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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2018  |  Volume : 29  |  Issue : 5  |  Page : 1109-1114
Acute kidney injury in intensive care unit, hospital Universiti Sains Malaysia: A descriptive study


1 Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
2 Institute of Community (Health) Development, Universiti Sultan Zainal Abidin, Terengganu, Malaysia
3 Chronic Kidney Disease Resources Center, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

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Date of Submission14-Sep-2017
Date of Decision28-Nov-2017
Date of Acceptance06-Dec-2017
Date of Web Publication26-Oct-2018
 

   Abstract 

Acute kidney injury (AKI) was frequently encountered complication among intensive care unit (ICU) patients and recognized as a major public health problem. The present study aimed to determine the basic features of AKI patients admitted to ICU. A retrospective cohort study was conducted among 106 AKI patients admitted to ICU, Hospital Universiti Sains Malaysia from January 1, 2007 until the end of December 2013. The AKI patients ranged from 18 to 80 years old with the mean (standard deviation) of 58.93 (15.76) years, 60.4% were male and 91.5% were Malay ethnicity. Hypertension and diabetes were in 38.1% and 28.8%, respectively. The median (interquartile range) length of ICU stay was 4.50 (9.00) days. Eighty-two patients (79.6%) were classified as the Acute Kidney Injury Network (AKIN)-I, 12 (11.7%) as AKIN-II, and nine (8.7%) as AKIN-III. Sepsis was the common etiology among AKI patients (74.3%). Twenty-four patients (22.9%) required dialysis and 90.5% were mechanically ventilated. In conclusion, AKI developed more in male patients, Malay ethnicity, presented with comorbid, caused by sepsis, admitted to ICU, required mechanical ventilation, and need for renal replacement therapy.

How to cite this article:
Hamid SAA, Adnan WNW, Naing NN, Adnan AS. Acute kidney injury in intensive care unit, hospital Universiti Sains Malaysia: A descriptive study. Saudi J Kidney Dis Transpl 2018;29:1109-14

How to cite this URL:
Hamid SAA, Adnan WNW, Naing NN, Adnan AS. Acute kidney injury in intensive care unit, hospital Universiti Sains Malaysia: A descriptive study. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2018 Dec 16];29:1109-14. Available from: http://www.sjkdt.org/text.asp?2018/29/5/1109/243961

   Introduction Top


Acute kidney injury (AKI) has arisen as a global public health problem and associated with high morbidity and mortality[1] where the AKI mortality is more than 50%.[2] It is a serious complication frequently occurred in intensive care unit (ICU) settings.[3]

In hospitalized patients, 15% of them developed AKI and around 40% of AKI patients were referred to ICU.[4] Based on the nationwide multicenter survey on AKI in China, over 30% of AKI patients are treated in ICU.[5] Previous study conducted in 10 ICU in Italy reported that 42.7% of patients developed AKI within 24 h of ICU admission.[6] A multinational AKI-EPI study documented among 1802 ICU patients, approximately 58% of them developed AKI.[7] Among AKI patients referred to ICU, 80% of them die and 13% of the survivors required dialysis.

The 2012 report by the Malaysian Registry of Intensive Care (MRIC) indicated that the incidence of AKI was 14% in Malaysia, by using the definition of serum creatinine twice the baseline or urine output of less than 0.5 mL/kg per hour for 12 h.[3] The sixth report of MRIC 2015 documented that 15.4% of patients had AKI during the first 24 h of ICU admission in the year 2015 while 15.2% and 13.7% in the year 2014 and 2013, correspondingly.[8]

In Kelantan itself, a total of 206 (16.5%) of AKI cases were reported within 24 h of ICU admission in Hospital Raja Perempuan Zainab II, Kota Bharu, 24 (6.2%) AKI cases in Hospital Kuala Krai and 44 (14.3%) AKI cases in Hospital Tanah Merah.[8]

This study was conducted in a tertiary level teaching hospital in Kelantan aimed to assess the sociodemographic details, comorbid, and characteristics of AKI patient admitted to ICU.


   Materials and Methods Top


Study design and population

A single-center, retrospective study was conducted at Hospital Universiti Sains Malaysia (USM), a tertiary level teaching hospital with 950 beds that serves an estimated 1.4 to 1.8 million populations of Kelantan.[9] Kelantan is an agrarian state positioned in the northeast of Peninsular Malaysia.[9] Hospital USM also functioned as referral centers for nearby districts and states.

One hundred and six AKI patients aged above 18 years old and were admitted to ICU, Hospital USM during the period from January 1, 2007 to December 31, 2013, were recruited. The medical record of all AKI patients admitted to ICU include high dependency unit (HDU), coronary care unit (CCU), and surgical ICU were reviewed, retrospectively.

The patients were included consecutively only if they were above 18 years of age and were admitted to the ICU with the diagnosis of AKI or developed AKI during hospitalization. The patients with chronic kidney failure, organ donors, underwent kidney transplantation or chronic dialysis, transferred from other hospital and had incomplete medical record were excluded from the study.

Data collection

All demographic particulars such as age, gender, and ethnicity were extracted from the patients’ medical record. Data regarding the comorbidities, the etiology of AKI, Acute Kidney Injury Network (AKIN) stage, type and reason of ICU admission, length of ICU and hospital stayed (in days), the requirement of mechanical ventilation and renal replacement therapy were recorded. Main outcome measurement: serum creatinine (SCr) was recorded at baseline, on the 1st and 7th days of ICU admission and the days at discharge or died. Data extraction sheets were used to record all the medical information.

Definition of acute kidney injury

The AKI was classified based on the AKIN criteria.[10] The present study only relied on the level of SCr. AKI patients were subsequently classified according to the increase of SCr into AKIN-I (defined as an increase in SCr of more than or equal to 0.3 mg/dL (more than 26.4 μmol/L) or increase to more than or equal to 150%–200% (1.5- to 2-fold) from baseline, AKIN-II (defined as an increase in SCr to more than 200% to 300% (>2- to 3-fold) from baseline and AKIN-III [defined as an increase in SCr more than 300% (>3-fold) from baseline or SCr of more than 4.0 mg/dL (more than 354 μmol/L) with an acute increase of at least 0.5 mg/dL (44 μmol/L)] [Table 1].
Table 1: Classification/staging of AKI using AKIN.

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   Statistical Analysis Top


Data entry and analysis were conducted using the Statistical Package for the Social Sciences (SPSS) software version 22.0 for Window.[11] As a first step, normal distribution of the sample was analyzed. Normal distribution was represented by mean and standard deviation (SD), whereas skewed distribution was expressed by median and interquartile range (IQR). Descriptive analysis was used to determine the basic features which provided simple summaries of AKI patients in our setting.

The study was approved by the Human Research Ethics Committee of USM. Permission to access patient’s folder was obtained from the Hospital Director of Hospital USM.


   Results Top


Demographic particular

Demographic particulars of the study patients are shown in [Table 2]. The age distribution of the patients ranged from 18 to 80 years old with the mean (SD) age of 58.93 (15.76) years. The majority of patients were male (60.4%) and Malay ethnic (91.5%).
Table 2: Sociodemographic details of AKI patients in ICU, Hospital USM (n=106).

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Comorbidities

[Table 3] shows the comorbid of AKI patients. More than half of the patients (71.2%) presented with comorbid. Most of them had more than one comorbid. Hypertension (38.1%) and diabetes mellitus (28.8%) were the common comorbid in AKI patients. Coronary heart disease, pulmonary disease, and neoplasm were in 22.9%, 18.8%, and 13.9%, respectively. Only two patients (2.0%) had HIV and one patient (1.0%) had liver failure.
Table 3: Comorbid of AKI patients in ICU, Hospital USM (n=106).

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Acute kidney injury characteristics

The characteristics of AKI patients are shown in [Table 4]. The AKI patients were admitted to ICU (67%), 26.4% in CCU, 3.8% in surgical ICU, and 2.8% in HDU [Table 3]. The majority of patients developed AKI because of sepsis (74.3%). Five patients developed AKI because of trauma (5.0%), one patient because of nephrotoxins (1.0%), and one patient because of burns (1.0%).
Table 4: Characteristics of AKI patients in ICU, Hospital USM (n=106).

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More than half of the patients (79.6%) were classified as AKIN-I, AKIN-II in 11.7%, and AKIN-III in 8.7% during ICU admission. The median (IQR) length of AKI patients stayed in ICU was 4.50 (9.00) days. Dialysis was performed in 24 cases (22.9%), and 95 patients (90.5%) were mechanically ventilated during ICU admission.


   Discussion Top


The current study was conducted in a tertiary level teaching hospital positioned in the Northeast of Peninsular Malaysia. The age distribution of the AKI patients in our setting ranged from 18 to 80 years old with the mean age of 58.93 years. The previous studies in the literature had shown that AKI is more common in elderly individuals.[12],[13],[14] Various studies have shown a clear age-dependent relationship between AKI and older age.[13],[14],[15]

AKI developed more in male patients compared to female patients. Male patients had consistently predominated in reports on the AKI incidence since there is a higher prevalence of smoking and some other risk factors among males.[16] The previous study was carried out in Hospital Kuala Lumpur also found a male predominance in developing AKI.[17] A study by Collins et al[18] also found that men were more likely to develop incident of AKI than women. In addition, Mallhi et al[9] found that males usually have better access to health care which may explain the higher reported incidence of AKI.

The Malays were the major ethnic group developed AKI in this study. Kelantan, with 1.6 million inhabitants, comprised 95% Malays and the remains made up of Chinese, Thai and Indian communities.[9] This might indicate that Malays had a higher frequency of AKI compared to other ethnic group.

Presence of comorbid at the time of presentation to the hospital was associated with a higher frequency of AKI. Hypertension and diabetes mellitus were the common comorbid in our AKI-ICU patients. Coronary heart disease, pulmonary disease, neoplasm, HIV, and liver failure also found in AKI patients in our setting. The majority of our AKI patients were admitted to ICU rather than CCU, HDU, and surgery ICU. The median duration of ICU stay was 4.50 days.

AKI is a common sequel of sepsis where the majority of the study patients developed AKI because of sepsis. It is a frequently fatal condition in which the mortality has been consistently associated with the increasing organ dysfunction.[19] During sepsis, the kidney was the commonly affected organ.[20]

The majority of AKI patients were mechanically ventilated which is has been a significant factor in the development of AKI probably due to associated hemodynamic instability.[21],[22],[23],[24]

Twenty-four AKI patients need renal replacement therapy (RRT). RRT is performed to treat patients with severe AKI and multiple organ failures.[25] In our setting, only nine patients had AKIN-III. This might explain the lower frequency of patients who required RRT.

The overall mortality was 92.5% in this study. A study in the United States of America (USA) reported the mortality rate for hospital-acquired AKI was 10.8% compared to 1.5% without AKI.[26]

Another study conducted by Okunola et al[27] reported the mortality rate of AKI was 28.8%. This rate was lower when compared to the similar research conducted in our setting and another two centers in Malaysia where the mortality rate of 92.5%, 48%, and 33.2% were reported, correspondingly.

Undeniably, the present study had several limitations. This study used the retrospective study which only relied on the medical record of patients. Some of the records were incomplete and need to be excluded from the study. Other than that, this study was a hospital-based study. There may be selection bias in the intake of cases, which may not be representative of AKI patients in Kelantan. This study might represent only a selective proportion of the actual proportion of AKI. Thus, the generalization of the findings might be limited.

In conclusion, AKI is associated with high mortality in our ICU setting. AKI developed more in male patients, Malay ethnic, presented with comorbid, admitted to ICU, required mechanical ventilation and need of renal replacement therapy. Sepsis was the common etiology of AKI in our study.


   Acknowledgment Top


We would like to thank the following individuals who have contributed to this study: staff in Record Unit of Hospital USM and Ethical Committee. This study was funded Short Term Grant USM: 304/PPSP/61313093.

Conflict of interest: None declared.

 
   References Top

1.
Li PK, Burdmann EA, Mehta RL; World Kidney Day Steering Committee 2013. Acute kidney injury: Global health alert. Intern Med J 2013; 43:223-6.  Back to cited text no. 1
    
2.
Case J, Khan S, Khalid R, Khan A. Epidemiology of acute kidney injury in the Intensive Care Unit. Crit Care Res Pract 2013;2013: 479730.  Back to cited text no. 2
    
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Sharifipour F, Hami M, Naghibi M, et al. RIFLE criteria for acute kidney injury in the Intensive Care Units. J Res Med Sci 2013;18: 435-7.  Back to cited text no. 3
    
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Druml W, Metnitz B, Schaden E, Bauer P, Metnitz PG. Impact of body mass on incidence and prognosis of acute kidney injury requiring renal replacement therapy. Intensive Care Med 2010;36:1221-8.  Back to cited text no. 4
    
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Yang L, Xing G, Wang L, et al. Acute kidney injury in China: A cross-sectional survey. Lancet 2015;386:1465-71.  Back to cited text no. 5
    
6.
Piccinni P, Cruz DN, Gramaticopolo S, et al. Prospective multicenter study on epidemiology of acute kidney injury in the ICU: A critical care nephrology Italian collaborative effort (NEFROINT). Minerva Anestesiol 2011;77: 1072-83.  Back to cited text no. 6
    
7.
Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: The multinational AKI-EPI study. Intensive Care Med 2015;41:1411-23.  Back to cited text no. 7
    
8.
Geok JT, Ling TL, Cheng TC, Har LC, Ismail NI. Malaysian Registry of Intensive Care Report; 2015.  Back to cited text no. 8
    
9.
Mallhi TH, Khan AH, Adnan AS, Sarriff A, Khan YH, Jummaat F. Incidence, characteristics and risk factors of acute kidney injury among dengue patients: A Retrospective analysis. PLoS One 2015;10:e0138465.  Back to cited text no. 9
    
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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.  Back to cited text no. 10
    
11.
IBM Corporation; 2013.  Back to cited text no. 11
    
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Hsu CY, McCulloch CE, Fan D, Ordoñez JD, Chertow GM, Go AS. Community-based incidence of acute renal failure. Kidney Int 2007; 72:208-12.  Back to cited text no. 12
    
13.
Bagshaw SM, George C, Bellomo R; ANZICS Database Management Committee. Changes in the incidence and outcome for early acute kidney injury in a cohort of Australian Intensive Care Units. Crit Care 2007;11:R68.  Back to cited text no. 13
    
14.
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. 14
    
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Coca SG. Acute kidney injury in elderly persons. Am J Kidney Dis 2010;56:122-31.  Back to cited text no. 15
    
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Ali T, Khan I, Simpson W, et al. Incidence and outcomes in acute kidney injury: A comprehensive population-based study. J Am Soc Nephrol 2007;18:1292-8.  Back to cited text no. 16
    
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Yee S, Wahab MA, Visvanathan R, Yahya R, Bavanandan S, Ahmad G. 090 incidence and outcome of patients with acute kidney injury in Hospital Kuala Lumpur. Kidney Int Rep 2017; 2:10.  Back to cited text no. 17
    
18.
Collins AJ, Foley RN, Herzog C, et al. US renal data system 2010 Annual Data Report. Am J Kidney Dis 2011;57:A8, e1-526.  Back to cited text no. 18
    
19.
Gómez H, Kellum JA. Sepsis-induced acute kidney injury. Curr Opin Crit Care 2016;22: 546-53.  Back to cited text no. 19
    
20.
Lynch KA, Moore VD. Bcl-2 dependency in cell culture and mouse models of sepsis-associated acute kidney injury. FASEB J 2017;31: 774.22.  Back to cited text no. 20
    
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Santos LL, Magro MC. Mechanical ventilation and acute kidney injury in patients in the Intensive Care Unit. Acta Paul Enferm 2015;28: 146-51.  Back to cited text no. 21
    
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Ko GJ, Rabb H, Hassoun HT. Kidney-lung crosstalk in the critically ill patient. Blood Purif 2009;28:75-83.  Back to cited text no. 22
    
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Ricci Z, Ronco C. Pulmonary/renal interaction. Curr Opin Crit Care 2010;16:13-8.  Back to cited text no. 23
    
24.
Zappitelli M. Epidemiology and diagnosis of acute kidney injury. Semin Nephrol 2008;28: 436-46.  Back to cited text no. 24
    
25.
Negi S, Koreeda D, Kobayashi S, Iwashita Y, Shigematu T. Renal replacement therapy for acute kidney injury. Renal Replace Ther 2016; 2:31.  Back to cited text no. 25
    
26.
Wang HE, Muntner P, Chertow GM, Warnock DG. Acute kidney injury and mortality in hospitalized patients. Am J Nephrol 2012;35: 349-55.  Back to cited text no. 26
    
27.
Okunola OO, Ayodele OE, Adekanle AD. Acute kidney injury requiring hemodialysis in the tropics. Saudi J Kidney Dis Transpl 2012;23: 1315-9.  Back to cited text no. 27
[PUBMED]  [Full text]  

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Correspondence Address:
Dr. Siti-Azrin Ab Hamid
Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan
Malaysia
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DOI: 10.4103/1319-2442.243961

PMID: 30381507

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