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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2008  |  Volume : 19  |  Issue : 6  |  Page : 1009-1014
Etiology of acute renal failure in a tertiary center

1 Department of Nephrology, The kidney Center, Post Graduate Training Institute Karachi, Pakistan
2 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan

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Acute renal failure (ARF) occurs commonly in developing countries. Our aim was to assess the etiologies and outcomes of ARF in a tertiary care hospital in Pakistan and compare them with data from developed and developing countries. All patients admitted to the Aga Khan University Hospital, Karachi from January 1991 to December 2000 fulfilling the criteria of acute renal failure were reviewed retrospectively. Acute renal failure for the purpose of this study was defined as persistent elevation of serum creatinine to above 2 mg/dL (177 umol/L) on two consecu­tive occasions despite correction of any abnormal hemodynamic or mechanical factors. We studied 898 patients fulfilling the criteria of ARF, 61% (551) were males, and the mean age was 53% ± 17.6 (range 15-91) years. Medical causes accounted for (88%) of ARF cases and surgical causes for (11%). Majority of the patients had pre-renal ARF, and 5% had drug related ARF. The base line creatinine was 1.9 ± 1.8 mg/dL, while 27% of the patients had pre-existing chronic kidney disease. The mean rise in creatinine was 7.18 ± 3.8 mg/dL. We conclude that ARF resulted from pre-renal etiologies in majority of the patients and early recognition and management may improve the prognosis of these potentially preventable causes.

Keywords: Acute renal failure, Etiology, Pakistan

How to cite this article:
Rabbani MA, Habib HB, Siddiqui BK, Tahir M H, Ahmad B, Murtaza G, Maria Q, Ahmad A. Etiology of acute renal failure in a tertiary center. Saudi J Kidney Dis Transpl 2008;19:1009-14

How to cite this URL:
Rabbani MA, Habib HB, Siddiqui BK, Tahir M H, Ahmad B, Murtaza G, Maria Q, Ahmad A. Etiology of acute renal failure in a tertiary center. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2021 Dec 7];19:1009-14. Available from: https://www.sjkdt.org/text.asp?2008/19/6/1009/43485

   Introduction Top

Acute renal failure is characterized by a dete­rioration of renal function over a period of hours to days, resulting in the failure of the kidney to excrete nitrogenous waste products and to maintain fluid and electrolyte homeo­ stasis. [1]

Mortality from ARF is still elevated and has changed little over time despite technical advances in renal replacement therapy and supportive care, possibly because of increasing age and increasing co-morbidity of patients. [2] It is important to know the causes of ARF, as prognosis is dependent upon specific etiology. [3] Mortality rates in ARF range from approximately 7% among patients admitted with pre­renal azotemia to more than 80% among pa­tients with postoperative ARF. [4]

Epidemiological studies may help in planning strategies to identify preventable insults resul­ting in ARF. Examples include ARF due to obs­tetric diseases, [5] renal calculi, [6] and dehydration from gastrointestinal causes. [7] These commonly occurring conditions in the developing are rare in the developed countries. [7]

The aim of this study was to assess the etio­logies and outcomes, and their trends with time, of ARF in a tertiary care hospital in Pakistan and compare them with data from developed and developing countries.

   Patients and methods Top

All patients admitted to the Aga Khan Univer­sity Hospital, Karachi from January 1991 to December 2000 fulfilling the criteria of acute renal failure were reviewed retrospectively. For inclusion in our study, the 1st serum creatinine obtained from the central laboratory after admi­ssion in our hospital was taken as the base line value. Acute renal failure was defined as per­sistent elevation of serum creatinine to above 2 mg/dL (177 µmol/L) on two consecutive occa­sions despite correction of any abnormal hemo­dynamic or mechanical factors. A detailed record of the patient's history, physical exa­mination, and laboratory investigations were documented to determine the cause of acute renal failure.

In order to find the cause of acute renal failure, a number of clinical criteria were applied. Dec­rease renal perfusion was identified if there was a decrease in blood pressure below 90/60 mm of Hg, signs of severe dehydration, orthostatic hypotension or clinically apparent congestive cardiac failure.

Nephrotoxic drugs were considered the cause of renal failure if a patient had received any of them for a minimum of 3 days prior to the defined increase in serum creatinine concen­tration. Septicemia was identified by positive blood culture or by fever more than 100°F (37.5°C), and/or associated with white cell count greater than 10×10 9 /L in an appropriate clinical setting. Radiographic contrast agents were considered to be the cause of ARF when serum creatinine increased within 72 hours following a radiological procedure employing such agents. Glomerulonephritis was implicated as the cause of ARF in the presence of hema­turia, RBC casts in the urine and appropriate clinical setting. Hepatorenal syndrome was diagnosed when urinary sodium concentration was < 10 mEq/L in a patient who developed renal failure in association with severe liver failure.

Renal size and anatomy were defined by ultrasonography, which also demonstrated obs­truction. Causes of acute on chronic renal fai­lure were also included in the study. Chronic renal failure was defined as a baseline crea­tinine > 1.4 mg/dL. Indications for dialysis were volume overload, hyperkalemia (above 7 mmol /L), severe uremia (blood urea nitrogen above 100 mg/dL), calculated GFR of < 15 mL/min, and severe metabolic acidosis (bicarbonate < 15 mEq/L). Renal biopsy was performed in selec­ted patients with unexplained renal failure, systemic disease, signs suggesting glomerular, vascular and interstitial lesions, and when dura­tion of oligouria exceeded 4 weeks. Mortality was defined as death during the episode of ARF.

   Statistical Analysis Top

The data was divided into two five year periods to observe the trends over time. The data was analyzed by using SPSS 10 software. Chi Square test was used to compare both five­year periods. Odds ratio were compared at 95% confidence interval.

   Results Top

A total of 898 patients were admitted to the Aga Khan University Hospital, Karachi from January 1991 to December 2000 fulfilling the criteria of acute renal failure; the majority was males 61% (551), and the mean age was 53% ± 17.6 (range 15-91) years. The base line creatinine was 1.9 ± 1.8 mg/dL. Two hundred and forty (27%) patients had a preexisting element of CKD of various etiologies and were classified as acute on chronic renal failure. The mean rise in serum creatinine was 7.18 ± 3.8 mg/dL.

The causes of ARF are listed in [Table 1]. Medical causes accounted for (88%) of ARF cases and surgical causes for (11%). Only 5 cases of ARF were due to obstetric complications. Of the medical causes, sepsis (25%) and dehydration secondary to diarrhea and vomiting (21%) were the commonest etiological factors of ARF. Thirty eight patients (4.8%) presented with ARF secondary to drugs [Table 2]. Radiocontrast media were the commonest drugs that caused ARF.

Among surgical causes, stone disease was the most common cause of ARF (38%).

The majority of patients had pre renal ARF (70%), although a significant number had renal (22%) and post renal ARF (8%) as well.

Although the number of cases of ARF rose significantly from 1995-2000 compared to 1990 -1995, there was no significant difference in mortality, need for dialysis, and etiology.

   Discussion Top

Before the 1970s, most studies in the deve­loped countries indicated that approximately 60% of ARF cases were related to surgery or trauma, 30% occurred in a medical setting, and about 10% were related to the complications of pregnancy. [2] Over the past three decades, there have been changes in the relative etiology of ARF in developed as well as in developing countries. [8] While ARF resulting from trauma and surgery has decreased, ARF due to medical diseases increased in developed countries. [2],[8] The most obvious change was the decline in the incidence of obstetric associated ARF. Preg­nancy-related ARF has become a rare cause in developed countries [8] because of safe and early delivery of complicated pregnancies, more effective treatment of pre-eclampsia, and dis­appearance of septic abortion. [2] In contrast, in developing countries, the decrease has been less pronounced. [9]

In contrast to a previous study done in the same city by Naqvi et al [10] where medical causes were found to be 57% of all ARF, we found that nearly 90% of our patients had a medical cause. Surgical causes were, however, similar to their population. Abreo and Breaman [8] have also found similar changing trends.

Obstetric causes were surprisingly found in less than 1% of the patients. This is in sharp contrast to studies in other developing coun­ tries, including Pakistan [10],[11] (24%), Bangladesh [7] (11%), India [12] (22.1%), Ethiopia [13] (55%) and Nigeria [14] (25.7%) where obstetric causes form a prominent bulk of ARF. Although there is an overall decline in obstetric ARF over the past few years in developing countries; it may be the center effect providing better obstetrical care for affluent class and therefore might not repre­sent other parts of Pakistan. Utas et al [5] from Turkey have also found a decline in frequency of ARF due to obstetric complications from 18.9% to 14.8% in a decade, presumably due to improved prenatal care and change in abortion laws. There were no deaths among obstetric patients with ARF at our hospital compared to a mortality rate of between 20% and 45% in other developing countries. [5],[13],[14],[15]

Preventable causes such as vomiting and dia­rrhea (19%), pyelonephritis (5%), nephrotoxic drugs (4%), stone disease (4%) and malaria (3%) still form a prominent bulk of our patients.

Diarrhea remains an important cause of ARF, as in other developing countries with 10% to 40% prevalence. [7],[10] The reasons are low socio­economic conditions, warm climate, poor sani­tation, and delay in correction of fluid and elec­trolyte loss. Health education of the public to promptly initiate oral rehydration therapy and better sanitation helps in reducing incidence of diarrhea related ARF.

Pakistan is endemic for malaria and 3.8 % of our patients had ARF related to malaria. [16] Trang TT et al [17] in Vietnam found that malaria­associated renal failure (MARF) was signifi­cantly associated with higher mortality than non malaria ARF. Our results are similar to theirs as well those of Naqvi et al. [10] The prevalence of stone disease or crystalluria in Pakistan is about 36%, [18],[19] and 3% are discovered incidentally. In our patients more than one third had ARF due to renal calculi.

ARF due to sepsis resulted in highest mortality and requirement of dialysis in concordance with various studies world wide. [15] Vega et al [20] found that mortality in septic patients was high due to associated respiratory failure, metabolic acido­sis, and oligouria, while in the non-septics it was associated with hepatic dysfunction, hyper­kalemia, respiratory failure, and infection ac­quired during the course of renal failure. Using a stepwise logistic regression model, Neveu et al [21] also found that sepsis was an independent predictor of hospital mortality.

Toxins also account for a large number of cases of acute renal failure in various series worldwide. [1] Four percent of patients in our series had a drug related ARF. Drugs can cause acute renal failure by directly damaging tubular cells or by various other mechanisms. Aminoglycosides and radio-contrast agents are the most common toxins encountered, [1] but heme­pigments with crush injuries, [22] chemothera­peutic agents such as cisplatin, [23] myeloma light­chain proteins, [24] and other drugs may also be responsible. Ischemia and toxins often combine to cause acute renal failure in severely ill patients with conditions such as sepsis. [1]

Mortality rates have been reported to be more than 80% among patients with postoperative ARF. [25] Turney et al. has reported that the mor­tality of ARF was higher in surgical than medical or obstetric ARF. [2] This is in contrast to our own population where mortality from surgi­cal causes was lower than medical causes (15% vs. 37%). The possible reasons could be that more than half of these patients included, otherwise healthy patients with bilateral stone disease or other urological problems with a good prognosis. [6] Furthermore, only 3 patients had post operative renal failure, which is the major cause of surgical mortality. [25]

When comparing the two 5-year periods (1990­95 vs. 1995-2000) there was a rise in incidence of ARF, but the mortality and causes of ARF remained unchanged. A static rate of mortality over time is in accordance with other data worldwide. [2]

In conclusion, we found that the majority of causes of ARF in our single tertiary care center were due to pre renal etiologies and sepsis remained the number one cause of mortality. Early recognition of infection and pre renal stated may help preventing the morbidity and mortality associated with ARF.

   References Top

1.Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med 1996;334(22):1448-60.  Back to cited text no. 1    
2.Turney JH, Marshall DH, Brownjohn AM, Ellis CM, Parsons FM. The evolution of acute renal failure, 1956-1988. Q J Med 1990;74(273):83-104.  Back to cited text no. 2    
3.Hadidy S, Asfari R, Shammaa MZ, Hanifi MI. Acute renal failure among a Syrian population: incidence, aetiology, treatment and outcome. Int Urol Nephrol 1989;21(5):455-61.  Back to cited text no. 3    
4.Butkus DE. Persistent high mortality in acute renal failure: are we asking the right question? Arch Intern Med 1983;143(2):209-12.  Back to cited text no. 4    
5.Utas C, Yalcindag C, Taskapan H, Guven M, Oymak O, Yucesoy M. Acute renal failure in Central Anatolia. Nephrol Dial Transplant 2000;15(2):152-5.  Back to cited text no. 5    
6.Shapiro SR, Bennett AH. Recovery of renal function after prolonged unilateral ureteral obstruction. J Urol 1976;115(2):136-40.  Back to cited text no. 6    
7.Chugh KS, Sakhuja V, Malhotra HS, Pereira BJ. Changing trends in acute renal failure in third-world countries--Chandigarh study. Q J Med 1989;73(272):1117-23.  Back to cited text no. 7    
8.Abreo K, Moorthy AV, Osborne M. Changing pattern and outcome of acute renal failure requiring hemodialysis. Arch Intern Med 1986; 146(7):1338-44.  Back to cited text no. 8    
9.Seedat YK, Nathoo BC. Acute renal failure in blacks and Indians in South Africa-comparison after 10 years. Nephron 1993;64(2):198-201.  Back to cited text no. 9    
10.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(2):29-30.  Back to cited text no. 10    
11.Naqvi R, Akhtar F, Ahmed E, et al. Acute renal failure of obstetrical origin during 1994 at one center. Ren Fail 1996;18(4):681-3.  Back to cited text no. 11    
12.Chugh KS, Singhal PC, Sharma BK, et al. Acute renal failure of obstetric origin. Obstet Gynecol 1976;48(6):642-6.  Back to cited text no. 12    
13.Zewdu W. Acute renal failure in Addis Ababa, Ethiopia: a prospective study of 136 patients. Ethiop Med J 1994;32(2):79-87.  Back to cited text no. 13    
14.Mate-Kole MO, Yeboah ED, Affram RK, Ofori­Adjei D, Adu D. Hemodialysis in the treatment of acute renal failure in tropical Africa: a 20­year review at the Korle Bu Teaching Hospital, Accra. Ren Fail 1996;18 (3):517-24.  Back to cited text no. 14    
15.Bamgboye EL, Mabayoje MO, Odutola TA, Mabadeje AF. Acute renal failure at the Lagos University Teaching Hospital: a 10-year review. Ren Fail 1993;15(1):77-80.  Back to cited text no. 15    
16.Prybylski D, Khaliq A, Fox E, Sarwari AR, Strickland GT. Parasite density and malaria morbidity in the Pakistani Punjab. Am J Trop Med Hyg 1999;61(5):791-801.  Back to cited text no. 16    
17.Trang TT, Phu NH, Vinh H, et al. Acute renal failure in patients with severe falciparum malaria. Clin Infect Dis 1992;15(5):874-80.  Back to cited text no. 17    
18.Vega J, Borja H, Videla C, et al. Acute kidney failure in patients with and without sepsis: prognosis and clinical course [Article in Spanish]. Rev Med Chil 1996;124(8):938-46.  Back to cited text no. 18    
19.Neveu H, Kleinknecht D, Brivet F, Loirat P, Landais P; The French Study Group on Acute Renal Failure. Prognostic factors in acute renal failure due to sepsis: results of a prospective multicentre study. Nephrol Dial Transplant 1996;11(2):293-9.  Back to cited text no. 19    
20.Better OS, Stein JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 1990; 322(12):825-9.  Back to cited text no. 20    
21.Meyer KB, Madias NE. Cisplatin nephrotoxi­city. Miner Electrolyte Metab 1994;20(4):201-13.  Back to cited text no. 21    
22.Kyle RA. Monoclonal proteins and renal disease. Ann Rev Med 1994;45:71-7.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]
23.Novis BK, Roizen MF, Aronson S, Thisted RA. Association of preoperative risk factors with postoperative acute renal failure. Anesth Analg 1994;78(1):143-9.  Back to cited text no. 23    
24.Naqvi SA. Nephrology services in Pakistan.Nephrol Dial Transplant 2000;15(6):769-71.  Back to cited text no. 24    
25.Buchholz NP, Abbas F, Afzal M, Khan R, Rizvi I, Talati J. The prevalence of silent kidney stones: an ultrasonographic screening study. J Pak Med Assoc 2003;53(1):24-5.  Back to cited text no. 25    

Correspondence Address:
Malik Anas Rabbani
The Kidney Center, Post Graduate Training Institute, 197/9 Rafiqui Shaheed Road, Karachi 75530
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