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Advisor(s)
Abstract(s)
Introdução: A lesão renal aguda é uma complicação comum e crescente dos doentes
hospitalizados, estando associada a uma elevada taxa de mortalidade. No entanto, pouca
atenção é dada à lesão renal aguda associada à comunidade, ao acompanhamento dos doentes
após a alta hospitalar ou à necessidade de diálise e à mortalidade a longo prazo. O objetivo
principal deste trabalho foi identificar os preditores independentes de diálise e de
mortalidade, assim como compreender o impacto, a longo prazo, da lesão renal aguda.
Material e Métodos: Estudo de coorte retrospetivo dos 92 doentes internados no Serviço de
Nefrologia do Hospital Amato Lusitano, entre dezembro de 2009 e abril de 2013, com
diagnóstico de lesão renal aguda. Foram incluídos todos os doentes adultos, consecutivos, com
um internamento hospitalar superior a 24 horas. A lesão renal aguda foi definida como
aumento da creatinina sérica acima de 2,0 mg/dL ou aumento superior ou igual a 1,5 vezes do
valor de creatinina basal. Foram registadas variáveis clínicas e demográficas: idade, género,
duração de internamento, causas da lesão renal aguda, comorbilidades (doença hepática
crónica, doença coronária, hipertensão arterial, acidente vascular cerebral e diabetes),
medicação habitual (anti-inflamatórios não esteroides, antagonistas dos recetores da
angiotensina, inibidores da enzima de conversão da angiotensina e outros nefrotóxicos), peso
corporal, balanço hídrico, débito urinário em internamento, diagnóstico concomitante de
sépsis, medicação e procedimentos realizados durante o internamento (ventilação, uso de
aminas, uso de furosemida superior a 60mg por dia, recurso a diálise e duração de diálise),
bem como parâmetros laboratoriais (creatinina sérica basal, máxima e à data de alta; valores
séricos máximos de potássio e fósforo, e mínimos de sódio, hemoglobina, bicarbonato e
albumina). Foram também recolhidos os valores da creatinina sérica aos 6 e 12 meses após a
alta hospitalar, assim como o estado clínico aquando a última observação médica. A
recuperação da função renal foi definida como o restabelecimento de pelo menos 90% da TFG
basal aos 12 meses. Para a análise estatística dos dados recolhidos foi utilizado o IBM SPPS
Statistics 21.
Resultados: Dos 92 doentes incluídos no estudo, 53% eram do sexo masculino e a mediana de
idade foi de 81 anos, com um intervalo interqualil de 13 anos. A lesão renal aguda foi pré-renal
em 37%, renal em 57,6% e pós-renal em 5,4 % dos casos. Cinquenta e quatro porcento dos
doentes necessitaram de diálise durante o internamento. Foram preditores independentes para
a necessidade de diálise: oligúria (RC 4.501, IC 95% 1.189 a 17.031, p= 0.027), uso de
furosemida endovenosa superior a 60mg por dia (RC 6.745; IC 95% 1.825 a 24.932; p = 0,004) e
potássio sérico máximo (RC 2.875; IC 95% 1.628 a 5.080 , p<0,001). No período total do
estudo, a mortalidade foi de 44,6%. A recuperação da função renal aos 12 meses ocorreu em 44,2% dos sobreviventes, contudo, 28,3% dos doentes não apresentaram dados disponíveis para
esta avaliação. Foram preditores independentes de mortalidade a idade aquando o episódio de
lesão renal aguda (RC 1,070, IC 95% 1,012 a 1,131, p=0,018), o maior valor de creatinina sérica
durante o internamento (RC 0,518; IC 95% 0,364 a 0,736; p ? 0,001), o valor da creatinina
sérica à data de alta (RC 1,561, IC 95% 1,117 a 2,182, p = 0,009) e a realização de diálise
durante o internamento (RC 14,486; IC 95% 3,341 a 62,813; p ?0,001).
Conclusão: Na nossa amostra, o estado de oligúria, o uso de elevadas doses de furosemida e o
valor máximo de potássio sérico, mensurado ao longo do internamento, foram preditores
independentes para necessidade de diálise em pacientes com lesão renal aguda. A idade, a
creatinina sérica basal, o valor máximo de creatinina sérica e a necessidade de diálise durante
o internamento foram preditores independentes de mortalidade. Estas observações sugerem
que o risco de diálise e o de mortalidade pode ser estimado relativamente cedo no curso desta
síndrome. Estudos devem continuar a ser feitos com o objetivo de definir modelos preditores
destes desfechos desfavoráveis. Melhorar a sensibilidade do diagnóstico da lesão renal aguda,
assim como oferecer um prognóstico preciso e estratificar com maior acurácia e precocidade
aqueles que beneficiariam de intervenções terapêuticas, deverão ser o enfoque dos novos
estudos.
Introduction: Acute kidney injury is a common and growing complication of hospitalized patients, associated with a high mortality rate. However, little attention is given to community acquired acute kidney injury, as well as the monitoring of the patients after discharge, including the need for dialysis and long-term mortality. The objective of this work was to identify independent predictors of dialysis and mortality, as well as to understand the long term impact of acute kidney injury. Material and Methods: Retrospective cohort study of 92 patients hospitalized in the Department of Nephrology of Hospital Amato Lusitano between December 2009 and April 2013. All consecutive, adult patients, with a hospital admission higher than 24 hours and acute kidney injury diagnosis were included. Acute kidney injury was defined as an increase in serum creatinine above 2.0 mg/dL or an increase equal or greater than 1.5 times the baseline creatinine value. Clinical and demographic variables were recorded: age, gender, length of stay, causes of acute kidney injury, comorbidities (chronic liver disease, heart disease, hypertension, stroke and diabetes), usual medication (nonsteroidal anti-inflammatory drugs, angiotensin II receptor antagonist, angiotensin-converting enzyme inhibitors and other nephrotoxic drugs), body weight, fluid balance, urine output, concomitant diagnosis of sepsis, medications and procedures performed during hospitalization (ventilation, use of amines, furosemide ? 60mg per day, use of dialysis and duration of dialysis), and laboratory parameters (baseline serum creatinine, maximum serum creatinine and serum creatinine at discharge, maximum serum potassium, maximum serum phosphorus, minimum serum sodium, minimum value of bicarbonate, hemoglobin and albumin) . The serum creatinine values at 6 and 12 months after the date of discharge were also collected, as well as the clinical status at the last medical observation. The recovery of renal function was defined as the restoration of at least 90% of baseline GFR at 12 months. The IBM SPPS Statistics 21 program was used for statistical analysis of the data collected. Results: Of 92 patients enrolled, 53% were male and the median age was 81 years. Acute kidney injury was pre-renal in 37%, intrinsic in 57.6 % and post-renal in 5.4% of cases. Fifty four percent of patients required dialysis during hospitalization. Identified as independent predictors of dialysis were oliguria (OR 4.501, 95% CI 1,189-17,031, p = 0.027), use of intravenous furosemide greater than 60mg per day (OR 6.745, 95% CI 1,825-24,932, p = 0.004) and maximum serum potassium (OR 2.875, 95% CI 1,628-5,080, p < 0.001). During the total time of study the mortality was 44.6%. Recovery of renal function at 12 months occurred in 44,2% of survivors, however 28.3 % of patients had no data available for evaluation. Independent predictors of mortality were age (OR 1.070, 95% CI 1.012 to 1.131, p = 0.018), the highest value of serum creatinine during hospitalization (OR 0.518, 95% CI 0.364 to 0.736; ? p 0.001), serum creatinine at discharge (OR 1.561, 95% CI 1.117 to 2.182, p = 0.009) and performing dialysis during hospitalization (OR 14.486, 95% CI 3.341 to 62.813, p 0.001 ?). Conclusion: In our sample the state of oliguria, the use of high-dose of furosemide and the maximum serum potassium measured during the hospitalization are independent predictors of dialysis. As well as age, baseline serum creatinine, the maximum value of serum creatinine and need for dialysis during hospitalization are important independent predictors of mortality. Continuous efforts must be directed at refining predictive models of acute kidney injury and its major outcomes. Improvement of the diagnosis sensitivity of acute kidney injury, as well as more accurate stratification of patients aimed to benefit from earlier therapeutic interventions and to offer precise prognosis, should be the focus of further studies.
Introduction: Acute kidney injury is a common and growing complication of hospitalized patients, associated with a high mortality rate. However, little attention is given to community acquired acute kidney injury, as well as the monitoring of the patients after discharge, including the need for dialysis and long-term mortality. The objective of this work was to identify independent predictors of dialysis and mortality, as well as to understand the long term impact of acute kidney injury. Material and Methods: Retrospective cohort study of 92 patients hospitalized in the Department of Nephrology of Hospital Amato Lusitano between December 2009 and April 2013. All consecutive, adult patients, with a hospital admission higher than 24 hours and acute kidney injury diagnosis were included. Acute kidney injury was defined as an increase in serum creatinine above 2.0 mg/dL or an increase equal or greater than 1.5 times the baseline creatinine value. Clinical and demographic variables were recorded: age, gender, length of stay, causes of acute kidney injury, comorbidities (chronic liver disease, heart disease, hypertension, stroke and diabetes), usual medication (nonsteroidal anti-inflammatory drugs, angiotensin II receptor antagonist, angiotensin-converting enzyme inhibitors and other nephrotoxic drugs), body weight, fluid balance, urine output, concomitant diagnosis of sepsis, medications and procedures performed during hospitalization (ventilation, use of amines, furosemide ? 60mg per day, use of dialysis and duration of dialysis), and laboratory parameters (baseline serum creatinine, maximum serum creatinine and serum creatinine at discharge, maximum serum potassium, maximum serum phosphorus, minimum serum sodium, minimum value of bicarbonate, hemoglobin and albumin) . The serum creatinine values at 6 and 12 months after the date of discharge were also collected, as well as the clinical status at the last medical observation. The recovery of renal function was defined as the restoration of at least 90% of baseline GFR at 12 months. The IBM SPPS Statistics 21 program was used for statistical analysis of the data collected. Results: Of 92 patients enrolled, 53% were male and the median age was 81 years. Acute kidney injury was pre-renal in 37%, intrinsic in 57.6 % and post-renal in 5.4% of cases. Fifty four percent of patients required dialysis during hospitalization. Identified as independent predictors of dialysis were oliguria (OR 4.501, 95% CI 1,189-17,031, p = 0.027), use of intravenous furosemide greater than 60mg per day (OR 6.745, 95% CI 1,825-24,932, p = 0.004) and maximum serum potassium (OR 2.875, 95% CI 1,628-5,080, p < 0.001). During the total time of study the mortality was 44.6%. Recovery of renal function at 12 months occurred in 44,2% of survivors, however 28.3 % of patients had no data available for evaluation. Independent predictors of mortality were age (OR 1.070, 95% CI 1.012 to 1.131, p = 0.018), the highest value of serum creatinine during hospitalization (OR 0.518, 95% CI 0.364 to 0.736; ? p 0.001), serum creatinine at discharge (OR 1.561, 95% CI 1.117 to 2.182, p = 0.009) and performing dialysis during hospitalization (OR 14.486, 95% CI 3.341 to 62.813, p 0.001 ?). Conclusion: In our sample the state of oliguria, the use of high-dose of furosemide and the maximum serum potassium measured during the hospitalization are independent predictors of dialysis. As well as age, baseline serum creatinine, the maximum value of serum creatinine and need for dialysis during hospitalization are important independent predictors of mortality. Continuous efforts must be directed at refining predictive models of acute kidney injury and its major outcomes. Improvement of the diagnosis sensitivity of acute kidney injury, as well as more accurate stratification of patients aimed to benefit from earlier therapeutic interventions and to offer precise prognosis, should be the focus of further studies.
Description
Keywords
Lesão Renal Aguda Preditores Diálise Mortalidade