| Abstract|| |
This study was performed to evaluate hospital-acquired renal insufficiency with special reference to the causative factors, clinical course and patient management. A total of 100 patients who were admitted to medical and surgical wards at the King Hussein Medical Center, Amman, Jordan over a 15-month period and who developed renal failure during their hospital stay, were referred to, and seen at the nephrology department. The patients ages varied from 18 to 77 years; there were 59 males and 41 females. Reduced renal perfusion, major surgery and administration of nephrotoxic drugs accounted for the majority of episodes of renal failure (77%). In general, non-oliguric patients fared better, they required dialysis less frequently and had lower mortality compared to the oliguric patients. Severity of renal failure and multi-organ involvement adversely affected the prognosis. However, age of the patient had no influence on the outcome.
Keywords: Acute renal failure, Hospital acquired, Reduced renal perfusion, Nephrotoxic drugs, Contrast media.
|How to cite this article:|
El-Lozi M, Akash N, Gneimat M, Smadi I, Nimri M, Hadidi M. Hospital Acquired Acute Renal Failure. Saudi J Kidney Dis Transpl 1996;7:378-82
|How to cite this URL:|
El-Lozi M, Akash N, Gneimat M, Smadi I, Nimri M, Hadidi M. Hospital Acquired Acute Renal Failure. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Jan 21];7:378-82. Available from: http://www.sjkdt.org/text.asp?1996/7/4/378/39407
| Introduction|| |
Unknown but it has been suggested as due to an increasingly larger number of older Acute renal failure (ARF) continues to be patients developing ARF  . Among the associated with a high mortality despite iatrogenic forms of renal injury, ARF with advances made in dialysis therapy as well as a mortality rate of 40% to 70% , poses care of the critically ill patients. The reason the most serious threat to survival. The for this apparent lack of progress is largely reason for this high mortality could be related to the fact that these patients frequently have multi-organ failure and die despite appropriate treatment of renal insufficiency  . This Prospective study was undertaken to evaluate hospital-acquired ARF with special reference to causative factors, clinical course and management.
| Patients and Methods|| |
Patients in this study were referred to the renal unit at the King Hussein Medical Center, Amman, Jordan from April 1994 to August 1995. The King Hussein Medical Center, a large teaching hospital, has all the facilities for peritoneal dialysis and hemodialysis and serves as a referral institution with a full complement of medical and surgical specialities. The study patients were admitted primarily for reasons other than renal impairment and were referred to the nephrology service when ARF developed. These patients were all seen by a nephrologist at the time of entry into the study as well as during the subsequent hospital course.
Acute renal failure for the purpose of this study was defined as elevation of serum creatinine to above 177 /mioI/L in patients with normal baseline serum creatinine (<133 /^inol/L) or an increase by more than 133 /xmol/L when baseline serum creatinine was 177-433 /xmol/L. This incremental definition was chosen so that patients with initially elevated serum creatinine values and subsequent minor changes due to laboratory variation would not be included in this study. Patients who were admitted specifically for the management of ARF or were receiving longterm hemodialysis treatment were also excluded from the study. After identification, detailed records of the patients' history, physical examination and laboratory investigations were made to document the demographic characteristics as well as the cause(s) of ARF.
All these patients were followed daily until discharge, death or return of renal function to baseline level. A serial record of urine output and serum creatinine was maintained; different complications associated with ARF were specifically looked for and recorded (e.g., hyperkalemia, acidosis, pericarditis, etc.).
Hemodialysis or peritoneal dialysis was instituted according to standard clinical indications. Assignment of proximate reason for each episode of renal insufficiency was made by the use of the following clinical criteria (and by exclusion of other pathogenic mechanisms):
Decreased Renal Perfusion:
Decreased renal perfusion was identified by one or more of the following observations:
i. Any documented decline in blood pressure to less than 90/60 mm Hg.
ii. Evidence of overt volume contraction on physical examination (e.g., decreased skin turgor and postural hypotension).
iii. Clinically evident congestive heart failure with improvement in renal function following appropriate treatment of heart failure.
Major surgery was assumed to be responsible for ARF whenever the serum creatinine concentration increased as defined, within 72 hours of surgery whether or not hypotension could be documented.
Nephrotoxic drugs were considered the cause of renal failure if a patient had received a drug with known nephrotoxic potential (e.g., aminoglycosides, NSAIDs) for a minimum of three days prior to the defined increase of serum creatinine.
Radiographic Contrast Media:
Contrast media were considered to be the cause of renal insufficiency when the serum creatinine increased as defined, within 72 hours following a radiological procedure employing such agents.
Obstruction was assumed to be the cause of renal failure if it was documented on physical or radiological examination and if improvement in renal function followed relief of obstruction.
The influence of such factors as presence or absence of oliguria, serum creatinine at the time of admission, age of the patient, severity of renal insufficiency and the presence or absence of multi-organ failure on the course and prognosis of ARF was studied.
| Results|| |
Between April 1, 1994 and August 1, 1995 a total of 100 patients who developed ARF while in the hospital were referred to the renal unit at the King Hussein Medical Center. None of the patients had more than one episode of ARF. The characteristics of these patients are presented in [Table - 1].
Decreased renal perfusion accounted for 36 (36%) of the episodes of hospital-acquired renal insufficiency; 24 of these 36 patients (66.7%) had volume contraction. Major cardiac dysfunction including severe heart failure, cardiogenic shock and arrhythmia accounted for 12 (33.3%) of these episodes. Five patients in this group died yielding a mortality of 13.8% [Table - 2].
Renal insufficiency following major surgery was observed in 20 patients (20%); 13 episodes occurred following cardiac surgery, four after major abdominal surgery, two after vascular surgery and one episode following intracranial surgery. Three patients in this group died giving a mortality rate of 15%.
Contrast media administration accounted for eight episodes of renal failure (8%); five episodes occurred after cardiac catheterization, two after aortic angiogram and one after intravenous pyelography. Six of the patients in this group were above 50 years of age, five were diabetics and two had preexisting renal insufficiency. None of the patients in the group died.
Nephrotoxic drugs accounted for 13 (13%) cases including five caused by aminoglycosides and two by non-steroidal anti-inflammatory drugs.
Five patients (5%) developed renal insufficiency due to septicemia. These patients had multiple intravenous lines and were on catheter drainage and assisted ventilation. The common organisms grown on blood cultures included Staphylococcus aureus, Candida and pseudomonas. This group was associated with a high mortality (80%).
Twelve patients with renal insufficiency had multi-factorial etiology which included a combination of dehydration, sepsis, nephrotoxic drugs and surgery. The mortality rate in this group was 16.7%.
Six patients had miscellaneous causes including vasculitis and obstruction in two patients each and hepatorenal syndrome and embolus in renal arteries in one patient each. Two patients in this group died (33.3%). Overall, a total of 15 patients (15%) died; death could be directly attributed to renal failure in only one patient (6.6%). The data concerning the causes of renal failure secondary to renal hypoperfusion and their mortality rates are summarized in [Table - 2].
Urine Output and Hospital Course
Of the 100 patients studied, 37 (37%) had oliguric renal failure and 63 (63%) were non-oliguric. Patients with contrast media and nephrotoxic drugs induced ARF had higher prevalence of non-oliguric renal failure (80%); in contrast, 69% of patients with decreased renal perfusion were oliguric. The oliguric patients had, in general, higher levels of serum creatinine and more frequent episodes of hyperkalemia, acidosis and volume overload compared to non-oliguric patients. They also had higher mortality rate (12/37, 32.5%) compared to the nonoliguric patients (3/63, 4.8%).
Severity of Renal Failure
Serum creatinine concentration increased from its baseline to the peak level by less than 365 ^mol/L in 64 patients (64%) and by more than 365 /^mol/L in 36 patients (36%). The mortality rate was higher (11/36, 30.5%) in the latter group compared to the former group (4/64, 6.2%). Overall, 13 patients required dialysis.
| Discussion|| |
Despite the wide variation in the spectrum of diseases in which hospital-acquired ARF supervenes, only a limited number of pathophysiological factors or clinical settings account for the majority of such cases , . In the present study, only few factors (decreased renal perfusion, major surgery and administration of radiographic contrast agent and nephrotoxic drugs) accounted for 70% of all episodes with decreased renal perfusion being the most frequent cause of ARF (36%). Post-operative renal insufficiency, the second most common cause of hospital-acquired ARF in our study (20%), was seen more frequently after cardiac surgery with the most consistent associated factor being the duration of extra-corporeal circulation (pump-time). Also, poor pre-operative cardiac function and pre-existing renal impairment are known to be associated with higher incidence of renal insufficiency  . Patients with contrast media induced ARF had some of the well recognized risk factors ,, including diabetes mellitus and pre-existing renal insufficiency. Administration of nephrotoxic drugs particularly aminoglycosides and non-steroidal antiinflammatory drugs accounted for 13% of all episodes. This is in contrast to other studies that have reported higher incidence of nephrotoxic drug-induced ARF , . The patients with vasculitis were admiited initially to the medical section for non-renal manifestations. They were referred to us when renal failure developed. The two patients with obstruction were elderly males with prostatic enlargement.
An important factor which influenced the course and outcome of renal failure was the presence or absence of oliguria. More than 60% of patients in our study were non-oliguric through their course and this could be partly related to the use of potent diuretics. It has been described that non-oliguric patients develop less severe azotemia  .
Severity of renal insufficiency is known to be an important adverse prognostic marker and increase in mortality has been observed with step wise increase in serum creatinine levels  . In the present study, 64% of patients had serum creatinine below 365 ^mol/L with a mortality rate of 6.25% while 36% of patients had serum creatinine of more than 365 ^mol/L with a mortality rate of 30.5%. Multiple organ system failure is also an important prognostic indicator and mortality rates approaching 100% have been reported if three or more organ-systems were involved  . In this study, the mortality rate was 80% in patients with sepsis accompanied by failure of two or more organ-systems. This comparatively lower mortality rate could be due to early referral of patients by their attending physicians to the nephrology service and to the fact that our policy is to intervene early enough in their course with dialysis therapy when indicated.
Although earlier studies have shown a significant increase in mortality with increasing age , we could not demonstrate a relationship between patient age and survival which was in agreement with some other studies , .
Our report further confirms that hospitalacquired ARF is a frequent phenomenon. It results from a relatively small number of pathophysiologic and iatrogenic processes.
It is worth re-emphasizing that therapeutic efforts to prevent the progression of hospital acquired renal insufficiency should be applied early since this problem considerably increases the length and cost of hospitalization in addition to accounting for considerable morbidity and mortality.
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Department of Nephrology, King Hussein Medical Center, Amman, P.O. Box 373, Amman 11831
[Table - 1], [Table - 2], [Table - 3]