Acute renal failure in the elderly

The prevalence of acute renal failure (ARF) in the elderly is much greater than in the general population. Important structural and functional changes are present in the aging kidneys and predispose the elderly patient to multiple types of acute renal disease. Prerenal failure, hemodynamically-mediated acute tubular necrosis, nephrotoxic ARF, ARF of vascular origin and obstructive ARF are of special importance in the geriatric population. In the present review we analyze some aspects of interest for the nephrologist and urologist regarding diagnosis and management of these severe but often reversible diseases. Elderly patients with ARF appear to have a moderately worse prognosis than younger patients, but age should not be used as a discriminant factor in therapeutic decisions concerning ARF. Instead, early clinical features such as hypotension, assisted respiration or coma are decidedly related to mortality in ARF patients of any age. Although elderly patients who survive after an ARF episode appear to need more time for total recovery and exhibit a lower level of renal function than younger survivors, long-term prognosis is quite good.     

Acute renal failure in the elderly: A demographic and clinical study of patients in Eastern India

A total of 638 patients with acute renal failure (ARF) of diverse etiology were studied over a period of 9 years (July 1985–Dec. 1994) of which 96 (15%) patients were classified as elderly ARF with mean age of 72.5 years. Medical causes accounted for 80% of geriatric ARF while 20% patients, had ARF of surgical origin. Decreased renal perfusion resulting from gastroenetritis was the predominant (52.8%) cause of ARF in the medical group. Nephrotoxic ARF and ARF due to F. malaria were seen in 10 and 7 patients respectively. Obstructive uropathy was observed in 12 patients in surgical group and in remaining 8 patients ARF developed following various surgical procedures. ARF in association with multiorgan failure was not observed in our study. Mortality was seen in 24 patients (25%). The causes of mortality were GI bleed (6), peripheral circulatory failure (5), hyperkalemia (4) and sepsis (4). Thus medical ARF remains the major cause of acute renal failure in elderly patients in our study in contrast to ARF associated with multiorgan failure and surgery in developed countries.     

老年住院患者急性肾衰竭的临床分析

目的探讨65岁及以上老年人急性肾衰竭(ARF)的特点、病因、预后及其相关因素。方法收集我院1995年1月至2005年12月11年间诊断的老年ARF共150例,统计分析老年人ARF的特点、病因、预后及其相关影响因素。结果老年人ARF占同期全部ARF患者总数33%,老年人医院内获得性ARF(HA-ARF)的发生率为54%,明显高于社区获得性ARF(CA-ARF,P<0.05)。老年ARF的发生有逐年增高的趋势。老年ARF以肾前性ARF为主,多因素综合病因分析显示:与感染(56%)相关为首位病因,其次与低血容量(30.7%)、肿瘤(26%)、心功能衰竭(25.3%)、肾毒性药物(22%)、手术(14%)、肾脏疾病(14.7%)及肾后性疾病(8.7%)相关。单因素病因分析显示与低血容量相关为首位病因(21.6%)。老年ARF多由多种病因共同导致,其死亡率高达53.3%,HA-ARF死亡率是CA-ARF死亡率的1.87倍。结论老年人易患ARF。HA-ARF的增多是主要原因。感染、低血容量、肿瘤、心功能衰竭、肾毒性药物及手术是老年人ARF的常见原因。加强原发病的整体治疗,尽早发现并治疗ARF,有助于改善预后。     

Early management and prevention of Acute Renal Failure

Despite major advances in nutritional support, membrane technology and dialytic techniques, the mortality of patients with acute renal failure (ARF) who require dialysis is still almost 50% (1). Increased patient age and co‐morbidity confer a poorer prognosis, and the condition is certainly commoner in this patient group. Hence, one study showed that the age‐related annual incidence of ARF increased from 17 per million in adults under 50 years to 949 per million in the 80–89 age group (2). Over 60% of cases of ARF ultimately result from renal hypoperfusion and consequent intra‐renal ischaemic damage, which leads to acute tubular necrosis (ATN) (3). Ischaemic ARF may thus result from a diversity of systemic and intra‐renal circulatory stresses including acute losses of blood and extra‐cellular fluids, from low cardiac output states such as following ischaemic or toxic myocardial damage, and even from drug‐induced renal perfusion shutdown (ACE inhibitors, non‐steroidal anti‐inflammatory agents). Many cases of ARF have a multi‐factorial aetiology (e.g. post‐surgical sepsis with hypovolaemia, hypotension and injudicious antibiotic use), and these patients, who often have other organ failure, fit into the poorer prognostic category. A large number of patients with ischaemic ARF pass through a phase of potentially reversible pre‐renal oliguria; early recognition and prompt, appropriate treatment of these pre‐renal factors can prevent progression to established ARF, with the genuine prospect of improved patient morbidity and mortality, and this is the main scope of this article. Early diagnosis in other patients with ARF, such as those with acute inflammatory renal disease (e.g. vasculitis) or urinary tract obstruction, will allow appropriate prompt treatment and the possibility for reversal of the ARF. The following account, which is composed of personal experience, that of colleagues, and the literature (1,4), is not intended to provide a comprehensive guide to the management of ARF, but seeks to highlight important common pitfalls and fundamental principles in the recognition and subsequent preventive treatment of these patients.     

老年人急性肾功能衰竭的临床特点

目的：探讨老年急性肾功能衰竭（ARF）的临床特点,方法：将151例ARF病人分为老年组（47例）和对照组（104例）,并比较两组病人的临床资料、治疗方法和预后。结果老年组引起ARF最常邮病因是感染,明显高于对照组（P＜0．01）,而肾实质性疾病引起的ARF明显低于对照组（P＜0．01）。多脏器功能衰竭的发生率、病死率均明显高于对照组（P＜0．01）。治疗开始前血清肌酐水平明显低于对照组（P＜0．01）。接受透析治疗病例数明显低于对照组P＜0．01）。结论老年ARF的原发疾病及临床经过有其特殊性。加强透析治疗,尤其早期预防透析是治疗成功的关键,预后与年龄、原发病能否控制及透析时机的选择有关。     

老年内科危重症患者急性肾衰竭的临床分析

目的 了解老年内科危重症患者发生急性肾衰竭(ARF)的致病因素及转归.方法 对我院内科近10年老年(≥60岁)ARF患者的临床资料进行回顾分析,将老年患者分为院外获得性ARF(院外ARF)组和院内获得性ARF(院内ARF)组,并与同期内科非老年ARF患者进行比较.结果 (1)老年内科ARF患者381例,院外获得性ARF为218例(57.2%),医院获得性ARF为163例(42.8%),其中来自内科重症监护室153例(93.9%);(2)与院外ARF组比较,院内ARF组患者年龄较高.慢性基础疾病较多,伴发感染和/或心力衰竭的比率和病死率较高,ARF的程度较重;(3)院内ARF组的致病因素以感染及心力衰竭或心肌缺血为主;(4)院内ARF组死亡147例,死亡组伴慢性基础疾病、合并严重感染及心力衰竭、伴发老年多器官功能障碍综合征(MODS)者均多于存活组,危霞症程度(APACHEⅡ评分)更高,肾衰竭程度更重;(5)与非老年组比较,老年组院内ARF构成比、伴发MODS、APACHEⅡ评分及病死率均显著增高. 结论 老年危重症患者更易发生ARF,医院获得性ARF的主要诱因为感染,心力衰竭或严重心肌缺血,病死率较高.     

Acute renal failure in the elderly treated by one-time peritoneal dialysis

To determine the factors affecting outcome of acute renal failure (ARF) in the elderly, we retrospectively studied 44 patients over the age of 65 who had undergone acute peritoneal dialysis. Thirteen patients (29%) survived 2 months or longer after dialysis treatment ("survivors"). Thirty-one patients (71%) died within this period ("nonsurvivors"). The main factor distinguishing survivors was the frequency of sepsis (none of 13 survivors vs 17 of 31 nonsurvivors). Preexisting malignancy and total number of acute insults to renal function were significantly less frequent, and immediate clinical and biochemical outcome of dialysis significantly better in survivors. The overall complication rate of dialysis was high (31 of 44 patients), but was significantly lower in survivors. Acute peritoneal dialysis is a useful procedure in the management of ARF in the elderly. However, we suggest that elderly patients in whom sepsis is a contributory factor to the development of ARF do not benefit from peritoneal dialysis therapy.     

Cardiovascular Risk Factors and Incident Acute Renal Failure in Older Adults: The Cardiovascular Health Study

Background and objectives: Although the elderly are at increased risk for acute renal failure, few prospective studies have identified risk factors for acute renal failure in the elderly.Design, setting, participants, & measurements: The associations of cardiovascular disease risk factors, subclinical cardiovascular disease, and clinical coronary heart disease with the risk for development of acute renal failure were examined in older adults in the Cardiovascular Health Study, a prospective cohort study of community-dwelling older adults. Incident hospitalized cases of acute renal failure were identified through hospital discharge International Classification of Diseases, Ninth Revision codes and confirmed through physician diagnoses of acute renal failure in discharge summaries.Results: Acute renal failure developed in 225 (3.9%) of the 5731 patients during a median follow-up period of 10.2 yr. In multivariate analyses, diabetes, current smoking, hypertension, C-reactive protein, and fibrinogen were associated with acute renal failure. Prevalent coronary heart disease was associated with incident acute renal failure, and among patients without prevalent coronary heart disease, subclinical vascular disease measures were also associated with acute renal failure: Low ankle-arm index (≤0.9), common carotid intima-media thickness, and internal carotid intima-media thickness.Conclusions: In this large, population-based, prospective cohort study, cardiovascular risk factors and both subclinical and clinical vascular disease were associated with incident acute renal failure in the elderly.Acute renal failure (ARF) occurs most commonly in older adults and is associated with significant morbidity and mortality, with death rates among hospitalized patients ranging from 25 to >70% (1–4). Despite the prevalence of ARF in elderly adults, few studies have examined potential risk factors (5–7), and no studies have examined risk factors in the elderly. The limited data from small studies suggest that cardiovascular disease (CVD) risk factors, such as hypertension, diabetes, and inflammatory markers, and clinical CVD may be associated not only with chronic kidney disease (CKD) but also ARF. These associations may be particularly important in the elderly, in whom CVD is prevalent. We hypothesized that CVD risk factors and subclinical and clinical disease would be associated prospectively with the risk for development of ARF in older adults. To address these hypotheses, we evaluated the associations of these characteristics with incident ARF in the Cardiovascular Health Study (CHS), a large cohort study of older adults. If our hypotheses are correct, then prospective identification of risk factors for ARF in the elderly may suggest potential subgroups of this high-risk population that may merit additional attention or intervention.     

The influence of age and respiratory failure on the outcome of complicated acute renal failure

Acute Renal Failure (ARF) is common in the Intensive Care Unit with elderly patients providing an increasing proportion of cases. We have reviewed 106 cases of ARF requiring renal replacement therapy between 1 January 1989 and 31 December 1991 to investigate the significance of age as a determinant of survival. The overall mortality of the group was 64%. No significant difference was found between the mean age of survivors (51±21 years, n=38) and the 68 patients who died (58±18 years). Twenty eight of the 106 patients were aged 70 years or older and 16 (57%) of these died. However, the mortality of all patients with ARF requiring mechanical ventilation survival was 72% compared to 26% in patients not requiring ventilation, p<0.01. Similarly, 78% (n=14) of the patients aged 70 years or older requiring renal replacement and ventilation died. We conclude that whereas age is not a useful determinant of survival from ARF, co-incident respiratory failure significantly reduces survival. These findings may have important implications for the provision of intensive care to the elderly.     

Acute renal failure: a study of elderly patients

Two hundred and forty-six patients over the age of 65 years treated for acute renal failure (ARF) between 1960 and 1987 are reviewed. Although the fatality has apparently not changed over the duration of the study, it is possible to identify groups with a relatively good prognosis with renal replacement therapy. This particularly applies to patients with an underlying medical illness or with urological problems (excluding neoplasia). ARF following surgery with perioperative sepsis continues to carry a poor prognosis. We would recommend early referral of elderly patients with acute renal failure to a specialist unit, as a substantial proportion of survivors will regain normal renal function and quality of life.     

Changing patterns and outcome of acute renal failure requiring hemodialysis

To identify factors that may explain the persistently high mortality of acute renal failure (ARF), we compared the cause, clinical course, and outcome of 55 consecutive patients with ARF who underwent hemodialysis (HD) from 1962 to 1969 with 46 similar patients from 1979 to 1981 at the same medical center. We noted an overall increase in mortality from 54.5% to 71.7%. There was an increase in the number of elderly patients developing ARF, but age per se did not influence survival. There was a significant increase in mortality in younger patients resulting from the severity of their underlying illness. We saw an increase in the number of complicating factors occurring at the onset of ARF that correlated with the increase in mortality. In survivors ARF was more prolonged in our most recent experience. The development of prolonged, complicated ARF and the poor survival seen in younger patients led to the increase in mortality in our patients.     

Renal Biopsy Findings in Acute Renal Failure in the Cohort of Patients in the Spanish Registry of Glomerulonephritis

Background and objectives: Renal biopsy in acute renal failure of unknown origin provides irreplaceable information for diagnosis, treatment, and prognosis. This study analyzed the frequency and clinicopathologic correlations of renal native biopsied acute renal failure in Spain during the period 1994 through 2006.Design, setting, participants, & measurements: Acute renal failure was defined as a rapid deterioration of glomerular filtration rate, with or without oligoanuria or rapidly progressive renal insufficiency, including acute-on-chronic renal failure. Patients who were younger than 15 yr were considered children, those between 15 and 65 yr adults, and those >65 elderly.Results: Between 1994 and 2006, data on 14,190 native renal biopsies were collected from 112 renal units in Spain. Of these, 16.1% (2281 biopsies) were diagnosed with acute renal failure. The prevalence of the main clinical syndromes was different in the three age groups: Biopsy-confirmed acute renal failure in children was 5.7%, in adults was 12.5%, and in elderly increased significantly to 32.9%. The prevalence of biopsy-confirmed acute renal failure according to cause was as follows: Vasculitis, 23.3%; acute tubulointerstitial nephritis, 11.3%; and crescentic glomerulonephritis types 1 and 2, 10.1%. The prevalence of the different causes differed significantly according to age group.Conclusions: The Spanish Registry of Glomerulonephritis provides useful information about renal histopathology in biopsy-confirmed acute renal failure. The prevalence of vasculitis and crescentic glomerulonephritis is high, especially in elderly patients. These data obtained from a national large registry highlight the value of renal biopsy in undetermined acute renal failure.The study of the epidemiology of biopsy-confirmed renal disease provides useful information about the prevalence of renal disease and its clinical manifestations. Although there are several renal biopsy registries around the world, most describe the distribution of histopathologic findings, and very few analyze in detail the main clinical pictures that indicate renal biopsy, yet knowledge of the epidemiology of renal syndromes is of paramount importance in clinical nephrology.The Spanish Registry of Glomerulonephritis has recorded individual patient data for all renal biopsies performed since 1994 (1,2). This information enables us to study the epidemiology of renal syndromes and histopathologic data. Renal biopsy in acute renal failure (ARF) of unknown origin provides irreplaceable information for diagnosis, treatment, and prognosis. In this report, we analyze the frequency and clinicopathologic correlations of renal native biopsied ARF in Spain during the period 1994 through 2006.     

Common places on clinical management of acute renal failure

Acute renal failure (ARF) is an abrupt decline of renal function, and acute tubular necrosis (ATN) is its more frequent expression. Recent contributions in physiopathological knowledge, specially in post-ischemic ARF, are scarcelly reflected in therapy. Morbidity and mortality due to ARF are very high, mainly in critically ill patients. Prevention and treatment of ATN are based in avoiding nephrotoxicity and renal ischemia. An adequate evaluation of renal risk factors in hospitalized patients is important. Maintaining euvolemia, effective cardiac output and adequate renal perfussion pressure are three paramount factors in ischemia prevention. The best dialytic schedule is not universally accepted. ARF replacement therapy must be flexible, tailoring techniques (IHD, SLED, CRRT) to the clinical situation of patients. There is not a consensus in dialysis dose in ARF. Nevertheless, despite a robust scientific evidence is lacking, some data suggest that a delivered minimum dose of sKtV >1 in IHD or >35 ml/kg/h in CRRT would be beneficial for patient survival.     

Acute renal failure following hypokalemic rhabdomyolysis due to chronic glycyrrhizic acid administration.

A 72-year-old man developed acute renal failure (ARF) following severe hypokalemic rhabdomyolysis. The hypokalemia was due to chronic glycyrrhizin (glycyrrhizic acid) administration. Although glycyrrhizin-induced hypokalemic rhabdomyolysis has been occasionally reported, the association of this type of rhabdomyolysis with ARF has not been described. In the present case, there was a sensitivity to glycyrrhizin the preceding renal insufficiency, and dehydration which was thought to have contributed to ARF. It should be recognized that elderly patients with such predisposing factors may be susceptible to a rapid deterioration of renal function after glycyrrhizin-induced hypokalemic rhabdomyolysis.     

10 Comparison of Four Prognostic Indexes in Severe Acute Renal Failure

Background Several prognostic indexes and models are in use for acute renal failure (ARF) patients in intensive care units (ICU). Some were designed on general ICU populations (like APACHE II) and some were made specifically for ICU patients with ARF. The purpose of our prospective clinical study was to compare APACHE II and three ARF‐specific prognostic indexes in their ability to discriminate survivors and non‐survivors among critically ill ARF patients requiring dialysis. Methods Forty‐four critically ill patients with ARF requiring dialysis were included. Patients with chronic renal insufficiency (creatinine > 200 µmol/L), transplanted kidney or urinary tract obstruction were excluded. Four prognostic indexes were measured at the time of first dialysis: APACHE II score (0–71), Cleveland Clinic Foundation (CCF) score (0–20), predicted mortality by Mehta and by Liano model. Primary end‐points were ICU survival and recovery of renal function. Results Patients were 65 ± 5 years old, 75% were male, 50% recovered renal function (22/44). Mean APACHE II score was 21.9 ± 6.5, CCF score was 9.2 ± 2.5, predicted mortality by Mehta model was 64 ± 5% and by Liano model 47 ± 20%. Patients that recovered renal function and those that died in ARF did not differ significantly in any of the prognostic indexes measured. Intensive Care Unit survival data was available for 32 patients, this group was not significantly different in prognostic indexes from the group for which ICU survival data was not available. Intensive Care Unit mortality was 75% (24/32). There was significant difference in APACHE II value in ICU survivors and non‐survivors (16.6 ± 6.1 vs. 23.4 ± 6.5, P = 0.015), but no difference in the other three indexes. Conclusions Only the APACHE II values measured at first dialysis were significantly different between ICU survivors and non‐survivors, whereas other three prognostic indexes were not.     

心血管疾患伴发急性肾功能衰竭及多脏器功能衰竭的救治及预后

目的 回顾性分析心血管疾病伴发急性肾功能衰竭及多脏器功能衰竭的病因、治疗及预后。方法14例患者主要因急性心肌梗死、心肺复苏后、心脏手术后、冠状动脉造影后发生急性肾功能衰竭或多脏器功能衰竭,进行肾脏替代疗法。结果 14例患者5例存活,9例死亡,病死率64.3％;其中7例伴糖尿病者,6例死亡;急性心肌梗死后7例患者4例死亡,心脏手术后4例患者3例死亡;死亡主要与器官衰竭数目相关。结论心血管疾病伴发急性肾功能衰竭及多脏器功能衰竭经肾脏替代疗法及血流动力学监测,有助于体液平衡,稳定心血管系统,是安全有效的治疗方法。     

Renal biopsy in patients 65 years of age or older. An analysis of the results of 334 biopsies

We studied the clinical and pathological data for 334 patients age 65 or more who underwent renal biopsy for acute renal failure (ARF, n = 55), subacute renal failure (SRF, n = 72), chronic renal failure (CRF, n = 57), proteinuria (n = 137), and hematuria (n = 13). Tissue diagnoses were glomerulopathy (n = 252, 75.4%), acute tubular lesions (n = 18), interstitial nephritis (n = 23), vascular diseases (n = 36, including 14 with cholesterol emboli), and five miscellaneous diagnoses. Of the 55 patients with ARF, 23 had a glomerular lesion, 15 had acute tubular necrosis, and 8 had acute interstitial nephritis. Of 72 patients with SRF, 49 had a glomerulopathy, 12 had a vascular disorder, and six had acute interstitial nephritis. Hence, patients with ARF or SRF exhibited a high potential for reversible lesions. Only 11.3% of patients with CRF had potentially reversible causes. The most common causes of proteinuria were membranous glomerulopathy (34.3%), minimal change disease (14.6%), focal segmental sclerosis (11.7%), and amyloidosis (8.8%). Of the 25 patients with advanced nephrosclerosis, 24 had renal failure, 20 were hypertensive, and 13 had cholesterol emboli. Of 33 patients with diabetes mellitus, 66.7% were found to have lesions not related to diabetes. We conclude that renal biopsy is most useful in older patients with ARF or SRF because of potentially reversible renal disease. Old age alone is not a contraindication to performing a renal biopsy.     

老年人急性胰腺炎122例临床分析

目的 探讨老年人急性胰腺炎的临床特点、诊治措施及影响预后的因素。方法 回顾性分析老年人急性胰腺炎（老年组）的临床资料122例，并与同期非老年患者（非老年组）120例作比较。结果 老年组的诱因主要为胆结石症（81例，66．3％），主要临床表现为腹痛、发热，其中2例因腹痛症状轻微，血淀粉酶升高不明显而漏诊，尸检证实为急性胰腺坏死。其中重症胰腺炎45例，老年组31例，非老年组14例，老年组重症胰腺炎突出表现为呼吸功能不全22例（70．9％），休克7例（22．5％），肾功能不全5例（16．1％）。并存症，老年组36例，非老年组10例，两组比较差异有统计学意义（P〈0．01），主要为心、脑、肺疾病及糖尿病。老年组死亡6例，病死率为4．9％，死因主要为休克；非老年组无死亡。结论 老年人急性胰腺炎具有临床表现不典型、病情重、并存症多的特点，积极内科综合治疗，能改善患者预后。     

连续性肾脏替代疗法在重症急性肾功能衰竭治疗中的应用

目的 回顾分析连续性肾脏替代疗法（ＣＲＲＴ）在重症急性肾功能衰竭（ＡＲＦ）治疗中的应用和影响预后的因素。方法 １９８６年５月至１９９９年１月用ＣＲＲＴ治疗重症ＡＲＦ患者１０１例,回顾性分析了患者临床特点、ＣＲＲＴ方法和预后。结果 １０１例患者中６０例（５９．４％）度过疾病的急性期（存活组）,４１例（４０．６％）在急性期死亡（死亡组）,对两组患者的临床统计学资料、肾功能衰竭的特点、疾病严重程度（ＡＰ     

老年肾病综合征并发急性肾功能衰竭21例临床分析

目的　深入探讨老年肾病综合征 (NS)并发急性肾功能衰竭 (ARF)的临床、病理及预后。　 方法　对 2 1例老年及 3 8例非老年NS并发ARF患者的病因、临床特征、病理特点以及预后等进行回顾性分析。　 结果　老年组NS并发ARF发病率为 2 4 7% ;非老年组为 7 3 %。老年组与非老年组比较有以下特点 :(1)老年NS并发ARF发病率高 ,男性多见 (71 4% ) ,病死率高 ,治愈率低 ;(2 )蛋白尿程度极重、血浆蛋白极低 ;(3 )病理以膜性肾病、局灶节段性肾小球硬化多见 ;(4 )病因以原发性肾小球疾病、糖尿病肾病为主。　 结论 　老年NS并发ARF发病率高 ,病理以膜性肾病、局灶节段性肾小球硬化为主 ,蛋白尿及低蛋白血症严重 ,预后差。