Access to Nephrology Care for Pregnancy-Related Acute Kidney Injury in Low- and Lower-Middle-Income Countries: A Perspective.

Pregnancy-related acute kidney injury (AKI) is a major public health problem with substantial maternal and fetal morbidity and mortality. Women with pregnancy-related AKI require immediate access to nephrology care to prevent deleterious kidney and health outcomes. Patients with pregnancy-related AKI in low-income and lower-middle-income countries experience disparities in access to comprehensive nephrology care for many reasons. In this perspective, we highlight the burden of pregnancy-related AKI and explore the challenges among different low-income and lower-middle-income countries. The lack of adequate nephrology workforce and infrastructure for kidney health care represents a fundamental component of the problem. A shortage of nephrologists hampers the care of patients with pregnancy-related AKI leading to poor outcomes. The lack of diagnostic tools and therapeutic options, including kidney replacement therapy, impedes the implementation of effective management strategies. International efforts are warranted to empower women to get the right services and support at the right time. Dedicated preventive and early care programs are urgently needed to decrease the magnitude of pregnancy-related AKI, a complication under-represented in the literature.

The Burden and In-Hospital Mortality of Stroke Admissions at a Tertiary Level Hospital in Namibia: A Retrospective Cohort Study.

Background: Despite stroke being a leading cause of morbidity and mortality globally, there is a dearth of information on the burden and outcomes of stroke in sub-Saharan Africa and Namibia in particular. Methods: A hospital-based, retrospective cohort study was conducted to analyse non-electronic medical records of all consecutive stroke patients who were admitted to one of the highest tertiary-level hospitals in Namibia for 12 months (2019-2020). The primary outcome of the study was to establish the in-hospital mortality, stroke subtypes, and associated complications. Results: In total, 220 patients were included in the study, their mean age was 53 (SD13.8) years, and 55.5% were males. 61.0% had an ischaemic stroke (IS), and 39.0% had a haemorrhagic stroke (HS). The mean age was significantly lower in patients with HS vs. IS (48.2 ± 12.2 vs. 56.1 ± 13.3, p < 0.001). Of the IS patients, the majority (29.0%) had total anterior circulation infarct (TACI), while in the HS group, 34.0% had basal ganglia haemorrhage with or without intraventricular extension. Hypertension (p = 0.015), dyslipidaemia (p = 0.001), alcohol consumption (p = 0.022), and other cardiovascular diseases (p = 0.007) were more prevalent in patients with IS compared to those with HS. The prevalence rate of intravenous thrombolysis was 2.2% in IS and use of intravenous antihypertensives in 25.9% of patients with HS than IS. The in-hospital mortality was 26.4% with complications such as raised ICP, aspiration pneumonia, hydrocephalus, and sepsis significantly high in those that died. Aspiration pneumonia (OR 2.79, 95% CI 1.63-4.76, p < 0.001) and increased ICP (OR 0.30, 95% CI 0.16-057, p < 0.001) were independent predictors of in-hospital mortality on the multivariate analysis. Conclusion: Our findings showed a younger mean age for stroke and mortality rate comparable to other low- to middle-income countries (LMICs). Hypertension and alcohol consumption were the main risk factors for both stroke subtypes, while aspiration pneumonia and raised intracranial pressure predicted in-hospital mortality.

Clinical profile and predictors of renal failure in emergency department patients at a tertiary level hospital, a cross sectional study.

Background: Since establishment of the emergency departments (ED) in the country, there is lack of information on clinical profile of patients admitted to the ED and predictors of renal failure in these patients. Renal failure is prevalent in critical patients and a cause of significant mortality and morbidity. The aim of this study was to assess the clinical profile and predictors of renal failure in admissions to the ED. Methods: This was a cross-sectional study that was conducted at a tertiary level hospital in Zambia from January to December, 2019 among admissions to the ED after ethical approval. The primary outcome of the study was to describe the clinical profile of admissions to the ED and proportion of renal failure defined as estimated glomerular filtration rate (eGFR) < 60 mls/1.72 m2. Results: The final analysis includes 152 patients, 7 excluded for missing key data. The median age was 43.5 years (IQR 32.5-59.5) and 94.7% of patients were medical. Nearly 70.0% of the patients were triaged as emergency (red) or very urgent (orange). The reason for admission to the ED were sepsis and/or sepsis shock in 25.0%, diabetic hyperglycaemia emergencies in 20.0%, hypertensive crisis in 10.5%, respiratory failure (9.9%), severe malaria (7.9%) and poisoning (5.0%). The prevalence of renal failure was 36.1% and proteinuria was observed in 23.0%. Oliguria and hypertension were 5.9-fold and 1.7-fold independent predictors of renal failure in the ED. Patients with renal failure were likely older, hypertensive, oliguric and anaemic compared to those without. During admission to the ED, 19.1% died. Conclusion: Sepsis and diabetic and hypertensive emergencies accounted for nearly half of ED admissions. Hypertension and oliguria were key predictors of renal failure. Early diagnosis, management and follow-up of hypertension including urine output monitoring for high-risk patients is key in surveillance and prevention of renal failure.

Prevalence and associated factors for kidney dysfunction in hospitalized patients with COVID-19 pneumonia in Zambia

Abstract Background: A significant link has been reported between COVID-19 pneumonia, disease severity and development of kidney dysfunction. This study assessed the prevalence and correlated factors for kidney impairment in hospitalized patients with COVID-19 infection Methods: This nested retrospective study examined medical files of patients with confirmed COVID-19 pneumonia. The outcome variable was kidney dysfunction ( defined as functional renal indexes beyond the normal range) and associated factors. Multivariate logistic regression was employed to establish factors associated with renal dysfunction. Results: 179 patients were included in this nested study and the mean age was 58.3 years (SD 16.5) and 49.0% were female. The prevalence of renal dysfunction was 51.9% and 39.3% these patients renal had eGFR<60 mL/min/1.73m2 The proportion of kidney impairment was higher in males than females (59.3% vs.44.3 %), patients with underlying hypertension than normotensive (60.5% vs. 39.5 %) and those with chronic kidney disease (CKD) than those without (90% vs. 10%). After adjusting for age, male gender, critical COVID-19 disease, and raised white cell count, hypertension was an independent predictor of kidney impairment with a AOR 1.54 (95% CI [1.06-2.23],p=0.022). Presence of HIV or diabetes mellitus showed a non statistical significance with renal dysfunction. Conclusion: The study demonstrated a high prevalence of kidney dysfunction in hospitalized patients with COVID-19 pneumonia and presence of hypertension predicted nearly 2-fold development renal impairment.

Biomarkers for Diagnosis and Prediction of Outcomes in Contrast-Induced Nephropathy.

BACKGROUND: Serum creatinine is suboptimal as a biomarker in the early diagnosis of contrast-induced nephropathy (CIN). In this study, we investigated a panel of novel biomarkers in the early diagnosis of CIN and in assessing patient outcomes. METHODS: This single-centre, nested, prospective case-controlled study included 30 patients with CIN and 60 matched controls. Serum and urine samples were collected before contrast administration and at 24 hours, 48 hours, and ≥5 days after contrast administration. Concentrations of NGAL, cystatin C, ß 2M, IL18, IL10, KIM1, and TNFα were determined using Luminex and ELISA assays. Outcomes were biomarker diagnostic discrimination performance for CIN and mortality after generation of area under receiver operating characteristic curves (AUROCs). RESULTS: Median serum levels for 24 h cystatin C (p < 0.01) and 48 h ß 2M levels (p < 0.001) and baseline urine NGAL (p=0.02) were higher in CIN patients compared to controls with AUROCs of 0.75, 0.78, and 0.74, respectively, for the early diagnosis of CIN. Serum ß 2M levels were higher in CIN patients at all time points. Elevated baseline serum concentrations of IL18 (p < 0.001), ß 2M (p=0.04), TNFα (p < 0.001), and baseline urine KIM (p=0.01) and 24 h urine NGAL (p=0.02) were significantly associated with mortality. Baseline serum concentrations of IL18, ß 2M, and TNFα showed the best discrimination performance for mortality with AUROCs, all >0.80. Baseline NGAL was superior for excluding patients at risk for CIN, with positive and negative predictive ranges of 0.50-0.55 and 0.81-0.88, respectively. Cystatin C (p=0.003) and ß 2M (p=0.03) at 24 h independently predicted CIN risk. ß 2M predicted increased mortality of 40% at baseline and 50% at 24 hours. CONCLUSION: Serum cystatin C at 24 h was the best biomarker for CIN diagnosis, while baseline levels of serum IL18, ß 2M, and TNFα were best for predicting prognosis.

Predictors of Acute Kidney Injury and Mortality in Intensive Care Unit at a Teaching Tertiary Hospital_ID.

BACKGROUND AND AIMS: Despite the increased rates of acute kidney injury (AKI) in intensive care units (ICU) and associated mortality, information on the epidemiology of AKI is sparse in sub-Saharan Africa (SSA). We investigated the rates and predictors of AKI and associated mortality in a tertiary ICU. MATERIALS AND METHODS: This retrospective study analyzed 280 hospital records of patients admitted to the ICU at a tertiary teaching hospital who were aged ≥15 years from January 2017 to May 31, 2018. The outcome parameters of the study were rates of AKI in the ICU, associated risk factors, and mortalities. Acute kidney injury and ICU mortality were established by the multivariate logistic analysis. RESULTS: The median age was 36 years (IQR 28, 52). The rate of AKI was 52.9%, and the presence of human immunodeficiency virus (HIV) and oliguria was 2.3-fold (0.004) and 4-fold (0.016) positive predictors of ICU-AKI, respectively. Male gender (0.003), diabetes mellitus (DM) (0.010), respiratory disease (0.001), inotropes (0.004), and ventilator support (0.017) were predictors for ICU mortality after controlling for confounders. CONCLUSION: The rate of AKI is significantly higher in a referral tertiary hospital in Zambia compared to developed countries and the presence of HIV and noncommunicable diseases such as DM impacts severely on outcomes. HOW TO CITE THIS ARTICLE: Banda J, Chenga N, Nambaya S, Bulaya T, Siziya S. Predictors of Acute Kidney Injury and Mortality in Intensive Care Unit at a Teaching Tertiary Hospital_ID. Indian J Crit Care Med 2020;24(2):116-121.

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BACKGROUND: Despite ranking third as a cause of hospital-acquired acute kidney injury (AKI), iatrogenic contrast-induced nephropathy (CIN) impacts significantly on morbidity and mortality and is associated with high hospital costs. In sub-Saharan Africa, the rates and risk factors for CIN and patient outcomes remain unexplored. METHODS: We conducted a prospective observational study at the Charlotte Maxeke Johannesburg Academic Hospital, South Africa, from 1 July 2014 to 30 July 2015. Hospitalised patients undergoing computed tomography scan contrast media administration and angiography were consecutively recruited to the study and followed up for development of AKI. CIN was defined as an increase in serum creatinine >25% or an absolute increase of >44 µmol/L from baseline at 48 - 72 hours post exposure to contrast media. Outcome variables were the occurrence of CIN, length of hospitalisation and in-hospital mortality. RESULTS: We recruited 371 hospitalised patients with a mean (standard deviation) age of 49.3 (15.9). The rates of CIN, assessed using an absolute or relative increase in serum creatinine from baseline, were 4.6% and 16.4%, respectively. Anaemia was an independent predictor for the development of CIN (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.01 - 2.87; p=0.04). The median serum albumin was 34 g/L (interquartile range (IQR) 29 - 39.5) and 38 g/L (IQR 31 - 42) in the CIN and control groups, respectively (p=0.01), and showed a significant trend for CIN development (RR 1.68, 95% CI 0.96 - 2.92; p=0.06). Mortality was significantly increased in the CIN group (22.4% v. 6.8%; p<0.001), and CIN together with anaemia increased mortality twofold (RR 2.39, 95% CI 1.20 - 4.75; p=0.01) and threefold (RR 3.32, 95% CI 1.48 - 7.43; p=0.003), respectively. CONCLUSIONS: CIN has a relatively high incidence in sub-Saharan Africa and predicts poorer clinical outcomes. The presence of CIN and anaemia positively predicted mortality. Caution should be exercised in patients with hypoalbuminaemia and anaemia undergoing contrast media administration.

Prevalence and Factors Associated with Renal Dysfunction in HIV Positive and Negative Adults at the University Teaching Hospital, in Lusaka.

BACKGROUND: Despite having the highest disease burden of HIV, Sub-Saharan Africa has limited data on HIV related kidney disease with most available data coming from the developed countries. Kidney disease is a recognised complication in HIV infected patients presenting with acute renal failure (ARF) or chronic kidney disease (CKD). This study investigated the prevalence and risk factors associated with renal dysfunction among hospitalised HIV infected patients at the University Teaching Hospital (UTH), Lusaka. METHODOLOGY: We conducted a cross sectional study at the University Teaching Hospital Lusaka, in Zambia. Inclusion criteria were hospitalised patients aged 16years and above who consented to the study. Both HIV infected and uninfected patients were included in the study. After obtaining demographic information, study participants were screened for HIV upon their consenting for the test. A full clinical history and examination was done by study physician to determine factors associated with renal dysfunction. RESULTS: Of the 300 recruited hospitalised patients in this cross sectional study, 142(47%) were HIV infected. We observed a high prevalence of renal dysfunction among hospitalised HIV infected patients compared to uninfected patients (42% vs. 27%, adjusted OR 1.99, 95% CI 1.20-3.28). They had a twofold increased likelihood of developing kidney dysfunction (OR 1.96,95 CI%; 1.21-3.17). The presence of vomiting was strongly associated with renal dysfunction in both HIV positive (AOR 7.77, 95% CI 2.46-24-53) and negative (AOR4.83, 95%CI 1.40-16.66) subgroups. WHO stage III was associated with renal dysfunction in HIV infected patients. Tenofovir use, (a first line antiretroviral drug in Zambia) and hypotension were not significant factors associated with kidney disease after adjusting for other clinical parameters. CONCLUSION: Renal dysfunction is significantly higher among hospitalised HIV infected compared to uninfected, however tenofovir and hypotension were not associated with renal dysfunction.