Clinical spectrum of hospital acquired acute kidney injury: A prospective study from Central India.

Acute kidney injury (AKI) is a common disorder worldwide that is associated with severe morbidity, mortality and cost. If managed adequately and in a timely manner, the majority of these cases are preventable, treatable and often reversible with simple measures. We conducted a two years prospective study of patients admitted to medical and surgical units of a tertiary care center in Central India to identify the causes of Hospital Acquired AKI (HAAKI) and its impact on patient outcomes. HAAKI occurred in 215 of 9,800 patients (2.1%). Sepsis (75; 34.88%), volume depletion and hypo perfusion (62; 28.83%), drugs (50; 23.25%), multifactorial (18; 8.37%) and radiocontrast agents (9; 4.2%) were the causes of HAAKI. Thirty-nine percent of patients had complete recovery and 9.3% had partial recovery of renal function. The overall inhospital mortality due to HAAKI was 41.86%. On multivariate analysis, oliguria, multi-organ failure, metabolic acidosis, anemia, and sepsis showed significant association with in-hospital mortality. The mortality and morbidity associated with HAAKI mandates the need for active measures to decrease its incidence. Knowledge of incidence and risk factors is crucial because it drives local and international efforts on detection and treatment. To the best of our knowledge, no epidemiological study has been conducted or published on HAAKI from the Central India.

Changing epidemiology of community-acquired acute kidney injury in developing countries: analysis of 2405 cases in 26 years from eastern India.

BACKGROUND: The epidemiology of acute kidney injury (AKI) differs from country to country and varies from center to center within a country. Owing to the absence of a central registry, data on overall epidemiology of AKI are scanty from India. METHODS: This study aimed at describing changes in epidemiology of community-acquired AKI (CAAKI) over a time span of 26 years in two study periods, namely, 1983-95 and 1996-2008. RESULTS: We studied 2405 (1375 male and 1030 female) cases of AKI in the age range 1-95 (mean: 40.32) years. The incidence of CAAKI in 1983-95 and 1996-2008 was 1.95 and 4.14 per 1000 admission, respectively (P < 0.01). Obstetrical AKI has decreased because of the declining number of post-abortal AKI. Surgical AKI decreased from 13.8% in 1983-95 to 9.17% in 1996-2008(P < 0.01). Malarial AKI increased significantly from 4.7% in the first half of the study to 17% in the later period (P < 0.01). Diarrhea-associated AKI had significantly decreased from 36.83% in 1983-95 to 19% in 1996-2008 (P < 0.01). Sepsis-related AKI had increased from 1.57% in 1983-95 to 11.43% in 1996-2008 (P < 0.01). Nephrotoxic AKI showed an increasing trend in recent years (P < 0.01) and mainly caused by rifampicin and NSAIDs. Liver disease-related AKI increased from 1.73% in 1983-95 to 3.17% in 1996-2008 (P < 0.01). Myeloma-associated acute renal failure (ARF) accounted for 1.25% of the total number of ARF cases in the period 1996-2008. HIV infection contributed to 1.65% of ARF of the total number of AKI cases in the second period (1996-2008). Incidence of renal cortical necrosis (RCN) decreased significantly from 5.8% in 1983-95 to 1.3% in 1996-2008 of the total number of ARF cases (P < 0.01). However, during the same period ARF due to acute tubular necrosis, acute glomerulonephritis and acute interstitial nephritis remained unchanged. The mortality rate from AKI decreased significantly from 20% in 1983-95 to 10.98% in 1996-2008 (P < 0.01). CONCLUSIONS: The epidemiological characteristics of CAAKI have changed over the past three decades. There has been an increase in the overall incidence of ARF with the changing etiology of AKI in recent years. Incidences of obstetrical, surgical and diarrheal AKI have decreased significantly, whereas those of AKI associated with malaria, sepsis, nephrotoxic drugs and liver disease have increased. RCN has decreased significantly. In contrast to developed nations, community-acquired AKI is more common in developing countries. It often affects younger individuals and is caused by single and preventable diseases.

Spectrum of kidney diseases in patients with preeclampsia-eclampsia.

AIM: The aim of this study was to analyse the clinical spectrum of renal manifestation of preeclampsia in pregnant women. METHOD: Diagnosis of preeclampsia was made using two cardinal feature of the disease after 20th weeks of gestation in previously normotensive and nonproteinuric women: (1) Blood pressure > 140/90 mm Hg and (2) urinary protein excretion of > 300 mg/24 hour. The patients with renal manifestations were followed up to 12 weeks postpartum or till death whichever was earlier. RESULT: Of 1805 pregnant women, preeclampsia was diagnosed in 106 (5.87%) patients. Primiparity constitutes 53.77% of total patients. Hypertension and proteinuria were observed in all patients. Hyperuricemia was observed in 93.65% of cases. Acute renal failure occurred in 22 patients. Dialysis support was needed in only four cases of ARF with complete recovery of renal function in 82% of cases. HELLP syndrome was seen in 16 (preeclampsia 5; eclampsia 11) patients. Sixty six patients (Death 13 and lost to follow up 27) were followed for 12 weeks. The renal parameters (Hypertension, Proteinuria and renal function) returned to normal in all except in two patients. Renal biopsy in these two cases revealed FSGS and MPGN in one each. CONCLUSION: The incidence of preeclampsia was 5.87%. Nephrotic syndrome was observed in 11.32% of patients. Acute renal failure occurred in 20.8% of patients. Hypertension, proteinuria and renal function resolved to normal over a average period of 35.8 days in all survivors. The overall mortality was 12%. Neurological complication, pulmonary edema and multiple organ failure were the causes of death.

Multiple myeloma--presenting as acute kidney injury.

BACKGROUND: Multiple myeloma (MM) is a commonly encountered hematological malignancy with significant renal involvement and often presents as renal failure. The aim of the present study is to analyze clinical spectrum of acute renal failure (ARF) in patients with MM. MATERIAL AND METHODS: We analyzed 26 (males 24; females 2) patients of multiple myeloma who were referred for evaluation of ARF between July 1994 - June 2007. The referral diagnosis did not include MM in majority 23 (88%) of the patients. Multiple myeloma was diagnosed by at least two of the four features; (1) lytic bone lesions, (2) serum or urine monoclonal peak, (3) Bence Jones proteinuria and (4) more than 20% plama cells in marrow aspirate. RESULTS: Multiple myeloma contributes 1.93% of total ARF cases (26/1342) over a period of thirteen years. Mean age of patients was 59.3 +/- 7.4 years. The clinical manifestations of myeloma included; anemia (100%), Bence Jones proteinuria (80%), "M" peak in serum electrophoresis (69%), lytic bone lesions (62%), "M" peak in urine electrophoresis (54%), body pain (58%), plasma cells more than 20% in bone marrow aspirate (38%). Oliguric ARF was seen in 73% patients. The precipitating factors of ARF identified were; hypercalcemia (31%); infection (23%); volume depletion (19%); and NSAIDs in (15%). Dialysis support was needed in 77% of the patients because of severe renal failure at presentation with mean serum creatinine of 9.05 +/- 2.84 mg%. Seventeen patients completed chemotherapy, seven last to follow up and two patients died. Ten (38.5%) patients had complete recovery of renal function; three patients had partial recovery and off dialysis and four patients remained dialysis dependent. Remission of myeloma was achieved in nine of seventeen patients treated with chemotherapy Renal biopsy finding in nine patients revealed-cast nephropathy in (4), amyloidosis in (3), proliferative glomerulonephritis in (1) and cast nephropathy with chronic interstitial nephritis and plasma cell infiltration in one patient. CONCLUSION: Acute reversible renal failure is a common complication in MM, multiple myeloma should be considered as cause a cause of unexplained ARF in middle aged and elderly patients.

Renal disease is a prodrome of multiple myeloma: an analysis of 50 patients from eastern India.

This study describes a spectrum of renal diseases that can precede the diagnosis of multiple myeloma (MM). Patients presenting manifestations of renal disease were recorded as individual patients of MM. Fifty patients (male 41; female 9) were included in this study. Diagnosis of MM was confirmed by two or more of the following four features: lytic bone lesions, serum or urine monoclonal peak, Bence Jones proteinuria, and greater than 20% plasma cells in bone marrow. Renal disease was present in 42 of 50 (84%) patients before MM was diagnosed. In only eight of 50 (16%) patients, diagnosis of MM preceded the detection of renal disease. Renal diseases consisted of acute renal failure in 26 patients (52%), chronic renal failure in 15 patients (30%) and nephrotic syndrome in 9 patients (18%). Some of the patients with acute or chronic renal failure also had heavy proteinuria. Percutaneous renal biopsy was done in 17 patients. Renal histopathology showed amyloidosis (n = 10), cast nephropathy (n = 5), nodular glomerulosclerosis (n = 1), and mesangioproliferative glomerulonephritis with plasma cell infiltration (n = 1). Hypercalcemia (calcium 11-13.8 mg/dL) was the most common precipitating factor for acute renal failure. All 50 patients received combination chemotherapy of melphalan and prednisolone or vincristine, Adriamycin, and dexamethasone. More than half of the total number of patients did not complete chemotherapy because of death or lost to follow-up. Nineteen patients with acute renal failure and eight patients with chronic renal failure were treated with hemodialysis. Fourteen patients (28%) with acute renal failure had recovery of renal function. Twenty-three patients (46%) were lost to follow-up. Seven patients (14%) died from sepsis, uremia, or hyperkalemia. Remission of MM was found in 9 of 21 (42.8%) patients who completed chemotherapy. Thus, acute renal failure is the most common renal disease preceding the diagnosis of MM. Reversal of renal function is achieved with chemotherapy and hemodialysis treatment.

High prevalence of malnutrition and inflammation in undialyzed patients with chronic renal failure in developing countries: a single center experience from eastern India.

BACKGROUND: Malnutrition is common in patients with chronic renal failure (CRF), and its prevalence before the initiation of dialysis is poorly characterized in these patients in developing countries. There is a paucity of data on the quantification of malnutrition and inflammation in undialyzed patients of CRF from India. This study analyzed the prevalence and causes of malnutrition in patients with CRF before the initiation of dialysis treatment. MATERIAL AND METHODS: In the present study, assessments of nutritional and inflammatory status were carried out in patients with CRF. Serum albumin, body mass index (BMI), triceps skin fold thickness (TST), mid-arm muscle circumference (MAMC), and subjective global assessment (SGA) scoring were used for assessment of nutritional parameters. Serum C-reactive protein and serum ferritin level were used to assess the inflammatory state of the patient. RESULTS: Two hundred and three (146 male, 57 female) patients with CRF were included in the study from August 2004 to April 2006. Overall, the prevalence of malnutrition was 65% (131/203). The age of malnourished patients (93 male, 38 female) ranged from 11-82, with mean age of 52 +/- 12.68 years. The mean serum total protein and albumin were also significantly lower in patients with malnutrition in comparison to non malnourished cases (5.50 +/- 0.40 gm/dL vs. 5.74 +/- 0.38 gm/dL; p < 0.05, and 3.18 +/- 0.58 gm/dL vs. 3.68 +/- 0.55 gm/dL; p < 0.05). The C-reactive protein and serum ferritin were significantly elevated in the malnourished group as compared to non-malnourished patients (63% vs. 33%; p < 0.05, and 301.2 +/- 127.1 mg/dL vs. 212.7 +/- 124.9 mg/dL; p < 0.05). CONCLUSION: Thus, malnutrition was common in patients with CRF before the commencement of dialysis. These data indicate that an emphasis should be placed on the assessment and prevention or correction of malnutrition in patients with CRF because of its documented adverse effect on the outcome on maintenance dialysis.

Diabetic retinopathy is a poor predictor of type of nephropathy in proteinuric type 2 diabetic patients.

BACKGROUND: Both diabetic nephropathy (DN) and nondiabetic nephropathy (NDN) are reported to occur in patients with type 2 diabetes mellitus (DM). The precise diagnosis of the type of nephropathy has obvious clinical and prognostic implication. The aim of the study was to evaluate the histologic spectrum of nephropathy in proteinuric type 2 diabetic patients and to find the correlation between type of nephropathy and diabetic retinopathy (DR). METHODS: Twenty eight proteinuric type 2 diabetic patients were included in the study. Five patients (ADPKD 3 and chronic pyelonephritis 2) were excluded from biopsy. Percutaneous renal biopsy was carried in remaining 23 patients. RESULTS: There was a preponderance of male (75%) and majority of the patients were in the age group of 30-78 years. Duration of diabetes ranged between 4 months to 25 years with mean +/- SD of 10.53 +/- 7.62 years. The presenting features were nephrotic syndrome 14 (60.9%), non-nephrotic proteinuria 9 (39.1%) and impaired renal function in 19 (82.6%) patients. Renal biopsy in 23 cases revealed; isolated diabetic nephropathy 13 (56.2%), NDN7 (13.43%) and 3 (13%) patients had NDN superimposed on diabetic nephropathy. Membranous nephropathy (2), focal segmental glomerulosclerosis (2), mesangiocapillary glomerulonephritis (1) were the nondiabetic glomerular disease in our type 2 diabetic patients. Chronic pyelonephritis and ischemic interstial nephropathy was the predominant tubulointerstial lesion in this study. Diabetic retinopathy (DR) observed in 12 (75%) patients with biopsy proven DN and absent in 4 (25%) patients with DN. The distribution of renal lesions in patients with DR (n = 15) showed DN in 9 (60%), NDN 3 (20%) and remaining 3 patients had combined lesions. Renal biopsy in 8 patients without DR showed typical DN in 4 (50%) and NDN in 4 (50%) patients. CONCLUSION: This study demonstrates presence of both glomerular and tubulointerstitial lesions unrelated to diabetes (NDN) in proteinuric type 2 diabetic patients. Further presence or absence of DR was a poor predictor of diabetic nephropathy because DN was noted in 50% of patients without DR and 40% of patients with DR had non-diabetic nephropathy either alone or in combination with DN.

Decreasing incidence of renal cortical necrosis in patients with acute renal failure in developing countries: a single-centre experience of 22 years from Eastern India.

BACKGROUND: Renal cortical necrosis (RCN) accounts for 2% of all cases of acute renal failure (ARF) in adults and 15-20% of ARF during the third trimester of pregnancy in developed nations. However, RCN incidence is higher in developing countries ranging from 6-7% of all cases of acute renal failure. The present study describes changing trends in the clinical spectrum of RCN in patients with ARF in Eastern India. METHODS: Patients with ARF suspected to have RCN on clinical grounds underwent percutaneous renal biopsy. Patients showing cortical necrosis on histology were included in the present study. Diffuse and patchy cortical necrosis was classified based on standard histological criteria. The patients with cortical necrosis were studied over a period of 22 years; from July 1984 to December 2005. The results of our observation were compared with respect to etiology, incidence, prognosis and outcome of renal cortical necrosis in two study periods; namely, 1984-1994 and 1995-2005. RESULTS: The incidence of RCN was 3.12% of all cases of ARF of diverse etiology. RCN was observed in 57 patients; obstetric 32 (56.2%); non-obstetric 25 (43.8%). Diffuse cortical necrosis was the dominant lesion in 41 (71.9%) patients and the remaining 16 (28%) patients had patchy cortical necrosis. The overall incidence of RCN in obstetric ARF was 15.2%; the incidence being higher (11.9%) in the post-abortal group in comparison to 3.3% in late pregnancy. RCN had occurred complicating abruptio placentae, puerperal sepsis and postpartum haemorrhage (PPH) in late pregnancy, while septic abortion was the sole cause of RCN in early pregnancy. Haemolytic uraemic syndrome (HUS) was the major (31.5%) cause of RCN in the non-obstetric group and miscellaneous factors were responsible in seven (12.3%) patients. Partial recovery of renal function was observed in 11 (19.2%), and 16 (28%) patients had progressed to ESRD. The incidence of RCN decreased from 6.7% in 1984-1994 to 1.6% in 1995-2005 of total ARF cases. RCN following obstetrical complication decreased significantly; 4.7% in the 1990s to 0.5% of the total ARF cases, in the 2000s. The mortality decreased to 19% in 1995-2005 from the initial high mortality of 72% in 1984-1994. The renal prognosis improved as a result of the decreased mortality of patients. CONCLUSION: We observed a decreasing trend in the incidence of RCN in patients with ARF in recent years, which is associated with increased patient survival and better renal prognosis. This improvement was mainly due to declining incidence and severity of RCN in obstetrical ARF.