|Year : 2020 | Volume
| Issue : 2 | Page : 77-81
Epidemiology and outcome of acute kidney injury in patients presenting to emergency department – Our experience
Venkatesh Satri1, V Siva Kumar2, V Satyanarayana3, B Siva Ramakrishna1, P. V L. N Srinivasa Rao4, M Madhusudan1
1 Department of Emergency Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Anaesthesiology and Critical Care, Apollo Institute of Medical Sciences, Chittoor, Andhra Pradesh, India
4 Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
|Date of Submission||12-Apr-2019|
|Date of Decision||23-Oct-2019|
|Date of Acceptance||19-Feb-2020|
|Date of Web Publication||4-Aug-2020|
Associate Professor, Department of Emergency Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Compared to the developed world, the pattern of acute kidney injury (AKI) is different in tropics. The present study was undertaken to study the epidemiological profile and outcomes in AKI.
Methods: This prospective observational study was conducted in a tertiary care teaching hospital in South India. Demographic details, detailed medical history, aetiological factors, comorbid conditions, prognostic factors and outcomes were studied. Acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores were calculated at admission for every patient to know the prognosis.
Results: A total of 193 patients who fulfilled the inclusion criteria were enrolled in the study. Majority of the patients were in their sixth decade of life. The mean age was 52.1 ± 14.8 years (male:female = 1.7:1). Hypertension (41.5%; n = 80) and diabetes mellitus (33.7%; n = 65) were the most common comorbid illnesses in our patients. The average duration of hospital stay was 8 days. AKI was secondary to medical causes in 69.4% (134/193), surgical causes in 25.4% (49/193) and obstetric is 5.18% (10/193). Renal replacement therapy was required in 56.4% (n = 109) of the study population. The mortality rate observed in our study was 21.8% (n = 42). The mean APACHE II score and mean SOFA score were found to be significantly higher in the non survivors compared to the survivors.
Conclusions: Patients with AKI who have higher APACHE II or SOFA score should be carefully monitored and aggressively treated to reduce mortality.
Keywords: Acute kidney injury, epidemiology, outcome
|How to cite this article:|
Satri V, Kumar V S, Satyanarayana V, Ramakrishna B S, Srinivasa Rao PL, Madhusudan M. Epidemiology and outcome of acute kidney injury in patients presenting to emergency department – Our experience. J Clin Sci Res 2020;9:77-81
|How to cite this URL:|
Satri V, Kumar V S, Satyanarayana V, Ramakrishna B S, Srinivasa Rao PL, Madhusudan M. Epidemiology and outcome of acute kidney injury in patients presenting to emergency department – Our experience. J Clin Sci Res [serial online] 2020 [cited 2020 Oct 29];9:77-81. Available from: https://www.jcsr.co.in/text.asp?2020/9/2/77/291377
| Introduction|| |
Acute kidney injury (AKI) describes the clinical syndrome earlier called acute renal failure. AKI is defined as structural or functional abnormality of the kidney that manifests within 48 h, as determined by blood, urine, tissue tests or by imaging studies. AKI is depicted by rapid (over hours to days) decline in glomerular filtration rate, retention of nitrogenous waste products and perturbation of the extra-cellular fluid volume, electrolytes and acid-base homeostasis. AKI constitutes approximately 5% of hospital admissions and up to 30% of admissions to intensive care units (ICU).,
Epidemiology of AKI differs amongst developed and developing countries, owing to differences in demographics, economics and co-morbid disease burden. Many aetiologies are region specific such as envenomation (snakes, spiders, caterpillars and bees), infectious causes (malaria, leptospirosis, scrub typhus, etc.,) and trauma (crush injuries, causing rhabdomyolysis).
Staging of AKI is mainly by either risk, injury, failure, loss and end-stage renal disease criteria or by AKI Network (AKIN) criteria. Recently, Kidney Disease Improving Global Outcome criteria are also in vogue. The development of AKI undoubtedly has important implications on both short- and long-term morbidity and mortality. Observational data consistently indicate that 4%–5% of all critically ill patients develop severe AKI and require renal replacement therapy (RRT). This cohort generally has a poor prognosis with more than 60% mortality rates.,,
Data regarding epidemiology and outcomes of AKI in patients presenting to the emergency medicine department has been sparsely published, especially from South India which prompted us to undertake the present study.
| Material and Methods|| |
In this prospective observational study, all patients presenting to the emergency room (ER) and diagnosed to have AKI based on AKIN criteria from February 2015 to June 2016 were studied. Written informed consent was taken from all patients or responsible attendants in case the patient was unconscious. Adult patients whose age was 18 years or above and who satisfied the AKIN criteria were included in the study. Patients with chronic kidney disease, age <18 years, whose in-hospital stay was <24 h, who were renal transplant recipients and who were not willing to participate were excluded from the study. The sequential organ failure assessment (SOFA) score, the acute physiology and chronic health evaluation II (APACHE II) score and AKIN staging were done for each patient at presentation. After initial stabilisation in the resuscitation bay, all the patients underwent a thorough physical examination. All the study patients were subjected to a diagnostic work-up as per our institute's standard care. Relevant laboratory and imaging investigations were performed to establish aetiological diagnosis. Once the diagnosis of AKI was made, all the patients were managed either in the wards or ICU depending on their severity of illness. Specific management of particular illnesses or disease was instituted as per the standard guidelines. Supportive treatment, such as nutritional management, mechanical ventilator support, glycaemic control, RRT, stress ulcer prophylaxis and deep venous thrombosis prophylaxis, were initiated wherever appropriate to all patients as per our institutes ICU protocols. Laboratory investigations were repeated whenever warranted. Parameters monitored around the clock during hospital stay included heart rate; non-invasive blood pressure; oxygen saturation; respiratory rate; Glasgow coma scale score; urine output and blood sugar. Critical illness severity scores, namely, APACHE II and SOFA were computed at the time of initial presentation. All patients were followed up to discharge from hospital or in hospital death to register their survival status.
The data were recorded in a predesigned study proforma and managed using Microsoft Excel 2007 (Microsoft Corp, Redmond, WA, USA) and Statistical Packages for Social Sciences (SPSS) ver -22.0 for windows (SPSS Inc.; Chicago, IL, USA) was used for statistcal analysis. All the entries were double-checked for any possible error. Patients were followed up until death or discharge from the hospital to register their survival status. “Worst case scenario” analysis was undertaken where all patients who were discharged against medical advise (DAMA) were considered to have died. Descriptive statistics for the categorical variables were performed by computing the frequencies (percentages) in each category. For the quantitative variables, approximate normality of distribution was assessed. Variables following normal distribution were summarised by mean and standard deviation; the remaining variables were summarised as median (inter-quartile range). Continuous variables were compared using Student's t-test, Mann–Whitney U-test; categorical variables were compared using Chi-square test as appropriate. Receiver-operator characteristic (ROC) curve analysis was done for calculating the cut-off value.
| Results|| |
Two hundred and eighteen patients who presented to ER with AKI, were screened for inclusion in the study, of which 25 patients were excluded (12 patients were excluded due to hospital stay <24 h, 9 were excluded due to age <18 years and 4 were excluded as patients attendants were not willing to participate in the study). The study plan is shown in [Figure 1]. The remaining 193 patients were included, and the results were analysed. Mean age distribution was 52.1 ± 14.8 years. The mean age in males was 53.4 ± 13.1 years and in females was 49.9 ± 17.31 years. Males outnumbered females in the study. The mean values of APACHE and SOFA were 16.6 ± 5.9 and 6.1 ± 3.3, respectively. Of 193 patients, 65 (33.7%) were diabetic, 80 (41.5%) were hypertensive, 35 (18.1%) patients have a history of smoking and 40 (20.7%) of them were alcoholics. Of 193 patients, 27 were classified under AKIN 1, 37 patients were placed under AKIN 2 and 129 patients come under AKIN 3. Of 193 patients, medical cases of AKI were 134 (69.4%), surgical cases were 49 (25.4%) and obstetric cases were 10 (5.2%). The most common aetiology in our study was acute febrile illness followed by acute gastroenteritis. These details are shown in [Table 1].
|Figure 1: Study plan. EMD= Emergency medicine department; AKI= Acute kidney injury|
Click here to view
The most common clinical finding in our study was fever (69.43%), followed by oliguria (31.08%). Details of the clinical findings in our study are shown in [Table 2]. Average duration of hospital stay was 8 days. Of 193 patients, 151 (78.2%) patients were discharged and 42 (21.8%) patients were expired. Of 193 patients, 109 (56.5%) received dialysis support and 84 (43.5%) were managed conservatively.
High mortality was observed in the patients who received dialysis support when compared to patients managed conservatively (35 vs. 7) (P = 0.00001). And also, the mortality rate was high in patients who had AKIN stage 3 AKI and mechanical ventilation support. Comparison between survivors and non-survivors is shown in [Table 3]. ROC curve analysis for calculating the cut-off values of APACHE II and SOFA for prediction of death is shown in [Figure 2] and [Figure 3], respectively. Comparison of management strategies for AKI in the present study and other published studies is shown in [Table 4].,,,
|Table 3: Comparison of APACHE II, SOFA and other variables between survivors and non.survivors|
Click here to view
|Figure 2: Receiver-operator characteristic-curve along with 95% confidence bounds for calculating the cut-off value for APACHE II score to predict severity. The area under the receiver-operator characteristic curve = 0.893; standard error = 0.0317; 95% confidence intervals = 0.840–0.933; z-statistic = 12.385; significance level, P (Area = 0.5) =0.0001. ROC= Receiver-operator characteristic curve; APACHE II= acute physiology and chronic health evaluation II|
Click here to view
|Figure 3: Receiver-operator characteristic-curve along with 95% confidence bounds for calculating the cut-off value for sequential organ failure assessment score to predict severity. The area under the receiver-operator characteristic curve = 0.880; standard error = 0.0276; 95% confidence intervals = 0.826 to 0.922; z-statistic = 13.774; significance level P (Area = 0.5) = <0.0001. SOFA = Sequential organ failure assessment; ROC = Receiver-operator characteristic curve|
Click here to view
|Table 4: Comparison of management strategies for AKI in the present study and other published studies|
Click here to view
| Discussion|| |
In the present study, a total of 193 patients were included based on AKIN criteria. Most of the cases in our study include CA-AKI cases. In another study, it was observed that, found that the prevalence of AKI was 5.5%. In our study, the prevalence is found to be 1.82% as per AKIN criteria.
In the present study, males outnumbered females by 1.7 times. The peak incidence of AKI was observed during the fifth decade of life. Their mean age was 52.13 ± 14.83. The mean age in males was 53.42 ± 13.07, and in females, it was 49.92 ± 17.31. The results were similar compared to that reported in other Indian studies., However, the results were divergent from the report in other studies, where the mean age was a decade older and younger.
In the present study and other studies conducted in different regions, sepsis was found to be the most common cause of AKI followed by acute gastroenteritis which is contrary to the observations recorded in the study from Bengaluru in which acute gastroenteritis was most common cause of AKI. All the patients have been classified by AKIN criteria. Based on this, 129 (66.8%) patients were AKIN 3, 37 (19.2%) patients were AKIN 2 and 27 (14%) patients were AKIN 1.
Of 129 patients, 36 patients from AKIN 3 stage died (P = 0.01). No mortality was observed in AKIN 1. These observations suggest that AKIN 3 patients are under high risk for mortality requiring more vigilance and care. In our study, 33.7% and 41.5% were known to have diabetes mellitus and hypertension respectively. Similar observations have been documented in other studies.,, We noted that fever (59.1%), oliguria (31.1%), were the most common presenting symptoms. Similar observations have been documented in other studies, ([Table 2]).
Compared to other studies,,,, the percentage of patients who are given RRT was high in our study. This may be attributed to the fact that our institute is a tertiary referral centre so that most of the cases were referred to after developing complications mostly requiring dialysis. Different studies have been compared regarding the treatment of AKI whether treated conservatively or dialysis has been done and shown in [Table 4].
In our study, mortality rate was higher amongst patients receiving RRT (P < 0.00001). In another study mortality was higher. AKI requiring dialysis is an ominous condition which has more risk of in-hospital mortality. This high mortality was due to the association of multi-organ failure in those cases who required dialysis.
Male gender and age >60 years were prevalent in majority of AKI cases. Hypertension and Diabetes were the first and second most common comorbidities, respectively. Mortality was found to be higher if there is any associated comorbidities. Majority of the patients required RRT. Probably, it may be due to the reason that our institute is tertiary referral care centre. Mortality was higher in those requiring RRT. At initial presentation, APACHE II and SOFA scores can predict the course of disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hou SH, Bushinsky DA, Wish JB, Cohen JJ, Harrington JT. Hospital-acquired renal insufficiency: A prospective study. Am J Med 1983;74:243-8.
Liu KD, Chertow GM. Acute renal failure. In: Fauci AS, Braunwald E, Kaspar DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison's principles of internal medicine. 17th
ed. New York: McGraw-Hill; 2008. p. 1752-61.
Clarkson MR, Friedewald JJ, Eustace JA, Rabb H. Acute kidney injury. In: Brenner BM, editor. Brenner and Rector's-The kidney. 8th
ed. Philadelphia: Saunders-Elsevier; 2008. p. 943-86.
The Kidney Disease Improving Global Outcomes (KDIGO) Working Group. Definition and classification of acute kidney injury. Kidney Int 2012;2:19-36.
Hoste EA, Schurgers M. Epidemiology of acute kidney injury: How big is the problem? Crit Care Med 2008;36:S146-51.
Metnitz PG, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, et al
. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002;30:2051-8.
Bagshaw SM, Laupland KB, Doig CJ, Mortis G, Fick GH, Mucenski M, et al
. Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: A population-based study. Crit Care 2005;9:R700-9.
Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, et al
. Acute renal failure in critically ill patients: A multinational, multicenter study. JAMA 2005;294:813-8.
de Mendonça A, Vincent JL, Suter PM, Moreno R, Dearden NM, Antonelli M, et al
. Acute renal failure in the ICU: Risk factors and outcome evaluated by the SOFA score. Intensive Care Med 2000;26:915-21.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29.
Mohan A, Naik GS, Harikrishna J, Kumar DP, Rao MH, Sarma K, et al
. Cleistanthus collinus poisoning: Experience at a medical intensive care unit in a tertiary care hospital in south India. Indian J Med Res 2016;143:793-7.
] [Full text]
Eswarappa M, Gireesh MS, Ravi V, Kumar D, Dev G. Spectrum of acute kidney injury in critically ill patients: A single center study from South India. Indian J Nephrol 2014;24:280-5.
] [Full text]
Liaño F, Pascual J. Epidemiology of acute renal failure: A prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group. Kidney Int 1996;50:811-8.
Kapadia MP, Kamdar PK, Jha PR. A study of clinical profile of patients with acute kidney injury in a tertiary care centre. Int J Adv Sci Res 2016;2:160-6.
Prakash J, Sen D, Usha, Kumar NS. Non-diabetic renal disease in patients with type 2 diabetes mellitus. J Assoc Physicians India 2001;49:415-20.
Abou-Arkoub R, Worrall JC, Clark EG. Emergency department patients with acute kidney injury: Appropriately discharged but inadequately followed-up? Acad Emerg Med 2018;25:815-8.
Mehta RL, Pascaul MT, Soroko S, Savage BR, Himmelfarb J, Ikizler TA, et al
. Program to Improve care in Acute Renal Disease (PICARD). Spectrum of Acute Renal Failure in the Intensive Care Unit. San Francisco, California: World Congress of Nephrology; 2001.
Balafa O, Andrikos E, Tseke P, Tsinta A, Pappas P, Kokkolou E, et al
. Outcome and epidemiology of hospitalacquired acute renal failure. Bantao J 2007;5:55-7.
Chertow GM, Christiansen CL, Cleary PD, Munro C, Lazarus JM. Prognostic stratification in critically ill patients with acute renal failure requiring dialysis. Arch Intern Med 1995;155:1505-11.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]