| Abstract|| |
To evaluate the approach of physicians to the diagnosis and management of acute renal failure (ARF) in the Kingdom of Saudi Arabia, a questionnaire was mailed to nephrologists, physicians attending to renal failure patients, specialists working in intensive care unit (ICU) and the general physicians in 110 hospitals, which have either an ICU or a dialysis unit. The questions were related to the areas of evaluation, conservative management, dialysis therapy, and prognosis of ARF. There were 135 responses from 76 hospitals (69%); 37 of small size (<150 beds), 21 of medium size (151-400 beds), and 18 of large size (401-1200 beds). There were 69 respondents from the small hospitals, 34 from the medium-sized, and 32 from the large hospitals. According to the respondents, the most encountered ARF patients were in the intensive care units and were most likely due to sepsis and nephrotoxic drugs. There were no differences among the respondents in the areas of initial evaluation, conservative and/or emergency treatment. However, the nephrologists were significantly more willing to follow-up their ARF patients and to carry more specific diagnostic procedures (i.e., renal biopsy) and specific advanced therapeutic procedures (i.e., dialysis), More ARF patients are being treated by continuous renal replacement therapy (CRRT) than intermittent hemodialysis or peritoneal dialysis. The minority of the respondents believed that the prognosis of ARF had not improved much, despite the improvement in diagnosis and therapy. They attributed this to the change in the demographics of ARF, since more ICU and elderly patients are seen in practice. We conclude that nephrologists are indispensable for the management of acute renal failure. More efforts may be needed to recruit nephrologists to hospitals in Saudi Arabia. A local fellowship program may help in this regard. Furthermore, CRRT facilities, at least in the large hospitals, are required.
Keywords: Acute renal failure, Survey, Saudi Arabia.
|How to cite this article:|
Souqiyyeh MZ, Shaheen FA, Al-Khader AA. Opinion Survey about the Evaluation and Management of Acute Renal Failure in Saudi Arabia. Saudi J Kidney Dis Transpl 1998;9:306-15
|How to cite this URL:|
Souqiyyeh MZ, Shaheen FA, Al-Khader AA. Opinion Survey about the Evaluation and Management of Acute Renal Failure in Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 1998 [cited 2020 Dec 5];9:306-15. Available from: https://www.sjkdt.org/text.asp?1998/9/3/306/39276
| Introduction|| |
Acute renal failure is caused by many conditions that lead to acute deterioration, or complete failure of the function of the kidneys. There have been changes in the patterns of causes of acute renal failure over the years ,,,, . Also emerging are new therapeutic methods whether in conservative management or dialysis therapies such as continuous renal replacement therapy ,, . There is also interest in assessment of professional competence and granting hospital and personnel privileges in practice ,,,, . Opinion surveys about practices in nephrology have been performed ,, . In this study we evaluated the approach of physicians to the diagnosis and management of acute renal failure in the Kingdom of Saudi Arabia according to the new trends in this field and the possible factors which may affect such practice.
| Methods and Materials|| |
A questionnaire surveying the approach to patients with acute renal failure (ARF) was mailed in late 1997 to nephrologists, physicians caring for renal failure patients, specialists working in intensive care unit (ICU) and the general physicians in 110 hospitals, which have either an ICU or dialysis unit in the Kingdom of Saudi Arabia. The questions related to the areas of evaluation, conservative management, dialysis therapy, and prognosis of ARF. The area of evaluation of ARF patients included history and physical examination, frequency of the most common causes of ARF encountered in practice, and the most common laboratory investigations used in the evaluation of ARF.
Referral to other hospitals and the reasons thereof were asked about, as well as indications for kidney biopsies in patients with ARF.
The questions about conservative management included the challenge with fluids with or without dopamine and/or diuretics in variable doses, as well as other regimens suggested by respondents.
The use of corticosteroids in interstitial nephritis, as well as using parenteral nutrition in oliguric ARF patients was explored.
The questionnaire also asked about the indications of dialysis therapy in ARF, modes of dialysis and referral to other hospitals for therapy. Specific questions about continuous renal function replacement therapy (CRRT) were included such as frequency of use, available machines, previous experience, and indications of CRRT. Questions about prognosis of ARF and reasons were also included.
| Statistical Analysis|| |
We used chi-square Student's "t" test to compare the groups of the respondents and Fisher's exact test, where appropriate.
| Results|| |
There were 135 responses from 76 hospitals (69%); 37 of small size (< 150 beds), 21of medium size (151-400 beds), and 18 of large size (401-1200 beds). [Table - 1] shows the distribution of the 135 respondents and their relation to the size of the hospitals in the study. The respondents included 45 nephrologists with at least one year of training in nephrology, 38 physicians who are not nephrologists but attend routinely to chronic renal failure patients in dialysis units due to unavailability of nephrologists in their hospitals, 33 medical residents working in the general medical wards, and 19 "other" physicians (six ICU specialists, eight anesthesiologists, four pediatricians and one surgeon). In all the following results the nephrologists were used as a basis for comparison with the other respondents.
Opinion about the Evaluation of ARF Patients
The most common causes of ARF are shown in [Table - 2]. The ARF patients in the ICU setting were ranked as number one for all the categories of respondents followed by septic causes. All the nephrologists and physicians could rank the causes encountered in their practices. However, respondents in other categories could rank only some of the most common causes of ARF in their practices. The respondents from the large hospitals in this study ranked their practice better than those in small or medium sized hospitals. Seventy percent of the nephrologists, 75% of the physicians, 75% of the medical residents and 78% of the "other" physicians believed that history and physical examination were sufficient to evaluate volume status of patients with acute oliguric renal failure in only 80% of the cases. All the respondents would always use the laboratory investigations to increase the percentage of accuracy of the diagnosis of ARF, given their availability. There were no significant differences in the responses in any respondent category. According to the respondents, the availability of some tests such as fractional sodium excretion and myoglobin in urine was 32% in the small, 42% in the medium, and 57% in the large hospitals. However, other tests such as ultrasound (US), chest x- ray (CXR), central venous pressure (CVP) and electrolytes were available and used by 95% of the respondents without significant differences due to the size of the hospitals. Two respondents added renal isotope to the list of investigations, two others added blood gases, one added creatinine phosphokinase, one added plain radiographs of the urinary system, and one added urinalysis.
The indications and use of renal biopsy in the evaluation of ARF are shown in [Table - 3].
As can be seen the nephrologists are more willing to use this procedure (p<0.001).
Only 22% of nephrologists as compared to 68% of physicians, 66% of medical residents and 47% of other physicians would refer patients to other hospitals to complete evaluation due to lack of some of the laboratory tests in their hospitals (p<0.0001). Seventy three percent of the respondents in the small sized hospitals compared to 41% of those in medium sized (p<0.0001), and to 4% of those in large size hospitals (p<0.0001), refer their patients to other institutes to complete investigations for ARF.
Opinion about the Conservative Management of ARF
The practice regarding the use of fluid challenge dopamine and/or diuretics in oliguric patients with suspected ARF is summarized in [Table - 4]. Only 26% of nephrologists use diuretics and dopamine in ARF cases. More ICU specialists, anesthesiologists, and surgeons, than nephrologists, use diuretics and dopamine with small amount of fluids (p<0.04), while only 9% of the medical residents use dopamine and diuretics in ARF cases (p<0.0001). However, most of the respondents use mainly large amounts of fluids with or without diuretics.
In answer to a question about the type of crystalline fluid mostly used in case of acute oliguric volume-depleted renal failure patients, 91% of the nephrologists, 92% of the physicians, 87% of the medical residents and 89% of the "other" physicians use isotonic saline infusion, while only 9-12% of respondents use hypertonic saline.
In response to a question about the methods of assessing fluid therapy in such patients, 82% of the nephrologists and 89% of the "other" physicians, compared to 68% of physicians attending renal failure patients and 69% of the medical residents use both CVP measurement and clinical evaluation to determine adequacy of the fluid therapy (p<0.01).
Regarding the use of steroids for acute interstitial nephritis, 75% of nephrologists, 31% of physicians, 62% of medical residents and 58% of "other" physicians would give a trail of steroids therapy (p<10").
Sixty-six percent of the nephrologists, 57% of the physicians and 54% of the medical residents compared to 77% of the "other" physicians would give parenteral nutritional therapy (PNT) to ARF patients (p<0.01). However, PNT would be administered indiscriminately to all patients by 20%, 13%, 26% and 54% of the respondents respectively.
Only 8% of the nephrologists occasionally refer their patients to other institutes for further management compared to 57% of the physicians and 52% of the "other" physicians (p<10 6 ).
Sixty-five percent of the respondents from the small-sized, 23% of those in the mediumsized and none of those in the large hospitals refer their patients for further management in other hospitals.
Opinion about the dialysis therapy for ARF Patients
[Table - 5] shows the dialysis method used for ARF patients with low blood pressure (less than 100 mm Hg systolic). Eighty-one percent of nephrologists would use the continuous renal replacement therapy (CRRT) in such cases compared to 16-26% of other categories of respondents (p<10" u ). On the other hand, 55%of the nephrologists use peritoneal dialysis instead compared to 77% of the medical residents (p 3 ). Only 16-26% of the respondents use intermittent hemodialysis for the hypotensive acute renal failure patient.
Fifty six percent of respondents from the small hospitals would use peritoneal dialysis in ARF patients with hypotension, while 13% would use CRRT in such cases, compared to 34% and 59% of those of the large hospitals would use these two modalities, respectively (p< 0.0001).
In response to a question about the frequency of use of CRRT in their institutes, 55% of the nephrologists, 86% of the physicians, 96% of the medical residents and 83% of the other physicians said that CRRT was not used at all over the previous 12 months in their hospitals. The rest of the respondents in each category reported usage in 5-10 ARF patients/year. Furthermore, 35% of the nephrologists and 27% of "other" physicians reported working in hospitals that have machines capable of performing CRRT versus 7% of the physicians, 3% of he medical residents in the study.
In response to a question about past experience in using CRRT and its various types (CAVH, CVVH, CAVHD etc.), 55% of the nephrologists compared to 21% of the physicians attending renal failure patients and 27% of the "other" physicians reported such experience (p<0.001).
There was a question about the indications of CRRT in some subgroups of ARF patients in case of availability of a machine capable of performing continuous venovenous hemo-filtration. [Table - 6] shows the percentage of responses to these indications. Ninetyfive percent of the nephrologists use CRRT in hypotensive ARF patients, 44% in acute liver failure patients, 77% in septic patients to hasten their recovery, 28% in preparing chronic liver failure patients for liver transplantation and 93% in congestive heart failure. A significantly lower number of physicians and medical residents use CRRT machines for such indications. CRRT machines are available in none of the smallsized hospitals, but in 5/21 medium-sized (23%) and 7/18 large hospitals (38%).
Opinion about Prognosis
According to the opinion of the respondents, 77% of the nephrologists, 97% of the physicians attending renal failure patients, 87% of the medical residents and 84% of the other physicians believed the prognosis of ARF was getting better due to better diagnosis and management, while the minority thought the prognosis of ARF was getting worse and attributed that to the more elderly and ICU patients having ARF.
| Discussion|| |
The respondents in our study have ranked the ICU patients high in their lists of practice, followed by ARF associated with sepsis and /or nephrotoxic drugs. There is a trend to see more patients in ARF in the ICU of any hospital as a part of multi-organ failure , . Also, community or hospital acquired sepsis has been seen more frequently , . Nephrotoxic drugs remain of importance in causing ARF , . Trauma and obstetric causes of ARF are seen less frequently ,, .
In our study, there were no significant differences among respondents in ranking the causes of ARF in their practices though the nephrologists gave higher frequency than the other respondents.
There were no differences among the majority of the respondents about the ability of clinical evaluation alone to define the volume status in ARF patients, which is close to what has been reported in the literature ,, . Also, most of the respondents would use the standard laboratory investigations in the evaluation of ARF patients.
According to the majority of the respondents, most of the necessary tools of investigations were available in their hospitals, regardless of the size of the hospital. These responses may reflect good general basic knowledge of the respondents about the evaluation of ARF patients with no differences related to their specialty or work place. However, the number of referrals was greater in the small hospitals due to lack of some investigations such as renal biopsy than the large hospitals. Furthermore, the nephrologists were more confident referring out fewer patients, and were more aggressive in performing renal biopsies than other specialists.
There were differences among respondents concerning the conservative management in our study. The nephrologists were more willing to give large amounts of fluids and diuretics and dopamine than the other respondents. This is compatible with the current trends in the literature, since using loop diuretics in large doses may help in reducing the recovering period and complications of ARF such as fluid overload and electrolytes disturbances ,,, . Furthermore, the use of low dose dopamine is advocated in the recent practices of ARF patients despite its marginal effect , .
The respondents were knowledgeable in terms of the types of fluids used for hyponatremic volume depleted ARF patient without significant differences in their answers. However, the nephrologists were more willing to follow-up such patients by clinical exam as well as CVP than other respondents.
Many more nephrologists would use corticosteroids, as an example of specific therapy to a type of ARF, than other specialties.
This is compatible with the recommendations in the literature  .
On the other hand, there were no significant differences among respondents in using parenteral nutritional therapy in the presence of malnutrition. This is in contrast with the new trends towards more use of nutritional support in ARF patients, however, there is no consensus yet on the best approach to it , .
The number of referrals by the nephrologists to other institutes for further management is much lower than the other respondents. Furthermore, the respondents from the small hospitals were more willing to refer out ARF patients than those in the large hospitals. This is most likely due to the significantly higher availability of nephrologists and dialysis units in the large hospitals.
The major differences in our study were in the choices of the methods of dialysis for the ARF patients. The nephrologists were more willing to use the CRRT than other respondents were. They showed more experience and contact with CRRT, which made them recommend it as the method of choice in hypotensive ARF patients. There is a trend among the respondents not to use hemodialysis in hypotensive patients, which is compatible with the trends in the literature, though the issue of choice of methods of dialysis therapy is still not settled ,, . The list of indications for CRRT is expanding. Despite the significantly greater knowledge of the nephrologists of these indications, some of their answers where not compatible with the current trends in literature, such as the indication of use of CRRT in acute liver failure  .
The prognosis has not improved much despite the improvement in diagnosis and management of ARF ,,, . This is attributed to more ARF in the elderly and ARF as secondary to multi-organ failure. The minority of the respondents in our study knew this fact.
In conclusion, we believe that nephrologists are more confident than any other specialist to pursue specific diagnosis and management in ARF patients, which make them indispensable in any hospital providing services to ARF patients. This calls for the recruitment of more nephrologists in Saudi Arabia. Establishing a Fellowship program in nephrology may be of help in this regard. Also, more equipment for CRRT in the large hospitals is required for better future management of ARF patients.
| Acknowledgment|| |
We are thankful to all the respondents in our study, which made it possible. We extend our thanks to Mr. Pedly F. Atienza and Mr. Mirza J.H. Baig of SCOT for their secretarial assistance in entering the manuscript.
| References|| |
|1.||Beaman M, Turney JH, Rodger RS: McGoingle RS, Adu D, Michael J. Changing pattern of acute renal failure. Q J Med 1987; 62:15-23. |
|2.||Turney JH, Marshall DH, Brownjohn AM, Ellis CM, Parsons FM. The evolution of acute renal failure 1956-1988. Q J Med 1990;74:83-104. [PUBMED] [FULLTEXT]|
|3.||Feest TG, Round A, Hamad S. Incidence of severe acute renal failure m adults: results of a community based study. BMJ 1993; 306:481-3. [PUBMED] [FULLTEXT]|
|4.||Rasmusscn HH, Ibels LS. Acute renal failure: multivariatc analysis of causes and risk factors. Am JMed 1982;73:211-8. |
|5.||Kaufman J, Dhakal M, Patel B, Hamburger R. Community-acquired acute renal failure. Am J Kidney Dis 1991; 17:191-8. [PUBMED] |
|6.||Rahman SN, Kim GE, Mathew AS, et al. Effects of atrial natriuretic peptide in clinical acute renal failure. Kidney Int 1994;45:1731-8. [PUBMED] |
|7.||Hummel M, Kuhn M, Bub A, et al. Urodilatin; a new peptide with beneficial effects in the postoperative therapy of cardiac transplant recipients. Clin Investig 1992:70:674-82. |
|8.||Golpcr TA. Continuous arteriovenous hemofiltration in acute renal failure. Am J Kidney Dis 1985:6:373-86. |
|9.||Kane MT. The assessment of professional competence. Evaluation and the health professionals 1992;15:163-82. |
|10.||Anonymous. Standards for individual competence assessment clarified. Joint Commission Perspectives 1992;12:12. |
|11.||Clinical competence in acute hemodialysis. Health and Public Policy Committee, American College of Physicians. Ann Intern Med 1988:108:732-4. |
|12.||Clinical competence in continous arteriovenous hemofiltration. Health and Public Policy Committee, American College of Physicians. Ann Intern Med 1988:108:900-2. |
|13.||Aluisc JJ, VanghanRW, Vanghan MS. The new health care civilization: integration of physician land and managerial? Physician Executive 1994;20:3-8. |
|14.||Parry RG, Crowe A, Stevens JM, Mason JC Roderick P. Referral of elderly patients with severe renal failure: questionnaire survey of physicians. BMJ 1996;313(7055):466. |
|15.||Bender FH, Holley JL. Most nephrologists are primary care providers for chronic dialysis patients: results of a national survey. Am J Kidney Dis 1996;28(1):67-71. |
|16.||Mendelssohn DC, Kua BT, Singer PA. Referral for dialysis in Ontario. Arch Intern Med l995;155(22):2473-8. |
|17.||Grocneveld AB, Tran DD, van der Meulen J, Nauta JJ, Thijs LG. Acute renal failure in the medical intensive care unit: predisposing, complicating factors and outcome. Nephron 1991;59:602-10. |
|18.||Brivet FG, Kleinknecht DJ, Loirat P, Landais PJ. Acute renal failure in intensive care units-causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on Acute Renal Failure. Cnt Care Med 1996;24:192-8. |
|19.||Rayner BL, Wilcox PA. Pascoe MD. Acute renal failure in community - acquired bacteraemia. Nephron 1990;54:32-5. |
|20.||Welage LS, Walawander CA, Timm EG, Grasela TH. Risk factors for acute renal insufficiency in patients with suspected or documented bacterial pneumonia. Ann Pharmacother 1994;28:515-22. [PUBMED] |
|21.||Cooper K, Bennett WM. Nephrotoxicity of common drugs used in clinical practice. Arch Intern Med 1987:147:1213-8. |
|22.||Hock R, Anderson RJ. Prevention of druginduced nephrotoxicity in the intensive care unit. J CntCare 1995:10:33-43. |
|23.||Morns JA Jr, Mucha P Jr, Ross SE, et al. Acute posttraumatic renal failure: a multcenter perspective. J Trauma 1991;31:1584-90. |
|24.||Turney JH, Ellis CM, Parsons FM Obstetric acute renal failure 1956-1987. Br J Obstet Gynaccol 1989;96:679-87. |
|25.||Charlson ME, MacKenzic CR. Gold JP, Shires GT. Postoperative changes in scrum creatinine. When do they occurc and how much is important? Ann Surgery 1989;209:328-33. |
|26.||Kamel KS, Ethier JH, Richardson RM; Bear RA, Halperin ML. Urine electrolytes and osmolality: when and how to use them. Am J Nephrol 1990; 10:89-102. |
|27.||Shoemaker WC. Temporal physiologicpatterns of shock and circulatory dysfunction based on early descriptions by invasive and noninvasive monitoring. New Honz 1996;4(2):300-18. |
|28.||Tuchschmidt JA, Mccher CE. Predictors of outcome from critical illness. Shock and cardiopulmonary resuscitation. Crit Care Clin 1994; 10:179-95. |
|29.||Bickell WH; Wall MJ Jr, Pepc PE; et al. Immediate versus delayed fluid resuscitation for hypertensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-9. |
|30.||Banerjee A, Jones R. Whither immediate fluid resuscitation? Lancet 1994;344:1450-1. [PUBMED] [FULLTEXT]|
|31.||Gallagher TJ, Banner MJ, Barnes PA. Large volume crystalloid resuscitation does not increase extravascular lung water. Anesth Analg 1985;64:323-6. [PUBMED] [FULLTEXT]|
|32.||Mcmoli B, Libetta C, Conte G. Andreucci VE. Loop diuretics and renal vasodilators in acute renal failure. Ncphrol Dial Transplant 1994;9(Suppl 4):168-71, |
|33.||Lindner A. Synergism of dopamine and furoseinidc in diuretic-resistant, oliguric acute renal failure. Nephron 1983;33:121-6. [PUBMED] |
|34.||Henderson IS, Beattie 17, Kennedy AC. Dopamine hydrochloride in oliguric states. Lancet 1980;2:827-8. |
|35.||Neilson EG. Pathogenesis and therapy of interstitial nephritis. Kidney Int 1989;35: 1257-70. [PUBMED] |
|36.||Druml W. Nutritional support in acute renal failure. Nutrition and the kidney, edited by Mitch WE, Klahr S, Boston, Little, Brown 8c Co., 1993;p374-75. |
|37.||Toback FG. Regeneration after acute tubular necrosis. Kidney Int 1992;41:226-46. [PUBMED] |
|38.||van Bommel EF, Ponssen HH. Intermittent versus continuous treatment for acute renal failure where do we stand? Am J Kidney Dis I997;30(Suppl 4):572-9. |
|39.||Mukau L, Latimer RG. Acute hemodialysis in the surgical intensive care unit. Am Surg 1988:54:548-52. |
|40.||Mehta RL. Modalities of dialysis for acute renal failure. Seminars in Dialysis 1996; 9(6):469-75. |
|41.||Davenport A. The management of established renal failure in patients with liver failure. Seminars in Dialysis 1996:9(2): 166-71. |
|42.||Mahcr ER; Robinson KN, ScobleJE, etal.Prognosis of critically ill patients with acute renal failure: APACHE 11 score and other predictive factors. Q J Med 1989;72: 857-66. |
|43.||Routh GS, Briggs JD, Mone JG, Ledmgham IM. Survival from acute renal failure with and without multiple organ dysfunction. Postgrad Med J 1980;56:244-7. |
|44.||Mclnnes EG, Lew DW, Chaudhuri MD, Bhan GL. Renal failure in the elderly. Q J Med 1987;64:583-8. |
|45.||Pascual J, Liano F, Ortuno J. The elderly patient with acute renal failure. J Am Soc Nephrol 1995,6:144-53. |
Muhammad Ziad Souqiyyeh
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]