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Early nephrologist referral of ICU patients with acute renal failure is associated with a reduced risk of death

From 45 to 70 percent of patients who suffer acute renal failure in the intensive care unit (ICU) die. Patients with delayed consultation with a nephrologist (48 hours or more from the first ICU day) are more likely to die or have longer ICU or hospital stays than those who see a nephrologist relatively early (less than 48 hours from the first ICU day). That's the conclusion of a study supported in part by the Agency for Healthcare Research and Quality (HS06466).

Researchers led by Ravindra L. Mehta, M.D., of the University of California, San Diego, explored associations among timing of nephrology consultation and in-hospital death, length of hospital and ICU stay, and recovery of renal function (not needing dialysis at discharge) in 215 patients admitted to the ICU with acute renal failure at four U.S. teaching hospitals.

Delayed consultation (28 percent of patients) was associated with increased mortality among patients receiving dialysis (74 vs. 49 percent) and those not receiving dialysis (53 vs. 22 percent), as well as longer hospital stays (median of 19 vs. 16 days) and ICU stays (17 vs. 6 days). There was no association between delayed consultation and eventual dialysis (69 vs. 67 percent in delayed vs. non-delayed consultation), although the time to initiation of dialysis was prolonged relative to ICU admission (median of 6 vs. 1 day).

The association between delayed consultation and death was weakened after adjusting for other factors (e.g., age, sex, urine output, liver failure, and other variables) and was no longer significant. Thus, it's not clear whether the consultation itself was responsible for the decrease in mortality risk. The results could still be explained by residual confounding factors, according to Dr. Mehta. Overall, the researchers could not determine whether these findings reflected specific benefits afforded to patients following consultation, adverse effects of delayed recognition of acute renal failure (and perhaps delayed consultation), residual confounding, or selection bias.

See "Nephrology consultation in acute renal failure: Does timing matter?" by Dr. Mehta, Brian McDonald, M.D., Francis Gabbai, M.D., and others, in the October 15, 2002, American Journal of Medicine 113, pp. 456-461.

Editor's Note: A second article by these researchers describes the data collection effort (also supported by AHRQ grant HS06466) for this study. See "Diuretics, mortality, and nonrecovery of renal function in acute renal failure," by Dr. Mehta, Maria T. Pascual, R.N., M.P.H., Sharon Soroko, M.S., and others in the November 27, 2002, Journal of the American Medical Association 288(20), pp. 2547-2553.

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