ESTABLISHING A DIALYSIS THERAPY PATIENT OUTCOME LINK IN INTENSIVE-CARE UNIT ACUTE DIALYSIS FOR PATIENTS WITH ACUTE-RENAL-FAILURE

The aim of this study was to describe a relationship between intensive care unit (ICU) patient acuity, delivered dialysis dosing, and patien t mortality from newly acquired acute renal failure (ARF) requiring di alytic support. A prospectively collected ICU ARF registry formed the basis for data comparison, All data was verified. Eight hundred forty- four ICU patients were identified who met biochemical or clinical crit eria of ARF and required first-time dialytic support. An acute dialysi s scoring system was established using 23 independent variables identi fied with univariant analysis, and reduced to eight variables with mul tiple regression analysis in 512 patients. These eight variables were assigned a weighted score derived from their odds ratio, and the scori ng system was than validated prospectively to either registry data not involved in the generation of the system (n = 148), or double-blinded score assignment at time of first dialysis (n = 130), Several establi shed scoring systems were also applied to the database for external co mparison. Dialysis dosing was analyzed using either direct dialysate q uantification or blood side urea kinetics once appropriate formulae we re identified from paired blood/dialysate results. Using our database and four published ARF acuity/predictive models (Lohr, Cioffi, Bullock , Acute Physiology and Chronic Health Evaluation [APACHE II]), outcome predictions were grossly inaccurate, Application of the Cleveland Cli nic Foundation (CCF) ARF acuity score showed highly predictable outcom es when compared using the Lemeshow, Hosmer goodness-of-fit statistics , and highly reproducible results in both the prospective database and double-blinded prospective clinical trials, When comparing dialytic s upport techniques received (intermittent dialysis v continuous therapi es), the CCF scoring system remained highly predictive of mortality, W hen one compares dose of delivered dialysis to patients with ARF in th e ICU setting, there seems to be no effect on outcome at the two ends of the scoring system, Those with very low (<4) and very high (>15) CC F scores had survivals of 78% and 0%, respectively, regardless of the dose of dialysis. Patients with intermediate scores seemed to be the m ost effected by dialysis dose delivery, with higher delivery (>58% ure a reduction ratio for intermittent hemodialysis; <45 mg/dL time-averag ed concentration of urea (TAC(Urea)) for continuous renal replacement therapy [CRRT]) associated with a significant reduction in mortality w hen compared with the same CCF scoring quartile with low-dialysis dose delivery, While underlying patient comorbidity has a significant effe ct on survival in ARF, the dose of delivered dialysis also seems to pl ay a major role in patients with moderated levels of severity, Methods that allow a higher delivered dialysis dose to this group of patients will be rewarded with improved patient outcome. (C) 1996 by the Natio nal Kidney Foundation, Inc.