title: Severe acute renal failure in adults: place of care, incidence and outcomes.
abstract: BACKGROUND
  Department of Health guidelines recommend specialist critical care facilities for patients with severe single-organ failure such as acute renal failure (ARF). Prospective studies examining incidence, causes and outcomes of ARF outside of intensive care settings are lacking.
  
  
  OBJECTIVE
  To determine the incidence, causes, place of care and outcomes of severe single-organ ARF.
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  For 6 weeks in June-July 2003, renal physicians were contacted daily, and ICUs on alternate days, to identify cases of severe single-organ ARF in the Greater Manchester area. All patients with serum creatinine >or=500 micromol/l and not requiring other organ support were included. Patients with end-stage renal disease were excluded. Survivors were followed up at 90 days and 1 year from admission. Two independent consultant nephrologists assessed each case using anonymized summaries.
  
  
  RESULTS
  Eighty-five patients had multi-organ ARF and 28 had severe single-organ ARF (380 and 125 pmp/year, respectively). Of those with single-organ ARF, 10 (36%) had known pre-existing chronic kidney disease. Renal replacement therapy (RRT) was required in 15 (54%). Total bed occupancy on ICUs relating to single-organ ARF was 59 days (range per patient 1-21). At 90 days, 18 (64%) were alive, and 17 (94%) had independent renal function. At 1 year, 4/18 had died, none receiving RRT at the time of death. Survivors all had independent renal function. In 13 (46%) cases there was an unacceptable delay in patient transfer and in 7 (25%), delays in assessment or commencement of RRT may have adversely affected patient outcome.
  
  
  CONCLUSIONS
  The incidence of ARF treated with RRT is rising. Delays in transfer to renal services may result in inappropriate ICU bed use, and may adversely affect patient outcomes. There are serious problems regarding the appropriate use of expensive and limited medical resources in the critical care area, and in providing safe and effective treatment of patients with ARF.
authors.affiliation: Department of Renal Medicine, Hope Hospital, Stott Lane, Salford, Manchester M6 8HD, UK. janet.hegarty@srht.nhs.uk
authors.forename: J
authors.initials: J
authors.lastname: Hegarty
authors.forename: R J
authors.initials: RJ
authors.lastname: Middleton
authors.forename: M
authors.initials: M
authors.lastname: Krebs
authors.forename: H
authors.initials: H
authors.lastname: Hussain
authors.forename: C
authors.initials: C
authors.lastname: Cheung
authors.forename: T
authors.initials: T
authors.lastname: Ledson
authors.forename: A J
authors.initials: AJ
authors.lastname: Hutchison
authors.forename: P A
authors.initials: PA
authors.lastname: Kalra
authors.forename: H C
authors.initials: HC
authors.lastname: Rayner
authors.forename: P E
authors.initials: PE
authors.lastname: Stevens
authors.forename: D J
authors.initials: DJ
authors.lastname: O'Donoghue
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D000368:Aged; D003422:Critical Care / Q000379:methods; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer; D011446:Prospective Studies; D017582:Renal Replacement Therapy / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome