The long-term outcome after acute renal failure

1. The long-term outcome after acute renal failure Presented by Ri 顏玎安

2. Introduction • Popular-based incidence and risk factors for developing severe acute renal failure • Long-term outcomes and prognosis for survivors of critical illness • Survival • Renal recovery • Heath-related quality of life • Health economics effects

3. Introduction • Popular-based incidence and risk factors for developing severe acute renal failure • Long-term outcomes and prognosis for survivors of critical illness • Survival • Renal recovery • Heath-related quality of life • Health economics effects

4. Annual incidence and mortality rate Annual incidence rate:11.0/10,000/year Annual mortality rate:7.3/10,000/year

5. Risk factors • Risk factors: • Previous heart dx • Stroke • Pulmonary dx • DM • Connective tissue dx • Chronic renal dysfunction • Alcoholism

6. Popular-based risk factors of ARF 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

7. Introduction • Popular-based incidence and risk factors for developing severe acute renal failure • Long-term outcomes and prognosis for survivors of critical illness • Survival • Renal recovery • Heath-related quality of life • Health economics effects

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

9. Survival Rate

10. Factors V.S Long-term mortality Associated ….. • Older age • Greater burden of co-morbid illness • Assessed by Charlson co-morbidity index • Chronic liver disease • High severity of illness • Assessed by APACHE Ⅱor SOFA scores • Severe sepsis/septic shock • Postcardiac surgical acute renal failure

11. Factors V.S Long-term survival Not significantly associated… • Renal replacement therapy modality • CRRT V.S IHD • Sex • Oliguria • Need for mechanical ventilation • Etiology of sARF • Indication for RRT • Pre-existing renal disease • High intensity of prescribed RRT: • only improve survival in short term

12. Factors associated with death in 1 year 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

13. Factors associated with death in 1 year 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

14. Introduction • Popular-based incidence and risk factors for developing severe acute renal failure • Long-term outcomes and prognosis for survivors of critical illness • Survival • Renal recovery • Heath-related quality of life • Health economics effects

15. Renal recovery • Important clinical measure of morbidity • Recovery to independence from RRT continues after hospital discharge • Peak recovery rate: 90 days with 60~70% independent form RRT • Long term recovery rate : not well described

16. Renal recovery • No studies have specifically addressed what factors are predictive of long-term recovery. • Factors associated with reduced recovery • Older age • Female sex • The presence of co-morbidities, esp CKD • Parenchymal etiology of ARF • Late initiation of RRT • Use of conventional intermittent RRT

17. Renal recovery- Recurring need for renal replacement therapy • Study of critically ill patients with severe acute renal failure with normal preexisting kidney function • Low recurrence rate for renal replacement therapy after initial recovery. ~Renal recovery from acute tubular necrosis requiring renal replacement therapy: a prospective study in critically ill patients. By Schiffl H. Nephrol -Dial Transplant 2006; 21:1248–1252.

18. Introduction • Popular-based incidence and risk factors for developing severe acute renal failure • Long-term outcomes and prognosis for survivors of critical illness • Survival • Renal recovery • Heath-related quality of life • Health economics effects

19. Health-related quality of life & Health economic implications • HRQoL is generally good and acceptable by survivors of critically illness and ARF • Provision of RRT in critically ill patients with sever ARF is expensive

20. Plasma concentration of tumor necrosis factor alpha may predict the outcome of patients with acute renal failure~Kidney and Blood Pressure Research. 29(4):203~209, 2006 • Background/Aims: • Plasma TNF-alpha • is frequently elevated chronic renal failure on HD • correlates with mortality • Results: • TNF-alpha in ARF patients • Markedly higher (70ng/ml) than reference value (<5 pg/ml) • Significantly lower than HD patients (216 pg/ml)

21. Plasma concentration of tumor necrosis factor alpha may predict the outcome of patients with acute renal failure~Kidney and Blood Pressure Research. 29(4):203~209, 2006 • Results: • TNF-alpha in ARF patients • Remained elevated in polyuric phase • Initially lower than70 ng/ml predicted the beneficial outcome with sensitivity of 64%, specificity of 70% • Conclusions: • TNF-alpha may predict the outcome of ARF • TNF-alpha remained elevated at polyuric phase despite marked improvement of excretory kidney func.

22. Predictors of mortality in patients with acute renal failure~Acta Medica. 49(3): 183-8,2006 • 3 independent predictors of mortality • Increased APACHE Ⅲ score • Presence of cor-morbid conditions • Low serum albumin level

23. Key messages • Factors independently associated with long-term mortality: • High-mortility and pre-existing co morbidities, liver disease, higher APACHE score on ICU admission, septic shock, albumin level • Majority of patients with sARF will die • In those who survive : majority will recover renal function and become independent of RTT within 1 year

24. Factors associated with mortality in acute renal failure (ARF) in children~Pediatirc Nephrology ;Jan2006 • The most affected age were newborns and infants • Mechanism:

25. Factors associated with mortality in acute renal failure (ARF) in children~Pediatirc Nephrology ;Jan 2006 • Type of clinical presentation:Nonoliguria

26. Factors associated with mortality in acute renal failure (ARF) in children~Pediatirc Nephrology ;Jan 2006 • In multinominal logistic regression analysis, only oliguria (P=0.07) and age group (P=0.049) were associated with mortality

27. Factors associated with mortality in acute renal failure (ARF) in children~Pediatirc Nephrology ;Jan 2006 • In the Cox model survival analysis, oliguria (P=0.003) and sepsis (P=0.03) influenced survival

28. Factors associated with mortality in acuterenal failure (ARF) in children~Pediatirc Nephrology ;Jan 2006 Oliguria Without sepsis non-Oliguria With sepsis

29. Reference: • The long-term outcome after acute renal failure -Curr Opin Crit Care 12:561–566. • Renal recovery from acute tubular necrosis requiring renal replacement therapy: a prospective study in critically ill patients. By Schiffl H. -Nephrol Dial Transplant 2006; 21:1248–1252. • Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study. Bagshaw SM, Laupland KB, Doig CJ, et al.-Crit Care 2005; 9:R700–R709 • Predictors of mortality in patients with acute renal failure • Acta Medica. 49(3): 183-8, 2006

30. Reference • Plasma concentration of TNF-alpha may predict the outcome of patients with acute renal failure • Kidney and Blood Pressure research. 29(4):203-9, 2006 • Factors associated with mortality in acute renal failure (ARF) in children • Pediatric Nephrology;Jan 2006, Vol.21, Issue 1,p106-9

31. ~Thank you~ ~Mucha gracias!