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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2018  |  Volume : 29  |  Issue : 5  |  Page : 1128-1132
Acute kidney injury in hospitalized patients during muslim pilgrimage (Hajj: 1432)


1 Department of Nephrology, Damanhour Medical National Institute, Damanhour, Egypt
2 Department of Nephrology, King Abdulaziz Hospital, Makkah, Saudi Arabia
3 Department of Nephrology, Mansoura Urology and Nephrology Center, Al-Mansoura, Egypt

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Date of Submission24-Nov-2017
Date of Decision02-Jan-2018
Date of Acceptance14-Jan-2018
Date of Web Publication26-Oct-2018
 

   Abstract 

Acute kidney injury (AKI) increases mortality and morbidity of hospitalized patients. We aimed to evaluate the prevalence of AKI, etiology, and associated risk factors among hospitalized patients during the Hajj time. Also to do comparative analysis for the use of slow continuous therapy versus conventional hemodialysis (HD) therapy on the patient outcome. The study was conducted between September 29 and November 25, 2011, inclusive (Islamic lunar dates Dhu’l-Qa’dah 1 to Dhul-Hijjah 29, 1432) at King Abdul-Aziz Hospital, a 250-bed hospital, in Makkah, Saudi Arabia. From 851 patients of 47 different countries were admitted, 87 (10.2%) patients developed AKI with mean age (±standard deviation) of 60.26 (±9.28) years with a male predominance: men constituted 65 (74.7%) and females 22 (25.3%). The major cause for admission was infections accounted for 51.7% (45 patients) of all the admitting patients who developed AKI. Hypertension and diabetes mellitus were the most common underlying comorbidities, present in 61 (70.1%) and 53 (60.9%) patients, respectively. Only 21 (24.1%) patients who developed AKI required replacement therapy (RRT). Fourteen patients (16.1%) received conventional HD, seven (8%) patients received continuous renal replacement therapy and 66 (75.9%) patients did not need RRT. Fifty-two (59.8%) patients had improved renal function on discharge from our hospital, 4 (4.6%) patients were discharged on dependent HD, 5 (5.7%) patients were discharged as chronic kidney disease patients on conservative management and 26 (29.9%) patients died during admission. There was no significant difference on the outcome according to the use or even the type of RRT. Infection was the main cause of admission for patients who developed AKI. The type of RRT used had no different effect on the outcome at time of discharge.

How to cite this article:
Elrewihby WH, Hasan NF, Fikry W, Wafa E. Acute kidney injury in hospitalized patients during muslim pilgrimage (Hajj: 1432). Saudi J Kidney Dis Transpl 2018;29:1128-32

How to cite this URL:
Elrewihby WH, Hasan NF, Fikry W, Wafa E. Acute kidney injury in hospitalized patients during muslim pilgrimage (Hajj: 1432). Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2018 Nov 15];29:1128-32. Available from: http://www.sjkdt.org/text.asp?2018/29/5/1128/243971

   Introduction Top


Hajj (a pilgrimage to Mecca in Saudi Arabia) is a principal religious obligation of an ablebodied adult Muslim who can afford to do so. As the largest pilgrimage in the world, it has become the epicenter of mass movement of millions of Muslims of enormous ethnic diversity.[1] According to Central Department of Statistics and Information, the total number of pilgrims for 1432 (2011) was 2,927,717 of those, 1,829,195 arrived from outside the Kingdom, and the rest came from within the kingdom. These figures are unparalleled to any other universal mass congregation. Many pilgrims perform Hajj only at an older age hence the likelihood of falling ill, developing more serious medical complications and death is understandably high.[2] Acute kidney injury (AKI) is a very common complication among pilgrims presenting with severe sepsis and septic shock. In addition, predictors of a worse outcome include advanced age and renal replacement therapy (RRT) requirement.[3]

There are many previous reports related to health problems among Hajj pilgrims;[4],[5],[6],[7],[8] however, there have been no studies focusing on the occurrence of AKI and their outcome. We aimed in our study to evaluate the prevalence of AKI, etiology, and associated risk factors among hospitalized patients during the Hajj time. In addition, we aimed to do a comparative analysis for the use of slow continuous therapy versus conventional hemodialysis (HD) therapy on the patient outcome.


   Methods Top


This was a retrospective observational study. The study was conducted at King Abdul Aziz Hospital, a 250-bed tertiary care hospital, in Makkah, Saudi Arabia. It is one of the four main Ministry of Health tertiary care hospitals in Makkah City that serve pilgrims during Hajj seasons. The study was conducted between September 29 and November 25, 2011 inclusive (Islamic lunar dates Dhu’l-Qa’dah 1 to Dhul-Hijjah 29, 1432).

AKI was defined and classified by means of the AKI Network (AKIN) classification[9] [Table 1]. Patients were categorized on serum creatinine or urine output, or both. At least two serum creatinine values within 48 h were considered to define the AKIN stage.
Table 1: Stages of AKI according to AKIN classification.

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The Statistical Package for the Social Sciences (SPSS) software version 11.0 (SPSS, Chicago, IL, USA) was used for the statistical analysis. Univariate and multivariate analysis of variables for comparison of outcome of different therapeutic modalities on patient survival will be carried out.


   Results Top


During the study, a total of 851 pilgrims were admitted to our hospital, 87 (10.2%) patients developed AKI. The mean age (±standard deviation) was 60.26 (±9.28) years with a male predominance: men constituted 65 (74.7%) and females 22 (25.3%). About 55.2% of patients were admitted to the medical ward, 29.9% to the ICU and the remaining 14.9% to the surgical ward [Table 2]. The primary cause of admission is shown in [Table 3]. The major cause for admission was infections accounted for 51.7% (45 patients) of all the admitting patients who developed AKI and included pneumonia (28 patients, 32.2%), skin infection (9 patients, 10.3%), gastroenteritis (5 patients, 5.7%), urinary tract infection (2 patients, 2.3%), and acute viral hepatitis (1 patient, 1.1%).
Table 2: Characteristics of patients.

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Table 3: The primary cause of admission.

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Renal diseases accounted for 14.9% of admissions and included AKI (11 patients, 12.6%), and urinary tract infection (2 patients, 2.3%).

Diabetes mellitus complications accounted for 9.2% (8 patients) of admissions and included diabetic ketoacidosis (5 patients, 5.7%), uncontrolled diabetes mellitus (2 patients, 2.3%), and drug-induced hypoglycemia (1 patient, 1.1%). Cerebrovascular strokes also accounted for 9.2% of admissions.

Cardiovascular diseases accounted for 9.2% (8 patients) of admissions, of them, three (3.4%) patients had angina, two (2.3%) patients had acute myocardial infarction, two (2.3%) patients had uncontrolled hypertension and one (1.1%) patient had atrial fibrillation. Two patients (2.3%) were admitted due to anemia, and two (2.3%) patients due to liver disease. In addition, another four (4.6%) patients were admitted to the surgical departments, two (2.3%) of them due to acute abdomen, and the other two (2.3%) patients due to traumatic fractures.

Based on clinical judgment as well as medical history when available, a total of 67 patients (77%) had at least one of the comorbid conditions summarized in [Table 4]. Hypertension and diabetes mellitus were the most common underlying diseases, present in 61 (70.1%) and 53 (60.9%) patients respectively.
Table 4: Comorbid diseases.

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Only 21 (24.1%) patients who developed AKI required RRT. Fourteen patients (16.1%) received conventional HD, seven (8%) hemodynamically unstable patients received continuous renal replacement therapy (CRRT), and 66 (75.9%) patients did not need RRT [Table 5]. The outcome according to the need for RRT during admission is shown in [Table 6]. Fifty-two patients (59.8%) had improved renal function on discharge from our hospital, four (4.6%) patients were discharged on dependent HD, five (5.7%) patients were discharged as chronic kidney disease patients on conservative management, and 26 (29.9%) patients died during admission.
Table 5: Need and type of hemodialysis required.

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Table 6: Outcomes on the discharge of all patients according to the need for RRT during admission.

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There was no significant difference in outcome between both groups those who need RRT during admission and those did not need (P = 0.93). In addition, we found no significant difference on the outcome between the group of patients who received conventional HD and those who received CRRT (P = 0.57).


   Discussion Top


This study is, to the best of our knowledge, the first study evaluating the incidence of AKI in Hajj pilgrims. The incidence of AKI accounted for about one-tenth of all Hajj patients admitted to our hospital. The age of patients was similar to previous studies in Hajj pilgrims,[10],[11] but with male distribution more than other studies.[3],[10],[11],[12] Pneumonia (32.2%) was the most common cause of admission followed by renal diseases (14.9%) and skin infections (10.3%). Similar observation has been reported previously.[4],[12] The prevalence of chronic obstructive lung disease including both COPD and asthma among the patient and their old age may be the leading cause of infection among this study group. Similar to other studies we found that sepsis in general was the dominant cause of acute kidney failure.[10],[13]

We found no significant differences in mortality, rate of recovery of kidney function, or duration of RRT between the group of patient who received conventional HD and the other group received CRRT. Our results were similar to that reported by Bouman et al[14] and were in contrast with some previous studies that showed improved survival with moreintensive RRT in patients with AKI.[15],[16],[17]

One of the limitations of our study was that the sample did not include all the hospitals in the Makkah area. Due to the langguae barrier not all comorbidites would have been captured during the initial admission. Language barriers and absence of translators has been previously documented during Hajj seasons and was associated with poorer outcome.[3],[12]

In summary, infection was the main cause of admission for patients who developed AKI. The type of renal replacement therapy used had no different effect on the outcome at time of discharge. Adequate fluid resuscitation in emergency rooms and using of invasive blood pressure monitoring devices can help in reducing the high incidence of AKI at the Hajj.

In conclusion, we are hoping that this data will be of help to healthcare planners, administrators, and officials to develop effective prevention strategies for providing cost-effective healthcare services to pilgrims in Hajj.

Conflict of interest: None declared.

 
   References Top

1.
Memish ZA. The Hajj: Communicable and non-communicable health hazards and current guidance for pilgrims. Euro Surveill 2010;15: 19671.  Back to cited text no. 1
    
2.
Madani TA, Ghabrah TM, Al-Hedaithy MA, et al. Causes of hospitalization of pilgrims in the Hajj season of the Islamic year 1423 (2003). Ann Saudi Med 2006;26:346-51.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Baharoon S, Al-Jahdali H, Al Hashmi J, Memish ZA, Ahmed QA. Severe sepsis and septic shock at the Hajj: Etiologies and outcomes. Travel Med Infect Dis 2009;7:247-52.  Back to cited text no. 3
    
4.
Ghaznawi HI, Khalil MH. Health hazards and risk factors in the 1406 H (1986) Hajj season. Saudi Med J 1988;9:274-82.  Back to cited text no. 4
    
5.
Khogali M. Epidemiology of heat illnesses during the Makkah Pilgrimages in Saudi Arabia. Int J Epidemiol 1983;12:267-73.  Back to cited text no. 5
    
6.
Ghaznawi HI, Ibrahim MA. Heat stroke and heat exhaustion in pilgrims performing the Hajj (annual pilgrimage) in Saudi Arabia. Ann Saudi Med 1987;7:323-6.  Back to cited text no. 6
    
7.
Al-Aska AK, Yaqub B, Al-Harthi SS, Al- Dalaan A. Rapid cooling in management of heat stroke: Clinical methods and practical implications. Ann Saudi Med 1987;7:135-8.  Back to cited text no. 7
    
8.
Bouchama A, Knochel JP. Heat stroke. N Engl J Med 2002;346:1978-88.  Back to cited text no. 8
    
9.
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. 9
    
10.
Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS. Pattern of admission to hospitals during Muslim pilgrimage (Hajj). Saudi Med J 2003;24:1073-6.  Back to cited text no. 10
    
11.
Yousuf M, Al-Saudi DA, Sheikh RA, Lone MS. Pattern of medical problems among haj pilgrims admitted to King Abdul Aziz Hospital, Madinah Al-Munawarah. Ann Saudi Med 1995;15:619-21.  Back to cited text no. 11
    
12.
Khan NA, Ishag AM, Ahmad MS, El-Sayed FM, Bachal ZA, Abbas TG. Pattern of medical diseases and determinants of prognosis of hospitalization during 2005 Muslim pilgrimage hajj in a tertiary care hospital. A prospective cohort study. Saudi Med J 2006;27:1373-80.  Back to cited text no. 12
    
13.
Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: A multinational, multicenter study. JAMA 2005; 294:813-8.  Back to cited text no. 13
    
14.
Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, Zandstra DF, Kesecioglu J. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: A prospective, randomized trial. Crit Care Med 2002;30:2205-11.  Back to cited text no. 14
    
15.
Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: A prospective randomised trial. Lancet 2000;356:26-30.  Back to cited text no. 15
    
16.
Schiffl H, Lang SM, Fischer R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med 2002;346:305-10.  Back to cited text no. 16
    
17.
Saudan P, Niederberger M, De Seigneux S, et al. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int 2006;70:1312-7.  Back to cited text no. 17
    

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Correspondence Address:
Dr. Walid H Elrewihby
Department of Nephrology, Damanhour Medical National Institute, Damanhour
Egypt
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DOI: 10.4103/1319-2442.243971

PMID: 30381509

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