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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 912-917
Outcome of sepsis-associated acute kidney injury in an intensive care unit: An experience from a tertiary care center of central Nepal


1 Department of Nephrology, College of Medical Sciences Teaching Hospital, Bharatpur, Nepal
2 Department of Cardiology, College of Medical Sciences Teaching Hospital, Bharatpur, Nepal
3 Department of Neurology, College of Medical Sciences Teaching Hospital, Bharatpur, Nepal

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Date of Web Publication24-Jun-2014
 

   Abstract 

Acute kidney injury (AKI) is a common and major complication of sepsis. Sepsis-induced AKI is associated with higher morbidity and mortality. A prospective study was designed to include all the patients with a provisional diagnosis of sepsis with AKI admitted in our inten­sive care unit from August 2009 to September 2010. Detailed demographic data including various clinical parameters, co-morbidities, investigations, complications and outcome were entered in a designated proforma and were analyzed. A total of 53 subjects with the provisional diagnosis of sepsis with AKI were included in the study. The majority of patients (60.37%) were female. The mean age of the study population was 45.84 ± 20.5 years. Forty-nine percent of the subjects were <45 years old and 26.4% patients were >65 years. Among the co-morbid conditions, 9.4% subjects had diabetes mellitus type 2. Among the primary causes of AKI, 72% of the cases were due to medical causes, in which pneumonia was the major cause, and 28% were due to surgical causes, in which cholecystitis was the major cause. 47.1% cases expired, 11.3% subjects left against medical advice and 41.5% cases had favorable outcome. Among the expired cases, 20.7% subjects expired within 24 h; for others, the median hospital stay was four days. This prospective study showed that the major causes of AKI were medical illness and pneumonia. Mortality in sepsis-induced AKI is significantly high. This highlights the importance of prevention of AKI in sepsis by early and renal-friendly aggressive treatment of sepsis and the need for improvement in the management of such AKI cases.

How to cite this article:
Ghimire M, Pahari B, Sharma SK, Thapa L, Das G, Das G C. Outcome of sepsis-associated acute kidney injury in an intensive care unit: An experience from a tertiary care center of central Nepal. Saudi J Kidney Dis Transpl 2014;25:912-7

How to cite this URL:
Ghimire M, Pahari B, Sharma SK, Thapa L, Das G, Das G C. Outcome of sepsis-associated acute kidney injury in an intensive care unit: An experience from a tertiary care center of central Nepal. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Sep 20];25:912-7. Available from: http://www.sjkdt.org/text.asp?2014/25/4/912/135229

   Introduction Top


Sepsis is a highly prevalent syndrome that demands admission to intensive care and is a leading cause of acute kidney injury (AKI). [1] AKI is associated with a high mortality in critically ill patients. [2] Sepsis-associated AKI (SAAKI) has been associated with an in­creased risk for death and longer hospital stay independently. [3] The causes of AKI are multi-factorial, but sepsis has consistently been the most common contributing factor, accounting for approximately 50% of all cases. [1]

Recently, two large multicenter cohort studies [4] , [5] have shown the occurrence of AKI in 36% of all patients admitted to the intensive care unit (ICU). Two other multicenter studies have shown that in critically ill patients, 46-48% of all AKI can be attributed to sepsis. [6] , [7] Prior studies have focused on the incidence, risk factors and prognosis of sepsis-induced AKI. [6] , [8] , [9] Only a few clinical studies have focused on the presentation, profile and outcome of septic AKI.10-12

In view of the relatively limited studies on septic AKI from Nepal and its importance in patient management and outcome, we con­ducted a study with an objective to describe the clinical outcomes of SAAKI.


   Aim Top


To describe the clinical outcomes of SAAKI.


   Settings and Design Top


Study protocol

A prospective, observational study of criti­cally ill patients admitted in the ICU with sep­sis and AKI were performed from August 2009 to September 2010. For this, a prospec­tive study was designed to include all the patients with a provisional diagnosis of sepsis with AKI. A formal informed verbal and writ­ten consent of the patients was obtained for the participation in the study as per the require­ments of the ethical committee for non-interventional studies.


   Methods and Materials Top


Study population

A total of 53 patients who were aged ≥12 years and admitted to a participating ICU with evidence of sepsis and AKI were enrolled for the study.

Case definition

AKI was defined by the Risk of Renal Failure, Injury to the Kidney, Failure of Kidney Function, Loss of Kidney Function and End-Stage Kidney Disease (RIFLE) criteria and sepsis by consensus criteria. [13] For this study, loss of kidney function and end-stage kidney disease in RIFLE criteria were not eva­luated. We considered SAAKI as having both sepsis and AKI simultaneously without any evidence of other established non-sepsis-rela­ted causes of AKI (e.g., radiocontrast and nephrotoxins). Any patient not meeting these criteria and those who were unable to give written consent were excluded from the study. The outcome of the study was assessed in terms of three parameters: (1) Death, (2) left against medical advice and (3) favorable out­come.

  1. Death was defined as expiry of the patients among the study population during the study period.
  2. Left against medical advice was defined as patients who terminated the treatment in the ICU and left against the medical advice.
  3. Favorable outcome was defined as patients who were discharged from the hospital.


Data collection

Details on demographic data including age, sex, date of admission and clinical data, in­cluding primary diagnosis, major medical or surgical illness, presence of co-morbidities and duration of ICU stay, were entered in a desig­nated proforma. During the hospital stay, these patients were followed-up till their discharge and their clinical outcome were recorded. De­tailed demographic data including various clin­ical parameters, co-morbidity, complications and outcome were entered in a designated proforma and were analyzed.


   Statistical Analysis Top


The convenience sampling was used for this study. Normally or near-normally distributed variables were reported as means with standard deviations and compared using the t test. Con­tinuous data were presented in the form of mean and the categorical data were analyzed using the χ- test. The SPSS package version 16.0 was used to carry out the statistical ana­lysis. P <0.05 was considered to be statistically significant.


   Results Top


A total of 53 subjects with a provisional diag­nosis of sepsis and AKI were included in the study. The majority of the cases were female (60.37%). The male to female ratio was 6:1. Patients who were ≤45 years were 49% (n = 26) and those who were ≥65 years were 26.4% (n = 14), and patients who were in between 46 and 64 years were 24.6% (n = 13). The mean age of the study group was 45.84 ± 20.5 years.

Among the primary causes of AKI, 72% (n = 38) cases were due to medical causes [Table 1] and 28% (n = 15) were due to surgical causes [Table 2]. The major medical illness in SAAKI was pneumonia, 47.1% (n = 25), suggesting the lung as the major organ as the primary fo­cus of sepsis, followed by urinary tract infection, 9.4% (n = 5), and enteric fever, 9.4% (n = 5).
Table 1: Major medical illness in sepsis-associated acute kidney injury.

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Table 2: Major surgical illnesses in sepsisassociated acute kidney injury.

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Among co-morbid conditions, 9.4% (n = 5) subjects had type 2 diabetes mellitus (DM), followed by chronic obstructive airways disease (COAD) 3.8% (n = 2), alcoholic liver disease 3.8% (n = 2), stroke 3.8% (n = 2) and coronary artery disease (CAD) 3.8% (n = 2).

In terms of outcome, 47.1% (n = 25) subjects expired, 11.3% (6) subjects left against medi­cal advice and 41.5% (n = 22) subjects had fa­vorable outcome [Table 3]. Among the expired cases, 7.5% (n = 4) subjects expired within 24 h, and for the others, the median hospital stay was four days [Table 4].
Table 3: Major outcome in sepsis-associated acute kidney injury.

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Table 4: ICU stay in sepsis-associated acute kidney injury.

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   Discussion Top


According to several reports from other coun­tries, sepsis is a serious problem in ICU pa­tients and accounts for 50% of AKI episodes. [14] However, the consensus criteria for AKI and the RIFLE classification were introduced in 2004 by the Acute Dialysis Quality Initiative group, [15] and the notion of septic AKI and its importance has only been emphasized in the recent years. We conducted a prospective ob­servational study to describe the clinical out­comes that are associated with septic AKI in critically ill patients using the RIFLE classi­fication. To the best of our knowledge, to date, no such study has been performed prospec-tively in our country in the ICU population with SAAKI.

In our study, we found SAAKI to be more prevalent in the younger population, 49% (n = 26) vs. 26.4% (n = 14) in the elderly patients (≥65 years). In contrast to our study, Neveu et al [16] showed that patients with septic AKI were generally older and had a greater burden of illness. Previous studies have generally found septic AKI to be associated with older age, greater co-morbid disease and medical ill-ness. [11],[12] Druml et al [17] found that, in elderly patients, ARF acquired within the ICU was associated with an extremely poor outcome. This contradictory finding in our study could be because of the fact that more patients in our study were ≤45 years were 49% (n = 26) and older people are getting less privilege and prio­rity from the family members in terms of health access during their illness, which is common in our part of world, neglecting the old.

In our SAAKI study, the source of infection was primarily the lung, followed by the abdo­men and urinary tract, which was quite similar to other reports. [6],[11] However, the source of infection had no significant impact on the outcome of the patient in our study, a finding supported by another study specifically addres­sing this issue. [18] In our study, pneumonia was the leading cause of SAAKI. The next com­mon etiologies were gastroenteritis and urinary tract infection. This was in contrast to the observations seen in India, [19] where over 60% of the AKI cases are related to gastroenteritis.

In the past, the mortality of patients in SAAKI was high despite our increasing abi­lity to support vital organs and resuscitate patients. However, over the past decade, mor­tality associated with severe sepsis has de­creased, as also recently evidenced from a large investigation in the USA. [20] A recent re­view of studies published from 1958-1997 also found a reduction in mortality from septic shock. [21]

In contrast to developed countries, where most cases of AKI are related to trauma and multi-organ failure, AKI in developing countries is often related to medical causes [22] that were similar to our study result, where we also observed medical causes to be the more fre­quent reasons for SAAKI.

In our SAAKI study, type 2 DM (9.4%) was the major co-morbidity, followed by alcoholic liver disease (3.8%), stroke (3.8%) and CAD (3.8%). Type 2 DM appeared to be the most strongly associated co-morbidity with the risk of death. About 60% of the patients had an unfavorable outcome in the form of death in patients with type 2 DM (P-value <0.5). In an episepsis study, chronic liver insufficiency and congestive heart failure appear to be the most strongly associated with the risk of death, as these two variables were selected after omitting the global severity of underlying disease. Simi­lar findings were reported from the analysis of the European Sepsis Database. [23]

Mortality from sepsis in ARF patients ranges between 57% and 89%. [24] Neveu et al [16] des­cribed an in-hospital mortality of 75% for patients with septic AKI, which is higher than the 58.4% cohort (expired cases together with left against medical advice group) seen in our study. This difference in mortality outcome may be due the difference in clinical setting and circumstances in which acute renal failure occurred. In addition, septic patients with sub­sequent ARF carry a higher mortality rate than patients without ARF, probably because of associated organ failure, mainly respiratory. In our study, we observed that 47.1% subjects ex­pired, 11.3% subjects left against medical ad­vice and 41.5% subjects had favorable out­come. Among the expired cases, 7.5% of the subjects expired within 24 h. Majority of the patients (60.4%) were female, of whom 40% expired [left against medical advice (LAMA) included in the expired cases] and 39.6% were male, of whom 24.5% expired. However, the gender difference did not influence outcome (P <0.5), a finding supported by another study specifically addressing this issue. [25]

The median hospital stay of patients in our study was four days, with a maximum hospital stay of 17 days in one patient. However, other studies have documented a protracted hospital stay in a substantial proportion of patients with severe sepsis. [17],[14],[22] For example, in the study done by Brun-Buisson et al, [17] 16% of patients were in the hospital 30 days after the occur­rence of sepsis. [17] In the PROWESS trial, more than 40% of the patients were still in hospital at 28 days. [26] Therefore, follow-up in sepsis trials should be extended longer, up to three months, to capture the overall pattern of the hospital outcome of patients. [27] The lower length of stay in the ICU of patients with SAAKI seems to be related to a high pro­portion of early deaths found in this patient population.


   Conclusions Top


Mortality in SAAKI is significantly high and has a negative impact on outcome indepen­dently. In accordance with previous studies, AKI should therefore be seen as a strong inde­pendent risk factor for mortality rather than merely an organ dysfunction associated with sepsis, oliguria and rising creatinine values. This dictates either on the prevention of AKI in sepsis by early diagnosis and renal-friendly aggressive treatment or the need of advanced or sophisticated ICU cares in the management of such AKI cases. Because the incidence of sepsis is expected to increase further as the population ages, so will the incidence of SAAKI. Hence, implementation of effective management strategies and continued research efforts are needed to prevent its occurrence and to identify patients at risk of developing kidney injury to improve the outcome of such patients.


   Acknowledgment Top


This work was performed in the College of Medical Sciences Teaching Hospital, Bharatpur, Nepal. The authors would like to acknowledge Dr. Mani, Gautam, Dr. Khusraj Dewan, Dr. Ramila Shilpakar and other medical ICU staffs of the CMSTH for their valuable help during the study and necessary suggestions, corrections and revision during the manuscript writing.

 
   References Top

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2.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;16:3365-70.  Back to cited text no. 2
    
3.Bagshaw SM, Uchino S, Bellomo R, et al. Septic acute kidney injury in critically ill patients: Clinical characteristics and outcomes. Clin J Am Soc Nephrol 2007;2:431-9.  Back to cited text no. 3
    
4.Bagshaw SM, George C, Dinu I, Bellomo R. A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients. Nephrol Dial Transplant 2008;23: 1203-10.  Back to cited text no. 4
    
5.Ostermann M, Chang RW. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007;35:1837-43.  Back to cited text no. 5
    
6.Bagshaw SM, Uchino S, Bellomo R, et al. Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators: Septic acute kidney injury in critically ill patients: Clinical characteristics and outcomes. Clin J Am Soc Nephrol 2007;2:431-9.  Back to cited text no. 6
    
7.Neveu H, Kleinknecht D, Brivet F, Loirat P, Landais P. Prognostic factors in acute renal failure due to sepsis. Results of a prospective multicentre study. The French Study Group on Acute Renal Failure. Nephrol Dial Transplant 1996;11:293-9.  Back to cited text no. 7
    
8.Ostermann M, Chang RW. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007;35:1837-43.  Back to cited text no. 8
    
9.Xue JL, Daniels F, Star RA, et al. Incidence and mortality of acute renal failure in Medicare beneficiaries, 1992 to 2001. J Am Soc Nephrol 2006;17:1135-42.  Back to cited text no. 9
    
10.Neveu H, Kleinknecht D, Brivet F, Loirat P, Landais P. Prognostic factors in acute renal failure due to sepsis. Results of a prospective multicentre study. The French Study Group on Acute Renal Failure. Nephrol Dial Transplant 1996;11:293-9.  Back to cited text no. 10
    
11.Hoste EA, Lameire NH, Vanholder RC, Benoit DD, Decruyenaere JM, Colardyn FA. Acute renal failure in patients with sepsis in a sur­gical ICU: Predictive factors, incidence, co-morbidity, and outcome. J Am Soc Nephrol 2003;14:1022-30.  Back to cited text no. 11
    
12.Yegenaga I, Hoste E, Van Biesen W, et al. Clinical characteristics of patients developing ARF due to sepsis/ systemic inflammatory response syndrome: Results of a prospective study. Am J Kidney Dis 2004;43:817-24.  Back to cited text no. 12
    
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14.Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epide­miology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-10.  Back to cited text no. 14
    
15.Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P; Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8:R204-12.  Back to cited text no. 15
    
16.Neveu H, Kleinknecht D, Brivet F, Loirat P, Landais P. Prognostic factors in acute renal failure due to sepsis. Results of a prospective multicentre study. The French Study Group on Acute Renal Failure. Nephrol Dial Transplant 1996;11:293-9.  Back to cited text no. 16
    
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22.Naqvi R, Ahmed E, Akhtar F, Yazdani I, Naqvi NZ, Rizvi A. Analysis of factors causing acute renal failure. J Pak Med Assoc 1996; 46:29-30.  Back to cited text no. 22
    
23.Alberti C, Brun-Buisson C, Goodman SV, et al. Influence of systemic inflammatory res­ponse syndrome and sepsis on outcome of critically ill infected patients. Am J Respir Crit Care Med 2003;168:77-84.  Back to cited text no. 23
    
24.Groeneveld AB, Tran DD, Van der Meulen J, Nauta JJ, Thijs LG. Acute renal failure in the medical intensive care unit: Predisposing, com­plicating factors and outcome. Nephron 1991; 59:602-10.  Back to cited text no. 24
    
25.Wichmann MW, Inthorn D, Andress HJ, Schildberg FW. Incidence and mortality of severe sepsis in surgical intensive care patients: The influence of patient gender on disease process and outcome. Intensive Care Med 2000;26:167-72.  Back to cited text no. 25
    
26.Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for sever sepsis. N Engl J Med 2001;344:699-709.  Back to cited text no. 26
    
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Correspondence Address:
Madhav Ghimire
Department of Nephrology, College of Medical Sciences-Teaching Hospital, Bharatpur
Nepal
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DOI: 10.4103/1319-2442.135229

PMID: 24969216

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    Tables

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    Abstract
   Introduction
   Aim
   Settings and Design
    Methods and Mate...
   Statistical Analysis
   Results
   Discussion
   Conclusions
   Acknowledgment
    References
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