Afhandling - Copenhagen. / Summary in Danish and English.

Afhandling - Copenhagen. / Summary in Danish and English.

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BACKGROUND: Acute renal failure (ARF) is a clinical syndrome characterised by a rapid deterioration of kidney function over hours to days which may recover/return to normal values following appropriate therapy. Various scoring systems currently exist to predict the severity and outcome in patients with ARF. Recently the Acute Dialysis Quality Initiative (ADQI) Group has established the RIFLE (Risk of injury, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage kidney disease) classification which has become widely used globally. There is however, limited data on its use in Africa. In order to provide data on the use of RIFLE criteria from an African facility, we conducted a retrospective chart review to assess the outcome of ARF in patients admitted in the Intensive Care Unit (ICU) at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). The data reviewed covered the period between January 1st to December 31st 2008. METHODS: This was a retrospective chart review conducted in the adult multi-disciplinary intensive care unit at CMJAH between January 1st to December 31st 2008. Medical records of patients admitted during this period were reviewed and patients with acute renal failure were identified. Demographic data, relevant clinical information such as reason for ICU admission, number of organ(s) involved, presence of co-morbidity, RIFLE criteria on admission and on discharge, modality and duration of treatment of ARF, need for mechanical ventilation and or inotropic support were recorded. For the purpose of this study, serum creatinine based on RIFLE classification was used to define ARF. Statistical analysis was performed using the data collected and STATA version 11. The Primary outcome, which was survival or death, was correlated with the maximum RIFLE classification during patients’ ICU stay. The study was approved by the Human Research Ethics Committee medical (HRECM) of the University of Witwatersrand with Clearance certificate number M090906 RESULTS: One hundred and ninety three (193) patients with acute renal failure were included in the study. The mean APACHE II score was 19 ± 6.4 SD, with the maximum score documented being 38. Patient ages ranged from 21 – 92 years with a mean of 50.5 years ± 18.3SD. Fifty two percent of the patients were male and 48% were female. Majority of patients were black (63%) with 36.8% being other race groups. According to RIFLE criteria on admission, 40.9% had normal renal function, 23.3%, 14.0% and 21.8% were in RIFLE R, I and F classes respectively. The overall mortality in ICU was 59.9%. Of those patients discharged to the ward from ICU, 14.1% subsequently demised. Factors associated with mortality in ICU included race, chronic pulmonary disease, mechanical ventilation, inotropic support, need for ventilation and inotropic support, dialysis and maximum RIFLE criteria reached in ICU. After multivariate analysis using Cox proportion regression model, factors such as race, inotropic support, need for both ventilation and inotropic support and maximum RIFLE criteria were independently associated with mortality in ICU, whereas for patients discharged from ICU to the ward, only cancer was found to be independently associated with mortality. Based on RIFLE criteria, patients in R, I, and F class had 5.41, 3.17 and 5.69 greater risk of dying respectively as compared to patients with normal renal function (Adjusted HR 5.41 95%CI 2.66 - 11.0, p-Value 0.000 for R class, HR 3.17 95%CI 1.65 - 6.07, p-value 0.001for I class, and HR 5.69 95%CI 2.93 - 11.06, p-value 0.001 for F class) CONCLUSION: RIFLE criteria is a useful tool for predicting the outcome of acute renal failure in the intensive care unit.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in Internal Medicine. Johannesburg, 2013 / This study reports a review of biopsy-confirmed renal pathology from Soweto Gauteng. A retrospective analysis was conducted of 1848 adult native renal biopsy reports from Chris Hani Baragwanath Academic Hospital from 1 January 1982 to 31 December 2011. The mean age of all patients biopsied was 33.5 ± 12.6 years and the majority of patients (96.4%) were black. The most frequent histological findings were secondary glomerular diseases (SGNs) (49.3%) and primary glomerular diseases (PGNs) (39.7%). SGNs increased, while PGNs decreased over time (p<0.001). The main contributors to SGN were lupus nephritis (31.0%) and HIV associated nephropathy (HIVAN) (13.3%) while for PGN it was focal segmental glomerulosclerosis (FSGS) (29.6%). HIV positive biopsies constituted 19.7% of all biopsies with a dominant diagnosis of HIVAN (32.7%). Changing patterns of renal disease are evident in the data. The increased SGNs likely reflect the influence of renal pathology secondary to HIV and lupus nephritis.

Thesis--PlanA (M.S.)--University of Wisconsin--Stout, 2002. / Includes bibliographical references.

A national study was devised to define, using prospective methods, the Scottish renal replacement therapy (RRT) population in terms of numbers, social circumstances, age, mode of presentation for RRT, aetiology of renal failure, comorbid illness, mode of RRT, hospitalisation, mortality and quality of life. The attainment of the recommended treatment standards (UK Renal Association) and their impact along with the factors listed above, upon patient outcomes was assessed. Care by a nephrologist prior to RRT increased the likelihood of a patient having definitive vascular access and attaining the haemoglobin standard, and decreased the time spent in hospital in the first year of RRT. The recommended percentage of patients did not attain haemoglobin, adequacy, albumin or other serum biochemistry standards throughout the first 18 months of RRT. The use of erythropoietin was fundamental to attaining recommended haemoglobin levels. Attaining the haemoglobin standard reduced the risk of death over two years and had beneficial influence upon the number of days spent in hospital. The presence of a fistula (or graft) was the most important factor positively influencing urea reduction ratio (URR). Increasing URR was shown to confer a survival benefit over 2 years in the group treated purely by haemodialysis and reduced time spent in hospital during the first year of treatment. A large demand upon in-patient services was demonstrated. Increased patient cormorbidity and age adversely affected frequency of hospitalisation and total time in hospital in the first year of treatment. Mortality is high amongst patients starting RRT. One year survival was 72.5% (84.2% excluding deaths in the first 90 days), two year survival was 58.5% (68% excluding 90 day deaths). 14% of the cohort died within the first 90 days of RRT. Comorbidity, age, serum albumin and attained haemoglobin significantly affected survival. This study expands the available evidence upon which to base future refinements to clinical practice and recommended standards of care. It provides vital data upon which to base future RRT service planning and research.