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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ASIA - AFRICA  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 391-396
Factors influencing hemodialysis and outcome in severe acute renal failure from Ilorin, Nigeria


Renal Unit, Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria

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Date of Web Publication28-Feb-2012
 

   Abstract 

The epidemiology of acute renal failure (ARF) varies between nations and even within the same country because of differences in diagnostic criteria, causes, mode of pre­sentation, and cost of therapy. To determine the factors influencing hemodialysis and outcome of severe ARF in Ilorin, Nigeria, we studied ARF patients on hemodialysis in our center between January 1989 and December 2009. There were 138 (58 males and 80 females) patients with age range between 18 and 69 years and a mean of 29.4 ± 11.9 years. Major etiologies of ARF included septicemia, acute glomerulonephritis, septic abortion, herbal remedies, post-partum bleeding, and gastroenteritis. The mean duration of illness and waiting time before dialysis was 11.7 ± 8.14 days and 3.28 ± 1.86 days, respectively. The mean number of dialysis was 2.24 ± 1.13 sessions and 89% of the patients received a maximum of three sessions before recovery. Hypotension, twitching of muscles, and back pains were common intradialysis complications. The factors that influenced hemodialysis and outcome were late presentation, severity of ARF, and financial constraints. The etiological agents are preventable and treatable conditions. The short duration of hospital stay, waiting time before dialysis, and total duration of illness influenced the outcome positively. We strongly recommend early referral of patients with severe ARF to nephrologists for proper management in a bid to reduce mortality from this disease.

How to cite this article:
Chijioke A, Makusidi A M, Rafiu M O. Factors influencing hemodialysis and outcome in severe acute renal failure from Ilorin, Nigeria. Saudi J Kidney Dis Transpl 2012;23:391-6

How to cite this URL:
Chijioke A, Makusidi A M, Rafiu M O. Factors influencing hemodialysis and outcome in severe acute renal failure from Ilorin, Nigeria. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Jul 23];23:391-6. Available from: http://www.sjkdt.org/text.asp?2012/23/2/391/93189

   Introduction Top


Ilorin is located in the Guinea savannah area of Nigeria and the university of Ilorin teaching hospital (UITH) serve as a referral center for most states in both North central and South west zones. Our dialysis center was established in the year 1987 with the aim of caring for pa­tients with acute and chronic renal failure. Acute renal failure (ARF) is a syndrome cha­racterized by rapid and possibly reversible deterioration in renal function following a variety of insults to previously normal kid-neys. [1],[2],[3],[4],[5] It may be difficult to distinguish bet­ween acute-on-chronic renal failure and acute renal failure because most of the CRF patients in the tropics present in acute setting. [6],[7],[8],[9],[10] The epidemiology of ARF varies between countries and even within the same country because of differences in the diagnostic cri-teria. [11],[12],[13],[14],[15],[16] In developed countries, elderly pa­tients predominate [17],[18] in contrast to tropical environment where acute renal failure is a disease of children and young adults. [19],[20],[21],[22],[23] In developing countries such as Nigeria, the lea­ding causes of ARF include volume deple-tion, l[8],[23],[24] infection, [8],[25],[26] obstetric, [2] and toxic agents. [28],[29],[30],[31],[32] Simple interventions like early oral rehydration, [33],[34] improvement in obstetric prac-tice, [35],[36] and use of potent antibiotics in the treatment of infection [37],[38] can dramatically re­duce the incidence and severity of ARF. [33],[34],[35],[36]

Prevention of ARF is often the realistic way to decrease its morbidity and mortality since the cost of renal replacement therapy (RRT) is prohibitively high, especially in the tropics. [19],[39]-[41] Early commencement, appropriate dosage and frequency of RRT are among factors asso­ciated with good outcome. [42]-[48]

The aim of our study was to document our experience on ARF with specific reference to causes, mode of presentation, factors affecting initiation of dialysis, duration of hospital stay, and outcome.


   Patients and Methods Top


We studied all the cases of ARF treated at our center from January 1989 to December 2009. All the patients met the RIFLE criteria for diagnosis of ARF. [2],[3] The inclusion criteria comprised some or all of the following fea­tures: short duration of illness in days and weeks, unusual weakness, vomiting, diarrhea, anorexia, malaise, hiccups, altered sensorium, body swelling, pruritus, polyuria, loin pains, urine output below 0.3 mL/kg/24 h and blood biochemistry that showed tripling of creatinine or creatinine levels greater than 355 mmol/L. All patients had glomerular filtration rate (GFR) reduced to greater than 75% in the pre­sence of normal-sized kidneys. Patients with previous history of renal disease, more than three months duration of illness, ultrasono-graphic evidence of shrunken kidneys and those who had suggestive clinical features but could not be investigated due to poor finances were excluded from the study. Also excluded were patients with ARF and who had treat­ment with peritoneal dialysis. The majority of the etiological factors were obtained from clinical features. All patients with suspected infections had septic work-up and complete blood count, which showed leucocytosis and toxic granulations with va-cuolization of neutrophils. The diagnosis of acute glomerulonephritis was confirmed in the presence of facial/ankle edema, macroscopic hematuria, hypertension, and mild proteinuria. None of the patients had renal biopsy for histological diagnosis. Dialysis was instituted on severely uremic patients who could afford the procedure. Most of the patients received two to three, four hourly sessions of hemo-dialysis before recovery of ARF. Survivors were followed up after discharge in the nephrology clinic till they achieved normal renal function based on clinical and laboratory parameters. Data were analyzed using SPSS version 16.


   Results Top


There were 138 (58 males and 80 females) out of 342 ARF patients (40.35%) who were dialyzed because of their disease, with a male-to-female ratio of 1:33. The age range was from 18 to 69 years with a mean of 29.4 ± 11.9 years, and 76% of the patients were below 40 years. The etiological factors are shown in [Figure 1]; the most frequent causes included septicemia (35.5%), acute glomerulonephritis (15.5%), and septic abortion. The duration of ARF before dialysis ranged from 1 to 30 days with a mean of 11.7 ± 8.14 days, and 80% of the cases were below 14 days. The waiting time before commencing dialysis ranged from 1 to 9 days with a mean of 3.28 ± 1.86 days, and the majority were less than seven days (91.1%). The majority of patients were traders and students followed by civil servant and housewives. Blood transfusion ranged between 1 and 6 units, with a mean of 2.24 ± 1.13 units, and 65% of the patients received at least three units. Hemodialysis sessions ranged between 1 and 6 times with a mean of 2.24 ± 1.13 times, and 89% of the patients received a maximum of three sessions before recovery. The major factors influencing hemodialysis and outcome were late presentation, severity of ARF, and financial constraints. The dura­tion of hospitalization was less than 21 days in 96% of the cases with a mean of 20.1 ± 9.69 days. Hypotension, twitching of muscle, cramps, and back pains were the common intradialysis-encountered complications [Figure 2]. The outcome was favorable with six deaths (13.3% of the cases).
Figure 1: Causes of acute renal failure in the study patients.

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Figure 2: Intradialysis complications.

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   Discussion Top


The majority of acute renal failure patients in this study presented in a setting of a septicemic illness with the females in their productive age, constituting 58% of cases. Most of these females, had sepsis complicating abortion, uri­nary tract infection in pregnancy, prepartum and postpartum bleeding. Anemia was a com­mon associated feature at presentation as 65% of cases received at least three unit of blood transfusion before recovery. The finding of severe anemia necessitating blood transfusion is not surprising as the etiology of ARF was multifactorial and late presentation was very common. Many of these patients had septi-cemia, septic abortion, obstetric bleeding, and acute glomerulonephritis in varying combi­nations, which can individually cause severe anemia. Although duration of illness before presentation was less than two weeks, the very poor condition of many of them casts doubt on the reliability of such information.

The waiting time before commencement of dialysis was less than a week in most of these patients. This was encouraging as the usual delay in raising funds for cost of laboratory work-up and treatment of the patients was not uncommon and might have impacted on the favorable outcome. The prevalence of anemia among the patients was comparable to reports from other centers. [7],[8],[10],[17] The widespread pre­valence of anemia in tropical developing coun­tries due to multiple causes preclude the use of this important clinical feature in distinguishing between acute renal failure and acute-on-chronic renal failure. [6],[7],[8],[30],[31],[32] However, the availability and increased utilization of renal ultrasonography have helped considerably in making this distinction in recent times.

The duration of hospital stay was less than three weeks in the majority of our patients. This is not surprising as the predisposing factors were mainly preventable prerenal con­ditions and the waiting time before initiating dialysis was considerably short, which contri­buted to the low mortality rate of 13%. The ob­served intra-dialysis complications were similar to those reported by other authors. [8],[12],[19],[48],[49] Most of the identified complications are pre­ventable and treatable conditions. [8],[48],[49]

We conclude from our study that ARF was a common cause of morbidity and mortality in our environment. The implicated etiological agents were preventable and treatable condi­tions with majority of them presenting in septi-cemic illness. A short duration of hospital stay, waiting time before commencing dialysis, and duration of illness before presentation had positive influence on the outcome. We strongly recommend early referral of patients with severe ARF to nephrologists for proper ma­nagement in order to further reduce mortality from this highly preventable and treatable condition.

 
   References Top

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Correspondence Address:
A Chijioke
Renal Unit, Department of Medicine, University of Ilorin Teaching Hospital, Ilorin
Nigeria
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