Long-term renal function and survival of renal transplant recipients admitted to the intensive care unit

Arulkumaran N, West S, Chan K, Templeton M, Taube D, Brett SJ. Long‐term renal function and survival of renal transplant recipients admitted to the intensive care unit.
Clin Transplant 2012: 26: E24–E31.
© 2011 John Wiley & Sons A/S. Abstract: Introduction: We determined the long‐term mortality and renal allograft function of renal transplant recipients admitted to the intensive care unit (ICU). Methods: A single institution retrospective observational cohort study of all renal transplant patients admitted to the ICU was performed. Serum creatinine was recorded up to one yr after hospital discharge and survival data were collected for three yr. Results: Chest sepsis was the commonest reason for ICU admission. ICU and hospital mortality were 32% and 19% respectively. Predictors of hospital mortality included the presence of sepsis and duration of mechanical ventilation (MV). Of the patients who were discharged from ICU, three‐yr mortality was 50%. Renal function at one yr was worse than that at hospital discharge and at baseline, though not statistically significant. Death‐censored allograft loss was 11% over the three‐yr follow up period. Conclusions: Sepsis and requirement for MV are independent predictors of mortality in renal transplant recipients admitted to ICU. Renal transplant recipients with chest sepsis may warrant earlier ICU admission. Any loss of renal allograft function during an episode of critical illness appears to have a lasting effect, and longterm patient and allograft survival is poor.     

Outcome of thirty patients with ANCA-associated renal vasculitis admitted to the intensive care unit

The natural course of as-yet-untreated ANCA-associated vasculitis (AAV) or complications of immunosuppressive treatment may result in rapid clinical deterioration with the need of admission to an intensive care unit (ICU). The aim of this retrospective study was to assess the outcome of patients with renal AAV admitted to the ICU in a single center. We reviewed the medical records of all 218 patients with AAV followed in our department between January 2001 and December 2006 and selected those admitted to the ICU. To assess the severity of critical illness, the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) score on the first ICU day were calculated. Birmingham Vasculitis Activity Score (BVAS) was calculated to represent the total disease activity. Thirty patients with AAV (11 women, 19 men; mean age 61.5 +/- 13.2 years; 20 x cANCA, 10 x pANCA positive) were included. The most common reasons for ICU admission were as follows: active vasculitis (13 patients, 43.3 %), infections (7 patients, 23.3%), and other causes (10 patients, 33.3%). The in-ICU mortality was 33.3% (10 patients). The most common cause of death was septic shock (in 5 patients). The APACHE II (33.5 vs. 23.8) and SOFA scores (11.9 vs. 6.6), but not BVAS (11.5 vs. 16.1), were statistically significantly higher in non-survivors than in survivors (p < 0.01). In conclusion, the in-ICU mortality in AAV patients may be predicted by APACHE II and SOFA scores. While active vasculitis is the most frequent reason for ICU admission, the mortality rate is highest in patients with infectious complications.     

Acute renal failure needing dialysis in the intensive care unit and prognostic scores

BACKGROUND: Generic prognostic scores used in acute renal failure (ARF) give imprecise results; disease-specific indices applied to distinct populations or intensive care practices becomes inaccurate. The current study evaluates the adequacy of prognostic scores, in patients with severe ARF needing dialysis. METHODS: Known generic (APACHE II) and disease-specific (ATN-ISS) indices were applied to a cohort (n = 280) with ARF needing dialysis, under intensive care. Possible risk factors as causal factors, organ dysfunctions and clinical variables were examined, and a local index assembled by multivariate logistic regression analysis. Area under the receiver operating characteristics (ROC) curves evaluated the indices discriminating capacity. Goodness-of-fit testing and linear regression analysis appraised calibration. Validation was accomplished by the bootstrapping technique. The end-point was hospital mortality. RESULTS: Overall mortality was 85%. Female gender < 44 years (OR: 0.29; 95% CI: 0.10-0.84), liver/obstructive biliary disease (OR: 6.03; 95% CI: 1.65-22.08), being conscious (OR: 0.49; 95% CI: 0.21-1.14), use of vasoactive drug (OR: 3.13; 95% CI: 1.25-7.83), respiratory dysfunction (OR: 5.20; 95% CI: 1.25-7.83) or sepsis (OR: 2.62; 95% CI: 1.14-6.02) were associated with outcome. Areas under the ROC curve of 0.815, 0.652 and 0.814; Goodness-of-fit test P = 0.593, P < 0.001 and P = 0.002; and linear regression R2 = 0.973, R2 = 0.526 and R2 = 0.919 for the local index, APACHE II and ATN-ISS, respectively, indicate better performance by the local index. The local index median area under the ROC curve, by bootstrapping, was 0.820 (95% CI: 0.741-0.907). CONCLUSIONS: APACHE II score was inaccurate, and ATN-ISS poorly calibrated. When mortality or intensive care practices significantly deviate, local scores may better evaluate prognosis in severe ARF.     

Respiratory problems in renal transplant recipients admitted to intensive care during long-term follow-up

Cardiovascular disease, malignancies, and infectious complications are major causes of morbidity and mortality of renal transplant recipients. Mortality rates vary between 16% and 40% in an intensive care unit (ICU). The aims of this study were to identify the types incidences of respiratory problems that affected renal transplant recipients admitted to the ICU during long-term follow-up thereby determining the impact of respiratory problems on mortality. We reviewed the data for 34 recipients who had 39 ICU admissions from January 2000 through December 2003. Twenty-four admissions (61.5%) had at least one respiratory problem at admission or developed at least one during the ICU stay. The most frequent problem was pneumonia (n=18, 46.2% of the 39 readmissions), followed by acute respiratory failure (n=10, 25.6%), atelectasis (n=9, 23.1%), pleural effusion (n=8, 20.5%), and pulmonary edema (n=2, 5.1%). The patients who had respiratory problems showed a significantly higher mortality rate than those who did not have respiratory problems (66.6% versus 26.6%, respectively; P<.05). The overall mortality rate was 58.8% (20 patients). Thus, infectious and respiratory problems are the most frequent indications for admission and the most common problems during an ICU stay. The prognosis for patients who either have a respiratory problem upon admission to the ICU or develop one during the ICU stay is poor.     

Acute renal failure in an intensive care unit in India--prognostic factors and outcome

We prospectively analyzed 70 consecutive patients who developed acute renal failure (ARF) in the intensive care unit (ICU) during a six year period to define prognostic factors and outcome. Age, sex, preexisting chronic diseases, systemic infections, number of organs failing during the disease course, need and mode of renal replacement therapy (RRT), and length of stay in ICU were recorded. Analysis of factors in survivors (n=7, Gp A) and nonsurvivors (n=63, Gp B) was done by univariate and multivariate analysis. The mean age of patients was 28.6 years. Forty nine (70%) patients developed ARF following surgery, whereas 21 (30%) developed ARF in a medical setting. Cardiovascular surgery (39) and pancreatic surgery (7) were important causes in the surgical group, whereas in the medical group acute pancreatitis (11) was the main causative factor. One patient had ARF only, while in the rest, other organs were also involved. In more than 80% of these patients, organ failure and sepsis were present before the onset of ARF. Fifty two (74.3%) patients required dialytic support. The overall mortality was 90%. Number of organs failing, (1.5 +/-9 in Gp A vs 3.6 +/- 8 in Gp B), presence of systemic infection (1 in Gp A vs 55 in Gp B), prolonged stay in ICU (3.7 +/- 1.1 days in Gp A vs 8.0 +/- 5.4 in Gp B) and need for RRT (2 in Gp A vs 50 in Gp B) correlated with the mortality. Using multiple logistic regression analysis, only multiple organ failure (3 or more) correlated with the mortality. We conclude that multiple organ failure is a poor prognostic factor in patients with ARF in the setting of the ICU.     

Acute kidney injury in preterm infants admitted to a neonatal intensive care unit

Background

The factors that contribute to the development of acute kidney injury (AKI) and treatment outcome among prematurely born neonates are not clearly understood.

Methods

This retrospective study included 150 prematurely born neonates. AKI was defined as an increase of serum creatinine levels ≥0.3 mg/dl compared to basal values.

Results

The majority of neonates with AKI (94.8 %) had a body weight <1,500 g. Logistic regression analysis showed that the Apgar score in the 5th minute <5, serum lactate levels >5 on the first day of life, core body temperature <36?ºC on the first day of life, occurrence of sepsis, intracranial hemorrhage, necrotizing enterocolitis, patent ductus arteriosus, as well as a treatment with vancomycin or dopamine were independent risk factors for the development of AKI. After the groups of neonates with and without AKI were adjusted, the calculated risk ratio for a negative outcome of treatment (death) was 2.215 (CI 1.27–3.86) for neonates with AKI. Neonates with AKI had higher serum sodium levels in the third and fourth days of life.

Conclusions

AKI is associated with high mortality in preterm neonates. It is very important to identify, as quickly as possible, all infants who are at high risk of developing AKI.     

Anemia and blood transfusion in trauma patients admitted to the intensive care unit

BACKGROUND: Anemia is a common occurrence in the intensive care unit (ICU). Although resuscitation, including the use of blood, is a mainstay of early treatment of trauma victims, the safety and efficacy of red blood cell (RBC) transfusion has come under scrutiny recently. The issue of blood use in critically injured patients requires evaluation. METHODS: This was a post hoc analysis of a subset of trauma patients (> or =18 years in age) from a prospective, multicenter, observational, cohort study in the United States. Patients were enrolled within 48 hours after ICU admission and followed for up to 30 days, or until hospital discharge or death. RESULTS: Five hundred seventy-six patients from 111 ICUs in 100 hospitals were enrolled between August 2000 and April 2001. At baseline, mean age was 44.1 +/- 20.2 years, 73.6% were men, and mean APACHE II score was 16.9 +/- 8.2. Mean baseline hemoglobin was 11.1 +/- 2.4 g/dL and patients remained anemic throughout the study either with or without transfusion; 55.4% of patients were transfused (mean, 5.8 +/- 5.5 units) during the ICU stay and 43.8% of patients had an ICU length of stay > or = 7 days. Mean pretransfusion hemoglobin was 8.9 +/- 1.8 g/dL. Mean age of RBCs transfused was 20.1 +/- 11.4 days. As compared with the full study population, patients in the trauma subset were more likely to be transfused and received an average of 1 additional unit of blood. CONCLUSION: Anemia is common in critically injured trauma patients and persists throughout the duration of critical illness. These patients receive a large number of RBC transfusions during their ICU course with aged blood.     

Prevalence of dysphosphoremia in patients admitted in intensive care unit with an impaired renal function

OBJECTIVE: To assess the frequency of dysphosphoremia in patients admitted in intensive care unit with an impaired renal function and to determine the associated risks factors. Study design. - Epidemiological prospective study. PATIENTS AND METHODS: The creatinine clearance and the phosphoremia were measured in 134 consecutive patients admitted in intensive care unit over a six-month period. Patients with chronic renal failure were excluded. Known risk factors for hypophosphoremia in intensive care unit were recorded. RESULTS: Seventy-nine out of one hundred thirty-four patients (59%) had an impaired renal function (arbitrarily defined by a creatinine clearance < 60 ml/min). The proportion of patients with impaired renal function that where hypo-, normo- (0.8 to 1.2 mmol/l) or hyperphosphoremic was 16, 34 and 50% respectively. Hypophosphoremia was severe (< 0.5 mmol/l) in 5 patients, all with impaired renal function. No risk factors usually associated with hypophosphoremia could be identified. CONCLUSION: As opposed to chronic renal failure patients who are mainly hyperphosphoremic, patients admitted in intensive care unit with an impaired renal function may present with a normo-, or hypophosphoremia. These dysphosphoremias are sometimes severe. Phosphate status should be promptly determined at admission.     

Rhabdomyolysis and acute renal failure in intensive care unit

Rhabdomyolysis is common clinical and laboratory syndrome resulting from skeletal muscle injury and acute renal failure is the most important complication. Acute renal failure is common in critically ill medical patients. The aim of our study was to determine the prevalence of rhabdomyolysis induced acute renal failure in these patients and to established the prognosis of critically ill patients with acute renal failure and rhabdomyolysis. In the study were included 1557 patients treated in our medical intensive care unit. Seventy-three patients had criteria for acute renal failure. Twelve of them (16.4%) had rhabdomyolysis, eight were women and four were men (average age was 71 years). Sixty-one patients (83.6%) had acute renal failure without rhabdomyolysis, 33 were women and 28 were men (average age was 69 years). We found no difference in age and sex between patients with acute renal failure with or without rhabdomyolysis. Ten patients (83.3%) with rhabdomyolysis and 39 patients (63.9%) without rhabdomyolysis had multiorgan failure syndrome. In patients with rhabdomyolysis, the number of failing organs were statistically significantly higher (p < 0.027). Nine patients (75%) with rhabdomyolysis and 27 patients (44.3%) without rhabdomyolysis died. Mortality was statistically significantly higher (p < 0.05) in patients with rhabdomyolysis. Rhabdomyolysis with acute renal failure was frequently observed in patients treated in our medical intensive care unit. Multiorgan failure syndrome was common in these patients and mortality was higher compared to patients without rhabdomyolysis.     

Management of acute renal failure in the intensive care unit

Acute renal failure is common in the critically ill and, when necessary, is managed with renal replacement therapy. This article focuses on the use of extracorporeal renal support including modality, indications, dosing, anticoagulation, type of replacement fluid and drug dosing.     

Acute renal failure in an intensive care unit: incidence, prediction and outcome

A review of the case notes of 475 patients with no history of renal disorder admitted to an intensive care unit, showed that 23% (109) developed acute renal failure. This complication occurred more commonly in patients with major burns (75%), and following surgery to the abdominal aorta (38%), but less commonly after self-poisoning episodes (5%).
Scores were provided from stepwise multiple regression analysis which were derived from the diagnostic group, the presence of sepsis, the presence of systolic hypotension and age, and correctly predicted development of acute renal failure in 79% of the cases studied. Attempted prophylaxis appears to have little effect on the incidence of acute renal failure whilst dialysis reduced the mortality from 95% to 72%. Use of the scoring system to allow earlier diagnosis and treatment of acute renal failure could reduce the present mortality by 43%.     

Acute renal failure during eclampsia: incidence risks factors and outcome in intensive care unit

OBJECTIVE: To assess the incidence, risk factors and the outcome of acute renal failure (ARF) associated with eclampsia in intensive care unit (ICU). DESIGN: Prospective and analytic study. SETTING: A surgical ICU in a university hospital. PATIENTS: 178 consecutive women with eclampsia admitted to an intensive care unit during seven years. ARF was defined by a serum creatinine concentration >140 micromol/L. RESULTS: The incidence of ARF was 25.8%. In univariate analysis the severity of patient illness, the complications associated with eclampsia (disseminated intravascular coagulation, Hellp syndrome, neurologic complications, abruptio placenta, aspiration pneumonia, delivery hemorrhage) were significantly associated with ARF. In a logistic regression model, risk factors for ARF included organ system failure (OSF) odds ratio (OR)=1.81 confidence interval (CI) [1.08-3.05], bilirubin >12 micromol/L OR=4.42 CI [1.54-12.68], uric acid >5.9 g/dL OR=16.5 CI [3.09-87.94], abruptio placenta OR=0.2 7 CI [0.08-0.99], and oliguria OR=0.10 CI [0.03-0.44]. In contrast, severity of blood pressure or proteinuria on dipstick were not associated with ARF. However, in this series, 15 women required dialysis in the short term and one required long-term dialysis. ARF associated with eclampsia was significantly associated with mortality (32.6% versus 9.1% p=0.0001). CONCLUSION: ARF with eclampsia is a frequent situation that required intensive management when risks factors were present. The need for dialysis was a rare condition.     

Improved outcomes of patients with cystic fibrosis admitted to the intensive care unit.

BACKGROUND: Invasive mechanical ventilation (IMV) has been previously associated with a poor outcome for patients with cystic fibrosis (CF), but with improved survival and the availability of lung transplantation intensive care unit (ICU) admission is being increasingly considered. This study aimed to review the outcomes of adult CF patients admitted to ICU, and to identify factors that may have influenced outcomes. METHODS: A retrospective audit was conducted of CF patients admitted to ICU. Anthropometric data, spirometry, nutritional status, sputum microbiology, arterial blood gas tensions, and mode of ventilation used were recorded. Immediate and 1-year survival and lung transplantation utilisation were recorded. RESULTS: Twenty patients were admitted to ICU and nine (45%) survived to hospital discharge. Five of the nine survivors had potentially reversible conditions. Four patients admitted with respiratory exacerbations alone who survived, were maintained on non-invasive ventilation (NIV). The relative risk of deaths for patients with a BMI < 18 and a FEV1 < 24% predicted were 3.25 (1.27-3.25), and 3.68 (1.11-16.33), respectively. CONCLUSIONS: The outcome of patients with CF admitted to ICU has improved, with 45% of the patients in this study surviving to hospital discharge. Five of these survivors underwent successful lung transplantation. Long-term use of NIV post discharge may have contributed to this favourable outcome. A BMI < 18 and FEV1 < 24% predicted were associated with a significantly higher relative risk of death.     

ICU患者压疮危险因素的Meta分析

目的系统分析重症监护室(ICU)患者压疮发生的危险因素。方法计算机检索中国知网(CNKI)、中国生物医学文献数据库(CBM)、万方数据库、维普中文生物医学期刊、Pub Med,Web of Science,Springer,Cochrane Library数据库,并对文献进行筛选,运用Stata/SE 12.0软件对符合纳入标准的文献进行Meta分析。结果 12篇文献符合纳入标准,发生压疮患者1 217例,未发生压疮患者5 538例,共纳入压疮危险因素17个,其中高龄、吸烟、发热、平均动脉压低、水肿、糖尿病史、入住ICU时间延长、镇静、糖皮质激素、血管活性药物、血管加压素、机械通气、机械通气时间延长、白蛋白和血红蛋白水平低15个是ICU住院患者压疮发生的危险因素。对各危险因素发表偏倚进行分析,结果显示发表偏倚不明显。结论 ICU患者发生压疮的危险因素较多,需采取针对性措施预防ICU患者压疮的发生。