Socio-demographics
There were a total of 144 patients diagnosed to have AKI in the TASH Emergency Department from August 2018 to May 2019, 79 (54.9%) of which were males, and the rest were female.The mean age of the patients was 46.6 ±16.6 and around 40% of the patients are found in the age group between 30-50 years. Although patients came from all around Ethiopia, nearly half of them (49.3%) came from Addis Ababa and more than a quarter of the patients came from Oromia (27.8%). (Table 1)
Table 1 Socio-demographic characteristics of patients with AKI, TASH, Addis Ababa, May 2019
Sociodemographic
Variable
|
Sub-variable
|
Frequency
|
Percent
|
Sex
|
Male
|
79
|
54.9
|
|
Female
|
65
|
45.1
|
|
Total
|
144
|
100
|
Age
|
<21
|
9
|
6.3
|
|
21-30
|
20
|
13.9
|
|
31-40
|
28
|
19.4
|
|
41-50
|
29
|
20.1
|
|
51-60
|
28
|
19.4
|
|
61-70
|
18
|
12.5
|
|
>70
|
12
|
8.3
|
|
Total
|
144
|
100
|
Region
|
Addis Ababa
|
71
|
49.3
|
|
Oromia
|
40
|
27.8
|
|
SNNPR
|
16
|
11.1
|
|
Amhara
|
9
|
6.3
|
|
Others
|
6
|
4.2
|
|
Total
|
142
|
98.6
|
|
Missing
|
2
|
1.4
|
Clinical characteristics of AKI
The commonest cause of AKI identified was sepsis (43.8%), (Table 2) 39(27.1%) of the patients were found to have preexisting CKD. The main underlying cause of CKD was extra-renal OUP which included 1/4th of the cases (25.6%) followed by hypertension (23.1%) and diabetes (20.5%). The mean baseline creatinine was 9.8 ± 6.6. The majority of deaths in AKI on CKD patients was found in those with extrarenal obstructive uropathy most of which are due to cervical ca. (38.5%). (Table 2)
More than half, 52.8%, of the patients with AKI had complications. Of these, the commonest complication identified was uremic encephalopathy which occurred in 42.1%, followed by anemia (40.8%) and hyperkalemia (28.9%).
A Chi-square test of independence was calculated comparing the frequency of clinical characters in men and women. A significant interaction was found in men with nephrolithiasis as compared with women
Table 2 Clinical characters and proportion of death of patients with AKI, TASH, Addis Ababa, 2019
|
Clinical characteristicsa
|
Frequency
N (%)
|
Male
N(%)
|
Female
N(%)
|
P-Value
|
Proportion
of death(%)
|
Causes of AKI
|
Sepsis
|
65(43.2)
|
36(55.4)
|
29(44.6)
|
0.854
|
25(56.8)
|
Volume depletion
|
36(25)
|
19(52.8)
|
17(47.2)
|
0.805
|
12(27.3)
|
CRS-1
|
23((16)
|
13(56.5)
|
10(43.5)
|
0.835
|
3(6.8)
|
OUP
|
23(16)
|
11(47.8)
|
12(52.2)
|
0.480
|
9(20.5)
|
AGN
|
8(5.6)
|
5(63)
|
3(37)
|
0.642
|
3(6.8)
|
Hypertensive crisis
|
7(4.9)
|
4(57.14)
|
3(42.86)
|
0.887
|
2(4.5)
|
|
Drug
|
5(3.5)
|
3(60)
|
2(40)
|
0.803
|
0(0)
|
|
TLS
|
4(2.8)
|
1(25)
|
3(75)
|
0.229
|
2(4.5)
|
|
Others
|
3(2)
|
3(100)
|
0(0)
|
0.194
|
1(2.3)
|
Causes
Of underlying CKD
|
Extra renal OUP
|
10(25.6)
|
4(40)
|
6(60)
|
0.349
|
5(38.5)
|
Hypertension
|
9(23.1)
|
6(66.7)
|
3(33.3)
|
0.462
|
3(23.08)
|
Diabetes
|
8(20.5)
|
5(62.5)
|
3(37.5)
|
0.655
|
3(23.08)
|
Nephrolithiasis
|
5(12.8)
|
5(100)
|
0(0)
|
0.039
|
0(0)
|
Others
|
7(18)
|
4(57.14)
|
3(42.86)
|
0.901
|
2(15.38)
|
Complications
of AKI
|
Uremic encephalopathy
|
32(42.7)
|
20(13.9)
|
12(8.3)
|
|
23(52.3)
|
Anemia
|
31(41.3)
|
15(10.4)
|
16(11.1)
|
|
8(18.12)
|
Hyperkalemia
|
22(29.3)
|
10(6.9)
|
12(8.3)
|
|
11(0.25)
|
Fluid overload
|
11(14.7)
|
7(63.64)
|
4(36.36)
|
|
6(13.64)
|
Uremic gastropathy
|
11(14.7)
|
6(54.55)
|
5(45.45)
|
|
3(6.82)
|
Uremic pericarditis
|
3(4.0)
|
3(100)
|
0(0)
|
|
1(2.27)
|
aSum is more than 100 % as most patients had more than one cause and complication
|
Laboratory values
The patients had complete blood count and renal function tests during admission and upon discharge. The mean white cell count is 13,138.8 ± 9558.1 and 11810 ± 6520.7 on admission and discharges respectively. There is a good decrement of creatinine upon discharge from a mean of 5.7±5.4 to 4.9±4.9. (Table 3)
Table 3: Selected laboratory values of patients with AKI, TASH, Addis Ababa, 2019
Laboratory values
|
Point in time
|
Mean ± Standard deviation
|
Urea
|
Admission
|
122±76.3
|
Discharge
|
116.2±82.4
|
Creatinine
|
Admission
|
5.7±5.4
|
Discharge
|
4.9±4.9
|
WBC count
|
Admission
|
13138.8±9558.1
|
Discharge
|
11810±6520.7
|
Hemoglobin
|
Admission
|
11.1±3.3
|
Discharge
|
10.8±2.9
|
Platelet count
|
Admission
|
212887.4±127867.3
|
Discharge
|
269042.5±138420.506
|
Treatment practice and outcome of patients with AKI
More than 3/4th of the patients (82.6%) took drug treatments for a variety of causes of AKI including cardiac, Septic ATN, hypertension, and AGN. On the other hand, around half of the patients took fluid treatment for the AKI.
18 patients (12.5%) underwent dialysis. (Figure 1) )Indications for dialysis are shown in Table 5. The commonest indication identified was uremic encephalopathy (72.2%) followed by hyperkalemia (27.8%) and refractory fluid overload (22.2%).
The rest minority underwent surgical management, percutaneous nephrostomy being the commonest surgical procedure. Cervical cancer was the cause in most cases of obstructive uropathy.
The average duration of hospital stay was 7.2 days, the minimum being 2 days and the maximum is 36 days, with a range of 34 days. (Table 6 ) More than half of the patients (61.1%) were discharged home. And nearly 1/3rd (30.6%) of the patients died. 4 patients were referred to other centers the reason being lack of bed and two patients self-discharged against medical advice. (Figure 2)
Table 4: Indication for dialysis of AKI patients, TASH, Addis Ababa, 2019
|
Dialysis b
|
Death
|
Indications for dialysis
|
|
Yes(%)
|
No(%)
|
Total(%)
|
Yes(%)
|
No(%)
|
Refractory
fluid overload
|
Yes(%)
|
4(22.2)
|
7(5.6)
|
11(7.7)
|
6(60)
|
4(40)
|
No(%)
|
14(77.8)
|
117(94.4)
|
131(92.3)
|
38(29.7)
|
90(70.3)
|
Hyperkalemia
|
Yes(%)
|
5(27.8)
|
17(13.7)
|
22(15.5)
|
11(55)
|
9(45)
|
No(%)
|
13(72.2)
|
107(86.6)
|
120(84.5)
|
33(28)
|
85(72)
|
Uremic encephalopathy
|
yes(%)
|
13(72.2)
|
18(14.5)
|
31(21.8)
|
23(74.2)
|
8(25.8)
|
No(%)
|
5(27.8)
|
106(85.5)
|
111(78.2)
|
21(19.6)
|
86(80.4)
|
b Sum is more than 100 % as most patients had more than one indication for dialysis
Table 5: mean hospital LOS in each type of AKI, TASH, Addis Ababa, 2019
Types of AKI
|
Mean hospital LOS±SE
|
Prerenal
|
6.50±6.65
|
Intrinsic renal
|
7.84±8.18
|
Post renal
|
8.39±6.73
|
Mixed
|
6.40±4.85
|
Common complications leading to deaths encountered were uremic encephalopathy, fluid overload, and hyperkalemia. From the death records, nearly 3/4th (74.2%) had uremic encephalopathy; whereas in 60% of deaths, there were complications of fluid overload. And more than half of the deaths (55%) had hyperkalemia. (Table 5)
Predictors of mortality
Binary logistic regression was implemented further to determine the independent predictors of mortality among AKI patients with and without CKD; In overall AKI patients (those AKI regardless of presence or absence of CKD) mortality was significantly correlated with the presence of Uremic encephalopathy [OR,0.061; 95 %CI (0.019,0.198); P=<0.001] and hyperkalemia which was marginally significant [OR,0.283; 95 %CI (0.077,1.046); P=0.058]. (Table 7)
Table 6: Binary logistic regression analyses for correlation between different factors and death in Overall as well as pure AKI (Without underlying CKD), TASH, Addis Ababa, 2019
|
|
Death
|
|
|
COR(95%CI)
|
P-value
|
AOR(95%CI)
|
P-Value
|
factors in AKI
|
Fluid Overload
|
3.55(0.95,13.3)
|
0.060
|
1.743(0.28,10.68)
|
0.548
|
Hyperkalemia
|
3.15(1.19,8.29)
|
0.02
|
5.06(1.291,19.87)
|
0.020
|
Sepsis
|
2.46(1.18,5.16)
|
0.017
|
3.151(1.23,8.07)
|
0.017
|
Uremic encephalopathy
|
11.8(4.6,30)
|
<0.001
|
13.71(4.32,43.5)
|
<0.001
|
Creatinine on admission
|
0.952(0.893,1.014)
|
0.128
|
1.049(0.954,1.154)
|
0.320
|
Factors
In
AKI without underlying CKD
|
Fluid overload
|
3.12(0.67,15.32)
|
0.144
|
1.189(0.090,15.627)
|
0.895
|
Hyperkalemia
|
6.32(1.51,26.44)
|
0.012
|
0.124(0.017,0.905)
|
0.039
|
Sepsis
|
2.31(0.96,5.54)
|
0.062
|
0.378(0.124,1.152)
|
0.087
|
Uremic encephalopathy
|
30.93(6.4,149.19)
|
<0.001
|
0.033(0.006,0.190)
|
<0.001
|
Creatinine on admission
|
0.90(0.811,0.999)
|
0.047
|
1.036(0.887,1.211)
|
0.653
|
|
|
|
|
|
|
|
A paired-samples t-test was conducted to compare selected laboratory values of patients with AKI upon admission and discharge. There was a significant difference between creatinine values upon admission (M=5.14, SD=4.9) and discharge (M=4.87, SD=4.85) conditions; t(46) =3.243, p = 0.002. These results showed that there was a real improvement in creatinine after the patient finished the course in the hospital. (Table 8)
Table 7: Paired-samples T-test for selected laboratory values of patients with AKI, TASH, Addis Ababa,2019
Laboratory values on admission and discharge
|
Mean
|
SD
|
SE means
|
95%CI of the difference
|
t
|
df
|
Sig. (2-tailed)
|
Lower
|
Upper
|
Urea
|
15.561
|
52.164
|
9.369
|
-3.573
|
34.695
|
1.661
|
30
|
0.107
|
Creatinine
|
1.067
|
2.256
|
0.329
|
0.405
|
1.730
|
3.243
|
46
|
0.002
|
WBC
|
1862.750
|
7816.859
|
1235.954
|
-637.203
|
4362.703
|
1.507
|
39
|
0.140
|
Hemoglobin
|
-0.0111
|
2.953
|
0.479
|
-1.081
|
0.860
|
-0.231
|
37
|
0.819
|
Survival of AKI patients
Probability of survival of AKI patients who have sepsis, who underwent dialysis and who had underlying CKD estimated using Kaplan-Meier curves, a lower survival of all AKI patients with sepsis over the hospital stay period was found with marginally significant P-value (Mean survival AKI with sepsis=16.967; SE= 3.169 vs. without sepsis=28.105; SE 3.413; P = 0.056). The comparison between AKI patients with CKD, time to death didn’t significantly differ from those who haven’t underlying CKD., For those patients who underwent dialysis, as is, no significance with regards to survival in-hospital stay. Finally, time to discharge was assessed between each type of AKI and there was no significant difference found. (Figure 3)