Incidence Of Acute Renal Failure In Patients Research Articles

Acute Renal Failure in Aneurysmal Subarachnoid Hemorrhage: Nationwide Analysis of Hospitalizations in the United States

Medical complications in the setting of aneurysmal subarachnoid hemorrhage (aSAH) are common and associated with poor prognosis. We analyzed the incidence, risk factors, and short-term outcomes associated with acute renal failure (ARF) in aSAH. We queried discharge records from all patients admitted to U.S. hospitals between 2002 and 2011 toidentify primary diagnoses of aSAH and secondary diagnoses of ARF. The effect of demographics, hospital characteristics, and pre-existing comorbidity on ARF occurrence and the impact of ARF occurrence on length of stay (LOS), in-hospital costs, moderate to severe disability, and in-hospital mortality were explored in both bivariate and multivariable analyses. The incidence of ARF in patients hospitalized for aSAH (N= 260,885) was 4.0% and increased from 2.1% in 2002 to 5.7% in 2011 (P < 0.0001). The strongest predictors of ARF in multivariable analysis were fluid and electrolyte disorder (odds ratio [OR], 3.24; 95% confidence interval [CI], 3.07-3.42), coagulopathy (OR, 2.43; 95% CI, 2.25-2.63), HIV (OR, 2.42; 95% CI, 1.79-3.27), and diabetes (OR, 2.37; 95% CI, 2.08-2.69). ARF onset in aSAH increased the mean length of stay by 7.2 days and mean total costs by $28,813 (all P < 0.0001). After adjusting for confounding factors, patients with ARF had increased likelihood of moderate to severe disability (OR, 2.03; 95% CI, 1.89-2.19) and in-hospital death (OR, 2.14; 95% CI, 2.03-2.26). The burden of ARF in hospitalized patients with aSAH has increased in the past decade and is detrimental to patient outcomes and healthcare costs. The identification of patient-centered risk factors may allow for close surveillance of high-risk patients.

The effects of intraoperative cryoprecipitate transfusion on acute renal failure following orthotropic liver transplantation.

PurposeThe definition of risk factors associated with acute renal failure (ARF) following orthotropic liver transplantation (OLT) is still controversial. Cryoprecipitate, which can supply fibrinogen and other coagulation factors, is widely used in OLT. However, the effects of intraoperative cryoprecipitate transfusion on ARF following OLT remain unclear.MethodsIn a series of 389 adult patients who received grafts from deceased donors and underwent their first OLT, the clinical correlation between intraoperative cryoprecipitate transfusion and ARF following OLT was retrospectively studied after adjusting for potential confounders. The distribution of ARF and the causes of death within the first year after OLT were also compared separately in patients with and without cryoprecipitate transfusion.ResultsThe incidence of ARF in patients with cryoprecipitate transfusion was significantly higher than in patients without cryoprecipitate transfusion (15.9 vs. 7.8 %, p = 0.012). A nonlinear relationship between intraoperative cryoprecipitate transfusion and ARF following OLT was observed. The risk of ARF increased with the cryoprecipitate transfusion level up to the turning point (16 U) (adjusted OR 1.1, 95 % CI 1.1–1.2; p < 0.001). When the cryoprecipitate level exceeded 16 U, the level of cryoprecipitate transfusion was not associated with the risk of ARF (OR 0.95, 95 % CI 0.85–1.1; p = 0.319). Deaths within the first year after the operation occurred more frequently in cases with cryoprecipitate transfusion (22.9 vs. 14.2 %, p = 0.029).ConclusionsThese findings suggested that intraoperative cryoprecipitate transfusion is associated with ARF following OLT. Cryoprecipitate transfusion during OLT should be performed carefully until more convincing evidence has been found.

Resuscitation with hyperoncotic colloids in the intensive care unit

Sir, Artificial colloids display nephrotoxicity, and the pathophysiological mechanisms are of considerable clinical interest [1]. In a cohort study report, Schortgen and collaborators [2] pose the question whether ‘‘highoncotic forces rather than the chemical nature of fluids have a deleterious effect on renal function’’. Unfortunately, the question is left unanswered. The study population of 1,013 intensive care unit patients was divided into four groups according to whether they received (1) crystalloids only, (2) hypo-oncotic colloids (gelatins and/or 4% albumin) with or without crystalloids, (3) artificial hyperoncotic colloids with or without crystalloids or hypo-oncotic colloids, or (4) hyperoncotic 20–25% albumin with or without crystalloids or other colloids. Dextrans and/or hydroxyethyl starches (HES) were placed in the hyperoncotic artificial colloid category. This classification scheme of itself already makes the study uninterpretable. The in vitro colloid osmotic pressure (COP) of human plasma is approximately 28 mmHg, and resuscitation fluids of comparable in vitro COP expand the intravascular space by roughly 100% of the administered volume. Such fluids are iso-oncotic. Concentration is a powerful determinant of oncotic properties. All 6% HES solutions, regardless of molecular weight and substitution, are essentially isooncotic, whereas 10% HES with an in vitro COP of 80 mmHg is hyperoncotic [3]. Therefore, the designated artificial hyperoncotic colloid group evidently received an unspecified mixture of isoand hyperoncotic fluid. Oncotic forces in vivo will also heavily depend on the volumes and properties of co-administered fluids. There was no accounting for concomitant crystalloid used in the three colloid groups or of other colloids with different oncotic properties in the two hyperoncotic colloid groups. Crucially, the plasma COP after fluid infusion was not measured. Consequently, the actual oncotic forces at work in patients remained totally undefined. Further confounding interpretation was clear bias in fluid selection. Hyperoncotic colloids were reserved for the sickest patients, as evidenced by significantly greater organ dysfunction, high-dose vasopressor use and need for mechanical ventilation at study entry. Multivariate adjustment and propensity scores were applied, but these methods cannot correct for unmeasured variables, and numerous known independent risk factors for acute renal failure (ARF) were not evaluated in this study. Indeed randomized trial evidence makes plain that the attempts to adjust for bias were unsuccessful. Thus, Schortgen et al. observed poorer renal function and increased mortality in the hyperoncotic albumin group. In contrast, in a recent metaanalysis of 25 randomized clinical trials evaluating hyperoncotic albumin for volume expansion among 1,485 total patients, there was no evidence of renal injury due to hyperoncotic albumin and no effect on survival (relative risk 0.95; 95% confidence interval 0.78–1.17) [4]. Available evidence shows that the type of fluid can govern renal effects irrespective of oncotic properties per se. For example, in randomized trials both isoand hyperoncotic HES solutions have increased the incidence of ARF in patients with severe sepsis or septic shock [5]. Conversely, in model system studies and clinical trials albumin solutions, including hyperoncotic albumin, have displayed renoprotective activity [1, 4]. Further mechanistic studies are needed to define more precisely the effects of colloids on the kidney.

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

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. 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. 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. 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.

Incidence of Acute Renal Failure Associated with Milrinone

Background: Milrinone is a phosphodiesterase type III inhibitor with positive inotropic and vasodilatory effects used in patients with severe congestive heart failure (CHF). Objectives: To determine the incidence rate of acute renal failure (ARF) associated with milrinone therapy. Methods: Medical records of 116 patients with cardiomyopathy/severe CHF who received milrinone were reviewed from January 1993 to January 1996. Twenty-nine patients were excluded, resulting in 87 patients, 4 of whom received milrinone twice. Results: During a 3-year period, 11 of 91 milrinone therapies became complicated with ARF (incidence 12%). The patients' age (mean ± SD) was 52.3 ± 13.6 years, baseline serum creatinine (SCr) was 1.6 ± 1.0 mg/dL, milrinone dose was 0.47 ± 0.16 μg/kg/min, and mean duration of therapy was 6.5 ± 10.6 days. Fourteen treatments were &lt;24 hours, 2 (14%) of which were complicated with ARF; of the remaining 77 treatments (≥24 h), 9 (11.7%) were complicated with ARF. Their peak SCr was 3.2 ± 1.5 mg/dL and time to peak SCr was 4.9 ± 2.8 days. There was no significant difference in the incidence of ARF in patients who received therapy for &lt;24 hours versus ≥24 hours; in the prevalence rate of diabetes mellitus, hypertension, coronary artery disease; or in baseline SCr, milrinone dose, and duration of therapy between patients who did and did not develop ARF. Conclusions: We found a 12% incidence of ARF in patients receiving milrinone therapy for severe CHF, which in the absence of an appropriate control group could be the aggregate effects of milrinone therapy and severe CHF.