Clinical Observation In Patients With Acute Kidney Injury Related To The Surgery Based On RIFLE Criteria

Background.The major limitation in improving outcomes from acute kidney injury(AKI)has been the lack of common standards for diagnosis and classification.Recognizing that, The Acute Dialysis Quality Initiative Group(ADQI)has published a consensus definition/classification system for AKI termed the RIFLE(Risk,Injury,Failure,Loss and End-stage)criteria.The RIFLE classification defines three grades of severity of AKI(Risk,Injury and Failure)based on changes to serum creatinine and urine output, and two clinical outcomes(Loss,End-stage).Patients who developed acute kidney injury in the general intensive care unit (ICU)and surgical departments have extremely high rates of mortality and morbidity. Besides the nephrologists,whether all of the physicians and surgeons should take care of the the acute renal failure and response as soon as possible or ask for consultation. The first part of this study was in order to identify correlates of the timing of nephrological consultation in acute renal failure,and to explore the relation between timing of consultation and outcomes based on the RIFLE criteria.In another hand,there is limited literature focus on the patients which were staged into L and E.Or we can concern the group in maintenance dialysis who require major abdominal surgery.The goals of the second part of present study were to evaluate peroperative management for surgery and safty among dialysis patients undergoing major abdominal operations.Methods.Part one:The patterns of patient encounters during the general academic teaching hospital nephrology residency program for three chief residents from April 2007 to September 2007 were retrospectively analyzed.Totally 179 patients admitted and underwent surgery with AKI in 16 different surgical divisions except cardio-thoracic Surgery and burn surgery were evaluated,then classified as risk,injury,or failure based the situation at the time of consultation.Compared the mortality,hospital stay and others outcomes between these three groups.Part two:Medical records for 34 long-term dialysis patients at our institution undergoing major abdominal operations from June 2003 to June 2007 were reviewed. Analyzed the characteristics of these 34 cases during the preoperative period.ResultsThe 179 patients(mean age 57.0±15.9)consulted were classified as risk(6.7%), injury(19.6%),failure(73.7%).Overall mortality was 32.4%and a 60 days follow up mortality was 38.5%.And the mortality in F group(132cases)was 37.9%,compare with R group(16.7%),and I group(17.1%).Also there were 98 patients in F team (74.2%)underwent the RRT,and RRT performed in 109 cases(60.9%)totally in this cohort.But there were no significant difference between the three categories about the mean length of hospital stay days.Anesthesia ASA class was grade 3 or 4 in about 76.5%dialysis patients,but it did not influence the outcomes of the 34 cases.Hemodialysis patients ready for selective operation received a hemodialysis during 24 h before operation to maintain the balance of fluid and electrolyte.Transfusion of RBC or plasma,and injection of EPO before were very useful tools to correct the anemia and the bleeding tendency before the surgery.There were 3 patients(8.8%)gone in the ICU.Cardiac function estimated by NYHA standard grade 3 or 4 was independent risk fact for mortality.The major vascular surgery also should be take care of.Conclusion.Consultation is an unique clinic practice and challenge to nephrology residents. But the recognition of AKI by the surgery also influenced the outcomes of there consulted cases.In part of this setting,the earlier the nephrologists come the the injured kidney and adjust the therapeutic measure appropriately,the rate of survival might be improved.Especially in the cases with simple renal factor damage who rely on dialysis.There were much more danger in MHD and CAPD patients who require abdominal surgery.But it can be performed with relative safety in the elective situation with intensive perioperative management.Also the abdominal surgery was not a contraindication for peritoneal dialysis and need to pay more attention to the emergency operation because of the features of acute abdomen in dialysis population.