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 Table of Contents  
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 142-145

Clinical pattern and outcome of acute kidney injury patients from a Tertiary Health Institution in Northwestern Nigeria

1 Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Nursing, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria

Date of Web Publication14-Oct-2016

Correspondence Address:
Makusidi Aliyu Muhammad
Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, PMB 2346, Sokoto
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1118-8561.192399

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Background: Acute kidney injury (AKI) is a common cause of hospitalization associated with high mortality, especially in developing countries. Despite better understanding of the pathophysiology, mortality from AKI remains source of concern worldwide. AKI varies between countries and even within the same environment due to diverse diagnostic criteria. Studies from developing nations have alluded to the high incidence of AKI from preventable and potentially reversible causes affecting predominantly children and young adults. The growing concern as to whether the pattern and outcome have changed in recent times prompted this study. Materials and Methods: All the patients that met RIFLE criteria for the diagnosis of AKI were audited with specific reference to clinical pattern and outcome in Northwestern Nigeria. Results: A total of 318 patients (198 males and 120 females) that met RIFLE criteria for AKI were seen with age range and mean of 20–80 years and 42.0 ± 12.0 years, respectively. Severe gastroenteritis, septicemia, obstetric complications, and toxic nephropathies were leading causes of AKI. Main clinical features in order of magnitude were oliguria, fever, body swelling, unusual weakness, and vomiting. Sixty-eight percent had hemodialysis while 32% were managed conservatively. Overall, mortality was 26.4%, and conservative management was associated with higher mortality than those that had hemodialysis. Factors associated with high mortality were late presentation, severe anemia, and sepsis. Conclusion: AKI is common in our setting and causes are largely preventable and treatable. Identification and prompt correction of reversible causes and timely referral of severe cases to nephrologists are of immense importance.

Keywords: Acute kidney injury, causes, pattern, treatment and outcome

How to cite this article:
Muhammad MA, Liman HM, Yakubu A, Isah MD, Abdullahi S, Chijioke A. Clinical pattern and outcome of acute kidney injury patients from a Tertiary Health Institution in Northwestern Nigeria. Sahel Med J 2016;19:142-5

How to cite this URL:
Muhammad MA, Liman HM, Yakubu A, Isah MD, Abdullahi S, Chijioke A. Clinical pattern and outcome of acute kidney injury patients from a Tertiary Health Institution in Northwestern Nigeria. Sahel Med J [serial online] 2016 [cited 2023 Feb 4];19:142-5. Available from: https://www.smjonline.org/text.asp?2016/19/3/142/192399

  Introduction Top

Acute kidney injury (AKI) is defined as a sudden deterioration in kidney function characterized by oligo-anuria or normal urine volume, rapid rise in plasma levels of urea and creatinine, and rapid fall in the estimated glomerular filtration rate occurring within a few days and lasting <3 months.[1] It is a common cause of hospitalization and associated with high morbidity and mortality, particularly in developing world.[2],[3] The incidence of AKI varies between countries and even within the same country due to diverse diagnostic criteria.[4],[5] Although elderly patients predominate in developed countries,[6],[7] it is a disease of children and young adults in developing countries.[8],[9] In Nigeria, as observed in other developing countries, the leading causes of AKI are usually preventable and consists of a triad: Infections, nephrotoxins, and obstetric complications.[10] Therefore, simple interventions such as prompt oral rehydration, improvement of obstetric practice, and use of potent antibiotics in the treatment of infections could dramatically reduce the incidence and severity of AKI.[11],[12]

Apart from conservative management, early commencement of renal replacement therapy in form of either peritoneal or hemodialysis is associated with improvement in AKI-outcome.[10],[11] The purpose of this study was to audit clinical pattern and outcome of AKI in Northwestern Nigeria over a 6-year period.

  Materials and Methods Top

This is a 6 year (May 2007–April 2013) audit of managed AKI at the Usmanu Danfodiyo University Teaching Hospital, which serves as a referral center to Sokoto, Kebbi, Zamfara, and Niger states in Northwestern Nigeria.

All the patients that met the RIFLE criteria for the diagnosis of AKI were studied.[3] Inclusion criteria comprise some or all of the following features: short duration of illness in days to weeks, vomiting, diarrhea, anorexia, malaise, hiccups, altered sensorium, facial/body swelling, fever, and urine output <0.3 ml/kg/day. Urinary output of 400 ml/day was used to distinguish between oliguric and nonoliguric AKI while AKI severity was determined in accordance with the RIFLE grading using serum creatinine (Scr). Risk = Scr 1.5-fold of baseline, injury = Scr 2-fold of baseline, failure = Scr 3-fold of baseline or Scr >355umol/L, loss = persistent AKI or complete loss of kidney function, and end-stage = kidney failure lasting longer than 3 months. Excluded from this study were patients who had clinical, radiological, and laboratory findings in keeping with an underlying chronic kidney disease.

Hemodialysis (the only form of renal replacement therapy available in our center) was instituted on severely uremic patients irrespective of the availability of funds by the patients. Those that survived were followed up in Nephrology clinic until they achieved normal renal function based on clinical and laboratory parameters. The data were analyzed using Statistical Package for Social Sciences version 19 (IBM SPSS version 19, SPSS Inc, Chicago, IL60606-6307, USA). Categorical variables were summarized using frequency and percentages while mean and standard deviations were used for continuous variables. Pearson's correlation test was used to establish a relationship between variables. Significant levels were set at P < 0.05.

  Results Top

A total of 318 patients (198 males, 120 females) were managed for AKI during the study period. Sixty-eight percent (140 males and 77 females) had intermittent hemodialysis while 32% (58 males and 43 females) were managed conservatively. The age range was 20–80 years with a mean age of 42.06 ± 12.0 years. There was no significant age difference between the two groups. Most (87%) of the patients were in their third decades of life. Male sex predominates in both groups (conservative and hemodialysis).

[Table 1] shows the distribution of etiological factors in AKI. Severe gastroenteritis was the leading cause followed by sepsis and obstetric complications. There were no differences in the pattern of AKI causes between those managed conservatively and those who had hemodialysis.
Table 1: Etiology of acute kidney injury

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The main clinical features in order of magnitude were oliguria, fever, body swelling, unusual weakness, vomiting, and hiccups [Figure 1].
Figure 1: Clinical features of acute kidney injury

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The duration of AKI before dialysis ranged from 1 to 10 days with a mean of 2.5 ± 1.3 days while the waiting time before the commencement of dialysis was between 1 and 3 days. Hemodialysis sessions ranged between one and eight times with a mean of 2.51 ± 1.49 times while over 80% had a maximum of three sessions before recovery.

Blood transfusion ranged between 2 and 8 units with majority (76%) receiving at least 2 units. Persistent oliguria, uremic symptoms, and poor response to conservative management were the main indications for initiation of hemodialysis.

The overall mortality rate of AKI was 26.4%, with 27.7% and 24.9% among those managed conservatively and hemodialysis, respectively. Factors associated with high mortality were late presentation, anemia, and septicemia.

  Discussion Top

This study was conducted in a tertiary health care center. Community-acquired AKI was the most common (95%) form of AKI. This is attributable to the poor socioeconomic status, poor standard of sanitation, overcrowding, and malnutrition commonly seen in our environment. Similar findings were reported by Kumar et al.[13] from India where community-acquired AKI accounted for 84.3%. There is gender disparity as male to female ratio was 2:1. This finding contrast with report from Ilorin by Chijioke et al.,[11] who found female predominance; however, Emem-Chioma et al.[14] reported similar male predominance. Our patients were mainly in their third decades of life which is the productive age group with associated socioeconomic consequences. This concurs with reports from other parts of Nigeria and developing world.[9],[10],[11],[12],[13],[14] It contrasts with reports from developed world where AKI is mainly seen in elderly probably due to the high rate of open heart and pancreatic surgeries.[15],[16]

The majority of AKI patients in this study presented with severe gastroenteritis and septicemic illness. The incidence of communicable disease is still a major health problem in developing world; hence, it is not surprising that our patients were in septicemic state. Similar reports [17],[18] from another center in Nigeria were in keeping with our findings. Pregnancy-related AKI due to septic abortion, ante/postpartum hemorrhage, and eclampsia accounted for over 13% of cases seen in the study. Similar findings have been reported in other parts of Nigeria.[19],[20],[21] Illiteracy, primigravidas, and poor antenatal care attendance were frequent findings among the patients.

The kidneys are particularly vulnerable to toxin-induced damage because it is highly vascularized, with largest exposed endothelial surface by the weight of any other organ in the body, presence of active metabolic processes, propensity to develop autoimmune diseases and the ability to ultrafiltrate, and concentrate blood borne nephrotoxins.[22] The use of drugs and herbal remedies accounts for 6.3% of AKI in our study. This figure is in accord with 8% and 9% reported by Bamgboye et al.[23] and Ojogwu.[24] It, however, contrasts sharply with 33% and 23% observed by Adelekun et al.[25] and Kumar et al.,[13] respectively. The differences in toxic agent exposure, patient population, and diagnostic criteria may be responsible for the noted disparity.

The main clinical features from this study were decrease in urine output, fever, and body swelling. This is not surprising as the leading cause of AKI were gastroenteritis and septicemic illness. Oliguria accounted for 79% of our cases which is similar to other studies that noted oliguria as a prominent feature of AKI.[8],[9],[10] Anemia was found in 38% of cases necessitating blood transfusion in which 76% received at least 2 units of blood. Factors alluded to the anemia included multifactorial nature of AKI; since many of these patients had septicemia, septic abortion, and obstetric bleeding.

Management of AKI is mainly by addressing the etiological cause and supportive treatment. Renal replacement therapy either in the form of peritoneal dialysis or hemodialysis is instituted following failed response to conservative management. Indications for dialysis in our study included worsening of clinical condition, uremic symptoms, and persistent oliguria. The waiting time is very short in our center because unavailability of the fund did not preclude the patient from having dialysis, in contrast to what obtains in other centers.[9],[10],[11] The majority (80%) had a maximum of three sessions of hemodialysis before recovery. This is in accord to report from other centers but sharply contrast with the finding by Emem-Chioma et al.[14] None of the patients had peritoneal dialysis because such facility is not available in our center and in fact not a popular mode of renal replacement therapy in our country. Renal biopsy was not done in any of the patients not because there were no indications but due to lack of good nephropathologist in the center and country at large.

The overall mortality rate in this study was 26.4%, which is similar to 28.8% reported by Okunola et al.[10] but in sharp contrast with findings by Chijioke et al.,[11] who reported 48%. The studies [26],[27] from Malaysia revealed mortality rate between 33 and 48%. The possible reason for low mortality rate in our study could be attributed to early referral to nephrologist and prompt commencement of intermittent hemodialysis. There was mortality difference between those who had hemodialysis and those managed conservatively (24.9% vs. 27.7%, respectively), though not statistically significant.

  Conclusion Top

AKI is common in our environment, and the leading causes are preventable and treatable. Early diagnosis, referral to nephrologist and institution of treatment, is associated with low mortality.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Chijioke A, Aderibigbe A, Olanrewaju TO, Adekoya AO. Prevalence of acute renal failure due to exogenous nephrotoxins in Ilorin. Trop J Nephrol 2007;1:43-8.  Back to cited text no. 22
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  [Figure 1]

  [Table 1]

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