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      Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study

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          Abstract

          Introduction

          Severe acute renal failure (sARF) is associated with considerable morbidity, mortality and use of healthcare resources; however, its precise epidemiology and long-term outcomes have not been well described in a non-specified population.

          Methods

          Population-based surveillance was conducted among all adult residents of the Calgary Health Region (population 1 million) admitted to multidisciplinary and cardiovascular surgical intensive care units between May 1 1999 and April 30 2002. Clinical records were reviewed and outcome at 1 year was assessed.

          Results

          sARF occurred in 240 patients (11.0 per 100,000 population/year). Rates were highest in males and older patients (≥65 years of age). Risk factors for development of sARF included previous heart disease, stroke, pulmonary disease, diabetes mellitus, cancer, connective tissue disease, chronic renal dysfunction, and alcoholism. The annual mortality rate was 7.3 per 100,000 population with rates highest in males and those ≥65 years. The 28-day, 90-day, and 1-year case-fatality rates were 51%, 60%, and 64%, respectively. Increased Charlson co-morbidity index, presence of liver disease, higher APACHE II score, septic shock, and need for continuous renal replacement therapy were independently associated with death at 1 year. Renal recovery occurred in 78% (68/87) of survivors at 1 year.

          Conclusion

          sARF is common and males, older patients, and those with underlying medical conditions are at greatest risk. Although the majority of patients with sARF will die, most survivors will become independent from renal replacement therapy within a year.

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          Most cited references37

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          Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score.

          A. de Mendonca, J-L Vincent, P Suter … (2000)
          To describe risk factors for the development of acute renal failure (ARF) in a population of intensive care unit (ICU) patients, and the association of ARF with multiple organ failure (MOF) and outcome using the sequential organ failure assessment (SOFA) score. Prospective, multicenter, observational cohort analysis. Forty ICUs in 16 countries. All patients admitted to one of the participating ICUs in May 1995, except those who stayed in the ICU for less than 48 h after uncomplicated surgery, were included. After the exclusion of 38 patients with a history of chronic renal failure requiring renal replacement therapy, a total of 1411 patients were studied. Of the patients, 348 (24.7%) developed ARF, as diagnosed by a serum creatinine of 300 micromol/l (3.5 mg/dl) or more and/or a urine output of less than 500 ml/day. The most important risk factors for the development of ARF present on admission were acute circulatory or respiratory failure; age more than 65 years, presence of infection, past history of chronic heart failure (CHF), lymphoma or leukemia, or cirrhosis. ARF patients developed MOF earlier than non-ARF patients (median 24 vs 48 h after ICU admission, p < 0.05). ARF patients older than 65 years with a past history of CHF or with any organ failure on admission were most likely to develop MOF. ICU mortality was 3 times higher in ARF than in other patients (42.8% vs 14.0%, p < 0.01). Oliguric ARF was an independent risk factor for overall mortality as determined by a multivariate regression analysis (OR = 1.59 [CI 95%: 1.23-2.06], p < 0.01). Infection increased the risk of death associated with all factors. Factors that increased the ICU mortality of ARF patients were a past history of hematologic malignancy, age more than 65 years, the number of failing organs on admission and the presence of acute cardiovascular failure. In ICU patients, the most important risk factors for ARF or mortality from ARF are often present on admission. During the ICU stay, other organ failures (especially cardiovascular) are important risk factors. Oliguric ARF was an independent risk factor for ICU mortality, and infection increased the contribution to mortality by other factors. The severity of circulatory shock was the most important factor influencing outcome in ARF patients.
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            Epidemiology of acute renal failure: a prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group.

            F Liaño, J Pascual (1996)
            There are very limited data on overall epidemiology of ARF. It is crucial to know the incidence, etiology and clinical feature of ARF to promote prevention strategies and to implement adequate resources for the management of this entity. During a nine month period, a collaborative prospective protocol with 98 variables was developed to assess all ARF episodes encountered in the 13 tertiary-care hospitals in Madrid, Spain (covering 4.2 million people of over 14 years of age). ARF was considered when a sudden rise in serum creatinine concentration (SCr) to more than 177 mumol/liter was found in patients with normal renal function, or when the sudden rise (50% or more) was observed in patients with previous mild-to-moderate chronic renal failure (SCr < 264 mumol/liter). Of the 748 cases of ARF studied, 665 episodes presented in inhabitants from the Madrid area. This gives an overall incidence of ARF of 209 cases per million population (p.m.p.; 95% CJ 195 to 223). The incidence of acute tubular necrosis (ATN) was 88 cases p.m.p. (95% CI 79 to 97), prerenal ARF 46 p.m.p (95% CI 40 to 52), acute-onset chronic ARF 29 p.m.p. (95% CI 24 to 34), and obstructive ARF 23 p.m.p. (95% CI 19 to 27). The mean age was 63 +/- 17 years. The most frequent causes of ARF were ATN (45%), prerenal (21%), acute-onset chronic renal failure (12.7%) and obstructive ARF (10%). Renal function was normal at admission in 48% of patients who later developed ARF. Mortality (45%) was much higher than that of the other patients admitted (5.4%, P < 0.001). This real outcome correlated extremely well with the expected outcome calculated through out the severity index of ARF (SI) 0.433 +/- 0.246 (mean +/- SD). In 187 cases, mortality was attributed to underlying disease, thus corrected mortality due to ARF was 26.7%. Dialysis was required in 36% of patients, and was associated with a significantly higher SI of ARF (0.57 +/- 0.23 vs. 0.35 +/- 0.19, P < 0.001) and mortality (65.9 vs. 33.2%, P < 0.001). Mortality in patients hemodialyzed with biocompatible synthetic membranes (N = 50) was similar to that observed with cellulosic ones (N = 84; 66% vs. 59.5%, NS). Mortality was higher in patients with coma, assisted respiration, hypotension, jaundice (all P < 0.001) and oliguria (P < 0.02). This study gives, for the first time, the incidence of all forms of ARF in a developed country. ARF is iatrogenically induced at a high rate by modern medicine. Prevention strategies, particularly in the perioperative period, are needed to decrease its impact.
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              Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients*

              Philipp G H Metnitz, Claus G Krenn, Heinz Steltzer … (2002)
              Acute renal failure is a complication in critically ill patients that has been associated with an excess risk of hospital mortality. Whether this reflects the severity of the disease or whether acute renal failure is an independent risk factor is unknown. The aim of this study was to analyze severity of illness and mortality in a group of critically ill patients with acute renal failure requiring renal replacement therapy in a number of Austrian intensive care units.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Crit Care
                Title: Critical Care
                Publisher: BioMed Central (London )
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Print): 2005
                Publication date (Electronic): 25 October 2005
                Volume: 9
                Issue: 6
                Pages: R700-R709
                Affiliations
                [1 ]Fellow, Departments of Critical Care Medicine, and Community Health Sciences, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                [2 ]Assistant Professor, Departments of Critical Care Medicine, Medicine, Community Health Sciences and Pathology and Laboratory Medicine, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                [3 ]Associate Professor, Departments of Critical Care Medicine, Medicine and Community Health Sciences, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                [4 ]Clinical Assistant Professor, Department of Medicine, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                [5 ]Professor, Department of Community Health Sciences, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                [6 ]Research Assistant, Department of Medicine, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                [7 ]Clinical Assistant Professor, Departments of Critical Care Medicine and Medicine, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                [8 ]Associate Professor, Department of Community Health Sciences, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                [9 ]Epidemiologist, Health Surveillance Branch, Alberta Health and Wellness, Edmonton Alberta, Canada
                [10 ]Associate Professor, Department of Public Health Sciences, University of Alberta, Edmonton Alberta, Canada
                [11 ]Associate Professor, Departments of Medicine and Community Health Sciences, Calgary Health Region and University of Calgary, Calgary Alberta, Canada
                Article
                Publisher ID: cc3879
                DOI: 10.1186/cc3879
                PMC ID: 1414056
                PubMed ID: 16280066
                SO-VID: cc96f31e-3d94-4637-bfa6-38f076edc6cc
                Copyright © Copyright © 2005 Bagshaw et al.; licensee BioMed Central Ltd.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 18 July 2005
                Date revision requested : 24 August 2005
                Date revision received : 18 September 2005
                Date accepted : 26 September 2005
                Categories
                Subject: Research

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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