Impact Of Acute Renal Failure Research Articles

The long-term impact of acute renal failure after aortic arch replacement for acute type A aortic dissection.

To determine the long-term impact of developing acute renal failure (ARF) on survival after open aortic arch reconstruction for acute type A aortic dissection (ATAAD). This was an observational study of consecutive aortic surgeries from 2007 to 2021. Patients with ATAAD were identified via a prospectively maintained institutional database and were stratified by the presence or absence of postoperative ARF (by RIFLE criteria). Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed. A total of 601 patients undergoing open surgery for ATAAD were identified, of which 516 (85.9%) did not develop postoperative ARF, while 85 (14.1%) developed ARF, with a median follow-up time of 4.6 years (1.6, 7.9). Baseline characteristics were similar across each group, except for higher rates of branch vessel malperfusion and lower preoperative ejection fraction in the ARF group. Patients with ARF underwent more total arch replacement and elephant trunk procedures, with longer cardiopulmonary bypass and circulatory arrest times than patients without ARF. ARF was associated with worse short-term outcomes, including increased in-hospital mortality, prolonged mechanical ventilation, higher rates of sepsis, more blood transfusions, and longer length of hospital stay. Unadjusted Kaplan-Meier survival estimates were significantly lower in the ARF group, compared to the group without ARF (p < .001, log-rank test). After multivariable adjustment, the development of postoperative ARF was significantly associated with an increased hazard of death over the study's follow-up time-period (hazard ratio: 2.74, 95% confidence interval: 1.95, 3.86, p < .001). ARF is a highly morbid postoperative event that may adversely impact long-term survival after aortic surgery.

Effect of renal support therapy on 5-year survival in patients discharged from the intensive care unit

BackgroundBetween 30 and 70% of patients admitted to the intensive care unit (ICU) have acute kidney injury (AKI), and 10% of these patients will require renal replacement therapy (RRT). A significant number of studies have compared the mortality of patients who require RRT versus those who do not require it, finding an increase in mortality rates in the short and medium term; however, few studies have evaluated the long-term survival in a mixture of patients admitted to the ICU.ObjectiveTo evaluate the impact of RRT on 5-year survival in patients with AKI admitted to the ICUMethodsUsing administrative databases of insurers of the Colombian health system, a cohort of patients admitted to the ICU between 1 January 2012 and 31 December 2013 was followed until 31 December 2018. ICD-10 diagnoses, procedure codes, and prescribed medications were used to establish the frequencies of the comorbidities included in the Charlson index. Patients were followed for at least 5 years to evaluate survival and establish the adjusted risks by propensity score matching.ResultsOf the 150,230 patients admitted to the ICU, 4366 (2.9%) required RRT in the ICU. Mortality rates for patients with RRT vs no RRT evaluated at ICU discharge, 1 year, and 5 years were 35%, 57.4%, and 67.9% vs 7.4%, 17.6%, and 30.1%, respectively. After propensity score matching, the hazard ratio was calculated for patients who received RRT and those who did not (HR, 2.46; 95% CI 2.37 to 2.56; p < 0.001), with a lower difference in years of survival for patients with RRT (mean effect in the treated) of − 1.86 (95% CI − 2.01 to to1.65; p < 0.001).ConclusionsThe impact of acute renal failure with the consequent need for RRT in patients admitted to the ICU is reflected in a decrease of approximately one quarter in 5-year survival, regardless of the different comorbidities.

The Impact of Acute Renal Failure on Early and Late Outcomes After Thoracic Aortic Endovascular Repair

Acute kidney injury (AKI) is an important risk factor for both early and late mortality following thoracic aortic endovascular repair (TEVAR).

The Impact of Acute Renal Failure on Early and Late Outcomes After Thoracic Aortic Endovascular Repair

The incidence of acute kidney injury (AKI) after thoracic aortic endovascular repair (TEVAR) is variably reported at 1% to 34%. This study utilized the RIFLE (risk, injury, failure) criteria to evaluate the incidence, risk factors, and late implications of AKI after TEVAR. In all, 350 patients without prior dialysis requirement underwent TEVAR (1993 to 2013). The mean age was 68.7 years (54% male). The mean preoperative glomerular filtration rate was 76.5 ± 37.6 mL/min, with 39 patients (11.7%) in chronic kidney stage 3 or 4. The TEVAR was performed for rupture in 20.6%. The mean contrast volume administered was 95.7 ± 52.9 mL. Early mortality was seen in 17 patients (4.9%). Acute kidney injury defined as RIFLE classes risk, injury, or failure was seen in 59 patients (17%; risk= 36, injury= 14, failure= 9). Independent predictors of AKI included history of saccular aneurysm, presentation with rupture, or need for arch repair or red blood cell transfusion (all p < 0.05). Only 2 patients (0.6%) needed dialysis,with none requiring permanent dialysis. Importantly, 10-year freedom from dialysis was 97.7%. Development of AKI predicted early mortality (p < 0.001, odds ratio 9.8). Ten-year survival was 38.1%. Both injury and failure AKI classes independently predicted late mortality (p < 0.05). The prevalence of AKI after TEVAR as assessed by RIFLE criteria is higher than seen in previous reports. Despite its infrequent progression to permanent dialysis dependence, AKI remains an important risk factor for both early and late mortality. Future studies should evaluate strategies to reduce the incidence of AKI after TEVAR to improve both early and late outcomes.

Impact of Acute Renal Failure on In-Hospital Outcomes Following Percutaneous Treatment of Acute Myocardial Infarction

ABSTRACT Background Acute renal failure (ARF) is a possible complication after percutaneous coronary intervention (PCI). The objective of this study was to evaluate the occurrence and prognostic impact of ARF after PCI in patients with ST segment elevation myocardial infarction (STEMI). Methods Single-center registry evaluating in-hospital outcomes of 501 patients admitted with STEMI undergoing primary, rescue or late PCI. The incidence and predictors of ARF after PCI were evaluated. Results Mean age was 60.7 ± 12.6 years and 67% were male. The populaton had high cardiovascular risk characteristics, with 30% of diabetics and 7.4% with preexisting chronic kidney disease (CKD). The left anterior descending artery was the culprit vessel in 49.4% of the cases and 15% of patients had Killip class III or IV. ARF was observed in 24.7% of patients, who were significantly older, had more diabetes, history of CKD or heart failure, had higher enzyme elevation and lower ejection fraction when compared to those without ARF. In-hospital mortality was higher in patients who developed ARF (29% vs. 4.8%; P 76 years, previous CKD, Killip class III or IV, need of vascular surgery or blood transfusion. Conclusions Acute renal failure after PCI in STEMI was a frequent complication and was associated with increased in-hospital mortality.

Impact of Acute Renal Failure on In-Hospital Outcomes Following Percutaneous Treatment of Acute Myocardial Infarction

Acute renal failure (ARF) is a possible complication after percutaneous coronary intervention (PCI). The objective of this study was to evaluate the occurrence and prognostic impact of ARF after PCI in patients with ST segment elevation myocardial infarction (STEMI). Single-center registry evaluating in-hospital outcomes of 501 patients admitted with STEMI undergoing primary, rescue or late PCI. The incidence and predictors of ARF after PCI were evaluated. Mean age was 60.7 ± 12.6 years and 67% were male. The populaton had high cardiovascular risk characteristics, with 30% of diabetics and 7.4% with preexisting chronic kidney disease (CKD). The left anterior descending artery was the culprit vessel in 49.4% of the cases and 15% of patients had Killip class III or IV. ARF was observed in 24.7% of patients, who were significantly older, had more diabetes, history of CKD or heart failure, had higher enzyme elevation and lower ejection fraction when compared to those without ARF. In-hospital mortality was higher in patients who developed ARF (29% vs. 4.8%; P < 0.01). Independent predictors of ARF were age > 76 years, previous CKD, Killip class III or IV, need of vascular surgery or blood transfusion. Acute renal failure after PCI in STEMI was a frequent complication and was associated with increased in-hospital mortality. Impacto da Insuficiência Renal Aguda na Evolução Hospitalar Após Tratamento Percutâneo do Infarto Agudo do Miocárdio A insuficiência renal aguda (IRA) é uma complicação possível após intervenção coronária percutânea (ICP). O objetivo deste estudo foi avaliar a ocorrência e o impacto prognóstico da IRA pós-ICP em pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IMCSST). Registro unicêntrico, que analisou a evolução hospitalar de 501 pacientes admitidos com IMCSST submetidos à ICP primária, de resgate ou tardia. Foram avaliados a incidência e os preditores de IRA pós-ICP. A idade média foi 60,7 ± 12,6 anos e 67% eram do gênero masculino. A população apresentava características de alto risco cardiovascular, sendo 30% diabéticos e 7,4% com doença renal crônica (DRC) preexistente. A artéria descendente anterior foi a principal artéria culpada (49,4%) e 15% dos pacientes se apresentaram em Killip III ou IV. A IRA ocorreu em 24,7% dos pacientes, que, quando comparados àqueles sem IRA, eram significativamente mais idosos, diabéticos, com DRC e insuficiência cardíaca, além de apresentarem maior elevação enzimática e menor fração de ejeção. A mortalidade hospitalar foi maior nos pacientes que desenvolveram IRA (29% vs. 4,8%; P < 0,01). Os preditores independentes de IRA foram idade > 76 anos, DRC prévia, Killip III ou IV, necessidade de cirurgia vascular ou transfusão sanguínea. A disfunção renal aguda após ICP no IMCSST foi uma complicação frequente e associada com aumento da mortalidade hospitalar.

Postliver Transplant Acute Renal Injury and Failure by the RIFLE Criteria in Patients With Normal Pretransplant Serum Creatinine Concentrations: A Matched Study

Acute renal injury (ARI) and acute renal failure (ARF) are serious complications after liver transplantation (LT). Few studies apply the risk, injury, function, loss, and end-stage criteria on the patients who have normal preoperative renal function. The aims of this study were to identify the incidence, risk factors, and impact of ARI and ARF in this patient population. After institutional review board approval, adult LT patients who had preoperative serum creatinine less than or equal to 1.5mmol/L were reviewed. Postoperative ARI and ARF were determined by the risk, injury, function, loss, and end-stage criteria. Risk factors were determined by multivariable regression. Postoperative outcomes were compared among patients with or without ARI or ARF. Among 334 patients included the study, 20.4% and 18.0% had ARI or ARF in the first week after LT, respectively. Then 118 ARI or ARF patients were matched with patients without post-LT renal injury by gender, creatinine, and body mass index. Multivariable analysis showed that increased requirement of red blood cell transfusion (odds ratio [OR] 2.7-8.8, P<0.05), vasopressors (OR 2.2, P=0.018), and pre-LT albumin less than or equal to 3.5 mg/dL (OR: 2.8, P=0.003) as risk factors for post-LT ARI or ARF. Both ARI and ARF were associated with longer hospital stay and higher reoperation rate. ARF, but not ARI, was associated with higher 30-day graft failure and mortality rates. Post-LT ARI or ARF occurred frequently in patients with normal preoperative renal function and was associated with both preoperative and intraoperative risk factors. Although both post-LT ARI and ARF are associated with significant post-LT morbidity, the impact of ARF is greater.

Impact of Acute Renal Failure on the Relationship between N-Terminal pro-B-Type Natriuretic Peptide and Hemodynamic Parameters

Background: We studied the influence of acute renal failure (ARF) on the relationship between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and hemodynamic parameters. Methods: The echocardiographic parameters and NT-proBNP levels were compared between 26 mechanically ventilated patients with ARF requiring continuous hemodiafiltration and 44 control patients. Results: The relationships between NT-proBNP and left ventricular ejection fraction (p = 0.001), left ventricular end-diastolic volume (p = 0.03), tricuspid annular plane systolic excursion (p = 0.008), and pulmonary artery pressure (p = 0.01) were found only in the control group. The median and interquartile range of NT-proBNP (1,717.5, 389.5–4,138 ng/l) were significantly higher (p < 0.001) in the low diuresis subgroup than the levels (748.8, 384.2–2,217 ng/l) in the subgroup where daily diuresis increased and both had significantly higher levels than controls (350.7, 130.2–661.2 ng/l, p < 0.001). Conclusion: The high levels of NT-proBNP >1,000 ng/l seem to be typical, particularly for oliguric ARF. It seems that ARF precludes its utilization for any hemodynamic diagnosis.

547: Impact of Acute Renal Failure on Survival after HM II LVAD Implantation

Acute renal failure (ARF) is a known complication after left ventricular assist device (LVAD) implantation. We sought to evaluate the effect of postoperative ARF on survival after HeartMate II (HM II) LVAD implantation.

Estimated GFR reporting is not sufficient to allow detection of chronic kidney disease in an Italian regional hospital

BackgroundChronic kidney disease (CKD) is an emerging worldwide problem. The lack of attention paid to kidney disease is well known and has been described in previous publications. However, little is known about the magnitude of the problem in highly specialized hospitals where serum creatinine values are used to estimate GFR values.MethodsWe performed a cross-sectional evaluation of hospitalized adult patients who were admitted to the medical or surgical department of Santa Maria della Misericordia Hospital in 2007. Information regarding admissions was derived from a database. Our goal was to assess the prevalence of CKD (defined as an estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2) and detection of CKD using diagnostic codes (Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]). To reduce the impact of acute renal failure on the study, the last eGFR obtained during hospitalization was the value used for analysis, and intensive care and nephrology unit admissions were excluded. We also excluded patients who had ICD-9-CM codes for renal replacement therapy, acute renal failure, and contrast administration listed as discharge diagnoses.ResultsOf the 18,412 patients included in the study, 4,748 (25.8%) had reduced eGFRs, falling into the category of Kidney Disease Outcomes Quality Initiative (KDOQI) stage 3 (or higher) CKD. However, the diagnosis of CKD was only reported in 19% of these patients (904/4,748). It is therefore evident that there was a "gray area" corresponding to stage 3 CKD (eGFR 30-59 ml/min), in which most CKD diagnoses are missed. The ICD-9 code sensitivity for detecting CKD was significantly higher in patients with diabetes, hypertension, and cardiovascular disease (26.8%, 22.2%, and 23.7%, respectively) than in subjects without diabetes, hypertension, or cardiovascular disease (p < 0.001), but these values are low when the widely described relationship between such comorbidities and CKD is considered.ConclusionAlthough CKD was common in this patient population at a large inpatient regional hospital, the low rates of CKD detection emphasize the primary role nephrologists must play in continued medical education, and the need for ongoing efforts to train physicians (particularly primary care providers) regarding eGFR interpretation and systematic screening for CKD in high-risk patients (i.e., the elderly, diabetics, hypertensives, and patients with CV disease).

Cirrhotics admitted to intensive care unit: the impact of acute renal failure on mortality

The exact role of renal dysfunction in critically ill cirrhotics admitted to an intensive care unit (ICU) has not been assessed extensively. To evaluate the impact of acute renal failure (ARF) on 6 weeks mortality in cirrhotics admitted to ICU. Three hundred and twelve cirrhotics (182 male, mean age 49.6+/-11.5 years) were consecutively admitted during the study period. The patients (n=128, 40%) (group 1) with ARF on admission and/or during ICU were compared with the patients whose ICU stay was not complicated with ARF (n=184, 60%) (group 2). At admission, 40 variables were available, whereas Child-Turcotte-Pugh, Model for End-stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment and Failure Organ System scores on admission, were evaluated and compared by receiver operating characteristic curves. Group 1, compared with group 2 patients, had longer ICU stay (7 vs. 4 days, P=0.04) and required cardiovascular support more frequently with inotropes (90 vs. 75%), (P<0.001). Mortality was significantly higher in group 1, compared with group 2 (91 vs. 47%, P<0.001). At admission, group 1, compared with group 2, had significantly higher Child-Turcotte-Pugh (12 vs. 11), Acute Physiology and Chronic Health Evaluation II (22 vs. 17), Model for End-stage Liver Disease (31 vs. 21), Sequential Organ Failure Assessment (13 vs. 9) and Failure Organ System (3 vs. 2) scores (P<0.001). In group 1, factors independently associated with mortality were: higher FiO2 (P=0.044), bilirubin (P=0.021) and creatinine (P=0.002) on admission. Mortality was not significantly different between those with ARF on admission, and those who developed ARF during ICU stay. ARF at admission or during ICU stay is strongly predictive of mortality, which is high, despite supportive therapeutic interventions. Preventive measures are needed to prevent ARF, to improve prognosis.

Impact of acute renal failure following percutaneous coronary intervention on long-term mortality

Acute renal failure (ARF) following percutaneous coronary intervention (PCI) has been shown to be associated with a worse outcome. Whether this event should be considered as a marker of disease severity or an independent contributor to mortality is still unclear. In a multicenter, prospective cohort study we investigated the predictive variables and the impact of postprocedural ARF on 2-year all-cause mortality in 2860 consecutive patients (50% with stable angina and 50% with non-ST-elevation acute coronary syndromes) undergoing PCI. Serum creatinine determinations were made immediately before and 24 h after PCI. ARF was defined as an increase in serum creatinine of > or =0.5 mg/dl over baseline. One hundred and six patients (3.7%) experienced ARF. At logistic regression analysis, ARF was associated with pre-existing low values of estimated glomerular filtration rate, reduced left ventricular ejection fraction, hypertension, and prior coronary bypass surgery. Mortality data at 2 years were available for all patients: 119 patients (4.16%) had died, 3.9% of those without and 11.3% of those with ARF (univariate hazard ratio 3.16; 95% confidence interval 1.68-5.94; P = 0.0004). At Cox regression analysis, the significant predictors of mortality were age, ejection fraction, preprocedural estimated glomerular filtration rate, PCI failure, atrial fibrillation, diabetes mellitus, and fluoroscopy time. In this comprehensive mortality model, ARF maintained a borderline statistical significance (hazard ratio 1.83, 95% confidence interval 0.98-3.44; P = 0.06). ARF following PCI occurs almost exclusively in patients with chronic kidney disease or left ventricular dysfunction. These risk factors are also among the most powerful predictors of long-term mortality and are likely to explain most of the association between postprocedural ARF and long-term mortality. After correction for clinical determinants, however, postprocedural ARF maintains a clinically significant impact on mortality that must be taken into account for benefit vs. risk evaluation of PCI in individual patients.

Wann und wie behandeln? Therapiestrategien im Überblick

Acute renal failure is a common condition in intensive care units. The negative impact of acute renal failure on mortality has been demonstrated in recent studies. All critically ill patients should be regarded as a high risk population for renal failure. The optimization of intravasal fluid status and mean arterial pressure are preventive strategies in these patients. The use of nephrotoxic drugs (including radiocontrast media) should be avoided if possible. In cases of established acute renal failure today therapeutic strategies are still limited to best supportive care. The use of diuretics can facilitate fluid balance, however they seem to have an adverse effect on excretional renal function. A number of patients with acute renal failure need extracorporal renal support. Overload of potassium or fluids, severe acidosis, uremic pericarditis or uremic encephalopathy are urgent indications for the start of renal replacement therapy. Small randomized trials give some evidence that an early start of renal replacement therapy may be beneficial in critically ill patients. In this patient group renal replacement therapy should be considered when serum urea concentrations exceed 100mg/dl and/or when early signs of indications mentioned above are present. Large randomized multicenter trials have shown that a favourable effect on mortality can only be achieved when renal replacement therapy is supplied with a sufficient dose. Daily hemodialysis or continuous hemofiltration with a filtrate volume of 35ml/kg/h is regarded as a standard of care. There is still controversy whether continuous hemofiltration is superior to intermittent hemodialysis. Large meta-analyses could not show a difference in mortality with either one of the two therapy options.

Acute renal failure in hospitalized patients with HIV: risk factors and impact on in-hospital mortality

Kidney disease is an increasingly important complication of HIV. To examine the incidence and predictors of acute renal failure before and after the introduction of HAART, and the impact of acute renal failure on in-hospital mortality in the post-HAART era. Adults hospitalized in acute care hospitals in New York State during 1995 (pre-HAART) or 2003 (post-HAART) were identified from the state Planning and Research Cooperative System database. HIV status was defined by primary or secondary diagnosis code. The impact of HIV and HAART on the incidence of acute renal failure and mortality, and the impact of acute renal failure on mortality, was assessed using chi analysis and multivariate regression. There were 52,580 HIV-infected patients discharged from hospital in 1995 and 25,114 in 2003. Compared with uninfected patients, HIV-infected patients had an increased incidence of acute renal failure in both the pre-HAART [adjusted odds ratio (OR), 4.62; 95% confidence interval (CI), 4.30-4.95] and post-HAART eras (adjusted OR, 2.82; 95% CI, 2.66-2.99). In the post-HAART cohort, acute renal failure was associated with traditional predictors such as age, diabetes mellitus, and chronic kidney disease, as well as acute or chronic liver failure or hepatitis coinfection (P < 0.001 for all comparisons). Acute renal failure was associated with mortality among HIV-infected patients in the post-HAART era (OR, 5.83; 95% CI, 5.11-6.65). Acute renal failure remains common among hospitalized patients with HIV and is associated with chronic kidney disease, liver disease, and increased mortality.

The Burden of Acute Renal Failure in Nonrenal Solid Organ Transplantation

Recipients of nonrenal solid organ transplants are at risk for acute renal failure resulting from cardiac or hepatic failure, prolonged surgery, and nephrotoxic effects of immunosuppression. Single-center studies have suggested a variable incidence of acute renal failure in this population, with an associated increase in mortality. This study examines the incidence of acute renal failure and its associated mortality and morbidity in a modern multicenter cohort. All adult liver, heart, and lung transplant recipients from 2002 were identified from the New York Statewide Planning and Research Cooperative System database. The impact of acute renal failure on mortality, length of stay, and charges was analyzed using multivariate regression models. Among 519 liver, heart, and lung transplant recipients, the incidence of acute renal failure was 25%, with 8% of patients requiring renal replacement therapy. Acute renal failure requiring renal replacement therapy was associated with increased mortality among both heart (odds ratio, 9.0; 95% confidence interval, 1.8-45.8) and liver transplant recipients (odds ratio, 12.1; 95% confidence interval, 3.9-37.3). This degree of acute renal failure also increased length of stay by nearly 3 weeks and charges by more than $115,000. Even among patients who did not require renal replacement, acute renal failure was strongly associated with increased mortality, length of stay, and charges. Acute renal failure remains a common complication of nonrenal solid organ transplantation and is associated with increased mortality, prolonged hospitalization, and significant financial costs.

Risk Factors for Development of Acute Renal Failure After Liver Transplantation

Background. Acute renal failure (ARF) is a common complication after liver transplantation (LTx). Identification of risk factors may prevent the development and attenuate the impact of ARF on patients outcome after LTX. Methods. Retrospective analysis of variables in the pre, intra, and postoperative periods of 92 patients submitted to LTx was performed in order to identify risk factors for development of ARF after LTx. ARF was defined as serum creatinine ≥2.0 mg/dL in the first 30 days after LTx. Univariate and multivariate analysis by logistic regression were performed. Results. ARF group comprised 56 patients (61%). Preoperative serum creatinine was higher in ARF group. During the intraoperative period, ARF group required more blood transfusions, developed more episodes of hypotension and presented longer anesthesia time. In the postoperative period, ARF group presented higher serum bilirubin and more episodes of hypotension. Dialysis was required in 10 patients (11%). The identified risk factors for development of ARF were: preoperative serum creatinine >1.0 mg/dL, more than five blood transfusions in the intraoperative period, hypotension during intra and postoperative periods. The identified mortality risk factors were hypotension in the postoperative period and no recovery of renal function after 30 days. Conclusions. Several factors are involved in the pathogenesis of ARF after LTx and may influence patients outcome and mortality. Pretransplant renal function and hemodynamic conditions in the operative and postoperative periods were identified as risk factors for development of ARF after LTx. Nonrenal function recovery and postoperative hypotension were identified as mortality risk factors after LTx.

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

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. 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. 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. 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.

LOW-DOSE “RENAL” DOPAMINE

Low dose renal dopamine continues to be infused in patients at risk for renal dysfunction or as a therapy after acute renal failure has been established. This article reviews the impact of acute renal failure on patients and reviews the history and use of dopamine therapy for patients. A discussion of the rationale, positive and equivocal evidence, side effects, and possible clinical indications for low-dose renal dopamine therapy is included.

Outcome of acute renal failure associated with cardiac surgery in infants

To analyze the impact of acute renal failure (ARF) on the evolution of infants undergoing cardiac surgery. We assessed 15 infants undergoing cardiac surgery who developed (ARF). Their demographic, clinical and surgical data, and evolution were analyzed. Their mean age was 4.4+/-4.0 months (8 days to 24 months). Twelve infants were males, and 4 patients already had ARF at surgery. The primary cause of ARF was immediate acute cardiac dysfunction in 10 infants, cardiac dysfunction associated with sepsis in 2 infants, and isolated sepsis in 3 infants. All children depended on mechanical ventilation during their postoperative period, 14 infants used vasoactive drugs, and 11 had an infectious process associated with ARF. Thirteen infants required dialytic treatment. Eleven infants developed oluguric ARF, and all had to undergo peritoneal dialysis; of the 4 patients with non-oliguric, 2 required dialysis, the main indication being hypervolemia. Of these 13 dialyzed infants, 4 died in the first 24 hours because of the severity of the underlying cardiac disease (mean urea level of 49+/-20 mg/dl). The mortality rate for the entire group was 60%, and it was higher among the patients with oliguria ARF (73% vs 25%, p<0. 001). The cause of death was acute cardiac dysfunction in 6 infants (early type-1 ARF) and sepsis in the 3 remaining infants (late type-2 ARF). The mortality rate of ARF associated with cardiac surgery in infants was hight, being higher among children with oliguria; peritoneal dialysis was indicated due to clinically uncontrolled hypervolemia and not to the uremic hypercatabolic state.

Impact of acute renal failure on antioxidant status in multiple organ failure.

Acute renal failure (ARF) can be triggered or aggravated by reactive oxygen species (ROS) but established ARF per se might also affect the antioxidant defence mechanisms of the organism. We evaluated a broad pattern of antioxidants in critically ill patients with multiple organ failure with (MOF-ARF) and without acute renal failure (MOF) to identify any potential involvement of renal dysfunction in the depletion of the antioxidant system. Observational study; 13 patients with MOF were investigated (9 with and 4 without ARF), and 17 healthy subjects served as controls. Blood samples were drawn after establishment of MOF. Plasma levels of ascorbate, alpha-tocopherol, retinol, beta-carotene, selenium and lipid peroxidation products (MDA) were determined and the activities of the antioxidant enzymes catalase (CAT), superoxide dismutase (SOD) and glutathione-peroxidase (GSH-PX) in erythrocytes were measured. In addition, ROS production (superoxide anion and hydrogen peroxide) in activated neutrophils was assessed. Plasma levels of ascorbate, beta-carotene and selenium were reduced in both patient groups, when compared to controls. Decrease in selenium was more pronounced in the MOF-ARF group. MDA levels were increased in both groups, again being more pronounced in MOF-ARF patients compared to MOF patients. Hydrogen peroxide production by neutrophils from both patient groups was lower than from controls. A depression of the antioxidative system is present in critically ill patients with MOF. In patients with associated ARF this was even more pronounced and plasma MDA levels were higher, suggesting an additional effect on the antioxidative potential in the presence of renal dysfunction and/or renal replacement therapy.