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

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Presentation on theme: "The long-term outcome after acute renal failure Presented by Ri 顏玎安."— Presentation transcript:

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

3 Introduction Popular-based incidence and risk factors for developing severe acute renal failure Popular-based incidence and risk factors for developing severe acute renal failure Long-term outcomes and prognosis for survivors of critical illness Long-term outcomes and prognosis for survivors of critical illness Survival Survival Renal recovery Renal recovery Heath-related quality of life Heath-related quality of life Health economics effects 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: Risk factors: Previous heart dx Previous heart dx Stroke Stroke Pulmonary dx Pulmonary dx DM DM Connective tissue dx Connective tissue dx Chronic renal dysfunction Chronic renal dysfunction Alcoholism 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 Popular-based incidence and risk factors for developing severe acute renal failure Long-term outcomes and prognosis for survivors of critical illness Long-term outcomes and prognosis for survivors of critical illness Survival Survival Renal recovery Renal recovery Heath-related quality of life Heath-related quality of life Health economics effects Health economics effects

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

9 Survival Rate

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

11 Factors V.S Long-term survival Not significantly associated … Renal replacement therapy modality Renal replacement therapy modality CRRT V.S IHD CRRT V.S IHD Sex Sex Oliguria Oliguria Need for mechanical ventilation Need for mechanical ventilation Etiology of sARF Etiology of sARF Indication for RRT Indication for RRT Pre-existing renal disease Pre-existing renal disease High intensity of prescribed RRT: High intensity of prescribed RRT: only improve survival in short term 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 Popular-based incidence and risk factors for developing severe acute renal failure Long-term outcomes and prognosis for survivors of critical illness Long-term outcomes and prognosis for survivors of critical illness Survival Survival Renal recovery Renal recovery Heath-related quality of life Heath-related quality of life Health economics effects Health economics effects

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

16 Renal recovery No studies have specifically addressed what factors are predictive of long-term recovery. No studies have specifically addressed what factors are predictive of long-term recovery. Factors associated with reduced recovery Factors associated with reduced recovery Older age Older age Female sex Female sex The presence of co-morbidities, esp CKD The presence of co-morbidities, esp CKD Parenchymal etiology of ARF Parenchymal etiology of ARF Late initiation of RRT Late initiation of RRT Use of conventional intermittent 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 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. 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 ~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. -Dial Transplant 2006; 21:1248 – 1252.

18 Introduction Popular-based incidence and risk factors for developing severe acute renal failure Popular-based incidence and risk factors for developing severe acute renal failure Long-term outcomes and prognosis for survivors of critical illness Long-term outcomes and prognosis for survivors of critical illness Survival Survival Renal recovery Renal recovery Heath-related quality of life Heath-related quality of life Health economics effects 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 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 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: Background/Aims: Plasma TNF-alpha Plasma TNF-alpha is frequently elevated chronic renal failure on HD is frequently elevated chronic renal failure on HD correlates with mortality correlates with mortality Results: Results: TNF-alpha in ARF patients TNF-alpha in ARF patients Markedly higher (70ng/ml) than reference value (<5 pg/ml) Markedly higher (70ng/ml) than reference value (<5 pg/ml) Significantly lower than HD patients (216 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 : Results : TNF-alpha in ARF patients TNF-alpha in ARF patients Remained elevated in polyuric phase Remained elevated in polyuric phase Initially lower than70 ng/ml predicted the beneficial outcome with sensitivity of 64%, specificity of 70% Initially lower than70 ng/ml predicted the beneficial outcome with sensitivity of 64%, specificity of 70% Conclusions: Conclusions: TNF-alpha may predict the outcome of ARF TNF-alpha may predict the outcome of ARF TNF-alpha remained elevated at polyuric phase despite marked improvement of excretory kidney func. 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 3 independent predictors of mortality Increased APACHE Ⅲ score Increased APACHE Ⅲ score Presence of cor-morbid conditions Presence of cor-morbid conditions Low serum albumin level Low serum albumin level

23 Key messages Factors independently associated with long-term mortality: 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 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 Majority of patients with sARF will die In those who survive : majority will recover renal function and become independent of RTT within 1 year 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 ;Jan 2006 The most affected age were newborns and infants The most affected age were newborns and infants Mechanism: Mechanism:

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

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

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

28 Oliguria non- Oliguria With sepsis Without sepsis

29 Reference: The long-term outcome after acute renal failure 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. 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. -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 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 Predictors of mortality in patients with acute renal failure Acta Medica. 49(3): 183-8, 2006 Acta Medica. 49(3): 183-8, 2006

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

31 ~Thank you~ ~Mucha gracias!

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