Six-month survival and quality of life of intensive care patients with acute kidney injury.

INTRODUCTION: Acute kidney injury (AKI) has high incidence among the critically ill and associates with dismal outcome. Not only the long-term survival, but also the quality of life (QOL) of patients with AKI is relevant due to substantial burden of care regarding these patients. We aimed to study the long-term outcome and QOL of patients with AKI treated in intensive care units. METHODS: We conducted a predefined six-month follow-up of adult intensive care unit (ICU) patients from the prospective, observational, multi-centre FINNAKI study. We evaluated the QOL of survivors with the EuroQol (EQ-5D) questionnaire. We included all participating sites with at least 70% rate of QOL measurements in the analysis. RESULTS: Of the 1,568 study patients, 635 (40.5%, 95% confidence interval (CI) 38.0-43.0%) had AKI according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Of the 635 AKI patients, 224 (35.3%), as compared to 154/933 (16.5%) patients without AKI, died within six months. Of the 1,190 survivors, 959 (80.6%) answered the EQ-5D questionnaire at six months. The QOL (median with Interquartile range, IQR) measured with the EQ-5D index and compared to age- and sex-matched general population was: 0.676 (0.520-1.00) versus 0.826 (0.812-0.859) for AKI patients, and 0.690 (0.533-1.00) versus 0.845 (0.812-0.882) for patients without AKI (P <0.001 in both). The EQ-5D at the time of ICU admission was available for 774 (80.7%) of the six-month respondents. We detected a mean increase of 0.017 for non-AKI and of 0.024 for AKI patients in the EQ-5D index (P = 0.728). The EQ-5D visual analogue scores (median with IQR) of patients with AKI (70 (50-83)) and patients without AKI (75 (60-87)) were not different from the age- and sex-matched general population (69 (68-73) and 70 (68-77)). CONCLUSIONS: The health-related quality of life of patients with and without AKI was already lower on ICU admission than that of the age- and sex-matched general population, and did not change significantly during critical illness. Patients with and without AKI rate their subjective health to be as good as age and sex-matched general population despite statistically significantly lower QOL indexes measured by EQ-5D.

Miniaturized versus conventional cardiopulmonary bypass in high-risk patients undergoing coronary artery bypass surgery.

OBJECTIVE: To review our results with the use of miniaturized cardiopulmonary bypass (Mini-CPB) versus conventional cardiopulmonary bypass (C-CPB) in high-risk patients (additive EuroSCORE>or=6) who have undergone coronary artery bypass graft surgery (CABG). PATIENTS AND METHODS: This study includes a consecutive series of 236 patients with an additive EuroSCORE>or=6 who underwent CABG, employing either C-CPB or Mini-CPB. Propensity score analysis was performed. RESULTS: The study groups had similar EuroSCOREs. Stroke rate was significantly higher among C-CPB patients (5.4% vs. 0%, p=0.026). In-hospital mortality (4.8% vs. 3.4%, p=0.75) and combined adverse end-point rate were higher in C-CPB patients (20.4% vs. 13.5%, p=0.18). Postoperative bleeding and need for transfusion were similar in the study groups, but re-sternotomy for bleeding was more frequent among C-CPB patients (4.8% vs. 1.1%, p=0.26). Seventy-four propensity matched pairs had similar immediate postoperative results: C-CPB patients had higher mortality (6.8% vs. 4.1%, p=0.72), stroke (5.4% vs. 0%, p=0.12) and combined adverse end-point rates (27.0% vs. 16.2%, p=0.11), but such differences failed to reach statistical significance. CONCLUSIONS: Mini-CPB achieved somewhat better results than C-CPB in these high-risk patients undergoing isolated CABG. This study confirmed that cerebral protection could be the main benefit associated with the use of Mini-CPB.

Is it possible to improve the accuracy of EuroSCORE?

OBJECTIVE: We derived a new risk-scoring method by modifying some of the risk factors included in the EuroSCORE algorithm. METHODS: This study includes 3613 patients who underwent cardiac surgery at the Vaasa Central Hospital, Finland. The EuroSCORE variables, along with modified age classes (< 60 years, 60-69.9 years, 70-79.9 years and > or = 80 years), eGFR-based chronic kidney disease classes (classes 1-2, class 3 and classes 4-5) and the number of cardiac procedures, were entered into the regression analysis. RESULTS: An additive risk score was calculated according to the results of logistic regression by adding the risk of the following variables: patients' age classes (0, 2, 4 and 6 points), female (2 points), pulmonary disease (3 points), extracardiac arteriopathy (2 points), neurological dysfunction (4 points), redo surgery (3 points), critical preoperative status (8 points), left ventricular ejection fraction (> 50%: 0; 30-50%: 2 and < 30%: 3 points), thoracic aortic surgery (8 points), postinfarct septal rupture (9 points), chronic kidney disease classes (0, 3 and 6 points), number of procedures (1: 0; 2: 2 and 3 or more: 7 points). The modified score had a better area under the receiver operating characteristic curve (additive: 0.867; logistic: 0.873) than the EuroSCORE (additive: 0.835; logistic: 0.840) in predicting 30-day postoperative mortality. The modified score, but not EuroSCORE, correctly estimated the 30-day postoperative mortality. CONCLUSION: EuroSCORE still performs well in identifying high-risk patients, but significantly overestimates the immediate postoperative mortality. This study shows that the score's accuracy and clinical relevance can be significantly improved by modifying a few of its variables. This institutionally derived risk-scoring method represents a modification and simplification of the EuroSCORE and, likely, it would provide a more realistic estimation of the mortality risk after adult cardiac surgery.