POSTOPERATIVE RENAL INSUFFICIENCY - 02/09/11

Doi : 10.1016/S0025-7125(05)70375-8

Byard F. Edwards, MD ^{^{*
Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia}}

Résumé

Renal impairment, hospital acquired or chronic, adversely affects patient surgical outcomes. A review of 3954 patients in 14 American Department of Veteran Affairs Medical Centers presenting with chronic renal impairment (serum creatinine >1.5 mg/dL) before surgery revealed higher incidences of stroke, bleeding complications, dialysis initiation, and death, with prolonged mechanical ventilation and increased length of stay.^{5 Anderson R.J., O’Brien M., MaWhinney S. , et al. Renal failure predisposes patients to adverse outcome after coronary artery bypass surgery. VA Cooperative Study #5 Kidney Int 1999 ; 55 : 1057-1062 [cross-ref]

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Although the incidence of hospital-acquired renal insufficiency (HARI) in developed countries is low (1.5 patients per 1000 admitted), the impact of HARI on hospital and community resources is significant because it increases the complexity of required care, triples the length of hospital stay, and worsens the patient's prognosis. Mortality averages 45% with HARI but may exceed 80% if dialysis is required.^{4 Anderson R.J., O’Brien M., MaWhinney S. , et al. Mild renal failure is associated with adverse outcome after cardiac valve surgery Am J Kidney Dis 2000 ; 35 : 1127-1134 [cross-ref]

Cliquez ici pour aller à la section Références, 12 Chertow G.M., Christiansen C.L., Cleary P.D. , et al. Prognostic stratification in critically ill patients with acute renal failure requiring dialysis Arch Intern Med 1995 ; 155 : 1505-1511

Cliquez ici pour aller à la section Références, 14 Chertow G.M., Lazarus J.M., Paganini E.P. , et al. Predictors of mortality and the provision of dialysis in patients with acute tubular necrosis. The Auriculin Anaritide Acute Renal Failure Study Group J Am Soc Nephrol 1998 ; 9 : 692-698

Cliquez ici pour aller à la section Références, 33 Hou S.H., Bushinsky D.A., Wish J.B. , et al. Hospital-acquired renal insufficiency: A prospective study Am J Med 1983 ; 74 : 243-248 [cross-ref]

Cliquez ici pour aller à la section Références, 47 Levy E.M., Viscoli C.M., Horwitz R.I. The effect of acute renal failure on mortality: A cohort analysis JAMA 1996 ; 275 : 1489-1494

Cliquez ici pour aller à la section Références, 49 Liano F., Pascual J. Outcomes in acute renal failure Semin Nephrol 1998 ; 18 : 541-550

Cliquez ici pour aller à la section Références} Death usually results from the original disease necessitating the hospitalization or from hospital-acquired complications of shock and infection,^{9 Barretti P., Soares V.A. Acute renal failure: Clinical outcome and causes of death Ren Fail 1997 ; 19 : 253-257 [cross-ref]

Cliquez ici pour aller à la section Références, 48 Liano F., Pascual J. Epidemiology of acute renal failure: A prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group Kidney Int 1996 ; 50 : 811-818 [cross-ref]

Cliquez ici pour aller à la section Références, 62 Obialo C.I., Okonofua E.C., Tayade A.S. , et al. Epidemiology of de novo acute renal failure in hospitalized African Americans: Comparing community-acquired vs hospital-acquired disease Arch Intern Med 2000 ; 160 : 1309-1313 [cross-ref]

Cliquez ici pour aller à la section Références} but HARI also independently increases patient mortality.^{5 Anderson R.J., O’Brien M., MaWhinney S. , et al. Renal failure predisposes patients to adverse outcome after coronary artery bypass surgery. VA Cooperative Study #5 Kidney Int 1999 ; 55 : 1057-1062 [cross-ref]

Cliquez ici pour aller à la section Références, 15 Chertow G.M., Levy E.M., Elliott M. , et al. Independent association between acute renal failure and mortality following cardiac surgery Am J Med 1998 ; 104 : 343-348 [cross-ref]

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Patients undergoing major surgery have a higher incidence of HARI than the average hospitalized patient population. An 8-year review of 42,773 patients in 43 American Department of Veteran Affairs Medical Centers indicated that 1.1% of patients undergoing coronary artery bypass or valvular surgery required the initiation of dialysis. Mortality was 63% when dialysis was required and only 4.3% when no dialysis was required. In contrast to previous studies that attributed the increased mortality in HARI patients to nonrenal causes, analysis of these data showed an independent association of HARI requiring dialysis with an increased patient mortality (odds ratio, 7.9; confidence interval, 6 to 10).^{15 Chertow G.M., Levy E.M., Elliott M. , et al. Independent association between acute renal failure and mortality following cardiac surgery Am J Med 1998 ; 104 : 343-348 [cross-ref]

Cliquez ici pour aller à la section Références} A similar 2-year review at a tertiary medical center showed that 8.6% of 2800 cardiac surgery patients developed HARI; 0.7% required dialysis. Mortality was 28% with dialysis, 14% without dialysis, and 1% if no HARI was present.^{20 Conlon P.J., Stafford-Smith M., White W.D. , et al. Acute renal failure following cardiac surgery Nephrol Dial Transplant 1999 ; 14 : 1158-1162 [cross-ref]

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Despite the advances in diagnostic imaging, surgical techniques, and support measures, the excessive mortality and morbidity associated with HARI continue. Until improved methods of treatment are developed, preventing HARI through risk reduction and reversing HARI through early detection and intervention are essential components of patient management.

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