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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 21-25

Epidemiology and outcomes of community-acquired-acute kidney injury in women: A study from tertiary care center in South India


Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India

Date of Submission10-Jan-2021
Date of Acceptance23-Jan-2021
Date of Web Publication21-Oct-2021

Correspondence Address:
Dr. Manjusha Yadla
Department of Nephrology, Gandhi Medical College, Hyderabad - 500 073, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrnm.jrnm_3_21

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  Abstract 


Introduction: Acute kidney injury (AKI) is sudden deterioration in kidney function for few days to weeks with or without kidney damage. Risk factors for AKI are diabetes, hypertension, pre-existing chronic kidney disease (CKD), and advanced age. Apart from the traditional risk factors, K-DOQI mentions the female gender as susceptibility factor for the development of AKI. Although it is well known that certain hospital-acquired causes of AKI such as contrast-induced nephropathy, aminoglycoside toxicity, care common in women, community acquired etiology is not well studied. Hence, we undertook this study to analyze community-acquired (CA)-AKI in women and their outcomes. Aim: The aim is to study the epidemiology and outcome of AKI in women. Material and Methods: A retrospective analysis of medical records of patients admitted with the diagnosis of AKI during the calendar year of 2018 was done. Data were collected from the computer system of the Aarogasree scheme, a flagship scheme of the Government providing cashless health services to the below poverty line patients. Under this, Code 6 is for Nephrology, 6.1 is for AKI. Demographic data, investigations, hospital stay, and treatment details are entered into the system. Patients with the final diagnosis of Acute on CKD and chronic dialysis were excluded. Age, gender, etiology, management, and the association between treatment and outcome were analyzed using descriptive statistics, and Chi-square test. The primary outcome analyzed was mortality. The secondary outcome in the form of geographical predisposition for the development of specific causes of AKI was also analyzed. Telangana State is divided into seven Zones geographically. We tried to analyze etiology and outcomes of AKI in these individual Zones. Results: A total of 390 patients were admitted with AKI as the presenting diagnosis to the female nephrology ward and intensive care unit (ICU) in our hospital. Out of 390 patients, 180 patients were excluded from the study. 210 patients were included in the study. The mean age of patients is 46.9 ± 16.2 years. Oliguria was presenting complaints in 33.8% and fever in 25.2% of patients with AKI. Febrile illness (22%) and acute gastroenteritis (15%) were major causes of AKI, followed by carcinoma cervix (14%) and PR-AKI (10%). Around one-third of patients belong to Zone 6 of Telangana state. The intrinsic renal cause was found to be the predominant cause of AKI in all zones except Zone 5 and Zone 7. Mortality was found to be highest (25%) in zone 4 followed by zone 2 (17.6%). The lowest mortality was found in Zone 1 and Zone NA (0%). No statistical significance was found for outcomes between those admitted to ICU and ward. The presence of diabetes (P = 0.53) or hypertension (P = 0.47) was not associated with increased mortality. Conclusion: Oliguria and fever are common clinical presentations of AKI in women. Febrile illness and acute gastroenteritis are the most common causes of AKI in women. Intrinsic renal cause for AKI was found to be common in all zones of Telangana state except Zone 5 and Zone 7 where post renal cause for AKI was predominant. Zone 4 and Zone 2 which are far from Zone 6 had the highest mortality. Neither diabetes mellitus nor hypertension was associated with increased mortality.

Keywords: Acute kidney injury, community-acquired, epidemiology, India, women, zones


How to cite this article:
Khandavali P, Yadla M. Epidemiology and outcomes of community-acquired-acute kidney injury in women: A study from tertiary care center in South India. J Renal Nutr Metab 2021;7:21-5

How to cite this URL:
Khandavali P, Yadla M. Epidemiology and outcomes of community-acquired-acute kidney injury in women: A study from tertiary care center in South India. J Renal Nutr Metab [serial online] 2021 [cited 2021 Dec 8];7:21-5. Available from: http://www.jrnm.in/text.asp?2021/7/1/21/328959




  Introduction Top


The acute kidney injury (AKI) is characterized by the rapid reduction in kidney function, resulting in failure to maintain fluid, electrolyte, and acid-base balance. AKI supersedes the term Acute Renal Failure and is a spectrum, extending from a less severe form to an advanced form, which necessitates the need of renal replacement therapy.[1]

AKI may be community-acquired (CA) or hospital-acquired. It is well known that in the presence of AKI, there is the potential lengthening of stay in the hospital, increased mortality risk, increased risk of readmission. Hence, AKI is called silent killer.

K-DIGO mentions the female gender as susceptibility factor for the development of AKI. Certain causes are seen only in women and certain are more common in women. Aminoglycoside toxicity, contrast-induced nephropathy are common in women compared to men. Literature is sparse regarding CA-AKI in women.

The hormonal milieu in the female gender is thought to have a protective role in the development of kidney diseases. Experimental models have reiterated the protective role for AKI in females. However, female sex is a predilection for AKI due to cardiac surgery, contrast nephropathy, and aminoglycoside toxicity.[2] Hospital-acquired AKI of the above said causes and CA of Pregnancy–AKI are reportedly common in women. How about other etiologies of AKI and their outcomes in women?

Animal models have shown that female sex gives protection against ischemia-reperfusion injury.[2],[3] Despite the above observations in various etiologies of AKI, K-DIGO considered female sex as susceptibility factor for the development of AKI.[3] Recent study of the analysis of 194,157,326 patients with AKI suggests that the male sex is 2.19 times more at risk than women in developing AKI.[4]

Recent studies in the Indian population shows nephrotoxic drugs as the most common cause of AKI among medical wards whereas sepsis among surgical wards and intensive care unit (ICU).[5],[6],[7],[8] AKI is an independent risk factor in critically ill patients leading to mortality.[1],[9],[10]> Long-term follow-up studies have shown AKI as risk factor for chronic kidney disease (CKD) or exacerbation of underlying CKD.

Wide variation and changing scenario of the epidemiology of AKI warrant a frequent understanding of clinical scenario and presentation, thus enabling the policymakers to frame regulations for reduction of the same.[11],[12]

Aim

The study was conducted with the primary objective of finding the distribution of AKI among different zones of the Telangana state of India. The secondary objective was to identify risk factors, etiology, and outcomes associated with AKI. The present study will provide us with the data regarding the distribution of AKI among 7 zones of Telangana state and also factors influencing outcomes.


  Patients and Methodology Top


A retrospective single-center observational study was conducted in a tertiary care teaching hospital for 1 year (January 2018 to December 2018). Data of patients aged ≥18 years admitted during January–December 2018 were collected from the officiating website medical records using the predefined code. The government of the Telangana state provides free care to all the people below the poverty line under this cashless Government scheme (Aarogyashree). In this treatment for AKI patients is given free of cost. Different predefined codes exist in web portal based on the syndromic diagnosis. For example., AKI, rapidly progressive renal failure, CKD, on dialysis, etc., All the patients requiring dialysis are included in this code.

We undertook the presentation of patients admitted with a specific diagnosis of AKI. Patients with discharge diagnosis of Acute on CKD or CKD were excluded from the study.

AKI cases who underwent dialysis were included. Those with lower serum creatinine or those not needing dialysis were excluded from the study.

Patient data such as demographic details, history, complaints on admission, medical and medication history, etiology, risk factors for suspecting AKI, laboratory values, urine output levels, management, and outcomes were studied.

Statistical analysis

Data analysis was performed using the Statistical software SPSS (Version 20.0) Statistical Package for the Social Sciences Statistical Package for the Social Sciences. Descriptive statistics were used for the analysis. The data for continuous variables were summarized as mean ± standard deviation Statistical tests were two-tailed, and P < 0.05 was considered to show a statistical difference. Chi-square test for association was performed between different treatment modalities used and the patient outcome at the time of discharge.


  Results Top


Of a total of 81770 patients admitted to our tertiary care teaching hospital between January to December 2018, 390 women patients were admitted with the diagnosis of AKI. Of 390 case records, 180 patients did not meet the inclusion criteria. Hence, the medical records of 210 patients were analyzed.

The mean age of the study population was 46.9 ± 16.2 years [Table 1]. Type 2 DM was present in 30/210 (14.2%), HTN was present in 22/210 (10.4%). Mean serum creatinine was 6.37 ± 2.9 mg/dl. The febrile illness was associated with AKI in the majority of women. Oliguria as presenting clinical features was observed in 1/3rd of the study group.
Table 1: Characteristics of women with community acquired-acute kidney injury

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The most common cause of AKI in this study group was acute febrile illness followed by acute gastroenteritis. We had 14 cases of carcinoma cervix and 10 cases of pregnancy AKI during the study period.

All 210 patients needed dialysis as they were in AKIN–III. Mean number of dialysis sessions was 5.4 + 2 in number. Patients received dialysis through internal jugular catheters except for those with thrombocytopenia in whom dialysis was given through femoral catheter. Those patients with hemodynamic stability were given hemodialysis and in those with unstable hemodynamics, either peritoneal dialysis or SLED was given.

Comparison of characteristics and outcomes in critically ill and those who did not receive ICU care did not reveal any significant factors affecting outcome except the duration of hospitalization [Table 2]. Among the factors influencing survival, thrombocytopenia was found to be associated with mortality [Table 3]. Our State is geographically divided into seven Zones [Figure 1]. Zonal analysis of CA-AKI in women showed that Zone 6 had a higher number of patients [Table 4], which is interior parts of the Metropolitan City [Figure 2]. Etiogically, all the Zones had Intrinsic cause except Zones 5 and 7 where post renal cause, carcinoma cervix, or nonmalignant obstructive AKI was common [Figure 3]. With the population being high in Zone 6, common etiologies like acute febrile illness and acute gastroenteritis were also commonly seen in this Zone. Mortality was more in Zone 6 compared to other Zones.
Table 2: Comparison of admissions to intensive care unit versus ward admissions

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Table 3: Factors associated with mortality

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Figure 1: Distribution of zones across the state

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Table 4: Zonal-wise distribution of death among women with community acquired-acute kidney injury

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Figure 2: Etiology of community-acquired-acute kidney injury in women

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Figure 3: Distribution of etiology of acute kidney injury in different zones

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  Discussion Top


Literature about CA-AKI is scarce despite the reported prevalence of 1%. Few studies done in Spain, UK, and North America observed that the HA-AKI is associated with a poorer prognosis compared to CA-AKI.[13],[14],[15],[16],[17] Delay in identification and nephrology referral in patients with HA-AKI had a significant influence on the outcome. Early recognition and management of CA-AKI were shown to be associated with a positive prognosis.

The focus of AKI in women was predominantly in pregnancy-related conditions. Other causes of AKI were less studied in women. Being the less accessible for medical care, definitive data are lacking regarding the prevalence of CA-AKI in women. Whether the female gender is at risk or at protection in the occurrence of AKI is not clear. The KDIGO identified female gender as a risk factor for AKI which was contrary to the observations of the recent meta-analysis of the female gender, being the protective factor against AKI.[15]

The prevalence of AKI in our study was found to be 2.5 cases/1000 patients per year. Our state Government provides free services like treatment of AKI, maintenance hemodialysis, organ transplantation for the benefit of below poverty line patients under the cashless Government scheme, Aarogyasree. Government allocates the highest amount to the Nephrology services surpassing the Cardiology, Trauma, Medical, and Surgical services, which is based on the number utilizing the services under the cashless Government scheme [Table 3] and [Figure 1]. Based on the statistical report from the state, the number of men and women who utilized the services of Aarogyasree was 50:38 (156,333 vs. 118,732) [Table 2] and [Table 5] which has been the same through the years 2016–2017 and 2017–2018. This implies that over 3 years period, there has been no increase in the percentage of women reaching for medical care.
Table 5: Etiology of acute kidney injury

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Our study had 210 women patients and in studies done by Mohammed et al. and Anvar and Raghavendra, the number of female patients was 144 and 78, respectively.[13],[14] Mean age of the cohort was 46.9 ± 16.2 years. Comorbidities such as diabetes and hypertension were between 7% and 10% of the total cohort.

The most common renal symptom was oliguria. Majority of CA-AKI were intrinsic in etiology. Prerenal was less because of the referral pattern by the internal medicine team. Post renal causes were seen in 37 patients, majority due to carcinoma cervix causing the ureteric obstruction. Febrile illness and acute gastroenteritis were common etiologies in our study, similar to the study by Anvar and Raghavendra[13] in which acute gastroenteritis was the most common cause. PR-AKI and carcinoma cervix causing obstruction-AKI, unique to women, contributed to 24% of total cases [Figure 1].

We also assessed the probable association of etiology with the geographical origin of the patients. Our State is geo-economically divided into Seven Zones for equal employment opportunities. These Zones may be considered as the zones which are with equal amenities and resources with the proportionate distribution of population [Figure 3]. Each Zone has a variable population and resources, i.e., Zone 1–28.29 lakhs, Zone 2–39.74 lakhs, Zone 3–43.09 lakhs, Zone 4–50.44 lakhs, Zone 5–45.23 lakhs, Zone 6–1.03 crore, and Zone 7–44.63 lakh population.

Out of 7 zones in the state, the majority of AKI cases were from zone 6 (71 patients) followed by Zone 7 (36 patients) and Zones 3, 5 (31 patients). Zones 5 and 7 had post renal cause of AKI and the remaining zones had intrinsic AKI as the most common cause of AKI. Among the intrinsic causes [Figure 2], febrile illness, acute gastroenteritis, and carcinoma cervix were common. In Zone1, the most common cause of AKI was carcinoma cervix, in Zones 2, 3, and 5, febrile illness-AKI was more common, and in Zone 6, AKI was commonly due to febrile illness and acute gastroenteritis and in Zone 7, carcinoma cervix was the more common cause of AKI. Mortality percentage among was high in Zones 6, 2, and 4. No factor was associated with mortality except the present study is the first of its kind in India where >200 women patients with AKI were included in the study. In comparison to outcomes with other studies, recovery was good with 88% in our study similar to the study done by Anvar and Raghavendra (86.8%) reported from by Mohammed et al.(64%).[14]

Identification of common causes of AKI in each Zone may help the public authorities in establishing certain strategies towards the early detection and management of the same. Its well known that early detection and management of AKI has positive prognosis. Etiology based screening would help in appropriate planning and utilization of resources which are known to be constrained in developing nations like India.

Strengths

  • First Indian study of >200 women patients with AKI
  • The distribution of patients characteristics was studied zone wise giving epidemiological significance.


Limitations

  • Retrospective study
  • Small sample study (Zone wise distribution)
  • Did not include cases of nonrecovering AKI.



  Conclusion Top


Oliguria and fever are common clinical presentations of AKI in women. Febrile illness and acute gastroenteritis are the most common causes of AKI in women. Intrinsic renal cause for AKI was found to be common in all zones of Telangana state except Zone 5 and Zone 7 where post renal cause for AKI was predominant. Zone 4 and Zone 2 which are far from Zone 6 had the highest mortality. Neither diabetes mellitus nor hypertension was associated with increased mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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UK Renal Association. Clinical Practice Guidelines. Module 5: Acute Kidney Injury. 4th ed. United Kingdom: Renal Association; 2008. Available from: https://renal.org/wpcontent/uploads/2017/06/module_5_acute_kidney_injury_-_4th_edition.pdf.  Back to cited text no. 1
    
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Lameire NH, Bagga A, Cruz D, de Maeseneer J, Endre Z, Kellum J, et al. Acute kidney injury: An increasing global concern. Lancet 2013;382:170-9.  Back to cited text no. 2
    
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Eswarappa M, Gireesh MS, Ravi V, Kumar D, Dev G. Spectrum of acute kidney injury in critically ill patients: A single center study from South India. Indian J Nephrol 2014;24:280-5.  Back to cited text no. 3
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    Figures

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    Tables

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