Incidence, clinical predictors and outcome of acute renal failure among North Indian trauma patients

Abstract

Context:There is a need for identifying risk factors aggravating development of acute renal failure after attaining trauma and defining new parameters for better assessment and management. Aim of the study was to determine the incidence of acute renal failure among trauma patients, and its correlation with various laboratory and clinical parameters recorded at the time of admission and in-hospital mortality.Subjects and Methods:The retrospective cohort study included admitted 208 trauma patients over a period of one year. 135 trauma patients at the serum creatinine level >2.0 mg/dL were enrolled in under the group of acute renal failure. 73 patients who had normal creatinine level made the control group. They were further assessed with clinical details and laboratory investigations.Results:Incidence of acute renal failure was 3.1%. There were 118 (87.4%) males and average length of stay was 9 (1, 83) days. Severity of injury (ISS, GCS) was relatively more among the renal failure group. Renal failure was transient in 35 (25.9%) patients. They had higher incidence of bone fracture (54.0%) (P= 0.04). Statistically significant association was observed between patients with head trauma and mortality 72 (59.0%) (P= 0.001). Prevalence of septic 24 (59.7%) and hemorrhagic 9 (7.4%) shock affected the renal failure group.Conclusion:Trauma patients at the urea level >50 mg/dL, ISS >24 on the first day of admission had 23 times and 7 times the risk of developing renal failure. Similarly, patients with hepatic dysfunction and pulmonary dysfunction were 12 times and 6 times. Patients who developed cardiovascular dysfunction, hematological dysfunction and post-trauma renal failure during the hospital stay had risk for mortality 29, 7 and 8 times, respectively. The final prognostic score obtained was: 14*hepatic dysfunction + 11*cISS + 18*cUrea + 12*cGlucose + 10*pulmonary dysfunction. Optimal score cut-off for prediction of renal failure was found to be ≥25 with specificity, sensitivity and positive likelihood ratio to be 84.9%, 78.4% and 3.9, respectively.

Utilizing Electronic Health Records to Predict Acute Kidney Injury Risk and Outcomes: Workgroup Statements from the 15th ADQI Consensus Conference

“… AKI by KDIGO criteria Kim JM et al 2014 [ 46 ] Liver transplant recipients n = 153 Hepatic encephalopathy, deceased donor liver donations, MELD score, intraoperative blood loss, and indication for liver transplantation Patients who needed renal replacement therapy Kim MY et al, 2011 [ 101 ] Isolated off-pump CABG patients n = 448 High systolic blood pressure, low baseline eGFR, coronary angiography less than 7 days prior to surgery AKI by AKIN criteria Kim WH et al 2013 [ 102 ] Aortic surgery with cardiopulmonary bypass n = 737 Age, preoperative glomerular filtration, ejection fraction, operation time, intraoperative urine output, intraoperative furosemide use AKI defined by RIFLE Kristovic D et al 2015 [ 26 ] Cardiac surgery patients n = 1056 age, atrial fibrillation, CHF classification, previous cardiac surgery, creatinine, endocarditis, weight, gender, COPD, bypass AKI stage by KDIGO AKI requiring dialysis Legrand M et al 2013 [ 103 ] Patients with endocarditis/ cardiac surgery with cardiopulmonary bypass n = 202 Age, gender, pre-existing comorbidities, presence of shock, systemic emboli, NYHA classification, hemoglobin, baseline creatinine, need for mechanical ventilation, characteristics of infection/surgery, use of nephrotoxic agents Development or progression of AKI in the 7 days following surgery. AKI defined per AKIN McMahon GM et al 2013 [ 104 ] Rhabdomyolysis within 3 days of admission n = 2371 Age, female sex, cause of rhabdomyolysis, initial creatinine, creatinine phosphokinase, phosphate, calcium, and bicarbonate Composite endpoint: Renal replacement therapy or mortality Medha et al 2013 [ 41 ] Trauma patients n = 4396 hepatic dysfunction, urea, glucose, pulmonary dysfunction, severity of injury serum creatinine level >2.0 mg/dL during the hospital stay Meersch M et al 2014 [ 42 ] Patients undergoing cardiac surgery with bypass n = 50 Diabetes, severity of illness, ejection fraction, baseline serum creatinine, cross-clamp time, chronic obstructive pulmonary disease AKI defined by RIFLE or AKIN together …”

“…); these variables may be better suited for a generalized model. Most models had modest predictive success with area under the receiver operating curves (AUC) approximating 0.75; a few models reached AUCs as high as 0.9, although the sample sizes were smaller and there was a pre-selection of high-risk patients [41–44]. Regardless of their ultimate utility in defining predictive variables, these models give us a minimum AUC threshold to target for successful model development.…”

Evaluation of Continuous Infusion Vancomycin Administration in a Critically Ill Trauma Population

“…14 Both groups in this cohort had an estimated creatinine clearance exceeding 100 mL/min, and a higher ISS, a known risk factor for increased renal complications, was noted in the continuous group. 15,16 This study did not include patients on renal replacement therapy. Similarly, a significantly higher proportion of those with intermittent therapy required therapy discontinuation secondary to adverse effects (12% vs 1%, P .05).…”

Gentamicin Therapeutic Drug Monitoring: Importance in the Hospital Setting

“…Gentamicin induced nephrotoxicity is usually assessed by the monitoring of the change in serum creatinine in patients (4). The risk, injury, failure, loss, end-stage renal disease (RIFLE) criteria proposed by the acute dialysis quality initiative (ADQI) group classifies acute renal dysfunction in five different classes, namely: R (Risk), I (injury), F (failure), L (loss) and E (end-stage kidney disease) and has been used to monitor acute change in renal function during gentamicin therapy (5).…”