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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2007  |  Volume : 18  |  Issue : 4  |  Page : 536-540
The Course and Outcome of Renal Transplant Recipients Admitted to the Intensive Care Unit at a Tertiary Hospital in Saudi Arabia


Assistant Professor, King Saud Bin Abdulaziz University for Health Science; Deputy Chairman on Critical Care, Consultant, Intensive Care and Pulmonary Medicine, King Abdulaziz Medical City, Saudi Arabia

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   Abstract 

Renal transplantation is the treatment of choice for most patients with end­stage renal disease (ESRD). This procedure provides a survival benefit compared to hemodialysis and is also cost effective. The aim of this study is to identify the types and incidence rates of complications that affect renal transplant recipients admitted to the intensive care unit (ICU) during long-term follow-up and, to examine the impact of these complications on the length of hospital stay as well as mortality, in a tertiary closed ICU in Saudi Arabia. We reviewed the data of all adult renal transplant recipients who were admitted to the ICU at the King Abdulaziz Medical City, Riyadh, between May 1999 and Oct 2006. During the study period, 80 patients had a total of 96 ICU admissions; 49% were females. The admission APACHE II score and expected mortality was 25+7 and 48+23 respectively. The hospital mortality rate was 42%. Sepsis was the major indication for ICU admission and pneumonia was the main cause of sepsis. In multivariate analysis the following variables were introduced in the model: APACHE II score, age, Glasgow Coma Score and need for hemodialysis in the ICU. We found only the need for hemodialysis during the ICU as an independent risk factor for mortality (P < 0.02). We found in this study that the main reason for ICU admissions among renal transplant recipients was infections. Mortality rates for this particular population are relatively high and are primarily linked to need for dialysis.

How to cite this article:
Aldawood A. The Course and Outcome of Renal Transplant Recipients Admitted to the Intensive Care Unit at a Tertiary Hospital in Saudi Arabia. Saudi J Kidney Dis Transpl 2007;18:536-40

How to cite this URL:
Aldawood A. The Course and Outcome of Renal Transplant Recipients Admitted to the Intensive Care Unit at a Tertiary Hospital in Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Oct 14];18:536-40. Available from: http://www.sjkdt.org/text.asp?2007/18/4/536/36508

   Introduction Top


The kidney is the most commonly trans­planted solid organ. [1] Successful renal trans­plantation improves the quality of life and increases survival as compared with long term cadaveric organs, the reported one-year patient survival is 90 to 100% and one-year graft survival is 75 to 90%. [1] In financial terms, renal transplantation is cost-effective as the cost of maintaining a patient with a functional graft is one third the cost of maintenance hemodialysis (HD). [4]

Unfortunately, the successes achieved in renal transplantation are tempered by the shortage of suitable organs. [5] Waiting list for solid organ transplantation in the United States of America (USA) now exceeds 92,000 of whom 67,000 are waiting for a kidney transplant while only 16,477 kidneys were transplanted (United Networks for Organ sharing (UNOS) at www.unos.org). However, with increasing long-term graft survival and thus, life-long immunosuppre­ssion, cardiovascular disease, de novo malig­nancy, and infectious complications have become major causes of morbidity and mor­tality. [6] Patients afflicted with such complica­tions get admitted to the intensive care unit (ICU), and carry mortality rates ranging bet­ween 16 and 59%. [1],[6],[7]

Data about mortality in such patients in Saudi Arabia is not clear. The purpose of our study is to identify the types and incidence of complications that affect renal transplant reci­pients admitted to the ICU during long-term follow-up and, to examine the impact of these complications on the length of stay in the hospital as well as mortality, in a tertiary closed ICU in Saudi Arabia.


   Methods Top


This prospective study was conducted in a 21-bed, medical and surgical ICU in a 800-bed tertiary care teaching hospital in Riyadh, Saudi Arabia. This ICU is a closed unit, run by in-house, full-time, board-certified intensivists, with more than a thousand admissions per year. All adult renal transplant recipients who were admitted to our ICU between May 1999 and Oct 2006 were included. We excluded patients younger than 16 years as well as those with burns or brain­death.

Data on renal transplant recipients admitted to the ICU were included in the analysis from a prospectively collected ICU data-base. We collected the following data: base-line demo­graphics including gender, age and the type of admission with pre-specified admission diagnoses. Acute Physiology and Chronic Health Evaluation II (APACHE II) [8] scores, length of stay (LOS) in the ICU was calculated as number of calendar days of ICU stay as well the hospital LOS. Mechanical venti­lation duration (MVD), calculated as number of calendar days on mechanical ventilation, was recorded. Patients were followed-up until discharge from the hospital or death, which­ever occurred first.

Continuous data were expressed as mean ± standard deviation (SD) and compared using the Student t-test. Categorical data are ex­pressed as percentage and compared using the chi-square test. Statistical significance was defined as alpha less than 0.05. Statistical analysis was performed using Minitab for windows (release 13.1).


   Results Top


During the study period, 80 patients had a total of 96 ICU admissions; 49% were females. The admission APACHE II score expected mortality was 25±7 and 48±23 respectively. [Table - 1] lists dome of the salient characteristics including mean age, gender, mean APACHE II, expected mortality, use and duration of MV, serum create-nine, and the total urine output in the first 24-hours of admission. The hospital mortality rate was 42%. Sepsis was the major reason for ICU admission and pneumonia was the main cause of sepsis. Liver diseases were the second most common reason for ICU admi­ssion. The indications for admission to the ICU are shown in [Table - 2].

[Table - 3] shows the comparison between survivors and non-survivors. In the univariate analysis, better outcome was seen in patients with high Glasgow Coma Score (GCS), younger age and those who did not require hemodialysis (HD) during the ICU admi­ssion. In multivariate analysis, [Table - 4] the following variables were introduced in the model: APACHE II score, age, GCS and need for HD in the ICU. We found only the need for HD during stay in the ICU as an independent risk factor for mortality (P < 0.02).


   Discussion Top


Patients with end-stage renal disease cons­titute a high-risk patient population. They are at increased risk for developing fluid and electrolyte abnormalities, cardiovascular disease, neurologic disorders and bacterial infections. After renal transplantation, these patients still carry a high risk of multiorgan dysfunction related to the pre-existing medical problems and post-operative complications. Immunosuppressive drugs not only increase the risk of infections, but their side effects also add to the risk of multi-organ failure. [1]

In our cohort study, the hospital mortality was 42%, which is close to the predicted mortality of 48%.

Our study demonstrated that patients who needed HD during their stay in the ICU had worse outcome. Older patients or patients with low GCS on admission or, sicker patients as reflected by higher APACHE II scores, were not associated with worse out­come when these parameters were adjusted to other factors on multivariate analysis. Neither use of mechanical ventilation nor the use of inotropes, or the urine output during the first 24-hours of admission were found to be independent predictors of relevant clinical outcomes. Sepsis was found as the pre­dominant cause of mortality.

Similar findings regarding the main reason for admission to the ICU were shown pre­viously by Sadghdar et al, [1] who conducted a prospective cohort study on consecutive adult renal transplant recipients admitted to the surgical ICU. In that study, infection was found to be the most common reason for admission to the ICU and the mortality of this population was twice that of general surgical ICU patients, which is in contrast to our findings. The study of Sadgdgar et al, had an inherent disadvantage in that they com-pared the transplant patients with general surgical patients, who usually have much lower mor­tality than the average ICU patients.

Similar to our results, Kee et al,[9] found that bacterial infections were the most common reason for ICU admission among renal transplant recipients. Supporting our findings on hospital mortality, Nicolet and co­workers[7] reported similar hospital and ICU mortality rates of 40% and 33% . However, they found that use of mechanical ventilation was associated with higher mortality rates.

Kirilov et al,[10] performed a retrospective case series study of 27 renal transplant reci­pients who were admitted to the ICU in which they reported a mortality rate of 22%. However, the main reason for admission to the ICU was the need for mechanical venti­lation following surgical procedures, since the majority of cases (59%) were post-anesthesia care patients. Such patients usually have lower mortality rates, which probably explains their different findings.

Chaung et al, [5] conducted a case-control study on renal transplant recipients within two years of transplantation; they found that cardiovascular disease was the most common cause of death in the first two years of trans­plantation followed by infections. In a recent study by Candan et al,[6] a retrospective ana­lysis was performed on 34 patients who had a total of 39 admissions to the ICU. As in our study, infection was the most common cause for admission to the ICU and the overall mortality in their series was 59%. They found also that the actual mortality rate was higher than expected mortality rate among patients with respiratory problems.

Our study has several strengths. A full-time dedicated data collector gathered and entered our data prospectively. Our unit is closed and is operated mainly by North American critical care board certified intensivists, which makes the management rather homogenous. On the other hand, our study has some limitations. It was conducted at a single center. No standard protocol was followed in treating such pa­tients and above all, the sample size is not large.

In conclusion, we found in this study that the main reason for ICU admissions among renal transplant recipients was infections. Mortality rates for this particular population are relatively high and are primarily linked to need for dialysis. Early diagnosis and treat­ment of underlying disease and precautions to reduce the risk of infections as well as renal protective strategies to preserve the kidney and obviate the need for dialysis, may be the key to improving the survival of renal transplant recipients.

 
   References Top

1.Sadaghdar H, Chelluri L, Bowles SA, Shapiro R. Outcome of renal transplant recipients in the ICU. Chest 1995;107 (5):1402-5.  Back to cited text no. 1    
2.Wolfe RA, Ashby VB, Milford EL, etal. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341(23):1725-30.  Back to cited text no. 2    
3.Thomson NM, Scott DF, Cesnik B, etal. Morbidity, mortality, and quality of life in long-term survivors of an integrated dialysis/renal transplant programme. Transplant Proc 1989;21(1 Pt 2):2184-5.  Back to cited text no. 3    
4.Eggers P. Comparison of treatment costs between dialysis and trans-plantation. Semin Nephrol 1992;12(3): 284-9.  Back to cited text no. 4    
5.Chuang P, Gibney EM, Chan L, Ho PM, Parikh CR. Predictors of cardio-vascular events and associated mortality within two years of kidney trans-plantation. Transplant Proc 2004;36(5): 1387-91.  Back to cited text no. 5    
6.Candan S, Pirat A, Varol G, Torgay A, Zeyneloglu P, Arslan G. Respiratory problems in renal transplant recipients admitted to intensive care during long­term follow-up. Transplant Proc 2006;38 (5):1354-6.  Back to cited text no. 6    
7.Nicolet L, Heng A, Souweine B, Mahnes G. Outcome of renal transplant recipeints and graft survival in the ICU. Crit Care 2001;5:221.  Back to cited text no. 7    
8.Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13(10): 818-29.  Back to cited text no. 8    
9.Kee T, Lu YM, Vathsala A. Spectrum of severe infections in an Asian renal transplant population. Transplant Proc 2004;36(7):2001-3.  Back to cited text no. 9    
10.Kirilov D, Cohen J, Shapiro M, Grozovski E, Singer P. The course and outcome of renal transplant recipients admitted to a general intensive care unit. Transplant Proc 2003;35(2):606.  Back to cited text no. 10    

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Correspondence Address:
Abdulaziz Aldawood
Deputy Chairman on Critical Care, King Abdulaziz Medical City, P.O. Box 1132, Riyadh 1149
Saudi Arabia
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PMID: 17951939

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    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]

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