Spectrum of Acute Kidney Injury and its Management in a Multispeciality Hospital Located at Hyderabad
A. Sushmitha, P. Surpiya, CH. Krishna Vamsi, A. Rajani*
Department of Pharmacy Practice, MNR College of Pharmacy, Sangareddy, TS, India.
*Corresponding Author E-mail: adepurajani05@gmail.com
ABSTRACT:
Aim and Objectives: The main aim and objective is to study the various causes and to understand the treatment and management of acute kidney injury in general population and critically ill patients and to have a thorough knowledge about acute kidney injury occurrence and its condition. Methodology: A hospital based prospective, observational, non-invasive study was carried out on all the inpatients attending the nephrology department, MNR Hospital for a period of 12 months. All the patients of either sex attending the nephrology department and patients admitted in critical care unit were included in the study. Patients of age 30 years and above with various causes involved in acute kidney injury are considered and patients are segregated accordingly. Patients with end stage renal disease and nephrology outpatient department is excluded in the study. Results: During the study period, total 157 cases of acute kidney injury have been recorded. Out of 157 cases 70 (44.58%) were male and 87(55.41%) were female patients and among these 12 fatal cases have been recorded. In this study highest percentage of AKI was recorded in the age group of 51-60 yrs (31.5%). Sepsis (42.1%) was the most common cause of AKI. In this study based on the aetiology of AKI, maximum incidence was seen in pre-renal cause having 136 (86.62%) patients. Maximum patients were non-oliguric. Out of 157 patients 94 (59.8%) required dialysis management, 51 (32.4%) patients were managed with conservative treatment. Conclusion: On the whole AKI is more common in critically ill patients who are in ICU. The majority of patients with AKI are in 51-60 years of age and most of them are managed with renal replacement therapy. Sepsis was found to be the most common cause of acute kidney injury. Through effective patient counselling clinical pharmacist can minimize the impact of drugs causing nephrotoxicity and improve the quality of life of patients with AKI. Early management is more beneficial for the patients to decrease the mortality rate.
Key Words: Acute kidney injury, oliguric, sepsis, dialysis.
INTRODUCTION:
Acute Kidney Injury (AKI) is defined as an abrupt decline in renal function resulting in the inability to excrete metabolic wastes and maintain proper fluid and electrolyte balance. Pre renal azotaemia and ischemic tubular necrosis occur in a continuum of the same pathophysiological process.1 Acute Kidney Injury reflects a broad spectrum of clinical presentations ranging from mild to severe injury that may result in complete and permanent loss of renal function. The range of severity and variety of causes of AKI has resulted in multiple classification systems complicating diagnosis and subsequent management.2,3 The clinical effects of AKI depend on clinical situation but almost invariably increase mortality and morbidity.4,5
Definition of AKI depends on measurement of serum creatinine as a surrogate marker for Glomerular Filtration Rate.6 Calculation of GFR is performed based on serum creatinine value despite the fact that creatinine has a complex metabolism and many factors cam alter serum creatinine values.7-11 Direct measurement of serum creatinine to determine renal function is also unreliable in critically ill patients due to the increased secretion of creatinine in renal tubules and significant overestimation of GFR.12
Many risk factors have been identified for the development of AKI including hypotension, pulmonary disease, liver failure, sepsis, hypovolemia, increased age, hypertension, pre existing renal disease, heart failure, bleach injection and many medications.13-18,19,20-28
Causes of AKI are frequently categorized as pre renal, intrinsic renal and post renal. Renal parenchymal tissue hypoperfusion due to hypovolemia or hypotension may initially cause reversible increase in creatinine.29 Acute tubular necrosis is the most common form of intrinsic renal failure comprising as much as 88% of all cases of AKI.30
MATERIALS AND METHODS:
A prospective, observational, non- invasive study was carried out on all inpatients attending the Nephrology Department, MNR Hospital for a period of 12 months. A total of 157 inpatients were included in the study based on the inclusion and exclusion criteria.
METHOD:
Obtaining clearance certificate from Institutional Ethical Committee
For obtaining the ethical clearance certificate, an application along with study protocol which included the proposed title, study site, inclusion and exclusion criteria, objective and methodology about the work to be carried out was submitted to the chairman of the Institutional Ethical Committee of MNR Hospital.
Collection of data:
The patients of either sex, in critical care unit and inpatients Nephrology department are observed for presence of any symptoms of acute kidney injury, and are enrolled as per the inclusion and exclusion criteria.
Inclusion criteria:
Patients above the age of 30 years and below the age of 80 years are included.
Exclusion criteria:
Patients below the age of 30 years, patients with end stage renal disease and other co morbidities are excluded.
Study schedule and plan:
The patients were enrolled with current medical history and diagnosis was noted during the first visit. After enrolment in to study, follow up was done for inpatients. At each follow up patients are asked for any new complaints, and the disease progress and management is examined.
Source of data:
Patient’s data relevant to the study will be obtained from patient data collection and treatment chart. Patient data collection form includes patient’s demographic details, chief complaints, family and social history, diagnosis, treatment chart. Laboratory parameters were measured using a semi-auto analyzer (SECOMAM, FRANCE) using regular diagnostic kits.
Ethical Considerations:
The study was conducted after obtaining ethical clearance from the Institutional Ethical Committee. Privacy and confidentiality were ensured during Clinical care services.
RESULTS AND DISCUSSION:
In the study out of 157 patients, 87 were found to be female and 70 were found to be male. The study population was classified into different age groups, most of them fall under the age group of 51 to 60 years with 39.5%. The results are well depicted in table no.1 and figure no. 1 and 2. Other studies demonstrated that majority of male population were at a higher risk of AKI, Elizabeth F Daber.31
The most common causes of AKI were found to be sepsis (42%), coronary artery disease (16%) , obstructive uropathy (9%) . The results are well depicted in table no. 2 and figure no.3. While the main cause of AKI was sepsis (4.5%) followed by hypovolemia (0.6%), Brivet et al.32
The etiological classification was done under 3 stages i.e. pre renal with 136 patients, intrinsic renal with 6 patients and post renal with 15 patients. The results are well depicted in table no. 3. The most commonly occurring clinical manifestation was low grade fever which accounted for 30.5% followed by nausea and vomiting with 26.2% and then shortness of breath which is 23% prevalent followed by other symptoms. The results are well depicted in table no. 4 and figure no. 5.
Various laboratory parameters were chosen as the diagnostic aids for AKI and few of them are listed in table no. 5 and table no. 6. Apparently, the results show that serum creatinine was the parameter which was found abnormal in most of the patients i.e. 53, followed by the serum urea i.e. 21 patients and then blood pH which accounted for 25 patients. Urine output was also considered as one of the major parameters and further classified into oliguric with 46 patients, non- oliguric with 65 patients, oligo- anuric with 20 patients and anuric with 26 patients. The result is well depicted in figure no. 6.
AKI is the major underlying cause for the occurrence of CKD and hence the study population was divided into AKI which consisted of 75 patients and AKI on CKD which consisted of 82 patients. The results are well depicted in table no. 7 and figure no. 7. Patients were classified according to RIFLE criteria as in risk, 9(7.2%), injury, 114(72.7%) , failure, 34(21.7%) . The p value was found to be significant at p<0.05. The results are well depicted in table no. 8. Different treatment alternatives were considered for each patient based on the severity of their condition. 94 patients were undergoing dialysis and 51 patients were on conservative treatment. The results are well depicted in table no. 9 and figure no.8. The conservative treatment consisted of different class of drugs prescribed for the patient with antibiotics accounting for highest number i.e. 83 followed by diuretics, iron supplements and Vasoactive drugs. The results are well depicted in table no. 10 and figure no. 9.
Figure 1: Age distribution of study population
Figure 2: Gender distribution of study population
Figure 3: Common cause distribution of AKI
Figure 4: Etiological distribution of AKI
Figure 5: Clinical features of AKI patients
Figure 6: Distribution of patients according to abnormal laboratory parameters |
Figure 7: Distribution of patients according to the urine output |
Figure 8: Distribution of patients having AKI or AKI on CKD
Figure 9. Type of treatment given to AKI patients
Table 1: Conservative treatment for patients with AKI along with dialysis
Class of Drugs |
No. of patients |
K-bind sachets(calcium polystyrene sulphonate) |
10 |
Vasoactive drugs |
11 |
Isotonic saline (0.9%) / blood / plasma |
7 |
Sodium bicarbonate |
8 |
Iron supplements |
14 |
Diuretics |
18 |
ACE inhibitors |
6 |
Antibiotics |
83 |
Table 2: RIFLE Criteria
Criteria |
No. of patients |
P value |
Risk |
34(21.7%) |
- |
Injury |
114(72.7%) |
0.01 |
Failure |
9(5.6%) |
- |
p value of 0.01 is statistically significant
CONCLUSION:
Nephrology is one of the major specialities of medicine that concerns itself with the study of normal kidney function, kidney problems, treatment of kidney problems and renal replacement therapy. Sepsis was found to be the most common cause of AKI which can be treated if detected early and progressive treatment is given but when the conservative treatment is refractory and multiple organ failure is observed then renal replacement therapy is preferred, but mortality is high in patients treated with dialysis due to Multiple Organ Dysfunction Syndrome (MODS). Clinical pharmacists can play a key role in identifying potential nephrotoxic agents and advising on appropriate fluid regimens/volumes, drug omission, drug dosing and the use of safer alternative therapy. Through effective patient counselling clinical pharmacist can minimize the impact of drugs causing nephrotoxicity and improve the quality of life of patients with AKI.
ACKNOWLEDGEMENTS:
Authors are very much thankful to Dr. V. Alagarsamy, Professor & Principal, MNR College of Pharmacy, Sangareddy for his constant support and encouragement.
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Received on 10.10.2019 Modified on 18.12.2019
Accepted on 08.02.2020 © RJPT All right reserved
Research J. Pharm. and Tech 2020; 13(9):4351-4356.
DOI: 10.5958/0974-360X.2020.00769.6