mL/min at endpoint. In the all-fluvastatin group, mean serum creatinine (± standard deviation) decreased from 1.14 (±0.20) mg/dL at baseline to 1.11 (±0.20) mg/dL at endpoint. In the placebo group, mean serum creatinine (±standard deviation) decreased from 1.15 (±0.22) mg/dL at baseline to 1.12 (±0.22) mg/dL at endpoint. The incidence of renal adverse events was low and comparable between the fluvastatin and placebo treatment groups. This pooled analysis demonstrates that fluvastatin treatment across the approved daily dose range of 20 mg to 80 mg does not adversely affect creatinine or creatinine clearance over time in dyslipidemic patients.     

Meaning and value of free water clearance in injured patients

Increased free water clearance (C_H2O) in seriously injured patients may precede the onset of renal failure (ARF). C_H2O (urine output - osmolar clearance) was measured in 197 injured patients requiring 14 blood transfusions during resuscitation; C_H2O was correlated with systemic pressure (MAP), central venous pressure (CVP), plasma volume (PV), interstitial fluid space (IFS), renal plasma flow (ERPF), filtration rate (GFR), and incidence of ARF. Three patient subgroups were seen: 126 patients (Group A) with normal C_H2O (C_H2O < ?0.25 ml/min); 14 patients (Group B) with C_H2O near unity (±0.25 ml/min); and 57 patients (Group C) with increased C_H2O (> +0.25 ml/min). Group A patients had a good ERPF (445 ml/min ERPF), GFR (106 ml/min), and the lowest incidence of ARF (3%). The PV/IFS ratio, an index of interstitial fluid space compliance, was 0.31. Group B patients had the lowest PV (3.0 liters), GFR (88 ml/min), ERPF (387 ml/min), and urine osmolality (371 mOsm/liter) with the highest incidence of ARF (21%). Group C patients had the highest PV (3.7 liters), cardiac output, ERPF (469 ml/min), CVP (11.6 cm H₂O), and PV/IFS (0.41). Increased C_H2O in Group C patients likely reflects decreased ADH effect. Increased C_H2O in Group B patients was inappropriate and likely reflects tubular dysfunction. The rise in C_H2O preceded azotemia in those Group B patients who later developed ARF. Identification of increased C_H2O in a seriously injured patient without PV expansion or increased CVP indicates impending ARF for which careful monitoring of vital signs, GFR, and fluid replacement are indicated over the next 24–72 hr until the C_H2O has returned to normal.     

Histological Features of Acute Tubular Necrosis in Native Kidneys and Long-Term Renal Function

There are few studies on the relationship between the morphology of acute tubular necrosis (ATN) in native kidneys and late functional recovery. Eighteen patients with acute renal failure (ARF) who had undergone renal biopsy were studied. All had the histological diagnosis of ATN and were followed for at least six months. Clinical characteristics of ARF were analyzed, and histological features were semi-quantitatively evaluated (tubular atrophy, interstitial inflammatory infiltrate, interstitial fibrosis, and ATN). According to the maximal GFR achieved during the follow-up, patients were divided into two groups: complete recovery (GFR ≥ 90 mL/min/1.73 m²) and partial recovery (GFR < 90 mL/min/1.73 m²). Only 39% of the patients achieved complete recovery. Patients with partial recovery achieved their maximal GFR (63 ± 9 mL/min/1.73 m²) 37 ± 14 months after ARF, a period of time similar to those patients with complete recovery (i.e., 54 ± 22 months). Patients with partial recovery had more severe ARF: oliguria was more frequent (90 versus 17%, p < 0.01), and they had higher peak creatinine (13.85 ± 1.12 versus 8.95 ± 1.30 mg/dL, p = 0.01), and longer hospitalization (45 ± 7 versus 20 ± 4 days, p = 0.03). No single histological parameter was associated with partial recovery, but the sum of all was when expressed as an injury index [4.00 (2.73–5.45) versus 2.00 (1.25–3.31), p < 0.05]. In conclusion, among patients with atypical ATN course, those with more severe ARF and tubule-interstitial lesions are more prone to partial recovery.     

Renal transplantation in the elderly: South Indian experience

In developing countries, renal transplantation is offered to young end-stage renal disease (ESRD) patients, while the older ones face limitations due to higher mortality risk. We retrospectively analyzed 225 patients who underwent renal transplantation from living donors, aged 40–60 years (Group A) and >60 years (Group B), focusing on their survival outcome. Group A (n = 181) had mean creatinine (mg/dL) 1.41 ± 0.84, 1.30 ± 0.65 and 1.40 ± 0.60 and mean eGFR (mL/min/1.73 m²) of 65.32 ± 23.03, 69.14 ± 32.65 and 59.21 ± 22.79 at 0, 3 and 6 months post-transplantation. Death-censored graft survival was 93.1% in first year followed by 91.2% in subsequent 4 years. Patient survival was 92.5% in first year, 90.7% in the next 2 years, and 89.2% in 4th year. Highest cumulative graft survival was 86.7% in the first year with 83.4%, 82.7% and 82.4% during the subsequent 3 years. Group B (n = 44) had mean creatinine (mg/dL) of 1.46 ± 1.02, 1.29 ± 0.23 and 1.2 ± 0.29 with a mean eGFR (mL/min/1.73 m²) of 67.90 ± 23.48, 67.02 ± 12.76 and 75.23 ± 15.19 at 0, 3 and 6 months. Highest death-censored graft survival was 97.4% in the first year with 94.7% in next 3 years. Patient survival was 88.1% throughout 4 years post-transplantation. Cumulative graft survival was 84.1% during 4 years. Biopsy-proven acute rejection rate was 28.7% in group A and 15.9% in group B (P = 0.058). There was higher mortality rate in group B with death mainly due to infections and cardiovascular complication. Cardiovascular risk assessment, pre-transplant cancer screening and judicious use of immunosuppressive agents should help minimize adverse events, balanced with an inherently reduced risk of acute rejection, hence the graft survival advantage and is the way forward to maximize patient and renal allograft survival in elderly patients.     

Acute Renal Failure in the Neonatal Period

Acute renal failure (ARF) is a common problem in the neonatal intensive care unit (NICU). In most cases, ARF is associated with a primary condition such as sepsis, metabolic diseases, perinatal asphyxia and/or prematurity. This retrospective study investigated the course of illness, therapeutic interventions, early prognosis and risk factors associated with development of ARF in the neonatal period. A total of 1311 neonates were treated in our NICU during the 42‐month study period, and 45 of these babies had ARF. This condition was defined as serum creatinine level above 1.5 mg/dL despite normal maternal renal function. The data collected for each ARF case were contributing condition, cause and clinical course of ARF, gestational age and birth weight, age at the time of diagnosis, treatment, presence of perinatal risk factors and need for mechanical ventilation. The frequency of ARF in the NICU during the study period was 3.4%. Premature newborns constituted 31.1% of the cases. The mean birth weight in the group was 2863 ± 1082 g, and the mean age at diagnosis was 6.2 ± 7.4 days. The causes of ARF were categorized as prerenal in 29 patients (64.4%), renal in 14 patients (31.1%) and postrenal in 2 patients (4.4%). Forty‐seven percent of the cases were nonoliguric ARF. Asphyxia was the most common condition that contributed to ARF (40.0%), followed by sepsis/metabolic disease (22.2%) and feeding problems (17.8%). Therapeutic interventions were supportive in 77.8% of the cases, and dialysis was required in the other 22.2%. The mortality rate in the 45 ARF cases was 24.4%. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were associated with significantly increased mortality (p < 0.05). There were no statistical correlations between mortality rate and perinatal risk factors, oliguria, prematurity or blood urea nitrogen and creatinine levels. The study showed that, at our institution, ARF in the neonatal period is frequently associated with preventable conditions, specifically asphyxia, sepsis and feeding problems. Supportive therapy is effective in most cases of neonatal ARF. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were identified as indicators of poor prognosis in these infants. Early recognition of risk factors and rapid effective treatment of contributing conditions will reduce mortality in neonatal ARF.     

Co-administration of Co-trimoxazole Does Not Augment Tacrolimus-Induced Impairment in Kidney Function in Rats

Co-trimoxazole is an antibiotic that is frequently used in organ transplant patients. Our objective was to determine the effect of co-trimoxazole on tacrolimus-mediated functional impairment of the kidney in rats. Sprague Dawley rats were divided into three groups. Group 1 (dextrose) received 5% dextrose and Group 2 (tacrolimus) received tacrolimus (1 mg/kg/day) as a continuous intravenous infusion for seven days. Group 3 (combination) received tacrolimus as above and co-trimoxazole (30 mg/kg/day trimethoprim and 150 mg/kg/day sulfamethoxazole) intraperitoneally for six or seven days. Biochemical and functional parameters were measured pre- and post-drug infusion. On day 7, glomerular filtration rate (GFR) was evaluated using ³H-inulin. while the effective renal plasma flow (ERPF)/cationic tubular secretion was assessed using ¹⁴C-tetraethylammoniumbromide (TEA).

GFR (mL/min/kg) as measured by inulin clearance was higher (p ≤ 0.05) in the dextrose (12.0 ± 1.4) group as compared to tacrolimus group (6.0 ± 1.3) and combination group (6.4 ± 1.6), but there was no difference between the tacrolimus and combination group. ERPF/cationic tubular secretion (mL/min/kg) was also significantly higher in the dextrose group (62.6 ± 10.3) as compared to the other two groups. ERPF/cationic tubular secretion was not different between the combination (33.3 ± 5.9) and the tacrolimus (35.1 ± 6.7) groups when there was no co-trimoxazole in the body. However, in the presence of co-trimoxazole ERPF/cationic tubular secretion was significantly reduced in the combination (23.1 ± 3.5) group as compared to the tacrolimus group (35.1 ± 6.7).

These results indicate that co-trimoxazole does not further potentiate tacrolimus induced impairment in kidney Junction but is likely to further inhibit cationic tubular secretion in patients on tacrolimus therapy.     

Role of Dyslipidemia in the Progression of Chronic Renal Disease

The connection between lipids and the rate of progression of chronic renal disease was retrospectively examined in 70 patients who were divided into 2 groups according to their baseline creatinine clearance (C_Cr): Group 1 (Gp1) contained 30 patients with C_Cr 60–40 mL/min followed for 40.0 ± 13.3 months; Group 2 (G2) contained 40 patients with C_Cr 39–15 mL/min followed for 39.0 ± 18.2 months. The following parameters were considered: basal and final C_Crproteinuria per unit of C_Cr (UProt/C_Cr); the difference between final and basal UProt/C_Cr (δUProt/C_Cr); the change in C_Cr/month (δC_Cr); baseline triglycerides (TG), total (TC), HDL (HDLG) and LDL (LDLC) cholesterol, Apo Al, Apo B, Lp(a).M.D. Institute of Nephrology, “S. Camillo De Lellis’ Hospital, 66100 Chieti, Italy.

Besides in basal C_Crthe 2 groups significantly differed in the final C_Crfinal UProt/C_CrδUProt/C_CrδC_Cr. No differences were observed concerning lipid parameters except for Lp(a) (G1 14.8 ± 13.6, G2 28.7 ± 27.4 mg/dL; p <0.05). Baseline TG (G1 184.1 ± 61.3, G2 187.5 ± 72.1 mg/dL) and Apo B (only G2 1.05 ± 0.32 g/L) were significantly higher than normal subjects and the Apo Al/Apo B ratio (G1 1.42 ± 0.43, G2 1.33 ± 0.45) were significantly lower than in normal subjects. δC_Crwhile inversely correlated in both groups with δUProt/C_Cr (p <0.01), only in G2 did it correlat directly with the Apo Al/Apo B ratio (p <0.05) and inversely with Apo B and LDLC (p <0.05). Although a correlation between Lp(a) and δC_Cr was not found, 20/22 patients (3/5 G1, 17/17 G2) with a level > 30 mg% ran a progressive course.

A natural progression of CRI, heralded by an increasing UProt, is highly frequent when baseline C_Cr is <40 mL/min; only then lipids seem to add a burden to the renal damage.     

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.     

The predictive value of 131I-hippurate clearance in the prognosis of acute renal failure

The aim of this investigation was to study the validity of the radionuclide methods in the estimation of kidney function, for prognosis and follow-up of acute renal failure (ARF). In thirty-one ARF patients, the evaluation of glomerular filtration rate (GFR) by 99mTc-DTPA clearance and effective renal plasma flow (ERPF) by 131 I-ortoiodohippurate (131I-OIH) clearance was performed within 7 days and after 6 months from ARF onset. All patients were divided in three groups according to 131I-OIH clearance values obtained within 7 days: group 1, under 150 mL/min; group 2, 150-250 mL/min; and group 3, over 250 mL/min. Seven days clearance values of both radiopharmaceuticals were found to be very low, however, GFR was found more severely impaired than ERPF. Clearance values obtained after 6 months demonstrated no recovery of renal function in the first group, partial recovery in the second and almost complete recovery in the third group. Patients with the lowest 131I-OIH clearance values at the ARF onset had no recovery of renal function, while in the other two groups recovery corresponded to initial 131I-OIH clearance values. In patients with ARF both, 99mTc-DTPA and 131I-OIH clearances were shown suitable for the follow up of renal function, however, only 131I-OIH clearance had a strong predictive prognostic value for renal function recovery in ARF.     

Renal function during and after childhood acute poststreptococcal glomerulonephritis

It is still debatable whether acute poststreptococcal glomerulonephritis (APSGN) can lead to permanent renal impairment. The clinical, immunological, and histological findings during the acute disease have been described thoroughly, however, the hemodynamic events are still poorly understood. In this retrospective study, the inulin and p-aminohippurate clearances were measured to evaluate glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) within a month of onset of the disease (acute stage) in 26 children, and 2–12 months after onset (follow-up) in 22 children with APSGN. During the acute stage, the mean GFR was 77±23 (SD) ml/min per 1.73 m², the mean ERPF 537±138 ml/min per 1.73 m², and the filtration fraction (FF) 14%±3%, compared with values for controls of 115±11 ml/min per 1.73 m², 607±72 ml/min per 1.73 m², and 19%±2%, respectively (n=42). At follow-up, GFR was 114±15 ml/min per 1.73 m², ERPF 600±68 ml/min per 1.73 m², and FF 19%±3%. Thus, during the disease both GFR and ERPF fell below values for controls, but later were restored. The GFR, however, was more reduced than the ERPF, as indicated by the reduced FF. This might reflect a relative hyperperfusion of individual nephrons, which might start processes later deleterious to the nephrons. This finding, however, needs to be further investigated and we have therefore started a long-term follow-up of these patients. Received: 24 June 1998 / Revised: 4 December 1998 / Accepted: 7 December 1998     

Renal dysfunction and serious infections after open-heart surgery

BACKGROUND: Infections and sepsis are important determinants of mortality in patients with renal dysfunction. We studied the influence of preoperative renal function or postoperative acute renal failure (ARF) on the frequency of infections after open-heart surgery. METHODS: This was a retrospective analysis of 24,660 patients undergoing open-heart surgery from 1993 to 2000. Primary outcome was occurrence of serious infections after open-heart surgery; secondary outcome was hospital mortality. RESULTS: Overall incidence of infections after open-heart surgery was 3.3%. The infection rate was higher in patients with lower preoperative creatinine clearance, ranging between 2.2% and 10.0%. Regarding postoperative ARF, the frequency of infections was 58.5% in those patients requiring dialysis vs. 23.7% in those with ARF not requiring dialysis (P < 0.001); within each subgroup, however, the infection rates were similar regardless of the baseline renal function. In patients who did not develop ARF by either of our definitions, the infection rate was 1.6%. By multivariate analysis, preoperative renal function was an independent risk factor associated with infections [odds ratio (OR) for preoperative creatinine>1.2 mg/dL, 1.3; CI, 1.1 to 1.6]. The relationship between preoperative renal function and infection prevailed even after excluding the patients with postoperative ARF. The overall morality was 2.2%; the mortality in patients with serious infection was 31.7%. CONCLUSION: Both preoperative renal dysfunction and postoperative ARF influence the frequency of serious infections after open-heart surgery. The infection rate was higher in patients with postoperative ARF regardless of the baseline renal function. However, preoperative renal dysfunction portended higher risk of infection, independent of the influence of postoperative ARF.     

Renal Function and Serum Albumin at the Start of Dialysis in 514 Chinese ESRD In-Patients

Background. The dialysis population has grown rapidly in recent decades. Despite the high cost and poor outcomes of dialysis treatment for ESRD, there are scant data about the level of renal function and the relationship of renal function and serum albumin at the start of dialysis in Chinese ESRD patients. Method. We report the level of serum creatinine (Scr), glomerular filtration rate (GFR), and serum albumin (Salb) in 514 ESRD in-patients who began their dialysis treatment between January 2001 through December 2007 at two large dialysis centers in Changsha, Hunan, China. Data were obtained through reviewing the case records of all 514 patients. GFR was predicted by an equation developed from the Modification of Diet in Renal Disease Study. In addition, serum albumin was analyzed in relation to levels of predicted GFR. Results. The mean (SD) and median predialysis serum creatinine was 1121.92 ± 458.24 and 1032 μmol/L. The mean (SD) and median predicted GFR was 4.98 ± 2.24 and 4.47mL/min/1.73m². The proportion of patients with predicted GFR of >10, 5 to 10, and <5 mL/min/1.73m² was 3.7, 36.2, and 60.1%, respectively. The mean predicted GFR was significantly lower among younger patients, uninsured patients, unemployed or farmer patients, patients who were employed, students, patients who selected hemodialysis, patients with ESRD caused by diseases other than diabetes, patients with BUN above the mean, and patients with hemoglobulin beneath the mean. Compared with patients who started with GFR >5mL/min, the patients who started with GFR ≤5mL/min had significantly higher plasma urea and creatinine levels but significantly lower creatinine clearance (mL/min per 1.73m²) and parameters of nutritional status, such as serum albumin, body weight, and BMI. Conclusion. A wide variation existed in renal function at the initiation of dialysis in partial Chinese ESRD patients. Most patients start dialysis at very low levels of predicted GFR. The nutritional status in patients who start dialysis early was better than those in patients who start dialysis when GFR ≤ 5mL/min. Further studies are needed to analyze the impact of level of renal function and nutritional status at the start of dialysis on the outcomes of ESRD.     

Spectrum of Acute Renal Failure and Factors Predicting Its Outcome in an Intensive Care Unit in India

Identification of factors causing acute renal failure (ARF) and its associated poor prognosis in critically ill patients can help in planning strategies to prevent ARF and to prioritize the utilization of sparse and expensive therapeutic modalities. Most of the studies in such patients have been done in the developed world, and similar data from the developing world is sparse.

We analyzed 45 consecutive patients who developed ARF in the intensive care unit (ICU) during a 12-month period. Demographic and detailed biochemical profile, previous chronic illness, precipitating factors, number of failed organs, type of ARF (oliguric/nonoliguric), and need for and type of renal replacement therapy (RRT) received were recorded at the time of admission to ICU and during the course of illness. The mean age of these patients was 43.1 years, with 75.6% being males. Hypotension, sepsis, and use of nephrotoxic drugs were common precipitating factors for ARF in these patients. However, multiple precipitating factors were present in the majority (80%): 81.5% had at least one organ failure prior to development of ARF, 71.1% had oliguria, and 71.1% required RRT. Intermittent hemodialysis was the most common form of RRT given. Patient mortality was 64.4%, with 15 of the 16 surviving patients becoming dialysis independent. We observed an increase in mortality from 0% to 100%, depending on the number of failed organs from one to six. On comparing the predictor outcomes between survivors and nonsurvivors by multivariate analysis, only the number of failed organs at the time of ARF (2.6 ± 0.9 vs. 4.5 ± 0.8) and serum albumin <3.0 g/dL were found to be statistically significant.

To conclude, ARF in critically ill patients is multifactorial in origin and carries a high mortality. Mortality in these patients increases with increasing numbers of failed organs and with a serum albumin of <3.0 g/dL.     

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.     

Extracorporeal Support: Improves Donor Renal Graft Function After Cardiac Death

Donors after cardiac death (DCD) could increase the organ pool. Data supports good long‐term renal graft survival. However, DCDs are <10% of deceased donors in the United States, due to delayed graft function, and primary nonfunction. These complications are minimized by extracorporeal support after cardiac death (ECS‐DCD). This study assesses immediate and acute renal function from different donor types. DCDs kidneys were recovered by conventional rapid recovery or by ECS, and transplanted into nephrectomized healthy swine. Warm ischemia of 10 and 30 min were evaluated. Swine living donors were controls (LVD). ECS‐DCDs were treated with 90 min of perfusion until organ recovery. After procurement, kidneys were cold storage 4–6 h. Renal vascular resistance (RVR), urine output (UO), urine protein concentration (UrPr) and creatinine clearance (CrCl), were collected during 4 h posttransplantation. All grafts functioned with adequate renal blood flow for 4 h. RVR at 4 h posttransplant returned to baseline only in the LVD group (0.36 mmHg/mL/min ± 0.03). RVR was higher in all DCDs (0.66 mmHg/mL/min ± 0.13), without differences between them. UO was >50 mL/h in all DCDs, except in DCD‐30 (6.8 mL/h ± 1.7). DCD‐30 had lower CrCl (0.9 mL/min ± 0.2) and higher UrPr >200 mg/dL, compared to other DCDs >10 mL/min and <160 mg/dL, respectively. Normothermic ECS can resuscitate kidneys to transplantable status after 30 min of cardiac arrest/WI.     

Renal plasma flow and glomerular filtration rate duringacute kidney injury in man

During acute kidney injury (AKI), lowered glomerular filtration rate (GFR) is believed to be consequent to reduced renal plasma flow (RPF). We aimed to systematically evaluate the evidence for such an association. Using specific search terms, we systematically interrogated the Pub Med electronic reference database for studies of human AKI where renal plasma or blood flow and GFR were measured; older articles were then identified by screening bibliographies of retrieved reports. We identified 22 articles describing 250 patients (203 native kidney, 47 in renal allograft). Of these studies, 8 articles (110 patients) estimated effective renal plasma flow (ERPF) by clearance techniques and 14 articles (140 patients) estimated true renal plasma flow (TRPF). Mean RPF was 272 mL/min (95% CI 213–331) and GFR 13.9 mL/min (9.9–17.9). Mean TRPF was significantly greater than mean ERPF (344 vs. 180, p = 0.004) despite lower mean GFR (8.8 vs. 20.4, p = 0.002). There was no significant association between RPF and GFR between studies. Eleven studies presented individual patient data (76 patients: 49 TRPF, 27 ERPF); here, individual patient ERPF was associated with GFR (r² = 0.52), but TRPF was not. During AKI in man, there is only a limited association between ERPF and GFR, and no detectable association between TRPF and GFR.     

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.