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Acute renal failure (ARF) is a common problem in the neonatal intensive care unit (NICU). In most cases, ARF is associated with a primary condition such as sepsis, metabolic diseases, perinatal asphyxia and/or prematurity. This retrospective study investigated the course of illness, therapeutic interventions, early prognosis and risk factors associated with development of ARF in the neonatal period. A total of 1311 neonates were treated in our NICU during the 42-month study period, and 45 of these babies had ARF. This condition was defined as serum creatinine level above 1.5 mg/dL despite normal maternal renal function. The data collected for each ARF case were contributing condition, cause and clinical course of ARF, gestational age and birth weight, age at the time of diagnosis, treatment, presence of perinatal risk factors and need for mechanical ventilation. The frequency of ARF in the NICU during the study period was 3.4%. Premature newborns constituted 31.1% of the cases. The mean birth weight in the group was 2863 +/- 1082 g, and the mean age at diagnosis was 6.2 +/- 7.4 days. The causes of ARF were categorized as prerenal in 29 patients (64.4%), renal in 14 patients (31.1%) and postrenal in 2 patients (4.4%). Forty-seven percent of the cases were nonoliguric ARF. Asphyxia was the most common condition that contributed to ARF (40.0%), followed by sepsis/metabolic disease (22.2%) and feeding problems (17.8%). Therapeutic interventions were supportive in 77.8% of the cases, and dialysis was required in the other 22.2%. The mortality rate in the 45 ARF cases was 24.4%. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were associated with significantly increased mortality (p<0.05). There were no statistical correlations between mortality rate and perinatal risk factors, oliguria, prematurity or blood urea nitrogen and creatinine levels. The study showed that, at our institution, ARF in the neonatal period is frequently associated with preventable conditions, specifically asphyxia, sepsis and feeding problems. Supportive therapy is effective in most cases of neonatal ARF. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were identified as indicators of poor prognosis in these infants. Early recognition of risk factors and rapid effective treatment of contributing conditions will reduce mortality in neonatal ARF.
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PMID:Acute renal failure in the neonatal period. 1535 81

This was a retrospective study to assess the clinical profile of children admitted with acute renal failure and to identify factors associated with poor outcome. Fifty-four children (age one month to 12 years) with acute renal failure were studied. Males outnumbered females (38/54; 70%). The leading precipitating causes for renal failure were acute gastro-enteritis (85%), underlying renal pathology (43%), proven sepsis (22%) and suspected sepsis (22%). The main presenting complaints were diarrhoea (86%),oliguria (72%), rapid respiration (37%), oedema (37%), vomiting (19%) and seizures (13%). All patients underwent standard investigations and treatment. Forty-eight per cent of patients required peritoneal dialysis and 15% required ventilation. The overall mortality was 52%. Underlying renal pathology and sepsis both contributed to the high morbidity and mortality. Mortality due to sepsis was 83%; it was 65% in dialysed patients and 100% in those requiring ventilatory support. Biochemical profile of the above patients showed that hyperkalaemia was significantly associated with high mortality (83%) as against 75% in those with hypokalaemia and 33% with normal levels (p<0.001). Patients with hyponatraemia and hypernatraemia similarly had an adverse outcome. Acidosis, seen in 20 patients, had a mortality of 45%. The outcome was poorer in those with high creatinine levels (63%).
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PMID:Clinical profile and outcome of acute renal failure in South Indian children. 1571 79

The medical care of children with acute renal failure and the necessity of the substituting the renal functions has dramatically modified over the past 15 years. The study has been conducted retrospectively on 35 children diagnosed with acute renal failure (ARF), for analyzing the etiological spectrum, the evolutionary patterns and the influence factors of the ARF evolution. The following parameters have been taken into consideration: ARF etiology, hTA/HTA, oliguria, level of serum creatinine, the type of treatment (renal substitution by hemodialysis, peritoneal dialysis, or conservative treatment). The ARF etiology is dominated by the sepsis (31.4%) and by the hemolytic and uremic syndrome (17.1%). The treatment applied was conservative in 48.5% of the cases; 51.50% of the patients were in critical state and required extrarenal substitution by hemodialysis--42.8%--and peritoneal dialysis--8.5%. Global mortality is reduced (22.8%), but in the dialysed patients it is of 44.44%. The main death causes were: severe hepatic failure, oncological diseases, severe neurological damage and hemodynamic damages. In conclusion, the ARF prognosis in children is influenced by the comorbidity states. Dialysis has improved the therapeutic results in the currently presented lot, the death causes being extrarenal.
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PMID:[Acute renal failure in children. Study of 35 patients]. 1583 76

The aim of the research was to determine causes of acute renal failure in children, their outcome and to define risk factors associated with mortality. 75 children with acute renal failure, who were treated at the Clinic of Children's Diseases of Kaunas University of Medicine between 1998-2003 years, were included in the study. The age range of patients was 1 month to 16 years. They were divided into two groups. Acute renal failure was diagnosed in 42 (56%) patients (the first study group) and in 33 (44%) patients acute renal failure was together with multiple organ failure (the second study group). In the first study group 69% of cases of acute renal failure were found to be due to renal diseases and in the second study group 97% were because of extrarenal diseases. Sepsis was the most frequent cause of acute renal failure in the second group (p<0.02). Dialysis was made for 28% patients. Hypertension was diagnosed more often in the first patients group (p<0.05). Hypertension persisted in 9 (36%) patients after recovery. Chronic renal failure developed in two patients. 28 (37.3%) patients of the original study group died. Mortality rate for children with multiple organ failure was higher than for the children, who had renal insufficiency only (78.8% vs 4.8%; p<0.001). Mortality rate of infants in the first study group was higher than for children of the same age in the second group (p<0.001). Mortality rate for children, who had oliguria or anuria, was higher in the second group, too (p<0.001).
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PMID:[Etiology and outcomes of acute renal failure in childhood]. 1590 71

Despite significant improvements in medical care, acute renal failure (ARF) remains a high risk for mortality. It is important to be able to predict the outcome in these patients in view of the emotional and ethical needs of the patients and to address questions of efficiency and quality of care. We analyzed the risk factors predicting mortality prospectively in a group of 265 patients using univariate and multiple logistic regression analysis. A prognostic model was evolved that included 10 variables. The model showed good discrimination [(receiver operating characteristic (ROC) area=0.91) and correctly classified 88.30% of patients. The variables significantly associated with mortality were coma odds ratio (OR)=9.8], oliguria (OR=4.9), jaundice (OR=3.7), hypotension (OR=3.1), assisted ventilation (OR=2.3), hospital acquired ARF (OR=2.3), sepsis (OR=2.2), and hypoalbuminemia (OR=1.7). Age and male gender were included in the model as they are clinically important. The score was validated in the same sample by boot strapping. It was also validated in a prospective sample of 194 patients. The model was calibrated by the Hosmer-Lemeshow goodness-of-fit test. It was compared with two generic illness scores and one specific ARF score and was found to be superior to them. The model was verified in different subgroups of ARF like hospital acquired, community acquired, intensive care settings, nonintensive care settings, due to sepsis, due to nonsepsis etiologies, and showed good predictability and discrimination.
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PMID:Prediction of mortality in acute renal failure in the tropics. 1595 45

Identification of factors causing acute renal failure (ARF) and its associated poor prognosis in critically ill patients can help in planning strategies to prevent ARF and to prioritize the utilization of sparse and expensive therapeutic modalities. Most of the studies in such patients have been done in the developed world, and similar data from the developing world is sparse. We analyzed 45 consecutive patients who developed ARF in the intensive care unit (ICU) during a 12-month period. Demographic and detailed biochemical profile, previous chronic illness, precipitating factors, number of failed organs, type of ARF (oliguric/nonoliguric), and need for and type of renal replacement therapy (RRT) received were recorded at the time of admission to ICU and during the course of illness. The mean age of these patients was 43.1 years, with 75.6% being males. Hypotension, sepsis, and use of nephrotoxic drugs were common precipitating factors for ARF in these patients. However, multiple precipitating factors were present in the majority (80%): 81.5% had at least one organ failure prior to development of ARF, 71.1% had oliguria, and 71.1% required RRT. Intermittent hemodialysis was the most common form of RRT given. Patient mortality was 64.4%, with 15 of the 16 surviving patients becoming dialysis independent. We observed an increase in mortality from 0% to 100%, depending on the number of failed organs from one to six. On comparing the predictor outcomes between survivors and nonsurvivors by multivariate analysis, only the number of failed organs at the time of ARF (2.6 +/- 0.9 vs. 4.5 +/- 0.8) and serum albumin < 3.0 g/dL were found to be statistically significant. To conclude, ARF in critically ill patients is multifactorial in origin and carries a high mortality. Mortality in these patients increases with increasing numbers of failed organs and with a serum albumin of < 3.0 g/dL.
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PMID:Spectrum of acute renal failure and factors predicting its outcome in an intensive care unit in India. 1653 68

To adjust adequately for comorbidity and severity of illness in quality improvement efforts and prospective clinical trials, predictors of death after acute renal failure (ARF) must be accurately identified. Most epidemiological studies of ARF in the critically ill have been based at single centers, or have examined exposures at single time points using discrete outcomes (e.g., in-hospital mortality). We analyzed data from the Program to Improve Care in Acute Renal Disease (PICARD), a multi-center observational study of ARF. We determined correlates of mortality in 618 patients with ARF in intensive care units using three distinct analytic approaches. The predictive power of models using information obtained on the day of ARF diagnosis was extremely low. At the time of consultation, advanced age, oliguria, hepatic failure, respiratory failure, sepsis, and thrombocytopenia were associated with mortality. Upon initiation of dialysis for ARF, advanced age, hepatic failure, respiratory failure, sepsis, and thrombocytopenia were associated with mortality; higher blood urea nitrogen and lower serum creatinine were also associated with mortality in logistic regression models. Models incorporating time-varying covariates enhanced predictive power by reducing misclassification and incorporating day-to-day changes in extra-renal organ system failure and the provision of dialysis during the course of ARF. Using data from the PICARD multi-center cohort study of ARF in critically ill patients, we developed several predictive models for prognostic stratification and risk-adjustment. By incorporating exposures over time, the discriminatory power of predictive models in ARF can be significantly improved.
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PMID:Mortality after acute renal failure: models for prognostic stratification and risk adjustment. 1685 28

The spectrum of acute renal failure (ARF) in the elderly population and the factors predicting poor outcome in these patients are not well defined in literature. Identification of risk factors and poor prognostic markers in these patients can help in planning strategies to prevent ARF and to prioritise the utilization of sparse and expensive therapeutic modalities, especially in a developing country like ours. We retrospectively analyzed data of 454 elderly patients (age >or=60 years), detected having ARF in a tertiary care super-speciality hospital in North India, from April 2000 to March 2004. The mean age of this population was 66.4 years with 70.5% being male. 64% patients had more than one precipitating factors for ARF, with volume depletion being the most common precipitating factor (33% cases). Infection/sepsis (21.6%) and drugs (11.5%) were other important precipitating factors. 31.8% were recorded as having oliguric ARF (urine output <400 ml/day) and 33.5% required renal replacement therapy (RRT). Acute peritoneal dialysis was the most frequent form of RRT given (62.5%). Mortality was 41.2% (187 cases), of whom 56 (29.8%) died inspite of recovery from ARF. Among the survivors, 103 patients (22.7%) had complete renal recovery, 141 (31.1%) had partial renal recovery, while 23 (8.6%), remained dialysis dependent. The factors which were found to be associated with increased mortality were; age >or=70 years, presence of previous chronic illness, ARF precipitated by cardiac failure and infection, need for RRT, oliguria and increasing numbers of failed organs. To conclude, ARF among elderly is a common problem in nephrology practice at our institute and is responsible for 48.9% of nephrology admissions/consultations among elderly patients. Majority of these patients are prone to multiple renal insults. Underlying chronic illness, presence of cardiac failure and sepsis, oliguria, need for RRT and increasing number of organ failure is associated with poor outcome.
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PMID:Factors affecting the outcome of acute renal failure among the elderly population in India: a hospital based study. 1686 17

Acute renal failure (ARF) incidence varies depending on whether the intensive care unit only or also general and specialist medicine departments are considered. In some cases, however, such as after major cardiosurgical operations, ARF can occur in up to 30% of patients. Most of ARFs in intensive care units are secondary to acute tubular necrosis occurring because of a multi-organ dysfunction syndrome. Factors most often associated with acute renal damage are: advanced age, volume depletion, arterial hypotension, massive bleeding, and sepsis. ARF often leads to complications for the following pathologies: serious liver disease, pancreatitis, pre-existing renal dysfunction, great burns, and cardiosurgical and vascular operations on large vessels. Among the so-called 'iatrogenic factors', contrast media and aminoglycosides are definitely the main cause of a rapid deterioration of renal function. Mortality is low for the isolated forms of ARF,whereas it peaks to 0-80% in multi-organ failures where co-existing pathologies often dominate. The mortality rate over the past 20 years has not changed, although pharmacological supports and especially dialysis instruments have improved. Patients are now older and older, affected by multiple pathologies and with poor recovery capacity. Mortality is higher among elderly patients, while toxic forms (from contrast media or from myoglobinuria) result generally in better outcomes. Patients with acute renal damage and oliguria have a worse prognosis than non-oliguric patients. Finally, some unfavorable prognostic factors include the prolonged use of high dose inotropic drugs, mechanical ventilation, cardiac failure and a septic state.
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PMID:[Epidemiology of acute renal failure]. 1706 24

The role of urinary biomarkers of kidney injury in the prediction of adverse clinical outcomes in acute renal failure (ARF) has not been well described. The relationship between urinary N-acetyl-beta-(D)-glucosaminidase activity (NAG) and kidney injury molecule-1 (KIM-1) level and adverse clinical outcomes was evaluated prospectively in a cohort of 201 hospitalized patients with ARF. NAG was measured by spectrophotometry, and KIM-1 was measured by a microsphere-based Luminex technology. Mean Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) score was 16, 43% had sepsis, 39% required dialysis, and hospital mortality was 24%. Urinary NAG and KIM-1 increased in tandem with APACHE II and Multiple Organ Failure scores. Compared with patients in the lowest quartile of NAG, the second, third, and fourth quartile groups had 3.0-fold (95% confidence interval [CI] 1.3 to 7.2), 3.7-fold (95% CI 1.6 to 8.8), and 9.1-fold (95% CI 3.7 to 22.7) higher odds, respectively, for dialysis requirement or hospital death (P < 0.001). This association persisted after adjustment for APACHE II, Multiple Organ Failure score, or the combined covariates cirrhosis, sepsis, oliguria, and mechanical ventilation. Compared with patients in the lowest quartile of KIM-1, the second, third, and fourth quartile groups had 1.4-fold (95% CI 0.6 to 3.0), 1.4-fold (95% CI 0.6 to 3.0), and 3.2-fold (95% CI 1.4 to 7.4) higher odds, respectively, for dialysis requirement or hospital death (P = 0.034). NAG or KIM-1 in combination with the covariates cirrhosis, sepsis, oliguria, and mechanical ventilation yielded an area under the receiver operator characteristic curve of 0.78 (95% CI 0.71 to 0.84) in predicting the composite outcome. Urinary markers of kidney injury such as NAG and KIM-1 can predict adverse clinical outcomes in patients with ARF.
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PMID:Urinary N-acetyl-beta-(D)-glucosaminidase activity and kidney injury molecule-1 level are associated with adverse outcomes in acute renal failure. 1726 47


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