Untitled Document
 
 
 
 
Untitled Document
Home
Current issue
Past issues
Topic collections
Search
e-journal Editor page

Impact and Incidence of Acute Kidney Injury (AKI) : A One-year Period of Study at a Center Hospital in Thailand

ผลกระทบและอุบัติการณ์ของภาวะไตวายฉับพลัน : ข้อมูลการศึกษาระยะเวลา 1 ปีของโรงพยาบาลศูนย์แห่งหนึ่งในประเทศไทย

Worapot Treamtrakanpon (วรพจน์ เตรียมตระการผล) 1, Wichitra Khongkha (วิจิตรา คงคา) 2




หลักการและวัตถุประสงค์: สถานการณ์ทั่วโลกพบว่าภาวะไตวายฉับพลันเป็นภาวะที่พบได้บ่อยและมีความรุนแรงสูง ปัจจุบันระบาดวิทยาของภาวะไตวายฉับพลันในประเทศไทยยังขาดข้อมูลที่ชัดเจน การศึกษานี้เป็นการศึกษานำร่องถึงข้อมูลระบาดวิทยาของภาวะไตวายฉับพลันในโรงพยาบาลศูนย์แห่งหนึ่งในภาคตะวันออกของประเทศไทย
วิธีการศึกษา: ทำการศึกษาในผู้ป่วยไตวายฉับพลันที่วินิจฉัยตามเกณฑ์ AKIN ที่เข้ารับการรักษาตัวในโรงพยาบาลเจ้าพระยาอภัยภูเบศรในช่วงเดือนตุลาคม พ..2554 – เดือนกันยายน พ..2555 ทั้งหมดและมีการติดตามข้อมูลผลการทำงานของไตของผู้ป่วยอย่างน้อย 3 เดือนหลังจำหน่าย เพื่อหาสาเหตุ และศึกษาลักษณะของไตวาย รวมถึงผลลัพธ์ที่เกิดขึ้นกับผู้ป่วยในที่เกิดภาวะไตวายฉับพลัน
ผลการศึกษา: อุบัติการณ์ของไตวายฉับพลันในโรงพยาบาลคิดเป็นร้อยละ 2.21 (หรือ 681 รายใน 1 ปี)   ส่วนใหญ่ของผู้ป่วยไตวายฉับพลัน (ร้อยละ 83) ได้รับการวินิจฉัยในวันแรกของการนอนโรงพยาบาล พบร้อยละ 78.1 ของผู้ป่วยไตวายมีปัสสาวะมากกว่า 400 มิลลิลิตรต่อวัน ชนิดของไตวายฉับพลันที่พบบ่อย 3 อันดับแรกได้แก่ ภาวะ ischemic ATN (ร้อยละ 46.7), prerenal AKI (ร้อยละ 20.4) และ septic induced AKI (ร้อยละ11.9)   ผู้ป่วยไตวายฉับพลันข้ารับการรักษาตัวในแผนกผู้ป่วยหนักร้อยละ 42.1 และได้รับการบำบัดทดแทนไตร้อยละ 4.8   อัตราการตายของผู้ป่วยไตวายฉับพลันคิดเป็นร้อยละ 41.1   ร้อยละ 3.8 ของผู้ป่วยถูกส่งต่อไปยังโรงพยาบาลที่มีศักยภาพสูงกว่า   ผลการทำงานของไตของผู้ป่วยหลังการติดตามพบว่าส่วนใหญ่มีการฟื้นตัวอย่างเต็มที่ (ร้อยละ 65.1) อีกร้อยละ33 ฟื้นตัวบางส่วน ที่เหลือร้อยละ 1.9 ได้รับการบำบัดทดแทนไตถาวร โรคร่วมสำคัญที่พบบ่อยในผู้ป่วยได้แก่ ภาวะติดเชื้อ (ร้อยละ 47) และภาวะหัวใจล้มเหลว (ร้อยละ12.9)   จากจำนวนผู้ป่วยไตวายฉับพลันที่ไม่เคยตรวจพบโรคไตมาก่อนทั้งสิ้น 481 ราย จัด อยู่ใน AKIN ระยะที่ 1 ร้อยละ19.5, AKIN ระยะที่ 2 ร้อยละ 31 และ AKIN ระยะที่ 3 ร้อยละ 49.5 ตามลำดับ ผู้ป่วย AKIN ระยะที่ 3 มีความเสี่ยงสูงในการนอนรักษาตัวในห้องผู้ป่วยวิกฤติ ได้รับการบำบัดทดแทนไตบ่อยกว่ารวมถึงมีอัตราตายสูงกว่าผู้ป่วย AKIN ระยะที่ 1 และ 2   โดยภาพรวมผู้ป่วยไตวายฉับพลัน มีอัตราการเสียชีวิตมากขึ้น 16.84 เท่า อัตราการเข้าห้องไอซียูมากขึ้น 7.81 เท่าและระยะเวลานอนโรงพยาบาลนานขึ้น 2.61 เท่า เมื่อเทียบกับผู้ป่วยที่ไม่มี AKI

สรุป: ไตวายฉับพลันเป็นภาวะที่พบบ่อยและรุนแรงในประเทศไทย ไตวายฉับพลันที่เกิดจากความผิดปกติของระบบไหลเวียนเลือดไปเลี้ยงไต ซึ่งได้แก่ ischemic  ATN, prerenal AKI และ septic induced  AKI เป็นสาเหตุที่พบบ่อยของไตวายฉับพลัน

 

Background and Objective: AKI  (acute kidney injury) is a common and serious condition in global countries.  The epidemiologic study of AKI in Thailand is currently insufficient. A pilot study as the initiative attempt for the beginning of the epidemiologic data collection in the eastern part of Thailand was set.

Methods: All of Abhaibhubejhr hospital inpatient data during Oct 2011 – Sep 2012 were collected. The AKI patients were defined and classified by AKIN criteria and the renal outcomes were followed for at least 3 months or longer. The purpose of this study was to evaluate the causes, the characteristics and the outcome of AKI in hospitalized Thai patients.

Results: The incidence of AKI was 2.21%. Most of the AKI patients (83%) were diagnosed at the first day of the admission. There were predominantly non-oliguric AKI (78.1%).The three most common causes of AKI were ischemic ATN (46.7%), prerenal AKI (20.4%) and sepsis induced AKI (11.9%).The mortality rate of AKI patients were 41.1% and 3.8% of patients were transferred to academic hospital. Regarding the renal outcome, there were mostly fully recovery (65.1%) or partial recovery (33%), however 1.9% of patients were dialysis dependent. The most common comorbid conditions in AKI patients were septic shock (47%) and congestive heart failure (12.9%). Among true AKI (481 cases), 19.50%, 35% and 49.5% of the patients were classified as AKIN stage 1, AKIN stage 2 and AKIN stage 3,  respectively. As expected, severe AKI (AKIN stage 3) patients had higher prevalence of intensive care unit (ICU) admission, renal replacement therapy (RRT) and higher mortality rate compared with other groups.  Overall, inpatient with AKI had greater mortality risk (RR 16.84; 95%CI 14.94-18.97), ICU admission rate (RR 7.81; 95%CI 7.00-8.70) and length of stay (2.61 times) compared with inpatient without AKI.

Conclusion: AKI is a common and serious condition in our country. Hemodynamically-mediated AKI (ischemic ATN, prerenal AKI and sepsis induced AKI) are the major causes of AKI in hospitalized patients.

 

Keywords: Acute kidney injury (AKI), AKIN (Acute Kidney Injury Network) criteria, Renal replacement therapy (RRT)

 

Introduction

          Although there is an increasing incidence of acute kidney injury (AKI) in global countries and knowledge of the causes and mechanisms of disease is growing, few preventive and therapeutic options exist. Even small acute changes in kidney function can result in both  short-term and long-term complications, including chronic kidney disease, end-stage renal disease, and death. Development or progression of chronic kidney disease after one or more episode of acute kidney injury could have striking socioeconomic and public health outcomes for all countries. Concerted international action encompassing many medical disciplines is needed to aid early recognition and management of AKI.

          For many years, varying definitions of AKI have appeared in the literature, making comparisons between studies difficult. In 2007, the Acute Kidney Injury Network (AKIN) classification and staging systems have advanced the field, allowing improved comparisons between study populations. Current epidemiologic findings demonstrate the strong association between AKI and hospital mortality. Other outcomes, such as length of hospital stay, readmission rate, development of end stage kidney disease and long term (1–10 years) mortality, are also affected by severe and less severe episodes of AKI during ICU.(1)

          In Thailand, the epidemiologic study of AKI is currently insufficient and the nephrology consultation system is not available for every hospital. The aims of this study were therefore to describe the real incidence of AKI in a typical general hospital setting in an unselected patient population and describe the associated short and long-term outcomes in our country. Also we decided to compare the clinical data of AKI by various AKIN stage and by AKI consultation system.

 

Materials and Methods

The retrospective observational database study was carried out by recruiting all of the new AKI patients, regardless of age group and ward admission, hospitalized in Abhaibhubejhr hospital during October 1st 2011–September 30th 2012. The AKI episodes were defined and classified by AKIN criteria. The AKI patient data were collected during their hospital stay and their renal outcome were followed for at least three months or longer. Patient medical record form and electronic hospital database was reviewed by single investigator.

Statistical analysis

          Categorical variables are expressed as percentage of number of cases. Comparisons between the outcomes of AKI patients who had consulted with nephrologist or not were performed using the Student's t-test. The burden of AKI was demonstrated in relative risk with 95% confidence intervals (CIs) and when compared between AKIN stages, ANOVA had been used. A two-tailed p-value <0.05 was considered significant.

 

Results

          During the study period, 681 inpatients or equal to 2.21% of total hospitalization had AKI and 0.71% of them were admitted in ICU (Figure 1). There was no difference between genders. AKI stage 3 was found in higher percentage than AKI stage 1 and 2. There was predominantly non-oliguric AKI over oliguric AKI. Most of the AKI patients (81%) were diagnosed on the first day of the admission. The other 16%, AKI developed as a complication and the rest (3%) was the main cause of admission respectively. UA and ultrasound were infrequently performed in clinical practice. However the nephrologist consultation system was available in the hospital, only 14% of patients had been consulted. The main problems of hospitalized patients with AKI were septic shock and heart failure (Table 1).

 

Figure 1 The incidence of AKI patients in Abhaibhubejhr hospital during October 2011 to September 2012.

 

Table 1 Characteristics of AKI in Abhaibhubejhr hospital

Characteristics

Percent

Background

- Male/female

- AKI/AKI on top CKD

- AKI stage: 1/ 2/ 3

- Oliguric/nonoliguric

 

53/45

71/29

19.5/ 31/ 49.5

22/78

AKI development

- Main cause of admission*

- Co-disease†

- Complication‡

 

3

81

16

Investigation

- Urinary analysis

- Ultrasound

 

28

9

Nephrologist consultation

14

Main disease

- Septic shock

- Heart failure

- Others

 

47

13

40

*It means that the patient was admitted form KUB symptoms eg. edema and hematuria form acute glomerulonephritis, anuria from obstructive uropathy

**It means that the patient was admitted form non KUB symptoms and also found the AKI condition eg. duodenal ulcer bleeding with rising of serum creatinine at admission date

*** It means that the patient developed AKI after admission by other condition eg. AKI after severe sepsis or abdominal paracentesis, cardio-renal syndrome type 1, toxic ATN (drugs). If high percentage was found, the hospital should take action on the prevention of AKI.

 

          The three major causes of AKI were ischemic ATN (47%), prerenal AKI (20%) and sepsis induced AKI (12%) (figure 2). The other cause of AKI was toxic ATN (11%), postrenal AKI (6%) and glomerulonephritis (1%). The other causes of other AKI was hepatorenal syndrome, myeloma cast nephropathy, malignant hypertension and unknown.

 

 

Figure 2 The causes of AKI

 

          Mostly AKI patients were admitted in major ward. 89% was admitted in medicine ward and 8% in surgery ward. Few patients were found in orthopedic, pediatric and ENT wards. (Figure 3)

Unless renal replacement therapy (RRT) was initiated in only 6% of AKI patients during the study, the renal outcome was poor. Roughly 40% of them, renal function was not fully gained. About 40% was dead and 40% need ICU. Of surviving patients, 2% remains dialysis dependent at 3 months after hospital discharge. (Table 2)

 

Figure 3 Hospitalized AKI patients classified by specialty care

 

Table 2 AKI outcome

AKI outcome

Percent

Need RRT/ Not need RRT

6/94

Need ICU/ Not need ICU

58/42

Renal recovery

- Full

- Partial

- Dialysis dependence

 

65

33

2

Patient recovery

- Survive

- Dead

- Referred

 

55

41

4

 

Comparing the case that were consulted nephrologist and those that not consulted nephrologist, the first group spent their time in ICU and overall hospital stay longer than the latter group. However, the patient survival and renal recovery rate of the first group was better than the latter group. (Table3)

 

Table 3 AKI outcome between the group that had nephrologist consultation and the group that handle by general medicine doctors (not consulted).

Nephrologist consultation

 

Consulted

Not consulted

p-value

Renal recovery rate

%

58

28

0.04*

Patient survival rate

%

73

56

0.051

ICU admission rate

%

56

44

0.109

Length of stay

days

16.17

12.73

0.228

 

          Morbidity and mortality of the AKI patients was higher than those without AKI (Table 4 (1)). The Patients with AKI development had chance to be dead and chance to admit ICU around 17 and 8 times above those without AKI development. The length of stay in patients with AKI was also longer than the other. After we classified the severity of AKI patients by AKIN criteria, patient who categorized in AKIN stage 3 had greater risk of in-hospital death, ICU admission, and required the longer time of treatment in hospital. (Table 4 (2-3)).

 

Table 4 (1) Burden of AKI overall

 

AKI

(n=481)

Non AKI

(n=30,275)

Relative risk

95% confidence

interval

Mortality rate

41%

2.43%

16.84

14.97-18.97

ICU admission rate

58%

6.53%

7.81

7.00-8.70

Length of stay (mean;days)

24

6.6

3.6

-

 

Table 4 (2) Burden of AKI categorized by AKIN stages displayed in relative risk compare with non AKI group

 

AKIN 1

AKIN 2

AKIN 3

Non AKI

Mortality risk

14.63

14.97

21.40

1x

ICU admission

5.68

6.59

9.40

1x

Length of stay

3.40

5.91

6.39

1x

 

Table 4 (3) Burden of AKI categorized by AKIN stages displayed in percent and mean

 

 

AKIN 1

AKIN 2

AKIN 3

p-value

Mortality rate

%

39.36

40.27

57.57

0.002*

ICU admission rate

%

32.98

38.26

54.62

0.000*

Length of stay

days

17.02

29.53

31.93

0.040*

 

Discussion

          This is the first study to define the incidence of hospitalized AKI in Thai population. The incidence of AKI was detected at 2% with in contrast to other studies the incidence was too low. This may be due to our study included all types of patients, while many studies show the data specified in critically ill patienst, ICU unit and cardiac center. AKI was not commonly found in some major wards such as obstetric or pediatric wards as well as some minor wards such as eye or psychiatric wards. However, the large retrospective data of USA reported in 20012, the average incidence of hospitalized AKI had the averaged range as ours. (Table 5)

Table 5 Comparative studies about AKI incidence by new AKI criteria.

Author

Hoste et al2

Ratanarat R.8

Cruz DN.9

 

Yue JF10

 

Treamtrakanpon W.

Journal

CCM 2008,

Meta-analysis

JMAT 2009

,Thailand

NEiPHROS

2007, Italy

Zonghua Yi Xue Za Zhi

2011, China

2013, Thailand

Incidence of AKI (%)

2-3

-

-

-

2.21

AKI definition

RIFLE

RIFLE

RIFLE

AKIN

AKIN

ICU patients with AKI (no;%)

81,387 up

60

121

47

234

10.8

191

35.5

287

9

RRT in ICU patients with AKI (%)

5

29

3.3

-

9

Mortality of ICU patients with AKI (%)

50-60

51.16

30-42

48

53.85

Dialysis dependent in ICU patients with AKI (%)

5-20

-

-

-

4

 

          It’s interesting that the incidence of AKI in ICU was high, nearly 30%, similar to the other publish literatures. Patients with AKI on ICU admission also had high mortality and need urgent renal replacement therapy. (Table 5) We also found that mortality of AKI patients treated with RRT remains constantly high, according to many studies published in several years ago. However, the outcomes after RRT improved during a 10-yr period3, several others report showed, in large multicenter databases, that patients are now more severely ill than 10–15 years before.4 Mortality of ICU patients treated with RRT depends heavily on associated organ dysfunctions and comorbidity, but for a general ICU population, mortality is approximately 50–60%.

          AKIN criteria seem to be a good predictor of hospitalized patient’s outcome. The patient with AKI had overall outcome worse than the patients without AKI. Patients in AKIN stage 3 had significantly less chance to survive, more chance to admit in ICU ward, and greater time staying in hospital than patients in the other two stages.

          Ischemic ATN was the most common cause of AKI in our study followed by prerenal AKI and sepsis induced AKI. These three causes were termed as hemodynamic mediated AKI that covered 79% of overall causes of AKI. Septic shock and heart failure were the common comorbidities of patients with AKI as same as the other studies.5-7 This was the reason why the hemodynamic mediated AKI was the major common cause of AKI. Patients with the condition of septic shock or congestive heart failure should receive special attention for AKI. Early detection and prompt renal supportive care could ameliorate sequelae of AKI events.

 

        Related to Thai herb, AKI patients who had document of Thai traditional medicine used was relatively high, about 28.6% (not shown in the figure). However, the data was collected from a few patients (less than 10% of total data). Further study should be designed for answer the risk of AKI from the Thai herb used.

          In our country, nephrologist was not the first doctor to take action with AKI from general wards. In routine, typical case of AKI, AKI that was not need renal replacement treatment (RRT), or AKI with good response to volume resuscitation was handled by general medicine doctors. The study showed that only 14% of patients had been consulted nephrologist. Moreover, the percentage of fully completed investigations to diagnosis cause of AKI such as ultrasound and urinary analysis was too low (table1). These may be that almost all doctors were not recognized the burden of AKI and they didn’t handle it carefully. The patients with AKI that consulted nephrologist had more severe clinical baseline than the patients with AKI that were not consulted nephrologist, however the clinical outcome in the first group was better than the latter. These data supported that the AKI consultation system should be cultivated and initiated in the public health system.

 

Conclusion

          AKI is indeed a big problem of our country. Hemodynamically-mediated AKI is the major cause of AKI in hospitalized patients. Patients with the condition of septic shock or congestive heart failure should receive special attention for AKI. AKIN criteria was useful for early detection and predicting severity of AKI. If nephrologist is available, the AKI consulting system should be set to decrease the sequelae of AKI.

Acknowledgements

This work was presented in abstract form at the annual meeting of the Royal College of Physicians of Thailand 2013, Pattaya, Thailand, April 26, 2013 and the annual Nephrology Meeting of Thailand 2013, Pattaya, Thailand, August 1, 2013

We are grateful to Dr.Asada Leelahavanichkul for proofreading our abstract.

 

Reference

1.       Jose Antonio Lopes, Sofia Jorge. The RIFLE and AKIN classifications for acute kidney injury: a critical and complehensive review. Clin Kidney J [In depth Review] 2013;  6:  8-14.

2.       Liangos O, Wald R, O'Bell JW, Price L, Pereira BJ, Jaber BL. Epidemiology and outcomes of acute renal failure in hospitalized patients: a national survey. Clin J Am Soc Nephrol 2006;  1:  43-51.

3.       Desegher A, Reynvoet E, Blot S, J De waele, S Claus, Hoste. E. Outcome of patients treated with renal replacement therapy for acute kidney injury. Crit Care 2006; 10(Suppl 1):  296.

4.       Bagshaw SM, George C, Bellomo R. Changes in the incidence and outcome for early acute kidney injury in a cohort of Australian intensive care units. Crit Care 2007;  11:  R68.

5.       Hata N, Yokoyama S, Shinada T, Kobayashi N, Shirakabe A, Tomita K, et al. Acute kidney injury and outcomes in acute decompensated heart failure: evaluation of the RIFLE criteria in an acutely ill heart failure population. Eur J Heart Fail 2010; 12:  32-7.

6.       Singh TB, Rathore SS, Choudhury TA, Shukla VK, Singh DK, Prakash J. Hospital-acquired acute kidney injury in medical, surgical, and intensive care unit: A comparative study. Indian J Nephrol 2013; 23:  24-9.

7.       Zarbock A, Gomez H, Kellum JA. Sepsis-induced acute kidney injury revisited: pathophysiology, prevention and future therapies. Curr Opin Crit Care 2014;  20:  588-95

8.       Ratanarat R, Hantaweepant C, Tangkawattanakul N, Permpikul C. The clinical outcome of acute kidney injury in critically ill Thai patients stratified with RIFLE classification. J Med Assoc Thai 2009;  92 (Suppl 2):  S61-7.

9.       Cruz DN, Bolgan I, Perazella MA, Bonello M, de Cal M, Corradi V, et al. North East Italian Prospective Hospital Renal Outcome Survey on Acute Kidney Injury (NEiPHROS-AKI): targeting the problem with the RIFLE Criteria. Clin J Am Soc Nephrol 2007;  2:  418-25.

10.     Yue JF, Wu DW, Li C, Zhai Q, Chen XM, Ding SF, et al. [Use of the AKIN criteria to assess the incidence of acute renal injury, outcome and prognostic factors of ICU mortality in critically ill patients]. Zhonghua Yi Xue Za Zhi 2011;  91:  260-4.

 

 

Untitled Document
Article Location

Untitled Document
Article Option
       Abstract
       Fulltext
       PDF File
Untitled Document
 
ทำหน้าที่ ดึง Collection ที่เกี่ยวข้อง แสดง บทความ ตามที่ีมีใน collection ที่มีใน list Untitled Document
Another articles
in this topic collection

Trichinosis (โรคทริคิโนสิส)
 
A comparison in Newborns of the In situ Duration, Phlebitis and Daily Needle Cost of Scalp Intravenous Uning Steel Needles vs. Intravenous Catheters (เปรียบเทียบการให้สารละลายทางหลอดเลือดดำส่วนปลายบริเวณศรีษะในผู้ป่วยทารกแรกเกิดระหว่างเข็มเหล็กกับเข็มพลาสติก ต่อระยะเวลาคงอยู่การเกิดหลอดเลือดดำอักเสบและราคาของเข็มที่ใช้ต่อวัน)
 
Update Treatment for Osteoporosis (Update Treatment for Osteoporosis)
 
Solitary Pulmonary Nodule : Evaluation and Management (ก้อนเดี่ยวในปอด : การดูแลและรักษา)
 
<More>
Untitled Document
 
This article is under
this collection.

Medicine
 
 
 
 
Srinagarind Medical Journal,Faculty of Medicine, Khon Kaen University. Copy Right © All Rights Reserved.
 
 
 
 

 


Warning: Unknown: Your script possibly relies on a session side-effect which existed until PHP 4.2.3. Please be advised that the session extension does not consider global variables as a source of data, unless register_globals is enabled. You can disable this functionality and this warning by setting session.bug_compat_42 or session.bug_compat_warn to off, respectively in Unknown on line 0