Acute Renal Failure in Hospitalized Patients in China: A Prospective Study

Acute renal failure (ARF) is a common complication in hospitalized patients, but little is known about the epidemiology of ARF in China. In this study, we performed a prospective examination of the cause, prognosis, and risk factors associated with ARF at a hospital in Shanghai, China. We considered all ARF patients who were admitted to our hospital from December 2003 to December 2006. Among the 320 ARF patients, 135 (42.2%) were over the age of 60. Sepsis, heart failure, and nephrotoxic drug use were the leading causes of ARF. The overall mortality rate was 31.9%, and mortality rate was significantly higher among the elderly. Logistic regression indicated that heart failure, respiratory failure, and malignant cancer were risk factors independently associated with poor prognosis. In this Shanghai hospital, there was a high incidence and mortality rate of patients hospitalized with ARF. The prognosis of patients who underwent renal replacement therapy was better than those who were treated more conservatively.     

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%.     

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 July1982 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 post‐abortal ARF and a reduction in maternal mortality as well. We noted a significant decrease (p < 0.001) in the incidence of cortical necrosis in PR-ARF. The reasons for this favorable outcome in obstetrical ARF seem to be due to improved medical care, decrease in the number of septic abortions, effective care of obstetrical complications, and legalization of abortion.     

Colchicine Overdose-Induced Acute Renal Failure and Electrolyte Imbalance

Colchicine has been used to control gouty arthritis for long time; colchicine overdose, however, causes multiple organ dysfunction. To date, no investigation has revealed the site of kidney lesion or dysfunction. This investigation describes the case of a male with a history of gout who ingested a large amount of colchicine and developed renal, hematopoietic, gastrointestinal, muscular, electrolytic, and hepatic disorder. Glucosuria was noted during hospital days. Colchicine intoxication is shown to induce proximal tubule damage. Severe electrolytes imbalance was noted, including hypomagnesemia, hypophosphatemia, and hypocalcemia. After management, the renal function and serum electrolyte of the patient recovered on the sixth day of hospitalization.     

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.     

Acute Renal Failure Complicating Severe Acute Pancreatitis

The records of 563 patients admitted to the hospital with diagnosis of acute pancreatitis have been studied retrospectively. The aim of the study was to investigate the prevalence of acute renal failure (ARF) in these patients, and to evaluate the most important risk factors for ARF development and mortality. The prevalence of ARF in studied population was 14%, but only 3.8% of ARF patients with acute pancreatitis had isolated renal failure. Other patients had additional failure of other organ systems, 68.4% of whom had multiorgan failure (MOF) before the onset of ARF. In only 8.9% of ARF patients was the renal system the first organ system to fail. Patients with ARF were significantly older, had more preexisting chronic diseases (including chronic renal failure), usually had MOF, and local pancreatic complications relative to these in the group with normal renal function. The development of ARF was directly influenced by severity of acute pancreatitis. The mortality rate in ARF patients was 74.7%, compared to an 7.4% mortality of patients with acute pancreatitis and normal renal function. Preexisting chronic disease, the presence of MOF and their number, local pancreatic complications, and older age of the patients increased mortality in ARF patients. The prognosis of patients with oliguric ARF requiring renal replacement therapy was extremely poor, indicating the importance of prevention of ARF in the patients with acute pancreatitis.     

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.     

Renal Transplantation for Chronic Renal Failure in Acute Porphyria

A woman with acute intermittent porphyria and a man with variegateporphyria developed chronic renal failure in middle age. Afterperiods on haemodialysis, both received successful cadavericrenal transplants. On the basis of animal porphyrinogenicitystudies prednisolone and azathioprine were used in preferenceto cyclosporin as immunosuppressive agents. Neither of the patientsshowed any evidence of activation of their porphyria during,or following, transplantation. The findings in these two patientsand a review of two previous reports indicate that acute porphyriais not a contraindication to renal transplantation.     

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.     

Fatal Cardiac Tamponade in Malarial Acute Renal Failure

Uremic hemorrhagic pericarditis occurs much less frequently in acute than in chronic renal failure, but when it does, it is a potentially fatal complication. The possibility of hemorrhagic pericarditis and cardiac tamponade should be considered in patients with acute renal failure and acute hemodynamic instability. This study reports a case of falciparum malaria complicated by acute renal failure that developed fatal cardiac tamponade in the recovery phase of acute renal failure.     

Acute renal failure in the elderly: experience from a single centre in India

A total of 139 patients with acute renal failure (ARF) werestudied, of which 41 (29.4%) were elderly with mean age of 67.1years and 98 (70.6%) were younger with mean age of 32.3 years.Surgical causes accounted for 65% of geriatric ARF while medicalcauses were predominant in the younger patients (55.1%). Amongstthe surgical causes, prostate-related problems due to obstructionor following transurethral resection of prostate were seen in20 patients (74%). Drugs and sepsis were the predominant causesof medical ARF in the geriatric patients (85.7%). Of all thecauses of geriatric ARF, which included both medical and surgical,nephrotoxic drugs either alone or in combination with otherpredisposing factors were the cause in 22 (51%) patients. Haemodialysiswas needed in 15 of geriatric (36.6%) and 64 of younger (65.3%)ARF patients. Recovery from ARF, as evidenced by normalizationof serum creatinine, was delayed in the elderly as comparedto the younger patients (32.0 versus 11.4 days, P< 0.001).Mortality, though higher in the elderly as compared to the youngerpatients, was not significantly different (9.75% versus 6.1%).     

Parathyroid Hormone as a Marker for the Differential Diagnosis of Acute and Chronic Renal Failure

It is often difficult to distinguish acute renal failure clinically from chronic renal failure, especially in patients who do not have records of their medical history. We investigated the magnitude of iPTH increase in ARF and the potential role of iPTH as a marker for differential diagnosis of ARF and CRF in new patients referred to our renal unit. We prospectively analyzed 122 (ARF n?=?64, CRF n?=?58) patients referred to our renal unit with serum creatinine higher than 2 mg/dL. ROC curve analysis was performed to investigate role of iPTH for differentiating ARF from CRF. The sensitivity, specificity, and positive predictive value of iPTH in discrimination of ARF and CRF were calculated. There was no statistically significant difference regarding the means of age, sex distribution, and serum chemistry between patients with ARF or CRF. But serum iPTH (p < 0.0001) levels were lower in patients with ARF than in those with CRF. A cutoff, set at 170pg/mL for iPTH to discriminate patients with CRF, yielded a sensitivity of 88% and a specificity of 89%. This study confirms that the iPTH measurement is of clinical value in differentiating acute from chronic renal failure.     

Heparin Allergy Accompanying Acute Renal Failure

A generalized cutaneous hypersensitivity reaction to a porcine heparin preparation was observed in a patient during the course of acute renal failure. Immunological studies, including gel diffusion and immunoelectrophoresis, suggested that the reaction was to a contaminant of the heparin and involved both IgG and IgE antibodies.     

Acute Renal Failure and Hypercalcemia

Hypercalcemia can result from excessive bone resorption, renal calcium retention, excessive intestinal calcium absorption, or a combination of these conditions. Hypercalcemia may also provoke acute renal failure (ARF) or hypertension, or aggravate the tubular necrosis that is frequently found in cases of ARF. The association of ARF and hypercalcemia was studied retrospectively in eight patients based in the data in their charts. Data are expressed as median and percentile (25th; 75th). Our results show that ARF associated with hypercalcemia was related with comorbidity in all cases (cancer, multiple myeloma, hyperparathyroidism, sarcoidosis, vitamin D intoxication, and leprosy). Maximum median serum creatinine levels were 3.3 mg/dL (2.7, 3.8 mg/dL) before treatment and 1.1 mg/dL (0.9, 1.3 mg/dL) after treatment. Maximum total median serum calcium was 15.9 mg/dL (13.5, 19.8 mg/dL) before treatment and 9.1 mg/dL (8.4, 9.7 mg/dL) after treatment. Maximum median ionized serum calcium was 2.1 mmol/L (1.8, 2.2 mmol/L) before treatment and 1.1 mmol/L (1.0, 1.2 mmol/L) after treatment. Different kinds of treatment induced a rapid fall in serum calcium concentration. All patients were treated with hydration and diuretics, and three patients also received calcitonin. Serum creatinine concentration always fell simultaneously with the decrease in serum calcium in all cases. All patients progressed with nonoliguric renal failure. In conclusion, in ARF, patients are frequently hypocalcemic. Usually, the presence of hypercalcemia associated with ARF is indicative of the presence of comorbidity, as observed in all eight patients studied here. There was an improvement of renal function in all cases as serum calcium levels decreased.     

Acute Renal Failure Secondary to Fenofibrate Monotherapy-Induced Rhabdomyolysis

Fenofibrate, a fibric acid derivative, is used to treat diabetic dyslipidemia, hypertriglyceridemia, and combined hyperlipidemia alone or in combination with statins. Rhabdomyolysis is defined as a pathological condition of skeletal muscle cell damage leading to the release of toxic intracellular material into the circulation. Its major causes include trauma, ischemia, toxins, metabolic disorders, infections, and drugs. Rhabdomyolysis associated with fenofibrate is extremely rare. In nearly all of the presented cases, there was a predisposing factor for rhabdomyolysis such as diabetes, older age, renal insufficiency, and hypothyroidism. Here, we report a nondiabetic, nonhypothyroidic young female patient without any known prior renal disease presenting with acute renal failure developing after fenofibrate treatment.     

Acute Renal Failure after Initiation of Tenofovir Disoproxil Fumarate

Despite initial evidence suggesting a relatively benign safety profile, several subsequent case reports have detailed nephrotoxicity in patients using tenofovir disoproxil fumarate for the treatment of HIV. We report a case of rapid renal failure that developed into an HIV-naïve patient initiated on an antiretroviral regimen that included tenofovir.     

Acute Renal Failure Due to Candida tropicalis Obstruction: An Overview

Acute renal failure (ARF) due to infection of urinary tract is reported in the literature. ARF due to Candida tropicalis obstruction is extremely rate. In this article, the author summarized the clinical characteristics of ARF due to Candida tropicalis obstruction.     

Mortality Risk Factors and Validation of Severity Scoring Systems in Critically Ill Patients with Acute Renal Failure

Background. Risk stratification and prediction of outcome in acute renal failure patients in the intensive care unit are important determinants for improvement of patient care and design of clinical trials. Methods. In order to identify mortality risks factors and validate general and specific predictive models for acute renal failure (ARF) patients in the intensive care unit (ICU), 324 patients were prospectively evaluated. Multivariate analysis by logistic regression was utilized for identification of mortality risk factors. Discrimination and calibration were used to evaluate the performance of the following models at referral to nephrologist and at initiation of renal replacement therapy: APACHE II, SAPS II, LODS, and ATN-ISI. Organ failure was assessed by SOFA and OSF. Results. The hospital mortality rate was 85%. The identified mortality risk factors were: age ≥ 65 yr, BUN ≥ 70 mg/dL, ARF of septic origin, and previous hypertension. Serum creatinine ≥ 3.5 mg/dL, systolic blood pressure ≥ 100 mm Hg, and normal consciousness were associated with mortality risk reduction. Performance of all prognostic models was disappointing with unsatisfactory calibration and underestimation of mortality on the day of referral to the nephrologist and at initiation of renal replacement therapy. Conclusions. Cross-validation of prognostic models for ARF resulted in poor performance of all studied scores. Therefore, a specific model is still warranted for the design of clinical trials, comparison of studies, and for prediction of outcome in ARF patients, especially in the ICU.     

双侧上尿路结石并发肾功能不全术后急性肾衰的处理

目的：探讨治疗双侧上尿路结石并发肾功能不全术后急性肾衰的方法。方法：对54例双侧上尿路结石并发肾功能不全术后急性肾功能衰竭（ARF）患者的治疗方法进行回顾性分析,根据不同病情分别行急诊输尿管镜碎石（URL）和输尿管逆行插管或经皮肾造瘘（PCN）后二期碎石。所有病例监测血肌酐（Cr）和尿素氮（BUN）。结果：术后全部患者血Cr和BUN进行性下降,恢复到正常43例,氮质血症6例,尿毒症4例,死亡1例。结论：双侧上尿路结石并发肾功能不全应早期诊断,选择恰当的外科治疗时机和方法,一旦术后出现ARF,要立即明确原因,进行治疗。