Showing papers by "Glenn M. Chertow published in 2002"

Diuretics, mortality, and nonrecovery of renal function in acute renal failure.

Abstract: Context Acute renal failure is associated with high mortality and morbidity. Diuretic agents continue to be used in this setting despite a lack of evidence supporting their benefit. Objective To determine whether the use of diuretics is associated with adverse or favorable outcomes in critically ill patients with acute renal failure. Design Cohort study conducted from October 1989 to September 1995. Patients and setting A total of 552 patients with acute renal failure in intensive care units at 4 academic medical centers affiliated with the University of California. Patients were categorized by the use of diuretics on the day of nephrology consultation and, in companion analyses, by diuretic use at any time during the first week following consultation. Main outcome measures All-cause hospital mortality, nonrecovery of renal function, and the combined outcome of death or nonrecovery. Results Diuretics were used in 326 patients (59%) at the time of nephrology consultation. Patients treated with diuretics on or before the day of consultation were older and more likely to have a history of congestive heart failure, nephrotoxic (rather than ischemic or multifactorial) origin of acute renal failure, acute respiratory failure, and lower serum urea nitrogen concentrations. With adjustment for relevant covariates and propensity scores, diuretic use was associated with a significant increase in the risk of death or nonrecovery of renal function (odds ratio, 1.77; 95% confidence interval, 1.14-2.76). The risk was magnified (odds ratio, 3.12; 95% confidence interval, 1.73-5.62) when patients who died within the first week following consultation were excluded. The increased risk was borne largely by patients who were relatively unresponsive to diuretics. Conclusions The use of diuretics in critically ill patients with acute renal failure was associated with an increased risk of death and nonrecovery of renal function. Although observational data prohibit causal inference, it is unlikely that diuretics afford any material benefit in this clinical setting. In the absence of compelling contradictory data from a randomized, blinded clinical trial, the widespread use of diuretics in critically ill patients with acute renal failure should be discouraged.

Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients.

Abstract: Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.

Refining Predictive Models in Critically Ill Patients with Acute Renal Failure

Abstract: Mortality rates in acute renal failure remain extremely high, and risk-adjustment tools are needed for quality improvement initiatives and design (stratification) and analysis of clinical trials A total of 605 patients with acute renal failure in the intensive care unit during 1989-1995 were evaluated, and demographic, historical, laboratory, and physiologic variables were linked with in-hospital death rates using multivariable logistic regression Three hundred and fourteen (519%) patients died in-hospital The following variables were significantly associated with in-hospital death: age (odds ratio [OR], 102 per yr), male gender (OR, 236), respiratory (OR, 262), liver (OR, 306), and hematologic failure (OR, 340), creatinine (OR, 071 per mg/dl), blood urea nitrogen (OR, 102 per mg/dl), log urine output (OR, 064 per log ml/d), and heart rate (OR, 101 per beat/min) The area under the receiver operating characteristic curve was 083, indicating good model discrimination The model was superior in all performance metrics to six generic and four acute renal failure-specific predictive models A disease-specific severity of illness equation was developed using routinely available and specific clinical variables Cross-validation of the model and additional bedside experience will be needed before it can be effectively applied across centers, particularly in the context of clinical trials

The Severity of Secondary Hyperparathyroidism in Chronic Renal Insufficiency is GFR-Dependent, Race-Dependent, and Associated with Cardiovascular Disease

Abstract: Secondary hyperparathyroidism (SHPT) is an important complication of end-stage renal disease. However, SHPT begins during earlier stages of chronic renal insufficiency (CRI), and little is known about risk factors for SHPT in this population. This study evaluated 218 patients in an ethnically diverse ambulatory nephrology practice at the University of California San Francisco during calendar years 1999 and 2000. Demographic data, comorbid diseases, medications, and laboratory parameters were collected, and independent correlates of intact parathyroid hormone (PTH) were identified by using multiple linear regression. The mean estimated GFR was 34 ml/min per 1.73 m(2) (10%-90% range, 13 to 61 ml/min per 1.73 m(2)); PTH was inversely related to GFR (P < 0.0001). The adjusted mean PTH was higher among African Americans and lower among Asian/Pacific Islanders compared with white patients (233 versus 95 versus 139 pg/ml; P < 0.0001). Moreover, among the 196 patients with GFR <60 ml/min per 1.73 m(2), the slope of GFR versus PTH was significantly steeper among African Americans than among white patients (10.6 versus 3.9 pg/ml per ml per min per 1.73 m(2); P = 0.01). After adjusting for age and diabetes, PTH was associated with a history of myocardial infarction (OR, 1.6; 95% CI, 1.1 to 2.3 per unit natural log PTH) and congestive heart failure (OR, 2.0; 95% CI, 1.3 to 2.9 per unit natural log PTH) and not associated with other co-morbid conditions. These factors should be considered when screening and managing SHPT in CRI.

Elevations of serum phosphorus and potassium in mild to moderate chronic renal insufficiency

Abstract: Background. Reduced renal function is associated with a variety of biochemical abnormalities. However, the extent of these changes and their magnitude in relation to renal function is not well defined, especially among individuals with mild to moderate chronic renal insufficiency (CRI). Methods. We analysed the Third National Health and Nutrition Examination Survey (NHANES III; 1988--1994) data for 14 722 adults aged ≥ 17 years with measurements of serum creatinine and all electrolytes including ionized calcium. General linear models were used to determine the relationship between mean concentrations of electrolytes and different levels of Cockeroft Gault creatinine clearance (CrCl). Sample weights were used to produce weighted regression parameters. Results. Changes in mean serum phosphorus and potassium concentration were evident at relatively modest reductions in CrCl (around 50 to 60 ml min). Changes in the anion gap and mean levels of ionized calcium and bicarbonate were not apparent until CRI was advanced (CrCl ≤ 20 ml min). For example, compared with women with CrCl > 80 ml min, those with CrCl 60 50, 50 40, 40 30, 30-20 and ≤ 20 ml min had mean serum phosphorus concentrations that were higher by 0.1, 0.1, 0.2, 0.3 and 0.8 mg dl (all P<0.05), and mean serum potassium concentrations that were higher by 0.1, 0.1, 0.1, 0.2 and 0.4 mmol /l (all P<0.05), respectively. These changes were independent of dietary intake and the use of angiotensin converting enzyme (ACE) inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs). Conclusions. Increases in serum phosphorus and potassium levels are apparent even among people with mild to moderate CRI. These findings should be broadly generalizable to the larger CRI population in the United States. Subtle elevations in serum phosphorus might contribute to the initiation and maintenance of secondary hyerparathyroidism, which is known to occur in mild to moderate CR1.

RENAL BIOPSY TEACHING CASE Renal Insufficiency With Monoclonal Gammopathy and Urticarial Vasculitis

Abstract: MANY SYSTEMIC diseases affect the kidney and the skin, including relatively common immunologic and inflammatory disorders (eg, systemic lupus erythematosus, scleroderma, cryoglobulinemia, Henoch-Schonlein purpura, microscopic polyangiitis, and atheroembolic disease) and rarer hereditary conditions, such as Fabry’s disease. We describe a case of renal insufficiency and chronic urticaria that presented a diagnostic dilemma.