Journal of Tropical Pediatrics, 2015, 61, 54–60 doi: 10.1093/tropej/fmu066 Advance Access Publication Date: 1 December 2014 Original Paper

by Christopher Imokhuede Esezobor,1,2 Taiwo Augustina Ladapo,1,2 and Foluso Ebun Lesi1,2 1

Department of Paediatrics, College of Medicine, University of Lagos, Idi-Araba, Mushin, Lagos State, Nigeria Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, 101014 Mushin, Lagos State, Nigeria Correspondence: Christopher Imokhuede Esezobor, Department of Paediatrics, College of Medicine, University of Lagos, P.M.B 12003, Lagos, Nigeria. Tel: þ234 805 844 0582. E-mail . 2

SU M MAR Y Introduction: In resource-constraint regions of the world, the spectrum of childhood diseases is changing, creating a need to clearly define the epidemiology of severe acute kidney injury (AKI). Methods: Medical records of children aged between 1 month and 17 years with stage 3 AKI in a tertiary hospital were reviewed. Results: Ninety-one children, comprising 63 (69.2%) males and 26 (28.6%) infants, were studied. Majority (75.8%) had stage 3 AKI at the point of hospitalization. Sepsis (41.8%), primary kidney diseases (PKD; 29.7%) and malaria (13.2%) were the most common causes of stage 3 AKI. Twenty-eight (30.8%) children died. Mortality was highest in those with sepsis, less than 5 years old and needing dialysis. Conclusion: Sepsis, PKD and malaria were the most common causes of severe AKI. A third of children with severe AKI died. Mortality was highest in those less than 5 years old, with sepsis and needing dialysis. K E Y W O R D S : acute kidney injury, dialysis, gastroenteritis, malaria, sepsis

INTRODUCTION Small increases in serum creatinine are associated with excess mortality and increased utilization of hospital resources. These adverse outcomes with increases in serum creatinine level underline the recent recommendations to harmonize acute kidney injury (AKI) definitions, mostly recently, by the Kidney Disease Improving Global Outcome (KDIGO) [1–4]. This recognition justifies the need to evaluate kidney function in sick children admitted to hospital. However,

detecting increases in serum creatinine requires prior or serial determination of serum creatinine, which is not usually the case in developing countries. In addition, because critically ill children in developing countries are managed in general wards rather than in intensive care units (ICU), unless they have severe AKI, deterioration in kidney function may not be recognized. Nonetheless, severe AKI is associated with the highest odds of deaths and demands the most of hospital resources. Therefore, identifying children with

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Clinical Profile and Hospital Outcome of Children with Severe Acute Kidney Injury in a Developing Country

Clinical Profile and Hospital Outcome of Children

METHODS Medical records of children aged more than 1 month and managed for stage 3 AKI by the Paediatric Nephrology Unit of Lagos University Teaching Hospital between July 2010 and June 2014 were reviewed. Children with evidence of chronic kidney disease were excluded.

Description of study centre The hospital is a 760-bed fee-for-service tertiary hospital in Lagos State, south west Nigeria. It is one of the largest tertiary hospitals in Nigeria. Sick children were hospitalized via the emergency room, where they present after self-referral or referral from other hospitals in Lagos State and neighbouring states. Children assessed to require more than 48 h of hospitalization were admitted into the general wards from the emergency room. In very few instances, children were admitted into the five-bed ICU of the hospital shared by both adults and children. Absence of ventilator services for smaller children and high cost of ICU admission meant that most critically ill children were managed in the general wards. Children in the emergency room or general wards with elevated serum creatinine, deranged serum electrolytes, reduced urine output, dark urine, facial or generalized oedema or suspected of having kidney diseases were referred to the paediatric nephrology unit for further assessment. The routine assessment done for these children has been previously described [8]. Analysis of serum creatinine was by the modified Jaffe method. Glomerular filtration rate was estimated using the Schwartz formula and a constant of 0.413 [9].

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Indications for dialysis Only children with the following were judged to require dialysis: symptomatic fluid overload such as difficult to control blood pressure and or pulmonary oedema in the presence of oliguria; features of ureamia manifesting as poorly controlled seizures, deterioration in level of consciousness, intractable vomiting or bleeding from mucosal surfaces; severe hyperkalemia; severe metabolic acidosis or severe hyponatraemia not amenable to medical interventions. Serum creatinine or urea values only were not used as the sole basis for dialysis. Only intermittent haemodialysis and manual peritoneal dialysis could be performed in the hospital. Ethical approval was obtained from the Health Research and Ethics Committee of the hospital before the commencement of the study. Definitions Stage 3 AKI was defined according to the consensus recommendations of the KDIGO clinical practice guidelines: [2] an in-hospital increase in serum creatinine by 300%, a serum creatinine 4 mg/dl or an estimated glomerular filtration rate (eGFR) 15  103/mm3. Other definitions used in this study have been previously described [8]. Data management Extracted data were analysed using IBM SPSS Statistics 21.0 (IBM Corporation 2012, USA). Categorical variables were represented as proportions. All continuous variables were tested for normality and summarized as mean or median, as appropriate. Association between demographic, clinical and laboratory variables and hospital outcome

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severe AKI carries added importance in developing countries where resources including skilled manpower are scarce. While decades ago gastroenteritis and primary kidney diseases (PKD) were the leading causes of AKI in children in developing regions of the world, more recent studies suggest that this may be changing, emphasizing the need to clearly identify common causes of AKI in children in our centre [5–7]. In addition, we described the clinical features and hospital outcome of children with severe AKI in the present study.



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Clinical Profile and Hospital Outcome of Children

was tested using Chi square test or student t-test as appropriate. In all analyses, p values < 0.05 were considered statistically significant.

RESULTS

Table 1. Clinical and laboratory features of children with severe acute kidney injury Descriptive variables

Frequency, n ¼ 91 (%)

Age

Clinical profile and hospital outcome of children with severe acute kidney injury in a developing country.

In resource-constraint regions of the world, the spectrum of childhood diseases is changing, creating a need to clearly define the epidemiology of sev...
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