Impact of different types of organ failure on outcome in intensive care unit patients with acute kidney injury.

PURPOSE: The aim of this study was to explore the impact of different types of associated organ failure in patients with acute kidney injury (AKI). MATERIALS AND METHODS: A retrospective analysis of 22 303 adult patients admitted to 22 intensive care units (ICUs) in the United Kingdom and Germany between 1989 and 1999 was done. RESULTS: A total of 7898 patients (35.4%) had AKI. Intensive care unit mortality was 10.7% in patients without AKI, 20.1% in those with AKI I, 25.9% in those with AKI II, and 49.6% in those with AKI III. Intensive care unit mortality rose with increasing number of associated failed organs and preexisting chronic health problems. Respiratory failure was the most common associated organ failure, followed by cardiovascular failure. Less than 2% of the patients had associated neurologic failure alone, but the associated ICU mortality was higher than with single respiratory or cardiovascular failure. In AKI patients with 2 or more failed organ systems, combined cardiovascular and respiratory failure were most common. In multivariate analysis, associated neurologic or hepatic failure had the strongest impact on ICU outcome. There was little change in ICU mortality but a decrease in the standardized mortality ratio over time. CONCLUSIONS: The prognosis of ICU patients with AKI depended on the total number and types of associated failed organ systems. Respiratory failure was the most common associated organ failure, but neurologic and hepatic failures were associated with the worst prognosis.

Black renal transplant recipients have poorer long-term graft survival than CYP3A5 expressers from other ethnic groups.

BACKGROUND: African American transplant recipients have poorer long-term outcomes than Caucasian Americans. This difference was not found in French patients, suggesting socialized medicine overcame this disparity. It has also been hypothesized that the difference relates to the higher prevalence of Black individuals who express the metabolic enzyme cytochrome P4503A5 (CYP3A5), with consequent altered handling of immunosuppressive drugs. METHODS: Records of 555 (50 Black; 505 non-Black) sequential renal transplant recipients from a single UK centre were analysed. RESULTS: Outcomes were significantly worse for Black patients: death-censored graft survival (5-year 66% versus 87%, P = 0.001); halving of year one estimated glomerular filtration rate (mean 8.8 versus 10.8 years, P = 0.008); first-year graft loss (12% versus 3.8%, P = 0.02); and death-censored graft survival in patients surviving the first year with functioning grafts (5-year 77% versus 94%, P = 0.02). Death-censored 5-year graft survival was poorer in Black CYP3A5 expressers than in non-Black CYP3A5 expressers (62% versus 93%, P = 0.002). Following multivariate analysis, the Black group demonstrated poorer graft survival as compared to the non-Black group (hazard ratio 0.46, 95% CI 0.25-0.85, P = 0.002). In a subgroup of genotyped transplant recipients, ethnicity (hazard ratio 0.31, 95% CI 0.15-0.64, P = 0.002), and not CYP3A5 expresser status, persists as an independent risk factor for graft survival following multivariate analysis. CONCLUSION: In this cohort of patients with socialized medicine, Black recipients had poorer long-term outcomes than individuals from other ethnic groups. This was independent of CYP3A5 expresser status.

Acute kidney injury in the intensive care unit according to RIFLE.

OBJECTIVES: To apply the RIFLE criteria "risk," "injury," and "failure" for severity of acute kidney injury to patients admitted to the intensive care unit and to evaluate the significance of other prognostic factors. DESIGN: Retrospective analysis of the Riyadh Intensive Care Program database. SETTING: Riyadh Intensive Care Unit Program database of 41,972 patients admitted to 22 intensive care units in the United Kingdom and Germany between 1989 and 1999. PATIENTS: Acute kidney injury as defined by the RIFLE classification occurred in 15,019 (35.8%) patients; 7,207 (17.2%) patients were at risk, 4,613 (11%) had injury, and 3,199 (7.6%) had failure. It was found that 797 (2.3%) patients had end-stage dialysis-dependent renal failure when admitted to an intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: : Patients with risk, injury, and failure classifications had hospital mortality rates of 20.9%, 45.6%, and 56.8%, respectively, compared with 8.4% among patients without acute kidney injury. Independent risk factors for hospital mortality were age (odds ratio 1.02); Acute Physiology and Chronic Health Evaluation II score on admission to intensive care unit (odds ratio 1.10); presence of preexisting end-stage disease (odds ratio 1.17); mechanical ventilation (odds ratio 1.52); RIFLE categories risk (odds ratio 1.40), injury (odds ratio 1.96), and failure (odds ratio 1.59); maximum number of failed organs (odds ratio 2.13); admission after emergency surgery (odds ratio 3.08); and nonsurgical admission (odds ratio 3.92). Renal replacement therapy for acute kidney injury was not an independent risk factor for hospital mortality. CONCLUSIONS: The RIFLE classification was suitable for the definition of acute kidney injury in intensive care units. There was an association between acute kidney injury and hospital outcome, but associated organ failure, nonsurgical admission, and admission after emergency surgery had a greater impact on prognosis than severity of acute kidney injury.

Retroperitoneoscopic live donor nephrectomy in a patient with a double inferior vena cava.

BACKGROUND: Vascular anomalies are considered a contraindication for laparoscopic live donor nephrectomy. We report a successful hand-assisted retroperitoneoscopic live donor nephrectomy from a donor with a double inferior vena cava. MATERIALS AND METHODS: A 37-year-old woman wanted to donate a kidney to her 44-year-old boyfriend who had hypertensive nephropathy. Preoperative donor imaging showed a double inferior vena cava. Each renal vein drains into the ipsilateral inferior vena cava division, making the left renal vein short. A single renal artery, vein, and ureter were noted on both sides. A hand-assisted retroperitoneoscopic left nephrectomy was performed. Blood loss was minimal and the warm ischemia time was 2 minutes. Renal transplantation was performed with good initial perfusion and urine output. Cold ischemia and rewarming time was 25 minutes. RESULTS: The donor postoperative period was uneventful with infrequent need for pain relief. The donor was discharged in good condition 3 days postoperatively. The donor's kidney functions were within the normal range at follow-up 4 months postoperatively. The recipient was discharged in good condition 7 days postoperatively. The recipient is alive with good graft function and unremarkable complications at 4 month follow-up. CONCLUSION: Although vascular anomalies present a surgical challenge, we have shown the feasibility of performing hand-assisted retroperitoneoscopic live donor nephrectomy in a donor with a double vena cava and short renal vein. With comprehensive preoperative assessment, laparoscopic live donor nephrectomy can be done safely in donors with anatomical anomalies. This may increase the number of living donor kidney transplants as it offers lower postoperative morbidity and economic disincentives for potential donors.