Two clinicians and the nursing sisters working in the ICU evaluated the chance of survival of ICU patients every day. Patients were assessed either as "outcome unknown or will die." These predictions were compared with those made by computerized trend analysis of daily acute physiology and chronic health evaluation (APACHE II) scores corrected for the presence and duration of major organ system failure. The predictions were not acted upon during the study. Comparing the predictions with actual hospital outcome, the doctors and nurses had a false-positive diagnosis rate for dying of between 7.7% and 16.7%, while there were no false predictions by the computer model. The patients predicted to die by the doctors and nurses were not completely identical to those predicted by the computer. Predictions of doctors and nurses that were confirmed by the computer had a sensitivity of 20% and no false predictions of death.
Vascular anomalies are considered a contraindication for laparoscopic live donor nephrectomy. We report a successful hand-assisted retroperitoneoscopic live donor nephrectomy from a donor with a double inferior vena cava.A 37-year-old woman wanted to donate a kidney to her 44-year-old boyfriend who had hypertensive nephropathy. Preoperative donor imaging showed a double inferior vena cava. Each renal vein drains into the ipsilateral inferior vena cava division, making the left renal vein short. A single renal artery, vein, and ureter were noted on both sides. A hand-assisted retroperitoneoscopic left nephrectomy was performed. Blood loss was minimal and the warm ischemia time was 2 minutes. Renal transplantation was performed with good initial perfusion and urine output. Cold ischemia and rewarming time was 25 minutes.The donor postoperative period was uneventful with infrequent need for pain relief. The donor was discharged in good condition 3 days postoperatively. The donor's kidney functions were within the normal range at follow-up 4 months postoperatively. The recipient was discharged in good condition 7 days postoperatively. The recipient is alive with good graft function and unremarkable complications at 4 month follow-up.Although vascular anomalies present a surgical challenge, we have shown the feasibility of performing hand-assisted retroperitoneoscopic live donor nephrectomy in a donor with a double vena cava and short renal vein. With comprehensive preoperative assessment, laparoscopic live donor nephrectomy can be done safely in donors with anatomical anomalies. This may increase the number of living donor kidney transplants as it offers lower postoperative morbidity and economic disincentives for potential donors.
Patients with advanced acute kidney injury (AKI) and end-stage dialysis dependent renal failure (ESRF) are characterized by loss of renal function as well as significant associated co-morbidities. However, prognosis appears to differ when they are admitted to the intensive care unit (ICU). Patients with advanced AKI have a reported ICU mortality between 25% and 90%, depending on the specific patient population and the definition of AKI [1,2], whereas ICU mortality in ESRF patients has been reported to be 9% to 26% [3-5]. In contrast, Uchino and coworkers [5] found no difference in outcome between 32 ESRF patients in an ICU and 32 diagnosis and severity score matched patients with AKI treated with renal replacement therapy (RRT).
We retrospectively analyzed the Riyadh Intensive Care Program database of 41,972 adult patients admitted to ICUs in 19 hospitals in the UK and three hospitals in Germany between 1989 to 1999, and we compared ESRF patients and patients with advanced AKI (defined by serum creatinine ≥ 354 μmol/l, treatment with RRT or a rise in serum creatinine by >300% from baseline). A total of 797 patients had pre-existing ESRF and 2,782 patients had advanced AKI, of whom 66.4% were treated with RRT. ESRF patients had a significantly lower ICU and hospital mortality and shorter stay in ICU compared with patients with advanced AKI (Table (Table1).1). In both groups the ICU mortality rate rose with increasing number of associated failed organ systems (Figure (Figure1).1). However, patients with AKI had significantly more associated organ failures during their stay in the ICU; 75.4% of patients with AKI on RRT and 54.5% of patients with advanced AKI not on RRT had two or more other failed organ systems, in contrast to only 25.6% of ESRF patients. In addition, significantly more patients with AKI on RRT needed mechanical ventilation compared with ESRF patients (91.3% versus 60.9%, P < 0.0001).
Figure 1
Associated maximum organ failure and impact on outcome. Shown are (a) incidence (%) and (b) ICU mortality (%). AKI, acute kidney injury; ESRF, end-stage renal failure; ICU, intensive care unit; OF, maximum associated organ failure during stay in ICU (excluding ...
Table 1
Characteristics of patients with AKI and ESRF
In a multivariate analysis, mechanical ventilation (odds ratio (OR) = 3.3), maximum number of failed organs (OR = 2.93) and nonsurgical admission (OR = 2.1) were the strongest independent risk factors for ICU mortality, followed by emergency surgery (OR = 1.75), pre-existing chronic disease (OR = 1.2), SOFA score on admission to ICU (OR = 1.05) and age (OR = 1.03).
Our study confirms that patients with ESRF admitted to ICU had a significantly better prognosis than did ICU patients with advanced AKI. The main reasons were due to differences in co-morbid risk factors, in particular need for mechanical ventilation and associated organ failure while in the ICU.
Objective: To determine whether the Acute Physiology and Chronic Health Evaluation (APACHE) II system for the measurement of severity of illness is able to provide an accurate risk of hospital death in patients with acetaminophen-induced acute liver failure or identify those patients needing transfer for possible hepatic transplantation. Design: Data for admission (first 24 hrs) APACHE II scores and King's criteria for urgent transplantation were collected prospectively to compare the APACHE II system and the King's criteria for the prediction of death or need for transplantation. Setting: A nine-bed specialist liver failure unit (LFU). Patients: One hundred two consecutive patients admitted to the LFU with acetaminophen self-poisoning and a prolonged prothrombin time were studied. Interventions: None. Measurements and Main Results: An APACHE II score of >15 points was associated with a high mortality (13/20 patients, five of whom survived following hepatic transplantation). There was no relation between APACHE II risk and outcome (mean APACHE II risk of death 0.8%, actual hospital mortality 16%). An APACHE II score of >15 had a similar power of prediction of death as the King's criteria (sensitivity 82% and 65%, respectively; specificity 98% and 99%, respectively), when considering those patients who were transplanted as "deaths." An APACHE II score of >15 was able to identify four more patients than the King's criteria on the first day of admission to the LFU. Conclusions: The crude admission APACHE II score correlated well with mortality in patients with acetaminophen-induced acute liver failure. However, the calculated APACHE II risk of death, using the original drug overdose coefficient, was poorly calibrated. Since specialist liver scores are unfamiliar in the general intensive care setting, the use of an APACHE II score might earlier identify more patients at risk of needing a liver transplant, and hence, expedite appropriate transfer to a specialist liver unit. (Crit Care Med 1998; 26:279-284) In the absence of specialist facilities, acute liver failure is a lethal condition with a high mortality. Self-poisoning with acetaminophen accounts for more than half the cases of acute liver failure in the United Kingdom (400 cases/yr) [1], and its frequency rate is increasing in the United States [2]. Clinical management relies heavily on the ability to identify early those patients who would inevitably die unless they receive a liver transplant. In those patients who receive an emergency graft, survival rates of up to 72% have been described [3]. The potential severity of the condition, however, often goes unrecognized, with late referral to a specialist liver unit. Delay can result in the onset of severe cerebral edema, spesis, multiple organ failure, and other relative contraindications for hepatic transplantation [4]. In an attempt to overcome this problem, a number of different schemes have been developed for grading the severity of the liver failure [5]. The King's criteria for transplantation were derived retrospectively by logistic regression from a large cohort of patients treated at King's College Hospital but tested prospectively. Nevertheless, this grading system (the King's criteria) and other specialized schemes[6,7] are usually unknown to general medical and intensive care clinicians who are much more familiar with the widely used Acute Physiology and Chronic Health Evaluation (APACHE) II system for measurement of severity of illness [8]. The latter allows the calculation of a "risk of hospital death" in an individual patient from the admission APACHE II score (obtained after the first 24 hrs following intensive care unit [ICU] admission) and the specific diagnostic category, but it is not clear that the system provides an accurate risk for patients with acetaminophen-induced acute liver failure. If this were the case, its routine use might identify those patients needing a lifesaving liver transplant, and hence, facilitate more appropriate and earlier transfer to specialist liver units. In the present study, we have attempted to validate the APACHE II system by estimating the hospital mortality risk from day 1 data in patients with acetaminophen-induced acute liver failure. We have compared the APACHE II system with the King's criteria used to identify patients who would otherwise die without a liver graft.
Continuous enteral feeding is widely practiced in intensive care units (ICU). We found that pneumonia developed in 54% of 24 ventilated patients on continuous enteral feeding for more than 3 days. This appeared to affect only patients with a persistently high morning (7:00 am) gastric pH, with 12 of 13 (92%) patients developing pneumonia. In 11 patients the causative organisms were cultured initially from the stomach, oropharynx and trachea before pneumonia supervened. This effect was distinct from that found with the prophylactic use of antacids or H 2 ‐receptor antagonists. The mortality (46%) of this group of patients was 1.6 times greater than the expected mortality predicted by the Apache II Severity of Disease Classification System. ( Journal of Parenteral and En teral Nutrition 14:353–356, 1990)
Serum cardiac troponin T (cTnT) concentrations may be increased in patients with renal dysfunction without evidence of cardiac damage, as assessed by conventional methods. It has been suggested that these positive measurements result from the expression in skeletal muscle of fetal isoforms of cTnT, which are detected by the cTnT immunoassay.Skeletal muscle (exterior oblique) biopsies were taken from healthy living kidney donors (n = 5) and transplant recipients (n = 19). The amounts of cTnT and creatine kinase (CK) isoenzymes in skeletal muscle of healthy controls were compared with those in patients with renal failure (Wilcoxon-Mann-Whitney test). cTnT was measured quantitatively by a second-generation assay, with a limit of detection of 1 microg/g of protein, and qualitatively by immunohistochemistry and immunoblotting. CK-MB was measured by quantitative electrophoresis.Minute quantities of cTnT were detected in 2 of the 5 (40%) control samples and 9 of the 19 (47%) renal failure samples, respectively, at mean concentrations of <5 microg/g of protein for both subject groups. This was <1/6000th that found in heart muscle. There was no significant difference in cTnT or CK-MB content in skeletal muscle between healthy controls and patients with renal failure. Increased serum cTnT did not predict detectable cTnT in skeletal muscle. cTnT was not detected qualitatively by immunoblotting or immunohistochemistry in any skeletal muscle samples.Uremia does not affect the content of cTnT or CK-MB in exterior oblique muscle, suggesting that cTnT detected in serum from patients with renal failure does not originate from skeletal muscle.
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