الفهرس 
Liver Cirrhosis
Clinical manifestations of liver cirrhosisOnly 14 pages are availabe for public view
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Abstract
End-stage liver disease is frequently complicated by renal function disturbances. Cirrhotic patients with renal failure admitted to intensive care units (ICUs) have high mortality rates. So, early detection of Acute Kidney Injury (AKI) in these patients is very important to prevent complication and eventually decreases mortality rate.
Most of the commonly used clinical scoring systems evaluate renal function according to the serum creatinine level which is unable to detect AKI in the early stages where the serum creatinine may be low while GFR is markedly reduced since there may not have been sufficient time for the creatinine to accumulate.
The RIFLE (risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal failure) classification was first proposed by the Acute Dialysis Quality Initiative (ADQI) group at the second ADQI conference in Vicenza, Italy, in May 2002, in an attempt to standardize the study of ARF. The RIFLE criteria classify ARF into three groups (risk, injury, and failure)according to changes in SCr and/or urine output and thus can detect small and early injury that might occur to the kidney.
This study was performed on 100 cirrhotic patients admitted to Intensive Care Unit in the hospital of Theodore Bilharz Research Institute. The objective of this study is to identify the association between hospital mortality and RIFLE criteria in critically ill cirrhotic patient. Other scoring systems, including Child score, SOFA score, MELD score and APACHE II score are also used for comparison with the RIFLE classification. The studied population was classified according to the primary outcome of this study (Hospital Mortality) into two main groups; Survivors and Non-Survivors.
There was statistically insignificant difference between both groups regarding age, gender distribution, DM, HTN and HCC occurance on both groups. The Non-Survivor group had significantly higher serum creatinine level at baseline and during follow up, also higher BUN, serum bilirubin, PT and INR in comparison to Survivor group. The Non-Survivor group had a significantly lower serum sodium level, serum albumin, blood PH and HCO3. There were also statistically insignificant differences between both groups regarding values of ALT, Hb, Hct, WBCs, PLT, PO2 and PCO2.
In this study, 60% of the ICU patients developed AKI; as defined by RIFLE classification; which was associated with increased mortality, compared with those who did not develop AKI. There were 40 Non-ARF patients, 22 RIFLE-R patients, 8 RIFLE-I patients and 30 RIFLE-F patients.
The overall mortality rate in this study was 62%, and is in agreement with previous reports indicating that cirrhotic patients admitted to an ICU have a very poor prognosis. This study identified that RIFLE classification on the first day of ICU admission was prognostically significant variables for critically ill cirrhotic patients. Importantly, even a mild degree of kidney dysfunction, RIFLE class risk or injury, was associated with elevated mortality rate, compared with patients who maintained normal function. In the present study, the hospital mortality rate of ICU patients was significantly higher for AKI patients (Risk, Injury, Failure) versus non-AKI (Non-ARF) patients. We also found that there is stepwise increase in the mortality rate among RIFLE classes (32.5% in Non-ARF group, 68% in RIFLE-R group, 75% in RIFLE-I group and 93% in RIFLE-F group).All scoring systems used in this study were highly predictive of poor outcome in cirrhotic patients at different cut-off points as studied by ROC curve analysis. Analytical results suggest that for critically ill cirrhotic patients, variables estimating the advanced liver diseases superimposed on one episode of bleeding or infection with multiple organs failure and/or changes in GFR and UO criteria are extremely useful prognostically (better than the Child–Pugh and APACHE II scores, SCr on admission or ICU day 1, and UO on ICU day1). The predictive value of the RIFLE classification for mortality in the ICU was examined by logistic regression and receiver operator characteristic curve analysis. The RIFLE-F group showed the worst parameters with regard to APACHE II score, SOFA score and MELD score. Given that the Predictive value of RIFLE classification is as high as that of other scoring systems used in addition to its dependence on only one parameter (changes in serum creatinine from base line), it could be used as a simple and easy tool for prediction of short term prognosis in critically ill patients.
This assay concluded that the development of AKI in critically ill patients has great impact on the hospital mortality and thus implementation of the RIFLE classification to this homogenous group of patients as a scoring system on the 1st day of hospitalization can predict the outcome of these patients especially when combined with other scoring systems like SOFA and APACHE scores.
In this light, the RIFLE classification appears to be a simple and useful clinical tool, using readily available clinical data, to detect and stratify the severity of AKI, and predict hospital mortality in critically ill patients.