Estimated glomerular filtration rate predicts 30-day mortality in medical emergency departments: Results of a prospective multi-national observational study.

BACKGROUND: Renal failure is common in patients seeking help in medical emergency departments. Decreased renal function is associated with increased mortality in patients with heart failure or sepsis. In this study, the association between renal function (reflected by estimated glomerular filtration rate (eGFR) at the time of admission) and clinical outcome was evaluated. METHODS/OBJECTIVES: Data was used from a prospective, multi-national, observational cohort of patients treated in three medical emergency departments of tertiary care centers. The eGFR was calculated from the creatinine at the time of admission (using the Chronic Kidney Disease-Epidemiology Collaboration equation,CKD-EPI). Uni- and multivariate regression models were used for eGFR and 30-day mortality, in hospital mortality, length of stay and intensive care unit admission rate. RESULTS: 6983 patients were included. The 30-day mortality was 1.8%, 3.5%, 6.9%, 11.1%, 13.6%, and 14.2% in patients with eGFR of above 90, 60-89, 45-59, 30-44, 15-29, and <15 ml/min/1.73m2, respectively. Using multivariate regression, the adjusted odds ratio (OR) was 2.31 (for 15-29 ml/min/1.73m2, 95% confidence interval 1.36 to 3.90, p = 0.002) and 3.73 (for eGFR <15ml/min/1.73m2 as compared to >90 ml/min/1.73m2, 95% CI 2.04 to 6.84, p<0.001). For 10 ml/min/1.73m2 decrease in eGFR the OR for the 30-day mortality was 1.15 (95% CI1.09 to 1.22, p<0.001).The eGFR was also significantly associated with in-hospital mortality, the percentage of ICU-admissions, and with a longer hospital stay. No association was found with hospital readmission within 30 days. As limitations, only eGFR at admission was available and the number of patients on hemodialysis was unknown. CONCLUSION: Reduced eGFR at the time of admission is a strong and independent predictor for adverse outcome in this large population of patients admitted to medical emergency departments.

Prediction of mortality using quantification of renal function in acute heart failure.

BACKGROUND: Renal function, as quantified by the estimated glomerular filtration rate (eGFR), is a predictor of death in acute heart failure (AHF). It is unknown whether one of the clinically-available serum creatinine-based formulas to calculate eGFR is superior to the others for predicting mortality. METHODS AND RESULTS: We quantified renal function using five different formulas (Cockroft-Gault, MDRD-4, MDRD-6, CKD-EPI in patients<70 years, and BIS-1 in patients≥70 years) in 1104 unselected AHF patients presenting to the emergency department and enrolled in a multicenter study. Two independent cardiologists adjudicated the diagnosis of AHF. The primary endpoint was the accuracy of the five eGFR equations to predict death as quantified by the time-dependent area under the receiver-operating characteristics curve (AUC). The secondary endpoint was the accuracy to predict all-cause readmissions and readmissions due to AHF. In a median follow-up of 374 days (IQR: 221 to 687 days), 445 patients (40.3%) died. eGFR as calculated by all equations was an independent predictor of mortality. The Cockcroft-Gault formula showed the highest prognostic accuracy (AUC 0.70 versus 0.65 for MDRD-4, 0.55 for MDRD-6, and 0.67 for the combined formula CKD-EPI/BIS-1, p<0.05). These findings were confirmed in patients with varying degrees of renal function and in three vulnerable subgroups: women, patients with severe left ventricular dysfunction, and the elderly. The prognostic accuracy for readmission was poor for all equations, with an AUC around 0.5. CONCLUSIONS: Calculating eGFR using the Cockcroft-Gault formula assesses the risk of mortality in patients with AHF more accurately than other commonly used formulas.

Triage with the French Emergency Nurses Classification in Hospital scale: reliability and validity.

INTRODUCTION: The FRench Emergency Nurses Classification in Hospital scale (FRENCH) is the first French triage tool for patients visiting an emergency department. The FRENCH scale modified in 2006, based on about 100 determinants (complaints, signs, and vital parameters), allows the triage of adult patients according to five increasing levels of complexity/severity. We evaluated FRENCH version 2 (v.2) in our emergency department. METHODS: Reliability was evaluated on 300 prospectively selected patient records (50% of patients admitted). Three nurse pairs, blinded with respect to the original triage, retrospectively and independently triaged 100 patients. Interrater reliability within the pairs was measured with a weighted kappa. Validity was evaluated on all triaged patients (N=941) over 14 days by studying the relationships between the original triage category assigned by the triage nurse and resource consumption and the admission rate. RESULTS: Interrater reliability was good [K=0.77 (95% confidence interval: 0.71-0.82)]. Distribution of the 941 patients included in the validation study (18% of whom were admitted) was as follows [n (%)]: 2 (0.2), 33 (4), 258 (27), 451 (48), and 197 (21) for a triage from 1 to 5, respectively. Resource consumption correlated well with case severity as assessed by the triage category (R=-0.643, P<0.0001). Finally, the area under the receiver operating characteristic curve for prediction of admission as a function of triage was 0.858 (95% confidence interval: 0.831-0.885). CONCLUSION: FRENCH v.2 is a reliable and validated triage tool to predict the complexity/severity of a patient in our emergency department.

Urinary acetoacetate or capillary beta-hydroxybutyrate for the diagnosis of ketoacidosis in the Emergency Department setting.

OBJECTIVES: We compared the semiquantitative measurement of acetoacetate using urinary dipsticks with the bedside quantitative fingerprick measurement of the principal ketone bodies 3-beta-hydroxybutyrate, for the diagnosis of ketoacidosis. METHODS: This is a one year retrospective study of patients who presented with hyperglycemia levels of 250 mg/l or greater in the Emergency Department setting. We compared the sensitivity, specificity, and predictive value of ketonuria and ketonemia for the diagnosis of ketoacidosis (urine or blood ketone bodies, blood bicarbonates <20 mmol/l, anion gap >16 meq/l) in a sample of patients for whom the levels of ketone bodies in the blood and urine as well as serum electrolytes were available. RESULTS: We studied 355 hyperglycemic patients. The median time between arrival and dipstick testing was 21 min, and was greater than 2 h in more than 10% of cases. Comparison between ketonuria and ketonemia was performed in 173 patients (6% with diabetic ketoacidosis). Ketonuria equal to or less than one cross or a 3-beta-hydroxybutyrate value lower than 3 mmol/l enabled ketoacidosis to be excluded (negative predictive value 100%). At two-cross cutoff points for ketonuria and at the 3 mmol/l cutoff point for ketonemia, the two tests had the same sensitivity (100%), but the specificity of 3-beta-hydroxybutyrate (94%) was significantly higher (P<0.0001) than that of ketonuria (77%). The best positive predictive value for ketonemia was obtained at the 5 mmol/l cutoff point (100%) and for ketonuria at the three-cross cutoff point (26%). At the three-cross cutoff point for ketonuria and at the 5 mmol/l cutoff point for ketonemia, the two tests had the same negative likelihood ratio (0.1), but the positive likelihood ratio of 3-beta-hydroxybutyrate (infinite) was higher than that of ketonuria. CONCLUSION: The measurement of 3-beta-hydroxybutyrate in capillary blood is faster and more effective than the use of dipsticks in the urine to detect ketoacidosis in the Emergency Department setting.