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A prospective, multicenter observational study with a duration of one year from February was carried out. A total of critical patients over 18 years of age were admitted to the CCU for more than 48 h.
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The incidence of ARF was UC detected ARF in The mortality rate was UC proved more effective than CC. There have been great difficulties for decades in defining the syndrome which we now refer to as formu,a renal failure ARF. The inconvenience of not having a single definition was first addressed by a review in which 28 studies published in the period between and 1 were seen to have used different criteria for diagnosing the condition.
In the yearBellomo, Kellum and Ronco 2 proposed formmula of the definition of ARF, and considered that only two of the multiple functions of the kidneys—urine production and the excretion of waste products of nitrogen metabolism—are easily and routinely determined in all Intensive Care Units ICUs. The validity of this approach and its capacity to predict mortality have been evaluated by a number of studies.
The results of a second consensus conference with the participation of representative specialists in Critical Care Medicine and Nephrology the Acute Kidney Injury Network were published in6 and proposed the AKIN classification with the purpose of improving the sensitivity and specificity of the RIFLE system.
Large studies have evaluated both systems. InBagshaw et al. InOsterman et al. InJoannidis et al. The incidence of ARF was found to be Both of the mentioned studies demonstrated an increase in morbidity-mortality associated to the development of ARF. The recommendations of an international consensus conference held in Canada in 10 with the purpose of establishing guidelines for the prevention and management of ARF in critical patients were published in The mentioned consensus document considered cystatin C to be a promising marker that appears to detect ARF earlier than changes in plasma creatinine.
However, both this and other biomarkers NGAL, kidney injury molecule-1, interleukin are still in the investigational stages. It therefore was concluded that plasma creatinine remains the main marker despite the disadvantages related to the influence of body weight, catabolic status, the presence of rhabdomyolysis, dilutional effects and drugs or other substances that alter creatinine secretionalong with the measurement of diuresis.
A prospective study of patients formulaa 9 polyvalent ICUs was carried out between February and February Table 1. The study was approved by the Ethics Committee of each participating center. Centers participating in the study.
The study included patients over 18 years of age admitted to the ICU for at least 48 h, with evaluation during the first 7 days of admission. The exclusion criteria were: Microsoft Excel was used for data collection, with recording of the following parameters: Urine collection was carried out diruesis two horaris depending on whether the patient carried a urinary catheter or not.
In patients without a catheter, each micturition episode was quantified, while urine was collected every two hours in the patients with a bladder catheter. In both cases these amounts were used to calculate the hourly average from previous sampling. In all patients we recorded the daily measured plasma creatinine MPC value. In addition, both criteria were evaluated separately. Based on CHD, we identified the cases that met the U criterion before the C criterion, during a continuous period of 6, 12 and 24 hours.
Meaning of “diuresis” in the Spanish dictionary
Accordingly, the registry of ARF was only obtained on days 3, 5 and 7 of the study, yielding one of the four possible grades: Neither volemia nor prior fluid therapy was considered. The analysis of the selected variables was made using a program that generated an SQL database with the collected registries. The homogeneity of the variables was controlled using the Levene test. The Student t -test for the comparison of means was used to detect significant differences between the participating institutions.
In the case of patient sex, we assessed differences in the proportion of females between institutions based on the chi-squared test. A total of A total of 8. In contrast, the cases of ARF that first complied with the C criterion were fewer in number than the cases that complied with both criteria simultaneously: Moreover, older age was associated to increased severity. A similar tendency was observed in the patients evaluated with the AKIN system, though in this case the values failed to reach statistical significance.
Most of the patients with ARF were non-surgical cases. Only 34 patients required RST intermittent daily hemodialysis in 31 cases, and continuous RST in 3 casesbased on the following indications: The corresponding values were lower in the patients with ARF, with significantly lesser values in situations of increasing severity. However, on evaluating the sensitivity of daily diuresis in detecting patients with ARF, the area under the receiver operating characteristic ROC curve was found to be In turn, on evaluating the patients only with the U criterion, daily diuresis decreased significantly with increasing risk of ARF.
On the other hand, MPC among the patients evaluated only according to the U criterion was also significantly higher in the more severe cases. Global mortality mortality in the ICU and up to 90 days after discharge was The proportion of deaths increased significantly with increasing severity of ARF Fig. The most severe grade of ARF was associated to markedly higher mortality rates Global mortality according to the severity of acute renal failure.
The mortality rate was higher in subjects with non-surgical conditions Global mortality in surgical and non-surgical patients with acute renal failure. Relative mortality risk in acute renal failure.
This increased incidence was observed for all grades of severity. Incidence of acute renal failure according to the literature. This suggested that the use of both systems would increase the capacity to detect ARF, as was effectively confirmed by the results obtained. The weaknesses of using plasma creatinine for the diagnosis of ARF have been widely commented in the literature.
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The latter has been validated only in patients who are stable an uncommon circumstance in the critically illand ignores the nonlinear relationship between the creatinine levels and the glomerular filtration rate GFR. Moreover, this formula includes information which is not usually reliable in the ICU: Here diurdsis previous creatinine value is not calculated but measured—suggesting that the results could be more reliable than in the case of the RIFLE system.
Thus, analysis of the changes in creatinine is questioned in both methods, and discussion focuses on which of the two is more reliable.
Since there is no gold standard for defining ARF, the specificity of the two methods cannot be compared. We thus consider that the most useful method should be that capable of detecting a larger number of cases of ARF with the purpose of adopting preventive or early management measures, despite the consequent incidence of horagia results.
In our study, the U criterion detected a larger number of patients with ARF than the C criterion, and was therefore more effective.
This increased sensitivity of the U criterion could be explained by the fact that we stratified the patients in an hourly manner according to a calculated hourly diuresisin contrast to creatinine, which requires a new value after 24 h in the case of the RIFLE system or after 48 h in the AKIN classification.
In our experience there was great variation in the way of monitoring diuresis in the different participating centers, and the literature likewise describes a lack of uniformity in the way this parameter is determined. On the other hand, when the urinary tract is not diurwsis it is not possible to record the urine produced every hour—theoretically making it impossible to apply the U criterion recommended by iduresis in such patients who, although perhaps in a less critical condition, are not free from risk of developing ARF.
However, the decrease in hourly urine output showed a good correlation to the presence of ARF and to more severe grades of the disease.
Here we must remember that the creatinine data were registered daily in the RIFLE system versus once every 48 h in the AKIN system; as a result, we can assume that increases in MPC have prognostic value when creatinine is measured at least once every 24 h. On the other hand, the isolated MPC values showed a sensitivity of In coincidence with the published data, our mortality rates were significantly higher among the patients with ARF than in the patients without ARF, on applying both the RIFLE and the AKIN classification—higher rates being associated to increased severity of the disease.
The results were similar on stratifying the patients according to the U criterion or C criterion separately. The larger proportion of deaths recorded among non-surgical patients is also consistent with the findings in the literature.
There were no significant differences with respect to patient sex or days of stay in the ICU. Furthermore, we found the highest incidence of ARF to correspond to non-surgical patients. Since there is no gold standard for knowing the true sensitivity and specificity of the RIFLE and AKIN systems, comparative assessment should aim to establish which of the two systems is more useful for improving the outcome in critically ill patients. The literature continues to present data that are difficult to compare, despite the consensus-based definitions.
Perhaps the incidences of ARF reported in the literature would have been greater if strict application of the U criterion had been observed. Despite the recommendations, it remains unclear how diuresis should be measured, particularly in patients without catheterization of the urinary tract.
In our experience, CHD allowed application of the urinary criterion in a standardized manner in all patients, independently of the diuresis monitoring intervals and the presence or absence of a bladder catheter. We therefore recommend its use in this context.
We feel the originality of our study to be fundamentally attributable to the fact of having applied the U criterion exactly as recommended by consensus, in contrast to most studies in which insufficient or absent diuresis information constituted an acknowledged weak point.
The authors declare that they have no conflicts of interest. Please cite this article as: Previous article Next article.
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