Acute renal failure: acute tubular necrosis: oliguria increased death and dialysis.

Clinical bottom line (level 4)

  1. Around half of patients with acute tubular necrosis died, and a half needed dialysis at some point.
  2. Patients without preexisting renal disease who have oliguria were at increased risk of dying (NNF = 2 for unknown) , and needing dialysis (NNF = 1 for unknown) .
  3. Many patients had multiple causes, which included hypotension, dehydration and sepsis.
Rasmussen and Ibels: American Journal of Medicine 1982; 73: 211-218
Expires July 2003

The study

Retrospective cohort study with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: renal unit of acute hospital, Australia

143 patients (aged range 16 to 88 years; mean 58, ?% male) hospitalised for reasons other than renal insufficiency, who were clinically diagnosed with acute tubular necrosis

Excluded if
  • glomerulonephritis
  • ureteric obstruction
  • interstitial nephritis
  • urate nephropathy




    • 100% followed for until discharge
    Outcomes studied:
  • death
  • dialysis (no preexisting renal disease)
  • cause was hypotension systolic blood pressure <100 mmHg
  • cause multifactorial
  • cause dehydration suggestive clinical setting plus one of: orthostatic fall in blood pressures of 10 mmHg; negative fluid balance of >1.5l in previous 48 hours; decreased skin turgor and dryness of the axillae
  • sepsis at least one of: documented bacteraemia; known focus of infection; neutropenia with corroborating clinical and laboratory findings suggestive of septicaemia
  • pigmenturia
  • aminoglycoside use
  • radiocontrast
  • liver disease

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    death until discharge 76/143 53%
    (45% to 61%)
    dialysis (no preexisting renal disease) until discharge 60/121 50%
    (41% to 59%)
    cause was hypotension until discharge 90/143 63%
    (55% to 71%)
    cause multifactorial until discharge 102/143 71%
    (64% to 79%)
    cause dehydration until discharge 42/143 29%
    (22% to 37%)
    sepsis until discharge 37/143 26%
    (19% to 33%)
    pigmenturia until discharge 27/143 19%
    (12% to 25%)
    aminoglycoside use until discharge 15/143 10%
    (5% to 16%)
    radiocontrast until discharge 15/143 10%
    (5% to 16%)
    liver disease until discharge 3/143 2%
    (0.0% to 4.5%)

    prognostic factor for
    death     		time to outcome unadjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    oliguria until discharge 2.81
    (1.84 to 4.30)     		2
    (1 to 4)

    prognostic factor for
    dialysis (no preexisting renal disease)     		time to outcome unadjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    oliguria until discharge 7.70
    (3.81 to 15.6)     		1
    (1 to 3)

    Comments

    1. A higher proportion of patients with preexisting disease sustained only a single, rather than multiple insults (59% versus 35%, p<0.05).
    2. The article is presented as a cohort study- however, there is no clear indication that patients were enrolled at a similar point in their disease. A multivariable analysis was performed, but since no comparison with a control group (without acute tubular necrosis) was made, this information is not helpful.

    Citation

    1. Rasmussen HH, and Ibels LS: Acute renal failure: multivariable analysis of causes and risk factors. American Journal of Medicine 1982; 73: 211-218
    Search Terms: bibliographic reference from a review article
    Contributor: Catherine Clase, Chris Ball and Clare Wotton, April 2000
    Reviewer: Catherine Clase

    Clinical Question.
    Patient acute tubular necrosis
    Intervention or Exposure oliguria
    Outcome death and dialysis