Letter to the Editor
Acute renal failure in a tertiary referral hospital, a relevant cause of chronic renal failure and mortality
Fracaso renal agudo en un hospital de tercer nivel, causa relevante de enfermedad renal crónica y mortalidad a medio plazo
J. Margarita Rufino Hernández
, Nayara Zamora Rodríguez, Concepción Rodríguez Adanero, Víctor Lorenzo Sellares, Armando Torres
Corresponding author
Servicio de Nefrología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
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Margarita Rufino Hernández, Nayara Zamora Rodríguez, Concepción Rodríguez Adanero, Víctor Lorenzo Sellares, Armando Torres" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J. Margarita" "apellidos" => "Rufino Hernández" "email" => array:1 [ 0 => "margaritarufino@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Nayara Zamora" "apellidos" => "Rodríguez" ] 2 => array:2 [ "nombre" => "Concepción Rodríguez" "apellidos" => "Adanero" ] 3 => array:2 [ "nombre" => "Víctor Lorenzo" "apellidos" => "Sellares" ] 4 => array:2 [ "nombre" => "Armando" "apellidos" => "Torres" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fracaso renal agudo en un hospital de tercer nivel, causa relevante de enfermedad renal crónica y mortalidad a medio plazo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The onset of acute renal failure (ARF) in a hospitalised patient is an important independent factor of morbidity/mortality and development of chronic kidney disease (CKD), and, therefore, preventive measures are essential for reducing their frequency.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Our aim was to analyse episodes of ARF in our department followed as referrals and their mid-term outcome.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This is a retrospective cohort study in which the referrals due to ARF requested to our department for a 10-month period (April 2013–January 2014), as well as their evolution over the following two years, were analysed.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We analysed the following variables: age, gender, comorbidity, kidney function, average duration of hospitalisation, need for haemodialysis, risk factors and mortality. To do this, we reviewed the electronic medical record (EMR) and the treatments received during hospitalisation. Continuous variables were expressed as mean and standard deviation; discrete variables, as percentages. Associations between related quantitative variables were analysed using the Student's <span class="elsevierStyleItalic">T</span>-test for related means.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Forty-eight patients were assessed for ARF, with an average of 17 visits per patient. The referrals came from Cardiology and Heart Surgery (33%), Internal Medicine (13%), Pulmonology (19%), Digestive Medicine and Neurology (19%); the rest were miscellaneous. Ten of these patients (21%) had previously been admitted to the Intensive Care Unit (ICU). Average age was 71<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10.5 years. 69% were male and the average hospital stay was long: 30.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>21.7 days.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In 25% of cases, ARF was related to symptoms of heart failure; a septic procedure in 27%; volume depletion or a drug in 31%; and 17% were classified multi-factorial. The main comorbidities were: 52% diabetes, 56% heart disease, 43% peripheral vascular disease and up to 50% had a prior history of CKD.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Moreover, 71% presented with hypoalbuminaemia; 65% with low blood pressure in the preceding days, 54% presented with hypovolaemia; 6% with rhabdomyolysis; and 10% with third-spacing.</p><p id="par0040" class="elsevierStylePara elsevierViewall">With regard to other factors<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a>: 21% had received NSAIDs in previous days; 60%, ACE inhibitors/angiotensin II receptor antagonists (ARBs); 25%, other drugs (aminoglycosides or chemotherapy); 21%, metformin; 16%, iodinated contrast; and, in 40% of cases, serum creatinine monitoring was not always performed daily.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Evolution: 12% required admission to ICU, 25% required haemodialysis during hospitalisation and 10% began a definitive haemodialysis programme. Kidney function remained impaired (creatinine at discharge 1.91<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.75 vs. 1.27<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.50<span class="elsevierStyleHsp" style=""></span>mg/dl), at 6 months (1.54<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.86 vs. 1.33<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.63<span class="elsevierStyleHsp" style=""></span>mg/dl), 12 months (1.68<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.84 vs. 1.33<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.56<span class="elsevierStyleHsp" style=""></span>mg/dl) and 24 months (1.67<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.70 vs. 1.29<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.52<span class="elsevierStyleHsp" style=""></span>mg/dl), with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001 in all comparisons.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A 66% of patients were followed in our Nephrology Clinic. Four patients died while in hospital and 15 after discharge (total mortality at 2 years: 39.5%), mainly due to cardiovascular and infectious causes, although five patients had advanced oncological diseases.</p><p id="par0055" class="elsevierStylePara elsevierViewall">There are a large number of known risk factors for the development of ARF<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–4</span></a>: age, CKD, diabetes, sepsis and nephrotoxic drugs. In our study, all of these factors were present in varying proportions. In spite of the efforts made from the publication of clinical guidelines for early diagnosis and ARF classification,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–4</span></a> the incidence continues to increase. This is important because ARF is a significant risk factor for the development of CKD.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Ishani's study<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> demonstrates that the risk of terminal nephropathy is 13 times greater in hospitalised elderly people with ARF than in those without ARF, and the risk is even 42 times greater if the ARF occurs on top of CKD. In our cohort it was observed that the majority of patient maintained a reduced kidney function after the episode of ARF; and the majority were followed as out-patients and in 10% was necessary to start chronic haemodialysis. Mortality may reach 30–50% in general series, and 40–80% in ICU series.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> The survival rate is comparable to that of a diabetic patient who survives a myocardial infarction with ST-elevation. In our study, considering our patients’ elevated co-morbidity, overall mortality was 39.5% at 2 years.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Serum creatinine measurement is inexpensive and is widely available in hospitals. Today this parameter is included in all ARF classification tables (RIFLE, AKIN, KDIGO), and yet, many times, it is not measured. While in the Hospital, Electronic Medical Records (EMR) could help to detect patients at risk for development of ARF<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> based on epidemiological, clinical, analytic and pharmaceutical prescription data. It could activate automated alert systems that signal the need for daily measurement of serum creatinine in these patients. This would shorten intervention time and reduce the number and duration of ARF episodes.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The findings of this study concur with the findings reported in other studies, and make us to think on the importance of identifying patients at risk of developing ARF at hospital admission using EMR, as well as on the importance of frequent serum creatinine measurement in these patients to reduce incidence and attenuate the consequences of the ARF, especially in relation to morbidity, mortality and CKD.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rufino Hernández JM, Rodríguez NZ, Adanero CR, Sellares VL, Torres A. Fracaso renal agudo en un hospital de tercer nivel, causa relevante de enfermedad renal crónica y mortalidad a medio plazo. Nefrologia. 2017;37:657–658.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factores predictores de fracaso renal agudo en ancianos con enfermedad renal crónica" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Heras" 1 => "M.J. Fernández-Reyes" 2 => "M.T. Guerrero" 3 => "R. Sánchez" 4 => "A. Muñoz" 5 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 6 | 13 |
| 2024 October | 37 | 31 | 68 |
| 2024 September | 50 | 27 | 77 |
| 2024 August | 79 | 62 | 141 |
| 2024 July | 38 | 25 | 63 |
| 2024 June | 60 | 38 | 98 |
| 2024 May | 63 | 44 | 107 |
| 2024 April | 65 | 39 | 104 |
| 2024 March | 47 | 25 | 72 |
| 2024 February | 35 | 40 | 75 |
| 2024 January | 37 | 23 | 60 |
| 2023 December | 40 | 27 | 67 |
| 2023 November | 42 | 32 | 74 |
| 2023 October | 38 | 25 | 63 |
| 2023 September | 30 | 36 | 66 |
| 2023 August | 34 | 28 | 62 |
| 2023 July | 39 | 27 | 66 |
| 2023 June | 49 | 23 | 72 |
| 2023 May | 50 | 165 | 215 |
| 2023 April | 24 | 10 | 34 |
| 2023 March | 45 | 23 | 68 |
| 2023 February | 41 | 21 | 62 |
| 2023 January | 33 | 23 | 56 |
| 2022 December | 53 | 35 | 88 |
| 2022 November | 43 | 34 | 77 |
| 2022 October | 88 | 55 | 143 |
| 2022 September | 48 | 33 | 81 |
| 2022 August | 44 | 58 | 102 |
| 2022 July | 36 | 44 | 80 |
| 2022 June | 35 | 44 | 79 |
| 2022 May | 66 | 35 | 101 |
| 2022 April | 58 | 76 | 134 |
| 2022 March | 46 | 45 | 91 |
| 2022 February | 58 | 42 | 100 |
| 2022 January | 39 | 37 | 76 |
| 2021 December | 38 | 47 | 85 |
| 2021 November | 53 | 35 | 88 |
| 2021 October | 45 | 48 | 93 |
| 2021 September | 26 | 36 | 62 |
| 2021 August | 33 | 39 | 72 |
| 2021 July | 30 | 41 | 71 |
| 2021 June | 34 | 39 | 73 |
| 2021 May | 43 | 49 | 92 |
| 2021 April | 91 | 74 | 165 |
| 2021 March | 73 | 46 | 119 |
| 2021 February | 70 | 41 | 111 |
| 2021 January | 54 | 29 | 83 |
| 2020 December | 62 | 19 | 81 |
| 2020 November | 33 | 23 | 56 |
| 2020 October | 27 | 21 | 48 |
| 2020 September | 43 | 15 | 58 |
| 2020 August | 55 | 15 | 70 |
| 2020 July | 43 | 14 | 57 |
| 2020 June | 47 | 25 | 72 |
| 2020 May | 69 | 12 | 81 |
| 2020 April | 57 | 18 | 75 |
| 2020 March | 51 | 22 | 73 |
| 2020 February | 72 | 21 | 93 |
| 2020 January | 59 | 30 | 89 |
| 2019 December | 49 | 29 | 78 |
| 2019 November | 45 | 29 | 74 |
| 2019 October | 45 | 14 | 59 |
| 2019 September | 40 | 10 | 50 |
| 2019 August | 45 | 14 | 59 |
| 2019 July | 46 | 21 | 67 |
| 2019 June | 36 | 23 | 59 |
| 2019 May | 42 | 10 | 52 |
| 2019 April | 81 | 22 | 103 |
| 2019 March | 56 | 22 | 78 |
| 2019 February | 33 | 13 | 46 |
| 2019 January | 34 | 29 | 63 |
| 2018 December | 79 | 44 | 123 |
| 2018 November | 96 | 24 | 120 |
| 2018 October | 44 | 12 | 56 |
| 2018 September | 56 | 21 | 77 |
| 2018 August | 41 | 18 | 59 |
| 2018 July | 36 | 13 | 49 |
| 2018 June | 39 | 11 | 50 |
| 2018 May | 46 | 20 | 66 |
| 2018 April | 42 | 12 | 54 |
| 2018 March | 37 | 13 | 50 |
| 2018 February | 25 | 4 | 29 |
| 2018 January | 36 | 9 | 45 |
| 2017 December | 47 | 12 | 59 |
| 2017 November | 10 | 1 | 11 |
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