the long-term outcome after acute renal failure.ppt

The long-term outcome The long-term outcome after acute renal failureafter acute renal failure

Presented by Ri Presented by Ri 顏玎安顏玎安

IntroductionIntroduction

Popular-based incidence and risk factors for Popular-based incidence and risk factors for developing severe acute renal failuredeveloping severe acute renal failure

Long-term outcomes and prognosis for surviLong-term outcomes and prognosis for survivors of critical illnessvors of critical illness

SurvivalSurvival Renal recovery Renal recovery Heath-related quality of lifeHeath-related quality of life Health economics effectsHealth economics effects

Annual incidence and mortality Annual incidence and mortality raterate

Annual incidence rate:11.0/10,000/year

Annual mortality rate:7.3/10,000/year

Risk factorsRisk factors

Risk factors:Risk factors: Previous heart dxPrevious heart dx StrokeStroke Pulmonary dxPulmonary dx DMDM Connective tissue dxConnective tissue dx Chronic renal dysfunctionChronic renal dysfunction AlcoholismAlcoholism

Popular-based risk factors of Popular-based risk factors of ARFARF

Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study, Critical Care 2005, 9:R700-R709

Survival Survival

Survival rates Survival rates 90 days: 46~74%90 days: 46~74% 6 months: 55~73%6 months: 55~73% 1 year: 57~65%1 year: 57~65% 5 years:65~70%5 years:65~70%

Survival Rate Survival Rate

0%

10%

20%

30%

40%

50%

60%

70%

80%

90 days 6 months 1 year 5 year

lower range

upper range

mean

Factors V.S Long-term Factors V.S Long-term mortalitymortality

Associated …..Associated ….. Older ageOlder age Greater burden of co-morbid illnessGreater burden of co-morbid illness

Assessed by Charlson co-morbidity indexAssessed by Charlson co-morbidity index Chronic liver diseaseChronic liver disease High severity of illnessHigh severity of illness

Assessed by APACHE Ⅱor SOFA scores Assessed by APACHE Ⅱor SOFA scores Severe sepsis/septic shockSevere sepsis/septic shock Postcardiac surgical acute renal failurePostcardiac surgical acute renal failure

Factors V.S Long-term Factors V.S Long-term survivalsurvival

Not significantly associated…Not significantly associated… Renal replacement therapy modalityRenal replacement therapy modality

CRRT V.S IHDCRRT V.S IHD SexSex OliguriaOliguria Need for mechanical ventilationNeed for mechanical ventilation Etiology of sARFEtiology of sARF Indication for RRTIndication for RRT Pre-existing renal diseasePre-existing renal disease High intensity of prescribed RRT: High intensity of prescribed RRT:

only improve survival in short termonly improve survival in short term

Factors associated with death in 1 Factors associated with death in 1 yearyear

Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study, Critical Care 2005, 9:R700-R709

Renal recoveryRenal recovery

Important clinical measure of Important clinical measure of morbiditymorbidity

Recovery to independence from RRT Recovery to independence from RRT continues continues after hospital dischargeafter hospital discharge

Peak recovery rate: Peak recovery rate: 9090 days with days with 60~70% independent form RRT60~70% independent form RRT

Long term recovery rate : not well Long term recovery rate : not well describeddescribed

Renal recoveryRenal recovery

No studies have specifically addressed what faNo studies have specifically addressed what factors are predictive of long-term recovery.ctors are predictive of long-term recovery.

Factors associated with Factors associated with reduced reduced recoveryrecovery Older ageOlder age Female sexFemale sex The presence of co-morbidities, esp CKDThe presence of co-morbidities, esp CKD Parenchymal etiology of ARFParenchymal etiology of ARF Late initiation of RRT Late initiation of RRT Use of conventional intermittent RRTUse of conventional intermittent RRT

Renal recovery- Renal recovery- Recurring need for renal replacement Recurring need for renal replacement

therapytherapy

Study of critically ill patients with severe Study of critically ill patients with severe acute renal failure with normal preexistiacute renal failure with normal preexisting kidney function ng kidney function

Low recurrence rate for renal replacemeLow recurrence rate for renal replacement therapy after initial recovery.nt therapy after initial recovery.

~Renal recovery from acute tubular necrosis requiring renal replacement t~Renal recovery from acute tubular necrosis requiring renal replacement therapy: a prospective study in critically ill patients. By Schiffl H. Nephrolherapy: a prospective study in critically ill patients. By Schiffl H. Nephrol

--Dial Transplant 2006; 21:1248–1252.Dial Transplant 2006; 21:1248–1252.


Popular-based incidence and risk factors Popular-based incidence and risk factors for developing severe acute renal failurefor developing severe acute renal failure

Long-term outcomes and prognosis for sLong-term outcomes and prognosis for survivors of critical illnessurvivors of critical illness


Health-related quality of life & Health-related quality of life & Health economic implicationsHealth economic implications

HRQoL is generally good and acceptablHRQoL is generally good and acceptable by survivors of critically illness and ARe by survivors of critically illness and ARFF

Provision of RRT in critically ill patients Provision of RRT in critically ill patients with sever ARF is expensivewith sever ARF is expensive

Plasma concentration of tumor Plasma concentration of tumor necrosis factor alpha may predict the necrosis factor alpha may predict the outcome of patients with acute renal outcome of patients with acute renal failurefailure ~Kidney and Blood Pressure Research. ~Kidney and Blood Pressure Research. 29(4):203~209, 200629(4):203~209, 2006 Background/Aims:Background/Aims:

Plasma TNF-alphaPlasma TNF-alpha is frequently elevated chronic renal failure on is frequently elevated chronic renal failure on

HD HD correlates with mortalitycorrelates with mortality

Results:Results: TNF-alpha in ARF patientsTNF-alpha in ARF patients

Markedly higher (70ng/ml) than reference Markedly higher (70ng/ml) than reference value (<5 pg/ml)value (<5 pg/ml)

Significantly lower than HD patients (216 Significantly lower than HD patients (216 pg/ml)pg/ml)

Plasma concentration of tumor Plasma concentration of tumor necrosis factor alpha may predict the necrosis factor alpha may predict the outcome of patients with acute renal outcome of patients with acute renal failurefailure ~Kidney and Blood Pressure Research. ~Kidney and Blood Pressure Research. 29(4):203~209, 200629(4):203~209, 2006

ResultsResults:: TNF-alpha in ARF patientsTNF-alpha in ARF patients

Remained elevated in polyuric phaseRemained elevated in polyuric phase Initially lower than70 ng/ml predicted the benefiInitially lower than70 ng/ml predicted the benefi

cial outcome with sensitivity of 64%, specificity cial outcome with sensitivity of 64%, specificity of 70%of 70%

Conclusions:Conclusions: TNF-alpha may predict the outcome of ARFTNF-alpha may predict the outcome of ARF TNF-alpha remained elevated at polyuric phase desTNF-alpha remained elevated at polyuric phase des

pite marked improvement of excretory kidney func.pite marked improvement of excretory kidney func.

Predictors of mortality in patients with acPredictors of mortality in patients with acute renal failureute renal failure ~Acta Medica. 49(3): 183-8,2006~Acta Medica. 49(3): 183-8,2006 3 independent predictors of mortality3 independent predictors of mortality

Increased APACHE Ⅲ scoreIncreased APACHE Ⅲ score Presence of cor-morbid conditionsPresence of cor-morbid conditions Low serum albumin levelLow serum albumin level

Key messagesKey messages

Factors independently associated with long-teFactors independently associated with long-term mortality:rm mortality: High-mortility and pre-existing co morbidities, liver High-mortility and pre-existing co morbidities, liver

disease, higher APACHE score on ICU admission, sedisease, higher APACHE score on ICU admission, septic shock, albumin levelptic shock, albumin level

Majority of patients with sARF will dieMajority of patients with sARF will die In those who survive : majority will recover renIn those who survive : majority will recover ren

al function and become independent of RTT wal function and become independent of RTT within 1 year ithin 1 year

Factors associated with mortality in acute Factors associated with mortality in acute renal failure (ARF) in childrenrenal failure (ARF) in children ~Pediatirc Nephrology ;Jan~Pediatirc Nephrology ;Jan 2006 2006 The most affected age were The most affected age were

newborns and infantsnewborns and infants Mechanism:Mechanism:

Type of clinical presentation:NonoliguriType of clinical presentation:Nonoliguriaa

Factors associated with mortality in acute Factors associated with mortality in acute renal failure (ARF) in childrenrenal failure (ARF) in children ~Pediatirc Nephrology ;Jan 2006~Pediatirc Nephrology ;Jan 2006

In multinominal logistic regression analysis, oIn multinominal logistic regression analysis, only nly oliguria oliguria ((PP=0.07) and =0.07) and age groupage group ( (PP=0.049) =0.049) were associated with were associated with mortalitymortality


In the Cox model survival analysis, In the Cox model survival analysis, oliguria oliguria ((PP==0.003) and 0.003) and sepsissepsis ( (PP=0.03) influenced survival =0.03) influenced survival


Factors associated with mortality in acuteFactors associated with mortality in acuterenal failure (ARF) in childrenrenal failure (ARF) in children ~Pediatirc Nephrology ;Jan 2006~Pediatirc Nephrology ;Jan 2006

Oliguria

non-Oliguria

With sepsis

Without sepsis

Reference:Reference:

The long-term outcome after acute renal failureThe long-term outcome after acute renal failure--Curr Opin Crit Care 12:561–566Curr Opin Crit Care 12:561–566..

Renal recovery from acute tubular necrosis requiring renal replacRenal recovery from acute tubular necrosis requiring renal replacement therapy: a prospective study in critically ill patients. By Scement therapy: a prospective study in critically ill patients. By Schiffl H.hiffl H.

-Nephrol Dial Transplant 2006; 21:1248–1252.-Nephrol Dial Transplant 2006; 21:1248–1252. Prognosis for long-term survival and renal recovery in critically ill Prognosis for long-term survival and renal recovery in critically ill

patients with severe acute renal failure: a population-based studpatients with severe acute renal failure: a population-based study. Bagshaw SM, Laupland KB, Doig CJ, et al.y. Bagshaw SM, Laupland KB, Doig CJ, et al. -Cri-Crit Care 2005; 9:R700–R709t Care 2005; 9:R700–R709

Predictors of mortality in patients with acute renal failurePredictors of mortality in patients with acute renal failure Acta Medica. 49(3): 183-8, 2006 Acta Medica. 49(3): 183-8, 2006

ReferenceReference

Plasma concentration of TNF-alpha may predict the oPlasma concentration of TNF-alpha may predict the outcome of patients with acute renal failureutcome of patients with acute renal failure

Kidney and Blood Pressure research. 29(4):203-9, 2006Kidney and Blood Pressure research. 29(4):203-9, 2006 Factors associated with mortality in acute renal failurFactors associated with mortality in acute renal failur

e (ARF) in childrene (ARF) in children Pediatric Nephrology;Jan 2006, Vol.21, Issue 1,p106-9Pediatric Nephrology;Jan 2006, Vol.21, Issue 1,p106-9

~Thank you~~Thank you~

~Mucha gracias!~Mucha gracias!

the long-term outcome after acute renal failure.ppt

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