Acute Renal Failure Requiring Dialysis Research Articles

Epidemiological, Clinical, and Evolutionary Aspects of Severe Obstructive Acute Renal Failure Requiring Dialysis in the Nephrology Department of the University Hospital of Brazzaville

Introduction: Obstructive anuria represents a medical and surgical emergency, sometimes necessitating immediate extrarenal replacement therapy. Our study aims to delineate the profile of hemodialyzed patients with obstructive acute renal failure (OARF), detailing indications for hemodialysis and observing the course of the condition. Patients and Methods: This retrospective study covers the period from 2019 to 2022, encompassing all patients with OARF requiring emergency dialysis at the Nephrology Department of the University Hospital of Brazzaville. Data analysis was performed using EPI Info software version 3.3.2 (CDC, Atlanta, USA). Results: The study involved 39 patients, with 69.23% being male. The average age was 58.10 years, and oliguria was the primary presenting symptom (82%). Tumoral obstruction accounted for 76%, while lithiasic obstruction constituted 14%. Two cases of retroperitoneal fibrosis were observed (2.8%). Neoplastic origins included prostate, bladder, cervical, and rectal cancers in 46.67%, 33.33%, 16.67%, and 3.33% of cases, respectively. Indications for hemodialysis were poorly tolerated uremia, acidosis, hyperkalemia, and pulmonary edema in 79.1%, 38.57%, 19.49%, and 13.21% of cases, respectively. The mortality rate was 25.64%. Conclusion: The reliance on hemodialysis in obstructive anuria underscores a delay in patient management. Emergency treatment revolves around urinary tract drainage, followed by addressing the underlying cause. Prevention hinges on early and adequate management of various causal pathologies.

Impact of Chronic Kidney Disease on Revascularization and Outcomes in Patients with ST-Elevation Myocardial Infarction

Chronic kidney disease (CKD) in patients with ST-elevation myocardial infarction (STEMI) is associated with worse outcomes. We assessed the impact of CKD on guideline directed coronary revascularization and outcomes among STEMI patients. The Nationwide Inpatient Sample dataset from 2012-2014 was used to identify patients with STEMI using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were categorized as non-CKD, CKD without dialysis, and CKD with dialysis (CKD-HD). Outcomes were revascularization, death and acute renal failure requiring dialysis (ARFD). A total of 534,845 were included (88.9% non-CKD; 9.6% CKD without dialysis, and 1.5% CKD-HD). PCI was performed in 77.4% non-CKD, 56.2% CKD without dialysis, and 48% CKD-HD patients (p < 0.0001). In-hospital mortality and ARFD were significantly higher in CKD patients (16.5% and 40.6%) compared with non-CKD patients (7.12% and 7.17%) (p < 0.0001). In-hospital mortality was significantly lower in patients treated revascularization compared with patients treated medically (non-CKD: adjusted odds ratio (aOR) 0.280, p < 0.0001; CKD without dialysis: aOR 0.39, p < 0.0001; CKD-HD: aOR 0.48, p < 0.0001). CKD was associated with higher length of hospital stay and cost (5.86 ± 13.97, 7.57 ± 26.06 and 3.99 ± 11.09 days; p < 0.0001; $25,696 ± $63,024, $35,666 ± $104,940 and $23,264 ± $49,712; p < 0.0001 in non-CKD, CKD without dialysis and CKD-HD patients respectively). In conclusion, CKD patients with STEMI receive significantly less PCI compared with patients without CKD. Coronary revascularization for STEMI in CKD patients was associated with lower mortality compared to medical management. The presence of CKD in patients with STEMI is associated with higher mortality and ARFD, prolonged hospital stay and higher hospital cost.

Smoking History and Pre-Transplant Pulmonary Function Predict Post-Transplant Respiratory Failure, Acute Renal Failure Requiring Dialysis and 100-Day Mortality in Allogeneic Bone Marrow Transplantation

Background:Transplant related mortality(TRM) associated with allogeneic stem cell transplantation (HSCT) has necessitated risk-stratification that allows practitioners to make informed choices regarding patient selection for HSCT. Although pulmonary function testing (PFT) is obtained prior to HSCT at most institutions, and incorporated into common comorbidity indices (e.g. HCT-CI) there is no standard protocol to determine suitability for HSCT specific to lung disease. Also, there is a lack of data regarding the impact of tobacco use prior to HSCT. Recently, the association between smoking and kidney disease has gained attention. Tobacco-mediated kidney disease may be prognostic for renal failure post-HSCT. We studied the impact of tobacco use and lung function prior to HSCT on 30- and 100-day mortality as well as the frequency of post-HSCT respiratory and renal failure.Methods:We reviewed consecutive patients undergoing allogeneic HSCT at our institution from 2004 -2014 for acute myeloid leukemia (AML), acute lymphoid leukemia (ALL), multiple myeloma (MM), non-Hodgkin lymphoma (NHL) and myelodysplastic syndrome (MDS). Smoking was categorized as never (0 pack years), low dose (<10 pack years) and high dose (≥10 pack years). FEV/FVC was categorized <0.7, 0.7-0.8 and ≥0.8 of predicted. Association of categorical variables with outcomes and potential confounding variables was assessed using Chi-square tests. Adjusted estimates of association were calculated using multivariable logistic regression. Outcomes were 30 day mortality, 100 day mortality, ventilator and dialysis dependence.Results:Of 373 subjects who underwent allogeneic HSCT, 315 (84%) had complete smoking histories (42% female, 58% male). AML (44.1%) accounted for the most frequent diagnosis followed by NHL (22.2%), ALL (14.3%), MDS (12.1%) and MM (7.3%). The 30 day mortality was 6.4%, 100 day mortality was 16.5%. 23.5% of patients required mechanical ventilation while 12.4% required dialysis. 46.7% of patients were smokers; 31.8% high dose smokers, 14.9% low dose smokers. There was an 11% increase in ventilator-dependency among high-dose smokers compared to none or low-dose (p=0.032), with a trend toward higher incidence of 100-day mortality with high dose smokers (31%) compared with low dose smokers (23.4%) and never-smokers (19.1%), (p=0.083). High dose smokers were more likely to have reduced pulmonary function with FEV/FVC < 70% (p=0.0004). Patients with FEV/FVC < 70% had a 14% increase in 100-day mortality with an almost 20% increased chance of ventilator dependency (p=0.022) and 17.6% increased incidence of dialysis dependency (p=0.032). DLCO did not correlate to any endpoint with statistical significance. Patients with MDS had the highest proportion of high dose smokers (47.4%; p=0.0023) and highest percentage of patients with FEV/FVC < 70% (18.4%, p=0.0037). Patients with MDS also had the highest 30-day mortality (18.4%, p=0.023), 100-day mortality (31.6%, p=0.0012), ventilator dependency (47.4%, p=0.0014) and dialysis dependency (31.6%, p=0.0036).Discussion:Our results differ from prior studies looking at the utility of FEV1 and DLCO in pre-HSCT PFTs as predictive markers; neither had prognostic value. We found that high dose smoking history and reduced FEV1/FVC were significantly associated with post-HSCT ventilator dependence, dialysis dependence and mortality. These results underscore the need for future studies that examine the relationship between smoking, lung function and renal failure post-HSCT. Our study did not demonstrate that low dose smoking predicts worse outcomes post-HSCT, but future studies may help provide patients with more accurate pre-HSCT counseling. Patients with MDS were the largest population of high dose-smokers and had the highest proportion of 100-day mortality, ventilator and dialysis dependency. DisclosuresNo relevant conflicts of interest to declare.

Acute Renal Failure Renal Replacement Therapy &amp; Outcome

Acute Renal Failure is an intractable problem, which can be actively and effectively managed, but can be prevented only to a little extent. Acute renal failure requiring dialysis is associated with high mortality and morbidity. In a study conducted by analyzing the literature and taking 15897 acute renal failure patients, it was found that mortality rates in most studies exceeded 30% [1]. Despite technical advancements in the management of acute renal failure over the last 50 years, mortality rates seem to have remained unchanged at around 50% [1]. In Kerala, the studies on acute renal shut down are sparse. Also the clinicodemographic profile of patients with acute renal failure varies in different parts of the world. Our objective was to study the clinicodemographic profile of acute renal failure patients who underwent renal replacement therapy and to identify the determinants of outcome at discharge or death. The present study is a retrospective cohort of 107 patients who required renal replacement therapy in Medical College, Thiruvananthapuram. The relevant data were collected from the case records of patients by a data collection sheet. Outcome was taken as survived or expired at the time of discharge or death. Continuous variables were represented as means and standard deviations. The statistical significance assessed by Odds ratio and Chi-square test. The present study had a mortality of 32.7% with women more prone. The average age of the subjects was 43.16±16.45 years. Univariate analysis of the variables with the outcome like women gender (p=0.490), pre-morbidities (p=0.079), only one comorbidity in a patient (p=0.769), oliguria on the day of Ist dialysis (p=0.549), oliguria on the next day of the Ist dialysis (p=0.363) and Liano’s score 0.3 & above on the day of Ist dialysis (p=0.065) were associated with increased mortality. Ages 45 years & above (p=0.006), sepsis syndrome (p=0.0008), more than one co-morbidity in a patient (p=0.032) and Liano’s score on the day after the Ist dialysis (p=0.024) were associated with obvious increase in mortality, which were statistically significant. Snake envenomation had the best prognosis (p=0.037) and serum creatinine level had weak association with outcome (p=0.065). The study conducted on 107 patients revealed 32.7% mortality. Snake envenomation had the best prognosis and sepsis syndrome the worst. Age 45 years & above and women gender were bad prognostic indicators. Pre-morbidities, co-morbidities and oliguria were probable bad indicators. Liano’s score 0.3 and above was a good predictor of mortality. Unfortunately, serum creatinine level had only weak association with the outcome.

Is time on cardiopulmonary bypass during cardiac surgery associated with acute kidney injury requiring dialysis?

It is commonly accepted that the longer the time on extracorporeal cardiopulmonary bypass (CPB), the higher is the likelihood of developing acute renal failure requiring dialysis (ARF-D). Nonetheless, previous works elicited conflicting evidence. We investigated the relationship between CPB duration and ARF-D occurrence. Data were extracted from a large observational study. All factors independently associated with ARF-D were detected. Overall, 11,092 case record forms were analyzed. At the univariate analyses, time on CBP was associated with an increase in the ARF-D risk (odds ratio of fifth vs. first quintile of CBP time: 3.84; 95% confidence interval: 2.58-5.7; P < 0.001). However, after adjusting for confounders, the association between time on CBP and ARF-D lost its statistical significance. In this large dataset, CBP time did not predict ARF-D occurrence. These results might suggest that an accurate risk assessment might be more important than time on CPB in determining ARF-D occurrence.

Mortality Trends Associated with Acute Renal Failure Requiring Dialysis after CABG Surgery in the United States

Background/Aims: Acute renal failure is associated with a high risk of mortality when it complicates coronary artery bypass graft (CABG) surgery. We examined a large nationwide database from 1988 to 2003 and hypothesized that mortality in CABG-associated acute renal failure needing dialysis (ARF-D) had declined during this period. Methods: The Nationwide Inpatient Sample containing data on inpatient stays across 20% of US hospitals was used for our study. Multivariate logistic regression was used to determine an association between year and ARF-D mortality with standardized risk adjustment. Results: Incidence of ARF-D increased from 0.2 to 0.6% while mortality simultaneously decreased from 47.4% in 1988 to 29.7% in 2003. In the multivariable model, year was significantly associated with declining ARF-D mortality. Conclusions: The incidence of post-CABG ARF-D more than doubled from 1988 to 2003, while mortality simultaneously decreased by over one-third. Improved survival after ARF-D following CABG may be counterbalanced by increased morbidity and resource utilization.

Validation of a clinical score to determine the risk of acute renal failure after cardiac surgery

Preoperative assessment of risk factors for postoperative acute renal failure (ARF) is a key point in the management of cardiac surgery patients. A reliable evaluation of individual risk permits the efficient application of prophylactic and therapeutic measures to patients with increased risk of ARF. In 2005, Thakar published a scoring system to determine the ARF risk prior to surgery. The score allowed calculation of the incidence of postoperative ARF requiring dialysis (ARF-D) with a high level of precision. In order to examine the reproducibility of the results on different patient populations, we retrospectively applied the scoring system to 3,508 cardiac surgery patients at the Goettingen University Hospital. We found a qualitative correlation between the score value and ARF-D, but prognostic significance, when judged by the area under the receiver operating characteristic (ROC) curve, was considerably reduced. Also, the incidence of ARF-D in the Goettingen population was remarkably higher than the incidence shown by Thakar for patients with the same score. The correlation between score values and incidence of ARF-D shows that the Thakar score is qualitatively transferable to cardiac surgery patients from other centres. Though the score allows the discrimination between patients with higher or lower risks of ARF-D within the Goettingen collective, it was not suitable to estimate the real incidence of postoperative ARF-D with sufficient precision.

The Effect of Aprotinin on Risk of Acute Renal Failure Requiring Dialysis after On-Pump Cardiac Surgery

The use of aprotinin in cardiac surgery to reduce perioperative bleeding and transfusion is controversial. We assessed the effect of aprotinin on the risk of acute renal failure in 423 patients who underwent on-pump cardiac surgery between January 1, 2005 and December 31, 2006. Of these 423 patients, 318 (75.2%) received aprotinin (median dose=3.0 million KIU, standard deviation=2.8 million KIU; interquartile range: 2 million KIU to 4 million KIU). Aprotinin was more likely to be used in patients who did not cease aspirin before surgery, in urgent or emergency surgery, who had impaired left ventricular function, a longer period of bypass and aortic cross-clamp time, and with both coronary artery bypass graft and valvular surgery performed. The overall incidence of acute renal failure requiring dialysis was 2.8%. The use of aprotinin was not associated with a reduction in transfusion nor an increased risk of renal failure requiring dialysis, atrial fibrillation, cerebrovascular accident or mortality in the univarate analyses. In the multivariate analysis, only preoperative serum creatinine concentration (odds ratio [OR] 1.06 per 10 micromol/l increment in creatinine, 95% confidence interval [CI]: 1.01 to 1.14, P=0.029) and urgency of the surgery (urgent vs. scheduled surgery: OR 12.8, CI: 2.3 to 70.8, P=0.004; emergency vs. scheduled surgery: OR 23.1, CI: 3.0 to 180.2, P=0.003) were significantly associated with an increased risk of acute renal failure requiring dialysis. The use of low-dose aprotinin did not significantly reduce perioperative transfusion requirements and was not a significant risk factor for acute renal failure requiring dialysis in our patients.

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.

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 ≥ 24 was found to have 63% sensitivity and 96% specificity, and OSF number ≥ 2 had 81.6% sensitivity and 60.9% specificity.

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.

Acute renal failure following cardiac surgery.

Acute renal failure requiring dialysis (ARF-D) occurs in 1.5% of patients following cardiac surgery, and remains a cause of major morbidity and mortality. While some preoperative risk factors have been characterized, the influence of preoperative and intraoperative factors on the occurrence of ARF following cardiac surgery is less well understood. Preoperative and intraoperative data on 2843 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) from February 1, 1995 to February 1, 1997 were recorded and entered into a computerized database. Two definitions of renal failure were employed: (i) ARF defined as a rise in serum creatinine (Cr) of 1 mg/dl above baseline; and (ii) ARF-D defined as the development of ARF for which some form of dialytic therapy was required. The association between preoperative and intraoperative variables and the development of ARF was assessed by multivariate logistic regression. A total of 2672 of the 2844 patients underwent isolated coronary artery bypass grafting (CABG) surgery, the remaining 172 underwent valve surgery with or without bypass grafting. Of the CABG patients 7.9% developed ARF and 0.7% developed ARF-D. The mortality for patients who developed ARF was 14% (OR 15, P = 0.0001) compared with 1% among those who did not develop ARF. The mortality for CABG patients who developed ARF-D was 28% (OR 20, P = 0.0001) compared with 1.8% among those who did not require dialysis. Variables that were significantly associated with the development of ARF by multivariate analysis included: increased age, elevated preoperative serum Cr, duration of CPB, presence of a carotid artery bruit, presence of diabetes, reduced cardiac ejection fraction and increased body weight. Variables independently associated with ARF-D included serum Cr, duration of CPB, carotid artery bruit and presence of diabetes. The utility of these models for predicting the development of ARF and ARF-D was confirmed by bootstrapping techniques. Because of the small number of patients who underwent valve surgery, none of these variables were significantly associated with the development of ARF or ARF-D in this group of patients. The development of ARF or ARF-D is associated with a high mortality following CABG surgery. We have identified perioperative variables, which may be useful in stratifying risk for the development of ARF.

Acute Renal Failure After Coronary Intervention: Incidence, Risk Factors, and Relationship to Mortality

PURPOSE: This study set out to define the incidence, predictors, and mortality related to acute renal failure (ARF) and acute renal failure requiring dialysis (ARFD) after coronary intervention. PATIENTS AND METHODS: Derivation-validation set methods were used in 1,826 consecutive patients undergoing coronary intervention with evaluation of baseline creatinine clearance (CrCl), diabetic status, contrast exposure, postprocedure creatinine, ARF, ARFD, in-hospital mortality, and long-term survival (derivation set). Multiple logistic regression was used to derive the prior probability of ARFD in a second set of 1,869 consecutive patients (validation set). RESULTS: The incidence of ARF and ARFD was 144.6/1,000 and 7.7/1,000 cases respectively. The cutoff dose of contrast below which there was no ARFD was 100 mL. No patient with a CrCl > 47 mL/min developed ARFD. These thresholds were confirmed in the validation set. Multivariate analysis found CrCl [odds ratio (OR) = 0.83, 95% confidence interval (CI) 0.77 to 0.89, P <0.00001], diabetes (OR = 5.47, 95% CI 1.40 to 21.32, P = 0.01), and contrast dose (OR = 1.008, 95% CI 1.002 to 1.013, P = 0.01) to be independent predictors of ARFD. Patients in the validation set who underwent dialysis had a predicted prior probability of ARFD of between 0.07 and 0.73. The in-hospital mortality for those who developed ARFD was 35.7% and the 2-year survival was 18.8%. CONCLUSION: The occurrence of ARFD after coronary intervention is rare (<1%) but is associated with high in-hospital mortality and poor long-term survival. Individual patient risk can be estimated from calculated CrCl, diabetic status, and expected contrast dose prior to a proposed coronary intervention.

Prognostic Stratification in Critically Ill Patients With Acute Renal Failure Requiring Dialysis

Despite the widespread availability of dialytic and intensive care unit technology, the probability of early mortality in critically ill persons with acute renal failure is distressingly high. Previous efforts to predict outcome in this population have been limited by small sample size and the absence of uniform exclusion criteria. Additionally, data obtained decades ago may not apply today owing to changes in case mix. The medical records of 132 consecutive patients in the intensive care unit with acute renal failure who required dialysis from 1991 through 1993 were evaluated by a blinded reviewer. The overall in-hospital mortality rate was 70%. Twelve readily available historical, clinical, and laboratory variables were significantly associated with in-hospital mortality. Multivariate logistic regression analysis showed that mechanical ventilation, malignancy, and nonrespiratory organ system failure were independently associated with in-hospital mortality. Using a 95% positivity criterion, this model identified 24% of high-risk patients who died, without misclassification of any survivors. Of those who survived to hospital discharge, 33% were dialysis dependent and 28% were institutionalized long-term. Among critically ill patients, acute renal failure requiring dialysis is an ominous condition with a high risk of in-hospital mortality. This risk appears to depend largely on comorbid conditions, such as the need for mechanical ventilation and underlying malignancy. While this prognostic model requires prospective validation, it appears to identify a substantial fraction of patients for whom dialysis may be of limited or no benefit.

Prognosis in Septicemia Complicated by Acute Renal Failure Requiring Dialysis

During a 12-year period 419 patients were admitted because of acute renal failure requiring dialysis. Fifty (12%) had septicemia verified by blood culture. In a retrospective study age, sex, focus of infection, blood culture results, kidney function, mode of dialysis treatment, numbers and durations of complicating organ failures, presence of gastrointestinal bleeding, and secondary complicating events of septicemia were recorded for the purpose of establishing a prognostic index based on clinical criteria. Respiratory failure was present in 34 patients, circulatory failure in 31 patients, failure of coagulation system in 25 patients, and hepatic failure in 10 patients. Overall mortality was 46%. Highest death-rates were found during the first days of dialysis. In patients with multiple organ failures, in elderly and in patients suffering from staphylococcus aureus septicemia, a non-significant trend towards higher mortality was found. The mode of dialysis treatment did not influence patient survival. Our intention of establishing a prognostic index based on bedside clinical criteria has not been fulfilled. Even though mortality-rate increases in patients with acute renal failure complicated by failure of one or more vital organs, survival-rate in patients with four or more organ failures was 30%.