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[IP] Higher Death Rate And Non-Recovery Of Kidney Function Seen In ICU

University Of California - San Diego <http://www.ucsd.edu/>



  Higher Death Rate And Non-Recovery Of Kidney Function Seen In ICU
  Patients Given Diuretics

A substantially higher death rate and inability to recover from kidney
failure was documented in a study of 552 critically ill, hospitalized
patients who were given diuretics, the most commonly used therapy for
kidney failure.

Published in the November 27, 2002 issue of the Journal of the American
Medical Association (JAMA), the study suggests that physicians treating
patients in acute kidney failure should reassess the use of diuretics,
particularly when there is a limited response in terms of increased
urine output.

A large percentage of patients who don't respond to diuretics may
require dialysis, the use of a medical device to support kidney function
by removing impurities that are usually eliminated by normal kidneys,
said first author Ravindra Mehta, M.D., University of California, San
Diego professor of medicine. He also noted that a delay in treatment,
while physicians wait for diuretics to have an effect, can lead to
numerous adverse medical outcomes.

The study was conducted over six years at four California hospitals by
researchers at the UCSD School of Medicine and the University of
California, San Francisco (UCSF).

Comparing kidney-failure patients who were prescribed diuretics to those
who were not, researchers found that diuretic use was associated with a
68 percent increase in mortality and a 77 percent increase in the
non-recovery of kidney function.

Diuretics are commonly prescribed to increase urine output in patients
whose kidneys fail to produce enough urine, an indicator that harmful
waste products are being retained, rather than filtered out by the
kidneys. Previous studies have shown that 300,000-500,000 hospitalized
patients in the U.S. develop kidney failure after admittance, making it
a fairly common occurrence. Approximately 50-75 percent of these
patients are traditionally given diuretics.

Noting that the JAMA paper describes an observational study, Mehta added
that further investigations are needed to determine the direct causal
link between diuretics and adverse outcomes.

The 552 patients studied had been admitted for a variety of medical
conditions, and were then diagnosed with acute renal (kidney) failure in
intensive care units at UCSD Medical Center, the San Diego Veterans
Affairs Medical Center, San Diego Naval Hospital, and UC Irvine Medical
Center from October 1989 to September 1995. Patients were followed from
the time of initial consultation by a kidney specialist through hospital
discharge or death. To compensate for variables, such as age, sex, race
and additional disease or organ malfunction, the researchers used
sophisticated statistical analysis to compare patients given diuretics
to those who were not.

In addition to the increased mortality and non-recovery of kidney
function, the investigators also found a variation in the time between
consultation with a kidney specialist and the start of dialysis
treatment, as physicians waited for a response to the diuretic therapy.
"Delay in initiation of dialysis (waiting for a response to diuretics)
may have untoward effects," the researchers said in the study. "These
effects could include the worsening of respiratory, cardiovascular,
central nervous system, and immune function due to volume overload and
the effects of uremia."

An accompanying editorial in JAMA said the study is timely and
clinically important because administration of diuretics to ICU patients
in kidney failure is still a relatively common practice. "Until data
from a sufficiently powered clinical trial can properly answer the
question of whether critically ill patients are harmed by loop
diuretics, the practice of routine administration of these agents to
such patients should be discouraged," the editorial stated.

"This study illustrates that kidney failure is prevalent and too
frequently under-diagnosed by ICU providers," Mehta said. "Kidney
failure is dangerous and the longer it goes on, the likelihood of an
adverse outcome increases. Physicians need to be aware that even small
changes in kidney function can have deleterious effects. They need to
recognize kidney failure early on and consider immediate dialysis as
their first treatment of choice."

Additional authors were Glenn M. Chertow, M.D., MPH, UCSF, and Maria T.
Pascual, R.N. and MPH, Sharon Soroko, M.S., UCSD Department of Medicine.
The study was funded by the National Institutes of Health, National
Institute of Diabetes and Digestive and Kidney Diseases.

Note: An additional study published by Mehta and others October 15, 2002
(Vol. 113) in the American Journal of Medicine used the same group of
ICU patients to compare the relationship between the time a kidney
specialist is consulted and the outcomes experienced by patients. The
researchers found that delayed consultation was associated with
increased mortality and worsening condition, whether or not dialysis was
ultimately required. Mehta noted that this is another argument for
immediate attention to kidney function in critically ill patients. This
paper can be seen at the following website:

*Editor's Note:* The original news release can be found here


/*Note*: This story has been adapted from a news release issued for
journalists and other members of the public. If you wish to quote any
part of this story, please credit *University Of California - San Diego
* as the original source. You may also wish to include the following
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