Abstract. Acute renal failure increases risk of death after cardiac surgery. However, it is not known whether more subtle changes in renal function might have an impact on outcome. Thus, the association between small serum creatinine changes after surgery and mortality, independent of other established perioperative risk indicators, was analyzed. In a prospective cohort study in 4118 patients who underwent cardiac and thoracic aortic surgery, the effect of changes in serum creatinine within 48 h postoperatively on 30-d mortality was analyzed. Cox regression was used to correct for various established demographic preoperative risk indicators, intraoperative parameters, and postoperative complications. In the 2441 patients in whom serum creatinine decreased, early mortality was 2.6% in contrast to 8.9% in patients with increased postoperative serum creatinine values. Patients with large decreases (⌬Crea ϽϪ0.3 mg/dl) showed a progressively increasing 30-d mortality (16 of 199 [8%]). Mortality was lowest (47 of 2195 [2.1%]) in patients in whom serum creatinine decreased to a maximum of Ϫ0.3 mg/dl; mortality increased to 6% in patients in whom serum creatinine remained unchanged or increased up to 0.5 mg/dl. Mortality (65 of 200 [32.5%]) was highest in patients in whom creatinine increased Ն0.5 mg/dl. For all groups, increases in mortality remained significant in multivariate analyses, including postoperative renal replacement therapy. After cardiac and thoracic aortic surgery, 30-d mortality was lowest in patients with a slight postoperative decrease in serum creatinine. Any even minimal increase or profound decrease of serum creatinine was associated with a substantial decrease in survival.Acute renal failure (ARF) develops in 5 to 30% of patients who undergo cardiac surgery and is associated with a more complicated clinical course and with an excessive mortality of up to 80% (1-4). Actually, development of ARF was identified as the strongest risk factor for death with an odds ratio of 7.9 in patients who undergo cardiac surgery (1). Certainly, ARF presents an indicator for the severity and/or complicated course of disease; thus, perioperative patients with renal dysfunction are at a higher risk of dying. However, recently, is was shown convincingly that ARF acts as a risk factor for a grim prognosis independent of the severity of the underlying disease: that patients do not die with but rather from ARF (5,6).Nevertheless, it remains unknown whether not only manifest ARF but also more subtle changes in postoperative renal function might predict outcome in surgical patients. In patients with contrast-induced nephropathy, renal impairment as defined by an increase of 25% to at least 2 mg/dl in serum creatinine was associated with an odds ratio of 5.5 for death (7). Thus, the aim of the present investigation was to determine the consequences of small changes in serum creatinine within 48 h after surgery on 30-d and late mortality, independent of other established perioperative risk indicators. Materials and MethodsBet...
The results of our study suggest that acute renal failure in patients undergoing renal replacement therapy presents an excess risk of in-hospital death. This increased risk cannot be explained solely by a more pronounced severity of illness. Our results provide strong evidence that acute renal failure presents a specific and independent risk factor for poor prognosis.
Our results suggest that both hypo- and hypernatremia present on admission to the ICU are independent risk factors for poor prognosis.
Acute kidney injury classified by either RIFLE or AKIN is associated with increased hospital mortality. Despite presumed increased sensitivity by the AKIN classification, RIFLE shows better robustness and a higher detection rate of AKI during the first 48 h of ICU admission.
The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.
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