|Year : 2018 | Volume
| Issue : 2 | Page : 60-65
Etiological variability affecting the clinical outcomes of patients admitted with acute kidney injury in a tertiary care hospital
Maniyar Iqbal Anvar1, Bellara Raghavendra2
1 Department of Nephrology, Vijayanagar Institute of Medical Sciences, Ballari, Karnataka, India
2 Department of Community Medicine, Vijayanagar Institute of Medical Sciences, Ballari, Karnataka, India
|Date of Web Publication||11-Oct-2018|
Dr. Maniyar Iqbal Anvar
Department of Nephrology, Vijayanagar Institute of Medical Science, Ballari - 583 104, Karnataka
Source of Support: None, Conflict of Interest: None
Objectives: The objectives are to study the clinical profile of patients admitted with acute kidney injury (AKI) and to study the determinants of the outcomes of patients with AKI. Subjects and Methods: The study was done in setting of tertiary care hospital in Department of Nephrology. It is a prospective observational study. A total of 220 patients who were admitted with community AKI in a tertiary care hospital were evaluated, and data were collected and analyzed. Patients were evaluated and followed up and if indicated were dialyzed until recovery. Primary outcomes were in-hospital mortality, complete recovery, and dialysis dependency at 3 months. Apart from these etiological profile, mortality of patients with various etiology, their RIFLE staging was assessed. Results: of 220 patients studied, 191 (86.81%) survived and 29 (13.19%) expired, 93 (42.27%) patients required dialysis and 123 (57.7%) did not require dialysis with oligoanuria being the most common (24.5%) indication for dialysis and gastroenteritis was the most common etiology of AKI in 60 (27.3%) reflecting the high incidence of disease in community, followed by sepsis 31 (14.1%), pyelonephritis 27 (12.3%), and snakebite and obstetrics 19 (8.6%) each. Among patients who died, patients with sepsis had highest mortality 11 (35.5%) and gastroenteritis and acute febrile illness had least mortality (1.7% and 0%), respectively, majority of patients (59.5%) were in RIFLE Stage 3 and they had the highest mortality 23 (17.6%). A significant association was observed between the etiology and mortality (P < 0.005). Conclusions: We conclude that underlying cause of AKI is important determinant of the clinical outcome where we found that patients with gastroenteritis had better outcome than other etiology of AKI.
Keywords: Acute kidney injury, gastroenteritis, mortality, outcome
|How to cite this article:|
Anvar MI, Raghavendra B. Etiological variability affecting the clinical outcomes of patients admitted with acute kidney injury in a tertiary care hospital. J Integr Nephrol Androl 2018;5:60-5
|How to cite this URL:|
Anvar MI, Raghavendra B. Etiological variability affecting the clinical outcomes of patients admitted with acute kidney injury in a tertiary care hospital. J Integr Nephrol Androl [serial online] 2018 [cited 2019 Sep 18];5:60-5. Available from: http://www.journal-ina.com/text.asp?2018/5/2/60/243123
| Introduction|| |
Acute kidney injury (AKI) is a complex syndrome associated with varied pathophysiology and several etiologic factors. AKI occurs in a variety of settings with clinical manifestations ranging from a minimal elevation of serum creatinine to anuric kidney failure.,, AKI is present in approximately 5% of hospitalized patients and is associated with mortality (range 20%–60%) The reported incidence of AKI is widely variable in different parts of the world. Whereas in the developed world, AKI is seldom community acquired. In the developing world, a number of cases of AKI are community acquired. Most common causes of AKI are predominantly caused by communicable diseases such as acute diarrheal diseases, malaria, snakebites, insect sting, intravascular hemolysis due to septicemia, chemical poisoning such as copper sulfate, vasmol, pregnancy, and leptospirosis, cause 40% of AKI in India. Since AKI acquired in community differs in epidemiology and clinical presentation and patients generally present with single-organ involvement, the mortality differs from AKI acquired in the hospital and Intensive Care Unit (ICU). Furthermore, the spectrum of illness in the developing countries differs with many young patients developing AKI compared to the elderly who acquire AKI in ICU; hence, these patients have better chances of survival but are more prone to complications secondary to poor nutrition and resource availability.
We, therefore, did a study to assess whether this different epidemiology of AKI in the developing countries, and varied etiology has any relation to the clinical outcomes and mortality in patients with AKI.
| Methodology|| |
With the acute dialysis quality initiative group definition and classification of AKI in 2004 of RIFLE classification risk, injury, failure, loss, and end-stage kidney failure, we were able to classify and grade the severity of AKI based on the maximal increase in serum creatinine or decreased urine output from the baseline condition: Risk (Class R), injury (Class I), and failure (Class F) and two outcomes (loss and end-stage renal disease) (L, E).
Over 71,000 patients were included in published studies with RIFLE classification system, these studies showed stepwise increase in the relative risk (RR) of death going from risk (RR: 2.40) to injury (RR: 4.15) and failure (RR: 6.33).
AKI was defined as an increase in serum creatine of ≥0.3 mg/dL within a 48-h period, or who within a 7-day period shows a ≥50% increase of serum creatine above the reference creatine or who has 6-h period of oliguria, defined as <0.5 mL/kg/h of urine output, fulfills the definition of AKI.
We collected data for analysis of outcomes of patients who got admitted to our hospitalized with the diagnosis of AKI and assessed their outcomes in terms of duration of stay, recovery at discharge, the requirement of dialysis, etiology of AKI, and morbidity and mortality.
This is a single center, where a prospective, observational case series study was conducted from April 2014 to August 2015 at the department of nephrology of a tertiary care hospital with majority of patients hailing from rural areas with poor sanitation and hygiene in South India.
Adults with the diagnosis of AKI at the emergency department and referral from allied departments with the diagnosis of AKI were enrolled and followed up till recovery or death also the requirement of dialysis. Postdischarge they were followed up for 3 months. Written informed consent was obtained from all the patients or their caregivers. The study protocol was approved by the Institutional Ethics Committee.
Since this was observational case series study over a period of 16 months, we enrolled 220 patients with the diagnosis of AKI.
Management of cases
Participants were monitored closely for vital parameters, requirements of fluids, inotropes, antibiotics, urine output measurement, volume status, the requirement of dialysis indications and monitoring of recovery of kidney function, duration of stay and if required biopsy in case of nonrecovery. Patients who required dialysis were dialyzed with either femoral or jugular nontunneled temporary catheter, with blood flow of 200 mL/min and dialysate flow of 500 mL/min and in patients with hypotension at lower blood flow rate of 100–150 mL/min and dialysate flow of 300 mL/min, using a hollow fiber polysulfone low flux dialyzer. Dialysis was done either on daily basis or alternate days based on the requirement of patients. All patients were followed till recovery or death.
After initial clinical assessment using RIFLE criteria, the recovery of renal function was assessed by increasing urine output, decrease in blood urea nitrogen and serum creatinine decrease in edema, and improvement in general well-being and also the need for dialysis was assessed. Duration of hospital stay and mortality in each group was noted.
The collected data were entered into excel sheet. After data filtration, the data sheet was transferred and analyzed using the SPSS software version 20.0 (SPSS South Asia, No. 2353/1-4, ‘Dolphin’, Bangalore, Karnataka). Descriptive statistics were used to describe the data variables, and the difference in the rates of outcome among the different groups was tested using the Chi-square test. A value of P < 0.05 was considered statistically significant.
| Results|| |
From April 2014 to August 2015, a total of 220 patients were enrolled in this study who were referred to nephrology with the diagnosis of AKI after the excluding patients with the diagnosis of CKD. Patients were grouped into different age groups, sex, etiology of AKI, survival, and death.
A total of 220 patients were included in the study. The mean age of patients was 43.94 ± 15.52 years, where nearly 60% (131) of them were in the age group of 31–60 years, 27.7% (61) were young in the age group of 18–30 years and 12.7% (28) were elderly patients. Nearly two-thirds were males (64.5%) and remaining were females (35.5%) [Table 1].
On eliciting symptoms at presentation, most of them had oliguria at presentation (94.1%) and other predominant symptoms were vomiting (64.5%), fever (53.2%) orthopnea (41.4%), anuria (34.1%), and burning micturition (31.8%) [Table 2].
All the patients were evaluated for the presence of comorbid conditions wherein 10.5% (23) of them were diabetic, 10.9% (24) of them were hypertensive, and 2.3% (5) of them were suffering from ischemic heart disease [Table 3].
At the time of admission, majority of them were hypotensive (with systolic blood pressure <100 mmHg) 85.9% (189) patients and initial assessment of AKI was done using RIFLE criteria where nearly 60% (131) of them had R3 stage, 34.5% (76) of them had R2 stage [Table 4].
Of 220 patients who came with various etiologies of AKI, the most common etiology was found to be gastroenteritis seen in 60 (27.3%) of patients followed by sepsis 31 (14.1%), pyelonephritis 27 (12.3%), snakebite 19 (8.6%), and Obstetrics 19 (8.6%), and obstructive uropathy was seen in 8 (3.7%) of cases [Table 4].
In the management of 220 patients, 93 (42%) required dialysis among whom oliguria/anuria and hypoxia (78%) was the most common indication for dialysis in the majority of patients. Other less common indications were acidosis (8.6%), encephalopathy (5.4%), and fluid overload (4.3%) [Table 5].
The clinical outcome was assessed on the 3rd day of admission wherein half (52.7%) had recovered and 47.3% of patients did not recover. In our study, 86.8% patients survived and mortality was 13.2%.
The various clinical parameters influencing the mortality were assessed where only the underlying etiology had a significant association with mortality (P < 0.001). The mortality rate was higher in patients with sepsis (35.5%), obstetric causes (21.1%) and snakebite victims (10.5%), compared to patients with gastroenteritis (1.7%), and acute febrile illness (0%) [Table 4].
| Discussion|| |
AKI constitutes an important public health problem with mortality in a range of 10%–30%. The epidemiology of AKI differs in different scenarios such as the hygiene of the communities and the public health measures taken and also between developed and developing world.
In this prospective study, we studied 220 patients during the hospital stay with the diagnosis of AKI. The diagnosis of AKI was established after excluding patients with chronic kidney disease.
In our study, the most common cause of AKI was hypovolemia due to gastroenteritis (27.3%), which was different from study by Nash et al., where the most common cause was decreased renal perfusion (39%) due to congestive cardiac failure, cardiac arrest, and volume contraction. In the study done by James case, the overall incidence of AKI was 20%–50% of ICU admission. This difference in etiology could be explained by varied population base with majority of patients coming from the rural background and lacking access to clean drinking water.
In our study, sepsis was the second common etiology of AKI 31 patients (14.09%), but it was the leading cause of AKI in many studies of patients with critical illness.,,,,,,,
We had pyelonephritis as the diagnosis of AKI as the third most common etiology 27 cases, (12.27%), but literature search revealed only case reports of patients of pyelonephritis as the cause of AKI.
We had obstetric-related and snakebite-related AKI as the fourth common cause of AKI 19 each (8.63%).
In our study, the mortality rate was 13.2% which was much lower than the mortality rate reported by Nash et al. (19.4%) which was based on patients of hospital-acquired AKI, which could be explained by the fact that the majority of our patients have community-acquired AKI and patients had less severe illness. In our study, the majority of the patients were aged <60 years (87%). In the study done by James case, the mortality was 50% among patients of ICU. This high mortality could be explained due to the fact that the majority of patients were the elderly and were critically ill with multiorgan involvement.
Regarding the mortality in various subgroups of patients, we found that in our patients with gastroenteritis had least mortality, only one patient of 60 had expired which was statistically significant (P < 0.001) compared to other etiologies and mortality. This difference in mortality could be explained based on the easy intervention done by replacing the volume lost at the right time and bringing down mortality significantly. Our study had mortality of 1.7% of gastroenteritis which was less than the mortality study done by Inbanathan and Lavanya where they studied 100 patients of AKI due to acute gastroenteritis, and they had mortality of 4%.
In our study, sepsis was the most common cause of mortality among patients with AKI (35%) which was comparable to the study done by Bagshaw et al. which was a multicenter study and they had a mortality rate of 29.7%. In other studies done by Seen Bagshaw and Carol Gorge where they compared mortality between septic and nonseptic AKI and found that among ICU patients septic patients had higher mortality (19.8%) compared to nonseptic AKI (13.4%) and among in-hospital mortality septic patients had higher mortality (29.7%) compared to nonseptic AKI (21.6%) (P < 0.001), suggesting septic AKI had distinct pathophysiology.,,, Septic AKI had important differences in patient characteristics response to intervention and clinical outcomes compared with nonseptic AKI.
With regarding mortality of patients with snakebite, we found that mortality of patients with snakebite was 10.5% which was less than mortality in the study done by Harshavardhan et al. where they found that 77.7% of patients survived and 23.6% of patients expired.
Reviewing various studies of snakebite, the mortality varied from 2.5% to 25% in a study by Dharod et al. In 336 cases studied by Kularatne the mortality was 2.6% only (9 patients). In 633 cases studied by Kulkarni and Anees the mortality rate was 5.2% (33 cases) of the total. In 1548 patient studied by Athappan et al., 159 (13.5%) patients developed AKI of which 36 (22.6%) expired. Furthermore, in the same study done by Athappan et al. required dialysis (45.3%) and 36 (22.6%) expired of them, 23 required dialysis showing higher mortality of snakebite with dialysis.
In subclass of obstetric-related AKI, we had 19 patients in which 4 patients died with mortality of 21.1% which was similar to the study done by Prakash et al. with overall mortality was 20% of cases. However, in a study done by Mishra Vineet et al. where they studied 52 patients of obstetric AKI and found that mortality rate was 32.69%.
Hence, due to young population and isolated renal failure in our population, the mortality rate was less (13.2%) in our population compared to other studies. We had also 19 patients who developed AKI after snakebite of 220 patients which reflect predominantly who had acquired AKI due to farming in fields.
| Conclusions|| |
The epidemiology of AKI in the developing countries had different etiology where predominant causes are gastroenteritis, sepsis, postpartum, and snakebites which have different clinical presentation in the form of isolated renal involvement, will affect young population and has less mortality compared to population developed countries where it is predominantly hospital acquired and affects the elderly, cardiac patients, and patients with comorbidities with high mortality and multiorgan involvement.
We conclude that the underlying cause of AKI is important determinant of the clinical outcome where we found that patients with gastroenteritis had a better outcome than other etiology of AKI.
We thank all the residents in the department of general medicine for there close follow up and timely referral and our dialysis unit team Dr. Vidya and all technicians for timely dialysis. This study was not funded and dialysis support was provided by institute department of nephrology. We also acknowledge the authors of all the articles which have referred for this scientific writing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Liaño F, Junco E, Pascual J, Madero R, Verde E. The spectrum of acute renal failure in the intensive care unit compared with that seen in other settings. The Madrid acute renal failure study group. Kidney Int Suppl 1998;66:S16-24.
Silvester W, Bellomo R, Cole L. Epidemiology, management, and outcome of severe acute renal failure of critical illness in Australia. Crit Care Med 2001;29:1910-5.
Vincent JL. Incidence of acute renal failure in the Intensive Care Unit. Contrib Nephrol 2001;(132):1-6.
Ahuja MM. Progress in Clinical Medicine in India. 3rd
ed. New Delhi: Arnold – Heinemann Publishers; 1979. p. 312-26.
Macedo E, Mehta RL. Epidemiology Diagnosis and Therapy of Acute Kidney Injury Schriers Diseases of Kidney. New Delhi, India: Wolters Kluwer, Lippincott Williams and Wilkins; 2013. p. 785-825.
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P; Acute Dialysis Quality Initiative Workgroup, et al
. Acute renal failure – Definition, outcome measures, animal models, fluid therapy and information technology needs: The second international consensus conference of the acute dialysis quality initiative (ADQI) group. Crit Care 2004;8:R204-12.
Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review. Kidney Int 2008;73:538-46.
Hoste EA, Kellum JA. Definitions, classification, epidemiology, and risk factors of acute kidney injury. Oxford: Textbook of Clinical Nephrology. 4th
ed., Vol. 2, Ch. 220. Oxford University Press: New Delhi, India (110001);1831-1843.
Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis 2002;39:930-6.
Case J, Khan S, Khalid R, Khan A. Epidemiology of acute kidney injury in Intensive Care Unit. Crit Care Res Pract 2013;2013:479130.
Rangal-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP. The natural history of systemic inflammatory response syndrome (SRS). A prospective study. JAMA 19995;273:117-23.
Bagshaw SM, Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, et al
. Septic acute kidney injury in critically ill patients: Clinical characteristics and outcomes. Clin J Am Soc Nephrol 2007;2:431-9.
Hoste EA, Lameire NH, Vanholder RC, Benoit DD, Decruyenaere JM, Colardyn FA, et al
. Acute renal failure in patients with sepsis in a surgical ICU: Predictive factors, incidence, comorbidity, and outcome. J Am Soc Nephrol 2003;14:1022-30.
Lopes JA, Jorge S, Resina C, Santos C, Pereira A, Neves J, et al
. Acute renal failure in patients with sepsis. Crit Care 2007;11:411.
Neveu H, Kleinknecht D, Brivet F, Loirat P, Landais P. Prognostic factors in acute renal failure due to sepsis. Results of a prospective multicentre study. The French study group on acute renal failure. Nephrol Dial Transplant 1996;11:293-9.
Oppert M, Engel C, Brunkhorst FM, Bogatsch H, Reinhart K, Frei U, et al
. Acute renal failure in patients with severe sepsis and septic shock – a significant independent risk factor for mortality: Results from the German prevalence study. Nephrol Dial Transplant 2008;23:904-9.
Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al
. Sepsis in European Intensive Care Units: Results of the SOAP study. Crit Care Med 2006;34:344-53.
Yegenaga I, Hoste E, Van Biesen W, Vanholder R, Benoit D, Kantarci G, et al
. Clinical characteristics of patients developing ARF due to sepsis/systemic inflammatory response syndrome: Results of a prospective study. Am J Kidney Dis 2004;43:817-24.
Inbanathan J, Lavanya BV, et al
. Int J Sci Stud 2010;4:48-52.
Bagshaw SM, George C, Bellomo R; ANZICS Database Management Committee. Early acute kidney injury and sepsis: A multicentre evaluation. Crit Care 2008;12:R47.
Langenberg C, Wan L, Egi M, May CN, Bellomo R. Renal blood flow in experimental septic acute renal failure. Kidney Int 2006;69:1996-2002.
Langenberg C, Wan L, Bagshaw SM, Egi M, May CN, Bellomo R, et al
. Urinary biochemistry in experimental septic acute renal failure. Nephrol Dial Transplant 2006;21:3389-97.
Licari E, Calzavacca P, Ronco C, Bellomo R. Fluid resuscitation and the septic kidney: The evidence. Contrib Nephrol 2007;156:167-77.
Bellomo R, Bagshaw S, Langenberg C, Ronco C. Pre-renal azotemia: A flawed paradigm in critically ill septic patients? Contrib Nephrol 2007;156:1-9.
Harshavardhan L, Lokesh AJ, Tejeshwari HL, Halesha BR, Metri SS. A study on the acute kidney injury in snake bite victims in a tertiary care centre. J Clin Diagn Res 2013;7:853-6.
Dharod MV, Patil TB, Deshpande AS, Gulhane RV, Patil MB, Bansod YV, et al
. Clinical predictors of acute kidney injury following snake bite envenomation. N Am J Med Sci 2013;5:594-9.
Kularatne SA. Common krait (Bungarus caeruleus
) bite in Anuradhapura, Sri Lanka: A prospective clinical study, 1996-98. Postgrad Med J 2002;78:276-80.
Kulkarni ML, Anees S. Snake venom poisoning: Experience with 633 cases. Indian Pediatr 1994;31:1239-43.
Athappan G, Balaji MV, Navaneethan U, Thirumalikolundusubramanian P. Acute renal failure in snake envenomation: A large prospective study. Saudi J Kidney Dis Transpl 2008;19:404-10.
] [Full text]
Prakash J, Niwas SS, Parekh A, Pandey LK, Sharatchandra L, Arora P, et al
. Acute kidney injury in late pregnancy in developing countries. Ren Fail 2010;32:309-13.
Mishra Vineet V, Goyal Preeti A, Aggarwal Rohina S, Choudhary S, Tanvir T, Dharaiya Nisarg D, et al
. A single-centre experience of obstetric acute kidney injury. J Obstet Gynaecol India 2016;66:207-11.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]