Outcome prediction for critically ill children with acute renal failure requiring continuous hemofiltration

Continuous hemofiltration has been used with increasing frequency for treating volume overload and acute renal failure in critically ill, hemodynamically unstable pediatric patients. This retrospective report investigates continuous hemofiltration in pediatric patients, and their survival rate. Sixty children treated between 1999 and 2001 with a diagnosis of acute renal failure and requiring continuous hemofiltration were admitted to this study to determine if pediatric risk of mortality III (PRISM III) scores were an accurate prediction of mortality. PRISM III scores were calculated on the day continuous hemofiltration commenced; mean PRISM III scores of non-survivors were significantly higher than mean scores of survivors. PRISM III scores may be a useful indicator of outcome in children receiving continuous hemofiltration.     

Prognosis in critically ill children requiring continuous renal replacement therapy

We performed an observational prospective study in 53 critically ill children to analyze the prognostic factors of children requiring continuous renal replacement therapy. Pediatric index of mortality (PIM), pediatric risk of mortality score (PRISM), multi-organ failure score, serum lactate levels, blood pressure, vasoactive drugs, renal function and characteristics of renal replacement therapy were analyzed. The mortality was 32.1%, with multi-organ failure being the most frequent cause of death (59%). The children who died presented a significantly lower blood pressure and required more doses of vasoactive drugs, dopamine and epinephrine than did the survivors. The PRISM and PIM scores and the serum lactate levels and the number of organs suffering failure were significantly higher in the patients who died than in the survivors. However, the PRISM and PIM scores underestimated the risk of mortality. The age, sex, urea and creatinine levels, type of pump and volume of ultrafiltrate did not affect the prognosis. The association of a mean BP<55 mmHg and epinephrine dose >0.6 g/kg/min was predictive of mortality in 76% of the patients. We conclude that the prognosis in children requiring renal replacement therapy depends on the severity of the clinical state at the time of starting therapy, principally on the hemodynamic situation.     

先心病术后合并急性肾功能不全的死亡危险因素分析

目的 探讨先天性心脏病术后合并急性肾功能衰竭预测病人的死亡风险临床和实验室指标.方法 2006年6月至2007年1月,1312例先天性心脏病病儿进行心内直视手术,27例术后因急性肾功能衰竭在ICU接受腹膜透析治疗,回顾分析腹膜透析前的临床和实验室资料,以期早期预测死亡风险.结果 27例中死亡13例(48.1%),生存14例.术后18 h心肌肌钙蛋白(cTnI)、腹膜透析前动脉pH值、碱剩余(BE)、乳酸(Lact)、胶体渗透压(COP)、中心动静脉氧饱和度差(△SO2)、正性肌力药物评分(InS)、气道峰压(PIP)等指标,在生存组和死亡组差异有统计学意义.逐步回归分析显示,近期转归(生存或死亡)受cTnI(P=0.01)、pH(P=0.04)、PIP(P=0.02)、COP(P=0.05)等多因素的影响.结论 cTnI、pH、PIP、COP等指标,有助于在腹膜透析早期预测死亡风险.     

Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy

BACKGROUND: Critical illness leading to multi-organ dysfunction syndrome (MODS) and associated acute renal failure (ARF) is less common in children compared to adult patients. As a result, many issues plague the pediatric ARF outcome literature, including a relative lack of prospective study, a lack of modality stratification in subject populations and inconsistent controls for patient illness severity in outcome analysis. METHODS: We now report data from the first multicenter study to assess the outcome of pediatric patients with MODS receiving continuous renal replacement therapy (CRRT). One hundred twenty of 157 Registry patients (63 male/57 female) experienced MODS during their course. RESULTS: One hundred sixteen patients had complete data available for analysis. The most common causes leading to CRRT were sepsis (N= 47; 39.2%) and cardiogenic shock (N= 24; 20%). Overall survival was 51.7%. Pediatric Risk of Mortality (PRISM 2) score, central venous pressure (CVP), and% fluid overload (%FO) at CRRT initiation were significantly lower for survivors versus nonsurvivors. Multivariate analysis controlling for severity of illness using PRISM 2 at CRRT initiation revealed that%FO was still significantly lower for survivors versus nonsurvivors (P < 0.05) even for patients receiving both mechanical ventilation and vasoactive pressors. We speculate that increased fluid administration from PICU admission to CRRT initiation is an independent risk factor for mortality in pediatric patients with MODS receiving CRRT. CONCLUSION: We suggest that after initial resuscitative efforts, an increased emphasis should be placed on early initiation of CRRT and inotropic agent use over fluid administration to maintain acceptable blood pressure.     

Outcomes and APACHE II predictions for critically ill patients with acute renal failure requiring dialysis

BACKGROUND: Despite the widespread availability of dialytic and intensive care unit technology, the probability of early mortality in critically ill patients with acute renal failure (ARF) is still high, and the evaluation of the patients' prognosis has been difficult. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score is a reliable indicator of severity of illness and likelihood of survival in critically ill patients with ARF. We have attempted to determine whether the APACHE II scoring system can be used to predict prognosis. METHODS: A retrospective cohort study evaluated the medical records of 100 consecutive patients in intensive care units with acute renal failure who required dialysis from January 1997 through December 1998. RESULTS: Of the 100 patients studied, 65 were men and 35 were women. The mean age of survivors and nonsurvivors was 59.4 +/- 20.3 years and 58.3 +/- 20.0 years. The overall mortality rate was 71%. There were no significant differences between survivors and nonsurvivors in age, gender, or indication for dialysis. The cause of death in the majority of patients was related to higher APACHE II score during the 24 hours immediately preceding the initiation of acute hemodialysis, and carry mortality rates exceeding 85% with an APACHE II score of 24 or higher. CONCLUSION: We conclude that mortality rate for acute renal failure in intensive care unit patients continues to be high. The use of the APACHE II score determined at the time of initiation of dialysis for patients with ARF is a statistically significant predictor of patient survival. There is a significant trend with APACHE II score for outcome.     

Integration of APACHE II and III scoring systems in extremely high risk patients with acute renal failure treated by dialysis

OBJECTIVE: Acute physiology, age, chronic health evaluation II and III (APACHE II and III) scoring systems obtained on the day of the initiation of dialysis were compared the mortality rate among in critically ill patients with acute renal failure requiring dialysis. DESIGN: Retrospective study. SETTING: Intensive care units in a tertiary care university hospital in Taiwan. PATIENTS: 100 patients diagnosed with acute renal failure and requiring dialysis were admitted to intensive care units from January 1997 through December 1998. INTERVENTIONS: Information deemed necessary to compute the APACHE II and APACHE III score on the day of dialysis initiation was collected. MEASUREMENTS AND RESULTS: The overall hospital mortality rate was 71%. The relationship between APACHE II and APACHE III scores for patients was linear and correlated significantly in all subgroups. Goodness-of-fit was good for APACHE II and APACHE III models. Both reported good areas under receiver operating characteristic curve. Death in most patients was related to a higher APACHE II or APACHE III score during the 24 h immediately preceding the initiation of acute hemodialysis. Our results indicated a significant rise in mortality rates associated with higher APACHE II or III scores among all patients. Although less than 60%, the mortality rates markedly increased extent when APACHE II score of 24 or higher or APACHE III score above 90 had mortality rates exceeding 85%. CONCLUSION: Both predictive models demonstrated a similar degree of overall goodness-of-fit. Although APACHE II showed better calibration, APACHE III was better in terms of discrimination. The prediction accuracy of the APACHE II score for extremely high-risk patients is further enhanced by specific utility of APACHE III scoring as a second prediction model when the AII score is 24 or higher.     

Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery

BACKGROUND: The development of renal dysfunction in the postoperative course of cardiac surgery is still associated with high mortality in pediatric patients. In particular for small infants peritoneal dialysis offers a secure and useful treatment option. The aim of the present study was to investigate if routinely used laboratory and clinical variables could help predict mortality at initiation of peritoneal dialysis. METHODS: We performed a retrospective chart analysis of pediatric intensive care unit patients with renal dysfunction who were treated with peritoneal dialysis after cardiac surgery between 1993 and 2001 and analyzed variables obtained 3 hours or less before starting peritoneal dialysis. RESULTS: Results are documented as means and standard errors. A total of 1141 children underwent a cardiac operation on cardiopulmonary bypass. Sixty-two children (5.4%) were treated with peritoneal dialysis. Mortality was 40.3% (37 survivors, 25 nonsurvivors). The pH in survivors was 7.35 (0.01); in nonsurvivors it was 7.23 (0.03; p = 0.0037). Base excess in survivors was -1.37 mmol/L (0.61); in nonsurvivors it was -7.17 mmol/L (1.49; p = 0.0026). Lactate in survivors was 4.5 mmol/L (0.60); in nonsurvivors it was 10.5 mmol/L (1.78; p = 0.0089). Positive inspiratory pressure in survivors was 24.6 cm H(2)O (0.78); in nonsurvivors it was 28.9 cm H(2)O (1.08; p = 0.0274). Tidal volume per kilogram bodyweight in survivors was 11.0 mL/kg (0.48); in nonsurvivors it was 8.7 mL/kg (0.50; p = 0.0493). CONCLUSIONS: We conclude from our data that the consideration of pH, base excess, lactate, positive inspiratory pressure, and tidal volume per kilogram bodyweight help predict mortality at initiation of peritoneal dialysis. We were able to observe significant differences between survivors and nonsurvivors using these variables.     

Determinants of survival and recovery in acute renal failure patients dialyzed in intensive-care units

The survival rate of critically ill patients who develop acute renal failure is extremely low, in spite of the sophisticated support systems, including dialysis. Therefore, it would be advantageous to identify, early in the disease course, those few survivors. We reviewed the clinical course of 43 consecutive critically ill patients who developed acute renal failure and were first dialyzed in an intensive-care unit setting to define comorbid conditions, present at the time of first dialysis, that were predictive of outcome. Mortality rate was 88%. Adult respiratory distress syndrome (p less than 0.05), requirement for antibiotics (p less than 0.01) and ventilatory failure (p less than 0.01) impacted negatively on recovery of renal function. The most powerful predictor of mortality was the need for ventilatory support (p less than 0.001). The presence of ventilatory failure at the initiation of dialysis predicted a 100% mortality (89-100%; 95% confidence limits). The initiation of dialysis in intensive-care unit patients with acute renal failure requiring ventilatory support did not alter the uniformly fatal outcome.     

Probability of surviving postoperative acute renal failure. Development of a prognostic index.

Sixty-five patients who developed postoperative acute renal failure requiring hemodialysis were retrospectively analyzed to identify variables that could be used to predict outcome. Our aim was to identify patients who would have an unfavorable outcome despite hemodialysis and to identify those factors that might be altered to improve outcome. A linear discriminant function capable of segregating survivors from nonsurvivors in the retrospective analysis was subsequently validated in a prospective fashion using a second patient population. Variables used were age, sex, number of transfusions, interval from onset of acute renal failure to dialysis, type of surgery, preoperative hypotension, and the presence of cardiac failure. Scores were formulated for each patient and then segregated into three groups: patients with no precedence for survival, patients with an intermediate risk of dying, and patients with low risk of dying. Based on the univariant analysis, the interval from onset of acute renal failure to first dialysis and the maximum serum creatinine prior to first dialysis were the only factors that might be altered to change mortality. The prognostic index we have developed enables one to select patients without a chance of survival.     

Extrarenal sequential organ failure assessment score as an outcome predictor of critically ill children on continuous renal replacement therapy

Background

The sequential organ failure assessment (SOFA) score is easy to calculate and has been well validated as an outcome predictor in critically ill adult patients. However, its use in children has been limited, mainly because of differences in basal reference levels of serum creatinine.

Methods

Data include 87 patients requiring continuous renal replacement therapy (CRRT) between January 2005 and July 2011. We modified the SOFA score by excluding the renal component to an extrarenal SOFA score, based on the assumption that CRRT may mitigate the renal effect on outcome and investigated the utility in predicting outcome with comparison with pediatric risk of mortality (PRISM) III, pediatric logistic organ dysfunction (PELOD), and SOFA scores.

Results

Results showed that 95.4 % (n?=?83) had multiple organ dysfunction syndrome with an overall mortality of 50.6 %. The extrarenal SOFA score at CRRT initiation and ≥20 % fluid overload were significantly associated with mortality. In comparison with the predictive power of various scoring systems, the extrarenal SOFA score showed the largest area under the receiver operating characteristic curve (extrarenal SOFA 0.774, SOFA 0.770, PRISM III 0.660, and PELOD 0.650).

Conclusions

The extrarenal SOFA score may be a useful prognostic marker in critically ill children treated with CRRT.     

Outcome and quality of life of patients with acute pancreatitis requiring intensive care

BACKGROUND: Patients with severe acute pancreatitis often require intensive care unit (ICU) admission, have multiple complications, spend weeks to months in the hospital, and consume a large amount of resources. The aim of this study was to evaluate the ICU course, costs, mortality, and quality of life of patients who require ICU admission for acute pancreatitis. METHODS: Patients with acute pancreatitis requiring ICU admission were identified retrospectively. Data regarding in-hospital morbidity, mortality, and hospital costs were obtained. Long-term quality of life was assessed using the Short Form-36 Health Survey (SF-36). RESULTS: Fifty-two patients were identified. There were 31 men and 21 women: the mean age was 53 years (range, 22-89). The most common causes of acute pancreatitis were gallstones (44%) and alcoholism (17%). Pulmonary failure (52% required mechanical ventilation) and renal failure (21% required dialysis) were common. There were 39 (75%) hospital survivors and 13 (25%) nonsurvivors. In the first 24 h, the mean Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 10 +/- 6 in survivors and 16 +/- 4 in the nonsurvivors (<0.01). Mean length of ICU (15 +/- 18 and 28 +/- 31 days) and hospital (40 +/- 34 and 38 +/- 34 days) stays were similar in survivors and nonsurvivors, respectively (NS). The mean hospital cost for survivors was $83,611 +/- 88,434 and that for nonsurvivors was $136,730 +/- 95,045 (P = 0. 09). The estimated cost to obtain one hospital survivor was $129,188. Of the 39 hospital survivors, 5 died later, 21 completed the SF-36, and 13 were lost to follow-up. Long-term quality of life (SF-36) was similar to that of an age-matched population. Twenty of twenty-one felt their general health was at least as good as it had been 1 year previously. CONCLUSIONS: Patients with severe acute pancreatitis need prolonged ICU and hospital stays. APACHE II may be a good predictor of outcome; further, prospective evaluation is needed. Although resource utilization is high, most patients survive and have good long-term quality of life.     

Organ system failures prediction model in intensive care patients with acute renal failure treated with dialysis.

OBJECTIVE: To evaluate the organ system failures hospital mortality predictions in critically ill patients with acute renal failure requiring dialysis. DESIGN: Prospective, cohort study. SETTING: Intensive care units in a tertiary care university hospital in Taiwan. PATIENTS: A total of 112 patients admitted to the intensive care units with acute renal failure who required dialysis from January 1999 through December 1999. INTERVENTIONS: Collection of information necessary to compute the number of failed organs. MEASUREMENTS AND RESULTS: Of the 112 patients studied, 75 were men and 37 were women. The mean age of survivors and non-survivors was 58.59 +/- 19.91 years and 58.76 +/- 19.62 years. The overall mortality rate was 67%. There were no significant differences between survivors and non-survivors in terms of age, gender, or indication for dialysis. The cause of death in the majority of patients was related to organ system failure during the 24 hours immediately preceding the initiation of acute hemodialysis, and carry mortality rates exceeding 83% with the coexistence of four or more failed organs. The area under the organ system failures prediction model receiver operating characteristic curve equaled 0.772 +/- 0.046. CONCLUSION: We conclude that mortality rate for acute renal failure in intensive care unit patients continues to be high. Organ system failures prediction model performed well and simple in its ability to identify patients who die in hospital. Mortality rate increases as number of failed organ increases.     

Does Early Initiation of Continuous Renal Replacement Therapy Affect Outcome: Experience in a Tertiary Care Center

Abstract

Background: Acute kidney injury (AKI) requiring dialysis commonly occurs in critically ill patients and is associated with high mortality. Factors impacting outcomes of individuals with AKI who underwent continuous renal replacement therapy (CRRT), including early versus late initiation and duration of CRRT, were examined. Methods: Survival and recovery of renal function for patients with AKI in the intensive care unit were retrospectively examined over a 7-year period. Factors associated with mortality and renal recovery were analyzed based on severity of illness as defined by Cleveland Clinic Foundation (CCF) score. Univariate and multivariate logistic regression analysis with backward elimination was performed to determine the most significant risk factors. Results: Of patients who underwent CRRT, 230/330 met inclusion criteria. During index admission 112/230 (48.7%) patients died. Median survival was 15.5 days [95% confidence interval (12.0, 18.0)]. Among survivors, renal recovery occurred in 84/118 (71.2%). Renal recovery overall was observed in 90/230 subjects (39.13%). A higher baseline CCF score correlated with higher mortality and lower probability of renal recovery. Patients initiated on CRRT > 6 days after AKI diagnosis had significantly higher mortality compared with those initiated earlier (odds ratio = 11.66, p = 0.0305). Patients receiving CRRT >10 days had a higher mortality rate compared with those with shorter exposure (71.3% vs. 45.5%, respectively, p = 0.012). Conclusions: CRRT remains an important dialysis modality in hemodynamically unstable patients with AKI. Mortality in these patients continues to be high. Renal recovery is high in survivors. Delay in initiation and length of CRRT exposure may portend poorer prognosis.     

Sustained low-efficiency daily dialysis with hemofiltration for acute kidney injury in the presence of sepsis

AIMS: Acute kidney injury (AKI) commonly occurs in critically ill patients with sepsis and is associated with poor outcomes. Unfortunately, the ideal mode of renal replacement therapy remains unknown. Because both higher doses of dialysis and hemofiltration have been associated with improved survival, we postulated that adding hemofiltration to the diffusive clearance achieved by sustained low-efficiency daily dialysis (SLEDD-f) would provide a survival advantage over SLEDD. METHODS: From December 2003 to October 2005, we retrospectively analyzed all patients with multisystem organ failure, vasopressor-dependent hypotension and oliguric acute kidney failure secondary to nonoperative sepsis who were treated with renal replacement therapy (RRT). After exclusionary criteria were applied, 8 patients received SLEDD-f and 13 patients received SLEDD. All treatments were for 8 - 16 h/day. SLEDD-f was continued until vasopressors were reduced to a minimal dose. Outcomes were mortality and recovery of renal function at 30 days after initiation of RRT. APACHE- II scores were calculated at the time of dialysis initiation to predict mortality. RESULTS: Despite higher APACHE II scores, 30-day survival was 100% in the SLEDD-f group and 38% in the SLEDD group. Furthermore, most of the SLEDD-f patients were able to have vasopressors weaned quickly and all patients in the SLEDD-f group recovered significant renal function to allow discontinuation of RRT. CONCLUSIONS: While the optimal treatment remains unknown, this small study raises the possibility that SLEDD-f offers a survival advantage and increases the chance of renal recovery while decreasing the need for vasopressors. A large randomized trial comparing SLEDD-f with other forms of renal replacement therapy is needed.     

Mortality risk in children after renal allograft failure: a NAPRTCS study

Studies have shown that adult dialysis patients with a failed renal allograft face a greater risk of mortality on dialysis compared with transplant-naïve patients. The outcome of children returning to dialysis after allograft failure has not been previously studied. Using the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry, we studied patients aged 2-21 years who initiated dialysis from 1 January 1992 to 31 December 2007. Of a total of 5,006 patients, 1,031 patients had a prior history of allograft failure and 3,975 did not (transplant-naïve). Demographic characteristics, including age at dialysis initiation, race, dialysis modality, primary renal disease, era of dialysis initiation, height Z score, and weight Z score were significantly different between the groups (p?p?=?0.08). After covariate adjustment, allograft failure was not a significant factor contributing to increased mortality risk on dialysis (HR 0.98, CI 0.64–1.50, p?=?0.94) based on Cox regression analysis. Children with failed allografts who return to dialysis are not at greater risk of mortality than their transplant-naïve dialysis counterparts.     

Prognosis of acute renal failure in children

Acute renal failure (ARF) is the acute loss of renal function over a period of hours or days. Given the poor prognosis of ARF among children, there is some urgency to identifying more effective prognostic indicators for detecting disease onset. Such indicators would help provide the means of selecting patients who would benefit the most from early aggressive treatment. In this study we assessed the etiologic and prognostic indicators of ARF, including several risk factors such as sepsis, respiratory distress, age, among others, in 300 children who were admitted to the Ali Asghar Children’s Hospital, Tehran, Iran, from 1990 to 2003. Statistical analysis was performed using multiple regression and chi-square methods, and a score to determine the prognosis of ARF in children was developed. Result: Based on the results of this study the three common causes of ARF are acute tubular necrosis (ATN, 38%), acute glumerulonephritis (24%) and hemolytic uremic syndrome (24.1%). The overall mortality rate among our patients was 24.7%, with the highest risk group being those patients suffering from ischemic ATN. In addition, the correlation (p<0.0005) between the etiology and mortality rate was particularly high in patients with ischemic ATN. Mortality was also high (68%) in children younger than 2 years. Multiple regression models revealed that among those factors that significantly differed between the survivors and nonsurvivors, only the necessity of dialysis (p<0.0005), the use of mechanical ventilation (p=0.05) and disseminated intravascular coagulation (p=0.038) can be regarded as independent determinants of ARF prognosis in children.     

Patients supported by extracorporeal membrane oxygenation and acute dialysis: acute physiology and chronic health evaluation score in predicting hospital mortality

Extracorporeal membrane oxygenation (ECMO) can provide short-term cardiopulmonary support to critically ill patients. Among ECMO patients, acute renal failure requiring dialysis has an ominous prognosis. However, a prognostic scoring system and risk factors adjustment for hospital mortality in these patients have not been elucidated previously. A multicenter observational cohort study was conducted from January 2002 to December 2006. Information obtained included demographics, biochemical variables, Acute Physiology and Chronic Health Evaluation (APACHE) II, III, and IV scores at ICU admission and initial acute dialysis, and hospital mortality in 102 non-coronary artery bypass graft (CABG) patients receiving ECMO support with acute dialysis. This retrospective cohort study included 70 men and 32 women with a mean age of 47.9 ± 15.7 years. Seventy-two patients (70.6%) had hospital mortality. The area under the receiver operating characteristic curve showed APACHE IV (0.653) had a better discriminative power to predict hospital mortality than APACHE II (0.584) and APACHE III (0.634) at initializing dialysis. Hosmer-Lemeshow statistics showed good calibration for all three scores to predict hospital mortality at initializing dialysis (APACHE IV, P = 0.392; APACHE III, P = 0.094; and APACHE II, P = 0.673). Independent predictors for hospital mortality by multivariate logistic regression analysis were higher central venous pressure (odds ratio [OR], 1.11; confidence interval [CI] 95%, 1.02-1.20; P = 0.016), higher APACHE IV score at initializing dialysis (OR, 1.03; CI 95%, 1.01-1.05; P = 0.003), and latency from hospital admission to dialysis (OR, 1.04; CI 95%, 1.00-1.08; P = 0.033). High mortality rate was noted in non-CABG patients receiving ECMO and acute dialysis. Predialysis APACHE IV scores had good calibration and moderate discrimination in predicting hospital mortality in these patients. Because ECMO support could stabilize cardiopulmonary status, APACHE IV scores would likewise underestimate disease severity at lower score ranges in these patients.     

Improved prediction of outcome in patients with severe acute pancreatitis by the APACHE II score at 48 hours after hospital admission compared with the APACHE II score at admission. Acute Physiology and Chronic Health Evaluation

HYPOTHESIS: The 48-hour APACHE (Acute Physiology and Chronic Health Evaluation) II score is a better predictor of pancreatic necrosis, organ failure, and mortality in patients with severe acute pancreatitis than the score at hospital admission. DESIGN: A retrospective analysis of 125 patients with acute pancreatitis. SETTING: A tertiary public teaching hospital. PATIENTS: Patients with severe acute pancreatitis as defined by 3 or more Ranson criteria or a hospital stay of longer than 6 days. MAIN OUTCOME MEASURES: Pancreatic necrosis, organ failure, and mortality. RESULTS: A significant association was found between the 48-hour score and the presence of pancreatic necrosis (P<.001), organ failure (P =.001), and death (P<.001). By contrast, the APACHE II score at admission was significantly associated only with the presence of organ failure (P =.007). Deteriorating APACHE II scores over 48 hours were significantly associated with a fatal outcome (P =.03). The combined APACHE II score (defined as the sum of the admission and 48-hour scores) was significantly higher among nonsurvivors than survivors (P<.001), and was strongly associated with the presence of pancreatic necrosis (P =.001) and organ failure (P<.001). The 48-hour and combined scores accurately predicted outcome in 93% of the patients compared with 75% by the admission score. CONCLUSIONS: The 48-hour APACHE II score has improved predictive value compared with the admission score for identifying patients with severe acute pancreatitis who have a poor outcome. A deteriorating APACHE II score at 48 hours after admission may identify patients at risk for an adverse outcome.     

Early initiation of peritoneal dialysis in neonates and infants with acute kidney injury following cardiac surgery is associated with a significant decrease in mortality

Association between early renal replacement therapy and better survival has been reported in adults with postoperative kidney injury, but not in children undergoing cardiac surgery. We conducted a retrospective cohort study of 146 neonates and infants requiring peritoneal dialysis following cardiac surgery in a tertiary referral hospital. A propensity score was used to limit selection bias due to timing of dialysis, and included baseline and intraoperative characteristics, requirement for postoperative extracorporeal membrane oxygenation, and creatinine clearance variation. Inverse probability of treatment weighting resulted in good balance between groups for all baseline and intraoperative variables. After weighting, 30-day and 90-day mortality were compared between the 109 patients placed on dialysis early, within the first day of surgery, and those with delayed dialysis, commencing on the second day of surgery or later, using logistic regression and survival analysis. Mortality was 28.1% at 30 days, and was 36.3% during follow-up. Early dialysis was associated with a 46.7% decrease in the 30-day and a 43.5% decrease in the 90-day mortality rate when compared with delayed dialysis. All other short-term outcome variables were similar. Thus, initiation of peritoneal dialysis on the day of or the first day following surgery was associated with a significant decrease in mortality in neonates and infants with acute kidney injury.     

Metabolic disturbances following the use of inadequate solutions for hemofiltration in acute renal failure

Continuous renal replacement therapy (CRRT) has become an important supportive therapy for critically ill children with acute renal failure. In Turkey, commercially available diafiltration and replacement fluids cannot be found on the market. Instead, peritoneal dialysis fluids for dialysis and normal saline as replacement fluid are used. The first objective of this study was to examine metabolic complications due to CRRT treatments. The second objective was to determine demographic characteristics and outcomes of patients who receive CRRT. We did a retrospective chart review of all pediatric patients treated with CRRT between February and December 2004. Thirteen patients received CRRT; seven survived (53.8%). All patients were treated with continuous venovenous hemodiafiltration. Median patient age was 71.8 ± 78.8 (1.5–180) months. Hyperglycemia occurred in 76.9% (n = 10), and metabolic acidosis occurred in 53.8% (n = 7) of patients. Median age was younger (48.8 vs.106.2 months), median urea level (106.2 vs. 71 mg/dl) and percent fluid overload (FO) (17.2% vs. 7.6%, respectively) were higher, and CRRT initiation time was longer (8.6 vs 5.6 days) in nonsurvivors vs. survivors for all patients, although these were not statistically significant. CRRT was stopped in all survivors, and four nonsurvivors (67%) were on renal replacement therapy at the time of death. Hyperglycemia and metabolic acidosis were frequently seen in CRRT patients when commercially available diafiltration fluids were not available. Using peritoneal dialysis fluid as dialysate is not a preferable solution. Early initiation of CRRT offered survival benefits to critically ill pediatric patients. Mortality was associated with the primary disease diagnosis.