Epidemiology of Acute Renal Failure

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EPIDEMIOLOGY OF ACUTE RENAL FAILURE

Study Period

Study Population

Incidence

Investigator, Year

Country (City)

(Study Length)

(millions)

(pmp/y)

Eliahou et al., 1973 [4]

Israel

1965-1966 (2 yrs)

2.2

52

Abraham et al, 1989 [5]

Kuwait

1984-1986 (2 yrs)

0.4

95

McGregor et al., 1992 [6]

United Kingdom

1986-1988 (2 yrs)

0.94

185

(Glasgow)

Sanchez et al., 1992 [7]

Spain (Cuenca)

1988-1989 (2 yrs)

0.21

254

Feest et al., 1993 [8]

United Kingdom

1986-1987 (2 yrs)

0.44

175

(Bristol and Devon)

Madrid ARF Study

Spain (Madrid)

1991-1992 (9 mo)

4.23

FIGURE 8-13

Prospective studies. Prospective epidemiologic studies of acute renal failure (ARF) in large populations have not often been published . The first study reported by Eliahou and colleagues [4] was developed in Israel in the 1960s and included only Jewish patients. This summary of available data suggests a progressive increase in ARF incidence that at present seems to have stabilized around 200 cases per million population per year (pmp/y). No data about ARF incidence are available from undeveloped countries.

EPIDEMIOLOGY OF ACUTE RENAL FAILURE: NEED OF DIALYSIS

Investigator, Year

Country

Cases (pmp/y)

Lunding et al., 1964 [9]

Scandinavia

28

Eliahou et al., 1973 [4]

Israel

17*

Lachhein et al, 1978 [10]

West Germany

30

Wing et al, 1983 [11]

European Dialysis and

29

Transplant Association

Wing et al, 1983 [11]

Spain

59

Abraham et al, 1989 [5]

Kuwait

31

Sanchez et al., 1992 [7]

Spain

21t

McGregor et al., 1992 [6]

United Kingdom

31

Gerrard et al., 1992 [12]

United Kingdom

71

Feest et al., 1993 [8]

United Kingdom

22t

Madrid ARF Study Group [1]

Spain

57

* Very restrictive criteria. t Only secondary care facilities.

* Very restrictive criteria. t Only secondary care facilities.

FIGURE 8-14

Number of patients needing dialysis for acute renal failure (ARF), expressed as cases per million population per year (pmp/y). This has been another way of assessing the incidence of the most severe cases of ARF. Local situations, mainly economics, have an effect on dialysis facilities for ARF management. In 1973 Israeli figures showed a lower rate of dialysis than other countries at the same time. The very limited access to dialysis in developing countries supports this hypothesis. At present, the need for dialysis in a given area depends on the level of health care offered there. In two different countries (eg, the United Kingdom and Spain) the need for dialysis for ARF was very much lower when only secondary care facilities were available. At this level of health care, both countries had the same rate of dialysis. The Spanish data of the EDTA-ERA Registry in 1982 gave a rate of dialysis for ARF of 59 pmp/y. This rate was similar to that found in the Madrid ARF Study 10 years later. These data suggest that, when a certain economical level is achieved, the need of ARF patients for dialysis tends to stabilize.

Proportion of Cases, %

India

France

India

South Africa

France 1973

1965-1974 1981-1986

1981-1986

1986-1988

Surgical

46

11

30

30

8

Medical

30

67

70

61

77

Obstetric

24

22

2

9

15

HISTORICAL PATTERNS OF ACUTE RENAL FAILURE

FIGURE 8-15

Historical perspective of acute renal failure (ARF) patterns in France, India, and South Africa. In the 1960s and 1970s, obstetrical causes were a great problem in both France and India and overall incidences of ARF were similar. Surgical cases were almost negligible in India at that time, probably because of the relative unavailability of hospital facilities. During the 1980s surgical and medical causes were similar in both countries. In India, the increase in surgical cases may be explained by advances in health care, so that more surgical procedures could be done. The decrease in surgical cases in France, despite the fact that surgery had become very sophisticated, could be explained by better management of surgical patients.

(Legend continued on next page)

FIGURE 8-15 (Continued)

Changes in classification criteria—inclusion of a larger percentage of medical cases than a decade before—could be an alternative explanation. In addition, obstetric cases had almost disappeared in France in the 1980s, but they were still an important cause of ARF in India. In a South African study that excluded the white population the distribution of ARF causes was almost identical to that observed in India 20 years earlier. In conclusion, 1) the economic level of a country determines the spectrum of ARF causes observed;

2) when a developing country improves its economic situation, the spectrum moves toward that observed in developed countries; and

3) great differences can be detected in ARF causes among developing countries, depending on their individual economic power. (Data from Kleinknecht [13]; Chugh et ail. [14]; Seedat et al. [15].)

FIGURE 8-17

FIGURE 8-16

Changing trends in the causes of acute renal failure (ARF) in the Third-World countries. Trends can be identified from the analysis of medical and obstetric causes by the Chandigarh Study [14]. Chugh and colleagues showed how obstetric (septic abortion) and hemolytic (mainly herbicide toxicity) causes tended to decrease as economic power and availability of hospitalization improved with time. These causes of ARF, however, did not completely disappear. By contrast, diarrheal causes of ARF, such as cholera and other gastrointestinal diseases, remained constant. In conclusion, gastrointestinal causes of ARF will remain important in ARF until structural and sanitary measures (eg, water treatment) are implemented. Educational programs and changes in gynecological attention, focused on controlled medical abortion and contraceptive measures, should be promoted to eradicate other forms of ARF that constitute a plague in Third World countries.

FIGURE 8-17

Evolution of dialysis techniques for acute renal failure (ARF) in Spain. A, The percentages of different modalities of dialysis performed in Spain in the early 1980s. B, The same information obtained a decade. At this latter time, 90% of conventional hemodialysis (HD) was performed using bicarbonate as a buffer. These rates are those of a developed country. In developing countries, dialysis should be performed according to the available facilities and each individual doctor's experience in the different techniques. PD—peritoneal dialysis; CRRT—continuous renal replacement technique; UF—isolated ultrafiltration. (A, Data from the EDTA-ERA Registry [11]; B data from the Madrid ARF Study [1].)

FIGURE 8-18

Serum creatinine (SCr) at hospital admission has diagnostic and prognostic implications for acute renal failure (ARF). A, Of the patients included in an ARF epidemiologic study 39% had a normal SCr concentration (less than 1.5 mg/dL) at hospital admission. It is worth noting that only 22% of the patients had clearly established ARF (SCr greater than 3 mg/dL) when admitted (no acute-on-chronic case was included). Mortality was significantly higher in patients with normal SCr at admission.

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