Regional microvascular function and vascular reactivity in patients with different degrees of multiple organ dysfunction syndrome

Microcirculation during surgery

Throughout the long history of surgery, there has been great advancement in the hemodynamic management of surgical patients. Traditionally, hemodynamic management has focused on macrocirculatory monitoring and intervention to maintain appropriate oxygen delivery. However, even after optimization of macro-hemodynamic parameters, microcirculatory dysfunction, which is related to higher postoperative complications, occurs in some patients. Although the clinical significance of microcirculatory dysfunction has been well reported, little is known about interventions to recover microcirculation and prevent microcirculatory dysfunction. This may be at least partly caused by the fact that the feasibility of monitoring tools to evaluate microcirculation is still insufficient for use in routine clinical practice. However, considering recent advancements in these research fields, with more popular use of microcirculation monitoring and more clinical trials, clinicians may better understand and manage microcirculation in surgical patients in the future. In this review, we describe currently available methods for microcirculatory evaluation. The current knowledge on the clinical relevance of microcirculatory alterations has been summarized based on previous studies in various clinical settings. In the latter part, pharmacological and clinical interventions to improve or restore microcirculation are also presented.

Perfusion index for assessing microvascular reactivity in septic shock after fluid resuscitation

Objective

Microcirculation disturbances are implicated in the prognosis of septic shock. Microvascular hyporesponsiveness can be assessed by an oximetry-derived perfusion index and reactive hyperemia. Using this perfusion index, we investigated reactive hyperemia and its relationship with peripheral perfusion and clinical-hemodynamic parameters in septic shock.

Methods

Eighty-two patients were evaluated: 47 with septic shock and 35 controls. Tests were performed within 24 hours after admission. The perfusion index was evaluated before and after a 3-min blood flow occlusion using a time-response analysis for 5 min. The perfusion index was also evaluated in the hyperemic phases and was mainly derived by mechanosensitive (ΔPI_0-60) and metabolic mechanisms (ΔPI_60-120). Correlation tests were performed between reactive hyperemia and clinical-hemodynamic data.

Results

Reactive hyperemia measured by the perfusion index was significantly lower in patients with septic shock, but this was only observed for the first 45 seconds after cuff-deflation. In the remaining period, there were no statistical differences between the groups. The peaks in the perfusion index were similar between groups, although the peak was reached more slowly in the septic group. Values of ΔPI_0-60 were lower in shock [01% (-19% - -40%) versus 39% (6% - 75%); p = 0.001]. However, ΔPI_60-120 was similar between the groups [43% (18% - 93%) versus 48% (18% - 98%); p = 0.58]. The time-to-peak of the perfusion index was correlated positively with the SOFA scores and negatively with C-reactive protein; the peak of the perfusion index was positively correlated with vasopressor doses; and the ΔPI_60-120 values were positively correlated with C-reactive protein and vasopressor doses. No other significant correlations occurred.

Conclusions

This perfusion index-based study suggests that septic shock promotes initial peripheral vascular hyporesponsiveness and preserves posterior vascular reactivity to a considerable degree. These results demonstrate a time-dependent peripheral hyperemic response and a significant ischemic reserve in septic shock.

Cutaneous Microvascular Blood Flow and Reactivity in Hypoxia

As is known, hypoxia leads to an increase in microcirculatory blood flow of the skin in healthy volunteers. In this pilot study, we investigated microcirculatory blood flow and reactive hyperemia of the skin in healthy subjects in normobaric hypoxia. Furthermore, we examined differences in microcirculation between hypoxic subjects with and without short-term acclimatization, whether or not skin microvasculature can acclimatize. Fourty-six healthy persons were randomly allocated to either short-term acclimatization using intermittent hypoxia for 1 h over 7 days at an FiO₂ 0.126 (treatment, n = 23) or sham short-term acclimatization for 1 h over 7 days at an FiO₂ 0.209 (control, n = 23). Measurements were taken in normoxia and at 360 and 720 min during hypoxia (FiO₂ 0.126). Microcirculatory cutaneous blood flow was assessed with a laser Doppler flowmeter on the forearm. Reactive hyperemia was induced by an ischemic stimulus. Measurements included furthermore hemodynamics, blood gas analyses and blood lactate. Microcirculatory blood flow increased progressively during hypoxia (12.3 ± 7.1–19.0 ± 8.1 perfusion units; p = 0.0002) in all subjects. The magnitude of the reactive hyperemia was diminished during hypoxia (58.2 ± 14.5–40.3 ± 27.4 perfusion units; p = 0.0003). Short-term acclimatization had no effect on microcirculatory blood flow. When testing for a hyperemic response of the skin's microcirculation we found a diminished signal in hypoxia, indicative for a compromised auto-regulative circulatory capacity. Furthermore, hypoxic short-term acclimatization did not affect cutaneous microcirculatory blood flow. Seemingly, circulation of the skin was unable to acclimatize using a week-long short-term acclimatization protocol. A potential limitation of our study may be the 7 days between acclimatization and the experimental test run. However, there is evidence that the hypoxic ventilatory response, an indicator of acclimatization, is increased for 1 week after short-term acclimatization. Then again, 1 week is what one needs to get from home to a location at significant altitude.

A systematic review of human and veterinary applications of noninvasive tissue oxygen monitoring

OBJECTIVE

To describe the methodology for and utilization of tissue oxygen monitoring by near infrared spectroscopy, and to review the current literature on the use of this monitoring modality in human and veterinary settings.

DATA SOURCES

Scientific reviews and original research found using the PubMed and CAB Abstract search engines with the following keywords: "tissue oxygen monitoring," "near-infrared tissue spectroscopy," and "tissue oxygen saturation (StO2 )."

HUMAN DATA SYNTHESIS

Tissue oxygen monitors have been evaluated in a wide variety of human clinical applications including trauma and triage, surgery, sepsis, and septic shock, and early goal-directed therapy. StO2 more rapidly identifies occult shock in human patients compared to traditional methods, which can lead to earlier intervention in these patients.

VETERINARY DATA SYNTHESIS

Veterinary studies involving tissue oxygen monitoring are limited, but the technology may have utility for identification of hemorrhagic shock earlier than changes in base excess, blood lactate concentration, or other traditional perfusion parameters.

CONCLUSION

Tissue oxygen monitoring is most commonly performed utilizing a noninvasive, portable monitor, which provides real-time, continuous, repeatable StO2 measurements. A decline in StO2 is an early indicator of shock in both human and veterinary patients. Low StO2 values in human patients are associated with increased morbidity, mortality, and length of hospitalization, as well as the development of multiple organ system dysfunction and surgical site infections.

The association of near infrared spectroscopy-derived StO2 measurements and biomarkers of endothelial activation in sepsis

Near infrared spectroscopy (NIRS) may be utilized in conjunction with a vascular occlusion test to quantify a tissue bed's ability to re-oxygenate by measuring continuous tissue oxygen saturation recovery rate. We hypothesize that NIRS recovery slope will be associated with expression of endothelial biomarkers, thus, making it a feasible bedside surrogate for assessing endothelial activation/dysfunction in patients with sepsis. A secondary analysis of a prospective, multicenter, observational study was done on a convenience sample of adult patients at four university emergency departments consisting of patients with septic shock, sepsis without shock and patients without infection. At enrollment we measured the NIRS-derived measurements and collected plasma to assay biomarkers of endothelial activation. 186 patients were enrolled in the study. The mean age was 63 (± 16) years with 60 % male gender. Univariate analysis assessing the linear relationship between the recovery slope with endothelial biomarkers, found a weak but statistical significant association between NIRS recovery slope and soluble fms-like tyrosine kinase-1 (sFLT-1) and tPAI-1 (r = -0.08, p < 0.0001 and r = -0.06, p = 0.002). When adjusting for diabetes, age and sequential organ failure assessment score at enrollment, only sFLT-1 persisted having a statistically significant association (r = -0.04, p = 0.01). We found a weak, but statistically significant relationship between NIRS-derived measurements and biomarkers of endothelial activation/dysfunction in patients with sepsis. This study fails to support the use of NIRS-derived measurements as a clinical or research tool to identify patients with endothelial cell activation/dysfunction and informs researchers that this is not a robust option for identifying this lesion at the bedside.

Hemoconcentration caused by microvascular dysfunction after blast injuries to the chest and abdomen of rabbits

BACKGROUND

One of the important causes of death after blast injuries is reduced blood volume, which typically results from hemorrhage but may also result from nonhemorrhagic causes. Hemoconcentration is one such alternate cause of reduced blood volume, but its mechanism is unclear. Because blood is condensed after chest-abdomen blast injuries in rabbits, a series of experiments was conducted to clarify this phenomenon.

METHODS

Chest-abdomen blast injuries from different distances (10 cm, 15 cm, 20 cm, and 30 cm) were induced in male rabbits. ¹²⁵I-albumin was injected into the blood, and its concentration in different organs was tested at various times after the blast injury. The residual radioactivity in different organs and the pre- and postinjury hematocrit was also tested. Histologic evaluations were conducted to detect the injuries to the different organs.

RESULTS

After injury, ¹²⁵I-albumin leaked out of the vessels into organs such as the lungs, liver, and kidneys. The volume of leakage was highly correlated with the distance from the blast. At a distance of 10 cm, the rate of leakage was the highest. The hematocrit was higher for 30 minutes and 3 hours after the injury; 6 hours after the injury, the hematocrit began to return to normal levels. The residual radioactivity of ¹²⁵I-albumin was increased in the heart, brain, lungs, and kidneys, especially at a distance of 10 cm. Histologic evaluation results showed that the cells, microvessels, and organelles of the microvessel endothelial cells in the vital organs, such as the kidneys, were damaged.

CONCLUSION

The preliminary results indicate that microvessels in the lungs and kidneys are the key targets of blast injuries. The damage to the microvessels leads to leakage of albumin, which is one of the important reasons for hemoconcentration in the absence of active bleeding after a blast injury. Treatment should be initiated in victims of blast injuries who are severely wounded as soon as possible after the explosion during the earliest stages of the injury to avoid the occurrence of shock or other severe complications.

Techniques to assess tissue oxygenation in the clinical setting

The microcirculation plays an essential role in health and disease. Microvascular perfusion can be assessed directly using laser Doppler flowmetry and various imaging techniques or indirectly using regional capnometry and measurement of indicators of mismatch between oxygen delivery and oxygen consumption or indices of disturbed cellular oxygen utilization. Assessment of microvascular oxygen availability implies measurement of oxygen pressure or measurement of hemoglobin oxygen saturation. Microvascular function is assessed using other methods, including venous plethysmography. In this paper, I review current knowledge concerning assessment of the microcirculation with special emphasis on methods that could be used at the bedside.

Recombinant activated protein C treatment improves tissue perfusion and oxygenation in septic patients measured by near-infrared spectroscopy

INTRODUCTION

The purpose was to test the hypothesis that muscle perfusion, oxygenation, and microvascular reactivity would improve in patients with severe sepsis or septic shock during treatment with recombinant activated protein C (rh-aPC) (n = 11) and to explore whether these parameters are related to macrohemodynamic indices, metabolic status or Sequential Organ Failure Assessment (SOFA) score. Patients with contraindications to rh-aPC were used as a control group (n = 5).

MATERIALS AND METHODS

Patients were sedated, intubated, mechanically ventilated, and hemodynamically monitored with the PiCCO system. Tissue oxygen saturation (StO2) was measured using near-infrared spectroscopy (NIRS) during the vascular occlusion test (VOT). Baseline StO2 (StO2 baseline), rate of decrease in StO2 during VOT (StO2 downslope), and rate of increase in StO2 during the reperfusion phase were (StO2 upslope) determined. Data were collected before (T0), during (24 hours (T1a), 48 hours (T1b), 72 hours (T1c) and 96 hours (T1d)) and 6 hours after stopping rh-aPC treatment (T2) and at the same times in the controls. At every assessment, hemodynamic and metabolic parameters were registered and the SOFA score calculated.

RESULTS

The mean +/- standard deviation Acute Physiology and Chronic Health Evaluation II score was 26.3 +/- 6.6 and 28.6 +/- 5.3 in rh-aPC and control groups, respectively. There were no significant differences in macrohemodynamic parameters between the groups at all the time points. In the rh-aPC group, base excess was corrected (P < 0.01) from T1a until T2, and blood lactate was significantly decreased at T1d and T2 (2.8 +/- 1.3 vs. 1.9 +/- 0.7 mmol/l; P < 0.05). In the control group, base excess was significantly corrected at T1a, T1b, T1c, and T2 (P < 0.05). The SOFA score was significantly lower in the rh-aPC group compared with the controls at T2 (7.9 +/- 2.2 vs. 12.2 +/- 3.2; P < 0.05). There were no differences between groups in StO2 baseline. StO2 downslope in the rh-aPC group decreased significantly at all the time points, and at T1b and T2 (-16.5 +/- 11.8 vs. -8.1 +/- 2.4%/minute) was significantly steeper than in the control group. StO2 upslope increased and was higher than in the control group at T1c, T1d and T2 (101.1 +/- 62.1 vs. 54.5 +/- 23.8%/minute) (P < 0.05).

CONCLUSIONS

Treatment with rh-aPC may improve muscle oxygenation (StO2 baseline) and reperfusion (StO2 upslope) and, furthermore, rh-aPC treatment may increase tissue metabolism (StO2 downslope). NIRS is a simple, real-time, non-invasive technique that could be used to monitor the effects of rh-aPC therapy at microcirculatory level in septic patients.

Muscle StO2 in critically ill patients

PURPOSE OF REVIEW

Tissue hypoperfusion is a common pathophysiologic process leading to multiple-organ dysfunction and death. An important goal of hemodynamic monitoring is the early detection of inadequate tissue perfusion and oxygenation. The use of simple, noninvasive monitoring techniques has the advantage of facilitating earlier initiation of therapy. Near-infrared spectroscopy has emerged in recent years as a tool for monitoring peripheral oxygenation (StO2) in various tissues, including muscle. Here, we review our current knowledge about the applicability, usefulness, and limitations of near-infrared spectroscopy as a technique to evaluate muscle oxygenation in acutely ill patients.

RECENT FINDINGS

StO2 may be an appropriate measure for early resuscitation of critically ill patients, especially in those with low cardiac output states or after severe trauma. Its usefulness in sepsis is less well established. However, by inducing an occlusion stress, a variety of dynamic variables can be measured to assess local metabolic demand and microvascular reactivity. Several recent studies have shown that profound alterations of these near-infrared-spectroscopy-derived dynamic variables are frequent in patients with severe sepsis and these alterations are associated with a poor outcome.

SUMMARY

Near-infrared spectroscopy provides a noninvasive measure of muscle oxygen metabolism and microvascular dysfunction in critically ill patients. It may be useful to guide the management of critically ill patients.

Systemic and hepatosplanchnic macro- and microcirculatory dose response to arginine vasopressin in endotoxic rabbits

OBJECTIVE

Arginine vasopressin (AVP) is being used increasingly to treat vasodilatory hypotension, although its effects on hepatosplanchnic perfusion have been debated.

DESIGN

Prospective study in a university-based experimental research laboratory.

SUBJECTS AND INTERVENTIONS

We compared the effect of AVP on systemic, gut, and liver blood flow in anesthetized and ventilated rabbits given either saline or endotoxin. Incremental i.v. boluses of AVP ranging from 1 to 1,000[Symbol: see text]ng were administered 90[Symbol: see text]min post-endotoxin or saline.

MEASUREMENTS AND RESULTS

Endotoxin induced a shock state with a transient decrease of mesenteric artery blood flow velocity (pulsed Doppler, in centimeters per second, V(mes)) but had no effect on liver surface microcirculation (laser Doppler in TPU, MicroFl(liver)). Gut microcirculatory (MicroFl(gut)) changes became independent of mean arterial pressure (MAP) after endotoxin. In control rabbits (n = 5), increasing doses of AVP elevated MAP but reduced aortic blood flow (pulsed Doppler, VAo), V(mes), and MicroFl(gut) (p < 0.05). In endotoxic animals (n = 6), AVP produced a similar rise in MAP (p < 0.05), while V(mes) and MicroFl(gut) only decreased for AVP doses above 100[Symbol: see text]ng (p < 0.05). Liver microcirculation was only minimally affected by AVP, although significantly, both in control and endotoxin animals.

CONCLUSION

Preservation of mesenteric blood flow as well as gut and liver microcirculation, with therapeutic doses of AVP during endotoxemia, supports its use as a hemodynamic agent during septic shock.

EVIDENCE FOR INTESTINAL AND LIVER EPITHELIAL CELL INJURY IN THE EARLY PHASE OF SEPSIS

The development of sepsis and multiple organ failure are important determinants of the outcome in critically ill patients. Hepatosplanchnic hypoperfusion and resulting intestinal and hepatic cell damage have been implicated as central events in the development of sepsis and multiple organ failure. Our aim was to study (1) the relation between intramucosal perfusion and intestinal and hepatic cell damage in an early phase of sepsis and (2) the correlation of these parameters with mortality. Two groups of patients were consecutively selected after intensive care unit admission: patients with postoperative abdominal sepsis (n = 19) and patients with pneumonia-induced sepsis (n = 9). Intramucosal perfusion was assessed by gastric tonometry (Pr-aCO2 gap, Pico2). Circulating levels of intestinal fatty acid binding protein (I-FABP) and liver (L)-FABP were used as markers for intestinal and hepatic cellular damage, respectively. Outcome was determined on day 28. Pr-aCO2 gap correlated with I-FABP (Pearson r = 0.56; P < 0.001) in all patients, and gastric mucosal Pico2 correlated significantly with I-FABP (r = 0.57; P = 0.001) in patients with abdominal sepsis. At intensive care unit admission, nonsurvivors had significantly higher I-FABP and L-FABP values than survivors (I-FABP: 325 vs. 76 pg/mL, P < 0.04; L-FABP: 104 vs. 31 ng/mL, P < 0.04). Patients with abdominal sepsis was especially responsible for high-admission I-FABP and L-FABP levels in nonsurvivors (I-FABP: 405 vs. 85 pg/mL, P < 0.04; L-FABP: 121 vs. 59 ng/mL, P < 0.04). This study shows that splanchnic hypoperfusion correlates with intestinal mucosal damage, and that elevated plasma levels of I-FABP and L-FABP are associated with a poor outcome in critically ill patients with abdominal sepsis.

Microcirculatory function monitoring at the bedside--a view from the intensive care

Microcirculatory dysfunction plays a key role in the pathophysiology of various disease states and may consequently impact patient outcome. Until recently, the evaluation of the microcirculation using different measurement techniques has been mostly limited to animal and human research. With technical advances, microcirculatory monitoring nowadays becomes more and more available for application in clinical praxis. Unfortunately, measurements within the microcirculation are mostly limited to easily accessible surfaces, such as skin, muscle and tongue. Due to major differences in the physiologic regulation of microcirculatory blood flow and in metabolism between organs and even within different tissues in one organ, the clinical importance of regional microcirculatory measurements remains to be determined. In addition, technical methods available demonstrate large differences in the measured parameters and sampling volume, making interpretation of data even more difficult. Nonetheless, the monitoring of the microcirculation may, ahead of time, alert physicians that tissue oxygen supply becomes compromised and it may lead to a better understanding of basic pathophysiological aspects of disease. In the present review, we describe available non-invasive microcirculatory measurement techniques which can be applied clinically at the bedside. After a short discussion of physiologic and pathophysiologic basics related to microcirculatory monitoring, the measuring principles, applications, strengths and limitations of different monitoring systems are discussed.

Oscillation frequency of skin microvascular blood flow is associated with mortality in critically ill patients

BACKGROUND

Microcirculatory dysfunction has been hypothesized to play a key role in the pathophysiology of multiple organ failure and, consequently, patient outcome. The objective of this study was to investigate the differences in reactive hyperemia response and oscillation frequency in surviving and non-surviving patients with multiple organ dysfunction syndrome.

METHODS

Twenty-nine patients (15 survivors; 14 non-survivors) with two or more organ failures were eligible for study entry. All patients were hemodynamically stabilized, and demographic and clinical data were recorded. A laser Doppler flowmeter was used to measure the cutaneous microcirculatory response. Reactive hyperemia and oscillatory changes in the Doppler signal were measured during 3 min before and after a 5-min period of forearm ischemia.

RESULTS

Non-survivors demonstrated a significantly higher multiple organ dysfunction score when compared with survivors (P= 0.004). Norepinephrine administration was higher in non-survivors (P= 0.018). Non-survivors had higher arterial lactate levels (P= 0.046), decreased arterial pH levels (P= 0.001) and decreased arterial Po(2) values (P= 0.013) when compared with survivors. A higher oscillation frequency of the skin microvasculature at rest (P= 0.033) and after an ischemic stimulus (P= 0.009) was observed in non-survivors. The flow motion frequency observed in reactive hyperemia was associated with the severity of multiple organ dysfunction (P= 0.009) and, although not statistically significant, with the arterial lactate concentration (P= 0.052).

CONCLUSION

Increased skin microvascular oscillation frequency at rest and in the hyperemic state after an ischemic stimulus is associated with increased mortality in patients suffering from multiple organ dysfunction. The underlying mechanism could be a response of the skin microvasculature to an impaired oxygen utilization of the skin tissue.

The prognostic value of muscle StO2 in septic patients

OBJECTIVE

To quantify sepsis-induced alterations in changes in muscle tissue oxygenation (StO(2)) after an ischemic challenge using near-infrared spectroscopy (NIRS), and to test the hypothesis that these alterations are related to outcome.

DESIGN

Prospective study.

SETTING

Thirty-one-bed, university hospital Department of Intensive Care.

PATIENTS

Seventy-two patients with severe sepsis or septic shock, 18 hemodynamically stable, acutely ill patients without infection, and 18 healthy volunteers.

INTERVENTIONS

Three-minute occlusion of the brachial artery using a cuff inflated 50[Symbol: see text]mmHg above systolic arterial pressure.

MEASUREMENTS AND MAIN RESULTS

Thenar eminence StO(2) was measured continuously by NIRS before (StO(2)baseline), during, and after the 3-min occlusion. Changes in StO(2) were assessed by the slope of increase in StO(2) during the first 14 s following the ischemic period and by the difference between the maximum StO(2) and StO(2)baseline (Delta). The slope was lower in septic patients than in controls and volunteers [2.3 (1.3-3.6), 4.8 (3.5-6.0), and 4.7 (3.2-6.3) %/s, p < 0.001]. Delta was also significantly lower in septic patients than in the other groups. Slopes were lower in septic patients with than without shock [2.0 (1.2-2.9) vs 3.2 (1.8-4.5) %/s, p < 0.05]. In 52 septic patients, in whom the slope was obtained every 24 h for 48 h, slopes were higher in survivors than in non-survivors and tended to increase in survivors but not in non-survivors.

CONCLUSIONS

Altered recovery in StO(2) after an ischemic challenge is frequent in septic patients and more pronounced in the presence of shock. The presence and persistence of these alterations in the first 24[Symbol: see text]h of sepsis are associated with worse outcome.

Making sense of multiple organ dysfunction syndrome

Despite recent advances in critical care medicine, caring for patients with MODS remains one of the most challenging experience a critical care can encounter. New therapies that current exist and continue to be developed contribute to successful outcomes for patients with MODS, but there is no substitute for prevention and early intervention for persons at risk for developing MODS. Early and subtle changes in the patient who is at risk and has endured an initial insult can make a great difference in the patient's outcome and chances of mortality. Goal-directed therapy, supportive management, as well as an understanding of the inflammatory process are key to decreasing the mortality rate among patients with MODS.

Hospital-acquired and community-acquired acute renal failure in hospitalized Chinese: a ten-year review

OBJECTIVES

To investigate the difference between hospital-acquired acute renal failure (HA-ARF) and community-acquired acute renal failure (CA-ARF) in hospitalized Chinese.

METHODS

The diagnosis of ARF in Peking University Third Hospital from January 1994 to December 2003 was reconfirmed and subdivided into AC-ARF and HA-ARF. Data of epidemiology, etiology, prognosis, and associated factors were analyzed. Single-variable analysis and multivariate logistic regression analyses were performed to investigate the correlation between clinical features and prognosis respectively. Results among 205 reconfirmed CA-ARF had a predominance of 59.5%, but HA-ARF demonstrated an increase by 1.06 during the last five years (p = 0.003). In all, 70.5% CA-ARF was diagnosed in internal medicine with 45.9% in department of nephrology, whereas 59.1% HA-ARF was diagnosed in surgical department with 51.8% in ICU. Distribution difference among departments was significant (p < 0.01). Further, 90.2% CA-ARF was associated with a single factor, while 36.1% of HA-ARF had two or more causes (p < 0.01). Also, 26.5% HA-ARF and 18.9% CA-ARF was drug-associated (p > 0.05) while 24.1% HA-ARF and 12.3% CA-ARF was infection-associated (p < 0.01). HA-ARF vs. CA-ARF was 62.7% vs. 23.0% in mortality (p < 0.01), 0.54 +/- 0.24 vs. 0.27 +/- 0.18 in ATI-ISS index (p < 0.01) and 19.6 +/- 4.9 vs. 15.7 +/- 5.6 in APACHE II scores (p < 0.01). MODS and SIRS were common independent predictors with oliguria for HA-ARF and advanced age for CA-ARF, respectively.

CONCLUSIONS

In hospitalized Chinese during the last ten years, CA-ARF was still predominant with simpler cause and lower mortality, whereas HA-ARF was increasing with more complicated cause and higher mortality.