Renal recovery after severe acute renal failure.

BACKGROUND: There is limited information about renal recovery to independence from renal replacement therapy (RRT) and about factors associated with its occurrence after severe acute renal failure (ARF). METHODS: We conducted a population-based surveillance among all adult residents of the Calgary Health Region surviving ICU admission from May 1, 1999 to April 30, 2002. The primary objective was to determine the rate of and the factors associated with 90-day survival and recovery to independence from RRT in critically ill patients with severe ARF. RESULTS: At 90 days, 96 patients (40%) were alive. Of these, 72% were RRT independent with most (87%) requiring <4 weeks to recover. Prior to RRT, the median (IQR) serum creatinine and mean (SD) serum urea were 395 (252-517) micromol/L and 29.2 (18) mmol/L, respectively. Oliguria was present in 76%. Intermittent hemodialysis was the initial modality in 46% and continuous renal replacement therapy (CRRT) in 54%. By multivariate analysis, male sex (odds ratio (OR) 7.6, 95% CI, 2.2-27, p=0.01) and a diagnosis of septic shock (OR 3.9, 95% CI 1.02-14.5, p=0.05) were associated with an increased odds of recovery. Conversely, a higher Charlson co-morbidity index score (OR 0.71, 95% CI, 0.6-0.85, p=0.04) and a higher pre-RRT serum creatinine (OR 0.20, 95% CI, 0.05-0.80, p=0.02, p=0.02) were associated with reduced odds of recovery. Chronic kidney disease or the initial modality of RRT were not associated with recovery. CONCLUSIONS: The majority of severe ARF patients who survive their acute illness are independent of RRT by 90 days. Male sex and a diagnosis of septic shock are independently associated with recovery while a greater co-morbidity score and a higher serum creatinine prior to RRT are predictive of non-recovery.

Progression of kidney dysfunction in the community-dwelling elderly.

Despite the high prevalence of chronic kidney disease among the elderly, few studies have described their loss of kidney function. We sought to determine the progression of kidney dysfunction among a community-based cohort of elderly subjects. The cohort included 10 184 subjects 66 years of age or older, who had one or more outpatient serum creatinine measurements during each of two time periods: 1 July to 31 December 2001 and 1 July to 31 December 2003. A mixed effects model, including covariates for age, gender, diabetes mellitus, and comorbidity, was used to determine the rate of decline in estimated glomerular filtration rate (eGFR, in ml/min/1.73 m2) per year over a median follow-up of 2.0 years. Subjects with diabetes mellitus had the greatest decline in eGFR of 2.1 (95% CI 1.8-2.5) and 2.7 (95% CI 2.3-3.1) ml/min/1.73 m2 per year in women and men, respectively. The rate of decline for women and men without diabetes mellitus was 0.8 (95% CI 0.6-1.0) and 1.4 (95% CI 1.2-1.6) ml/min/1.73 m2 per year. Subjects with a study mean eGFR<30 ml/min/1.73 m2, both those with and without diabetes mellitus, experienced the greatest decline in eGFR. In conclusion, we found that the majority of elderly subjects have no or minimal progression of kidney disease over 2 years. Strategies aimed at slowing progression of kidney disease should consider underlying risk factors for progression and the negligible loss of kidney function that occurs in the majority of older adults.

Quality of life in patients treated with hemodialysis or peritoneal dialysis: what are the important determinants?

BACKGROUND: Patients with end-stage renal disease (ESRD) have significant impairments in health-related quality of life (HRQOL). In part, this is due to the intrusiveness of the treatment (hemodialysis or peritoneal dialysis) that is required. It is unclear whether hemodialysis or peritoneal dialysis is associated with a higher HRQOL. METHODS: 192 prevalent patients who self-selected treatment with hemodialysis (either in-center, satellite or home/self-care hemodialysis) or peritoneal dialysis were studied to determine whether treatment with hemodialysis or peritoneal dialysis is associated with a higher HRQOL. Demographic, laboratory and clinical information (including the presence of comorbid conditions using the Charlson comorbidity index) was assessed at baseline. The outcome of interest was HRQOL, which was measured using the Kidney Disease Quality of Life-Short Form (KDQOL-SF), the Short-Form 36 (SF-36) and the EuroQol EQ-5D at baseline and after 6 and 12 months of follow-up. RESULTS: There was no significant difference in HRQOL scores for the SF-36, the EQ-5D and for 9 of 11 KDQOL dimensions for patients treated with hemodialysis or peritoneal dialysis at baseline. As expected, HRQOL was significantly lower for patients who had more comorbid disease, required assistance with their daily care, and for patients with less than a grade 12 education. After controlling for the effect of other important variables, HRQOL (as measured by the EQ-5D visual analog or index scores) did not differ between hemodialysis and peritoneal dialysis patients. HRQOL was stable over time, both for patients who started on hemodialysis or peritoneal dialysis. CONCLUSIONS: There is no significant difference in HRQOL for prevalent ESRD patients treated with hemodialysis or peritoneal dialysis. It will be important to determine if this finding holds true for incident patients treated with hemodialysis or peritoneal dialysis.

The Southern Alberta Renal Program database: a prototype for patient management and research initiatives.

The Southern Alberta Renal Program (SARP) database was developed to respond to an urgent need for local information on clinical outcomes, laboratory information, and health care costs, and to enable our local renal program to monitor the implementation of established clinical practice guidelines. The database captures detailed demographic, clinical, and laboratory information and is unique by also capturing comorbidity, health-related quality of life and costing information for patients with end-stage renal disease (ESRD) in southern Alberta, storing the information in one common database. By collecting information on patient comorbidity, health outcomes and costs, the SARP database has enabled many quality assurance initiatives as well as research opportunities for projects involving patients with ESRD. Due to the availability of links with other available local clinical and administrative databases, information is collected with a minimal need for manual data entry. This type of database is a method by which health programs could improve the quality of patient care. Programs caring for patients with chronic medical conditions such as ESRD should examine how computer databases could assist in clinical care and improve the efficiency with which that care is delivered to their patients.