Ya-Chung Tian

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.

Prospective cohort study comparing sequential organ failure assessment and acute physiology, age, chronic health evaluation III scoring systems for hospital mortality prediction in critically ill cirrhotic patients

The aim of the study was to evaluate the usefulness of sequential organ failure assessment (SOFA) and acute physiology, age, chronic health evaluation III (APACHE III) scoring systems obtained on the first day of intensive care unit (ICU) admission in predicting hospital mortality in critically ill cirrhotic patients. The study enrolled 102 cirrhotic patients consecutively admitted to ICU during a 1‐year period. Twenty‐five demographic, clinical and laboratory variables were analysed as predicators of survival. Information considered necessary to calculate the Child–Pugh, SOFA and APACHE III scores on the first day of ICU admission was also gathered. Overall hospital mortality was 68.6%. Multiple logistic regression analysis revealed that mean arterial pressure, SOFA and APACHE III scores were significantly related to prognosis. Goodness‐of‐fit was good for the SOFA and APACHE III models. Both predictive models displayed a similar degree of the best Youden index (0.68) and overall correctness (84%) of prediction. The SOFA and APACHE III models displayed good areas under the receiver–operating characteristic curve (0.917 ± 0.028 and 0.912 ± 0.029, respectively). Finally, a strong and significant positive correlation exists between SOFA and APACHE III scores for individual patients (r2 = 0.628, p < 0.001). This investigation confirms the grave prognosis for cirrhotic patients admitted to ICU. Both SOFA and APACHE III scores are excellent tools to predict the hospital mortality in critically ill cirrhotic patients. The overall predictive accuracy of SOFA and APACHE III is superior to that of Child–Pugh system. The role of these scoring systems in describing the dynamic aspects of clinical courses and allocating ICU resources needs to be clarified.

Hemodynamics and metabolic studies on septic shock in patients with acute liver failure

BACKGROUND Acute liver failure is often accompanied by hyperdynamic circulation, which is also a characteristic of septic shock. Pre-existing acute liver failure may worsen the hemodynamic impairment and prognosis in sepsis. AIMS To evaluate the hemodynamic and metabolic characteristics and clinical outcomes of septic shock in patients with acute liver failure. METHODS Twenty patients with acute liver failure and 19 patients without preexisting liver disease were evaluated. Systemic hemodynamics, arterial and mixed vein blood gases, arterial lactate levels, plasma renin activity, and plasma aldosterone levels were checked during the early phase of septic shock. RESULTS In acute liver failure group, cardiac index (4.92 +/- 1.13 vs 3.69 +/- 1.06 L/min per square meter, P < .001) and oxygen delivery (604.7 +/- 139.7 vs 485.4 +/- 137.3 mL/min per square meter, P = .011) were significantly higher than those without preexisting liver diseases, while systemic vascular resistance index (1041.2 +/- 503.3 vs 1409 +/- 505.25 dyne.s/cm(5).m(2)), oxygen consumption (119.1 +/- 29.2 vs 162.4 +/- 49.4 mL/min per square meter) and oxygen extraction ratio (20% +/- 6% vs. 32% +/- 8%) were significantly higher in the latter group. Furthermore, the patients with acute liver failure had higher arterial lactate (P = .026), plasma renin activity (P = .03), plasma aldosterone levels (P < .001), and intensive care unit as well as hospital mortality rates (P = .005, and 0.02 respectively). CONCLUSIONS In patients with acute liver failure, septic shock was characterized by an accentuated hyperdynamic circulation, hyperlactatemia and an augmented renin-angiotensin-aldosterone system activity. Pre-existing liver failure has a significant impact on the disease severity of septic shock and portends a grave prognosis.

Role of serum sodium in assessing hospital mortality in cancer patients with spontaneous tumour lysis syndrome inducing acute uric acid nephropathy

Spontaneous tumour lysis syndrome (STLS) inducing acute uric acid nephropathy, a rare and neglected disease, presents more insidiously than conventional post‐treatment tumour lysis syndrome. Although STLS is a serious and potentially fatal complication in patients with neoplastic disorders, few investigations have addressed the relevance of clinical and laboratory features in assessing prognosis. A retrospective study was conducted, reviewing the records of all patients who developed acute renal failure (ARF) at Chang Gung memorial hospital between 1 July 1999 and 30 June 2003. STLS‐induced acute uric acid nephropathy was identified in 12 of 1072 ARF patients (1.1%) during the study period. All patients had advanced stage tumours with large tumour burden, and 66.7% of cases had abdominal organ involvement. All 12 hyperuricemic patients became oliguric despite conservative therapy, and remained hyperuricemic (21.6 ± 5.2 mg/dl) before dialysis therapy. Diuresis developed in eight patients (66.7%), with associated resolution of hyperuricemia, azotemia and metabolic derangements following dialysis initiation. Overall hospital mortality was 58.3%. Death in most patients was related to hyponatremia and hypoalbuminemia on admission. The serum sodium was found to have the best Youden index (0.86) and highest overall prediction accuracy (93%). Moreover, serum sodium and serum albumin for individual patients were significantly and positively correlated (r = 0.617, p = 0.032). This investigation confirms a grave prognosis for cancer patients with STLS inducing acute uric acid nephropathy. Hyponatremia and hypoalbuminemia on the first day of admission indicate poor prognosis in such patients.

Comparison of intracerebral hemorrhage and subarachnoid hemorrhage in patients with autosomal-dominant polycystic kidney disease.

Background/Aims: Subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) are two subtypes of hemorrhagic stroke that may cause severe complications in patients with autosomal-dominant polycystic kidney disease (ADPKD). The differences in clinical features between SAH and ICH associated with ADPKD are not known. Methods: Among 647 ADPKD patients hospitalized between 1997 and 2007 in our hospital, 11 with ICH (1.7%) and 6 with SAH (0.9%) were identified. Results: Patients with SAH were significantly younger than patients with ICH (39 ± 6 vs. 57 ± 15 years, p = 0.013). The systolic blood pressure on admission was significantly higher in patients with ICH (194 ± 26 vs. 145 ± 18 mm Hg, p = 0.001). Two patients (18.2%) with ICH died after a first episode, 6 had a second episode, and 2 had a third episode. Two patients (33.3%) with SAH died after a first episode but the survivors had no recurrence during follow-up. The 30-day survival curves comparing patients with ICH and SAH were not significantly different. Patients with a Glasgow Coma Score less than 9 on arrival had a significantly worse outcome. Conclusion: Clinical features differed between ICH and SAH associated with ADPKD. Nevertheless, blood pressure control and early recognition of hemorrhagic stroke are important in ADPKD 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.

Rhabdomyolysis associated with acute renal failure in patients with severe acute respiratory syndrome

An outbreak of severe acute respiratory syndrome (SARS) occurred in Taiwan in 2003. SARS complicated with rhabdomyolysis has rarely been reported. This study reported three cases of rhabdomyolysis developing during the clinical course of SARS. Thirty probable SARS patients were admitted to the isolation wards at Linkou Chang Gung Memorial Hospital between 4 April and 4 June 2003. Thirty patients, including four men and 26 women aged from 12 to 87 years (mean age 40). Eleven (36.7%) patients had respiratory failure and required mechanical ventilation with paralytic therapy; three (10%) patients had rhabdomyolysis complicated with acute renal failure and one received haemodialysis; four (13.3%) patients died. Three cases with rhabdomyolysis all received sedative and paralytic therapy for mechanical ventilation. Haemodialysis was performed on one patient. Two patients died from multiple organ failure, and one patient fully recovered from rhabdomyolysis with acute renal failure. SARS is a serious respiratory illness, and its aetiology is a novel coronavirus. Rhabdomyolysis resulting from SARS virus infection was strongly suspected. Immobilisation under paralytic therapy and steroids may also be important in developing rhabdomyolysis.

Concurrent Renal Cell Carcinoma and Central Nervous System Lymphoma in a Patient with Autosomal Dominant Polycystic Kidney Disease

Objective: To report an unusual case of synchronous renal cell carcinoma and CNS lymphoma in a patient with autosomal dominant polycystic kidney disease (ADPKD). Case Presentation and Intervention: A 58-year-old woman presented with progressive right hemiparesis of 2 months’ duration. A brain CT scan revealed multiple enhanced lesions in the basal ganglia and the right occipital lobe. CNS lymphoma was confirmed by a stereotactic biopsy. Polycystic kidneys and a right renal mass were found incidentally. It was decided to treat the patient with cranial radiotherapy and chemotherapy first. The patient achieved complete remission of CNS lymphoma after 3 months, but the renal mass remained unchanged. A needle biopsy of the renal mass revealed renal cell carcinoma and unilateral nephrectomy was performed successfully. The patient remained in complete remission at 6-year follow-up. Conclusion: The patient was treated successfully with a combination of chemotherapy, radiotherapy, and unilateral nephrectomy. This report highlights the need for clinicians to remain alert to the possibility of double malignancies while caring for ADPKD patients, especially when multiple unexplained manifestations exist.

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.

Long-Term Online Hemodiafiltration Does Not Reduce the Frequency and Severity of Acquired Cystic Kidney Disease in Hemodialysis Patients

Background. Acquired cystic kidney disease (ACKD) is a frequent complication in chronic hemodialysis (HD) patients and a risk factor for renal cell carcinoma. Online hemodiafiltration (HDF) provides better clearance of middle molecular weight solutes, but its effect on ACKD has not been investigated. Materials and methods. This case-control study enrolled 86 patients (43 HDF patients and 43 HD patients) who were matched according to age, sex, and duration of renal replacement therapy. The mean duration of HDF was 63 (± 35) months. The frequency and severity of ACKD was evaluated by ultrasonography using a severity scoring system. Results. We observed ACKD in 23 of the HD patients (53.5%) and 21 of the HDF patients (48.8%). This difference was not statistically significant (p = 0.829). The overall ACKD severity scores were similar in the two groups (p = 0.875). Patients on HDF had significantly lower serum levels of alkaline phosphatase and intact parathyroid hormone. Multiple logistic regression analysis indicated that duration of renal replacement therapy was the only risk factor for the presence of ACKD (p < 0.001). There was a significant correlation between duration of renal replacement therapy and ACKD severity score (r = 0.589, p < 0.001). Conclusions. Our results suggest that long-term online HDF does not reduce the frequency and severity of ACKD in dialysis patients. Duration of renal replacement therapy is the most important risk factor for ACKD. Factors that cannot be corrected by use of HDF may contribute to the formation of renal cysts.