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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 1315-1319
Acute kidney injury requiring hemodialysis in the tropics

1 Department of Medicine, Ladoke Akintola University of Technology, Osogbo, Nigeria
2 Department of Obstetrics and Gynecology, Ladoke Akintola University of Technology, Osogbo, Nigeria

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Date of Web Publication17-Nov-2012


The morbidity and mortality from acute kidney injury (AKI) have remained relatively high over the last six decades. The triad of infections, nephrotoxins and obstetric complications are still major causes of acute kidney injury in the tropics. This retrospective study is a five-year audit of acute renal failure (ARF) (or stage 3 AKI) in patients requiring hemodialysis at the renal unit of the Department of Medicine of the Ladoke Akintola University of Technology (LAUTECH) Teaching Hospital, Osogbo, Nigeria. A total of 80 patients with AKI were treated over a five-year period at our center, of which 45 (56.2%) were in ARF, i.e. stage 3 AKI requiring hemodialysis. There were 24 males and 21 females. The most common cause of ARF among the patients was sepsis syndrome 16 (35.5%), while pregnancy-related cases accounted for 15 (33.3%) and nephrotoxins for 6 (13.3%). Five (33%) of the 15 pregnancy-related patients survived, and all were cases of septic abortion. Of the other 10 patients that did not survive, three (30%) had post-partum hemorrhage and seven (70%) post-partum eclampsia. In all, the mortality rate among our AKI presenting for hemodialysis at our center over a given year period was 28.8%. Majority of these were eclampsia related. The causes of ARF still remain the same in the tropics, eclampsia portends poor prognosis. Concerted efforts should be made at limiting this trend by active preventive services and early recognition of high-risk obstetrics cases.

How to cite this article:
Okunola OO, Ayodele OE, Adekanle AD. Acute kidney injury requiring hemodialysis in the tropics. Saudi J Kidney Dis Transpl 2012;23:1315-9

How to cite this URL:
Okunola OO, Ayodele OE, Adekanle AD. Acute kidney injury requiring hemodialysis in the tropics. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2023 Jan 29];23:1315-9. Available from: https://www.sjkdt.org/text.asp?2012/23/6/1315/103587

   Introduction Top

Acute kidney injury (AKI) refers to an abrupt (within 48 h) reduction in kidney function - a rise in serum creatinine (Scr) by ≥0.3 mg/dL, a percentage increase in Scr of ≥50% from baseline or documented oliguria of <0.5 mL/kg/h for more than 6 h. [1] Acute renal failure (ARF) represents the end of the continuum of the spectrum of AKI. The actual incidence is not well known. However, the estimated incidence world-wide ranges from 1% to 31% of all medical cases, while mortality ranges between 19% and 83%. [2] It accounts for 13-40% of adult admission for kidney disease in Nigeria. [3]

Dialytic support, mainly in the form of hemodialysis therapy, was ultimately offered when indicated. Indications included: symptomatic uremia, severe hyperkalemia (serum potassium >6.5 mmol/L), uremic pericarditis, acute pulmonary edema especially in the setting of anuria or oliguria, intractable acidosis especially with serum bicarbonate <12 mmol/L, azotemia with serum creatinine >500 μmol/L and serum urea >20 mmol/L and hypercatabolic state, defined as daily rise in serum urea >10 mmol/L, serum creatinine >100 μmol/L and potassium >1 mmol/L.

This study is a five-year audit of ARF or stage 3 AKI patients requiring hemodialsis at the renal unit of the Department of Medicine of the LAUTECH Teaching Hospital, Osogbo, Nigeria. The unit provides both acute and maintenance hemodialysis to patients in at least six catchment states in the Southwestern and North-central regions of Nigeria. The aims and objectives of this study are to determine the types of ARF requiring hemodialytic support at our unit, to determine the peculiar characteristic features of each and to proffer possible solutions.

   Materials and Methods Top

The log book of dialysis sessions and the ward records were used for the analysis. The data obtained from these records included the age, sex, primary diagnosis (as recorded by the managing internist), the number of dialysis sessions and the eventual outcome. All patients diagnosed with ARF (serum urea ≥8 mmol/L and serum creatinine ≥140 μmol/L) or stage 3 AKI using the AKIN criteria were included in this study. A cut-off of 400 mL was used to distinguish between oliguric and non-oliguric ARF. Excluded from this study were patients who had clinical, radiological and laboratory features in keeping with an underlying chronic kidney disease, patients who had positive serology to HIV I/II, hepatitis B surface antigen and hepatitis C viruses and patients with symptoms and radiological features suggestive of an obstructive uropathy. Consumption of nephrotoxic antibiotics or analgesics or herbal medications (in the form of plant/animal origin) and other alternative toxic medications were generally classified as nephrotoxins.

Septicemia was defined as having a microbiological focus of infection and deterioration of the clinical state, evidenced by at least one of the following: temperature >39°C on two or more occasions, leucocytosis >10 × 10 9 /L and positive blood culture. [2]

Pregnancy-related cases included all cases of pre-eclampsia, eclampsia, septic abortion and bleeding conditions, both antepartum and post-partum hemorrhages. Acute glomerulonephritis was diagnosed based on clinical features and the presence of proteinuria, microscopic hematuria and hypertension.

The data were analyzed using Epi Info 2002. Categorical variables were summarized using frequency and percentages, while mean and standard deviation were used for continuous variables. Measure of association was carried out using Fisher's exact test. Significance was put at less than 5%.

   Results Top

A total of 80 patients with AKI were seen over a five -year period at our center, of which 45 (56.2%) were in ARF, i.e. stage 3 AKI requiring hemodialysis. The mean age of the study population was 33.7 years (SD ± 10.1, range 16-65years). The mean age for the males was 37.6 years (SD ± 11.7, range 16-65 years) and that of the females was 29.3 years (SD ± 5.3, range 21-38 years). There was a significant age difference between the males and females (t = 4.85, P < 0.01). [Table 1] shows the distribution of the etiological factors of the ARF in the population studied. The most common cause of ARF among the patients was sepsis syndrome 16 (35.5%), while pregnancy related cases accounted for 15 (33.3%) and nephrotoxins six (13.3%). Others included acute glomerulonephritis, viperidae snake bite and rhabdomyolysis due to flame injury.
Table 1: The etiology and the outcome.

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During the same period, 225 were offered hemodialysis (HD) 180 (80%) patients with chronic kidney failure and 45 (20%) with ARF. There were 24 males and 21 females, with a ratio 1:1. Five (33%) out of the 15 pregnancy-related cases survived, and all cases were of septic abortion. The other ten that did not survive were post-partum hemorrhage cases three (30%) and eclampsia-related cases seven (70%). It may be noted here that they were all unbooked referral cases [Table 2]. The only case of burns-related AKI due to rhabdomyolysis did not survive.
Table 2: Pattern of pregnancy-related AKI.

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Twenty-five of the 45 patients were oliguric at presentation, while the remaining 20 were non-oliguric (using a daily urinary cut-off of 400 mL/day), and the non oliguric cases were cases of septicemia, pregnancy related (especially eclampsia) and nephrotoxins.

Of the six patients with nephrotoxin-induced AKI, four had a history of ingestion of undefined herbal remedies, while there was a history of usage of conventional medications such as nephrotoxic antibiotics in two of the patients. There was only a slight difference in terms of survival with respect to the place of management, i.e. the general medical wards and the intensive care units [Table 3]. Fifteen of the 45 patients were managed at the intensive care unit after the first session of hemodialysis, of which ten survived and five died. Thirty patients were managed at the general medical wards, with 22 patients surviving. In all, the mortality rate among our AKI presenting for hemodialysis at our center over a five-year period was 28.8%.
Table 3: Comparing the outcomes in the intensive care unit with medical ward admissions.

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   Discussion Top

ARF, which is a subset of the spectrum of AKI, is a major indication for renal replacment therapy with hemodialysis worldwide. Other forms of renal replacement therapy in ARF, such as acute peritoneal dialysis and continuous renal replacement therapies (CRRT), are presently not available in most parts of the Africa sub-region (apart from Sudan) due to the nonavailability of peritoneal dialysis fluids and the high cost of maintenance of the CRRT machines. [5],[6] As in most other works done earlier, septicemia, pregnancy-related cases and nephrotoxin-induced cases still accounted for majority of the cases of ARF seen at our setting. [7]

Nephrotoxins at our centers were mainly undefined in the majority of the cases, and constituted about 13.3% of ARF patients presenting for HD. This figure is in agreement with works done at Ilorin [8] and Nairobi, [9] but apparently lower than that reported by Seedat in South Africa. [10] The other peculiarities of the nephrotoxin-induced ARF at our center are that it has a periodic variation as there is often an upsurge in such cases whenever there is a herbal medicinal trade fair; also, we observe that this is more common among the semi literates who would rather purchase such undefined and unverified medications. They tend to present with the oliguric form of ARF, which, at most times, is the common reason for presenting to the hospital. A similar work done at Ibadan and Ife had earlier revealed a similar pattern, and all these (including this present work) showed a low mortality pattern among these patients. [11],[12]

ARF complicates malaria in 1-5% of patients in endemic areas, but, in non-immune visitors, the figure goes up to 30%, while mortality could be as high as 38%. [13] Malaria as a cause of ARF requiring dialysis therapy as reported in many works in the tropics was not seen at our practice. This may be partly due to the fact that malaria in our environment is mainly sub-clinical in nature and most people seek treatment with early symptoms. Another reason could be the current universal treatment guideline for malaria, which focuses on artemisinin-based combination therapy, better, faster and patient friendly diagnostic kits, free provision of insecticide-treated nets by most governmental and non-governmental agencies. It is also conceivable that the aggressive management of the pre-renal azotemia done via intensive fluid and diuretic management at our center could be another reason for this low incidence. Lastly, the study population was mainly adults; hence, instances of severe malaria in the vulnerable groups, e.g. pediatric population, might have unwittingly be left out.

Pregnancy-related cases of acute kidney injury (PRAKI) such as post-partum eclampsia and septic abortions were the most common obstetrical cases that needed dialysis. As distinct from other centers in the developing countries where the incidence is as low as 8%, [14] the incidence of PRAKI at our center over a five-year period was 33.3% with a mortality of 66.6%. These specific cases (post-partum eclampsia and complications of unsafe abortions) still forms a major proportion of pregnancy-related cases presenting with ARF from works done in other centers in Nigeria. [15],[16],[17] Most of the eclamptics were unbooked cases initially managed at unregistered nursing/maternity homes and sub-standard health centers in which the antenatal care is often poor. Other obstetrics-associated cases seen during this period included post-partum hemorrhages mostly seen in the age bracket of 25-37 years, and majorly occurring in primigravidas.

Similar reasons also account for the cases of septic abortion, and these were majorly performed by unskilled professionals with concomitant use of nephrotoxic medications. It should be noted that septic abortion as a cause of ARF is virtually non-existent is some other parts of the world. Current estimates indicate that Nigeria has the second highest rate of maternal mortality in the developing world, put at 1000/100,000 live births. Nigeria is said to contribute 10% of the global maternal mortality figure despite the fact that it only constitutes 1.7% of the worlds population. [18]

The mortality rate of 28.8% in this study is lower than that of a similar works done in two centers in Malaysia where a mortality rate of 48% and 33.2% were respectively reported, [19],[20] although these studies were done under a relatively different setting from ours, especially the use of peritoneal dialysis as the main form of treatment in less-severe cases by these centers. The outcome of these studies actually challenges the role of acute PD as a treatment option for ARF, in terms of the slow rate of toxin clearance, although studies done at another dialysis center in Nigeria by Arogundade et al did not find any significant difference in mortality between PD and hemodialytic therapy in ARF. [21]

Finally, there seems to be a role for the management of ARF in the intensive care unit in the tropics similar to what is done in the developed countries (although the etiology necessitating admissions differ significantly) in view of the life support systems offered and the ability for continuous monitoring of high-risk patients. A similar work done at a center in Nigeria had earlier confirmed this trend. [22]

Challenges over the period under review probably still remain in our population, such as late presentation, the deleterious effects of nephrotoxins on the kidneys, and the high morbidity and mortality in pregnancy related cases, especially post-partum hemorrhages, complications of unsafe abortion and post-partum eclampsias. Addressing this is vital in view of the high maternal mortality rate in Nigeria.

Ultimately, there is a compelling need for active preventive services, especially in terms of intensive health education highlighting the risks involved in the consumption of poorly defined alternative remedies and the benefits of early recognition of basic symptoms of acute kidney insufficiency. The need for prompt referrals to tertiary care centers for specialized management is also important.

   References Top

1.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. 1
2.Nissensor AR. Acute renal failure; Definition and Pathogenesis. Kidney Int 1988; 66: Suppl. S7-10.  Back to cited text no. 2
3.Bamgboye EL, Mabayoje MO, Odutola TA, Mabadeje AF. Acute Renal Failure at the Lagos University Teaching Hospital: A 10 year review. Ren Fail 1993;15:77-80.  Back to cited text no. 3
4.Knaus WA, Draper EA, Wagner DP, Zimmerman JE. Prognosis in acute organ system failure. Ann Surg 1985;202:685-93.  Back to cited text no. 4
5.Abu-Aisha H, Elamin S. Peritoneal Dialysis in Africa. Perit Dial Int 2010;30:23-8.  Back to cited text no. 5
6.Bamgboye EL. Hemodialysis management problems in developing countries with Nigeria as a surrogate. Kidney Int Suppl 2003;83:S93-5.  Back to cited text no. 6
7.Naicker S, Aboud O, Gharbi MB. Epidemiology of acute kidney injury in Africa. Semin Nephrol 2008;28:348-53.  Back to cited text no. 7
8.Chijioke A, Aderibigbe A, Olanrewaju TO. Prevalence of acute renal failure due to exogenous nephrotoxins in Ilorin. Trop J Nephrol 2007;1:43-8.  Back to cited text no. 8
9.Otieno IS, Ligoyoso MC, Luta M. Acute renal failure following the use of herbal remedies. E Afr Med J 1991;68:993-8.  Back to cited text no. 9
10.Seedat YK, Nathoo BC. Acute renal failure among Blacks and Indians in South Africa. S Afr Med J 1978;54;427-31.  Back to cited text no. 10
11.Kadiri S, Ogunlesi A, Osinfade K, Akinkugbe OO. The causes and course of Acute tubular necrosis in Nigerian. Afr J Med Med Sci 1992; 21:91-6.  Back to cited text no. 11
12.Adelekun TA, Ekwere TR, Akinsola A. The pattern of acute toxic nephropathy in Ife, Nigeria, West Afri J Med 1999;18:60-3.  Back to cited text no. 12
13.Barsoum RS. Malarial Acute Renal Failure. J Am Soc Nephrol 2000;11:2147-54.  Back to cited text no. 13
14.Randeree IG, Czarnocki A, Moodley J, Seedat YK, Naiker IP. Acute renal failure in pregnancy in South Africa. Ren Fail 1995;17:147-53.  Back to cited text no. 14
15.Odum CU. Eclampsia: An analysis of 845 cases treated in the Lagos University Teaching Hospital, Nigeria over a 20 year period. J Obstet Gynaecolol East Cent Afr 1991;9:16-70.  Back to cited text no. 15
16.Oladokun A, Okewole AI, Adewale IF. Evaluation of cases of Eclapsia at the University College Hospital, Ibadan over a 10 year period. West Afr J Med 2000;19:192-4.  Back to cited text no. 16
17.Loto OM, Owolabi AT, Orji EO, et al. Trends in maternal mortality in Ile-Ife - a 20 year analysis. Nig Health Sciences 2008;8;5-7.  Back to cited text no. 17
18.Chukwudebelu WO. Maternal mortality. Trop J Obstet Gynaecol 1995;(12):1-3.  Back to cited text no. 18
19.Hooi LS. Acute renal failure requiring dialysis - a 5 year series. Med J Malaysia 1997;52:251-6.  Back to cited text no. 19
20.Suleiman AB. Clinical review of acute renal failure: A 5 year experience at Kuala Lumpur. Ann Acad Med Singapore 1982;11:32-5.  Back to cited text no. 20
21.Arogundade FA, Sanusi AA, Okunola OO. Acute Renal Failure (ARF) in developing countries; which factors actually influence survival. Cent Afr J Med 2007;53:34-9.  Back to cited text no. 21
22.Okunola OO, Arogundade FA, Sanusi AA. Acute renal failure in the Intensive Care Unit: etiological and predisposing factors and outcome. West Afr J Med 2009;28:240-4.  Back to cited text no. 22

Correspondence Address:
Oluyomi O Okunola
Department of Medicine, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.103587

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  [Table 1], [Table 2], [Table 3]

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