Intensive care unit Acute renal failure in patients with sepsis in a surgical ICU: Predictive factors,Incidence, Comorbidity, and Outcome E Hoste, N Lameire, R Vanholder, D Benoit, J Decruyenaere, F Colardyn. J Am Soc Nephrol 14: , 2003

Intensive care unit ARF in patients with sepsis Introduction Etiology ARF: Numerous possible causes Often multifactorial Mortality ARF: 28 to 83 % Differences in patient population? E.g. young trauma patient vs old patient with CHF The ‘my study is important’ statement: death toll sepsis = AMI (USA) % ARF cases is sepsis related No data on risk factors ARF in sepsis

Intensive care unit ARF in patients with sepsis Aims of the study Epidemiology of ARF in SICU patients with sepsis Predisposing factors leading to ARF Impact of ARF on outcome

Intensive care unit ARF in patients with sepsis M & M Study population: 22 bed SICU 16 mo study period Sepsis (ACCP/SCCM consensus conference) Excluded: chronic renal insufficiency (Cr> 1.5) treated elsewhere before Data collection: Retrospective cohort Electronic database Data till 14 days of septic episode Organ failure: whole ICU episode ARF: Cr ≥ 2 mg/dL

Intensive care unit ARF in patients with sepsis Results 185 patients included 30 patients (16.2 %) with ARF ARF: Sepsis day: 3 (1 - 5) 21 (70%) treated with RRT

Intensive care unit ARF in patients with sepsis Results: demographics Non-ARFARFP N155 (83.8%)30 (16.2%) Sex (M/F)106/4920/ Age (yr)53 ( )62 ( )0.063 APACHE II16 (10-20)21 ( )0.002 APACHE II exp mort 29% (15-43)43% (19-69)0.009

Intensive care unit ARF in patients with sepsis Results: Scoring systems Non-ARF ARF APACHE II SOFA

Intensive care unit ARF in patients with sepsis Results: Clinical outcome Non-ARFARFP LOS ICU (d)10 (5-18)20 (13-27)0.001 LOS Hosp (d)30 (15-60)27 ( )0.734 mortality ICU (%)22.6 %53.3 %0.002 mortality Hosp (%)28.4 %56.7 %0.007

Intensive care unit ARF in patients with sepsis Results: scoring systems, non-renal Non-ARF ARF APACHE IISOFA

Intensive care unit ARF in patients with sepsis Results: Risk factors on day 1 of sepsis Non-ARFARFP MAP72 (63-81)66 (57-70)0.004 CVP5 (3-8)8 (4-13)0.008 Vasoactive therapy 36.1 %56.7%0.035 Urea (mg/dL)40 (20-50)55 (40-162)< Cr (mg/dL)0.91 ( )1.43 ( )< Vol balance (L/24 h) 1 ( )2.1 ( )< 0.001

Intensive care unit ARF in patients with sepsis Variables on day 1 of sepsis, associated with ARF Odds ratio95% CIP pH < Cr > 1 mg/dL Stepwise forward logistic regression model (Wald) 89.1 % of ARF episodes predicted P = (Hosmer & Lemeshow)

Intensive care unit ARF in patients with sepsis Results: Mortality and organ dysfunction SurvivorsNon-SurvivorsP N67%33%0.004 Age50 (31-66)62 (45-70)0.393 APACHE II15 (10-19)19 (14-26)0.001 LOS ICU 12 (5-20)13 (6-20)0.974 LOS Hosp 40 (23-78)15 (9-26)<0.001 ARF %11 %28 %0.003 RRT %4 %26 %<0.001 Mech Vent77 %98 %<0.001 Vasoactive therapy 44 %82 %<0.001

Intensive care unit ARF in patients with sepsis Results: Mortality and organ dysfunction Stepwise forward logistic regression model (Wald) Odds Ratio95%CIP Vasoactive therapy <0.001 Age (/decade) Need for RRT % correct prediction of mortality P = (Hosmer-Lemeshow)

Intensive care unit ARF in patients with sepsis Discussion Occurence rate ARF = 16.4 % (70 % RRT) ARF = early organ failure (< 3 d), in contrast to data of the past ARF patients had more pronounced capillary leak on day 1 (lower MAP, higher CVP, and more positive volume balance)  We were too late  early goal directed therapy  Volume repletion alone is not sufficient  activated Protein C?

Intensive care unit ARF in patients with sepsis Discussion ARF patients more sick on admission and day 1 of sepsis (APACHE II/SOFA), and higher mortality, however, non-renal organ failure the same. RRT was independent risk factor for mortality. “Patients do not die with ARF; they die because of ARF”