|Year : 2020 | Volume
| Issue : 2 | Page : 103-110
Acute kidney injury in intensive care unit patients in Benha University Hospitals
Ayman M El-Badawy, Ahmed E Mansour, Rasha O Abdelmoniem
Department of Internal Medicine, Benha University, Benha, Egypt
|Date of Submission||28-Aug-2019|
|Date of Acceptance||23-Dec-2019|
|Date of Web Publication||27-Apr-2020|
Dr. Ahmed E Mansour
Department of Internal Medicine, Benha University, Benha, 11311
Source of Support: None, Conflict of Interest: None
Background Acute kidney injury (AKI) is classically described as abrupt or rapidly reversible reduction of excretion of nitrogenous waste products including urea, nitrogen, and creatinine. In critical care setting, patients with AKI constitute an important subgroup in that they have higher short-term and long-term mortality, prolonged hospital stay, and more resource consumption. Risk factors for AKI in patients with severe illness are multifactorial, including underlying certain predisposing factors, as aged patients tend to acquire AKI more than younger patients, together with underlying comorbidities AKI is common and carries a high mortality rate. Most epidemiological studies were retrospective and were done in Western populations.
Aim The aim was to highlight the risk factors, mechanisms, and prognosis in AKI in patients in ICU.
Patients and methods This is a prospective, observational study that was carried out in ICU, Benha University Hospitals, from January 2018 to July 2018. This study included 50 critical ill patients admitted to ICU. Oral and written consent was taken from every participant after explaining the procedures of the analysis. All patients were clinically evaluated and had routine assessment.
Results The mean age of our studied population was 56.3±6.8 years, demonstrating a significant trend toward an increased number of AKI cases with older age. Males represented 68.9% of the included patients, and 62% of patients with AKI had a history of diabetes mellitus. Mortality was evident in 14% of patients with AKI. Patients with AKI with older age, male sex, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, mechanical ventilation, and vasopressor were significantly associated with renal replacement therapy.
Conclusion AKI was associated with high mortality rate, and early identification may cause a dramatic decrease in mortality and morbidity, which could be expected in these high-risk patients.
Keywords: acute kidney injury, dialysis, intensive care units
|How to cite this article:|
El-Badawy AM, Mansour AE, Abdelmoniem RO. Acute kidney injury in intensive care unit patients in Benha University Hospitals. J Egypt Soc Nephrol Transplant 2020;20:103-10
|How to cite this URL:|
El-Badawy AM, Mansour AE, Abdelmoniem RO. Acute kidney injury in intensive care unit patients in Benha University Hospitals. J Egypt Soc Nephrol Transplant [serial online] 2020 [cited 2020 May 28];20:103-10. Available from: http://www.jesnt.eg.net/text.asp?2020/20/2/103/283244
| Introduction|| |
Acute kidney injury (AKI) is a major global public health concern, with an incidence of ∼2100 per million populations . AKI development in ICU is associated with a risk of long-term renal dysfunction and short-term and long-term mortality .
AKI is characterized by a rapid deterioration of kidney function and accumulation of waste products, electrolytes, fluids, and also less obvious effects, including reduced immunity and dysfunction of nonrenal organs (organ cross-talk) .
The incidence of AKI is high and is increasing in patients admitted to ICU. Approximately 30–60% of critically ill patients have AKI based on RIFLE criteria, and of them, 4–5% require dialysis.
Underlying comorbidities predisposing to AKI include diabetes mellitus, hypertension, chronic kidney disease, and heart failure, all set the background for subsequent renal injury through the interplay of renal autoregulation, pre-existing renal damage, and concomitant use of nephrotoxic drugs.
Ischemia, inflammation, and direct toxic injury to the kidney are all major areas that contribute to the pathogenesis of AKI in critically ill patients.
Critically ill patients receive a myriad of medications including nephrotoxic drugs and antibiotics, which are responsible for 19–20% of AKI cases in ICU. Comorbidities that enhance the nephrotoxicity of the drugs are CKD, liver cirrhosis, and acute and chronic heart failure. Sepsis has been found to be the leading cause of AKI in ICU patients, and no single pathway can explain all features of septic AKI.
The current study aimed to highlight the risk factors, mechanisms, and prognosis in AKI in patients in ICU.
| Patients and methods|| |
Ethical approval was obtained from the Medical Institution Commission (27/8/2017), and a knowledgeable written informed consent with a proof concerning the concept of the analysis was taken from all of the registered patients. This is a prospective, observational study that was carried out in Benha University Hospitals at ICU from January 2018 to July 2018. This study included 50 critical ill patients admitted to ICU.
Inclusion criteria included age more than 18 years and patients who stayed in the ICU for longer than 48 h. Exclusion criteria included ICU admission of less than 48 h, postelective surgery, and ICU readmission. All included patients underwent detailed history taking, with special attention to age, residence, comorbid diseases such as diabetes, hypertension, and heart failure. Cause of admission, duration of hospital stay, risk factors of AKI, and nephrotoxic drugs were assessed. The patients were clinically evaluated generally, with stress on blood pressure respiratory rate, cardiac, chest, and abdominal examination, and laboratory investigations, which were done including complete blood picture, C-reactive protein, urine analysis, serum electrolyte (Na, K, Ca, and phosphorus), arterial blood gases, cardiac enzymes, serum creatinine, blood urea, chest radiography, and echocardiography.
All data were collected, tabulated, and statistically analyzed using SPSS 19.0 for windows (SPSS Inc., Chicago, Illinois, USA). Data were expressed as mean±SD. Analysis of variance test was used to assess the difference between the studied parameters in the studied groups. The frequencies were expressed in percentage. χ2-Test was used to assess the difference between the studied frequencies in the studied groups. P was considered significant if less than 0.05 and highly significant if less than 0.001.
| Results|| |
Analysis of the baseline data of the study population revealed that the mean age of our study population is 56.3±6.8 years, 68% of them are males, 62% of them are diabetics, 42% are hypertensive, 42% of them had history of cardiovascular diseases, 50% had chronic liver disease, 48% had chronic renal failure, and 56% of them had cancer. Mortality was evident in 14% of our study population ([Table 1]).
Analysis of laboratory investigations of our study population revealed that the mean of serum creatinine was 3.6±0.9 mg/dl, and the mean of serum urea was 143.4±44.4 mg/dl ([Table 2],[Table 3],[Table 4]).
|Table 3 Comparison between types of acute kidney injury regarding baseline data|
Click here to view
|Table 4 Comparison between types of acute kidney injury regarding laboratory investigations|
Click here to view
Comparison between patients with AKI who underwent renal replacement therapy (RRT) and patients with AKI without RRT regarding different parameters revealed, that there was no significant difference regarding Glasgow coma scale. Patients with AKI with RRT were older age than those without RRT. Males, diabetes mellitus (DM), chronic obstructive pulmonary disease, congestive heart failure, mechanical ventilation, vasopressor, and Acute Physiology and Chronic health Evaluation II (APACHE-II) and Sequential Organ Failure Assessment (SOFA) scores were significantly increased among RRT group ([Table 5] and [Table 6]).
|Table 6 Multivariate regression analysis to determine risk factors for mortality in acute kidney injury|
Click here to view
Comparison between survivors and nonsurvivors regarding baseline data revealed that there was no significant difference between the two groups regarding age, sex, DM, hypertension, congestive heart failure, chronic liver disease, chronic kidney disease, and cancer ([Table 7] and [Figure 1],[Figure 2],[Figure 3]).
|Table 7 Comparison between survivors and nonsurvivors regarding baseline data and laboratory investigation|
Click here to view
|Figure 3 Comparison between survivors and nonsurvivors regarding morbidity.|
Click here to view
Comparison between survivors and nonsurvivors regarding laboratory investigations revealed that nonsurvivors had significant increased values of serum creatinine, whereas there was no significant difference between the two groups regarding serum urea ([Figure 4] and [Figure 5]).
|Figure 4 Comparison between survivors and nonsurvivors regarding serum creatinine.|
Click here to view
|Figure 5 Comparison between survivors and nonsurvivors regarding serum urea.|
Click here to view
| Discussion|| |
In the present study, 94% of the studied patients were aged more than 45 years. Old age is a well-defined risk factor of occurrence of AKI and related to compromised kidney function owing to aging-induced physiological and pharmacokinetic changes. Moreover, elderly patients have comorbid conditions for which they are using medications, including nephrotoxic drugs, which make them more susceptible to AKI .
In the present study, males represented 68.9% of the included patients. Previously, it was demonstrated that the rate of AKI development was the same in either sex . In accordance with our findings, Malleshappa et al.  found that male represented 62.3% of ICU patients with AKI. Doddakula et al.  identified that female patients with AKI were associated with a higher risk of dialysis requirement.
In the current study, 62% of patients with AKI had a history of DM. These findings are in accordance with the findings of Schmitz et al. , as they noted that critically ill patients with diabetes have a higher incidence of developing AKI. This can be explained as hyperglycemia induces release of free fat acids, the inactivation of nitric oxide (NO), and increased production of reactive oxygen species (ROS), correspondingly .
However, Nisula et al. , found no significant difference between patients with AKI and those without AKI regarding history of DM as DM was evident in 22% of ICU patients with AKI.
In the current study, 53% of patients with AKI have cancer. This can be explained as patients with cancer are particularly at risk for AKI secondary to infection and sepsis , tumor lysis syndrome , kidney damage induced by immunosuppression after hematopoietic stem cell transplantation , and direct effects from the primary malignancy .
However, these findings disagree with the findings of Mao and Qin , as they noted no significant difference between patients with AKI and those without AKI regarding history of malignancy as cancer was evident in 25.5% of ICU patients with AKI.
AKI in ICU is multifactorial, and true etiology is still needed to be evaluated . Primary diagnosis on ICU admission may vary from clinicians to clinicians; therefore suggest studies with well-defined diagnostic criteria are suggested in order to determine the exact cause of AKI .
In the present study, congestive heart failure was evident in 60% of patients with AKI. It was reported that heart failure is often regarded as one of the most important risk factors for perioperative AKI .
In the present study, chronic liver disease was evident among 30% of the included patients. Piano and his colleagues  reported that AKI has an estimated prevalence of ∼20–50% among hospitalized patients with cirrhosis and patients with cirrhosis are more likely to develop renal failure compared with individuals without liver disease.
In the present study, mortality was evident in 14% of the studied population. AKI is independently associated with short-term and long-term mortality . Critically ill patients with AKI are ∼2–5 times more likely to die compared with those without AKI, with mortality exceeding 50% .
Patients with AKI in ICU are usually managed with conservative treatments or RRT. Conservative treatment includes management of volume, electrolyte, and acid-base homeostasis and specific drug management. RRT is indicated for management of specific problems such as volume overload, hyperkalemia, acidosis and symptoms of uremia .
Because of limited health resources and complications associated with RRT, many critically ill patients with AKI are often managed conservatively with mechanical ventilation, inotropes, diuretics, and intravenous fluids; RRT is usually initiated when major complications of fluid overload, acidosis, uremia, or hyperkalemia develop. Early prediction of the requirement for acute RRT would be useful in ICU where physicians have excessive workload .
Therefore, several risk factors of dialysis treatment were determined in the current study. In this context, the current study determined risk factors of dialysis treatment among patients with AKI. Patients with AKI with old age were found to be significantly associated with dialysis treatment. Similar findings were reported by Elsevier et al.  that patients with AKI requiring RRT were significantly older than those who did not need RRT in ICU. We also identified that female patients were associated with a higher risk of dialysis requiring AKI and similar findings have been reported by Doddakula et al. .
In the present study, presence of congestive heart failure and chronic obstructive pulmonary disease was associated with dialysis. These results are in agreement with other findings evaluating different factors of RRT need among patients with AKI .
In this study, the dialysis treatment was significantly associated with DM. Faulk et al.  have also reported association of DM with RRT.In this study, the percentage of patients who were treated with vasopressor drugs was significantly increased among RRT group. Myc et al.  found that estimated glomerular filtration rates were also significantly lower in the AVP group.
In the present study, the percentage of patients who needed mechanical ventilation was significantly increased among RRT group. Doddakula et al.  found that ventilator duration and pulmonary complications are significantly associated with RRT risk.
Other risk factors of dialysis initiation were mechanical ventilation and high disease severity scores. The severity of disease, as evaluated by recognized prognostic scales in ICU, considerably affects the risk of dialysis treatment . The results of the current study also showed increased risk of dialysis with high SOFA and APACHE-II results.
These results are also in concordance with the findings of Czempik et al.  where they found that dialysis increased with each score increase. Need of mechanical ventilation and vasopressors denotes seriously ill patients, as evidenced by the high Glasgow coma scale, APACHE-II, and SOFA scores, and these patients had higher risks of dialysis in the present study. These findings are consistent with other studies conducted in ICU .
| Conclusion|| |
AKI was associated with high mortality rate and. Early identification may cause a dramatic decrease in mortality and morbidity in these high-risk patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ronco C, Ricci Z. The concept of risk and the value of novel markers of acute kidney injury. Critical Care 2013; 17:117.
Wang Y, Fang Y, Teng J, Ding X, Xu JR, Zhu JM, Jiang J et al.
Acute kidney injury epidemiology: from recognition to intervention. Acute Kidney Injury 2016; 187:1–8.
Ostermann M, Joannidis M. Acute kidney injury: diagnosis and diagnostic workup. Critical Care 2016; 20:299.
Mallhi TH, Khan AH, Adnan AS, Sarriff A, Khan YH, Jummaat F et al.
Incidence, characteris- tics and risk factors of acute kidney injury among dengue patients: a retrospective ana- ysis. PLoS One 2015; 10:e0138465.
Mataloun SE, Machado FR, Senna AP, Guimarães HP, Amaral JL, Braz J et al.
Incidence, risk factors and prognostic factors of acute renal failure in patients admitted to an intensive care unit. Med Biol Res 2006; 39:1339–1347.
Malleshappa P, Vikrant S, Gupta D, Singh M, Kumar S, Patial RK et al.
Spectrum of acute kidney injury and its outcome in Intensive Care Unit in Tertiary Care Center in India. Turk Neph Dial Transpl 2015; 24:74–81
Doddakula K, Al-Sarraf N, Gately K, Hughes A, Tolan M, Young V et al.
Predictors of acute renal failure requiring renal replacement therapy post cardiac surgery in patients with preoperatively normal renal function. Interact Cardiovasc Thorac Surg 2007; 6:314–318.
Schmitz M, Tillmann FP, Paluckaite A, Laufer EA, Rayner B, Rump LC et al.
Mortality risk factors in intensive care unit patients with acute kidney injury requiring renal replacement therapy: a retrospective cohort study. Clin Nephrol 2017; 88:27–32.
Angeli F, Reboldi G, Poltronieri C, Lazzari L, Sordi M, Garofoli M et al.
Hyperglycemia in acute coronary syndromes: from mechanisms to prognostic implications. Terap Adv Cardiovasc Dis 2015; 9:412–424.
Nisula S, Vaara ST, Kaukonen KM, Reinikainen M, Koivisto SP, Inkinen O et al.
Six-month survival and quality of life of intensive care patients with acute kidney injury. Crit Care 2013; 17:R250.
Heung M, Koyner JL. Entanglement of sepsis, chronic kidney disease, and other comorbidities in patients who develop acute kidney injury. Semin Nephrol 2015; 35:23–37.
Howard SC, Trifilio S, Gregory TK, Baxter N, McBride A, Scott C et al.
Tumor lysis syndrome in the era of novel and targeted agents in patients with hematologic malignancies: a systematic review. Ann Hematol 2016; 95:563–573.
Kogon A, Hingorani S. Acute kidney injury in hematopoietic cell transplantation. Semin Nephrol 2010; 30:615–626.
Benoit DD, Hoste EA, Depuydt PO, Offner FC, Lameire NH, Vandewoude KH et al.
Outcome in critically ill medical patients treated with renal replacement therapy for acute renal failure: comparison between patients with and those without haematological malignancies. Nephrol Dial Transplant 2005; 20:552–558.
Mao Y, Qin ZH. Risk factors of acute kidney injury and dialysis among patients attending intensive care units in China. Int J Clin Exp Med 2017; 10:12056–12067.
Peres LA, Wandeur V, Matsuo T, Adame AP, Venazzi A, D Avilla V et al.
Predictors of acute kidney injury and mortality in an Intensive Care Unit. J Bras Nefrol 2015; 37:3846.
Thakar CV, Christianson A, Himmelfarb J, Leonard AC. Perioperative acute kidney injury. Adv Chronic Kidney Dis 2013; 20:67–75.
Piano S, Rosi S, Maresio G, Fasolato S, Cavallin M, Romano A et al.
Evaluation of the Acute Kidney Injury Network criteria in hospitalized patients with cirrhosis and ascites. J Hepatol 2013; 59:482–489.
Ympa YP, Sakr Y, Reinhart K, Vincent JL. Has mortality from acute renal failure decreased? A systematic review of the literature. Am J Med 2005; 118:827–832.
Elseviers MM, Lins RL, Van der Niepen P, Hoste E, Malbrain ML, Damas P et al.
Renal replacement therapy is an independent risk factor for mortality in critically ill patients with acute kidney injury. Crit Care 2010; 14:R221.
Faulke D, Walters S, Liang J. Clinical predictors of acute renal replacement therapy in critically ill patients with acute renal impairment. Crit Care Resusc 2003; 5:97.
Myc LA, Stine JG, Chakrapani R, Kadl A, Argo CK, Feltenberger JD et al.
Vasopressin use in critically ill cirrhosis patients with catecholamine-resistant septic shock. World J Hepatol 2017; 9:106–113.
Wijeysundera DN, Karkouti K, Dupuis JY, Rao V, Chan CT, Granton JT et al.
Derivation and validation of a simplified predictive index for renal replacement therapy after cardiac surgery. JAMA 2007; 297:1801–180.
Czempik P, Cieśla D, Knapik P, Krzych ŁJ. Risk factors of acute kidney injury requir- ing renal replacement therapy based on regional registry data. Anaesthesiol Intensive Ther 2016; 13:122–129.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]