Predictors of Mortality in Acute Renal Failure in a Developing Country: A Prospective Study

Kohli, Harbir Singh; Bhat, Ashok; Jairam, A; Aravindan, Ananthakrishnapuram; Sud, Kamal; Jha, Vivekanand; Gupta, Kritika; Sakhuja, Vinay

doi:10.1080/08860220701260651

Cited by 58 publications

(57 citation statements)

References 19 publications

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“…Studies from developing countries have shown that AKI incidence varies (14,(19)(20)(21)(22)(23) and that AKI is often community acquired and preventable (i.e., due to gastroenteritis and infections) (23)(24)(25)(26)(27). However, a formal comparison between developed and emerging countries is lacking (14,28).…”

Section: Introductionmentioning

confidence: 99%

A Prospective International Multicenter Study of AKI in the Intensive Care Unit

Bouchard

Acharya

Cerdá

et al. 2015

Clinical Journal of the American Society of Nephrology

239

166

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Background and objectives AKI is frequent and is associated with poor outcomes. There is limited information on the epidemiology of AKI worldwide. This study compared patients with AKI in emerging and developed countries to determine the association of clinical factors and processes of care with outcomes.Design, setting, participants, & measurements This prospective observational study was conducted among intensive care unit patients from nine centers in developed countries and five centers in emerging countries. AKI was defined as an increase in creatinine of $0.3 mg/dl within 48 hours.Results Between 2008 and 2012, 6647 patients were screened, of whom 1275 (19.2%) developed AKI. A total of 745 (58% of those with AKI) agreed to participate and had complete data. Patients in developed countries had more sepsis (52.1% versus 38.0%) and higher Acute Physiology and Chronic Health Evaluation (APACHE) scores (mean6SD, 61.1627.5 versus 51.1625.2); those from emerging countries had more CKD (54.3% versus 38.3%), GN (6.3% versus 0.9%), and interstitial nephritis (7.0% versus 0.6%) (all P,0.05). Patients from developed countries were less often treated with dialysis (15.5% versus 30.2%; P,0.001) and started dialysis later after AKI diagnosis (2.0 [interquartile range, 0.75-5.0] days versus 0 [interquartile range, 0-5.0] days; P=0.02). Hospital mortality was 22.0%, and 13.3% of survivors were dialysis dependent at discharge. Independent risk factors associated with hospital mortality included older age, residence in an emerging country, use of vasopressors (emerging countries only), dialysis and mechanical ventilation, and higher APACHE score and cumulative fluid balance (developed countries only). A lower probability of renal recovery was associated with residence in an emerging country, higher APACHE score (emerging countries only) and dialysis, while mechanical ventilation was associated with renal recovery (developed countries only).Conclusions This study contrasts the clinical features and management of AKI and demonstrates worse outcomes in emerging than in developed countries. Differences in variations in care may explain these findings and should be considered in future trials.

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Section: Introductionmentioning

confidence: 99%

A Prospective International Multicenter Study of AKI in the Intensive Care Unit

Bouchard

Acharya

Cerdá

et al. 2015

Clinical Journal of the American Society of Nephrology

239

166

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“…It is estimated that in the USA 17 million admissions per year are complicated by AKI. 34 In developing countries AKI is a disease of the young [35][36][37] and children; 38,39 in developed countries it is a disease of the elderly. 40,41 With overall decreases in birth rate and mortality, life expectancy is increasing and is now longer than 80 years in most developed countries.…”

Section: Incidencementioning

confidence: 99%

Development of risk models for the prediction of new or worsening acute kidney injury on or during hospital admission: a cohort and nested study

Bedford

Stevens

Coulton

et al. 2016

Health Serv Deliv Res

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BackgroundAcute kidney injury (AKI) is a common clinical problem with significant morbidity and mortality. All hospitalised patients are at risk. AKI is often preventable and reversible; however, the 2009 National Confidential Enquiry into Patient Outcome and Death highlighted systematic failings of identification and management, and recommended risk assessment of all emergency admissions.ObjectivesTo develop three predictive models to stratify the risk of (1) AKI on arrival in hospital; (2) developing AKI during admission; and (3) worsening AKI if already present; and also to (4) develop a clinical algorithm for patients admitted to hospital and explore effective methods of delivery of this information at the point of care.Study designQuantitative methodology (1) to formulate predictive risk models and (2) to validate the models in both our population and a second population. Qualitative methodology to plan clinical decision support system (CDSS) development and effective integration into clinical care.Settings and participantsQuantitative analysis – the study population comprised hospital admissions to three acute hospitals of East Kent Hospitals University NHS Foundation Trust in 2011, excluding maternity and elective admissions. For validation in a second population the study included hospital admissions to Medway NHS Foundation Trust. Qualitative analysis – the sample consisted of six renal consultants (interviews) and six outreach nurses (focus group), with representation from all sites.Data collectionData (comprising age, sex, comorbidities, hospital admission and outpatient history, relevant pathology tests, drug history, baseline creatinine and chronic kidney disease stage, proteinuria, operative procedures and microbiology) were collected from the hospital data warehouse and the pathology and surgical procedure databases.Data analysisQuantitative – both traditional and Bayesian regression methods were used. Traditional methods were performed using ordinal logistic regression with univariable analyses to inform the development of multivariable analyses. Backwards selection was used to retain only statistically significant variables in the final models. The models were validated using actual and predicted probabilities, an area under the receiver operating characteristic (AUROC) curve analysis and the Hosmer–Lemeshow test. Qualitative – content analysis was employed.Main outcome measures(1) A clinical pratice algorithm to guide clinical alerting and risk modeling for AKI in emergency hospital admissions; (2) identification of the key variables that are associated with the risk of AKI; (3) validated risk models for AKI in acute hospital admissions; and (4) a qualitative analysis providing guidance as to the best approach to the implementation of clinical alerting to highlight patients at risk of AKI in hospitals.FindingsQuantitative – we have defined a clinical practice algorithm for risk assessment within the first 24 hours of hospital admission. Bayesian methodology enabled prediction of low risk but could not reliably identify high-risk patients. Traditional methods identified key variables, which predict AKI both on admission and at 72 hours post admission. Validation demonstrated an AUROC curve of 0.75 and 0.68, respectively. Predicting worsening AKI during admission was unsuccessful. Qualitative – analysis of AKI alerting gave valuable insights in terms of user friendliness, information availability, clinical communication and clinical responsibility, and has informed CDSS development.ConclusionsThis study provides valuable evidence of relationships between key variables and AKI. We have developed a clinical algorithm and risk models for risk assessment within the first 24 hours of hospital admission. However, the study has its limitations, and further analysis and testing, including continuous modelling, non-linear modelling and interaction exploration, may further refine the models. The qualitative study has highlighted the complexity regarding the implementation and delivery of alerting systems in clinical practice.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…The annual population growth rate is 2.4% and children under 15 years old constitute approximately 45% of the total population (1). It is well recognized that acute kidney injury (AKI) in developed countries affects the elderly more, while in developing countries AKI is a disease of the young and children in whom pre-renal causes are predominant (2,3).…”

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confidence: 99%