Acute Kidney Injury in Sub-Sahara Africa: A Single-Center Experience from Khartoum, Sudan

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1 Originl Pper Advnces in CKD 2018 Published online: Jnury 26, 2018 Acute Kidney Injury in Sub-Shr Afric: A Single-Center Experience from Khrtoum, Sudn Dli E. Yousif Alice R. Topping b Mh F. Osmn Jochen G. Rimnn b Elfdil M. Osmn Peter Kotnko b, c Omr I. Abboud Deprtment of Medicine, Division of Nephrology, Sob University Hospitl, Khrtoum, Sudn; b Renl Reserch Institute, New York, NY, USA; c Ichn School of Medicine t the Mount Sini Hospitl, New York, NY, USA Keywords Hemodilysis Acute kidney injury Sub-Shrn Afric Acute kidney injury outcomes Acute kidney injury etiology Abstrct Bckground: The burden of cute kidney injury (AKI) is high in Afric. While there re no relible sttistics bout AKI in Afric, the Globl Snpshot Study of the 0by25 inititive of the Interntionl Society of Nephrology hs determined dehydrtion, infections, niml envenomtion, nd complictions during pregnncy s the min cuses. Methods: This study ws conducted t the Sob University Hospitl (SUH), Khrtoum, Sudn, tertiry referrl center. We included ll hemodilysis ptients treted for AKI t SUH between Jnury 1, 2013 nd December 31, 2014 in the study. We reviewed ptients hospitl records nd chrcterized pthogenesis, tretment, nd ptient outcomes. In ddition, we investigted survivl by Kpln-Meier nd Cox regression nlysis. Results: Out of 520 ptients who received emergency HD, 71 ptients (14%) hd AKI (ge 40.6 ± 17.3 yers, 56.5% were mles). Glomerulr nd tubulr-interstitil diseses were the leding cuse of AKI, followed by envenomtion nd intoxiction by hir dye. Ptients received medin of 5 dilysis sessions for medin of 8 dys. In 32 ptients (45%) renl function recovered, 10 ptients (14%) died, nd 29 ptients (41%) remined dilysis-dependent. Mortlity ws significntly higher in femles compred to men (hzrd rtio 4.1 [95% CI ]). Outcomes were worse in ptients with pre-renl AKI nd intoxictions. Conclusion: Our results indicte higher mortlity in femles nd in ptients with pre-renl AKI nd intoxictions. Awreness of fctors ssociting with poor outcomes is centrl to dignostic nd therpeutic efforts, nd must be considered in the design of inititives to reduce risk fctors nd improve outcomes of AKI in developing countries. Introduction 2018 S. Krger AG, Bsel Acute kidney injury (AKI) is well-estblished, frequent, nd often under-recognized condition ssocited with high mortlity, nine-fold incresed risk of development of chronic kidney disese (CKD), nd other orgn dysfunctions [1, 2]. Dignosis nd tretment of AKI E-Mil krger@krger.com S. Krger AG, Bsel Dli E. Yousif, MRCP (UK), FISN Deprtment of Medicine, Division of Nephrology Sob University Hospitl PO Box 8081, Khrtoum (Sudn) E-Mil gmil.com

2 re chllenging prticulrly in low resource settings such s in prts of Afric, continent where finncil nd medicl resources re scrce nd consequently provision of dequte helthcre limited for substntil prts of the popultion. Even tody the epidemiology of AKI in developing countries is incompletely understood. The Interntionl Society of Nephrology conducted Globl Snpshot bout AKI in 2014, where most cses (45%) were from low nd lower middle-income countries [3]. However, these dt my be incomplete, since mny of the low-income ntions lck the resources to mintin ntionl disese registries, nd it is chllenging to ccurtely report cses of AKI outside of mjor helth centers. AKI ffects pproximtely 13.3 million individuls globlly per yer. An estimted 85% of those ffected live in the developing world. AKI is thought to contribute to bout 1.7 million deths every yer [2]. In order to increse the wreness of AKI, it is crucil to understnd its most frequent etiologies nd clinicl fetures. These insights then help to promote prevention strtegies nd the implementtion of dequte resources for AKI cre [4]. Bsed on the initil findings of the Interntionl Society of Nephrology 0by25 inititive, AKI is more often cused by one single disese nd is more likely community cquired. In ddition, AKI etiology vries by geogrphy. In some regions, AKI is more frequently secondry to infections such s mlri, leptospirosis, nd Dengue fever, while in other res, envenomtion by snkes or rthropods is frequent cuse. In ddition to regionl vritions, sesonlity of AKI with pek in summer hs been noted [2, 5, 6]. Prticulrly in the remote settings, lck of dequte medicl infrstructure often results in high AKI mortlity rtes. With lnd re of 1,882,000 km 2 Sudn is the third lrgest Africn country nd the sixteenth worldwide. Its popultion is 36 million (July 2016 estimte) [7]. The nnul popultion growth rte is 1.69%; the nnul deth rte is 7.5 deths per 1,000 citizens [7]. Kidney disese is the 13th frequent cuse of deth, contributing 18.5% to the nnul mortlity [8]. AKI is common helth problem in Sudn owing to the widespred prevlence of infectious diseses, the use of potentilly nephrotoxic trditionl remedies, nd certin locl trditions such s the use of henn tttoos. In order to promote prevention strtegies nd to implement dequte resources for AKI mngement, it is importnt to understnd the etiology nd clinicl fetures of AKI. To tht end, we hve collected dt on AKI cuses nd outcomes in tertiry referrl center in Sudn s cpitl Khrtoum. Methods Study Design We hve conducted retrospective nlysis of ll ptients dmitted with dignosis of AKI to the nephrology unit in Sob University Hospitl (SUH) between Jnury 1, 2013 nd December 31, SUH is 500-bed tertiry hospitl in southern Khrtoum, Khrtoum stte, Sudn. SUH is the min teching hospitl for the fculty of medicine t the University of Khrtoum nd is one of the mjor hospitls in Sudn. It ws estblished in 1975 nd hosts the lrgest medicl, surgicl, obstetrics, nd peditrics deprtments in the country. SUH hs ctchment re of 5.3 million people. Dt Collection Demogrphic nd medicl dt, history, clinicl exmintion nd investigtions were collected for ech ptient. Renl ultrsound ws done in ech ptient nd kidney biopsies when indicted. Becuse of issues with pper documenttion, regrettbly the results of the biopsies were not vilble to us. Definitions AKI ws defined s per the Risk, Injury, Filure, Loss of kidney function, nd End-stge kidney disese criteri [9]. Ptients were treted conservtively with fluid mngement, diuretics nd in the presence of sepsis with ntibiotics, until the decision of dilysis initition ws mde following consultncy by the ttending nephrologist. Following the unit protocol bsed on recommendtions of the Kidney Disese Improving Outcome guideline for AKI [10] nd the Acute Dilysis Qulity Inititive ( the criteri considered in mking the decision to dilyze ptient included volume overlod unresponsive to diuretic therpy, electrolyte nd cid bse disturbnces refrctory to medicl mngement, nd overt uremic mnifesttions, such s pericrditis or encephlopthy. As per unit protocol nd locl stndrd prctice, ptients received three consecutive HD sessions vi non-tunneled temporry HD ctheter. The consecutive sessions durtions were 2, 3, nd 4 h respectively. We used polysulfone dilyzer with surfce re between 1.5 nd 1.7 m 2. Blood flow t initition ws 180 ml/ min; it then incresed grdully in the next sessions up to 250 ml/ min. Unfrctionted heprin t dose of 50 IU/kg/session ws used s n nticogulnt. If contrindicted, heprin-free HD with intermittent sline flushes ws conducted. Blood pressure ws monitored throughout HD session. After 3 dilysis sessions, ptients were ressessed nd HD ws continued ccording to their clinicl presenttion; most of the ptients subsequently received dily HD. The frequency of HD, length of HD session, blood flow rte, nticogultion use nd fluid removl were tilored to individul ptients needs. CKD ws defined s n estimted glomerulr filtrtion rte <60 ml/min/1.73 m 2 body surfce re; we used the Cockcroft-Gult formul [11]. Renl recovery from AKI ws defined s dilysis independence t hospitl dischrge [12]. AKI cuses were clssified s prerenl (including fluid depletion nd sepsis), intrinsic, obstructive uropthy, systemic, intoxiction, nd unknown. The reserch ws conducted in ccordnce with locl rules nd regultions pproved by the SUH Ethics Committee. It ws lso 202 Yousif/Topping/Osmn/Rimnn/ Osmn/Kotnko/Abboud

3 520 ptients received emergency hemodilysis t SUH between Jnury 2013 nd December ESRD ptients 71 ptients with AKI Recovery n = 32 (45.1%) CKD n = 27 (38%) Deth n = 10 (14.1%) Trnsferred n = 2 (2.8%) Fig. 1. Flowchrt of the ptient popultion. Fluid depletion nd sepsis (n = 4) Intoxiction nd drugs (n = 8) Intrinsic (n = 7) Post-renl (n = 1) Systemic diseses (n = 5) Length of tretment by dignosis ctegory, mong ptients who recovered (n = 32) Unknown (n = 7) Medin number of sessions Medin dys on dilysis Fig. 2. Length of hemodilysis therpy mong those with renl recovery reviewed by the Western Institutionl Review Bord s Affirs Deprtment nd ws deemed to meet the conditions for exemption under 45 CFR (b) [4]. Sttisticl Methods Continuous vribles re presented s men ± SD when normlly distributed nd s medins (interqurtile rnge) otherwise. Ctegoricl vribles re presented s percentges of the group from which they were derived. The number of dilysis sessions nd number of dys on dilysis were nlyzed s count dt with the medin vlues reported. The difference in the number of dilysis sessions nd number of dys on dilysis by gender ws investigted using the Mood medin test. The medin dys on dilysis nd number of sessions mong those tht recovered were lso nlyzed bsed on the ctegory of dignosis. Outcome nd dignosis ctegory were nlyzed s ctegoricl vribles. A comprison of outcome type by gender ws done by the χ 2 test for 4 ctegories: CKD not requiring dilysis; died; recovered; nd loss to follow-up (e.g., becuse the ptient ws trnsferred to nother deprtment). Kpln-Meier survivl curves were used to estimte survivl probbilities. Kpln-Meier curves were lso generted in cohorts strtified by gender nd dignostic ctegories nd compred by log-rnk tests. A Cox proportionl hzrd ws built with gender nd ge s predictors of mortlity. All nlyses were done using SAS 9.4 (SAS Institute, Cry, NC, USA). Results During the observtion period from Jnury 1, 2013 to December 31, 2014, 520 ptients were dmitted to the SUH deprtment of nephrology, renl unit, for emergency hemodilysis. Out of these 520 ptients, 449 (86.3%) hd end-stge renl disese nd 71 (13.8%) met the criteri for AKI (Fig. 1). The men ge of the AKI ptients ws 40.6 (17.3) yers. Forty (56.5%) of these 71 AKI ptients were mle, resulting in mle-to-femle rtio of In these 71 AKI ptients, medin of 5 dilysis sessions ws deployed over medin of 8 dys. Length of tretment mong those tht recovered per cuse of AKI is presented in Figure 2. A longer HD durtion ws required in ptients with AKI due to post-renl nd systemic cuses. Serum cretinine nd blood ure levels on dmission (n = 71 ptients) were 15 ± 7.0 nd ± mg/dl respectively. Serum cretinine nd blood ure levels t dischrge (n = 24 ptients) were 2.5 ± 2.4 nd 53.4 ± 31.9 mg/dl respectively (Tble 1). AKI in Sudn 203

4 Tble 1. Demogrphics of study popultion All Mle Femle p vlue Bseline chrcteristics, men (SD) n (%) (56) 31 (44) 0.29 Age, yers 40.6 (17.3) 42.9 (17.9) 37.6 (16.2) 0.21 Ure on dmission, mg/dl (124.9) (138.5) (106.1) 0.59 Ure on dischrge, mg/dl (n = 20) 53.4 (31.9) 61.6 (37.4) 43.2 (21.3) 0.21 Cretinine on dmission, mg/dl 15.0 (7.0) 16.0 (7.6) 13.6 (6) 0.18 Cretinine on dischrge, mg/dl (n = 24) 2.5 (2.4) 3.0 (2.9) 1.8 (1.4) 0.2 Outcome, n (%) 0.18 CKD not requiring dilysis 27 (38) 15 (37.5) 12 (38.7) Died 10 (14.1) 3 (7.5) 7 (22.6) Recovered 32 (45.1) 20 (50) 12 (38.7) Trnsferred nd lost to follow-up 2 (2.8) 2 (5) 0 (0) Number of hemodilysis sessions, medin (25th 75th percentile) 5 (3 12) 6 (3 15) 4 (3 10) 0.45 CKD not requiring dilysis 8 (3 16) 10 (3 24) 7 ( ) Died 2.5 (1 3) 2 (1 2) 3 (1 4) Recovered 5 (3 10) 5 (3 8) 5 (3 11.5) Trnsferred nd loss to follow-up 10.5 (6 15) 10.5 (6 15) Dys on dilysis, medin (25th 75th percentile) 8 (4 28) 10 (4 30) 6 (3 15) 0.23 CKD not requiring dilysis 17 (5 45) 30 (5 60) 13 ( ) Died 2.5 (1 6) 2 (1 2) 3 (1 7) Recovered 6 (4 14) 6 (4 14) 5.5 ( ) Trnsferred nd lost to follow-up 20 (10 30) 20 (10 30) CKD, chronic kidney disese. AKI Cuses Intrinsic renl disese ws the most common cuse of AKI (n = 18; 25.3%), with equl gender distribution. Prerenl cuses (minly severe volume depletion nd sepsis) were dignosed in 10 ptients (14.1%), without significnt gender difference. Obstructive uropthy ws more frequent in men (n = 17.5%) compred to women (n = 6.5%). Intoxiction by hir dye nd snke bites ws cusl in 9 (12.7%) ptients without ny gender difference. Systemic diseses like mlri, hemolytic uremic syndrome, nd others were cusl in 9 (12.7%) ptients nd evenly distributed between genders (Tble 2). Multiple myelom (n = 2) nd Lngerhns histocytosis (n = 1) were rre cuses. No cuse ws conclusively determined in 14 ptients (19.7%), including 4 ptients (5.6%) with cute-on-chronic kidney disese. Cuses of AKI strtified by gender re shown in Tble 2. AKI Outcomes Recovery from AKI ws observed in 32 (45.1%) ptients, nd 27 (38%) progressed to non-dilysis dependent CKD. Two ptients (2.8%) were referred to surgery without follow-up dt being vilble. Ten ptients (14.1%) died with AKI (Tble 1). Univrite nlysis indicted trend towrd better survivl in mles (Fig. 3). This finding ws corroborted in ge-djusted Cox regression nlysis (hzrd rtio 4.1 for femle gender [95% CI ]). Kpln-Meier nlysis indicted survivl differences by gender. Outcomes were prticulrly grve for ptients with prerenl AKI nd intoxictions. Discussion Principl Findings Our reserch fills knowledge gps nd extends the body of literture on cuses nd outcomes of AKI in one of the lrgest Sub-Shrn countries. While in the overll popultion renl recovery ws 45.1% nd mortlity 14.1%, there were significnt differences between genders, with femles showing worse outcomes, nd by AKI etiology, with AKI due to pre-renl cuses, envenomtion, nd intoxiction by hir dye hving the highest mortlity. While not entirely cler from our dt, we speculte tht the differences in outcomes between genders my be relted to differences in ccess to cre nd AKI etiologies. 204 Yousif/Topping/Osmn/Rimnn/ Osmn/Kotnko/Abboud

5 Tble 2. Cuses of AKI in the overll popultion ctegorized by gender Cuse of AKI Overll (n = 71), n (%) Mle (n = 40), n (%) Femle (n = 31), n (%) Pre-renl/fluid depletion nd sepsis 10 (14.08) 5 (12.5) 5 (16.13) Dehydrtion with hypovolemi 2 (2.81) 1 (2.5) 1 (3.22) Post ERCP* cute pncretitis 1 (1.4) 1 (2.5) 0 Sepsis + 5 (7.04) 2 (5) 3 (9.68) Heptorenl syndrome 2 (2.81) 1 (2.5) 1 (3.22) Intrinsic 18 (25.34) 10 (25) 8 (25.81) Interstitil nephritis 2 (2.81) 1 (2.5) 1 (3.22) Tuberculosis 1 (1.4) 0 1 (3.22) Rhbdomyolysis 1 (1.4) 1 (2.5) 0 Nephrotic syndrome 3 (4.23) 2 (5) 1 (3.22) Gouty nephropthy 1 (1.4) 0 1 (3.22) Trnsplnt rejection 2 (2.81) 2 (5) 0 Multiple myelom 2 (2.81) 0 2 (6.45) Glomerulonephritis 6 (8.45) 4 (10) 2 (6.45) Post streptococcl 1 (1.4) 0 1 (3.22) Acute of unknown etiology 5 (7.04) 4 (10) 1 (3.22) Obstructive uropthy 9 (12.68) 7 (17.5) 2 (6.45) Systemic diseses 9 (12.68) 5 (12.5) 4 (12.9) Mlri 2 (2.81) 2 (5) 0 Leukemi 1 (1.4) 0 1 (3.22) Lngerhns histocytosis 1 (1.4) 1 (2.5) 0 Systemic lupus erythemtodes 1 (1.4) 0 1 (3.22) Hemolytic uremic syndrome 3 (4.23) 2 (5) 1 (3.22) Systemic vsculitis 1 (1.4) 0 1 (3.22) Intoxiction nd drugs 11 (15.49) 6 (15) 5 (16.13) Hir dye 4 (5.63) 2 (5) 2 (6.45) Snke bite 5 (7.04) 4 (10) 1 (3.22) Chemotherpy of cervicl cncer 1 (1.4) 0 1 (3.22) Chemotherpy of ovrin cncer 1 (1.4) 0 1 (3.22) Unknown 14 (19.72) 0 7 (22.58) Unknown cuse 10 (14.08) 7 (17.5) 3 (9.68) Acute on chronic (unknown etiology) 4 (5.63) 7 (17.5) 4 (12.9) + Sepsis including (cholngitis, urosepsis nd recurrent renl stones). * ERCP, endoscopic retrogrde cholngiopncretogrphy. Discussion in Reltion to Other Studies In developing countries, AKI primrily ffects mles nd those who re in their 3rd to 5th decdes of life [13, 14], notion corroborted by our study. Gender disprities in AKI referrls, etiologies, nd outcomes hve previously been recognized [6]. AKI etiologies in our popultion differed from those reported in Sudn by Kbllo et l. [13], where cute tubulr necrosis ws the most common cuse in 50 ptients (56.1%); mjority s compliction of volume depletion, fulminnt infections (prticulrly mlri nd typhoid fever) or snkebites, followed by prphenylene-dimine (hir dye) poisoning in 12 (13.4%) ptients. There re severl noteworthy differences, most importntly the outcomes, where ptients with AKI ssocited with ATN hd fvorble prognosis. This is in contrst to the findings of our study, where worse outcomes were observed for those ffected by pre-renl AKI nd intoxictions. It is to be noted tht worldwide, the prevlence of AKI cused by mlri vries from 0.6 to 60% of mlri cses, depending on the geogrphicl region [15]; in our popultion, it ws 2.8%. In developing countries, cute glomerulonephritis (GN) remins n importnt cuse of AKI nd ccounts for 9 to 10% of cses of totl AKI nd is minly post-infectious in origin [16]. In our study ccounted for bout AKI in Sudn 205

6 1.0 + censored 0.8 Survivl probbility Fig. 3. Kpln-Meier survivl curve nlysis of study popultion (71 AKI ptients) strtified by gender Dys on dilysis 60 Gender F 80 M 8% of AKI cses, in greement with regionl nd interntionl dt. AKI ssocited with obstructive nephropthy constitutes 12.9% of the cses, with higher prevlence in mles. Results were similr to regionl reports which re mostly from tropicl nd desert res [17]. Hir nd henn dye poisoning is well-recognized cuse of AKI nd mortlity in Sudnese ptients [18, 19] nd one of the importnt cuses of intentionl self-hrm in the developing world. Hir dyes contin prphenylene-dimine nd host of other chemicls tht cn cuse rhbdomyolysis, lryngel edem, severe metbolic cidosis, nd cute renl filure [20]. Snke bite-ssocited AKI responded well to dilysis with high rtes of renl function recovery. Comprble dt were reported from other res [21]. Strengths nd Weknesses of the Study Strengths of this study re tht AKI dignosis nd tretment were bsed on well-structured unit protocols with dherence being supervised by nephrologists. Given our hospitl s lrge ctchment popultion of 5.3 million citizens, we believe tht our results could be generlized to other geogrphiclly nd socioeconomiclly comprble regions of Sudn. However, the generlizbility to more remote plces where ptients do not hve the opportunity to seek timely medicl ttention is likely limited. Weknesses of the study re its retrospective nture nd the single-center setting. In ddition, it is regrettble tht results of kidney biopsies were not vilble to us becuse of documenttion issues. Mening of the Study In developing countries, the epidemiology of AKI is poorly documented, which is due to lck of resources, trined personnel, nd n infrstructure for epidemiologicl dt collection. A lrge proportion of countries from sub-shrn Afric does not hve sufficient trined personnel providing services for AKI mngement nd renl replcement therpy progrms re found in lrge cities only. In ddition, in most countries, renl replcement therpy is vilble only to those who cn fford to py these services. In our study, AKI recovered prtilly in only 38% of our ptients, rendering it mjor risk fctor for progression to end-stge renl disese [12]. In the light of the high costs of renl replcement therpies [22], it is cler tht AKI prevention is often the only relistic wy to decrese its severe impct on morbidity nd mortlity, nd helth costs. The most common cuses of AKI re frequently ssocited with volume-responsive pre-renl, [23, 24] obstetric [25], infectious [15], or toxic mechnisms [26, 27]; thus, inexpensive, simple interventions such s orl rehydrtion nd fluid therpy to prevent AKI [28] nd mngement of infection [29] my result in substntil reduction in AKI incidence nd severity [6, 28, 29]. This emphsizes the importnce to focus much effort nd reserch on dignostic tools, risk recognition, nd protocols to immeditely tret with simple pproch such s fluid resuscittion, voiding the need for dilysis. In contrst to the high mortlity ssocited with AKI in developed countries (25 80%), AKI-ssocited mortlity seems to be lower in developing countries between 206 Yousif/Topping/Osmn/Rimnn/ Osmn/Kotnko/Abboud

7 10 nd 40% [5, 30]. In summry, AKI in our study is commonly cused by community cquired single diseses such s mlri, post-dirrhel hemolytic uremic syndrome, dirrhe, sepsis, nd poisoning. Thus, mny cses of AKI in comprble countries my be prevented by community-bsed interventions (e.g., trining, eduction, provision of clen wter, lgorithms to provide immedite orl rehydrtion in the cse of dehydrtion, nd widespred mlri prevention). Identifying ptients t incresed risk, thus instituting timely dignostic nd therpeutic interventions re keys to improve survivl. Unnswered Questions nd Future Reserch More reserch is needed to ddress risk fctors nd comorbidities prticulrly in popultions in remote nd rurl res where AKI wreness is poor. Identifiction of new nd improved biomrkers llowing erlier detection of AKI nd thus more timely therpy is nother re in need for reserch. Acknowledgments This work ws supported by Sob University Hospitl, The Sudn Ntionl Center for Kidney Disese nd Trnsplnttion. 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