Perez-Valdivieso, J.R. (José Ramón)
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- Timing of renal replacement therapy after cardiac surgery: a retrospective multicenter Spanish Cohort Study(Karger Publishers, 2011) Herreros, J. (Jesús); Perez-Valdivieso, J.R. (José Ramón); Lavilla, J. (Javier); Bes-Rastrollo, M. (Maira); Vives, M. (Marc); Monedero, P. (Pablo); Garcia-Fernandez, N. (Nuria)Background: The optimal time to initiate renal replacement therapy (RRT) in cardiac surgery-associated acute kidney injury (CSA-AKI) is unknown. Evidence suggests that the early use of RRT in critically ill patients is associated with improved outcomes. We studied the effects of time to initiation of RRT on outcome in patients with CSA-AKI. Methods: This was a retrospective observational multicenter study (24 Spanish hospitals). We analyzed data on 203 patients who required RRT after cardiac surgery in 2007. The cohort was divided into 2 groups based on the time at which RRT was initiated: in the early RRT group, therapy was initiated within the first 3 days after cardiac surgery; in the late group, RRT was begun after the 3rd day. Multivariate nonconditional logistic and linear regression models were used to adjust for potential confounders. Results: In-hospital mortality was significantly higher in the late RRT group compared with early RRT patients (80.4 vs. 53.2%; p < 0.001; adjusted odds ratio of 4.1, 95% CI: 1.6–10.0). Also, patients in the late RRT group had longer adjusted hospital stays by 11.6 days (95% CI: 1.4–21.9) and higher adjusted percentage increases in creatinine at discharge compared with baseline by 67.7% (95% CI: 28.5–106.4). Conclusions: Patients who undergo early initiation of RRT after CSA-AKI have improved survival rates and renal function at discharge and decreased lengths of hospital stay.
- Cardiac-surgery associated acute kidney injury requiring renal replacement therapy. A Spanish retrospective case-cohort study(BioMed Central, 2009-09) Perez-Valdivieso, J.R. (José Ramón); Bes-Rastrollo, M. (Maira); Vives, M. (Marc); Monedero, P. (Pablo); Garcia-Fernandez, N. (Nuria)Acute kidney injury is among the most serious complications after cardiac surgery and is associated with an impaired outcome. Multiple factors may concur in the development of this disease. Moreover, severe renal failure requiring renal replacement therapy (RRT) presents a high mortality rate. Consequently, we studied a Spanish cohort of patients to assess the risk factors for RRT in cardiac surgery-associated acute kidney injury (CSA-AKI). METHODS: A retrospective case-cohort study in 24 Spanish hospitals. All cases of RRT after cardiac surgery in 2007 were matched in a crude ratio of 1:4 consecutive patients based on age, sex, treated in the same year, at the same hospital and by the same group of surgeons. RESULTS: We analyzed the data from 864 patients enrolled in 2007. In multivariate analysis, severe acute kidney injury requiring postoperative RRT was significantly associated with the following variables: lower glomerular filtration rates, less basal haemoglobin, lower left ventricular ejection fraction, diabetes, prior diuretic treatment, urgent surgery, longer aortic cross clamp times, intraoperative administration of aprotinin, and increased number of packed red blood cells (PRBC) transfused. When we conducted a propensity analysis using best-matched of 137 available pairs of patients, prior diuretic treatment, longer aortic cross clamp times and number of PRBC transfused were significantly associated with CSA-AKI.Patients requiring RRT needed longer hospital stays, and suffered higher mortality rates. CONCLUSION: Cardiac-surgery associated acute kidney injury requiring RRT is associated with worse outcomes. For this reason, modifiable risk factors should be optimised and higher risk patients for acute kidney injury should be identified before undertaking cardiac surgery.
- External validation and comparison of three scores to predict renal replacement therapy after cardiac surgery: A multicenter cohort(SAGE Publications, 2011) Herreros, J. (Jesús); Perez-Valdivieso, J.R. (José Ramón); Lavilla, J. (Javier); Bes-Rastrollo, M. (Maira); Vives, M. (Marc); Monedero, P. (Pablo); Garcia-Fernandez, N. (Nuria)Purpose: Cardiac surgery-associated acute kidney injury requiring renal replacement therapy (RRT) is independently associated with mortality. Several risk scores have been developed to predict the need for RRT after cardiac surgery. We have compared and verified the external validity of the three main available scores for RRT prediction after cardiac surgery: the Thakar score, the Mehta tool, and the Simplified Renal Index. Methods: The risk scores were calculated in a cohort of 1084 adult patients, 248 of whom required RRT, who underwent open-heart surgery in 24 Spanish hospitals in 2007. The performance of the systems was determined by examining their discrimination (areas under the receiver operating characteristic curves (aROC) and calibration (Lemeshow-Hosmer chi-square goodness-of-fit statistics). Results: The aROCs in the Thakar score, the Mehta tool, and the Simplified Renal Index were 0.82, 0.76 and 0.79, respectively. The three scoring systems were poorly calibrated and tended to underestimate the actual need for RRT. Conclusions: The Thakar score and the Simplified Renal Index discriminated well between low - and high-risk patients in our cohort, and Thakar outperformed the Mehta tool. These best-performing scores may aid in the selection of optimal therapy, facilitate the planning of hospital resource utilization, improve preoperative counseling, select participants for clinical trials of renal-protective therapies and enable an accurate comparison between different institutions or surgeons.
- Karnofsky performance score in acute renal failure as a predictor of short-term survival(Wiley-Blackwell, 2007) Perez-Valdivieso, J.R. (José Ramón); Lavilla, F.J. (Francisco Javier); Bes-Rastrollo, M. (Maira); Monedero, P. (Pablo); Irala, J. (Jokin) deKarnofsky Performance Scale Index (KPS) is a measure of functional status that allows patients to be classified according to their functional impairment. We aim to assess if the prior KPS may predict the risk of death among patients with acute renal failure (ARF). METHODS: A cohort of 668 consecutive patients who had been admitted in an university-affiliated hospital between June 2000 and June 2006, and had been diagnosed with ARF, were studied. Three hundred and eighty-six patients with ARF who matched at least one of the RIFLE (Risk, Injury, Failure, Loss and End stage) criteria on increased serum creatinine were included for subsequent analysis. The group was divided into four categories, according to different Karnofsky scores measured by a nephrologist (>or=80, 70, 60 and or=80 Karnofsky group. Adjusted odds ratios were 8.87 (95% confidence interval (CI) 3.03-25.99), 6.78 (95% CI 2.61-17.58) and 2.83 (95% CI 1.04-7.68), for Karnofsky groups of
- Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study(BioMed Central, 2007) Perez-Valdivieso, J.R. (José Ramón); Lavilla, F.J. (Francisco Javier); Bes-Rastrollo, M. (Maira); Monedero, P. (Pablo); Irala, J. (Jokin) deThe aim of this study is to evaluate the association between acute serum creatinine changes in acute renal failure (ARF), before specialized treatment begins, and in-hospital mortality, recovery of renal function, and overall mortality at 6 months, on an equal degree of ARF severity, using the RIFLE criteria, and comorbid illnesses. METHODS: Prospective cohort study of 1008 consecutive patients who had been diagnosed as having ARF, and had been admitted in an university-affiliated hospital over 10 years. Demographic, clinical information and outcomes were measured. After that, 646 patients who had presented enough increment in serum creatinine to qualify for the RIFLE criteria were included for subsequent analysis. The population was divided into two groups using the median serum creatinine change (101%) as the cut-off value. Multivariate non-conditional logistic and linear regression models were used. RESULTS: A >or= 101% increment of creatinine respect to its baseline before nephrology consultation was associated with significant increase of in-hospital mortality (35.6% vs. 22.6%, p < 0.001), with an adjusted odds ratio of 1.81 (95% CI: 1.08-3.03). Patients who required continuous renal replacement therapy in the >or= 101% increment group presented a higher increase of in-hospital mortality (62.7% vs 46.4%, p = 0.048), with an adjusted odds ratio of 2.66 (95% CI: 1.00-7.21). Patients in the >or= 101% increment group had a higher mean serum creatinine level with respect to their baseline level (114.72% vs. 37.96%) at hospital discharge. This was an adjusted 48.92% (95% CI: 13.05-84.79) more serum creatinine than in the < 101% increment group. CONCLUSION: In this cohort, patients who had presented an increment in serum level of creatinine of >or= 101% with respect to basal values, at the time of nephrology consultation, had increased mortality rates and were discharged from hospital with a more deteriorated renal function than those with similar Liano scoring and the same RIFLE classes, but with a < 101% increment. This finding may provide more information about the factors involved in the prognosis of ARF. Furthermore, the calculation of relative serum creatinine increase could be used as a practical tool to identify those patients at risk, and that would benefit from an intensive therapy.
- Evaluation of the prognostic value of the risk, injury, failure, loss and end-stage renal failure (RIFLE) criteria for acute kidney injury(Wiley-Blackwell, 2008) Perez-Valdivieso, J.R. (José Ramón); Lavilla, F.J. (Francisco Javier); Bes-Rastrollo, M. (Maira); Monedero, P. (Pablo); Irala, J. (Jokin) deAIM: The experts have argued about the use of the risk, injury, failure, loss and end-stage renal failure (RIFLE) criteria as a prognosis scoring system. We examined the association between in-hospital mortality and the RIFLE criteria, and discussed its accuracy as a prognosis factor. METHODS: In this prospective study, we analysed the data gathered from a cohort of 956 patients admitted in a Spanish tertiary hospital between January 1998 and April 2006. Hazard ratios for mortality, and survival curves within 60 days were calculated. Discrimination and calibration of the model were also assessed. RESULTS: Excluding 53 patients, 903 patients were finally analysed. We classified them into groups according to the maximum RIFLE class reached during their admission. The RIFLE class was assessed by the glomerular filtration rate criterion. We found an increase in the in-hospital mortality risk. Cox proportional hazard models showed that RIFLE classes risk, injury, and failure were significant predictive factors (hazard ratios were 2.77, 3.23 and 3.52, respectively; P for trend was 0.005). The multivariate analyses from the cross-classification of the participants according to Liano score values (severity of illness) and RIFLE classes showed additive effects of the exposures on in-hospital mortality. CONCLUSION: In this population, the risk of in-hospital mortality during the acute kidney injury (AKI) episode was positively associated with RIFLE classes. We showed that the RIFLE classification system had discriminative power in predicting hospital mortality within 60 days in AKI patients, but not better than a specific AKI predictive model. However, a combined use of both may give a more robust prognosis system.
- Serum C-reactive protein on the prognosis of oncology patients with acute renal failure: an observational cohort study(Elsevier, 2008) Perez-Valdivieso, J.R. (José Ramón); Lopez-Olaondo, L. (Luis); Lavilla, F.J. (Francisco Javier); Bes-Rastrollo, M. (Maira); Monedero, P. (Pablo); Irala, J. (Jokin) deWe undertook this study to evaluate the significance of the C-reactive protein level (CRP) as a prognostic factor in oncology patients with acute renal failure (ARF) during nephrology consultation. METHODS: The study was comprised of a cohort of 375 consecutive oncology patients who had been admitted to a university-affiliated hospital between March 1998 and April 2006 and had been diagnosed with ARF. One hundred and fifty nine patients with ARF who matched at least one of the RIFLE criteria on increased serum creatinine were included for subsequent analysis. We used a Cox proportional hazard model. RESULTS: Clinical pathological variables were compared among patients with serum CRP levels > or =8 mg/dL (exposed group; cut-off point: median) and patients with serum CRP level <8 mg/dL (control group). In-hospital mortality rates associated with CRP levels were 53.8% for > or =8 mg/dL and 21.5% for <8 mg/dL (p <0.001). After adjusted analysis, the presence of a CRP level > or =8 mg/dL was significantly associated with an increased in-hospital mortality (HR 2.10; 95% CI: 1.17-3.78) than in those patients with similar Liano scoring, the same RIFLE classes, and the same treatment for ARF. In addition, each increment of 1 mg/dL of serum CRP was associated with an adjusted 4% increment of in-hospital mortality (HR 1.04, 95% CI: 1.01-1.06). CONCLUSIONS: CRP levels at nephrology consultation were an independent predictor of death in this cohort of oncology patients with ARF. Patients with levels > or =8 mg/dL may be considered at higher risk of death.