Chang-Chyi Jenq

Outcome predictors and new score of critically ill cirrhotic patients with acute renal failure

BACKGROUND End-stage liver disease is often complicated by renal function disturbances. Cirrhotic patients with acute renal failure admitted to intensive care units (ICUs) have high mortality rates. This work seeks to identify specific predictors of hospital mortality in critically ill cirrhotic patients with acute renal failure. METHODS A total of 111 patients with cirrhosis and acute renal failure were admitted to ICU from March 2003 to February 2005. Twenty-six demographic, clinical and laboratory variables were prospectively gathered as predictors of survival on the first day of ICU admission. RESULTS The overall hospital mortality rate was 81.1%. The univariate analysis identified 11 of the 32 variables as prognostically valuable. The multiple logistic regression analysis (excluding five scoring systems) indicates that the mean arterial pressure (MAP), serum bilirubin, respiratory failure and sepsis on the first day in ICU are significantly related to prognosis. The best Youden index (sensitivity + specificity - 1) yields cutoff points of 80 MAP (in mmHg) and 80 serum bilirubin (in micromol/L) (or 4.7 mg/dL) and indicates acute respiratory failure and sepsis. A simple model for mortality is developed on the basis of these four readily available parameters on Day 1 of ICU admission. The new score (MBRS score: MAP + bilirubin + respiratory failure + sepsis) displays an excellent area under the receiver operating characteristic curve (0.898 +/- 0.031, P < 0.001). The mortality rate exceeds 90% when the MBRS (MAP + bilirubin + respiratory failure + sepsis) score is 2 or higher. CONCLUSION The MBRS score is a straightforward, reproducible and easily adopted evaluative tool with good prognostic abilities, which generates objective data for patient families and physicians and supplements a clinical judgment of prognosis.

Scoring short-term mortality after liver transplantation.

Liver transplantation can prolong survival and improve the quality of life of patients with end‐stage liver disease. This study retrospectively reviewed the medical records of 149 patients who had received liver transplants in a tertiary care university hospital from January 2000 to December 2007. Demographic, clinical, and laboratory variables were recorded. Each patient was assessed by 4 scoring systems before transplantation and on postoperative days 1, 3, 7, and 14. The overall 1‐year survival rate was 77.9%. The Sequential Organ Failure Assessment (SOFA) score had better discriminatory power than the Child‐Pugh points, Model for End‐Stage Liver Disease score, and RIFLE (risk of renal dysfunction, injury to the kidney, failure of the kidney, loss of kidney function, and end‐stage kidney disease) criteria. Moreover, the SOFA score on day 7 post–liver transplant had the best Youden index and highest overall correctness of prediction for 3‐month (0.86, 93%) and 1‐year mortality (0.62, 81%). Cumulative survival rates at the 1‐year follow‐up after liver transplantation differed significantly (P < 0.001) between patients who had SOFA scores ≤ 7 on post–liver transplant day 7 and those who had SOFA scores > 7 on post–liver transplant day 7. In conclusion, of the 4 evaluated scoring systems, only the SOFA scores calculated before liver transplantation were statistically significant predictors of 3‐month and 1‐year posttransplant mortality. SOFA on post–liver transplant day 7 had the best discriminative power for predicting 3‐month and 1‐year mortality after liver transplantation. Liver Transpl 16:138–146, 2010.

Serum interleukin-18 at commencement of renal replacement therapy predicts short-term prognosis in critically ill patients with acute kidney injury.

Background Acute kidney injury (AKI) requiring renal replacement therapy (RRT) in critically ill patients results in a high hospital mortality. Outcome prediction in this selected high-risk collective is challenging due to the lack of appropriate biomarkers. The aim of this study was to identify outcome-specific biomarkers in this patient population. Methodology/Principal Findings Serum samples were collected from 101 critically ill patients with AKI at the initiation of RRT in intensive care units (ICUs) of a tertiary care university hospital between August 2008 and March 2011. Measurements of serum levels of cystatin C (CysC), neutrophil gelatinase-associated lipocalin, and interleukin-18 (IL-18) were performed. The primary outcome measure was hospital mortality. The observed overall mortality rate was 56.4% (57/101). Multiple logistic regression analysis indicated that the serum IL-18 and CysC concentrations and Acute Physiology and Chronic Health Evaluation III (ACPACHE III) scores determined on the first day of RRT were independent predictors of hospital mortality. The APACHE III score had the best discriminatory power (0.872±0.041, p<0.001), whereas serum IL-18 had the best Youden index (0.65) and the highest correctness of prediction (83%). Cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.001) for serum IL-18 <1786 pg/ml vs. ≥1786 pg/ml in these critically ill patients. Conclusions In this study, we confirmed the grave prognosis for critically ill patients at the commencement of RRT and found a strong correlation between serum IL-18 and the hospital mortality of ICU patients with dialysis-dependent AKI. In addition, we demonstrated that the APACHE III score has the best discriminative power for predicting hospital mortality in these critically ill patients.

Effectiveness of oral and intravenous iron therapy in haemodialysis patients

Anaemia is a common and serious complication in patients with end‐stage renal disease. Iron therapy is crucial in managing anaemia and maintenance of haemodialysis (HD) patients. This study investigated the efficacy of both oral and intravenous (i.v.) therapies, and the possible factors deleteriously affecting patient response to iron therapy.

Medical record review for faculty promotion: A cohort analysis

Background: A medical record is an important source of information regarding medical care and medical record review plays an important role in the evaluation of the teaching proficiency. The study analyzed the difference between internal and external auditing when conducting medical record review for faculty promotion in a study institute. Methods: We analyzed the scores related to the medical records maintained by applicants for the faculty promotion of attending physicians during the period between 2008 and 2010 at the Chang Gung Memorial Hospital. The scores were obtained from one internal reviewer of the study institute and two external reviewers from other medical centers, and routine scores were obtained from the Committee of Medical Record 1 year before application. Pearson′s correlation coefficient was used to analyze the correlation and statistical significance. Results: There were 259 applicants for faculty promotion enrolled in this study [professors (n = 33, 13%), associate professors (n = 63, 24%), assistant professors (n = 90, 35%), lecturers (n = 73, 28%)]. The scores of the external reviewers 1 and 2 were correlated with routine scores (r = 0.187, p = 0.002; r = 0.198, p = 0.001; N= 259), respectively. The correlation between external reviewers′ average and ordinary scores was significant for assistant professor (r = 0.334, p = 0.001, n = 90) and professor grades (r = 0.469, p = 0.006, n = 33). However, the internal reviewer scores did not correlate with the routine scores (r = 0.073, p = 0.241, N = 259). Conclusions: The scores from external reviewers correlated more with routine scores than the scores from internal reviewers, suggesting that utilizing an external auditing system of medical records for the faculty promotion of attending physicians is quite feasible and balanced.

Serum Immunoglobulin E Can Predict Minimal Change Disease Before Renal Biopsy

Objectives:Minimal change disease (MCD) is a major cause of nephrotic syndrome in both children and adults. The diagnosis of MCD in adults relies on findings of renal biopsy. Complications, although rare, may occur. This invasive procedure is also a suffering experience for some patients. Although Shu et al described the increase of serum immunoglobulin E (IgE) level in patients with MCD, whether IgE could be a predicting factor of MCD has not been determined. Methods:The sample was composed of 76 nonlupus patients with nephrotic range (≧3.5 g/d/1.73 m2) proteinuria and normal creatinine level who received renal biopsy since January 2006 to December 2007. Twenty-four demographic, clinical, and laboratory variables as predictors of MCD, including IgG, IgA, IgM, and IgE, were retrospectively gathered by chart review 1 day before renal biopsy. Results:The overall prevalence of MCD in this group (nonlupus and normal creatinine level) was 27.6% (21 of 76). The independent Student t test identified that 3 of 24 variables is statistically significant (P < 0.05). Serum IgE was found to have a good discriminative power (area under the receiver operating characteristic curve 0.868 ± 0.053; P < 0.001) according to the area under the receiver operating characteristic curve. Conclusions:Serum IgE exhibited high discriminative power in predicting MCD. Serum IgE is a straightforward and easily applied evaluative tool with good predictive abilities.