Abstract              Background: Acute renal failure (ARF), now increasingly referred to as “acute kidney injury” (AKI), is characterized by sudden (i.e., hours to days) impairment of kidney function. Acute kidney injury (AKI) is defined as a rapid (over hours to weeks) and usually reversible decline in glomerular filtration rate (GFR) that can occur either in the setting of previously normal renal function (“classical” AKI) or in a patient with pre-existing chronic kidney disease (acute-onchronic renal failure; ACRF). Aims and Objectives: To Study the Clinical features and Outcome of patients suffering from Acute Renal Failure requiring dialysis reporting to the Department of medicine of Tertiary care centre. Materials and Methods: In the present hospital based retrospective cross-sectional study all the adult AKI patients who required haemodialysis and admitted during the January 2016 to December 2016 were enrolled in the study. The medical records of all patients admitted during the study period were studied. All patients of age 14 and above with AKI and have been dialyzed at least once during the study period were included. In the hospital patients of age 14 and above are considered as “adults” and admitted to the adult patient wards. Those patients who had dialysis for overdose of dialyzable drugs; those who were under the age of 14 or had incomplete or missing records were excluded. Data on sociodemographic details, clinical features and causes associated with AKI were recorded on a prestructured proforma. Results: Majority of the patients requiring dialysis with acute kidney disease were young with age less than 40 years of age. Male patients were 59.57%. 70.21% patients were from urban area. Oligouria (80.85%), edema (65.96%) and encephalopathy (46.81%) were the common presenting features. The commonest causes of acute kidney dieses was hypovolemia (27.66 %) followed by Acute Glomerulonephritis was observed in 25.53%. Pregnancy Related Cause and sepsis was seen in 10.64% cases respectively. The mortality due to AKI was 10.63% in the present study. Conclusion: The acute renal failure requiring dialysis was seen commonly in young male, mostly belonging to urban area and presents with Oliguria, Edema and Encephalopathy. The most common cause for acute renal failure and mortality associated with it was Hypovolemia and Acute Glomerulonephritis.

Key Words: Acute Renal Failure, dialysis, Clinical features, Outcome.

 

INTRODUCTION

Acute kidney injury (AKI) is defined as a rapid (over hours to weeks) and usually reversible decline in glomerular filtration rate (GFR) that can occur either in the setting of previously normal renal function (“classical” AKI) or in a patient with pre-existing chronic kidney disease (acute-onchronic renal failure; ACRF).^1-3 Acute renal failure (ARF), now increasingly referred to as “acute kidney injury” (AKI), is characterized by sudden (i.e., hours to days) impairment of kidney function. Descriptions of AKI date back to the ancient Greek period⁴, when the diagnosis was possible only by observing a reduction in urine volume. The modern day conception of AKI has evolved alongside developments in pathology and clinical biochemistry, which have permitted clinicopathologic correlations and early diagnosis⁵. Initial descriptions of AKI from the early 20^th century centered around specific conditions, such as crush injuries⁶, war nephritis⁷, and falciparum malaria⁸. Sir William Osler in 1912 described several recognizable causes of AKI under the heading of “acute Bright’s disease,” including sepsis, pregnancy, burns, and toxins⁹. Early identification of high-risk patients would allow greater targeting of tailored interventions and more appropriate allocation of limited clinical resources¹⁰. Additionally, robust prognostic models would aid in the conduct of clinical trials by enriching the study population with individuals who are more likely to experience the clinical event of interest^11,12.

 

MATERIALS AND METHODS

The present hospital based retrospective cross-sectional study was done at department of medicine of Dr. Ulhas Patil Medical College and Hospital All the adult AKI patients who required haemodialysis and admitted during the January 2016 to December 2016 were enrolled in the study. The medical records of all patients admitted during the study period were studied. All patients of age 14 and above with AKI and have been dialyzed at least once during the study period were included. In the hospital patients of age 14 and above are considered as “adults” and admitted to the adult patient wards. Those patients who had dialysis for overdose of dialyzable drugs, those who were under the age of 14 or had incomplete or missing records were excluded. AKI was defined as an increase in SCr by 0.3 mg/dl within 48 h or a 50% increase in SCr from the baseline within 7 days according to the KDIGO criteria ^[ref2-16]. Patients were classified according to the KDIGO criteria as specified by stage 1, stage 2 and stage 3. The date of AKI onset was defined as the earliest day that the SCr change met the KDIGO criteria. The stage of AKI was determined using the peak SCr level after the date of AKI onset. Data on sociodemographic details, clinical features and causes associated with AKI were recorded on a prestructured proforma. The collected data was entered in Microsoft excel and was analysed and presented with appropriate tables and graphs.

 

RESULTS

Table 1: Demographic distribution of study patients

It was observed that majority of the patients requiring dialysis with acute kidney disease were young with age less than 40 years of age. The proportion of male patients (59.57%) was more as compared to female patients (40.43%). It was seen that 70.21% patients were from urban area and remaining 29.79% were belonging form rural area.

 

Table 2: Distribution according to presenting symptoms

The most common presenting features were oligouria (80.85%), edema (65.96%) and encephalopathy (46.81%).

 

Table 3: Distribution according to Common Causes of dialysis requiring AKI

It was seen that the commonest causes of acute kidney dieses was hypovolemia (27.66 %) followed by Acute Glomerulonephritis was observed in 25.53%. Pregnancy Related Cause and sepsis was seen in 10.64% cases respectively.

Table 4: Distribution of outcome according to specific cause of AKI

It was seen that there were total 5 deaths in the study patients in AKI. Out of them 3 were due to Hypovolemia, one was due to Acute Glomerulonephritis and one was due to Nephrotoxic Drugs. Thus the mortality due to AKI was 10.63% in the present study.

 

DISCUSSION

The present study was conducted at the department of medicine with the aim to study the Clinical features and Outcome of patients suffering from Acute Renal Failure requiring dialysis. Thus total 47 cases were studied; admitted during the study duration with AKI and requiring dialysis. It was observed that majority of the patients requiring dialysis with acute kidney disease were young with age less than 40 years of age. Ibrahim et al¹³ observed that the mean age of patients with AKI was 36.7 ± 14.5 years, with more than two third being in the age group between 21 to 40 years. The proportion of male patients (59.57%) was more as compared to female patients (40.43%). Gender distribution observed by Ibrahim et al¹³ was nearly equal, with 50.3% being male. It was seen that 70.21% patients were from urban area and remaining 29.79% were belonging form rural area. Similar findings were also observed by Ibrahim et al¹³. Acute Kidney Injury (AKI) is an abrupt decline in kidney function and is a clinical condition that occurs in 10- 20% of hospital admissions and remains the most common reason for inpatient nephrology consultation^14,15,16. Patients who develop AKI have higher rates of morbidity, mortality, and end-stage kidney disease¹⁷. The most common presenting features were oligouria (80.85%), edema (65.96%) and encephalopathy (46.81%). Similar findings were also reform Emen-Chioma¹⁸ and Bagshaw¹⁹ and Ibrahim et al¹³. It was seen that the commonest causes of acute kidney dieses was hypovolemia (27.66%) followed by Acute Glomerulonephritis was observed in 25.53%. Pregnancy Related Cause and sepsis was seen in 10.64% cases respectively. Severe preeclampsia, eclampsia, postpartum haemorrhage and puerperal sepsis wee the pregnancy related causes. In the study by Ibrahim et al^ref1 the commonest causes of AKI (22.5 %) was observed to be hypovolemia due to gastrointestinal loss (in the form of diarrhoea or vomiting) or blood loss. AGN and pregnancy related cause was seen in 21.9% and 18.5%.  It was seen that there were total 5 deaths in the study patients in AKI. Out of them 3 were due to Hypovolemia, one was due to Acute Glomerulonephritis and one was due to Nephrotoxic Drugs. Thus the mortality due to AKI was 10.63% in the present study. Ibrahim et al¹³ observed the mortality rate of 29.1% in their study. The mortality observed in the study was much lower than the data from a global meta-analysis of studies done across the globe which has shown a pooled AKI-associated mortality rate 49.4 % for dialysis requiring AKI. The rate of AKI-associated mortality seems to be lower in developing countries and varies from 10% to 40%.^20,21,22 In contrast to developing countries, very high mortality rates of AKI are reported from developed countries, ranging between 37% and 81%.^23-27

 

CONCLUSION

Thus we conclude that acute renal failure requiring dialysis was seen commonly in young male, mostly belonging to urban area and presents with Oliguria, Edema and Encephalopathy. The most common cause for acute renal failure and mortality associated with it was Hypovolemia and Acute Glomerulonephritis.

 

REFERENCES

1. Sharfuddin A, Weisbord SD, Palevsky PM, Molitoris BA. Acute kidney injury. In: Taal MW, Chertow GM, Marsden PA, Skorecki K, Yu ASL, Brenner BM, editors. Brenner and Rector’s the kidney. 9th ed. Philadelphia: Elsevier Saunders; 2012. p. 1044-99.
2. Lameire N, Van Biesen W, Vanholder R. Acute renal failure. Lancet 2005; 365:417-30.
3. Lameire N, Van Biesen W, Vanholder R. The changing epidemiology of acute renal failure. Nat Clin Pract Nephrol 2006; 2: 364-77.
4. Marketos SG, Eftychiadis AG, Diamandopoulos A: Acute renal failure according to ancient Greek and Byzantine medical writers. J R Soc Med 86: 290–293, 1993
5. Eknoyan G, Bulger RE, Dobyan DC: Mercuric chlorideinduced acute renal failure in the rat: I. Correlation of functional and morphologic changes and their modification by clonidine. Lab Invest 46: 613–620, 1982
6. Bywaters EG, Beall D: Crush injuries with impairment of renal function. 1941. J Am Soc Nephrol 9: 322–332, 1998
7. Davies FC, Weldon RP: A contribution to the study of “war nephritis.” Lancet 2: 118–120, 1917
8. Yorkes W, Nauss RN: The mechanism of the production of suppression of urine in blackwater fever. Ann Trop Med Parasitol 12: 287–312, 1911
9. Osler W: The Principles and Practice of Medicine, 1912
10. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney inter., Suppl. 2013; 3: 1±150.
11. Riley RD, Hayden JA, Steyerberg EW, Moons KG, Abrams K, Kyzas PA, et al. Prognosis Research Strategy (PROGRESS) 2: prognostic factor research. PLoS Med. 2013; 10(2):e1001380.
12. Boessen R, Heerspink HJ, De Zeeuw D, Grobbee DE, Groenwold RH, Roes KC. Improving clinical trial efficiency by biomarker-guided patient selection. Trials. 2014; 15:103.
13. Ahmed Ibrahim, Momina M. Ahmed, Seman Kedir and Delayehu Bekele. Clinical profile and outcome of patients with acute kidney injury requiring dialysis—an experience from a haemodialysis unit in a developing country. 2016; 17:91.
14. Uchino S, Bellomo R, Goldsmith D, Bates S, Ronco C. An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med. 2006; 34(7):1913-7.
15. Ali T, Khan I, Simpson W, Prescott G, Townend J, Smith W, et al. Incidence and outcomes in acute kidney injury: a comprehensive population-based study. J Am Soc Nephrol. 2007; 18(4):1292-8.
16. Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005; 16(11):3365-70.
17. Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int. 2012; 81(5):442±8.
18. Mehta RL, Kellum JA, Shah SV, et al. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007; 11:R31.
19. Metcalfe W, Simpson M, Khan IH, Prescott GJ, Simpson K, Smith WCS, Macleod AM. Acute renal failure requiring renal replacement therapy: incidence and outcome. Q J Med. 2002; 95:579–83.
20. Prakash J, Singh TB, Ghosh B, Malhotra V, Rathore SS, Vohra R, et al. Changing epidemiology of community acquired acute kidney injury in developing country: analysis of 2405 cases in 26 years from eastern India. Clin Kidney J 2013; 6:150-5.
21. Kohli HS, Bhat A, Jairam A, Arvindan AN, Sud K, Jha V, et al. Predictors of mortality in acute renal failure in a developing country: a prospective study. Ren Fail 2007; 29:463e9.
22. Cerda´ J, Lameire N, Eggers P, Pannu N, Uchino S, Wang H, et al. Epidemiology of acute kidney injury. Clin J Am Soc Nephrol 2008; 3:881-6.
23. 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.
24. Mehta RL, Pascual MT, Soroko S, Savage BR, Himmelfarb J, Ikizler TA, et al. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int 2004; 66:1613-21.
25. Lian˜o F, Pascual J. Epidemiology of acute renal failure: a prospective, multicenter, community-based study. The Madrid Acute Renal Failure Study Group. Kidney Int 1996; 50:811-8.
26. Waikar SS, Curhan GC, Wald R, McCarthy EP, Chertow GM. Declining mortality in patients with acute renal failure, 1988 to 2002. J Am Soc Nephrol 2006; 17:1143-50.
27. Guerin C, Girard R, Selli JM, Perdrix JP, Ayzac L. Initial versus delayed acute renal failure in the intensive care unit: a multicenter prospective epidemiological study. Rhoˆne-Alpes Area Study Group on Acute Renal Failure. Am J Respir Crit Care Med 2000; 161:872-9.