Ming-Yang Chang

Acute kidney injury classification: comparison of AKIN and RIFLE criteria.

The Acute Kidney Injury Network (AKIN) group has recently proposed modifications to the risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification system. The few studies that have compared the two classifications have revealed no substantial differences. This study aimed to compare the AKIN and RIFLE classifications for predicting outcome in critically ill patients. This retrospective study investigated the medical records of 291 critically ill patients who were treated in medical intensive care units of a tertiary care hospital between March 2003 and February 2006. This study compared performance of the RIFLE and AKIN criteria for diagnosing and classifying AKI and for predicting hospital mortality. Overall mortality rate was 60.8% (177/291). Increased mortality was progressive and significant (chi-square for trend; P < 0.001) based on the severity of AKIN and RIFLE classification. Hosmer and Lemeshow goodness-of-fit test results demonstrated good fit in both systems. The AKIN and RIFLE scoring systems displayed good areas under the receiver operating characteristic curves (0.720 ± 0.030, P = 0.001; 0.738 ± 0.030, P = 0.001, respectively). Compared with RIFLE criteria, this study indicated that AKIN classification does not improve the sensitivity and ability of outcome prediction in critically ill patients.

Prognosis of Patients on Extracorporeal Membrane Oxygenation: The Impact of Acute Kidney Injury on Mortality

BACKGROUNDnExtracorporeal membrane oxygenation (ECMO) has been utilized for patients in critical condition, such as those with life-threatening respiratory failure or postcardiotomy cardiogenic shock. This study analyzed the outcomes of patients treated with ECMO and identified the relationship between prognosis and the Acute Kidney Injury Network (AKIN) scores obtained at pre-ECMO support (AKIN0-hour); and at post-ECMO support 24 hours (AKIN24-hour) and 48 hours (AKIN48-hour).nnnMETHODSnThis study reviewed the medical records of 102 critically ill patients on ECMO support at a specialized intensive care unit at a tertiary care university hospital between March 2002 and January 2008. Demographic, clinical, and laboratory variables were retrospectively collected as survival predicators.nnnRESULTSnThe overall mortality rate was 57.8%. The most common condition requiring ECMO support was cardiogenic shock. Goodness-of-fit was good for AKIN0-hour, AKIN24-hour, and AKIN48-hour criteria. The AKIN0-hour, AKIN24-hour, and AKIN48-hour scoring systems also had excellent areas under the receiver operating characteristic curve (0.804±0.046, 0.811±0.045, and 0.858±0.040, respectively). Furthermore, multiple logistic regression analysis indicated that AKIN48-hour, age, and Glasgow Coma Scale score on the first day of intensive care unit admission were independent risk factors for hospital mortality. Finally, cumulative survival rates at 6-month follow-up after hospital discharge differed significantly (p<0.05) for AKIN48-hour stage 0 versus AKIN48-hour stages 1, 2, and 3; and AKIN48-hour stage 1 and 2 versus AKIN48-hour stage 3.nnnCONCLUSIONSnDuring ECMO support, the AKIN48-hour scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.

RIFLE CLASSIFICATION FOR PREDICTING IN-HOSPITAL MORTALITY IN CRITICALLY ILL SEPSIS PATIENTS

Severe sepsis and septic shock, often complicated by acute kidney injury (AKI), are the most common causes of mortality in noncoronary intensive care units (ICUs). This study investigates the outcomes of critically ill patients with sepsis and elucidates the association between prognosis and risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification. A total of 121 sepsis patients were admitted to ICU from June 2003 to January 2004. Forty-seven demographic, clinical, and laboratory variables were prospectively recorded for post hoc analysis as predictors of survival on the first day of ICU admission. Overall in-hospital mortality rate was 47.9%. Mortality was significantly associated (chi-square for trend; P < 0.001) with RIFLE classification. Septic shock, RIFLE category, and number of organ system failures on the first day of ICU admission were independent predictors of hospital mortality according to forward conditional logistic regression. The severity of RIFLE classification correlated with organ system failure number and Acute Physiology and Chronic Health Evaluation (APACHE) II to IV and sequential organ failure assessment scores. Cumulative survival rates at 6-month follow-up after hospital discharge significantly (P < 0.05) differed between non-AKI versus RIFLE injury, non-AKI versus RIFLE failure (RIFLE-F), and RIFLE risk versus RIFLE F. At 6-month follow-up, full recovery of renal function was noted in 85% of surviving patients with AKI (RIFLE risk, RIFLE injury, and RIFLE-F). In conclusion, these findings are consistent with a role for RIFLE classification in accurately predicting in-hospital mortality and short-term prognosis in ICU sepsis patients.

Serum Sodium Predicts Prognosis in Critically Ill Cirrhotic Patients

Background End-stage liver disease is often complicated by hyponatremia. Cirrhotic patients with hyponatremia admitted to intensive care units (ICUs) have high mortality rates. This study analyzed the outcomes of critically ill cirrhotic patients and identified the prognostic value of serum sodium concentration. Methods One hundred twenty-six consecutive cirrhotic patients admitted to the ICU of a tertiary center during a 1.5-year period were enrolled in this study. Demographic, clinical, and laboratory variables on the first day of ICU admission were prospectively recorded for post hoc analysis. Results Overall hospital mortality was 65.1%. Comparing with serum sodium >135u2009mmol/L, patients with serum sodium ≤135u2009mmol/L had a greater frequency of ascites, illness severity scores, hepatic encephalopathy, sepsis, renal failure, and in-hospital mortality (55.9% vs. 73.1%, P=0.043). Multiple Cox proportional hazards analysis revealed that serum sodium levels, hepatocellular carcinoma, and sequential organ failure assessment scores on the first day of ICU admission were independent risk factors for 6-month mortality. Cumulative survival rates at 6-month follow-up after hospital discharge differed significantly (P<0.05) between patients with serum sodium >135u2009mmol/L versus those with serum sodium ≤135u2009mmol/L. Conclusions Low serum sodium levels in critically ill cirrhotic patients are associated with high complications of liver cirrhosis, in-hospital mortality, and poor short-term prognosis. The serum sodium concentration is important predictor of survival among candidates for liver transplantation. Future research with sequential application of serum sodium may reflect the dynamic aspects of clinical conditions, thus providing complete data for mortality risk.

DIFFUSE ALVEOLAR HEMORRHAGE IN SYSTEMIC LUPUS ERYTHEMATOSUS: A SINGLE CENTER RETROSPECTIVE STUDY IN TAIWAN

This study is to describe our clinical experience of diffuse alveolar hemorrhage (DAH) in patients with systemic lupus erythematosus (SLE) in Taiwan. From July 1994 to June 2001, eight patients of DAH among 1541 different SLE patients (0.52%) admitted to the Chang Gung Memorial Hospital were included for chart review. Dyspnea (100%) and fever (87.5%) were the most common symptoms instead of hemoptysis (62.5%). The most common extrapulmonary presentation was renal involvement (100%), which included clinical nephritis, nephrotic syndrome or acute renal failure. The overall mortality rate was 50%. Two pregnant patients were successfully treated with combined plasmapheresis and continuous venovenous hemofiltration in addition to high dose corticosteroid. Analysis of the prognostic factors showed that the higher APACHE II (Acute physiology, Age and Chronic Health Evaluation) and organ system failure (OSF) scores, but not the SLE activity index (SLEDAI), were associated with the greater mortality. The higher serum creatinine level or the need of hemodialysis did not adversely affect the survival. In conclusion, DAH in SLE patients are often accompanied with multiple organ failure, aggressive immunosuppressive therapy and multiple modalities of extracorporeal organ support should be started early for a favorable outcome.

Outcome scoring systems for short-term prognosis in critically ill cirrhotic patients.

Cirrhotic patients admitted to intensive care units (ICUs) have high mortality rates. This study evaluated specific predictors and scoring systems for hospital and 6-month mortality in critically ill cirrhotic patients. This investigation is a prospective clinical study performed in a 10-bed specialized hepatogastroenterology ICU in a tertiary care university hospital in Taiwan. Two hundred two consecutive cirrhotic patients admitted to the ICU during a 2-year period were enrolled in this study. Demographic, clinical, and laboratory variables recorded on the first day of ICU admission and scoring systems applied were prospectively recorded for post hoc analysis for predicting survival. The overall hospital mortality was 59.9%, and the 6-month mortality rate was 70.8%. The main causes of cirrhosis were hepatitis B (29%), hepatitis C (22%), and alcoholism (20%). The major cause of ICU admission was upper gastrointestinal bleeding (36%). Multiple logistic regression analysis revealed that the Acute Kidney Injury Network (AKIN) score at the 48th hour of ICU admission and the Sequential Organ Failure Assessment (SOFA) as well as the Model for End-Stage Liver Disease scores on the first day of ICU admission were independent risk factors for hospital mortality. The SOFA score had the best discriminatory power (0.872 ± 0.036), whereas the AKIN had the best Youden index (0.57) and the highest correctness of prediction (79%). Cumulative survival rates at the 6-month follow-up after hospital discharge differed significantly (P < 0.05) for AKIN stage 0 vs. stages 1, 2, and 3, and for AKIN stage 1 vs. stage 3. The AKIN, SOFA, and Model for End-stage Liver Disease (MELD) scores showed well discriminative power in predicting hospital mortality in this group of patients. The AKIN scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.

Acute kidney injury biomarkers for patients in a coronary care unit: a prospective cohort study.

Background Renal dysfunction is an established predictor of all-cause mortality in intensive care units. This study analyzed the outcomes of coronary care unit (CCU) patients and evaluated several biomarkers of acute kidney injury (AKI), including neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18) and cystatin C (CysC) on the first day of CCU admission. Methodology/Principal Findings Serum and urinary samples collected from 150 patients in the coronary care unit of a tertiary care university hospital between September 2009 and August 2010 were tested for NGAL, IL-18 and CysC. Prospective demographic, clinical and laboratory data were evaluated as predictors of survival in this patient group. The most common cause of CCU admission was acute myocardial infarction (80%). According to Acute Kidney Injury Network criteria, 28.7% (43/150) of CCU patients had AKI of varying severity. Cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.05) between patients with AKI versus those without AKI. For predicting AKI, serum CysC displayed an excellent areas under the receiver operating characteristic curve (AUROC) (0.895±0.031, p<0.001). The overall 180-day survival rate was 88.7% (133/150). Multiple Cox logistic regression hazard analysis revealed that urinary NGAL, serum IL-18, Acute Physiology, Age and Chronic Health Evaluation II (APACHE II) and sodium on CCU admission day one were independent risk factors for 6-month mortality. In terms of 6-month mortality, urinary NGAL had the best discriminatory power, the best Youden index, and the highest overall correctness of prediction. Conclusions Our data showed that serum CysC has the best discriminative power for predicting AKI in CCU patients. However, urinary NGAL and serum IL-18 are associated with short-term mortality in these critically ill patients.

OUTCOME SCORING SYSTEMS FOR ACUTE RESPIRATORY DISTRESS SYNDROME

Acute respiratory distress syndrome (ARDS) is commonly diagnosed in intensive care units (ICUs), often in association with acute kidney injury. In this study, we compared the predictive value of outcome scoring systems: Acute Physiology and Chronic Health Evaluation IV (APACHE IV), earlier APACHE models, Sequential Organ Failure Assessment (SOFA), the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal failure (RIFLE) classification, and Acute Lung Injury score in critically ill patients with ARDS. We retrospectively abstracted data from the medical records of 135 critically ill ARDS patients in two medical ICUs of a tertiary care hospital from December 1999 to June 2006. Overall mortality rate was 65% (88/135). Forward conditional logistic regression identified APACHE IV, alveolar-arterial O2 tension difference, age, sepsis, and maximum RIFLE (RIFLEmax) score on ICU days 1 and 3 to be independent predictors of hospital mortality. The area under the receiver operating characteristic curve for the APACHE IV score revealed good fit (Hosmer and Lemeshow goodness-of-fit test results) and discriminative power (area under the receiver operating characteristic curve, 0.792 ± 0.038; P < 0.001). The cumulative survival rates at 6-month follow-up after hospital discharge were significantly (P < 0.001) different among ARDS patients with APACHE IV mortality rate 35% or less and APACHE IV mortality rate higher than 35%. The APACHE IV score and RIFLEmax score are predictors of hospital mortality in ARDS patients, with APACHE IV demonstrating desirable properties of prognostic accuracy.

Scoring systems for 6-month mortality in critically ill cirrhotic patients: a prospective analysis of chronic liver failure - sequential organ failure assessment score (CLIF-SOFA).

Cirrhotic patients admitted to intensive care units (ICUs) have high mortality rates. The Chronic Liver Failure–Sequential Organ Failure Assessment (CLIF‐SOFA) score, a modified Sequential Organ Failure Assessment (SOFA) score, is a newly developed scoring system exclusively for patients with end‐stage liver disease.

Ethambutol-Induced Optic Neuritis in Patients with End Stage Renal Disease on Hemodialysis: Two Case Reports and Literature Review

Ethambutol, a synthetic bacteriostatic agent, is a first line agent against Mycobacterium tuberculosis. Although optic neuritis is the most serious adverse effect of ethambutol, most cases in the literature are reversible. Renal failure prolongs the half‐life of ethambutol and increases the risk of ethambutol‐induced optic neuritis. We present two patients with end stage renal disease (ESRD), who were on maintenance dialysis and suffering ethambutol‐induced optic neuritis. The first woman had been suffering ESRD on hemodialysis for 2 years. After tuberculosis was diagnosed, she was prescribed three‐combined anti‐tuberculosis medications, including ethambutol 800 mg/day. Bilateral blurred vision suddenly occurred 4 months after the start of treatment, and she became totally blind despite discontinuing ethambutol. The second woman had been on hemodialysis for 5 months. Tuberculosis was diagnosed by lung biopsy. After 3 weeks of three‐combined anti‐tuberculosis medications including ethambutol (1200 mg/day), reduced visual acuity and color vision defects occurred. One year after the discontinuation of ethambutol, visual acuity remained little improved. Physicians should be aware of ethambutol‐induced optic neuritis and ethambutol should be used cautiously in patients with renal failure.