Acute Kidney Injury: Incidence, Aetiology, Management And Outcome Measures Of A Samoan Case Series
May 07, 2024
ABSTRACT
Background: Acute Kidney Injury (AKI) is a major and under-recognized cause of morbidity and mortality worldwide. Low and middle-income countries bear the greatest burden of AKI (85%). There is currently no published literature on AKI from the Pacific Islands. The present study aimed to report the incidence, etiology, management, and outcome measures of AKI from the tertiary referral hospital of Samoa. Materials and methods: Single-centre prospective observational study. Participants were recruited by the lead investigator from the hospital patient information system. The inclusion criteria for participation was (1) adults (>18 years) admitted to general wards of Tupua Tamasese Meaole (TTM) Hospital with a diagnosis of AKI between December 1, 2019, and May 31, 2020, and (2) serum creatinine level of >200 μmol/L, and (3) compliance with the current Kidney Disease Improving Global Outcomes (KDIGO) criteria for AKI diagnosis. The data collection form was adapted from the International Society for Nephrology - Global Snapshot Project and recorded demographic and baseline characteristics, precipitating causes of AKI, treatment/management, and outcome measures.
HOW LONG DOES IT TAKE FOR CISTANCHE TO WORK FOR KIDNEY DISEASE PATIENTS?
Results: There was a total of 114 AKI admissions over the study period corresponding to a hospital-based AKI incidence of 26.8 per 1000 admissions per 6 months. 75% of AKI cases were community-acquired. The leading causes of AKI were dehydration (79%) and sepsis (64%). More than 40% of cases presented with two or more Non-Communicable Disease co-morbidities. The in-patient mortality rate was 20.2%. In the 3 months following discharge from the hospital, 25% of AKI cases had completely resolved, 25% of patients had died, and 18.7% of AKI cases had progressed to chronic kidney disease. The leading causes of mortality were cardiovascular events (35%) and sepsis (35%). Conclusions: The hospital-based incidence and unfavorable outcomes of AKI are high in Samoa. Greater awareness of this under-recognized condition is warranted among the public, government officers, and health professionals.
1. Introduction
Acute Kidney Injury (AKI) is described as a rapid increase in serum creatinine, decrease in urine output, or both [1]. AKI is not a disease in itself, but rather a silent and under-recognized syndrome that exists on a spectrum, usually secondary to other major aetiologies such as heart failure and sepsis/shock [1]. AKI is associated with various pathophysiological processes that include retention of waste products, impaired electrolyte homeostasis, and generalized inflammatory response affecting distant organs [2]. It represents 10–15% of hospitalisations worldwide, and AKI prevalence in the intensive care unit may exceed 50% [1]. Early recognition of AKI enables timely management and improvement/recovery of kidney function and therefore reduces the risk of long-term morbidity and mortality from both kidney disease and the primary/precipitating health concern (i.e., myocardial infarct) [1, 2].
The current international consensus regarding the definition of AKI is when, over a period of seven days or less, a patient presents with a ≥ 1.5 times increase in baseline serum creatinine (or increase of ≥ 0.3 mg/dL within any 48h period), and/or a urine volume =< 0.5 ml/kg for more than 6 h. The definition of AKI is further classified into three stages of increasing severity (Table 1). These criteria were published by the Kidney Disease Improving Global Outcomes (KDIGO) group to serve as an international gold standard, as well as to facilitate unity and comparison between AKI research findings worldwide.
According to global epidemiology studies [2–4], the greatest burden of AKI (85%) is found in low-income and lower-middle-income nations (LLMICs). The high incidence of AKI in these countries is largely attributed to environmental factors, specifically to contaminated water and endemic disease (i.e., malaria on the African continent) [2]. There is also evidence that AKI affects younger individuals in low-resourced settings, with volume-responsive renal failure, obstetric complications, infections, and toxins as the main causes of kidney injury [5]. While the overwhelming proportion of AKI research (82.7%) is generated by high-income nations, the few studies from low-resourced settings indicate that a significant proportion of AKI is preventable. To this end, the International Society of Nephrology launched the "0by25 Initiative", which aims to eliminate preventable AKI as a cause of mortality worldwide [6,7]. The review of the literature found that there are currently no publications on AKI in the Pacific Islands.
Samoa is a Polynesian nation of the Pacific Island region (Fig. 1). Tupua Tamasese Meaole (TTM) Hospital is the only tertiary referral center in the country, and it is located in the capital city Apia. A caseload review of the Emergency and Internal Medicine Departments suggested that AKI may be a significant yet under-recognized presentation to the TTM hospital. Given the published reports on kidney failure and hemodialysis in Samoa [8,9], the aims of the present study were to evaluate the incidence, etiology, management, and outcome measures of adult patients attending the TTM Hospital with an AKI diagnosis. The results of the study should not only improve early identification and management of AKI in our setting, it may also lead to reducing the burden of chronic kidney disease on our country.
2. Methods
2.1. Ethical approval
Ethical approval for the present study was obtained from the Fiji National University College Health Research Ethics Committee (CHREC) and the Government of Samoa Ministry of Health – Health Research Committee (MoH-HRC). Gatekeeper approval was also obtained from the Deputy Director General of the TTM Hospital.
2.2. Registration
In accordance with the Declaration of Helsinki that "Every research study involving human subjects must be registered in a publicly accessible database", the present study was registered with ClinicalTrials.gov (Protocol ID: 117.19; ClinicalTrials.gov ID: NCT05167292).
Table 1 KDIGO definition of AKI.
