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Clinical Profile and Management of Patients Admitted with Acute Kidney Injury Secondary to Gastroenteritis in a Tertiary Care Teaching Hospital

Aim: To study clinical profile, laboratory features and importance of rehydration in patients admitted with acute kidney injury due to gastroenteritis. Materials and Methods: The study was carried out as a prospective observational study of 70 patients at medicine department of a medical college and tertiary health care center, over a period of two years that included cases of acute kidney injury due to gastroenteritis in the age group of 18-40 years. Results: Study showed male predominance (72.86%) in elderly age group. Prerenal type was more common (75.71%) as compared to acute tubular necrosis. Duration and frequency of diarrhea was associated with severity of the disease. Mortality was high (100%) in those who required more time (>12 hours) to achieve normal mean arterial pressure. Maximum deaths (93.33%) were observed in anuric patients. Most common complication observed was septicemia in 20% of patients. Overall mortality observed in our study was 21.43%, while 78.57% patients survived. Mortality was high in those having severe dehydration, high baseline creatinine, who received dialysis. Conclusion: Acute kidney injury due to gastroenteritis is preventable if presented early and adequate hydration can decrease mortality.


Introduction
Prevalence of Acute kidney Injury (AKI) is growing in developing countries and is linked with severe morbidity and mortality. Most etiologies of AKI are preventable by interventions at the individual, community, regional and in-hospital levels. Efforts should be focused on minimizing causes of AKI, rising awareness of the significance of sequential measurements of serum creatinine in high risk patients, and documenting urine volume in severely ill people to attain early diagnosis.
KDIGO guidelines for management of AKI provide an helpful reference to assist clinicians for managing AKI, however the successful implementation of guidelines and their application to individual patients can be slow and requires concerted efforts 3,4 . Prevention of AKI starts in the community with prompt assessment of those at risk, for example in taking prompt action following effective evaluation of the severity of fluid depletion in acute diarrhea. Currently serum creatinine and urinary volume remain the clinical pointers to AKI diagnosis. In the hospital setting, AKI preventive measures include adequate hemodynamic control, hydration, hematocrit and oxygen profiling, avoidance of nephrotoxic drugs and preventive manoeuvres for particular diseases or conditions causing AKI. Prompt diagnosis, early treatment, timely haemodialysis and adequate supportive therapy are associated with improved outcome in AKI 5,6,7 .

Materials and Methods
This was prospective observational study carried out in tertiary care teaching hospital with 70 patients included over period of two years.

Inclusion Criteria
• Diagnosed cases of acute kidney injury due to gastroenteritis of either sex in age group of 18-40 years in the in-patients department in tertiary care teaching hospital.

Exclusion Criteria
• Acute kidney injury due to causes other than gastroenteritis. • Acute on chronic kidney disease due to diabetes, hypertension or other co-morbidities.
The KDIGO (Kidney Disease Improving Global Outcome) Clinical Practice Guideline for AKI, defines AKI as any of the following: 3 • Increase in serum creatinine by ≥ 0.3 mg/dl (≥ 26.5 μmol/l) within 48 hours; or • Increase in serum creatinine to ≥ 1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or • Urine volume < 0.5 ml/kg/h for 6 hours.
• Each patient in the study was informed in detail about the aim of the study.
• A fully informed written consent was obtained from him/her prior to the study.  Figure -1). • With maximum number (54.29%) of patients belonging to age group of 31-40 years, i.e., elderly group. • Most common complication observed was septicemia in 20% of patients, followed by uremic encephalopathy in 15.71% of patients.

Discussion
• Incidence of AKI due to gastroenteritis was greater in males. Males were 72.86% and females  12,13 . MAP is also a parameter to assess the adequacy of volume resuscitation 14 . MAP of 21.43% of patients was < 60mm Hg, suggesting poor organ perfusion and further deterioration of kidney function. Average time taken to achieve normal MAP (≥60 mmHg) by these patients was 14.13±2.50 hours. More prompt rehydration was needed for this group of patient as compared to those who had normal MAP. • Majority of patients presented in our study as non oliguric (58.57%), followed by anuric and oliguric (21.43% and 20% respectively). • In J inbanathan et al., study 8 , oliguria was present in 30% and anuria was present in 2% patients. • Higher serum creatinine, serum potassium was associated with poor outcome. • Hyponatremia is one of the common complications of acute kidney injury. It is because of relative or absolute rise in free water intake. Cause of death in our study was septicemia, pulmonary edema, and uremic encephalopathy. • Mortality in ATN group was 41.17% as compared with the mortality in pre renal group which was 15.09%. Which showed that prognosis was good in pre renal group of patients. • Probable cause for relatively low mortality in our study as compared to other studies described above was the age group we studied. In our study we have included patients from 18-40 years of age with no other co morbidities. Other studies described above also included patients with age more than 40 and patients with co morbidities like diabetes and hypertension which also contributes to mortality.

Conclusion
Acute kidney injury due to gastroenteritis is very common in developing countries like India. Most probable cause behind this must be unhygienic conditions, low socio-economic standard of living, poor access to health care facilities in right time.
This study was prospective observational study which was aimed at clinical profile, laboratory features and rehydration of acute kidney injury due to gastroenteritis. This study was conducted at tertiary heath care teaching hospital.
Early detection of AKI due to gastroenteritis and starting fluid therapy in time is very important to avoid further deterioration of kidney function. Preventive measure to reduced community acquired diseases like gastroenteritis can reduce burden over the health care system. Study showed that males and elderly group was more common as compared to females and young population, mostly due to more exposure for community acquired diseases like gastroenteritis in our case. This concludes that special care should be taken in this group of patients to avoid acute kidney injury.
A Central tenet of the "World Kidney Day" message since 2006 has been that "kidney disease is common, harmful and treatable"