Acute renal failure in Central Anatolia.

BACKGROUND: The aetiological spectrum of acute renal failure (ARF) has changed in developed countries. It was the purpose of the study to evaluate whether similar changes have occurred in this part of the world as well. METHODS: In a prospective study a total of 439 patients with ARF were evaluated. They had been admitted to one hospital during two successive periods, i.e. 1983-1990 and 1991-1997. RESULTS: Of 439 patients with ARF, 116 were admitted in 1983-1990 (first period) and 323 in 1991-1997 (second period). The age of presentation increased from 49.8+/-6.2 years in the first period to 58.8+/-16.4 years in the second. Medical causes were present in 259 cases (59%), surgical causes in 110 cases (25%), and obstetric causes in 70 cases (16%). The frequency of surgical cases decreased from 28.4% in the first period to 23.8% in the second period. The respective figures for obstetric cases were 18.9% and 14.8%. Mortality did not change with time (33.6% in the first and 31.0% in the second period); the overall mortality was 31.7%. The mortality was higher for surgical (45.5%) than for obstetric (27.8%) and medical ARF (24.3%). CONCLUSION: In the mid-1970s, the most common causes of ARF in Turkey were obstetric complications and septic abortion. The aetiological spectrum of ARF has changed and today medical causes predominate. ARF resulting from septic abortion has become rare, possibly because of liberalization of abortion in 1983 in Turkey.     

Assessment of acute renal failure patients treated in our nephrology clinic between 1996 and 2002

Acute renal failure (ARF) is a cause of high morbidity and mortality associated with long hospital stay, and expensive treatment. The initial approach to patients with ARF should be focused on preventing future injury to the kidney. Two hundred eighty-three ARF patients, treated from January 1996 to June 2002, were retrospectively investigated for their etiology, clinic features, and laboratory characteristics, as well as treatment results and mortality rate. The mean age was 52.3 +/- 18.7 years. Patients with hospital-acquired ARF comprised 38.8% of the sample. Renal causes (60%) were responsible for most ARF patients. They were medical (63.95%), surgical (23.67%), and obstetric (12.4%) causes. Twenty-five percent of patients with ARF had multiple etiologies. Hemolysis elevated liver enzymes low platelets (HELLP) syndrome was seen in the most of the obstetric-related ARF cases. Signs of hypervolemia were present in approximately 50% of the cases. Oliguric patients comprised 59.7% of the sample, and the mean time to oliguria was 5.2 +/- 4.1 days. The necessity of dialysis was greater in oliguric patients (42.6%) and the ratio of complete/partial improvement (82.2%) was greater among non-oligoanuric patients. However, there was no significant difference between mortality rates. Irreversible renal insufficiency did not develop in the non-oliguric cases. Also, 7.4% of ARF patients died, with the main causes being infection (31.8%) and cardiovascular events (27.2%). Medical problems are important in the etiology of ARF as well as obstetric cases. The mortality rate was low in our cases, a situation that may be explained by medical causes being of importance in the etiology. We are of the opinion that early referral of patients to a nephrologist and following treatment in the nephrology clinic may positively affect the outcome.     

Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes

BACKGROUND: Acute renal failure (ARF) is associated with a persistent high mortality in critically ill patients in intensive care units (ICUs). Most studies to date have focused on patients with established, intrinsic ARF or relatively severe ARF due to multiple factors. None have examined outcomes of dialysis-dependent chronic renal failure [end-stage renal disease (ESRD)] patients in the ICU. We examined the incidence and outcomes of ARF in the ICU using a standard definition and compared these to outcomes of ICU patients with either ESRD or no renal failure. We sought to determine the impact of renal dysfunction and/or loss of organ function on outcome. METHODS: We prospectively scored 1530 admissions to eight ICUs over a 10-month period for illness severity at ICU admission using the Acute Physiological and Chronic Health Evaluation (APACHE III) evaluation tool. Patients were defined as having ARF based on the definition of Hou et al (Am J Med 74:243-248,1983) designed to detect significant measurable declines in renal function based on serum creatinine. ESRD patients were identified as being chronically dialysis-dependent prior to ICU admission and the remainder had no renal failure. Clinical characteristics at ICU admission and ICU and hospital outcomes were compared between the three groups. RESULTS: We identified 254 cases of ARF, 57 cases of ESRD and 1219 cases of no renal failure for an incidence of ARF of 17%. Roughly half the ARF patients had ARF at ICU admission and the remainder developed ARF during their ICU stay. Only 11% of ARF patients required dialysis support. ARF patients had significantly higher acute illness severity scores than those with no renal failure, whereas patients with ESRD had intermediate severity scores. ICU mortality was 23% for patients with ARF, 11% for those with ESRD, and 5% for those with no renal failure. There was no difference in outcome between patients who had ARF at ICU admission and those who developed ARF in the ICU. Patients with ARF severe enough to require dialysis had a mortality of 57%. APACHE III predicted outcome very well in patients with no renal failure and patients with ARF at the time of scoring but underpredicted mortality in those who developed ARF after ICU admission and overestimated mortality in patients with ESRD. CONCLUSIONS: ARF is common in ICU patients and has a persistent negative impact on outcomes, although the majority of ARF is not severe enough to require dialysis support. The mortality of patients with ARF from all causes is almost exactly similar to that noted using the same criteria two decades ago. More profound ARF requiring dialysis continues to have an even greater mortality. Nevertheless, acute declines in renal function are associated with a mortality that is not well explained simply by loss of organ function. The majority of ARF patients who did not require dialysis still had a considerably higher mortality than the ESRD patients, all of whom required dialysis; while ARF patients who did require dialysis had a much higher morality than ESRD patients. APACHE III performs well and captures the mortality of patients with ARF at the time of scoring. Development of ARF after scoring has a profound effect on standardized mortality. We were unable to identify a unique mortality associated with ARF, but the presence of measurable renal insufficiency continues to be a sensitive marker for poor outcome.     

Hemodialysis in the Treatment of Acute Renal Failure in Tropical Africa: A 20-Year Review at the Korle Bu Teaching Hospital,Accra

From 1972 to 1992, 170 patients with acute renal failure (87 M, 83 F; mean age 32.51 ± SE 0.945) underwent hemodialysis at the renal unit of the Korle Bu Teaching Hospital, Accra. Vascular access was established initially by arteriovenous shunt (133 cases), femoral venous cannulation (10 cases), and subclavian vein cannulation (27 cases). The overall mortality for acute renal failure (ARF) was 31.8% (54/170). The mortality for obstetric cases was 43.7% (14/32); for surgical cases, 33.3% (6/18); medical cases, 28.3% (13/32); and gynecologic (posthysterectomy) cases, 28.3% (2/7). The most important causes of death in ARF were pulmonary edema (42%), sepsis (20%), and cardiac tamponade (10.4%). Hemodialysis is now established as a form of treatment for ARF and a overall survival rate of 68.2% justifies the development of our program. With improvement of economies of developing countries and health insurance schemes, this form of treatment should be available in all developing countries.     

Acute renal failure in patients with pre-existing renal dysfunction following coronary artery bypass grafting

BACKGROUND: Pre-existing renal dysfunction predisposes to acute renal failure (ARF) in patients undergoing coronary artery bypass grafting. We assessed the incidence and impact of the development of ARF in this patient population in our unit. METHODS: One-hundred and six patients had a preoperative serum creatinine of >or=0.13 mmol/L and underwent coronary artery bypass grafting in the year 2000. The incidence of ARF (as defined by a >or=50% rise in postoperative serum creatinine), hospitalization days, dialysis requirement, in-hospital and 1-year mortality, and potential risk factors for ARF were recorded. RESULTS: Of the patients recorded, 43/104 (41.35%) developed ARF following coronary artery bypass grafting. Patients with ARF stayed in hospital longer (P < 0.02). Ten out of forty-three patients required some form of dialysis and the in-hospital mortality of the renal failure group was 23% compared to 3.1% in the other group (P < 0.002). One year postoperatively, the group with renal failure had significantly worse survival (71.8% vs 98%P < 0.0001). CONCLUSION: For patients undergoing coronary artery bypass grafting, pre-existing renal dysfunction predisposes to the development of ARF, this is associated with prolonged hospitalization and increased mortality.     

Acute renal failure in the neonatal period

Acute renal failure (ARF) is a common problem in the neonatal intensive care unit (NICU). In most cases, ARF is associated with a primary condition such as sepsis, metabolic diseases, perinatal asphyxia and/or prematurity. This retrospective study investigated the course of illness, therapeutic interventions, early prognosis and risk factors associated with development of ARF in the neonatal period. A total of 1311 neonates were treated in our NICU during the 42-month study period, and 45 of these babies had ARF. This condition was defined as serum creatinine level above 1.5 mg/dL despite normal maternal renal function. The data collected for each ARF case were contributing condition, cause and clinical course of ARF, gestational age and birth weight, age at the time of diagnosis, treatment, presence of perinatal risk factors and need for mechanical ventilation. The frequency of ARF in the NICU during the study period was 3.4%. Premature newborns constituted 31.1% of the cases. The mean birth weight in the group was 2863 +/- 1082 g, and the mean age at diagnosis was 6.2 +/- 7.4 days. The causes of ARF were categorized as prerenal in 29 patients (64.4%), renal in 14 patients (31.1%) and postrenal in 2 patients (4.4%). Forty-seven percent of the cases were nonoliguric ARF. Asphyxia was the most common condition that contributed to ARF (40.0%), followed by sepsis/metabolic disease (22.2%) and feeding problems (17.8%). Therapeutic interventions were supportive in 77.8% of the cases, and dialysis was required in the other 22.2%. The mortality rate in the 45 ARF cases was 24.4%. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were associated with significantly increased mortality (p<0.05). There were no statistical correlations between mortality rate and perinatal risk factors, oliguria, prematurity or blood urea nitrogen and creatinine levels. The study showed that, at our institution, ARF in the neonatal period is frequently associated with preventable conditions, specifically asphyxia, sepsis and feeding problems. Supportive therapy is effective in most cases of neonatal ARF. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were identified as indicators of poor prognosis in these infants. Early recognition of risk factors and rapid effective treatment of contributing conditions will reduce mortality in neonatal ARF.     

Acute Renal Failure in the Neonatal Period

Acute renal failure (ARF) is a common problem in the neonatal intensive care unit (NICU). In most cases, ARF is associated with a primary condition such as sepsis, metabolic diseases, perinatal asphyxia and/or prematurity. This retrospective study investigated the course of illness, therapeutic interventions, early prognosis and risk factors associated with development of ARF in the neonatal period. A total of 1311 neonates were treated in our NICU during the 42‐month study period, and 45 of these babies had ARF. This condition was defined as serum creatinine level above 1.5 mg/dL despite normal maternal renal function. The data collected for each ARF case were contributing condition, cause and clinical course of ARF, gestational age and birth weight, age at the time of diagnosis, treatment, presence of perinatal risk factors and need for mechanical ventilation. The frequency of ARF in the NICU during the study period was 3.4%. Premature newborns constituted 31.1% of the cases. The mean birth weight in the group was 2863 ± 1082 g, and the mean age at diagnosis was 6.2 ± 7.4 days. The causes of ARF were categorized as prerenal in 29 patients (64.4%), renal in 14 patients (31.1%) and postrenal in 2 patients (4.4%). Forty‐seven percent of the cases were nonoliguric ARF. Asphyxia was the most common condition that contributed to ARF (40.0%), followed by sepsis/metabolic disease (22.2%) and feeding problems (17.8%). Therapeutic interventions were supportive in 77.8% of the cases, and dialysis was required in the other 22.2%. The mortality rate in the 45 ARF cases was 24.4%. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were associated with significantly increased mortality (p < 0.05). There were no statistical correlations between mortality rate and perinatal risk factors, oliguria, prematurity or blood urea nitrogen and creatinine levels. The study showed that, at our institution, ARF in the neonatal period is frequently associated with preventable conditions, specifically asphyxia, sepsis and feeding problems. Supportive therapy is effective in most cases of neonatal ARF. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were identified as indicators of poor prognosis in these infants. Early recognition of risk factors and rapid effective treatment of contributing conditions will reduce mortality in neonatal ARF.     

Early prognostic factors in patients with acute renal failure requiring dialysis

PURPOSE: Despite improvements in renal therapy and technology, the mortality rate of patients with acute renal failure (ARF) remains high. Because ARF is a heterogeneous syndrome, occurring in patients with diverse etiologies and comorbid conditions, predicting its outcome is difficult. This study aims to identify early clinical and laboratory prognostic factors, including acute-phase reactants such as C-reactive protein (CRP), fibrinogen, and albumin, in ARF patients requiring dialysis. MATERIAL AND METHODS: From June 2002 to March 2004, 61 patients with ARF requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively analyzed. For each patient, the worst values of prognostic variables 24 hr before starting dialysis were prospectively assessed. RESULTS: Oliguria, low plasma fibrinogen levels, hypotension, cardiac disease, and neoplastic disease were statistically significant in predicting hospital mortality. Using Youden's index, the best cut-off value for plasma fibrinogen in predicting mortality was 300 mg/dL with a sensitivity and specificity of 61% and 96%, respectively. Serum CRP and serum albumin were not predictive of hospital mortality. CONCLUSION: Early prognostic factors in predicting mortality for patients with ARF requiring dialysis identified by multivariate logistic regression were oliguria, low plasma fibrinogen, hypotension, cardiac disease, and neoplastic disease. Serum CRP and albumin were not predictive of hospital mortality, whereas a plasma fibrinogen level < or =300 mg/dL had 61% sensitivity and 96% specificity in predicting mortality.     

Renal failure in Yemen

Renal failure remains a serious cause of mortality in Yemen. Our region has 1.25 million population and our hospital is the central hospital, which has a nephrology department and performs dialysis for the region. Between January 1998 and December 2002, we admitted 547 patients; including children, with acute renal failure (ARF) and chronic renal failure (CRF). CRF was observed in 400 patients, an incidence of 64 per million per year and a prevalence of 320 per million. ARF occurred in 147 persons with an incidence of 23.5 per million per year and a prevalence of 117.5 patients per million. Of all patients, 72% were adults (age range, 20-60 years) with a male preponderance. As a tropical country, malaria (27.9%), diarrhea (13.6%), and other infectious diseases were the main causes. Next most common were obstructive diseases causing CRF and ARF (26.8% and 12.9%, respectively), mainly urolithiasis, Schistosomiasis, and prostatic enlargement. However the cause of CRF in 57.5% of patients was unknown as most persons presented late with end-stage disease (64.7%), requiring immediate intervention. Other causes, such as hepatorenal syndrome, snake bite, diabetes mellitus, and hypertension, showed low occurrence rates. Patients presented to the hospital mostly in severe uremia and without a clear history of prior medications. The major findings were vomiting, acidosis, and hypertension with serum creatinine values ranging between 2.8-45 mg/dL (mean value, 13.4 mg/dL). Anemia was observed in 80.4% of CRF versus 62.6% of ARF patients. Hypertension prevalence was 65.5% among CRF patients, of whom 25% were in hypertensive crisis, whereas among ARF the prevalence was only 26.5%.     

Influence of renal dysfunction on mortality after cardiac surgery: modifying effect of preoperative renal function

BACKGROUND: Acute renal failure (ARF) requiring dialysis is an independent risk factor of mortality after cardiac surgery; the level of preoperative renal function influences the risk of both postoperative ARF and mortality. The relationship between mild renal dysfunction and mortality, and the modifying effect of baseline renal function on this association, is less clear. METHODS: We studied 31,677 patients undergoing cardiac surgery between 1993 and 2002. We used a logistic regression model to assess the relationship between postoperative renal dysfunction and mortality, while adjusting for preoperative renal function, postoperative ARF requiring dialysis, and other risk factors. RESULTS: The overall postoperative mortality rate was 2.2% (698/31,677). For the entire cohort, a clinically relevant increase in the adjusted risk of mortality occurred beyond 30% decline in postoperative GFR. The mortality rate was 5.9% (N, 292/4986) among patients who developed 30% or greater decline in postoperative GFR not requiring dialysis versus 0.4% (N, 106/26,136) among those with <30% decline (P < 0.001). A significant interaction between preoperative GFR and percent change in postoperative GFR (P < 0.001) indicated that at equivalent degrees of renal dysfunction, the mortality risk was greater at a lower preoperative GFR. ARF requiring dialysis was strongly associated with mortality in the model (odds ratio 4.2; 95% CI 3.1-5.7). CONCLUSION: Renal dysfunction not requiring dialysis is an independent risk factor of mortality after cardiac surgery. A better preoperative GFR attenuates the effect of postoperative renal dysfunction on mortality; this interaction needs to be considered while defining a clinically relevant threshold of ARF.     

Acute posttraumatic renal failure: a multicenter perspective.

Acute renal failure (ARF) following trauma is rare. Historically, ARF has been associated with a high mortality rate. To investigate this entity we conducted a retrospective review of 72,757 admissions treated at nine regional trauma centers over a 5-year period. Seventy-eight patients (0.098%) developed acute renal failure requiring hemodialysis. Detailed demographic, clinical, and outcome data were collected. Patients with pre-existing medical conditions (group I) had a 70% increase in mortality over those without pre-existing conditions (p less than 0.004). Twenty-four patients (31%) developed ARF less than 6 days after injury (group II). The remainder (group III) developed late renal failure (mean time to first dialysis, 23 days). The predominant cause of death was multiple organ failure (82%). There were no differences in mortality because of multiple organ failure among the three groups of patients. Of the 33 survivors, six (18%) were discharged with renal insufficiency, three (9%) were discharged on dialysis, 23 (70%) were discharged home or to rehabilitation, and 27 (82%) had no significant evidence of renal insufficiency. Conclusion: Posttraumatic renal failure requiring hemodialysis is rare (incidence, 107 per 100,000 trauma center admissions), but the mortality rate remains high (57%). Two thirds of the cases of posttraumatic renal failure develop late and are secondary to multiple organ failure; one third of the cases of posttraumatic renal failure develop early and may result from inadequate resuscitation.     

Causes and prognosis of nontraumatic acute renal failure requiring dialysis in adult patients with and without diabetes

Despite advanced techniques of renal replacement therapy the overall mortality of patients with ARF is still high. The majority of patients with ARF requiring dialysis are those with nontraumatic ARF. In a retrospective study we compared the causes of nontraumatic ARF, the risk factors for the development of renal failure and the mortality rates in patients with and without diabetes mellitus who received dialysis therapy in the years 1991-2000. A total of 232 patients were included in the study, 34 (14.6%) of them with and 198 patients (85.4%) without diabetes. The predominant causes of nontraumatic ARF like congestive heart failure (26.4 vs. 13.6, p < 0.05) and hypotension/hypovolemia (20.6 vs. 7.6%, p < 0.05) occurred more frequently in diabetic patients. The prevalence of sepsis (8.8 vs. 10.1%, NS), malignancy/ hypercalcemia (5.8 vs. 11.6%, NS) and other causes of nontraumatic ARF were similar in both groups. The prevalence of hepato-renal syndrome (5.8 vs. 13.6%, p < 0.05) and acute kidney graft failure (2.9 vs. 15.1%, p < 0.05) was higher in the nondiabetic individuals. Patients with diabetes showed more often chronic predictors for the onset of ARF like pre-existing hypertension (93.6 vs. 51.0%, p < 0.05), congestive heart failure (44.1 vs. 14.6%, p < 0.005), pre-existing renal insufficiency (76.4 vs. 46.9%, p < 0.05) and ACE-inhibitor therapy (32.3 vs. 9.6%, p < 0.005). Additionally, the prevalence of multiple organ failure (MOF) as prognostic factor was significantly higher in the diabetic patients (47.0 vs. 21.7%, p < 0.05). The mean number of dialyses therapy was 4.7 vs. 4.5 per patient. The overall mortality was 41.1 vs. 44.% (NS). In conclusion, the prevalence of the most common causes of nontraumatic ARF was different between the patients with and without diabetes. The diabetic individuals had more frequently predictors for the onset of ARF. The overall mortality was approximately the same in both groups.     

Prognostic Indexes and Mortality in Critically 111 Patients with Acute Renal Failure Treated with Different Dialytic Techniques

The objective of this study was to compare the evolution of patients with acute renal failure (ARF) treated conservatively or with different dialytic techniques in an intensive care unit (ICU). From June 1992 to November 1994, 1087 consecutive patients were admitted in our ICU. Two hundred and twenty of these presented with ARF, and were divided into three groups: group I (control group): 156 patients with ARF who did not receive substitutive techniques; group II: 21 patients under intermittent hemodialysis (IHD) or peritoneal dialysis (PD); group III: 43 patients under continuous hemodiafiltration (CHDF). The studied variables were age, etiology of renal failure, requirement of dialysis, type of dialysis, length of ICU and hospital stay, and renal function outcome. APACHE II and SAPS scores were recorded on admission and analyzed for hospital mortality. Chi-square test and the analysis of variance were used for the statistical analysis. Results are presented as mean ± SD. A p value below 0.05 was considered statistically significant. Although etiology of ARF was multifactorial, we found a high frequency of ARF due to sepsis (56.8%), hypoperfusion (58.7%), and acute tubular necrosis (62.5%). Sepsis and heart failure were clinical conditions associated to a greater mortality. We did not find any statistical difference between the two dialyzed groups for all the studied variables, nor between the three groups regarding APACHE II and hospital stay. Significant differences were found between dialyzed and non-dialyzedpatients respect to age, group I: 64.1 ± 13.6, group II: 56.4 ± 19.7, and group III: 56.0 ± 14.1 fp < 0.001), creatinine peak serum levels, group I: 260 ± 130, group II: 494 ± 209, and group III: 441 ± 170 μmol/L (p < 0.0001), and mortality, group 1:46.9%, group II: 66.7%, and group III: 76.2% (p < 0.002). SAPS score showed differences between the control group and the CHDF group 13.9 ± 4.8 and 16.4 ± 5.4 (p < 0.007), respectively. The use of dialytic techniques in critically ill ARF patients is associated with greater mortality. Prognostic indexes on admission did not correctly classify our patients with ARF. Continuous hemodiafiltration does not involve greater mortality or length of stay as compared to conventional dialysis.     

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 children. Study of 35 patients

The medical care of children with acute renal failure and the necessity of the substituting the renal functions has dramatically modified over the past 15 years. The study has been conducted retrospectively on 35 children diagnosed with acute renal failure (ARF), for analyzing the etiological spectrum, the evolutionary patterns and the influence factors of the ARF evolution. The following parameters have been taken into consideration: ARF etiology, hTA/HTA, oliguria, level of serum creatinine, the type of treatment (renal substitution by hemodialysis, peritoneal dialysis, or conservative treatment). The ARF etiology is dominated by the sepsis (31.4%) and by the hemolytic and uremic syndrome (17.1%). The treatment applied was conservative in 48.5% of the cases; 51.50% of the patients were in critical state and required extrarenal substitution by hemodialysis--42.8%--and peritoneal dialysis--8.5%. Global mortality is reduced (22.8%), but in the dialysed patients it is of 44.44%. The main death causes were: severe hepatic failure, oncological diseases, severe neurological damage and hemodynamic damages. In conclusion, the ARF prognosis in children is influenced by the comorbidity states. Dialysis has improved the therapeutic results in the currently presented lot, the death causes being extrarenal.     

Renal dysfunction and serious infections after open-heart surgery

BACKGROUND: Infections and sepsis are important determinants of mortality in patients with renal dysfunction. We studied the influence of preoperative renal function or postoperative acute renal failure (ARF) on the frequency of infections after open-heart surgery. METHODS: This was a retrospective analysis of 24,660 patients undergoing open-heart surgery from 1993 to 2000. Primary outcome was occurrence of serious infections after open-heart surgery; secondary outcome was hospital mortality. RESULTS: Overall incidence of infections after open-heart surgery was 3.3%. The infection rate was higher in patients with lower preoperative creatinine clearance, ranging between 2.2% and 10.0%. Regarding postoperative ARF, the frequency of infections was 58.5% in those patients requiring dialysis vs. 23.7% in those with ARF not requiring dialysis (P < 0.001); within each subgroup, however, the infection rates were similar regardless of the baseline renal function. In patients who did not develop ARF by either of our definitions, the infection rate was 1.6%. By multivariate analysis, preoperative renal function was an independent risk factor associated with infections [odds ratio (OR) for preoperative creatinine>1.2 mg/dL, 1.3; CI, 1.1 to 1.6]. The relationship between preoperative renal function and infection prevailed even after excluding the patients with postoperative ARF. The overall morality was 2.2%; the mortality in patients with serious infection was 31.7%. CONCLUSION: Both preoperative renal dysfunction and postoperative ARF influence the frequency of serious infections after open-heart surgery. The infection rate was higher in patients with postoperative ARF regardless of the baseline renal function. However, preoperative renal dysfunction portended higher risk of infection, independent of the influence of postoperative ARF.     

Prognosis in acute pancreatitis complicated by acute renal failure requiring dialysis

Acute pancreatitis complicated by acute renal failure (ARF) requiring dialysis is a rare condition with a mortality rate of 80%. During the period 1977-1988 419 patients were admitted to our hospital because of ARF requiring dialysis. Fourteen (3%) had ARF caused by acute pancreatitis. Ten patients developed respiratory failure, eight patients circulatory failure, four hepatic failure, and one disseminated intravascular coagulation. Three patients had complicating septicemia and two gastrointestinal bleeding. Ten patients (71%) died. All patients with four or more organ failures besides the pancreatic failure died. Median time from start of symptoms until death was 28 days. Mortality in this series does not differ from that reported over the last 40 years. The need of multicenter trials for the purpose of improving prognosis is emphasized.     

Early Prognostic Factors in Patients with Acute Renal Failure Requiring Dialysis

Purpose. Despite improvements in renal therapy and technology, the mortality rate of patients with acute renal failure (ARF) remains high. Because ARF is a heterogeneous syndrome, occurring in patients with diverse etiologies and comorbid conditions, predicting its outcome is difficult. This study aims to identify early clinical and laboratory prognostic factors, including acute-phase reactants such as C-reactive protein (CRP), fibrinogen, and albumin, in ARF patients requiring dialysis. Material and methods. From June 2002 to March 2004, 61 patients with ARF requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively analyzed. For each patient, the worst values of prognostic variables 24 hr before starting dialysis were prospectively assessed. Results. Oliguria, low plasma fibrinogen levels, hypotension, cardiac disease, and neoplastic disease were statistically significant in predicting hospital mortality. Using Youden's index, the best cut-off value for plasma fibrinogen in predicting mortality was 300 mg/dL with a sensitivity and specificity of 61% and 96%, respectively. Serum CRP and serum albumin were not predictive of hospital mortality. Conclusion. Early prognostic factors in predicting mortality for patients with ARF requiring dialysis identified by multivariate logistic regression were oliguria, low plasma fibrinogen, hypotension, cardiac disease, and neoplastic disease. Serum CRP and albumin were not predictive of hospital mortality, whereas a plasma fibrinogen level ≤300 mg/dL had 61% sensitivity and 96% specificity in predicting mortality.     

Epidemiologic trend changes in acute renal failure--a tertiary center experience from South India

BACKGROUND: There are little data on the incidence of acute renal failure (ARF) from India due to the absence of central registry. The etiology, course, and outcome of ARF differ in various parts of India. Significant trend changes were reported even within a same center over a period of time. AIM: To find out the epidemiologic trend changes in ARF patients, the authors compared the profile of patients admitted by the Department of Nephrology from 1995-2004 with previously published data from 1987-1991. METHODS: Data collected from case records of patients admitted with ARF were systemically analyzed for age, gender, etiology, course, and outcome. A total of 32 variables were collected per person retrospectively. The chi-square test, Fisher's exact test, and student t-test were used as tests of significance (p<0.05 was taken as statistically significant). RESULTS: A total of 1112 patients were diagnosed to have ARF from 1995-2004. The mean age was 37.08 +/- 3.4 yrs. There were 669 (60.1%) males. Medical, obstetric, and surgical causes accounted for 87.6, 8.9, and 3.4 percent of ARF, respectively. Among the medical causes of ARF, acute diarrheal disease was the most common. Other causes of medical ARF included drugs, glomerulonephritis, sepsis, snake bite, leptospirosis, malaria, and copper sulphate, which accounted for 13.4, 9.3, 8.8, 7.8, 7.5, 4.4, and 4.3 percent, respectively. In comparison with the data from 1987-1991, medical ARF remained the most common cause of ARF, though without any statistical significance (87.6 percent vs 89.5 percent, p>0.32). Though surgical ARF had more than doubled from 1.5 percent from 1987-1991 to 3.4 percent (p<0.01) during the present study, it is much less when compared to similar studies in the literature. Obstetric renal failure more or less remained the same (8.9 percent vs 9 percent, p>0.4). A statistically significant decline was noted in overall as well as individual group mortality. The overall mortality declined from 26.4 percent to 19.6 percent (p<0.02). Regarding the outcome of ARF, 611 patients (54.94 percent) showed a total recovery, a partial recovery was noted in 192 patients (17.26 percent), and 91 patients (8.18 percent) had persistent dialysis-dependent renal failure. The factors noted to occur more frequently in the deceased were high entry serum creatinine (>440 micromol), jaundice, sepsis, oliguria, anemia, hypoalbuminemia, and hospital-acquired ARF. The overall requirement of dialysis was 69.0 percent. Hemodialysis was the most common modality of renal replacement therapy. CONCLUSIONS: ARF in South India differs in some important aspects when compared with data from other parts of the country. Significant trend changes were noted with time even within our center. Acute diarrheal disease was the most common cause of ARF. Leptospiral ARF was on the decline, and drugs, sepsis, and malaria were the emerging ARF causes. The incidence of surgical ARF was on the rise. Despite improvements in antenatal care, obstetric renal failure remained a significant cause of ARF. Hemodialysis became the preferred mode of renal replacement therapy.     

A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure

BACKGROUND: Acute renal failure (ARF) requiring dialysis in critically ill patients is associated with an in-hospital mortality rate of 50 to 80%. The worldwide standard for renal replacement therapy is intermittent hemodialysis (IHD). Continuous hemodialysis and hemofiltration techniques have recently emerged as alternative modalities. These two therapies have not been directly compared. METHODS: A multicenter, randomized, controlled trial was conducted comparing two dialysis modalities (IHD vs. continuous hemodiafiltration) for the treatment of ARF in the intensive care unit (ICU). One hundred sixty-six patients were randomized. Principal outcome measures were ICU and hospital mortality, length of stay, and recovery of renal function. RESULTS: Using intention-to-treat analysis, the overall ICU and in-hospital mortalities were 50.6 and 56.6%, respectively. Continuous therapy was associated with an increase in ICU (59.5 vs. 41.5%, P < 0.02) and in-hospital (65.5 vs. 47.6%, P < 0.02) mortality relative to intermittent dialysis. Median ICU length of stay from the time of nephrology consultation was 16.5 days, and complete recovery of renal function was observed in 34.9% of patients, with no significant group differences. Despite randomization, there were significant differences between the groups in several covariates independently associated with mortality, including gender, hepatic failure, APACHE II and III scores, and the number of failed organ systems, in each instance biased in favor of the intermittent dialysis group. Using logistic regression to adjust for the imbalances in group assignment, the odds of death associated with continuous therapy was 1.3 (95% CI, 0.6 to 2.7, P = NS). A detailed investigation of the randomization process failed to explain the marked differences in patient assignment. CONCLUSIONS: A randomized controlled trial of alternative dialysis modalities in ARF is feasible. Despite the potential advantages of continuous techniques, this study provides no evidence of a survival benefit of continuous hemodiafiltration compared with IHD. This study did not control for other major clinical decisions or other supportive management strategies that are widely variable (for example, nutrition support, hemodynamic support, timing of initiation, and dose of dialysis) and might materially influence outcomes in ARF. Standardization of several aspects of care or extremely large sample sizes will be required to answer optimally the questions originally posed by this investigation.