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Effects of early changes in organ dysfunctions on the outcomes of critically ill patients in need of renal replacement therapy.

Maccariello E, Rocha E, Valente C, Nogueira L, Rocha PT, Bonomo H, Serpa LF, Ismael M, Valença RV, Machado JE, Soares M - Clinics (Sao Paulo) (2008)

Bottom Line: However, neither A-SOFA nor Delta-SOFA discriminated survivors from non-survivors on an individual basis.Adjusting for other covariates (including SOFA on D1), A-SOFA and Delta-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes.However, no prognostic score should be used as the only parameter to predict individual outcomes.

View Article: PubMed Central - PubMed

Affiliation: D'Or de Hospitais, Rio de Janeiro, Brazil. emaccariello@yahoo.com.br

ABSTRACT

Introduction: Acute kidney injury usually develops in critically ill patients in the context of multiple organ dysfunctions.

Objective: To evaluate the effect of changes in associated organ dysfunctions over the first three days of renal replacement therapy on the outcomes of patients with acute kidney injury.

Methods: Over a 19-month period, we evaluated 260 patients admitted to the intensive care units of three tertiary-care hospitals who required renal replacement therapy for > 48 h. Organ dysfunctions were evaluated by SOFA score (excluding renal points) on the first (D1) and third (D3) days of renal replacement therapy. Absolute (A-SOFA) and relative (Delta-SOFA) changes in SOFA scores were also calculated.

Results: Hospital mortality rate was 75%. Organ dysfunctions worsened (A-SOFA>0) in 53%, remained unchanged (A-SOFA=0) in 17% and improved (A-SOFA<0) in 30% of patients; and mortality was lower in the last group (80% vs. 84% vs. 61%, p=0.003). SOFA on D1 (p<0.001), SOFA on D3 (p<0.001), A-SOFA (p=0.019) and Delta-SOFA (p=0.016) were higher in non-survivors. However, neither A-SOFA nor Delta-SOFA discriminated survivors from non-survivors on an individual basis. Adjusting for other covariates (including SOFA on D1), A-SOFA and Delta-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes.

Conclusions: In addition to baseline values, early changes in SOFA score after the start of renal replacement therapy were associated with hospital mortality. However, no prognostic score should be used as the only parameter to predict individual outcomes.

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Related in: MedlinePlus

Hospital mortality rates (y-axis) according to the degree of severity of organ failures on Day 1. The values corresponding to the terciles of distribution of the SOFA score on Day 1 (SOFA D1) (x-axis) were used to establish a cut-off point for stratifying the patients into three groups (columns). Patients in whom associated organ failures improved (A-SOFA < 0), remained unchanged (A-SOFA = 0) and worsened (A-SOFA > 0) are represented in gray, square-lined and black columns, respectively. a) P = 0.05; b) P = 0.19; c) P = 0.04.
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f2-cln63_3p0343: Hospital mortality rates (y-axis) according to the degree of severity of organ failures on Day 1. The values corresponding to the terciles of distribution of the SOFA score on Day 1 (SOFA D1) (x-axis) were used to establish a cut-off point for stratifying the patients into three groups (columns). Patients in whom associated organ failures improved (A-SOFA < 0), remained unchanged (A-SOFA = 0) and worsened (A-SOFA > 0) are represented in gray, square-lined and black columns, respectively. a) P = 0.05; b) P = 0.19; c) P = 0.04.

Mentions: The overall ICU and hospital mortality rates were 71% and 75%, respectively. The main outcome data for patients are presented in Table 1. Non-survivors were older than survivors (75.4±12.9 vs. 65.5±17.6 years, P<0.001) and had higher Charlson comorbidity scores [3 (2 – 4) vs. 2 (0 – 4), P=0.023]. As is predictable, SAPS II (49.2±9.7 vs. 42.5±11.5, P<0.001), SOFA D1 [6 (4 – 8) vs. 5 (2 – 7), P=0.011] and SOFA D3 [7 (5 – 9) vs. 5 (1 – 7), P<0.001] scores were higher in decedents than in survivors. A-SOFA [1 (0 – 2) vs. 0 (−2 – 0), P=0.019] and Δ-SOFA [0.11 (0.02 – 0.38) vs. 0 (−0.33 – 0.25), P=0.016] were also higher in non-survivors (Figures 1a and 1b). However, neither the SAPS II score [AROC = 0.69 (95% CI = 0.61 – 0.76)], the A-SOFA [AROC = 0.60 (95% CI = 0.52 – 0.68)] nor the Δ-SOFA [AROC = 0.60 (95% CI = 0.52 – 0.68)] discriminate survivors from non-survivors on an individual basis. In Figure 2, the mortality rates for the different possibilities of the A-SOFA according to the different degrees of severity of organ failures at baseline (SOFA-D1) are depicted. The values corresponding to the terciles of distribution of the SOFA score on D1 (SOFA D1) were used to establish a cut-off point to stratify the patients into three groups. The hospital mortality was significantly higher in patients in whom organ dysfunction worsened or remained unchanged.


Effects of early changes in organ dysfunctions on the outcomes of critically ill patients in need of renal replacement therapy.

Maccariello E, Rocha E, Valente C, Nogueira L, Rocha PT, Bonomo H, Serpa LF, Ismael M, Valença RV, Machado JE, Soares M - Clinics (Sao Paulo) (2008)

Hospital mortality rates (y-axis) according to the degree of severity of organ failures on Day 1. The values corresponding to the terciles of distribution of the SOFA score on Day 1 (SOFA D1) (x-axis) were used to establish a cut-off point for stratifying the patients into three groups (columns). Patients in whom associated organ failures improved (A-SOFA < 0), remained unchanged (A-SOFA = 0) and worsened (A-SOFA > 0) are represented in gray, square-lined and black columns, respectively. a) P = 0.05; b) P = 0.19; c) P = 0.04.
© Copyright Policy
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC2664247&req=5

f2-cln63_3p0343: Hospital mortality rates (y-axis) according to the degree of severity of organ failures on Day 1. The values corresponding to the terciles of distribution of the SOFA score on Day 1 (SOFA D1) (x-axis) were used to establish a cut-off point for stratifying the patients into three groups (columns). Patients in whom associated organ failures improved (A-SOFA < 0), remained unchanged (A-SOFA = 0) and worsened (A-SOFA > 0) are represented in gray, square-lined and black columns, respectively. a) P = 0.05; b) P = 0.19; c) P = 0.04.
Mentions: The overall ICU and hospital mortality rates were 71% and 75%, respectively. The main outcome data for patients are presented in Table 1. Non-survivors were older than survivors (75.4±12.9 vs. 65.5±17.6 years, P<0.001) and had higher Charlson comorbidity scores [3 (2 – 4) vs. 2 (0 – 4), P=0.023]. As is predictable, SAPS II (49.2±9.7 vs. 42.5±11.5, P<0.001), SOFA D1 [6 (4 – 8) vs. 5 (2 – 7), P=0.011] and SOFA D3 [7 (5 – 9) vs. 5 (1 – 7), P<0.001] scores were higher in decedents than in survivors. A-SOFA [1 (0 – 2) vs. 0 (−2 – 0), P=0.019] and Δ-SOFA [0.11 (0.02 – 0.38) vs. 0 (−0.33 – 0.25), P=0.016] were also higher in non-survivors (Figures 1a and 1b). However, neither the SAPS II score [AROC = 0.69 (95% CI = 0.61 – 0.76)], the A-SOFA [AROC = 0.60 (95% CI = 0.52 – 0.68)] nor the Δ-SOFA [AROC = 0.60 (95% CI = 0.52 – 0.68)] discriminate survivors from non-survivors on an individual basis. In Figure 2, the mortality rates for the different possibilities of the A-SOFA according to the different degrees of severity of organ failures at baseline (SOFA-D1) are depicted. The values corresponding to the terciles of distribution of the SOFA score on D1 (SOFA D1) were used to establish a cut-off point to stratify the patients into three groups. The hospital mortality was significantly higher in patients in whom organ dysfunction worsened or remained unchanged.

Bottom Line: However, neither A-SOFA nor Delta-SOFA discriminated survivors from non-survivors on an individual basis.Adjusting for other covariates (including SOFA on D1), A-SOFA and Delta-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes.However, no prognostic score should be used as the only parameter to predict individual outcomes.

View Article: PubMed Central - PubMed

Affiliation: D'Or de Hospitais, Rio de Janeiro, Brazil. emaccariello@yahoo.com.br

ABSTRACT

Introduction: Acute kidney injury usually develops in critically ill patients in the context of multiple organ dysfunctions.

Objective: To evaluate the effect of changes in associated organ dysfunctions over the first three days of renal replacement therapy on the outcomes of patients with acute kidney injury.

Methods: Over a 19-month period, we evaluated 260 patients admitted to the intensive care units of three tertiary-care hospitals who required renal replacement therapy for > 48 h. Organ dysfunctions were evaluated by SOFA score (excluding renal points) on the first (D1) and third (D3) days of renal replacement therapy. Absolute (A-SOFA) and relative (Delta-SOFA) changes in SOFA scores were also calculated.

Results: Hospital mortality rate was 75%. Organ dysfunctions worsened (A-SOFA>0) in 53%, remained unchanged (A-SOFA=0) in 17% and improved (A-SOFA<0) in 30% of patients; and mortality was lower in the last group (80% vs. 84% vs. 61%, p=0.003). SOFA on D1 (p<0.001), SOFA on D3 (p<0.001), A-SOFA (p=0.019) and Delta-SOFA (p=0.016) were higher in non-survivors. However, neither A-SOFA nor Delta-SOFA discriminated survivors from non-survivors on an individual basis. Adjusting for other covariates (including SOFA on D1), A-SOFA and Delta-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes.

Conclusions: In addition to baseline values, early changes in SOFA score after the start of renal replacement therapy were associated with hospital mortality. However, no prognostic score should be used as the only parameter to predict individual outcomes.

Show MeSH
Related in: MedlinePlus