Prognosis Of Acute Renal Failure Research Articles

Characteristics and prognosis of acute renal failure on dialysis in ANCA vasculitis

Renal involvement in ANCA (Anti Neutrophil Cytoplasmic Antigen) vasculitis is common and is associated with increased mortality with a significant risk of progression to end-stage renal disease. The aim of this study is to investigate the epidemiological, clinicopathological, therapeutic and evolutionary characteristics of patients with ANCA vasculitis with acute renal injury, and to evaluate the impact of haemodialysis in the acute phase on mortality and renal recovery. Secondary objectives are to investigate other risk factors that impact on overall and renal survival. 31 patients were included; the mean follow-up time was 30 months. The mean age was 68.52 years, and the sex ratio 0.72. All patients had acute renal failure, with histology revealing a mixed form in 45% of cases and a sclerotic form in 12.9% of cases. Pulmonary involvement was found in 58% of cases. 71% of patients had ANCA with anti-myeloperoxydase specificity, and 25.8% anti-proteinase3 specificity. 32.2% of patients required haemodialysis, of which 60% were weaned. As initial treatment, 58.1% of patients received cyclophosphamide and 35.5% rituximab. The relapse rate was 6.5%. Infectious and cardiovascular complications affected more than half of the patients. The mortality rate was 19.35%. Comparing the two groups of patients dialysed in the acute phase and not dialysed, it appears that the overall and renal mortality was comparable. The progression to end-stage renal failure was higher in the dialysis patients. In a multivariate study, the presence of chronic kidney disease in the history and pulmonary involvement were associated with higher mortality.

Incidence and Prognosis of Acute Renal Failure in Patients with Severe Sepsis and Septic Shock

Background: Sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. Acute kidney injury (AKI), previously called acute renal failure (ARF) is an abrupt loss of kidney function, Generally it occurs because of damage to the kidney tissue caused by decreased kidney blood flow (Kidney ischemia) from any cause. AKI may lead to a number of complications, including metabolic acidosis, high potassium levels, uremia, changes in body fluid balance, and effects on other organ systems, including death. Aim: The aim of the study is to show the incidence and prognosis of acute renal failure in patients with sepsis and septic shock. Patients and methods: This prospective randomized study was conducted on patients who were admitted to ICU in Ain Shams University Hospitals. Forty patients were included in this study and an informed written consent was obtained from patients and/or relatives. All patients were adult, more than 18 years old, admitted to ICU suffering from severe sepsis or had septic shock for monitoring, management and follow up to their condition in period of six months. All patients were more than 18 years old that were critically ill either in severe sepsis or had septic shock. We excluded patients less than 18 years old, patient or relatives who refused to be included in this study, and if he/she has a history of previous kidney troubles or dysfunction. All patients were subjected to assessment of the demographic data of the patient, causes and site of infection, pathogenic bacteria as declared by different cultures, APACHE 2 score on admission, all patients were managed as declared by ICU, protocol for septic patients, hemodynamic monitoring was done daily, routine lab investigation daily, coagulation profile had to be done on days 0, 3, 7 of admission, SOFA score on days 0, 3, 7 of admission, renal functions include blood urea and creatinine clearance test had to be done daily, any deterioration of renal function was reported, and if the patient was in need for renal replacement therapy or dialysis, this would be reported. Results: Forty patients were included in this study, their ages with a mean of 58.37 ± 15.66 years. 23 patients (57.5%) were males and 17 patients (42.5%) were females. The most frequent risk factors were hypertension (62.5%) followed by diabetes (52.5%). The incidence of AKI was 60% of patients and the need for renal replacement therapy (RRT) was 9 (22.5%). Outcome of admitted patients in ICU was 23 (57.5%) survived patients and 17 (42.5%) non-survived patients. The study showed that there were no statistical significant differences between AKI and Non-AKI patients except for; gender (male), BMI, gram –ve bacterial infection, creatinine, BUN, creatinine clearance, history of ACE administration, use of vasopressors, APACHE II score at admission and mortality were statistically significant (p < 0.05). Conclusion: The incidence of AKI was 60% of patients in our study. The development of septic AKI adversely affected clinical outcomes. Moreover, the severity of AKI was associated with increased short-term mortality as observed in ICU patients. The study showed that there were no statistical significant differences between AKI and Non-AKI patients except for; gender (male), BMI, gram –ve bacterial infection, creatinine, BUN, creatinine clearance, history of ACE administration, use of vasopressors, APACHE II score at admission and mortality were statistically significant (p < 0.05).

Incidence and Prognosis of Acute Renal Failure in Patients with Severe Sepsis and Septic Shock

Incidence and Prognosis of Acute Renal Failure in Patients with Severe Sepsis and Septic Shock

Prognosis of Acute Renal Failure of the Child during Severe Malaria in Niamey-Niger

Introduction: In malaria-endemic areas, acute renal failure (ARF) is one of the most serious complications, it occurs in 40% of severe forms of malaria in adults and is linked to 75% of deaths, especially when extra-renal cleaning is not available. In children, studies of ARF during malaria are limited. We have no published studies on this topic in Niger. The main objective of our study is to evaluate the prognosis of ARF during severe malaria in children. Patients and Method: This is a one-year prospective study (January 1, 2016 to December 31, 2016) conducted in the resuscitation unit of the pediatric department of the National Lamorde Hospital of Niamey (Niger). We included in the study children aged 0 to 15 years hospitalized for severe malaria with impaired renal function. Patients who had chronic renal failure or who had acute renal failure with a thick negative drop were excluded from the study. Acute renal failure is defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria basing on creatinine clearance. Results: The incidence of ARF was 12.60%. The mean age of the patients was 4.25 ± 1.3 years [8 months - 15 years]. The mean hemoglobin level was 8.2 ± 2.7 g/dl. In 54.02% of cases, the hemoglobin level is ≤5 g/dl. Mean serum creatinine was 543.7 ± 69.5 μmol/l [107 - 2500 μmol/l] and mean azotemia was 27.5 ± 3.5 mmol/l. Severe anemia (54.02%) were more related to the occurrence of ARF(with p = 0.014). According to the RIFLE classification, 55 patients (63.22%) were in the Risk stage, 18 patients (20.69%) were in the injury stage and 14 patients (16.09%) in the failure stage. All patients were placed on injectable Artesunate. The average length of hospital stay was 8.6 ± 4.5 days [5 to 22 days]. Dialysis was reported in 15/87 (17.24%). For technical and financial reasons only 8 patients were hemodialysed. Indications for dialysis were severe uremic syndrome 7 cases (8.04%), fluid overload 5 cases (5.75%) and severe hyperkalemia 3 cases (3.45%). Conclusion: The etiological factors of ARI in malaria were massive hemoglobinuria, severe anemia and shock. Adequate management of simple cases of malaria and the early transfer of severe cases to resuscitation services can prevent certain complications such as acute renal failure.

PP.17.21] ACUTE RENAL FAILURE SECONDARY TO RENINE ANGIOTENSIN SYSTEM BLOKERS

Objective: Blockers of the renin angiotensin system (BSRA) are commonly used in hypertension, cardiovascular and renal diseases. However their use is associated with risk including renal affects. The aim of this study is to determine the progression and prognosis of acute renal failure (ARI) secondary to BSRA. Design and method: study is retrospective during 9 years (January 2004-December 2012) interesting patients admitted for ARI secondary to the BSRA. The endpoints were:short-term improvement of renal function (1 month) and long-term hemodialysis (5 years). Results: We collected 116 cases of ARI secondary to BSRA therapy. the average age was 69 ± 12 years with a sex ratio of 0.7. A history of hypertension, diabetes, heart failure and CKD was observed in 85.3%, 38.8%, 21.6% and 35.3%, respectively. An associated drug was noted 28.4%: anti inflammatory drugs (17.2%), aminosides (3.4%) and Iodized contrast agents (7%). In the short term, the absence of improvement in renal function was observed in 19% of cases. Patients who did not improve their renal function were older (70 ± 10 years versus 64 ± 16 years) than those with improvement (p = 0.028). After discharge, 31% of these patients are lost to follow-up, 4.3% have aggravated their renal function and / or reached the end stage of CKD. Diabetes (p = 0.012), hypertension (p = 0.015), history of nephropathy (p = 0.001) and winter season (p = 0.002) are factors for poor long-term prognosis. Conclusions: The ARI due to BSRA is associated with a high morbidity and mortality. Our study showed that advanced age is a factor of poor short term progression. Long-term prognostic factors were hypertension, diabetes a history of nephropathy and the winter season. The ARI to BSRA represents an often avoidable adverse event, the prognosis of which is usually better than that of ARI related to other etiologies.

Gabriel Richet (1916-2014).

Raymond A. Ardaillou1 and Pierre M. Ronco2,3 for the Tenon community 1National Academy of Medicine, Paris, France; 2Renal Medicine, University Pierre and Marie Curie, Paris, France and 3Department of Nephrology and Dialysis and INSERM 1155, Tenon Hospital, Paris, France Correspondence: Pierre M. Ronco, University Pierre and Marie Curie, INSERM Unit 702, 4 rue de la Chine, Tenon Hospital, F-75020 Paris, France. E-mail: pierre.ronco@tnn.aphp.fr B orn in 1916 during the First World War, Gabriel Richet was the fourth of a lineage of famous academic medical doctors, all professors at the Faculte de Medecine in Paris, including his grandfather Charles Richet, who was awarded the Nobel Prize in 1913 for the discovery of anaphylaxis. Gabriel Richet was 23 years old at the outbreak of the Second World War. He had just passed the highly competitive residency examination when he was enlisted in the French army and actively participated in the military campaign. After being a prisoner of war in Germany for a short period, he was released and resumed his activities as a physician in the Paris hospital system. During the German occupation all members of the Richet family were actively engaged in the resistance movement. His father, Charles Richet, was deported by the occupational forces to the concentration camp Dachau, his brother Olivier to Dora, and his cousin Jacqueline Richet-Souchere to Ravensbruck, and his mother, Marthe, was jailed at Fresnes outside of Paris. Soon after the liberation of Paris in 1944, Gabriel Richet enrolled in the army under the high command of General Leclerc, whose army freed Strasbourg in November 1944. In the first months of 1945, fights continued in the area of Colmar in the south of Alsace where Gabriel Richet was active as a doctor of the French commandos. He was injured, received three military citations, and was decorated with the award of Chevalier de la Legion d’Honneur by General de Gaulle in April 1945. Demobilized from the army, Gabriel Richet joined the department of Louis Pasteur ValleryRadot, where he met Jean Hamburger, whom he followed to Necker Hospital to establish in 1950 the first French department of nephrology. He worked together with Jean Hamburger for 10 years, and both are considered to rank among the postwar rebuilders of French academic medicine. At Necker Hospital, Richet introduced treatment of acute kidney injury with the artificial kidney, which dramatically improved the prognosis of acute kidney failure associated with sepsis and crush syndrome. Together with the other members of the team of Jean Hamburger, Gabriel Richet was a leading investigator contributing to the worldwide reputation of the Necker ne phrology department. He was involved in the first allogenic kidney transplantation from a mother to her son, opening up exciting new therapeutic perspectives in living related transplantation. Introducing the percutaneous kidney biopsy pioneered by Claus Brun, Richet together with Hamburger contributed to the routine histological diagnosis of glomerular diseases, including the first studies by electron microscopy. The Necker team also demonstrated that most patients with advanced renal failure died from serious electrolyte changes rather than from retention of waste products such as urea. This led Richet together with Jean Hamburger and Jean Crosnier to develop the concept of renal intensive care aimed at correcting disorders of the major fluid, electrolyte, acid–base, and other metabolic functions, thereby markedly improving the prognosis of acute renal failure. In 1961, Gabriel Richet was appointed chief of nephrology at Tenon Hospital, at that time an inconspicuous city hospital in the middle of nowhere. He immediately set out to create a clinical and research nephrology center by recruiting a team that initially included Claude Amiel, Raymond Ardaillou, and Liliane Morel-Maroger. This team was then joined by Francoise Mignon, JeanDaniel Sraer, Pierre Verroust, Pierre Ronco, Eric Rondeau, and many others. This nephrology center was made possible by a new hospital wing supported by the French state through the Assistance Publique–Hopitaux de Paris and by INSERM (the French equivalent of the US National Institutes of Health), the University of Paris, the Association Claude Bernard, and the CNRS (National Center for Scientific Research), which also supported the research. Thereby Gabriel Richet succeeded in his goal of making the nephrology center at Tenon Hospital a place of national and international excellence for renal diseases as well as an intellectual haven, a foyer intellectuel, as he used to call it. The success could be measured by the large number of fellows and visiting faculty from countries all over the world who trained or did research in this multilingual and multicultural Tenon community, a virtual nephrological tower of Babel. Gabriel Richet provided a unique atmosphere of intellecGabriel Richet (1916–2014)

Common toxicological conditions in the cat

ABSTRACT:This article examines three of the most common toxins for cats in a home environment. Permethrin-based spot-on products are widely available and often used accidentally on cats, resulting in twitching or seizures. Lilies often result in vomiting and severe renal failure when only a very small amount is ingested, if not identified and treated promptly. Ethylene glycol, most commonly found in antifreeze products, often carries a grave prognosis of acute renal failure. Basic treatment, expected clinical signs and prognosis are outlined for each poison, along with general poisoning first aid advice.

Acute kidney injury in the tropics

Acute kidney injury (AKI) is one of the most challenging problems faced by clinicians in the tropics owing to its fast-changing burden. AKI in the tropics is strikingly different from that in the developed world in terms of etiology and presentation. In addition, there is a stark contrast between well-developed and poor areas in the tropics. The true epidemiological picture of AKI in the tropics is not well understood due to the late presentation of patients to tertiary centers. Infections remain the major culprit in most cases of AKI, with high mortality rates in the tropics. Human immunodeficiency virus–related AKI, related to nephrotoxicity due to antiretroviral therapy, is on the rise. Acute tubular necrosis and thrombotic microangiopathy are the most common mechanisms of AKI. A notable problem in the tropics is the scarcity of resources in health centers to support patients who require critical care due to AKI. This article reviews the unique and contrasting nature of AKI in the tropics and describes its management in each situation.

A positive fluid balance is associated with a worse outcome in patients with acute renal failure.

IntroductionDespite significant improvements in intensive care medicine, the prognosis of acute renal failure (ARF) remains poor, with mortality ranging from 40% to 65%. The aim of the present observational study was to analyze the influence of patient characteristics and fluid balance on the outcome of ARF in intensive care unit (ICU) patients.MethodsThe data were extracted from the Sepsis Occurrence in Acutely Ill Patients (SOAP) study, a multicenter observational cohort study to which 198 ICUs from 24 European countries contributed. All adult patients admitted to a participating ICU between 1 and 15 May 2002, except those admitted for uncomplicated postoperative surveillance, were eligible for the study. For the purposes of this substudy, patients were divided into two groups according to whether they had ARF. The groups were compared with respect to patient characteristics, fluid balance, and outcome.ResultsOf the 3,147 patients included in the SOAP study, 1,120 (36%) had ARF at some point during their ICU stay. Sixty-day mortality rates were 36% in patients with ARF and 16% in patients without ARF (P < 0.01). Oliguric patients and patients treated with renal replacement therapy (RRT) had higher 60-day mortality rates than patients without oliguria or the need for RRT (41% versus 33% and 52% versus 32%, respectively; P < 0.01). Independent risk factors for 60-day mortality in the patients with ARF were age, Simplified Acute Physiology Score II (SAPS II), heart failure, liver cirrhosis, medical admission, mean fluid balance, and need for mechanical ventilation. Among patients treated with RRT, length of stay and mortality were lower when RRT was started early in the course of the ICU stay.ConclusionIn this large European multicenter study, a positive fluid balance was an important factor associated with increased 60-day mortality. Outcome among patients treated with RRT was better when RRT was started early in the course of the ICU stay.

Nefropatía inducida por contraste y fracaso renal agudo tras cateterismo cardiaco urgente: incidencia, factores de riesgo y pronóstico

The aim was to investigate the incidence and prognosis of, and predictive factors for, acute renal failure following emergent cardiac catheterization. The study involved 602 consecutive patients who underwent emergent cardiac catheterization. Acute renal failure (ARF) was defined as an increase in serum creatinine level > or =0.5 mg/dL within 72 hours following the procedure. Predictive factors for and the prognosis of ARF were evaluated in an initial cohort of 315 patients, and a risk score was derived. The risk score was validated in a second cohort of 287 patients. The median (interquartile) follow-up time was 1.3 years (0.8-2.0 years). Seventy-two of the 602 patients (12.0%) developed ARF. In the initial cohort of 315 patients, the following factors were predictors of ARF: cardiogenic shock at admission (odds ratio [OR] 4.56), diabetes mellitus (OR 2.98), time to reperfusion >6 hours (OR 3.18), anterior myocardial infarction (OR 2.61), baseline serum creatinine level > or =1.5 mg/dL (OR 3.51), and baseline serum urea level > or =50 mg/dL (OR 3.00). A risk score based on these variables was constructed in which cardiogenic shock = 3 points and each of the remaining variables = 2 points. Patients in the validation cohort were divided into five risk categories: in those with 0 points, the incidence of ARF was 1.2%; with 2-3 points, 8.7%; with 4-5 points, 12.5%; with 6-7 points, 46.2%; and with > or =8 points, 66.7% (P< .0001). Cox regression analysis showed that ARF was a powerful predictor of total mortality (hazard ratio [HR] 5.97, 95% confidence interval [CI] 2.54-14.03; P< .0001) and of a major cardiovascular event (HR 3.29, 95% CI 1.61-6.75; P=.001). The incidence of ARF after emergent cardiac catheterization is high. Cardiogenic shock, diabetes mellitus, myocardial infarction location, time to reperfusion, and serum creatinine and urea levels are predictors of ARF. Patients who developed this complication had higher mortality and major cardiovascular events rates.

Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study

BackgroundThe aim of this study is to evaluate the association between acute serum creatinine changes in acute renal failure (ARF), before specialized treatment begins, and in-hospital mortality, recovery of renal function, and overall mortality at 6 months, on an equal degree of ARF severity, using the RIFLE criteria, and comorbid illnesses.MethodsProspective cohort study of 1008 consecutive patients who had been diagnosed as having ARF, and had been admitted in an university-affiliated hospital over 10 years. Demographic, clinical information and outcomes were measured. After that, 646 patients who had presented enough increment in serum creatinine to qualify for the RIFLE criteria were included for subsequent analysis. The population was divided into two groups using the median serum creatinine change (101%) as the cut-off value. Multivariate non-conditional logistic and linear regression models were used.ResultsA ≥ 101% increment of creatinine respect to its baseline before nephrology consultation was associated with significant increase of in-hospital mortality (35.6% vs. 22.6%, p < 0.001), with an adjusted odds ratio of 1.81 (95% CI: 1.08–3.03). Patients who required continuous renal replacement therapy in the ≥ 101% increment group presented a higher increase of in-hospital mortality (62.7% vs 46.4%, p = 0.048), with an adjusted odds ratio of 2.66 (95% CI: 1.00–7.21). Patients in the ≥ 101% increment group had a higher mean serum creatinine level with respect to their baseline level (114.72% vs. 37.96%) at hospital discharge. This was an adjusted 48.92% (95% CI: 13.05–84.79) more serum creatinine than in the < 101% increment group.ConclusionIn this cohort, patients who had presented an increment in serum level of creatinine of ≥ 101% with respect to basal values, at the time of nephrology consultation, had increased mortality rates and were discharged from hospital with a more deteriorated renal function than those with similar Liano scoring and the same RIFLE classes, but with a < 101% increment. This finding may provide more information about the factors involved in the prognosis of ARF. Furthermore, the calculation of relative serum creatinine increase could be used as a practical tool to identify those patients at risk, and that would benefit from an intensive therapy.

Prognosis of acute renal failure in children

Acute renal failure (ARF) is the acute loss of renal function over a period of hours or days. Given the poor prognosis of ARF among children, there is some urgency to identifying more effective prognostic indicators for detecting disease onset. Such indicators would help provide the means of selecting patients who would benefit the most from early aggressive treatment. In this study we assessed the etiologic and prognostic indicators of ARF, including several risk factors such as sepsis, respiratory distress, age, among others, in 300 children who were admitted to the Ali Asghar Children's Hospital, Tehran, Iran, from 1990 to 2003. Statistical analysis was performed using multiple regression and chi-square methods, and a score to determine the prognosis of ARF in children was developed. Based on the results of this study the three common causes of ARF are acute tubular necrosis (ATN, 38%), acute glumerulonephritis (24%) and hemolytic uremic syndrome (24.1%). The overall mortality rate among our patients was 24.7%, with the highest risk group being those patients suffering from ischemic ATN. In addition, the correlation (p<0.0005) between the etiology and mortality rate was particularly high in patients with ischemic ATN. Mortality was also high (68%) in children younger than 2 years. Multiple regression models revealed that among those factors that significantly differed between the survivors and nonsurvivors, only the necessity of dialysis (p<0.0005), the use of mechanical ventilation (p=0.05) and disseminated intravascular coagulation (p=0.038) can be regarded as independent determinants of ARF prognosis in children.

The Rise of Prevalence and the Fall of Mortality of Patients with Acute Renal Failure

Acute renal failure (ARF) remains one of the most enigmatic syndromes in nephrology, with reported incidence rates varying from 0.9 to 20% and mortality rates between 25 to 80% ([1][1]). There is little doubt that these discrepancies are caused by large differences in the definition of ARF ([2][2

Year in review 2005: Critical Care – nephrology

We summarize original research in the field of critical care nephrology accepted or published in 2005 in Critical Care and, when considered relevant or directly linked to this research, in other journals. The articles have been grouped into four categories to facilitate a rapid overview. First, physiopathology, epidemiology and prognosis of acute renal failure (ARF): an extensive review and some observational studies have been performed with the aim of describing aspects of ARF physiopathology, precise epidemiology and long-term outcomes. Second, several authors have performed clinical trials utilizing a potential nephro-protective drug, fenoldopam, with different results. Third, the issue of continuous renal replacement therapies dose has been addressed in a small prospective study and a large observational trial. And fourth, alternative indications to extracorporeal treatment of ARF and systemic inflammatory response syndrome have been explored by three original clinical studies.

Place de la ponction biopsie rénale dans l'insuffisance rénale aiguë en réanimation

Acute renal failure (ARF) in intensive care unit patients is mostly due to ischemic acute tubular necrosis. ARF may have numerous other etiologies and the timely institution of the appropriate treatment for some causes may preserve renal function and improve outcome. The role of renal biopsy (RB) in the diagnosis and prognosis of ARF is debated and only few data have been published on this topic in ICU patients. RB is unnecessary when ARF is due to urinary tract obstruction, to vascular obstruction, and to acute tubular necrosis. The use of RB in the early phase of ARF is usually considered in patients with extrarenal manifestations suggesting the possibility of a systemic disease, in patients with a clinical evaluation and biological findings suggesting a glomerulonephritis, an acute interstitial nephritis or a microangiopathy, and in the absence of an obvious cause of ARF. The contraindications to RB included uncontrolled hypertension, cysts and tumors in the kidney, renal artery aneurysm, uncontrolled hemorrhagic diathesis, single or malformative kidney, perinephric abcess, and pyonephrosis. The precautions in performing RB included correcting arterial hypertension, normalizing coagulation and keeping hematocrit over 30%. The technique of RB in ICU patients is quite similar to the standard procedure and use of 18-gauge automated needle with real time ultrasonography guidance is recommended, making the procedure safer. Following the biopsy, blood pressure and pulse rates should be monitored and urines samples should be checked for possible macroscopic hematuria. The patient hematocrit should be checked 6 hours and then 24 hours after biopsy. In patients with contraindications open renal biopsy is a safer procedure. Recently, the transjugular renal biopsy technique was reported to be a relatively safe, reliable and minimally invasive procedure with an excellent diagnostic yield in high risk patients.

Acute Renal Failure After Cardiac Surgery for Carcinoid Heart Disease: Incidence, Risk Factors, and Prognosis

Cardiac surgery for carcinoid heart disease may be associated with acute renal failure (ARF) and multiorgan dysfunction postoperatively. This study was performed to determine the incidence, risk factors, and prognosis of ARF after cardiac surgery for carcinoid heart disease. This is a case-control study of 86 consecutive patients who underwent cardiac surgery for carcinoid heart disease. ARF is defined as hemodialysis requirement or serum creatinine level 50% greater than baseline, resulting in an estimated creatinine clearance less than 40 mL/min (0.67 mL/s). Preoperative, operative, and postoperative characteristics were examined and compared between groups to determine risk factors and prognosis of ARF. ARF occurred in 22% of cases (19 of 86 patients). Preoperative characteristics and type of procedure did not differ between groups. Operative variables associated with ARF by means of univariate analysis included longer surgical and bypass times, intra-aortic balloon pump use, and perioperative epinephrine requirement. Postoperatively, ARF was associated with epinephrine use, prolonged mechanical ventilation, prolonged intensive care unit admission, and higher Acute Physiology and Chronic Health Evaluation II scores. Perioperative mortality in the ARF group was 47% versus 4.5% in the control group (odds ratio, 36.1; 95% confidence interval, 8.0 to 261.8). ARF developed in a relatively high proportion of this cohort, but traditional preoperative risks failed to predict post-cardiac surgery ARF. Variables closely related to perioperative hemodynamic compromise were associated with ARF. ARF portends a particularly poor prognosis in this cohort that is explained largely by multiorgan failure syndrome.

Prognosis of acute renal failure: an evaluation of proposed consensus criteria

To validate the recently proposed criteria for acute renal injury (ARI), acute renal failure syndrome (ARFS) and severe acute renal failure syndrome (SARFS) and to evaluate the significance of other prognostic factors. Retrospective analysis of the Riyadh ICU Program database of patients admitted to 22 ICUs in UK and Germany between 1989 and 1998. Included in the study were 41,972 patients, of whom 7,522 (17.9%) had ARI, 2,641 (6.3%) had ARFS and 1,747 (4.2%) had SARFS. Patients with ARI, ARFS or SARFS had a hospital mortality of 29.5%, 49.2% or 63.0%, respectively, compared to 10.3% among patients without acute renal failure. In the presence of contemporaneous failure of any other organs on the day of acute renal failure, hospital mortality increased to 73.3%, 76.2%, 72.1% and 18%, respectively. Multivariate analysis showed that non-surgical admission, need for emergency surgery, development of acute renal failure during stay in ICU, need for mechanical ventilation and the number of other failed organ systems had a greater impact on prognosis than the need for renal replacement therapy. The proposed criteria for ARI, ARFS and SARFS correlated with mortality, but other factors had a greater impact on prognosis. Renal replacement therapy did not increase the risk of hospital mortality among patients with acute renal failure.

Re-evaluation and modification of the Stuivenberg Hospital Acute Renal Failure (SHARF) scoring system for the prognosis of acute renal failure: an independent multicentre, prospective study.

A prognostic scoring system for hospital mortality in acute renal failure (Stuivenberg Hospital Acute Renal Failure, SHARF score) was developed in a single-centre study. The scoring system consists of two scores, for the time of diagnosis of acute renal failure (ARF) and for 48 h later, each originally based on four parameters (age, serum albumin, prothrombin time and heart failure). The scoring system was now tested and adapted in a prospective study. The study involved eight intensive care units. We studied 293 consecutive patients with ARF in 6 months. Their mortality was 50.5%. The causes of ARF were medical in 184 (63%) patients and surgical in 108 (37%). In the latter group, 74 (69%) patients underwent cardiac and 19 (18%) vascular surgery. As the performance of the original SHARF scores was much lower in the multicentre study than in the original single-centre study, we re-analysed the multicentre data to customize the original model for the population studied. The independent variables were the score developed in the original study plus all additonal parameters that were significant on univariate analysis. The new multivariate analysis revealed an additional subset of three parameters for inclusion in the model (serum bilirubin, sepsis and hypotension). For the modified SHARF II score, r(2) was 0.27 at 0 and 0.33 at 48 h, respectively, the receiver operating characteristic (ROC) values were 0.82 and 0.83, and the Hosmer-Lemeshow goodness-of-fit P values were 0.19 and 0.05. After customizing and by using two scoring moments, this prediction model for hospital mortality in ARF is useful in different settings for comparing groups of patients and centres, quality assessment and clinical trials. We do not recommend its use for individual patient prognosis.

P386 The prognosis of acute renal failure in an intensive care unit

P386 The prognosis of acute renal failure in an intensive care unit

Risk Factors of Emergency Hemodialysis

Objectives: Emergency hemodialysis (HD) is a chal1en~e to patients, their families and nephrologists. The majority of previous reports focused on the prognosis of acute renal failure, but acute renal failure is not the only indication for emergency HD in the emergency department (ED): chronic renal failure accounts for the majority of HD cases. The aim of this study was to analyze the risk factors of all patients who need emergency HD in ED. Methods: We retrospectively collected 90 emergency HD cases from July 1999 to August 2000. By analyzing their basic data, vital signs and laboratory data, we were able to determine the risk factors of emergency HD. Results: The mortality rate was 24.4%. The leading causes of death were septic shock, respiratory failure, and multiple organ failure. Thirty-seven-patients had no history of hemodialysis, and they did not have significant mortality risk. Some of the indications for emergency HD did predict survival rate. For example, pulmonary edema was the benign factor but metabolic acidosis, uremic encephalopathy and intractable gastrointestinal upset were the predictors of mortality. Younger patients and those with a history of diabetes mellitus had good prognoses. Those who had received cardiopulmonary resuscitation (CPR) or mechanical ventilator therapy before emergency HD had poor prognoses. Metabolic acidosis, leukocytosis, high C-reactive protein and blood urea nitrogen levels were all poor prognostic factors. Conclusions: The main indicators of the need for patients receiving emergency HD were pulmonary edema, hyperkalemia, metabolic acidosis and uremic encephalopathy. The leading cause of death was septic shock. Risk factors of emergency HD included patients who were elderly, and those who received mechanical ventilator support and CPR; the indicators for dialysis were metabolic acidosis, uremic encephalopathy, and intractable GI upset; laboratory data indicators included leukocytosis, high C-reactive protein and blood urea nitrogen levels.