| Abstract|| |
Over a period of six months, 55 patients out of 11,216 (0.49%) admitted to the hospital developed acute renal failure (ARF). The diagnosis of ARF was based on the usual criteria, a sudden rise in blood urea nitrogen and creatinine with or without oliguria. Patients age ranged between 15 and 81 years with a mean of 51.9 years. Renal ischemia (69%) and nephrotoxic drugs (16.3%) were the two main etiologic factors. Among the causes of ischemia, septic shock was the commonest (29%), followed by severe hypotension due to several causes such as hemorrhage, burns, severe diarrhea and cardiogenic shock (25.4%), and ACE inhibitors (10.9%). ARF was associated with an average of 15.8 days stay in hospital versus 5.1 days for the overall hospital admissions. Immediate management of hypotension by intravenous fluid replacement, vasopressor agents and the necessary surgical intervention was appropriately considered. Intravenous frusemide was used for oliguric patients. Intermittent hemodialysis was used in 18 patients and continuous venovenous hemofiltration in six patients. Twelve patients with ARF due to ischemia died, while there were no deaths in the nephrotoxic group (p < 0.05). The overall mortality was (21.8%), which had no correlation with patient age. All non-oliguric patients survived with the mortality being exclusively in the oliguric group.
Keywords: Acute renal failure, Causes, Qatar.
|How to cite this article:|
Rashed A, Abboud O, Addasi A, Taha M, El Sayed M, Ashour A. Acute Renal Failure: Six Months Pilot Study in Qatar. Saudi J Kidney Dis Transpl 1998;9:298-300
|How to cite this URL:|
Rashed A, Abboud O, Addasi A, Taha M, El Sayed M, Ashour A. Acute Renal Failure: Six Months Pilot Study in Qatar. Saudi J Kidney Dis Transpl [serial online] 1998 [cited 2019 Jul 20];9:298-300. Available from: http://www.sjkdt.org/text.asp?1998/9/3/298/39274
| Introduction|| |
Qatar is a country with a population of 693,000 and an area of 11,200 square kilometers. The Hamad Medical Complex is the only center for in-patient care receiving admission from all over the country. The largest effort to establish the incidence of acute renal acute renal failure (ARF) was the European Dialysis and Transplant Association survey from 32 countries giving a mean of 28.9 (range 0.4-177.1) patients per million population per year, who required dialysis for ARF  . For every patient with ARF requiring dialysis, there are 10-12 patients with milder renal insufficiency who are managed conservatively  . Feest, et al, from England, reported an overall incidence of ARF of 140 patients per million population per year, 18 of whom required dialysis  . The incidence of ARF was not previously studied in Qatar, nor was the etiology, management or outcome. We conducted a prospective pilot study of all cases of ARF that were admitted to Hamad Corporation Medical Complex over a period of six months. We report the results of this study with emphasis on the etiology, management and outcome of ARF in those cases.
| Patients and Methods|| |
All patients with ARF (serum creatinine of 176 µmol/L, blood urea nitrogen 15mmol/L) were prospectively enrolled in the study for a period of six months (August 1997January 1998). Our initial assessment notes included the patient's age, sex, previous health status, preexisting organ dysfunction, clinical evaluation, the cause of ARF and presence of other organ failure. The patients were usually admitted to Intensive Care Units (ICU). The ICU protocol applied for all patients, including blood urea nitrogen (BUN), serum creatinine, electrolytes, complete blood count, blood culture urine for osmolality, protein, microscopic examination and sodium content. Renal ultrasound was performed in all patients. Patients with severe hypotension were started on intravenous (I.V) fluids and vasopressor agents. Any source of fluid loss was identified. The volume intake, urine output and body weight were daily charted. The clinical complications of uremia were noticed. Patients with respiratory failure received assisted ventilation.
| Results|| |
Over a period of six months, 55 patients with ARF were seen; 19 females and 36 males. Their age ranged between 15-81 years. The causes of ARF were septic shock in 16 patients, severe hypotension caused by bleeding, severe diarrhea and dehydration in 11, nephrotoxins in nine, angiotensin converting enzyme (ACE) inhibitors in six, obstructive nephropathy in five, cardiogenic shock in three, systemic vascular disease involving renal arteries in two, rhabdomyolysis in two, and primary renal lymphoma in one. Hospital stay ranged between 4 and 42 days (mean 15.8 days). During the same six months, the total hospital admissions were 11,216 with a mean period of hospital stay of 5.1 days. Thirty-one patients were kept on conservative treatment, 18 received intermittent hemodialysis and continuous venovenous hemofiltration (CVVH) was performed in six cases. The cultured microorganisms were Pseudomonas aeruginosa in five cases, E. coli in three, Streptococci in three, Staphylococci in two, Klebsiella pneumonia in two, Enterobacter in two, Candida albicans in one and Clostridium difficile in one. Twelve patients with ARF due to ischemia died, while there were no deaths in the nephrotoxic group (p < 0.05). The overall mortality was (21.8%), which had no correlation with patient age. All nonoliguric patients survived with the mortality being exclusively in the oliguric group.
| Discussion|| |
Functional derangement in ARF consist of a sudden decrease in glomerular filtration rate, sufficient to result in elevation of the plasma urea and creatinine concentration, retention of salt and water and the development of acidosis and hyperkalemia  . The present study is a pilot investigation, aimed at short-term screening, to be useful as a guide for future studies on the same subject in Qatar.
ARF is frequently observed in the setting of multi-organ dysfunction syndrome (MODS)  . Septic shock, caused mainly by gram negative bacteria, is the most common cause of ARF in our patients resulting in inadequate renal perfusion and release of endotoxins and endogenous mediators. The persistent sepsis-induced hypotension results in hypoperfusion of the body organs despite adequate fluid resuscitation. All the septic shock patients received vasopressor agents and considerable effort has been directed towards early identification and initiation of antimicrobials. However, mortality was (62%) in this group of patients.
The recovery rate was higher in ARF caused by severe hypotension without evidence of sepsis. One out of three patients with cardiogenic shock died, and one patient with severe systemic vascular disease died because of cerebrovascular accident.
Dopamine in a dose of 2.5µg per kilogram per minute has been administered in combination with fluid replacement, however clinical studies have not demonstrated the efficiency of dopamine drip  . Continuous infusion of 4-10mg furosemide per hour was used to improve the diuresis in patients who did not respond to conventional pulse furosemide administration regimens  .
ACE inhibitors used in the setting of heart failure, resulted in ARF in six patients. Discontinuation of these drugs, resulted in the recovery of kidney function. Cytotoxic drugs used to treat non-Hodgkin lymphoma, gentamicin and vancomycin were all incriminated of causing ARF that responded to supportive measures and discontinuation of the drugs.
Renal ultrasonography detected obstructive uropathy, manifested by dilation of the urinary tract above the level of obstruction, in five patients. Nephrostomy, correction of dehydration and treatment of infection resulted in the return of serum creatinine levels to normal. This was followed by surgical repair of the obstruction. Intermittent hemodialysis was performed in 18 patients; seven of them died. CVVH was chosen for treatment of six patients, who were critically ill and unstable, but they all died.
We concluded that the reversibility of many entities of ARF mandates that a rapid diagnosis be made and appropriate therapy initiated. Future studies are needed to estimate the incidence, to evaluate the precipitating factors and perhaps to introduce new methods of therapy.
| References|| |
|1.||Teschan PE, Baxter CR: O'Brien TF, ,Fruehof JN, Hall WH. Prophylactic hemodialysis in the treatment of acute renal failure. Ann Int Med 1960;53:992. |
|2.||Hou SH, Bushmsky DA, Wish JB, Cohen JJ, Harrington JT. Hospital acquired renal insufficiency: a prospective study. Am J Med 1983; 74:243-8. |
|3.||Feest TG, Round A, Hamad S. Incidence of severe acute renal failure in adults: results of a community based study. BMJ 1993;306: 481-3. [PUBMED] [FULLTEXT]|
|4.||Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med 1996;334:1448-60. [PUBMED] [FULLTEXT]|
|5.||DuBose TD Jr, Warnock DG, Mehta RL, et al. Acute renal failure in the 21 st Century: Recommendations for management and out comes assessment. Am J Kidney Dis 1997;29:793-9. [PUBMED] |
|6.||Martin SJ, Danziger LH. Continuous infusion of loop diuretics in the critically ill: a review of the literature. Crit Care Med 1994:22: 1323-9. |
Department of Medicine, Hamad General Hospital, P.O. Box 3050, Doha