Kashinkunti MD et.al / International Journal of Pharmaceutical and Biological Research (IJPBR)

Clinical spectrum of Acute Kidney injury: A study from tertiary care hospital Kashinkunti MD M.D*, Dhananjaya M M.B.B.S** Department and institutions: * Professor, ** Postgraduate student, Department of Medicine, SDM college of medical sciences and hospital, Sattur, Dharwad-580009, State-Karnataka, India. [email protected] Abstract Introduction: Acute Kidney injury (AKI) or Acute Renal Failure (ARF) is a common medical problem. Variety of conditions can lead to ARF. Many factors can influence the outcome of AKI. The aim of the present study was to analyze the clinical spectrum, causes, risk and prognostic factors and final outcome of AKI. Methods: This prospective study involved patients admitted to tertiary care hospital during March 2012 to February 2013. The clinical and laboratory data were collected at admission and then on daily basis. Patient characteristics, underlying medical conditions, dialysis, need for ventilation, total duration of hospital and ICU stay and final outcome, and these data were analyzed. Results: One hundred and twenty patients were admitted to our hospital fulfilled the criteria of acute kidney injury. Most of the patients 43.3% were in 31-50 years and 56.6% were males. Comorbidity was seen in 41(34.2%) patients were diabetes was most common 43.9%. ARF had developed complicating medical and surgical conditions in 74 (61.6%) and 35 (29.2%) patients respectively. The etiology of ARF was multifactorial and included; sepsis 51.3%, hypotension (33.7%), volume depletion (18.9%). Multiple organ dysfunctions noted in 55% of cases and dialysis was required in 51.6% patients. Mortality occurred in 28.3% of patients. MODS and sepsis were found to be significant adverse prognostic factors. Conclusions: AKI was seen in 4.2% of cases in our hospital admission. Presence of sepsis, MODS and ventilation need were correlated with higher mortality in AKI patients. Keywords: Acute Kidney injury, acute renal failure, sepsis, multi organ dysfunction syndrome, Diabetes mellitus, North Karnataka Introduction Acute kidney injury (AKI), previously known as acute renal failure is characterized by the sudden impairment of kidney function resulting in the retention of nitrogenous and other waste products normally cleared by the kidneys. AKI is not a single disease but, rather, a designation for a heterogeneous group of conditions that share common diagnostic features: specifically, an increase in the blood urea nitrogen (BUN) concentration and/or an increase in the plasma or serum creatinine concentration often associated with a reduction in urine volume. Acute renal failure (ARF) is a less appreciated problem with various etiologies. [1] ARF is reversible when recognized and managed early. [2] Delay in diagnosis of ARF may lead to increased morbidity and mortality. [3] Early identification, referral and treatment of pre-renal failure with proper therapeutic decisions can substantially improve the incidence and outcome of ARF [4] Data on overall epidemiology of ARF is crucial to implement adequate resources for the management of this entity. [3] A comprehensive understanding of the clinical spectrum of a disease is needed to identify potential areas of intervention. Different aspects regarding outcome of ARF, in relation to severity scores, ICU setting, age, dialysis, and underlying illness have been studied in various parts of the world. [5, 6] The probability of death in patients with AKI is still high.[7] It affects as many as 5% of all hospitalized patients with a higher prevalence in ICU patients, patients with multi organ failure and elderly patients with complex diseases. The mortality is high in hospitalized patients with ARF as compared to patients with ARF in community setups. [8] The most common causes of death are sepsis, respiratory failure and multiple organ failure. ARF tells the gravity of the underlying disease and not the cause of death. [9] This study was meant to describe various etiological factors of AKI or ARF in a teaching hospital of North Karnataka were there are few reports of severity of this problem.

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Patients and Methods One hundred twenty patients of more than 15 years of age of either sex admitted in our Hospital, meeting following inclusion criteria were included in the study March 2012 to February 2013. Patients who presented with oliguria or anuria for more than 24 hours and showed rise in urea and creatinine, or increase in serum creatinine of 0.5 mg per deciliter over base line value, or an increase of more than 50 percent over the normal value. The Exclusion criteria was age < 15 years, patients with known renal diseases, established diabetic or hypertensive nephropathy, bilateral small shrunken kidneys, disparity of renal sizes of more than 2.0 cm or polycystic kidney disease. Clinical evaluation included a history of nausea, vomiting and/or diarrhea, bleeding, previous renal insufficiency, heart failure or recent symptoms of dyspnea, jaundice, hepatitis or chronic liver disease, edema, high blood pressure or change in color of urine, present and past medications, prolonged episode of hypotension, use of any contrast dyes and renal stone disease, or evidence of lower urinary tract obstruction. Laboratory Tests included Dipstick Urine analysis and microscopy was done in all patients. Protein quantification was done by sulphosalicylic acid test. Complete Blood counts, Urea, BUN, Serum creatinine, Electrolytes, Ultrasonography were done in all cases. Immunologic tests included ANA, LE CELL, C3 AND C4, Anti DNA and Renal biopsy was done in selected cases. A daily estimation of urine output, urea, and creatinine was performed and exposure to therapeutic options/ management was recorded. The therapeutic management options were conservative and dialysis. The criteria for carrying out hemodialysis were uremic symptoms and metabolic acidosis, hyperkalemia, fluid overload, oliguria, anuria non-responsive to fluid therapy and rising urea, creatinine, and uremic pericarditis. The outcome of the patients who were followed up was recorded for those requiring conservative therapy and improved, requiring dialysis support temporarily and improved, requiring temporary dialysis and discharged with advice for future dialysis, Expired, despite any of the above. All patients were followed daily until discharged, died or attained normal renal functions. Data Analysis Data entry was done using SPSS package. Data was analyzed by mean, standard deviation, frequency and comparison between various groups using student t test for statistical significance. Factor(s) determining outcome of ARF were analyzed by univariate and multivariate analysis. Results The study included 120 patients of AKI with maximum number of patients between 31-50 years 43.3%. Age ranged from 16 to 75 years. The male to female ratio was 1.3:1 (68:52). Causes leading to AKI included conditions related to medical (74%), surgical (35%) and obstetrical (11%) origin. Most common medical illness causing ARF was sepsis 38(51.3%), hypovolemia secondary to acute gastroenteritis (18.9%).TABLE1 Abdominal surgical procedures among surgical group were mainly associated with ARF. Postpartum hemorrhage and eclampsia were the two conditions associated with AKI in obstetrical cases. Patients were classified in two groups based on treatment modality which was either conservative or dialysis. Sixty two patients received dialysis and remaining 58 received conservative management. This frequency of treatment modalities was same for patients having medical origin of disease. Surgical illnesses were treated mostly by conservative method. Two broad outcomes in this study were improved (86) or expired (34). Among those who improved (n=86) by the end of the study 54 patients were managed conservatively, while 32 were dialyzed. Among those who expired (n=34), 30 patients were dialyzed and 4 were managed conservatively. Factors affecting outcome of patients with ARF in terms of improved and expired are shown in Tables 2 and 3. The patients were divided into subgroups for each factor by level defined in Table 2 and 3. These subgroups were compared for outcome of ARF (Table 2). Treatment groups were also compared for each subgroup in terms of outcome of ARF (Table 3).The multivariate analysis revealed that the presence of oliguria is the only significant independent predictor for good outcome with dialysis. Discussion Acute Kidney injury is a very common condition in hospitalized patients. [9] Barret et al reported 200 patients of ARF in a three years study.[5] and another study from Arabian Gulf reported 77 patients of ARF in 2 years.[9] A study from Philippines reported 110 patients of ARF in 5 years period.10 This study included 120 patients with ARF in a teaching hospital over a period of 1 year. This study has a higher number probably because our hospital is tertiary referral center and higher number of sepsis and multi organ dysfunction patients. AKI is caused due to multiple factors which explain its common occurrence in hospitalized patients. ARF affects patients cared for by nearly all health care professionals. [11] Liano has grouped ARF into medical (34%),ICU (27%), Surgical (23%), Obstetrical (1%), nephrological (13%) and traumatic (2%) ARF.[12] Saxena in his review classified etiology of ARF in medical (75%), obstetrical (15%),obstructive and surgical cases (10%).[13] Naqvi et al [14] in which the major cause was medical conditions (57%) followed by obstetrical

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Kashinkunti MD et.al / International Journal of Pharmaceutical and Biological Research (IJPBR)

(24%), obstructive (7%),surgical (5%) and undetermined cause (7%).The reason is that infections as a cause of ARF has declined all over the world but it is still a significant cause for renal insufficiency in the developing country. A large proportion of medical causes in developing countries is due to a high incidence of infections, specially gastrointestinal diseases, falciparum malaria and viral hemorrhagic fever with multi organ failure. The other conditions like snake bite, leptospirosis, heavy metal poisoning and glomerulonephritis may cause ARF. The prognosis of AKI depends on the cause, underlying co-morbid conditions and severity of the disease. Because of the ability to provide long-term renal replacement therapy, in the form of dialysis or renal transplantation, a poor renal outcome is not necessarily fatal. Mortality of ARF in hospitalized patient is reported from 14-70% in different studies. [4] Mortality in this study is 34(28.3%). Previous co-morbid conditions, hospital and/or ICU management of ARF and age of the patient seem to affect outcome. The poor outcome of ARF in advanced age may be a reflection of increased frequency of chronic (malignancy, cardiac and pulmonary failure) diseases. AKI observed in the ICU setting has a poorer prognosis than treated in general wards. This study had 78 (65%) patients who were in ICU. Many factors affect the outcome of ARF in hospitalized patients. [16, 17] Dela Cruz et al [10] concluded four variables significantly increased the risk of death from ARF: older age, hyperkalemia, oliguria, and presence of sepsis on admission.[4] Obialo and his associates[18] reported oliguria as a factor causing increased mortality among patients with ARF. Similar factors including increasing age, higher levels of FEna, urea, creatinine and potassium along with associated medical illnesses, oliguria and acidosis contributed to high mortality in this study. Our analysis demonstrated oliguria to be the major predictor of non-recovery of renal function as reported in almost all other studies mentioned above. Conclusion AKI remains a common disorder among critically ill patients. ARF in the setting of ICU is characterized by increasing mortality, high incidence sepsis, multi-organ failure and mortality. Sepsis and multi-organ failure are the major causes of mortality in these patients. These findings alarms for early detection and aggressive management of sepsis and its associated complications so as to bring down the mortality in patients admitted to intensive care unit. It is important for preventive measures such as restoration of intravascular volume status, maintenance of adequate renal perfusion pressures, and limiting exposure to nephrotoxins should be undertaken. Acknowledgements: Nil References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18]

Albright RC Jr. Acute Renal Failure: a practical update. Mayo Clin Proc 2001;76:67-74. Jorres AJ. Acute Renal Failure: pathogenesis, diagnosis and conservative treatment. Minerva Med 2002;93:85-93. Morgera S, Kraft AK, Siebert G, Luft FC, Neumayer HH. Long-term outcomes in acute renal failure patients treated with continuous renal replacement therapies. Am J Kidney Dis 2002;40:275-9.Kelly KJ, Molitoris BA. Acute renal failure in the new millennium: time to consider combination therapy. Semin Nephrol 2000;20:4-19. Barretti P, Soares VA. Acute Renal Failure: Clinical outcome and causes of death. Ren Fail 1997;19:253-57. Mandal AK, Baig M, Koutoubi Z. Acute Renal Failure in elderly: Treatment Options. Drugs Aging 1996;9:226-50. Davda RK, Guzman NJ. Acute renal failure. Prompt diagnosis is key to effective management. Postgrad Med 1994;96:89-92,95,98. Kaufman J, Dhakal M, Patel B, Hamburge L. Community Acquired Acute Renal Failure. Am J Kidney Dis 1991;17:191-8. Albright RC Jr. Acute Renal Failure: a practical update. Mayo Clin Proc 2001;76:67-74. Dela Cruz CM, Pineda L, Rogelio G, Alano F. Clinical profile and factors affecting mortality in acute renal failure. Ren Fail 1992;14:161-8. Agrawal M, Swartz R. Acute Renal Failure. Am Fam Physician 2000;61:2077-88. Liano F. Acute renal failure; causes and prognosis. In: Schrier RW. Ed. Atlas of diseases of kidney. Philadelphia. Churchil Livingstone 2000;Chapter 8. Sexena S. Dialytic support in acute renal failure. J Indian Med Assoc 2001;99:378-81. Naqvi R, Ahmed A, Akhtar F, Yazdani I, Zafar MN, Naqvi SAA, et al.Analysis of Factors Causing Acute Renal Failure. J Pak Med Assoc 1996;46:29-30. Loo CS, Zainal D. Acute renal failure in a teaching hospital. Singapore Med J 1995;36:278-81. McCarthy JT. Prognosis of Acute Renal Failure in intensive care unit. Mayo Clinic Proc 1996;71:117-26. Liano F, Pascual J. Outcomes in acute renal failure. Semin Nephrol 1998;18:541-50. Obialo CI, Crowell AK, Okonofua EC. Acute renal failure mortality in hospitalized African Americans: age and gender considerations J Natl Med Assoc 2002;94:127-34.

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Kashinkunti MD et.al / International Journal of Pharmaceutical and Biological Research (IJPBR)

ETIOLOGY MEDICAL

SURGICAL

OBSTETRICS

SUBGROUP Sepsis Gastroenteritis MI CVA Chronic liver disease Malaria OP poison Laparotomy Orthopedic surgery CABG Miscellaneous PPH Eclampsia

NO. OF CASES 38 14 6 5 5 4 1 11 9 7 8 6 5

TOTAL 75

35

11

Table 1: Etiological Subgroups of AKI in Hospitalized Patients.

VARIABLES

NO OF CASES

OUTCOME IMPROVED EXPIRED

1.ETIOLOGY

74 35 11 66 54 52 68 64 56 59 61 63 57 65 55 58 62

48 29 9 36 50 25 61 49 37 33 55 57 30 39 47 54 32

Medical Surgical obstetrics 2.OLIGURIA Present Absent 3.ACIDOSIS Present Absent 4.AGE < 40 > 40 5.POTASSIUM >5 200 < 200 7.creatinine >4.5 < 4.5 8. Treatment conservative Dialysis

26 6 2 30 4 27 7 15 19 26 6 7 27 26 8 4 30

Table2: Univariate analysis of factors affecting outcome of AKI

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Kashinkunti MD et.al / International Journal of Pharmaceutical and Biological Research (IJPBR)

VARIABLES

NO OF CASES

TREATMENT CONSERVATIVE DIALYSIS

P value

1.ETIOLOGY

Medical Surgical obstetrics 2.OLIGURIA Present Absent 3.ACIDOSIS Present Absent

74 35 11 66 54 52 68

42 25 8 24 34 25 58

32 10 3 42 20 27 10

NS

4.AGE

64 56 59 61 63 57 65 55 39 71

47 35 17 41 18 30 25 41 30 44

17 21 42 20 45 27 40 14 9 27

< 40 > 40 5.POTASSIUM >5 200 < 200 7.creatinine >4.5 < 4.5 8. Hb >12