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Prognostic Stratification in Critically Ill Patients With Acute Renal Failure Requiring Dialysis

Prognostic Stratification in Critically Ill Patients With Acute Renal Failure Requiring Dialysis Abstract Background: Despite the widespread availability of dialytic and intensive care unit technology, the probability of early mortality in critically ill persons with acute renal failure is distressingly high. Previous efforts to predict outcome in this population have been limited by small sample size and the absence of uniform exclusion criteria. Additionally, data obtained decades ago may not apply today owing to changes in case mix. Methods: The medical records of 132 consecutive patients in the intensive care unit with acute renal failure who required dialysis from 1991 through 1993 were evaluated by a blinded reviewer. Results: The overall in-hospital mortality rate was 70%. Twelve readily available historical, clinical, and laboratory variables were significantly associated with in-hospital mortality. Multivariate logistic regression analysis showed that mechanical ventilation, malignancy, and nonrespiratory organ system failure were independently associated with in-hospital mortality. Using a 95% positivity criterion, this model identified 24% of high-risk patients who died, without misclassification of any survivors. Of those who survived to hospital discharge, 33% were dialysis dependent and 28% were institutionalized long-term. Conclusions: Among critically ill patients, acute renal failure requiring dialysis is an ominous condition with a high risk of in-hospital mortality. This risk appears to depend largely on comorbid conditions, such as the need for mechanical ventilation and underlying malignancy. While this prognostic model requires prospective validation, it appears to identify a substantial fraction of patients for whom dialysis may be of limited or no benefit.(Arch Intern Med. 1995;155:1505-1511) References 1. Maher E, Robinson K, Scoble J, et al. Prognosis of critically ill patients with acute renal failure: APACHE II score and other predictive factors. Q J Med . 1989;72:857-866. 2. McMurray S, Luft F, Maxwell D, et al. Prevailing patterns and predictor variables in patients with acute tubular necrosis. Arch Intern Med . 1978;138:950-955.Crossref 3. Wheeler D, Feehally J, Walls J. High-risk acute renal failure. Q J Med . 1986; 61:977-984. 4. Schaefer J, Jochimsen F, Keller F, Wegscheider K, Distler A. Outcome prediction of acute renal failure in medical intensive care. Intensive Care Med . 1991; 17:19-24.Crossref 5. Barton I, Hilton P, Taub N, et al. Acute renal failure treated by haemofiltration: factors affecting outcome. Q J Med . 1993;86:81-90. 6. Lohr J, McFarlane M, Grantham J. A clinical index to predict survival in acute renal failure patients requiring dialysis. Am J Kidney Dis . 1988;11: 254-259.Crossref 7. Cioffi W, Ashikaga T, Gamelli R. Probability of surviving postoperative acute renal failure. Ann Surg . 1984;200:205-211.Crossref 8. Berisa F, Beaman M, Adu D, et al. Prognostic factors in acute renal failure following aortic aneurysm surgery. Q J Med . 1990;76:689-698. 9. Spiegel D, Ullian M, Zerbe G, Berl T. Determinants of survival and recovery in acute renal failure patients dialyzed in intensive care units. Am J Nephrol . 1991; 11:44-47.Crossref 10. Groeneveld A, Tran D, van der Meulen J, Nauta J, Thijs L. Acute renal failure in the medical intensive care unit: predisposing, complicating factors and outcome. Nephron . 1991;59:602-610.Crossref 11. Lien J, Chan V. Risk factors influencing survival in acute renal failure treated by hemodialysis. Arch Intern Med . 1985;145:2067-2069.Crossref 12. Rasmussen H, Pitt E, Ibels L, McNeil D. Prediction of outcome in acute renal failure by discriminant analysis of clinical variables. Arch Intern Med . 1985; 145:2015-1018.Crossref 13. Corwin H, Teplick R, Schreiber M, Fang L, Bonventre J, Coggins C. Prediction of outcome in acute renal failure. Am J Nephrol . 1987;7:8-12.Crossref 14. Bullock M, Umen A, Finkelstein M, Keane W. The assessment of risk factors in 462 patients with acute renal failure. Am J Kidney Dis . 1985;5:97-103.Crossref 15. Lanore J, Brunet F, Pochard F, et al. Hemodialysis for acute renal failure in patients with hematologic malignancies. Crit Care Med . 1991;19:346-351.Crossref 16. Frost L, Pedersen R, Bentzen S, Bille H, Hansen H. Short- and long-term outcome in a consecutive series of 419 patients with acute dialysis—requiring renal failure. Scand J Urol Nephrol . 1993;27:453-462.Crossref 17. Turney J, Marshall D, Brownjohn A, Ellis C. The evolution of acute renal failure, 1956-1988. Q J Med . 1991;74:83-104. 18. Routh G, Briggs J, Mone J, Ledingham I. Survival from acute renal failure with and without multiple organ dysfunction. Postgrad Med J . 1980;56:244-247.Crossref 19. Gottlieb M, Hoette M, Lazarus M, Lowrie E, Merrill J. Analysis of risk factors in acute renal failure. Am Soc Nephrol . 1976;9:14. Abstract. 20. Tran D, Oe P, deFijter C, van der Meulen J, Cuesta M. Acute renal failure in patients with acute pancreatitis: prevalence, risk factors, and outcome. Nephrol Dial Transplant . 1993;8:1079-1084. 21. Abreo K, Moorthy V, Osborne M. Changing patterns and outcome of acute renal failure requiring hemodialysis. Arch Intern Med . 1986;146:1338-1341.Crossref 22. Anderson R, Linas S, Berns A, et al. Nonoliguric acute renal failure. N Engl J Med . 1977;296:1134-1138.Crossref 23. Acchiardo S, Moore L, LaTour P. Malnutrition as the main factor in morbidity and mortality of hemodialysis patients. Kidney Int . 1983;24( (suppl) ):S199-S203. 24. Harter H. Review of findings from the National Cooperative Dialysis Study and recommendations. Kidney Int . 1983;23( (suppl) ):S107-S112.Crossref 25. Lowrie E, Lew N. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis . 1990;15:458-482.Crossref 26. Hakim R, Levin N. Malnutrition in hemodialysis patients. Am J Kidney Dis . 1993;21:125-137.Crossref 27. Owen W, Lew N, Liu Y, Lowrie E, Lazarus J. The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med . 1993;329:1001-1006.Crossref 28. Hou S, Bushinsky D, Wish J, Cohen J, Harrington J. Hospital-acquired renal insufficiency: a prospective study. Am J Med . 1983;74:243-248.Crossref 29. Kaufman J, Dhakal M, Patel B, Hamburger R. Community-acquired acute renal failure. Am J Kidney Dis . 1991;17:191-198.Crossref 30. Knaus W, Draper E, Wagner D, Zimmerman J. APACHE II: severity of disease classification system. Crit Care Med . 1985;13:818-829.Crossref 31. Knaus W, Draper E, Wagner D, Zimmerman J. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med . 1986;104:410-418.Crossref 32. Stott R, Cameron J, Ogg C, Bewick M. Why the persistently high mortality in acute renal failure? Lancet . 1972;2:75-79.Crossref 33. Chew S, Lins R, Daelemans R, DeBroe M. Outcome in acute renal failure. Nephrol Dial Transplant . 1993;8:101-107. 34. Feest T, Round A, Hamad S. Incidence of severe acute renal failure in adults: results of a community based study. BMJ . 1993;306:481-483.Crossref 35. Kleinbaum D, Kupper L, Muller K. Straight-line regression analysis. In: Applied Regression Analysis and Other Multivariable Measures . 2nd ed. Boston, Mass: Duxbury Press; 1988:41-79. 36. Efron B, Gong G. A leisurely look at the bootstrap, the jackknife, and cross validation. Am Statistician . 1983;37:36-48. 37. Kaplan E, Meier P. Nonparametric estimation from incomplete observations. JAm Stat Assoc . 1958;53:457-481.Crossref 38. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep . 1966;50:163-170. 39. Spurney R, Fulkerson W, Schwab S. Acute renal failure in critically ill patients: prognosis for recovery of kidney function after prolonged dialytic support. Crit Care Med . 1991;19:8-11.Crossref 40. Zager R, O'Quigley J, Zager B, et al. Acute renal failure following bone marrow transplantation: a retrospective study of 272 patients. Am J Kidney Dis . 1989; 13:210-216.Crossref 41. Butkus D. Persistent high mortality in acute renal failure: are we asking the right questions? Arch Intern Med . 1983;143:209-212.Crossref 42. Conger J. A controlled evaluation of prophylactic dialysis in post-traumatic acute renal failure. J Trauma . 1975;15:1056-1063.Crossref 43. Gillum D, Dixon B, Yanover M, et al. The role of intensive dialysis in acute renal failure. Clin Nephrol . 1986;25:249-255. 44. Bellomo R, Parkin G, Love J, Boyce N. Management of acute renal failure in the critically ill with continuous venovenous hemodiafiltration. Ren Fail . 1992; 4:183-186.Crossref 45. Henrich W. Arteriovenous or venovenous continuous therapies are not superior to standard hemodialysis in all patients with acute renal failure. Semin Dial . 1993;6:174-176.Crossref 46. Paganini E. Continuous renal replacement is the preferred treatment for all acute renal failure patients receiving intensive care. Semin Dial . 1993;6:176-179.Crossref 47. Lazarus J. Which dialytic therapy is best for the patient with an unstable cardiovascular system? hemodialysis is the optimal therapy. Semin Dial . 1992; 5:208-211.Crossref 48. Mehta R. Therapeutic alternatives to renal replacement for critically ill patients in acute renal failure. Semin Nephrol . 1994;14:64-82. 49. Hakim R. Clinical implications of hemodialysis membrane biocompatibility. Kidney Int . 1993;44:484-494.Crossref 50. Hakim R, Wingard R, Parker R. Dialysis membranes in the treatment of patients with acute renal failure. N Engl J Med . 1994;331:1338-1342.Crossref 51. Abel R, Beck C, Abbott W, Ryan J, Barnett G, Fischer J. Improved survival from acute renal failure after treatment with intravenous essential L-amino acids and glucose. N Engl J Med . 1973;288:695-699.Crossref 52. Blumenkrantz M, Kopple J, Koffler A, et al. Total parenteral nutrition in the management of acute renal failure. Am J Clin Nutr . 1978;31:1831-1840. 53. Compher C, Mullen J, Barker C. Nutritional support in renal failure. Surg Clin North Am . 1991;71:597-608. 54. US Renal Data System. USRDS Annual Data Report . Bethesda, Md: National Institute of Diabetes and Digestive and Kidney Diseases; July 1994. 55. Humphrey H, Hall J, Szajder I, Silverstein M, Wood L. Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure. Chest . 1990;97:1176-1180.Crossref 56. Wasson J, Sox H, Neff R, Goldman L. Clinical prediction rules: applications and methodologic standards. N Engl J Med . 1985;313:793-799.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Prognostic Stratification in Critically Ill Patients With Acute Renal Failure Requiring Dialysis

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430140075007
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Abstract

Abstract Background: Despite the widespread availability of dialytic and intensive care unit technology, the probability of early mortality in critically ill persons with acute renal failure is distressingly high. Previous efforts to predict outcome in this population have been limited by small sample size and the absence of uniform exclusion criteria. Additionally, data obtained decades ago may not apply today owing to changes in case mix. Methods: The medical records of 132 consecutive patients in the intensive care unit with acute renal failure who required dialysis from 1991 through 1993 were evaluated by a blinded reviewer. Results: The overall in-hospital mortality rate was 70%. Twelve readily available historical, clinical, and laboratory variables were significantly associated with in-hospital mortality. Multivariate logistic regression analysis showed that mechanical ventilation, malignancy, and nonrespiratory organ system failure were independently associated with in-hospital mortality. Using a 95% positivity criterion, this model identified 24% of high-risk patients who died, without misclassification of any survivors. Of those who survived to hospital discharge, 33% were dialysis dependent and 28% were institutionalized long-term. Conclusions: Among critically ill patients, acute renal failure requiring dialysis is an ominous condition with a high risk of in-hospital mortality. This risk appears to depend largely on comorbid conditions, such as the need for mechanical ventilation and underlying malignancy. While this prognostic model requires prospective validation, it appears to identify a substantial fraction of patients for whom dialysis may be of limited or no benefit.(Arch Intern Med. 1995;155:1505-1511) References 1. Maher E, Robinson K, Scoble J, et al. Prognosis of critically ill patients with acute renal failure: APACHE II score and other predictive factors. Q J Med . 1989;72:857-866. 2. McMurray S, Luft F, Maxwell D, et al. Prevailing patterns and predictor variables in patients with acute tubular necrosis. Arch Intern Med . 1978;138:950-955.Crossref 3. Wheeler D, Feehally J, Walls J. High-risk acute renal failure. Q J Med . 1986; 61:977-984. 4. Schaefer J, Jochimsen F, Keller F, Wegscheider K, Distler A. Outcome prediction of acute renal failure in medical intensive care. Intensive Care Med . 1991; 17:19-24.Crossref 5. Barton I, Hilton P, Taub N, et al. Acute renal failure treated by haemofiltration: factors affecting outcome. Q J Med . 1993;86:81-90. 6. Lohr J, McFarlane M, Grantham J. A clinical index to predict survival in acute renal failure patients requiring dialysis. Am J Kidney Dis . 1988;11: 254-259.Crossref 7. Cioffi W, Ashikaga T, Gamelli R. Probability of surviving postoperative acute renal failure. Ann Surg . 1984;200:205-211.Crossref 8. Berisa F, Beaman M, Adu D, et al. Prognostic factors in acute renal failure following aortic aneurysm surgery. Q J Med . 1990;76:689-698. 9. Spiegel D, Ullian M, Zerbe G, Berl T. Determinants of survival and recovery in acute renal failure patients dialyzed in intensive care units. Am J Nephrol . 1991; 11:44-47.Crossref 10. Groeneveld A, Tran D, van der Meulen J, Nauta J, Thijs L. Acute renal failure in the medical intensive care unit: predisposing, complicating factors and outcome. Nephron . 1991;59:602-610.Crossref 11. Lien J, Chan V. Risk factors influencing survival in acute renal failure treated by hemodialysis. Arch Intern Med . 1985;145:2067-2069.Crossref 12. Rasmussen H, Pitt E, Ibels L, McNeil D. Prediction of outcome in acute renal failure by discriminant analysis of clinical variables. Arch Intern Med . 1985; 145:2015-1018.Crossref 13. Corwin H, Teplick R, Schreiber M, Fang L, Bonventre J, Coggins C. Prediction of outcome in acute renal failure. Am J Nephrol . 1987;7:8-12.Crossref 14. Bullock M, Umen A, Finkelstein M, Keane W. The assessment of risk factors in 462 patients with acute renal failure. Am J Kidney Dis . 1985;5:97-103.Crossref 15. Lanore J, Brunet F, Pochard F, et al. Hemodialysis for acute renal failure in patients with hematologic malignancies. Crit Care Med . 1991;19:346-351.Crossref 16. Frost L, Pedersen R, Bentzen S, Bille H, Hansen H. Short- and long-term outcome in a consecutive series of 419 patients with acute dialysis—requiring renal failure. Scand J Urol Nephrol . 1993;27:453-462.Crossref 17. Turney J, Marshall D, Brownjohn A, Ellis C. The evolution of acute renal failure, 1956-1988. Q J Med . 1991;74:83-104. 18. Routh G, Briggs J, Mone J, Ledingham I. Survival from acute renal failure with and without multiple organ dysfunction. Postgrad Med J . 1980;56:244-247.Crossref 19. Gottlieb M, Hoette M, Lazarus M, Lowrie E, Merrill J. Analysis of risk factors in acute renal failure. Am Soc Nephrol . 1976;9:14. Abstract. 20. Tran D, Oe P, deFijter C, van der Meulen J, Cuesta M. Acute renal failure in patients with acute pancreatitis: prevalence, risk factors, and outcome. Nephrol Dial Transplant . 1993;8:1079-1084. 21. Abreo K, Moorthy V, Osborne M. Changing patterns and outcome of acute renal failure requiring hemodialysis. Arch Intern Med . 1986;146:1338-1341.Crossref 22. Anderson R, Linas S, Berns A, et al. Nonoliguric acute renal failure. N Engl J Med . 1977;296:1134-1138.Crossref 23. Acchiardo S, Moore L, LaTour P. Malnutrition as the main factor in morbidity and mortality of hemodialysis patients. Kidney Int . 1983;24( (suppl) ):S199-S203. 24. Harter H. Review of findings from the National Cooperative Dialysis Study and recommendations. Kidney Int . 1983;23( (suppl) ):S107-S112.Crossref 25. Lowrie E, Lew N. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis . 1990;15:458-482.Crossref 26. Hakim R, Levin N. Malnutrition in hemodialysis patients. Am J Kidney Dis . 1993;21:125-137.Crossref 27. Owen W, Lew N, Liu Y, Lowrie E, Lazarus J. The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med . 1993;329:1001-1006.Crossref 28. Hou S, Bushinsky D, Wish J, Cohen J, Harrington J. Hospital-acquired renal insufficiency: a prospective study. Am J Med . 1983;74:243-248.Crossref 29. Kaufman J, Dhakal M, Patel B, Hamburger R. Community-acquired acute renal failure. Am J Kidney Dis . 1991;17:191-198.Crossref 30. Knaus W, Draper E, Wagner D, Zimmerman J. APACHE II: severity of disease classification system. Crit Care Med . 1985;13:818-829.Crossref 31. Knaus W, Draper E, Wagner D, Zimmerman J. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med . 1986;104:410-418.Crossref 32. Stott R, Cameron J, Ogg C, Bewick M. Why the persistently high mortality in acute renal failure? Lancet . 1972;2:75-79.Crossref 33. Chew S, Lins R, Daelemans R, DeBroe M. Outcome in acute renal failure. Nephrol Dial Transplant . 1993;8:101-107. 34. Feest T, Round A, Hamad S. Incidence of severe acute renal failure in adults: results of a community based study. BMJ . 1993;306:481-483.Crossref 35. Kleinbaum D, Kupper L, Muller K. Straight-line regression analysis. In: Applied Regression Analysis and Other Multivariable Measures . 2nd ed. Boston, Mass: Duxbury Press; 1988:41-79. 36. Efron B, Gong G. A leisurely look at the bootstrap, the jackknife, and cross validation. Am Statistician . 1983;37:36-48. 37. Kaplan E, Meier P. Nonparametric estimation from incomplete observations. JAm Stat Assoc . 1958;53:457-481.Crossref 38. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep . 1966;50:163-170. 39. Spurney R, Fulkerson W, Schwab S. Acute renal failure in critically ill patients: prognosis for recovery of kidney function after prolonged dialytic support. Crit Care Med . 1991;19:8-11.Crossref 40. Zager R, O'Quigley J, Zager B, et al. Acute renal failure following bone marrow transplantation: a retrospective study of 272 patients. Am J Kidney Dis . 1989; 13:210-216.Crossref 41. Butkus D. Persistent high mortality in acute renal failure: are we asking the right questions? Arch Intern Med . 1983;143:209-212.Crossref 42. Conger J. A controlled evaluation of prophylactic dialysis in post-traumatic acute renal failure. J Trauma . 1975;15:1056-1063.Crossref 43. Gillum D, Dixon B, Yanover M, et al. The role of intensive dialysis in acute renal failure. Clin Nephrol . 1986;25:249-255. 44. Bellomo R, Parkin G, Love J, Boyce N. Management of acute renal failure in the critically ill with continuous venovenous hemodiafiltration. Ren Fail . 1992; 4:183-186.Crossref 45. Henrich W. Arteriovenous or venovenous continuous therapies are not superior to standard hemodialysis in all patients with acute renal failure. Semin Dial . 1993;6:174-176.Crossref 46. Paganini E. Continuous renal replacement is the preferred treatment for all acute renal failure patients receiving intensive care. Semin Dial . 1993;6:176-179.Crossref 47. Lazarus J. Which dialytic therapy is best for the patient with an unstable cardiovascular system? hemodialysis is the optimal therapy. Semin Dial . 1992; 5:208-211.Crossref 48. Mehta R. Therapeutic alternatives to renal replacement for critically ill patients in acute renal failure. Semin Nephrol . 1994;14:64-82. 49. Hakim R. Clinical implications of hemodialysis membrane biocompatibility. Kidney Int . 1993;44:484-494.Crossref 50. Hakim R, Wingard R, Parker R. Dialysis membranes in the treatment of patients with acute renal failure. N Engl J Med . 1994;331:1338-1342.Crossref 51. Abel R, Beck C, Abbott W, Ryan J, Barnett G, Fischer J. Improved survival from acute renal failure after treatment with intravenous essential L-amino acids and glucose. N Engl J Med . 1973;288:695-699.Crossref 52. Blumenkrantz M, Kopple J, Koffler A, et al. Total parenteral nutrition in the management of acute renal failure. Am J Clin Nutr . 1978;31:1831-1840. 53. Compher C, Mullen J, Barker C. Nutritional support in renal failure. Surg Clin North Am . 1991;71:597-608. 54. US Renal Data System. USRDS Annual Data Report . Bethesda, Md: National Institute of Diabetes and Digestive and Kidney Diseases; July 1994. 55. Humphrey H, Hall J, Szajder I, Silverstein M, Wood L. Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure. Chest . 1990;97:1176-1180.Crossref 56. Wasson J, Sox H, Neff R, Goldman L. Clinical prediction rules: applications and methodologic standards. N Engl J Med . 1985;313:793-799.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 24, 1995

References