Predictors of mortality in elderly patients with acute renal failure in a developing country

This prospective study was undertaken to systematically analyze the predictors of mortality in the elderly in a developing country. All elderly patients with ARF hospitalized at this tertiary care centre over 1 year were studied. Various predictors analyzed were hospital-acquired ARF, causative factors of ARF, preexisting hypertension and diabetes mellitus, severity of renal failure (initial and peak serum creatinine, need for dialysis), and complications of ARF: infection during the course of illness; serum albumin levels and critical illness defined as presence of two or more organ system failures excluding renal failure. Of 33,301 patients admitted, 4,255 (12.7%) were elderly. Of these 69 (1.6%) had ARF. On analysis of the whole group, both young and elderly, age >60 years had an independent predictor of mortality (odds ratio 5.6, P = 0.001). Forty-two of the 69 (60.9%) elderly ARF patients died. The mortality was significantly increased in those elderly with hospital-acquired ARF (79.2%, P = 0.027), those with sepsis as a cause of ARF (71.2%, P = 0.004), those who required dialysis (72.5%, P = 0.022), those developing an infection during the course of ARF (87.9%, P = 0.000) and in those with a critical illness (90.0%, P = 0.00). On logistic regression analysis of those variables that were significant on univariate analysis, only critical illness (odds ratio 9.97) and infection during course (odds ratio 9.72) were the independent predictors of mortality. To conclude, ARF complicates only 1.6% of hospitalized elderly patients but is associated with a high mortality rate of 61%. Infection during the course of illness and critical illness were the independent predictors of mortality.     

Thrombocytopenia in renal failure in a developing country.

A retrospective study over a 3-year period was done looking at predialysis platelet levels, in particular, thrombocytopenia. Seventy-five patients with acute renal failure (ARF) and 75 patients with chronic renal failure (CRF), treated at King Edward VIII Hospital, were randomly chosen. Platelet counts were performed on a coulter counter (S + 2) and counts of less than 150 x 10(9)/L were considered as thrombocytopenia. Of the 75 CRF patients, 47 were males. Eleven (14.7%) were thrombocytopenic with a mean platelet count of 118.3 x 10(9)/L and a range of 83-146 x 10(9)/L. The mean creatinine level was 1510 micrograms/L. The remaining nonthrombocytopenic patients had a mean platelet count of 268 x 10(9)/L and a mean creatinine of 1080 micrograms/L. Of the ARF patients, 39 were males. Twenty-two (29.3%) had thrombocytopenia with a mean platelet count of 98 x 10(9)/L and a range of 22-147 x 10(9)/L. The mean creatinine level was 819 micrograms/L. The remaining nonthrombocytopenic patients had a mean platelet count of 319 x 10(9)/L and a mean creatinine of 1020 micrograms/L. In CRF patients no correlation was found between thrombocytopenia and the disease process. Creatinine levels appear to be higher in the thrombocytopenia group than in the nonthrombocytopenic group. In the ARF group of patients, females had a higher frequency of thrombocytopenia than males. Obstetrical and gynecological causes and herbal ingestion were the 2 major underlying etiologies in the thrombocytopenic group. Thrombocytopenia appears to be a common presenting feature in ARF as opposed to CRF, and this may be accounted for by the underlying etiologies in ARF.     

Treatment-related acute renal failure in the elderly: a hospital-based prospective study.

BACKGROUND: Elderly individuals need a host of diagnostic procedures and therapeutic interventions to take care of ailments. This prospective study was carried out to determine the magnitude of treatment-related acute renal failure (ARF) in the elderly in a hospital setting, to know about pathogenetic factors and to study the factors that could predict an adverse outcome. METHODS: All elderly patients (>60 years) admitted over a 12-month period were screened prospectively throughout their hospital stay for the development of ARF. RESULTS: Of 31860 patients admitted, 4176 (13%) were elderly. Of these 59 (1.4%) developed ARF in the hospital. Nephrotoxic drugs contributed towards development of ARF in 39 (66%), sepsis and hypoperfusion in 27 (45.7%) each, contrast medium in 10 (16.9%) and postoperative ARF occurred in 15 (25.4%) patients. These pathogenetic factors were responsible for ARF in different combinations. Amongst these combination of pathogenetic factors, radiocontrast administration (partial chi(2) 28.1, P<0.0001), surgery (partial chi(2) 14.89, P=0.001), and drugs (partial chi(2) 6. 22, P=0.0126) predicted ARF on their own. Nine patients (15.23%) needed dialytic support. Of 59 patients, 15 (25.4%) died, of those who survived, 38 (86.3%) recovered renal function completely and six (13.6%) partially. Mortality in the elderly with ARF was significantly higher than in those without ARF (25.4 vs 12.5%; chi(2) 8.3, P=0.03). Sepsis (odds ratio 43), oliguria (odds ratio 64), and hypotension (odds ratio 15) were independent predictors of poor patient outcome on logistic regression analysis. CONCLUSION: Incidence of treatment-related ARF in the elderly was 1.4%, with more than one pathogenetic factor playing a role in the development of ARF in the majority. Sepsis, hypotension, and oliguria were the independent predictors of poor patient outcome.     

Analgesic and non-steroidal anti-inflammatory drug-associated acute renal failure: a prospective collaborative study

During a one-year period analgesic and non-steroidal anti-inflammatory drug-(NSAID) associated acute renal failure (ARF) was recorded in 147 of 398 patients registered in 58 nephrology units. This figure represented 36.9% of drug-associated ARF, and 6.8% of total patients with ARF hospitalized during the same period. Drugs involved were primarily glafenin (79), NSAID (62), paracetamol (5) and phenacetin (1 case). Hypersensitivity reactions were documented in 32 patients. Acute tubular necrosis was found in 20, and interstitial nephritis (AIN) in 9 of 34 biopsied patients. All patients in the glafenin group and 71.4% in the NSAID group recovered fully or regained previous renal function (p less than 0.01). Permanent renal damage (9.5% of total cases) was more frequent in patients with AIN than in those with other types of ARF (p less than 0.001). Preventive measures should be especially directed to older patients receiving NSAID, by avoiding the combined use of drugs potentiating their action and by correcting any predisposing factor to ARF.     

Acute renal failure in pregnancy in a developing country: twenty years of experience

Acute renal failure (ARF) has become a rare complication of pregnancy in developed countries. The aim of this study was to describe changing trends in pregnancy-related acute renal failure (PR-ARF) in two successive periods; 1982-1991 and 1992-2002. From July 1982 to December 2002, 190 cases of PR-ARF were observed in Eastern India (11.6% of total number of ARF needing dialysis). Obstetrical complications were causative factors for ARF in 15% (65/426) and 10% (125/1201) of patients in the two periods, respectively. The incidence of PR-ARF fell from 15% in 1982-1991 to 10% in 1992-2002, with respect to the total number of acute renal failure cases. Post-abortal ARF showed a declining trend, 9% in the 1980s to 7% in the 2000s, of the total number of ARF cases. Preeclampsia-eclampsia was the cause of obstetrical ARF in 23% (1982-1991) and 14.4% (1992-2002) of cases in these two periods. The percentage of total ARF due to eclampsia declined from 3.5% during the period 1982-1991 to 1.4% in 1992-2002. Puerperal sepsis contributed to 0.8% of total ARF in recent years, compared to 2.4% in the earlier period. The incidence of cortical necrosis decreased significantly (p < 0.001) from 17% in 1982-1991 to 2.4% in the 2000s. The maternal mortality reduced to 6.4% in 1992-2002 from initial high mortality of 20% in the period of 1982-1991. CONCLUSION: PR-ARF which remained high in the initial period has decreased in recent years. This is associated with a declining trend in     

Validation of Liano score in acute renal failure: a prospective study in Indian patients

Aim  To validate Liano score as a prognostic scoring system in acute renal failure (ARF): a prospective study in Indian patients. Patients and methods  Prospective study including 100 patients over a period of 1 year, from March 2006 to July 2007. Inclusion criteria were patients with no previous renal disease or any systemic disease known to affect the kidney and who presented with acute rise (hours to days) in serum creatinine. Exclusion criteria were patients with preexisting chronic renal failure, age younger than 12 years and ultrasound of the abdomen showing contracted kidneys. Results and conclusions  In this study there were 68 males and 32 females. Peak incidence by age was in the fifth decade. There was no increased mortality in any age group (p = 0.278). A total of 19 patients had pre-renal ARF, 74 patients had intrinsic ARF, of which 46 were acute tubular necrosis (ATN); 7 patients had obstructive ARF. A total of 21 patients had Liano score greater than 0.9, of which 18 patients died and 3 were discharged against medical advice in a critical condition (and died later at home). Calculated sensitivity was 62.1%, specificity was 100% and positive predictive value was 100%. Sensitivity and specificity when calculated separately for intrinsic renal ARF (after excluding post renal ARF) were 60.7% and 100%, respectively. There was statistically significant correlation between Liano score and mortality (p < 0.001).     

Predictors of renal and patient outcomes in atheroembolic renal disease: a prospective study

Atheroembolic renal disease (AERD) is part of a multisystemic disease accompanied by high cardiovascular comorbidity and mortality. Interrelationships between traditional risk factors for atherosclerosis, vascular comorbidities, precipitating factors, and markers of clinical severity of the disease in determining outcome remain poorly understood. Patients with AERD presenting to a single center between 1996 and 2002 were followed-up with prospective collection of clinical and biochemical data. The major outcomes included end-stage renal disease (ESRD) and death. Ninety-five patients were identified (81 male). AERD was iatrogenic in 87%. Mean age was 71.4 yr. Twenty-three patients (24%) developed ESRD; 36 patients (37.9%) died. Cox regression analysis showed that significant independent predictors of ESRD were long-standing hypertension (hazard ratio [HR] = 1.1; P < 0.001) and preexisting chronic renal impairment (HR = 2.12; P = 0.02); use of statins was independently associated with decreased risk of ESRD (HR = 0.02; P = 0.003). Age (HR = 1.09; P = 0.009), diabetes (HR = 2.55; P = 0.034), and ESRD (HR = 2.21; P = 0.029) were independent risk factors for patient mortality; male gender was independently associated with decreased risk of death (HR = 0.27; P = 0.007). Cardiovascular comorbidities, precipitating factors, and clinical severity of AERD had no prognostic impact on renal and patient survival. It is concluded that AERD has a strong clinical impact on patient and renal survival. The study clearly shows the importance of preexisting chronic renal impairment in determining both renal and patient outcome, this latter being mediated by the development of ESRD. The protective effect of statins on the development of ESRD should be evaluated in a prospective study.     

Predictors of mortality after hip fracture: a 10-year prospective study

The role of medical, social, and functional covariates on mortality after hip fracture was examined over a 16-year period. A total of 1109 patients with hip fractures were included in a prospective database. The inclusion criteria were patients who were age 65 years or older, ambulatory prior to fracture, cognitively intact, living in their own home at the time of the fracture, and had sustained a nonpathological femoral neck or intertrochanteric chip fracture. Data were analyzed using a Cox proportional hazards model. Mortality was compared with a standardized population, and standardized mortality ratios were calculated for 1, 2, 3, 5, and 10 years,respectively. The 1-, 2-, 5- and 10-year mortality rates were 11.9%, 18.5%, 41.2%, and 75.3%, respectively. The predictors of mortality were advanced age, male gender, high American Society of Anesthesiologists (ASA)classification, the presence of a major postoperative complication, a history of cancer, chronic obstructive pulmonary disorder, a history of congestive heart failure,ambulating with an assistive device, or being a household ambulator prior to hip fracture. The increased mortality risk was highest during the first year after hip fracture and returned to the risk of the standard population 3 years postoperatively. Males who are 65 to 84 years had the highest mortality risk.     

Low-flux versus high-flux synthetic dialysis membrane in acute renal failure: prospective randomized study

The influence of dialyzer membrane on the morbidity and mortality of patients with acute renal failure remains a matter of debate. The aim of the prospective randomized clinical study was to assess the influence of the flux of a synthetic dialyzer membrane on patients' survival rate, restitution of renal function, and duration of hemodialysis treatment of patients with acute renal failure as a part of multiorgan failure. Seventy-two patients treated in intensive care units of the University Medical Center Ljubljana were randomized according to the dialyzer used throughout the duration of hemodialysis treatment. There were 38 patients in the low-flux group (dialyzer F6, low-flux polysuphone, Fresenius, Bad Homburg, Germany) and 34 patients in the high-flux group (dialyzer Filtral 12, sulphonated high-flux polyacrylonitrile, Hospal, Industrie Meyzieu, France). Both groups were balanced in terms of sex, age, APACHE II score, oliguria before dialysis, cause of acute renal failure, inotropic support, mechanical ventilation, and the number of failing organs. The patients' survival rate was 18.7% in the low-flux group and 20.6% in the high-flux group. Ten patients (26.3%) recovered their renal function in the low-flux group and 8 (23.5%) in the high-flux group. Hemodialysis treatment lasted 11.2 days in the low-flux and 10.7 days in the high-flux group. An analysis of subgroups with a lower mortality rate (subgroup of patients without oliguria and subgroup of patients with less than 4 failed organ systems) did not show significant differences between the low-flux and high-flux groups in terms of survival rate, recovery of renal function, and duration of hemodialysis treatment. In conclusion, no significant differences were found in the results of low-flux versus high-flux synthetic membrane dialyzer treatment in patients with acute renal failure as a part of multiorgan failure in terms of survival rate, recovery of renal function, incidence of oliguria during hemodialysis, and duration of hemodialysis treatment. The number of failing organs seems to be the most important single factor determining the survival of patients with acute renal failure as a part of multiorgan failure.     

Race and mortality after acute renal failure

Black patients receiving dialysis for end-stage renal disease in the United States have lower mortality rates than white patients. Whether racial differences exist in mortality after acute renal failure is not known. We studied acute renal failure in patients hospitalized between 2000 and 2003 using the Nationwide Inpatient Sample and found that black patients had an 18% (95% confidence interval [CI] 16 to 21%) lower odds of death than white patients after adjusting for age, sex, comorbidity, and the need for mechanical ventilation. Similarly, among those with acute renal failure requiring dialysis, black patients had a 16% (95% CI 10 to 22%) lower odds of death than white patients. In stratified analyses of patients with acute renal failure, black patients had significantly lower adjusted odds of death than white patients in settings of coronary artery bypass grafting, cardiac catheterization, acute myocardial infarction, congestive heart failure, pneumonia, sepsis, and gastrointestinal hemorrhage. Black patients were more likely than white patients to be treated in hospitals that care for a larger number of patients with acute renal failure, and black patients had lower in-hospital mortality than white patients in all four quartiles of hospital volume. In conclusion, in-hospital mortality is lower for black patients with acute renal failure than white patients. Future studies should assess the reasons for this difference.     

Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study

Malnutrition is a frequent finding in hospitalized patients and is associated with an increased risk of subsequent in-hospital morbidity and mortality. Both prevalence and prognostic relevance of preexisting malnutrition in patients referred to nephrology wards for acute renal failure (ARF) are still unknown. This study tests the hypothesis that malnutrition is frequent in such clinical setting, and is associated with excess in-hospital morbidity and mortality. A prospective cohort of 309 patients admitted to a renal intermediate care unit during a 42-mo period with ARF diagnosis was studied. Patients with malnutrition were identified at admission by the Subjective Global Assessment of nutritional status method (SGA); nutritional status was also evaluated by anthropometric, biochemical, and immunologic parameters. Outcome measures included in-hospital mortality and morbidity, and use of health care resources. In-hospital mortality was 39% (120 of 309); renal replacement therapies (hemodialysis or continuous hemofiltration) were performed in 67% of patients (206 of 309); APACHE II score was 23.1+/-8.2 (range, 10 to 52). Severe malnutrition by SGA was found in 42% of patients with ARF; anthropometric, biochemical, and immunologic nutritional indexes were significantly reduced in this group compared with patients with normal nutritional status. Severely malnourished patients, as compared to patients with normal nutritional status, had significantly increased morbidity for sepsis (odds ratio [OR] 2.88; 95% confidence interval [CI], 1.53 to 5.42, P < 0.001), septic shock (OR 4.05; 95% CI, 1.46 to 11.28, P < 0.01), hemorrhage (OR 2.98; 95% CI, 1.45 to 6.13, P < 0.01), intestinal occlusion (OR 5.57; 95% CI, 1.57 to 19.74, P < 0.01), cardiac dysrhythmia (OR 2.29; 95% CI, 1.36 to 3.85, P < 0.01), cardiogenic shock (OR 4.39; 95% CI, 1.83 to 10.55, P < .001), and acute respiratory failure with mechanical ventilation need (OR 3.35; 95% CI, 3.35 to 8.74, P < 0.05). Hospital length of stay was significantly increased (P < 0.01), and the presence of severe malnutrition was associated with a significant increase of in-hospital mortality (OR 7.21; 95% CI, 4.08 to 12.73, P < 0.001). Preexisting malnutrition was a statistically significant, independent predictor of in-hospital mortality at multivariable logistic regression analysis both with comorbidities (OR 2.02; 95% CI, 1.50 to 2.71, P < 0.001), and with comorbidities and complications (OR 2.12; 95% CI, 1.61 to 2.89, P < 0.001). Malnutrition is highly prevalent among ARF patients and increases the likelihood of in-hospital death, complications, and use of health care resources.     

Vascular injuries following road traffic collisions in a high-income developing country: a prospective cohort study

Background  

The mechanism and pattern of vascular injury vary between different populations. The commonest mechanism of vascular injury in civilian practice is road traffic collisions. We aimed to prospectively study the incidence, detailed mechanism and anatomical distribution of hospitalized vascular trauma patients following road traffic collisions in a high-income developing country.     

Identifying critically ill patients at high risk for developing acute renal failure: a pilot study

BACKGROUND: Acute renal failure (ARF) occurs commonly in the intensive care unit (ICU), but predicting which patients will develop ARF is difficult. We set out to determine which risk factors would predict the development of ARF in critically ill patients who are admitted to the ICU without ARF. METHODS: From August 2002 to April 2003, we enrolled medical-surgical ICU admissions into a cohort using a sampling tool based on their risk factor (RF) profile. The risk factors we identified were separated into 3 categories: chronic major, chronic minor, and acute RFs. Combinations of these RFs were used to create a sampling tool and identify patients to enroll into our cohort. Patients with end-stage renal disease and ARF upon admission to the ICU were excluded. RESULTS: We enrolled 194 patients over a 14-month period. The mean age of the cohort was 64.6 +/- 14.7 years. The percentage of Caucasians, African Americans, and Hispanics was 40.7%, 50.5%, and 3.6%, respectively. In a univariate analysis of the entire cohort, increasing APACHE II quartile, increased A-a gradient, presence of systemic inflammatory response syndrome (SIRS), decreased levels of serum albumin, and presence of active cancer predicted ARF. In a multiple logistic regression analysis, decreased serum albumin (high levels of serum albumin were protective), increased A-a gradient, and cancer were associated with development of ARF (OR 2.17, 1.04, and 2.86, respectively). CONCLUSION: Decreased levels of serum albumin concentration, increased A-a gradient, and presence of active cancer predict which patients who are admitted to the ICU will develop ARF.     

Prognostic factors in acute renal failure due to sepsis. Results of a prospective multicentre study

BACKGROUND.: Sepsis is a major cause of acute renal failure in hospital patients,but its incidence and the associated prognostic factors haverarely been assessed prospectively by multivariate analysis. METHODS.: We conducted a prospective 6-month study in 20 multidisciplinaryintensive care units to assess the prognosis of patients hospitalizedwith acute renal failure due to sepsis. Sepsis syndrome andseptic shock were defined according to the criteria of the Societyof Critical Care Medicine Consensus Conference. Severity scoringindexes (SAPS, APACHE II, and organ system failure (OSF)) weremeasured on ICU admission and on inclusion. The end-point washospital mortality. RESULTS.: Acute renal failure had a septic origin in 157 patients (Group1), comprising 68 with septic shock and 89 with sepsis syndrome,and did not result from infection in 188 patients (Group 2).Patients with septic acute renal failure were older (mean age:62.2 versus 57.9 years, P<0.02) and had on inclusion a higherSAPS (19.3 versus 16.1, P<0.001), APACHE II (29.6 versus24.3, P<0.001), and OSF (2.07 versus 1.52, P<0.001) thanpatients with non-septic acute renal failure. They had a higherneed for mechanical ventilation (69.1% versus 47.3%, P<0.001),and acute renal failure was more often delayed during the ICUstay than was present on admission (47.7% versus 32.4% respectively,P<0.005). Hospital mortality was higher in patients withseptic acute renal failure (74.5%) than in those whose renalfailure did not result from sepsis (45.2%, P<0.001). Mortalitywas influenced by the presence of a septic shock (79.4%) orof a sepsis syndrome on inclusion (70.8%). Using a stepwiselogistic regression model, sepsis was an independent predictorof hospital mortality (OR, 2.51; 95% CI, 1.44–4.39) aswell as a delayed occurrence of acute renal failure, oliguria,an altered previous health status, hospitalization prior toICU, need for mechanical ventilation, age and severity scoringindexes on inclusion. In total patients, mortality was higherin dialyzed than in non-dialyzed patients (P<0.001), andin those treated by continuous compared to intermittent techniques(P<0.01). Patients dialysed with biocompatible membraneshad a lower mortality than those treated with cellulose membranes(P<0.005). CONCLUSIONS.: Patients with acute renal failure due to sepsis have a worseprognosis than those with non-septic acute renal failure. Sepsisand the above-defined predictive factors are to be consideredin studies on prognosis of ARF patients. Our results suggestthat the use of biocompatible membranes may reduce significantlymortality in these patients.     

Prediction of mortality in acute renal failure in the tropics

Despite significant improvements in medical care, acute renal failure (ARF) remains a high risk for mortality. It is important to be able to predict the outcome in these patients in view of the emotional and ethical needs of the patients and to address questions of efficiency and quality of care. We analyzed the risk factors predicting mortality prospectively in a group of 265 patients using univariate and multiple logistic regression analysis. A prognostic model was evolved that included 10 variables. The model showed good discrimination [(receiver operating characteristic (ROC) area=0.91) and correctly classified 88.30% of patients. The variables significantly associated with mortality were coma odds ratio (OR)=9.8], oliguria (OR=4.9), jaundice (OR=3.7), hypotension (OR=3.1), assisted ventilation (OR=2.3), hospital acquired ARF (OR=2.3), sepsis (OR=2.2), and hypoalbuminemia (OR=1.7). Age and male gender were included in the model as they are clinically important. The score was validated in the same sample by boot strapping. It was also validated in a prospective sample of 194 patients. The model was calibrated by the Hosmer-Lemeshow goodness-of-fit test. It was compared with two generic illness scores and one specific ARF score and was found to be superior to them. The model was verified in different subgroups of ARF like hospital acquired, community acquired, intensive care settings, nonintensive care settings, due to sepsis, due to nonsepsis etiologies, and showed good predictability and discrimination.     

Outcome of pediatric renal transplants in a developing country

This study was conducted to evaluate the outcome of pediatric renal transplants at our center. A retrospective analysis was done on 39 pediatric transplants (age at transplant <18 years) done at our center over the last 10 years. The mean age at transplant was 15.6±1 years (10–17 years). They comprised 4.2% of all renal transplants done at our center (39/921) over the period. Girls comprised 17.5% of total recipients (n=7). Two patients had a preemptive transplant. The underlying causes of end stage renal disease were chronic glomerulonephritis (n=21), chronic interstitial nephritis (n=17) and Alport syndrome [1]. All the 39 children were initiated on triple drug immunosuppression (cyclosporin A (CsA) azathioprine, prednisolone). All patients received grafts from living related donors. In the first month, three patients had graft loss (serum creatinine, SCr, >5 mg/dl). Of these, two patients died because of septicemia and one had acute cortical necrosis. There was evidence of infection in 16 patients (40%). Acute rejection was seen in 17 patients (45.8%). The 1-year patient and graft survival was 89% and at 3 years 70%. The actuarial graft survival at 5 years was 50%. Twelve children discontinued CsA after 1 year post-transplant and five of these had graft loss. Graft losses were significantly greater in patients who discontinued CsA as compared to those who continued CsA (5/12 vs 2/22). After a mean follow-up of 31.5±3.5 months, of the 37 patients, 10 had graft loss and chronic graft dysfunction was observed in another 9 patients. The rest of the 17 (48%) patients had a mean SCr of 1.2 mg/dl. The long-term outcome of pediatric renal transplants in our country remains suboptimal. CsA discontinuation due to financial constraints and/or non-compliance remain the most important reasons for this.