Intensive renal support in critically ill patients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy involving a defined dose of intermittent hemodialysis three times per week and continuous renal-replacement therapy at 20 ml per kilogram per hour. (ClinicalTrials.gov number, NCT00076219.)

The usefulness and clinical applicability of quantitative plasma polymorphonuclear elastase determinations in the diagnosis of the severity of acute pancreatitis was analysed in a multicentre study and was compared with the usual prognostic systems of Ranson and Osborne et al. The study comprised 182 patients, 154 with a mild episode of acute pancreatitis and 28 with a severe episode, defined by the development of major complications or a fatal outcome. In the severe cases neutrophilic elastase reached significantly higher values than in mild cases (P less than 0.001) by the time the patient was admitted (2-12 h after the onset of the disease), reflecting considerable leucocyte activation. The sensitivity and specificity of this test are therefore greater than 90 per cent, with a positive severity predictive value of almost 80 per cent at the time of admission and 97 per cent after 24 h, and a negative predictive value of approximately 98 per cent. In addition to requiring 48 h for evaluation, the usual prognostic systems show a sensitivity of 77-85 per cent, a specificity of 70-77 per cent, a positive predictive value of 40-48 per cent, and a negative predictive value of 92-95 per cent, clearly lower than those obtained with leucocyte elastase. Polymorphonuclear elastase is therefore a very early and reliable marker in the diagnosis of the severity of acute pancreatitis, in addition to being easily adaptable to the routine of any hospital laboratory.

The clinical usefulness of the APACHE I1 and SAPS systems in the early prognostic classification of patients with acute pancreatitis has been evaluated in a prospective multicenter study. We aimed to identify early those patients with acute pancreatitis who should be monitored closely to expedite the detection and treatment of complications. One hundred eighty-two patients with acute pancreatitis were included; 28 were classified as severe, having developed at least one major complication of the disease. The scores obtained through the APACHE I1 and SAPS systems in these severe cases were significantly higher than the scores in the mild cases of acute pancreatitis (p < 0.001). The sensitivity of these systems in the prognostic classification of acute pancreatitis was 70.4% for APACHE I1 and 66.7% for SAPS, and the specificity was 79.1% for both. When applying APACHE I1 and SAPS systems in the early phase of acute pancreatitis, the possibility of misdiagnosing the seventy exists, thus limiting the application of these systems in the initial assessment of prognostic classification. In conclusion, APACHE I1 and SAPS systems are of limited clinical utility in the early prognostic evaluation of acute pancreatitis because of their low positive predictive value.