Important differentiation of factors that predict outcome in peritoneal dialysis patients with different degrees of residual renal function.

BACKGROUND: Residual renal function (RRF) is an important predictor of outcome in peritoneal dialysis (PD) patients. Whether results from survival studies in dialysis patients with RRF can also be extrapolated to anuric patients remains uncertain. In this observational study, we examined the characteristics of PD patients with a residual glomerular filtration rate (GFR) > or =1 ml/min per 1.73 m2 vs those with complete anuria and differentiated factors that predict outcome in the two groups of patients. METHODS: Two hundred and forty-six continuous ambulatory peritoneal dialysis (CAPD) patients (39% being completely anuric) were recruited from a single regional dialysis centre. Assessments of haemodynamic, echocardiographic, nutritional and biochemical parameters and indices of dialysis adequacy were done at study baseline and were related to outcomes. RESULTS: During the prospective follow-up of 30.8+/-13.8 (mean+/-SD) months, 28.0% of patients with residual GFR > or =1 ml/min per 1.73 m2 vs 50.5% of anuric patients had died (P = 0.005). The overall 2 year patient survival was 89.7 and 65.0% for patients with GFR > or =1 ml/min per 1.73 m2 and anuric patients, respectively (P = 0.0012). Compared with patients with GFR > or =1 ml/min per 1.73 m2, anuric patients were dialysed for longer (P<0.001), were more anaemic (P<0.005), and had higher calcium-phosphorus product (P<0.01), higher C-reactive protein (P<0.001), lower serum albumin (P<0.05), greater prevalence of malnutrition according to subjective global assessment (P<0.05) and more severe cardiac hypertrophy (P<0.001) at baseline. Using multivariable Cox regression analysis, serum albumin, left ventricular mass index and residual GFR were significant factors associated with mortality in patients with GFR > or =1 ml/min per 1.73 m2, while increasing age, atherosclerotic vascular disease and higher C-reactive protein were associated with greater mortality in anuric PD patients. CONCLUSIONS: Our study demonstrates more adverse cardiovascular, inflammatory, nutritional and metabolic profiles as well as higher mortality in anuric PD patients. Furthermore, factors associated with mortality are also not equivalent for PD patients with and without RRF, suggesting that patients with and without RRF are qualitatively different.     

Declining mortality in patients with acute renal failure, 1988 to 2002

Despite improvements in intensive care and dialysis, some experts have concluded that outcomes associated with acute renal failure (ARF) have not improved significantly over time. ARF was studied in hospitalized patients between 1988 and 2002 using the Nationwide Inpatient Sample, a nationally representative sample of discharges from acute-care, nonfederal hospitals. During a 15-yr period, 5,563,381 discharges with ARF and 598,768 with ARF that required dialysis (ARF-D) were identified. Between 1988 and 2002, the incidence of ARF rose from 61 to 288 per 100,000 population; the incidence of ARF-D increased from 4 to 27 per 100,000 population. Between 1988 and 2002, in-hospital mortality declined steadily in patients with ARF (40.4 to 20.3%; P < 0.001) and in those with ARF-D (41.3 to 28.1%; P < 0.001). Compared with 1988 to 1992, the multivariable-adjusted odds ratio (OR) of death was lower in 1993 to 1997 (ARF: OR 0.62, 95% confidence interval [CI] 0.61 to 0.64; ARF-D: OR 0.63, 95% CI 0.59 to 0.66) and 1998 to 2002 (ARF: OR 0.40, 95% CI 0.39 to 0.41; ARF-D: OR 0.47, 95% CI 0.45 to 0.50). The percentage of patients who had ARF with a Deyo-Charlson comorbidity index of 3 or more increased from 16.4% in 1988 to 26.6% in 2002 (P < 0.001). This study provides evidence from an administrative database that the incidence of ARF and ARF-D is rising. Despite an increase in the degree of comorbidity, in-hospital mortality has declined.     

Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study

Malnutrition is a frequent finding in hospitalized patients and is associated with an increased risk of subsequent in-hospital morbidity and mortality. Both prevalence and prognostic relevance of preexisting malnutrition in patients referred to nephrology wards for acute renal failure (ARF) are still unknown. This study tests the hypothesis that malnutrition is frequent in such clinical setting, and is associated with excess in-hospital morbidity and mortality. A prospective cohort of 309 patients admitted to a renal intermediate care unit during a 42-mo period with ARF diagnosis was studied. Patients with malnutrition were identified at admission by the Subjective Global Assessment of nutritional status method (SGA); nutritional status was also evaluated by anthropometric, biochemical, and immunologic parameters. Outcome measures included in-hospital mortality and morbidity, and use of health care resources. In-hospital mortality was 39% (120 of 309); renal replacement therapies (hemodialysis or continuous hemofiltration) were performed in 67% of patients (206 of 309); APACHE II score was 23.1+/-8.2 (range, 10 to 52). Severe malnutrition by SGA was found in 42% of patients with ARF; anthropometric, biochemical, and immunologic nutritional indexes were significantly reduced in this group compared with patients with normal nutritional status. Severely malnourished patients, as compared to patients with normal nutritional status, had significantly increased morbidity for sepsis (odds ratio [OR] 2.88; 95% confidence interval [CI], 1.53 to 5.42, P < 0.001), septic shock (OR 4.05; 95% CI, 1.46 to 11.28, P < 0.01), hemorrhage (OR 2.98; 95% CI, 1.45 to 6.13, P < 0.01), intestinal occlusion (OR 5.57; 95% CI, 1.57 to 19.74, P < 0.01), cardiac dysrhythmia (OR 2.29; 95% CI, 1.36 to 3.85, P < 0.01), cardiogenic shock (OR 4.39; 95% CI, 1.83 to 10.55, P < .001), and acute respiratory failure with mechanical ventilation need (OR 3.35; 95% CI, 3.35 to 8.74, P < 0.05). Hospital length of stay was significantly increased (P < 0.01), and the presence of severe malnutrition was associated with a significant increase of in-hospital mortality (OR 7.21; 95% CI, 4.08 to 12.73, P < 0.001). Preexisting malnutrition was a statistically significant, independent predictor of in-hospital mortality at multivariable logistic regression analysis both with comorbidities (OR 2.02; 95% CI, 1.50 to 2.71, P < 0.001), and with comorbidities and complications (OR 2.12; 95% CI, 1.61 to 2.89, P < 0.001). Malnutrition is highly prevalent among ARF patients and increases the likelihood of in-hospital death, complications, and use of health care resources.     

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.     

Acute renal failure after Crotalus durissus snakebite: a prospective survey on 100 patients

BACKGROUND: Acute renal failure (ARF) is the main cause of death after the South American crotalid snakebite. The aim of this study was to assess the prevalence, risk factors, and characteristics of Crotalus durissus venom-induced ARF. METHODS: One hundred cases of Crotalus durissus bite were studied from hospitalization to discharge or death. Creatinine clearance (GFR) <60 mL/min/1.73 m(2) in the first 72 hours after snakebite was defined as ARF. Data are expressed as median (range of variation) or%, and were analyzed by univariate analysis and logistic regression. RESULTS: Twenty-nine patients developed ARF. Of those, 24% required dialysis and 10% died. ARF patients had smaller body surface [1.55 (0.6-2.3) vs. 1.7 (0.6-2.1) m(2), P= 0.0097], received antivenom (AV) later [12 (2-48) vs. 2 (1-14) hours, P < 0.0001], received more AV [190 (90-536) vs. 158 (75-500) mg/m(2), P < 0.0001], presented lower diuresis at admission [62 (0-182) mL/hr vs. 100 (25-325) mL/hr, P= 0.0004], and showed a striking creatine kinase (CK) increase [50,250 (69-424,120) vs. 1108 (88-133,170) U/L, P < 0.0001]. Age <12 years (OR 5.6, P= 0.026), time for AV >2 hours (OR 11.1, P= 0.032), CK at admission >2000 U/L (OR 12.7, P= 0.0009) were identified as independent risk factors for ARF, whereas diuresis at admission >90 mL/hr (OR 0.20, P= 0.014) was an independent protector factor. CONCLUSION: C. durissus venom-induced ARF had high prevalence (29%). Delay for AV treatment, CK at admission >2000 U/L, and age <12 years were independent risk factors for ARF development. Diuresis at admission >90 mL/hr was a protective factor.     

Are peritoneal dialysis patients with and without residual renal function equivalent for survival study? Insight from a retrospective review of the cause of death.

BACKGROUND: It remains unknown whether results of survival studies in anuric patients can be extrapolated to those who still have significant urine output. It is possible that after a prolonged period on dialysis, anuric patients are qualitatively different from patients with residual renal function. METHODS: We performed a retrospective review to study the cause of death of 296 peritoneal dialysis patients of our centre over a 7 year period, and compared the mortality and distribution of cause of death between patients with and without residual renal function. RESULTS: One hundred and forty-two cases (48.0%) died of vascular diseases, 82 cases (27.7%) died of infections and 72 cases (24.3%) died of other causes. Anuric patients had a higher overall mortality rate than non-anuric patients (14.9 vs 9.9%, P=0.0005), and the difference was almost completely attributed to the difference in mortality from vascular diseases (8.0 vs 4.1%, P<0.0001). Vascular disease was a more common cause of death in anuric patients than those with residual renal function (55.3 vs 40.8%, P=0.011). The difference was largely explained by the higher prevalence of sudden cardiac death in anuric patients (39 in 149 vs 19 in 147 cases). Patients without pre-existing cardiovascular disease more commonly died of vascular disease after they became anuric (47.4 vs 34.0%, P=0.017). The difference could not be explained by the longer duration of dialysis in anuric patients because there was no significant change in the distribution of cause of death with time on dialysis (chi-square test, P=0.341). CONCLUSIONS: Our observation suggests that peritoneal dialysis patients with and without residual renal function are qualitatively different. Studies on peritoneal dialysis adequacy and survival in anuric patients should only be extrapolated to the general dialysis population with caution.     

Family history of end-stage renal disease among hemodialyzed patients in Poland

BACKGROUND: In previous reports of end-stage renal disease (ESRD) patients, family history of ESRD was associated with race, younger age, higher education levels and ESRD etiology. This study aimed to analyze how often Polish caucasian dialysis patients reported relatives with ESRD, and to evaluate which risk factors are associated with family history of ESRD. METHODS: 4808 ESRD patients provided data about renal disease etiology, diabetes and hypertensive status of first- and second-degree relatives, socioeconomic status and education level. RESULTS: Reported ESRD etiologies were: chronic glomerular disease, 19.4 %; diabetic nephropathy, 11.3%; interstitial nephritris, 11.2%; hypertension, 7.8%; polycystic kidney disease (PKD), 7.1%; other or no response, 40.0%. Positive ESRD family history was reported by 745 patients (15.5%); positive history of diabetes, 932 (19.4%); hypertension, 1904 (39%). Positive ESRD family history according to kidney disease etiology was: PKD, 53.1%; glomerulonephritis, 12%; diabetic nephropathy, 11.9%; hypertension, 11.8%; interstitial nephritis, 10.8%. PKD as ESRD etiology (odds ratio (OR) 8.06, 95% confidence interval (CI) 6.35-10.23, p < 0.0001), positive family history of diabetes (OR 1.64, 95% CI 1.34-1.99, p < 0.0001) and positive history of hypertension (OR 1.64, 95% CI 1.39-1.95, p < 0.0001), were independently associated with positive ESRD history. Patients with later ESRD onset had a less frequent positive ESRD family history: for ESRD < 45 yrs, 16% (OR 1.0); 45-64 yrs, 14.4% (OR 0.83, 95% CI 0.70-0.99); > or = 65 yrs, 9.2 % (OR 0.5, 95% CI 0.35-0.72). CONCLUSIONS: Results of our study strongly support the contention that familial predisposition contributes to ESRD development.     

Risk factors of acute renal failure after liver transplantation

The objective of this study was to determine the risk factors of postoperative acute renal failure (ARF) in orthotopic liver transplantation (OLT). We reviewed 184 consecutive OLT. Postoperative ARF was defined as a persistent rise of 50% increase or more of the S-creatinine (S-Cr). The patients were classified as early postoperative ARF (E-ARF) (first week) and late postoperative ARF (L-ARF) (second to fourth week). Preoperative variables were age, sex, comorbidity, indication for OLT, Child-Pugh stage, united network for organ sharing status, analysis of the blood and urine, and donor's data. Intraoperative variables were systolic arterial pressure, mean arterial pressure, pulmonary capillary wedge pressure, cardiac index, and systemic vascular resistance index. Surgical technique, number of blood products transfused, need for adrenergic agonist drugs, and intraoperative complications were also important. Postoperative variables were duration of stay in the intensive care unit, time on mechanic ventilation, liver graft dysfunction, need for adrenergic agonist drugs, units of blood products infused, episodes of acute rejection, re-operations, and bacterial infections. Firstly we carried out a univariate statistical analysis, and secondly a logistic regression analysis. The risk factors for E-ARF were: pretransplant ARF (odds ratio (OR)=10.2, P=0.025), S-albumin (OR=0.3, P=0.001), duration of treatment with dopamine (OR=1.6, P=0.001), and grade II-IV dysfunction of the liver graft (OR=5.6, P=0.002). The risk factors for L-ARF were: re-operation (OR=3.1, P=0.013) and bacterial infection (OR=2.9, P=0.017). The development of E-ARF is influenced by preoperative factors such as ARF and hypoalbuminemia, as well as postoperative factors such as liver dysfunction and prolonged treatment with dopamine. The predicting factors of L-ARF differ from E-ARF and correspond to postoperative causes such as bacterial infection and surgical re-operation.     

Acute Renal Failure in Open Heart Surgery

A case–control study was performed to establish possible risk factors for acute renal failure (ARF) and mortality in patients undergoing cardiac surgery. A consecutive series of 704 patients were included in the study. A randomized sample of 255 patients was taken to analyze risk factors for ARF and mortality. Incidence of acute renal failure was 3.8% (27/704). Low cardiac output (LCO) was observed in all patients who developed ARF and in 72/255 without ARF (p < 0.0005). When LCO was isolated, no difference was found between groups. Association to prolonged perfusion time and sepsis increased the probability of developing ARF: 5/27 versus 0/255, p < 0.001; and 9/27 versus 0/255, p < 0.001, respectively. Overall mortality was 7.2% (51/704). Significant difference was found between ARF (55.6%, 15/27) and non-ARF patients (5.4%, 36/704), p < 0.005. Neither age nor sex was associated to outcome. Nonsurvivor patients were more oliguric (11/15 vs. 0/12, p < 0.005), required dialysis more frequently (7/15 vs. 0/12, p < 0.005), and were complicated with sepsis more often (9/15 vs. 0/12, p < 0.005), compared to survivors. We concluded that ARF was an uncommon complication in this group of patients, but mortality rate was dramatically high. This study identified LCO associated to prolonged perfusion time and sepsis as risk factors for ARF. Severity of ARF (oliguric forms and dialysis requirement) and postoperative events (sepsis) were associated with mortality.     

Prognostic value of acute physiology and chronic health evaluation II and organ system failure in patients with acute renal failure requiring dialysis

BACKGROUND: Despite advances in modern technology of dialysis, prognosis of patients with acute renal failure (ARF) remains poor. To give the clinicians the most useful information, a model that accurately predicts outcome early in the course of ARF is required. However, because ARF is a heterogeneous syndrome and occurs in patients with diverse etiologies and some coexisting diseases, predicting outcome early is hard. The aim of this study is to evaluate prospectively the Acute Physiology and Chronic Health Evaluation (APACHE II) and organ system failure (OSF) models, evaluated prior to dialysis, in predicting hospital mortality. METHODS: From June 2002 to March 2004, ARF patients requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively recruited for this study. The worst clinical and laboratory data in the 24 hours before initiation of dialysis were prospectively evaluated, and the patients' APACHE II score and OSF number were assessed. RESULTS: A total of 61 patients (40 male and 21 female) were enrolled, of whom 38 (62.3%) died before discharge. By multivariate logistic regression, the APACHE II score (odds ratio 1.3 per increase in one score; P<0.001), or OSF number (odds ratio 1.9 per increase in one OSF; P<0.01) and oliguria (odds ratio 4.2; P=0.04), were found to be statistically significant prognostic factors for hospital mortality. Mortality increased progressively and significantly as OSF number (chi-square for trend; P=0.001) or the APACHE II score (chi-square for trend; P < 0.001) increased. By using Youden's index, the best cut-off value for APACHE II was 24, with 63% sensitivity and 96% specificity. The best cut-off value for OSF number was 2, with a sensitivity of 81.6% and a specificity of 60.9%. The areas under the receiver operating characteristic curves for APACHE II and OSF number were 0.847 (95% confidence interval (CI)=0.752-0.942; P<0.01) and 0.769 (95% CI=0.646-892; P<0.001), respectively, indicating good model discrimination. CONCLUSIONS: This study concludes that APACHE II and OSF number measured prior to initiation of dialysis reliably predict outcomes of ARF patients requiring dialysis. The mortality rates increase as the APACHE II score or OSF number increases. For predicting mortality, the APACHE II score > or = 24 was found to have 63% sensitivity and 96% specificity, and OSF number> or = 2 had 81.6% sensitivity and 60.9% specificity.     

Acute and chronic renal disease in hospitalized AIDS patients

We performed a retrospective chart analysis on 449 AIDS patients admitted to Bellevue Hospital Center from 1983-1986 to characterize the etiologies and clinical course of acute renal failure (ARF) and to define the incidence and clinical course of AIDS-associated nephropathy (AAN) in an unselected hospitalized AIDS population. Defining ARF as a rise from baseline serum creatinine of at least 2.0 mg%, we found 88 cases (a prevalence of almost 20%) or 14.5 cases per 100 admissions. Volume depletion was the most common etiology and was as severe a cause of ARF as other etiologies. There were 21 cases of ARF in 17 patients with a peak serum creatinine greater than or equal to 6.0 mg%. Volume depletion accounted for 7/21 of these cases. Baseline renal insufficiency existed in 9/17 patients (12/21 cases) and volume depletion was the cause of ARF in 3 of these cases. Only 4 cases required dialysis. There were 34 patients (prevalence of 7.6% or 3.0 cases per 100 patient-years) with otherwise unexplained chronic renal insufficiency and/or persistent qualitative or quantitative proteinuria and thus were defined on clinical grounds to have AIDS-associated nephropathy. Thirty-two of these patients (94%) had evidence of AAN at or within 1 year of presentation. Eleven patients (32%) reached ESRD (serum creatinine greater than or equal to 6.0 mg%); 9 patients did so within 1 year of presentation and 3 required dialysis. In those with adequate follow-up (9 cases), the mean survival from time of ESRD was 25.5 days and all cases died within 6 months of reaching ESRD.(ABSTRACT TRUNCATED AT 250 WORDS)     

Incidence and risk factors for the development of acute renal failure in patients with ventilator-associated pneumonia

AIM: Infections are one of the most important risk factors for the development of acute renal failure (ARF) and ventilator-associated pneumonia (VAP) has been reported as one of the most frequent infection in intensive care units (ICU). Sepsis, shock, multiorgan dysfunction syndrome (MODS), use of nephrotoxic antibiotics and mechanical ventilation are potential risk factors for development of ARF during VAP. The objective of the study was to evaluate the incidence of ARF in patients with VAP and the role of VAP-related potential risk factors in the development of ARF. METHODS: One hundred and eight patients who were admitted to the pulmonary ICU of a university hospital and developed VAP were included in this prospective observational cohort study. Only first episodes of VAP were studied. Diagnosis was based on microbiologically confirmed clinical findings. Potential outcome variables including responsible pathogens, recurrence, polymicrobial aetiology, bacteraemia, multidrug resistance of microorganisms, late/early VAP and sepsis and other known risk factors for development of ARF were evaluated. Risk factors were analysed by logistic regression analysis for significance. RESULTS: Incidence of ARF was 38% (n = 41). Pneumonia with multidrug resistant pathogens (odds ratio, (OR) 5; 95% confidence interval (95%CI), 1.5-18; P = 0.011), sepsis (OR, 5.6; 95%CI, 1.7-18; P = 0.005) and severity of admission disease (Acute Physiology and Chronic Health Evaluation II score: OR, 1.1; 95%CI, 1.02-1.3; P = 0.017) were independent risk factors for the development of ARF during VAP episodes in multivariate analysis. CONCLUSION: These results showed that the incidence of ARF is high during the VAP episodes and that VAP developed with multidrug resistant pathogens and sepsis have an independent effect on the development of ARF.     

Acute renal failure in bone marrow transplant patients admitted to the intensive care unit

BACKGROUND/AIMS: Review of bone marrow transplant (BMT) cases admitted to our intensive care unit (ICU) and to compare co-morbidity and outcome of BMT patients developing or not developing acute renal failure (ARF). METHODS: A case review of BMT patients admitted to the ICU (a 16-bed medico-surgical ICU in a tertiary care teaching institution) over a 4-year period. RESULTS: Between January 1994 and December 1998, 57 among 441 BMT patients (12.9%) were admitted to the ICU, mainly for respiratory distress (58%) and hypotension (32%). Forty-two patients (73.7%) presented ARF as defined as a doubling of serum creatinine. Compared to the 15 other patients, ARF patients had a higher APACHE II score (30 +/- 8 vs. 25 +/- 7, p < 0.05). For ARF vs. non-ARF patients, there was no difference in age (43.8 +/- 10.8 vs. 44.3 +/- 11.1 years), in requirement for mechanical ventilation (76 vs. 73%) and vasopressors (69 vs. 60%), and in prevalence of graft-versus-host disease (19 vs. 13%) or neutropenia (69 vs. 67%), but the prevalence of sepsis (83 vs. 60%) and liver failure (69 vs. 40%) was higher. Maximum serum bilirubin was markedly increased in ARF compared to non-ARF patients (p < 0.005). For both subgroups, no difference in the administration of potential nephrotoxic agents was identified. Usually, ARF was considered multifactorial by clinicians, with ATN being the most frequent diagnosis (55%). Maximum serum creatinine reached a mean of 330 +/- 130 micromol/l. In 74% of cases, ARF occurred concomitantly or after admission to the ICU. Oligoanuria was present in 38%, whereas polyuria was observed in 17%. Fourteen ARF patients (33%) required dialytic support. Mortality rates were significantly different in ARF vs. non-ARF patients (88 vs. 60%, p < 0.05). Predictive factors for the development of ARF were liver failure (odds ratio (OR) 5.9), low serum albumin (OR 1.2) and APACHE II score (OR 1.1), whereas variables predictive of mortality were mechanical ventilation (OR 14.8), ARF (OR 5.8), liver failure (OR 3.7), and APACHE II score (OR 1.2). CONCLUSIONS: This study confirms that ARF in BMT patients admitted to the ICU is frequent, multifactorial, related to liver failure, and that its development has a negative impact on outcome.     

Prognosis of patients with acute renal failure requiring dialysis: results of a multicenter study

Despite several decades of clinical experience, the mortality rate for patients with acute renal failure (ARF) requiring dialysis remains high, and the evaluation of the patients prognosis has been difficult. To date, the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system has been used more frequently for prediction in studies of ARF than any other scoring system, but has not been prospectively validated in controlled multicenter studies of this entity. In a multicenter, prospective, controlled trial evaluating the use of biocompatible hemodialysis membranes (BCMs) in patients with ARF, we evaluated the extent to which the APACHE II scoring system, based on the physiological variables in the 24 hours before the onset of dialysis and the presence or absence of oliguria, is predictive of outcome. Analysis of survival and recovery of renal function for the 153 patients treated in this study show that APACHE II scores are predictive both of survival and recovery of renal function, whether analyzed separately by type of dialysis membrane used (BCM or bioincompatible [BICM]) or for both groups combined (all P < 0.01). There was no evidence of a significant center effect or interaction of APACHE II score with dialysis membrane in our study. After adjusting for the APACHE II score, there was a positive effect of the BCM on both probability of survival (P < 0.05) and recovery of renal function (P < 0.01). In patients dialyzed with BCMs, oliguria at onset of dialysis had an adverse effect on both survival and recovery of renal function (both P < 0.01). Receiver operator curves (ROCs) using APACHE II score and the use of BCMs in nonoliguric patients yielded a statistically significant improvement versus the use of APACHE II score alone in the area under the curve (AUC) for survival (0.747 to 0.801; P < 0.05) and recovery of renal function (0.712 to 0.775; P < 0.05). We conclude that 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 and recovery of renal function. The use of the APACHE II score measured at the time of dialysis initiation, especially when modified by the presence or absence of oliguria, should help in predicting outcome when evaluating interventions for patients with 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.     

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.     

Acute renal failure early after heart transplantation: risk factors and clinical consequences

Gude E, Andreassen AK, Arora S, Gullestad L, Grov I, Hartmann A, Leivestad T, Fiane AE, Geiran OR, Vardal M, Simonsen S. Acute renal failure early after heart transplantation: risk factors and clinical consequences.
Clin Transplant 2010: 24: E207–E213. © 2010 John Wiley & Sons A/S. Abstract: Limited information exists about acute renal failure (ARF) early after heart transplantation (HTx). We correlated pre‐, per‐, and post‐operative patient and donor parameters to the risk of developing ARF. We also analyzed the consequences of ARF on kidney function after HTx, risk of later need for chronic dialysis or kidney transplantation, and mortality. In a retrospective study from 1983 to 2007, 145 (25%) of 585 HTx recipients developed ARF, defined as ≥26.4 micromol/L or ≥50% increase in serum creatinine from pre‐operatively to the seventh day post‐HTx and/or the need of early post‐operative dialysis. Independent risk factors for ARF were intravenous cyclosporine immediately post‐operatively (odds ratio [OR] 2.16, 95% CI 1.34–3.50, p = 0.02), donor age (OR 1.02, 95% CI 1.00–1.04, p = 0.02), and pre‐operative cardiac output (OR 1.38, 95% CI 1.12–1.71, p = 0.003). The development of ARF was a predictor for short‐term survival (≤3 months) ranging from 98% for patients who improved their creatinine after HTx vs. 79% for those in need of dialysis (p < 0.001). However, ARF did not predict subsequent end stage renal disease in need of dialysis or renal transplantation. ARF is a common complication post‐HTx. As ARF is associated with short‐term survival, post‐operative strategies of preserving renal function have the potential of reducing mortality. Of avoidable risk factors, the use of intravenous CsA should be discouraged.     

Acute renal failure in leptospirosis in the black-see region in Turkey

Leptospirosis is an infectious disease caused by pathogenic leptospires and is characterized by a broad spectrum of clinical manifestations, varying from inappearent infection to fulminant, fetal disease. Eighty-five to 90% of leptospirosis infections are self-limiting. However, 5–10% of infection by L.interrogans can cause renal tubular damage, microvascular injury, acute renal failure (ARF), and interstitial nephritis.We studied 36 patients with leptospirosis. Twenty-seven (65%) cases of 36 patients had ARF. Fourteen (51%) had nonoliguric ARF. In thirteen (48%) oliguria appeared on the third or fourth days of hospitalization. Serum BUN, creatinine, serum bilirubine, ALT, AST, potassium and thrombocytopenia levels were higher in oliguric than nonoliguric patients (p < 0.05). However, serum sodium, CPK levels were not different between oliguric and nonoliguric groups (p > 0.05). Thirteen patients (48%) needed in renal replacement therapy (RRT). 8 of them were treated by hemodialysis (HD) alone and 5 patients by HD in combination with hemoperfusion. Twenty-five patients (92%) recovered completely after 3–5 weeks. Two patients (7.4%) who had severe hepatorenal and hemorrhagic syndromes, died.We concluded that till now leptospirosis is actual problem for nephrologist in the developing countries because of very high percentage of renal disease, with good prognosis in patients without multiorgan failure and early treatment.     

Acute renal failure in intensive care unit: which factors predict future dialysis dependency?

Management of acute renal failure (ARF) in an intensive care unit (ICU) is difficult. The aim of this study was to identify prognostic factors determining ARF outcome in the ICU in terms of dialysis dependency or independency. We included 35 patients who turned out to be dialysis dependent (DD) and 11 patients who turned out to be dialysis independent (DI) after ARF in the ICU, which necessitated renal replacement therapy. In the post-ARF period, acetylsalicylic acid was protective against dialysis dependency (p < 0.05, odds ratio [OR] = 0.078) and dopamine increased the likelihood of dialysis dependency (p = 0.016, OR = 10.6). Multiorgan dysfunction (p = 0.001, OR = 13.6), especially cardiac (p = 0.009) and hepatic failure (p < 0.0001) were determined to increase risk of dialysis dependency. Mean systolic blood pressures during the first 24 hours (p = 0.023) and 24-48 hours (p = or < 0.0001), mean diastolic blood pressures during first the 24-48 hours (p = 0.03) and 48-72 hours of ARF in ICU (p = 0.023) and at discharge (p = 0.03) were significantly lower in the DD group than in the DI group. Mean thrombocyte counts at hospitalization (p = 0.034), during the first 24 hours (p = 0.019) and 24-48 hours of ARF in ICU (p = 0.038) were lower in the DD than DI group. This study demonstrates the very early prognostic factors influencing ARF outcome in terms of dialysis dependency. Early thrombocyte count and systolic blood pressure and follow-up diastolic blood pressure were prognostic factors for ARF outcome. Acetylsalicylic acid seemed to improve renal outcome, whereas dopamine seemed to worsen the disease process.     

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 µmol/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 µmol/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.