Nephrol Dial Transplant (1992) 7. 230-234 £, 1992 European Dialysis and Transplant Association-European Renal Association
Nephrology
Dialysis
Transplantation
Original Article Cause of death in acute renal failure G. Woodrow and J. H. Turney Renal Unit, The General Infirmary at Leeds, Great George Street, Leeds, LSI 3EX, UK
Abstract. The cause of 636 deaths during acute renal failure (ARF) occurring between 1956 and 1989 were analysed. Deaths due to haemorrhage and to nonrecovery of renal function have declined but cardiovascular deaths and withdrawal of active treatment have increased. The causes of death varied with the clinical situation in which ARF arose. The most important factor contributing to death was the underlying cause of ARF. 67% deaths due to sepsis resulted from infection present at the time of development of ARF. Deaths due to secondary complications have declined, indicating that the precipitating causes of ARF are the main determinant of overall mortality. Key words: acute renal failure; cause of death
Introduction Survival in acute renal failure (ARF) remains poor despite advances in management. It has long been recognized that appropriate supportive therapy reduces the mortality due to uraemia, but nevertheless there has not been a reduction in overall mortality in recent years. The apparent lack of improvement in outcome of ARF may in part be explained by changes in the patient population and casemix [1]. To address the question of whether these changes have altered the causes of death during ARF and whether these deaths are in general preventable, we
have retrospectively reviewed a series of patients dying with ARF over a 33 year period.
Subjects and methods 1458 patients with severe ARF were treated at the Leeds General Infirmary between 1956 and 1989, and 753 died during their acute illness (one-year actuarial survival 48.2%). Documentation on 636 (84.5%) of these deaths was sufficient to determine the cause of death. Availability of adequate case-notes was more or less constant over the period of the study, ranging from 72% to 94% for each decade. Only patients with creatinine >600|imol/l or requiring dialysis were included. Patients were divided into the clinical categories in which ARF arose: general and cardiovascular surgery, medical, obstetrics and intrinsic renal parenchymal disease. The case-notes were reviewed and the cause of death determined. The causes of death were categorized as haemorrhage, infection, neurological, cardiovascular, withdrawal of treatment, non-recovery of renal function (patients who did not recover independent renal function and for whom long-term renal replacement therapy was either not available or inappropriate, or in whom death was related to complications of chronic renal failure after the acute illness). The relationship of the cause of death to the underlying cause of the ARF was also noted. It was permissible for patients to be entered in more than one category (for example, a patient with ARF due to sepsis and dying of the original infection would be categorized as death due to both infection and the underlying disease).
Results
There was no significant change in overall mortality between 1956 and 1989 (Table 1). There was not only Corrv\pimJcmc untl nfiprini requests . Renal l.'nit. a significant increase in age at presentation with acute The General Infirmar> at Leeds. Great George Street. Leeds, LSI 3EX. UK renal failure [1], but also an increase in the median
Downloaded from https://academic.oup.com/ndt/article-abstract/7/3/230/1810434 by University of Auckland Library user on 08 April 2018
Cause of death in acute renal failure
231
Table 1. Acute renal failure: numbers, deaths, and percentage mortality (%). 1956-1989
100
Year
90
1956 1960 1970 1980
9 9 9 9
All
Number
Deaths
203 579 170 506 1458
97 283 104 269 753
47.8 48.9 61.2 53.8 51.9
Hotroirha;s
80 Infection
70
ages of both survivors and those who died (Table 2). Although age is an important determinant of death from ARF [1], the difference in age between survivors and non-survivors has become less marked in recent years. The pattern of causes of death has changed during the study period (Table 3, Figure 1). Haemorrhage, predominantly gastrointestinal (Table 4), has become rare in recent years (1960/9 versus 1980/9, P=0.0\4, X2 test) and deaths due to non-recovery of renal function have declined (1950/9 and 1960/9 versus 1980/9, both P< 0.00001). Cardiovascular deaths have increased (1960/9 versus 1980/9, P=0.026), as a result of an older patient population, and withdrawal of active treatment has also increased (1960/9 versus 1980/9, P = 0.0023). Infection and central nerv-
60
CHS
50
CVS
30
20 Withdrawn
10 HonRacovrry
56/9
Table 2. Acute renal failure: median ages (years) for all patients and those who survived or died, 1956-1989 Year
Survivors
Deaths
All
1956/9 1960/9 1970/9 1980/9 1956-1989
35.5 39.6 51.3 59.2 47.2
51.5 53.5 63.9 64.0 59.5
42.0 46.4 60.3 61.7 53.7
Haemorrhage Infection Neurological Cardiovascular Treatment withdrawn Non-recovery—renal Underlying disorder
19609
19709
14 4 (5.5) (4.1) 49 97 (38.2) (50) (5.1) (5.1) 58 19 (22.8) (19.4) 14 13 (5.5) (13.3) 47 5 (18.5) (5.1) 151 67 (59.5) (68.4)
(15.4) 5 (2.3) 149 (69.6)
70 (II)
254 98 (39.9) (15.4)
214 (33.6)
5
5 (2.3) 94
(43.9) 6 (2.8) 77 (36) 33
Other All
80/9
ALL
Table 4. Sites of fatal haemorrhage in acute renal failure Site
No. patients
Gastrointestinal Operative Pulmonary Nasopharynx Total
15 7 3 2 27
1980 9 All
4 (5.7) 30 (42.9) 2 (2.9) 14 (20) 4 (5.7; 13 (18.6) 35 (50)
13
70/9 Y«ars
Fig. 1. Cause of death in acute renal failure (percentage) by decade of presentation.
Table 3. Numbers (percentage) of causes of death in acute renal failure 19569
60/9
Downloaded from https://academic.oup.com/ndt/article-abstract/7/3/230/1810434 by University of Auckland Library user on 08 April 2018
27 (4.2) 270 (42.5) 26 (4.1) 168 (26.4) 64 (10.1) 70 (11) 401 (63.1) 6 (1.0) 636
ous system events have remained constant. The clinical categories of causes of ARF are associated with different patterns of deaths (Table 5, Figure 2). Sepsis was more common in medical and surgical cases {P< 0.005, versus other categories). Neurological deaths, related to head injury, were more common following trauma (/>=0.0002 versus surgery) and renal cases (P
Nephrology
Dialysis
Transplantation
Original Article Cause of death in acute renal failure G. Woodrow and J. H. Turney Renal Unit, The General Infirmary at Leeds, Great George Street, Leeds, LSI 3EX, UK
Abstract. The cause of 636 deaths during acute renal failure (ARF) occurring between 1956 and 1989 were analysed. Deaths due to haemorrhage and to nonrecovery of renal function have declined but cardiovascular deaths and withdrawal of active treatment have increased. The causes of death varied with the clinical situation in which ARF arose. The most important factor contributing to death was the underlying cause of ARF. 67% deaths due to sepsis resulted from infection present at the time of development of ARF. Deaths due to secondary complications have declined, indicating that the precipitating causes of ARF are the main determinant of overall mortality. Key words: acute renal failure; cause of death
Introduction Survival in acute renal failure (ARF) remains poor despite advances in management. It has long been recognized that appropriate supportive therapy reduces the mortality due to uraemia, but nevertheless there has not been a reduction in overall mortality in recent years. The apparent lack of improvement in outcome of ARF may in part be explained by changes in the patient population and casemix [1]. To address the question of whether these changes have altered the causes of death during ARF and whether these deaths are in general preventable, we
have retrospectively reviewed a series of patients dying with ARF over a 33 year period.
Subjects and methods 1458 patients with severe ARF were treated at the Leeds General Infirmary between 1956 and 1989, and 753 died during their acute illness (one-year actuarial survival 48.2%). Documentation on 636 (84.5%) of these deaths was sufficient to determine the cause of death. Availability of adequate case-notes was more or less constant over the period of the study, ranging from 72% to 94% for each decade. Only patients with creatinine >600|imol/l or requiring dialysis were included. Patients were divided into the clinical categories in which ARF arose: general and cardiovascular surgery, medical, obstetrics and intrinsic renal parenchymal disease. The case-notes were reviewed and the cause of death determined. The causes of death were categorized as haemorrhage, infection, neurological, cardiovascular, withdrawal of treatment, non-recovery of renal function (patients who did not recover independent renal function and for whom long-term renal replacement therapy was either not available or inappropriate, or in whom death was related to complications of chronic renal failure after the acute illness). The relationship of the cause of death to the underlying cause of the ARF was also noted. It was permissible for patients to be entered in more than one category (for example, a patient with ARF due to sepsis and dying of the original infection would be categorized as death due to both infection and the underlying disease).
Results
There was no significant change in overall mortality between 1956 and 1989 (Table 1). There was not only Corrv\pimJcmc untl nfiprini requests . Renal l.'nit. a significant increase in age at presentation with acute The General Infirmar> at Leeds. Great George Street. Leeds, LSI 3EX. UK renal failure [1], but also an increase in the median
Downloaded from https://academic.oup.com/ndt/article-abstract/7/3/230/1810434 by University of Auckland Library user on 08 April 2018
Cause of death in acute renal failure
231
Table 1. Acute renal failure: numbers, deaths, and percentage mortality (%). 1956-1989
100
Year
90
1956 1960 1970 1980
9 9 9 9
All
Number
Deaths
203 579 170 506 1458
97 283 104 269 753
47.8 48.9 61.2 53.8 51.9
Hotroirha;s
80 Infection
70
ages of both survivors and those who died (Table 2). Although age is an important determinant of death from ARF [1], the difference in age between survivors and non-survivors has become less marked in recent years. The pattern of causes of death has changed during the study period (Table 3, Figure 1). Haemorrhage, predominantly gastrointestinal (Table 4), has become rare in recent years (1960/9 versus 1980/9, P=0.0\4, X2 test) and deaths due to non-recovery of renal function have declined (1950/9 and 1960/9 versus 1980/9, both P< 0.00001). Cardiovascular deaths have increased (1960/9 versus 1980/9, P=0.026), as a result of an older patient population, and withdrawal of active treatment has also increased (1960/9 versus 1980/9, P = 0.0023). Infection and central nerv-
60
CHS
50
CVS
30
20 Withdrawn
10 HonRacovrry
56/9
Table 2. Acute renal failure: median ages (years) for all patients and those who survived or died, 1956-1989 Year
Survivors
Deaths
All
1956/9 1960/9 1970/9 1980/9 1956-1989
35.5 39.6 51.3 59.2 47.2
51.5 53.5 63.9 64.0 59.5
42.0 46.4 60.3 61.7 53.7
Haemorrhage Infection Neurological Cardiovascular Treatment withdrawn Non-recovery—renal Underlying disorder
19609
19709
14 4 (5.5) (4.1) 49 97 (38.2) (50) (5.1) (5.1) 58 19 (22.8) (19.4) 14 13 (5.5) (13.3) 47 5 (18.5) (5.1) 151 67 (59.5) (68.4)
(15.4) 5 (2.3) 149 (69.6)
70 (II)
254 98 (39.9) (15.4)
214 (33.6)
5
5 (2.3) 94
(43.9) 6 (2.8) 77 (36) 33
Other All
80/9
ALL
Table 4. Sites of fatal haemorrhage in acute renal failure Site
No. patients
Gastrointestinal Operative Pulmonary Nasopharynx Total
15 7 3 2 27
1980 9 All
4 (5.7) 30 (42.9) 2 (2.9) 14 (20) 4 (5.7; 13 (18.6) 35 (50)
13
70/9 Y«ars
Fig. 1. Cause of death in acute renal failure (percentage) by decade of presentation.
Table 3. Numbers (percentage) of causes of death in acute renal failure 19569
60/9
Downloaded from https://academic.oup.com/ndt/article-abstract/7/3/230/1810434 by University of Auckland Library user on 08 April 2018
27 (4.2) 270 (42.5) 26 (4.1) 168 (26.4) 64 (10.1) 70 (11) 401 (63.1) 6 (1.0) 636
ous system events have remained constant. The clinical categories of causes of ARF are associated with different patterns of deaths (Table 5, Figure 2). Sepsis was more common in medical and surgical cases {P< 0.005, versus other categories). Neurological deaths, related to head injury, were more common following trauma (/>=0.0002 versus surgery) and renal cases (P
