RENAL DATA FROM THE ASIA - AFRICA
Year : 2008 | Volume
: 19 | Issue : 6 | Page : 1009--1014
Etiology of acute renal failure in a tertiary center
Malik Anas Rabbani1, Haseeb Bin Habib2, Bilal Karim Siddiqui2, M Hammad Tahir2, Bushra Ahmad2, Ghulam Murtaza2, Qamaruddin Maria2, Aasim Ahmad1,
1 Department of Nephrology, The kidney Center, Post Graduate Training Institute Karachi, Pakistan
2 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
Malik Anas Rabbani
The Kidney Center, Post Graduate Training Institute, 197/9 Rafiqui Shaheed Road, Karachi 75530
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.
|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;19:1009-1014
|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 Jan 17 ];19:1009-1014
Available from: https://www.sjkdt.org/text.asp?2008/19/6/1009/43485
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. 
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.  It is important to know the causes of ARF, as prognosis is dependent upon specific etiology.  Mortality rates in ARF range from approximately 7% among patients admitted with prerenal azotemia to more than 80% among patients with postoperative ARF. 
Epidemiological studies may help in planning strategies to identify preventable insults resulting in ARF. Examples include ARF due to obstetric diseases,  renal calculi,  and dehydration from gastrointestinal causes.  These commonly occurring conditions in the developing are rare in the developed countries. 
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
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 > 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  Over the past three decades, there have been changes in the relative etiology of ARF in developed as well as in developing countries.  While ARF resulting from trauma and surgery has decreased, ARF due to medical diseases increased in developed countries. , 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  because of safe and early delivery of complicated pregnancies, more effective treatment of pre-eclampsia, and disappearance of septic abortion.  In contrast, in developing countries, the decrease has been less pronounced. 
In contrast to a previous study done in the same city by Naqvi et al  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  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 , (24%), Bangladesh  (11%), India  (22.1%), Ethiopia  (55%) and Nigeria  (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  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. ,,,
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. , 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.  Trang TT et al  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.  The prevalence of stone disease or crystalluria in Pakistan is about 36%, , 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.  Vega et al  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  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.  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,  but hemepigments with crush injuries,  chemotherapeutic agents such as cisplatin,  myeloma lightchain proteins,  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. 
Mortality rates have been reported to be more than 80% among patients with postoperative ARF.  Turney et al. has reported that the mortality of ARF was higher in surgical than medical or obstetric ARF.  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.  Furthermore, only 3 patients had post operative renal failure, which is the major cause of surgical mortality. 
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. 
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.
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