الفهرس 
Introduction and Aim of the studyOnly 14 pages are availabe for public view
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Abstract
Acute kidney injury (AKI) is one of the most frequent conditions occurring among critically ill adult patients. It is mostly community-acquired acute kidney injury (CA-AKI) suggesting that this complex condition may go overlooked since the clinical presentation may be ambiguous and early signs of AKI may be perplexing to be recognized by health care provider.
Preventive measures are crucial to reduce incidence and mortality due to AKI. The diagnosis of AKI in critically ill patients during their hospital admission contributed toward worsening of the clinical course, increasing in the consumption of hospital resources, increased hospital and critical care unit mortality. Early detection of AKI in susceptible patients is substantial to decrease the heavy burden and critical care unit mortality of this lethal disease.
The aim of the present study was to investigate the problem AKI among critically ill patients admitted to the medical and with the following specific objectives:
1. To estimate the frequency of AKI among the study patients.
2. To identify the possible determinants of AKI among the study patients.
The study was conducted using a cross-sectional approach. It included 290 critically ill patients aged from 18 years and above admitted to the medical critical care units at Alexandria Main University Hospital. The study extended throughout six months (from January to June 2017) during which data were collected and recorded over a follow up period of two weeks starting from the date of critical care unit admission. All data were recorded until the end of the period of two weeks, discharge or death; whichever came earlier. In the event of multiple admissions for a particular patient, only the initial critical care unit admission was considered. Those patients directly transferred from one critical care unit to another included in the study were considered part of the first admission.
Data collection was done using two approaches; predesigned structured interviewing questionnaire and medical records and review sheet.
The predesigned structured interviewing questionnaire included socio-demographic characteristics, smoking status, history of comorbid diseases, drug history and estimated weight and height while medical records and review sheet included admission data, mechanical ventilation, stage of AKI, presence of sepsis, Acute Physiology and chronic Health Evaluation (APACHE) II score at the time of critical care unit admission, laboratory tests, fluid balance (fluid intake and urine output) and monitoring charts.
Data entry and statistical analysis were done using SPSS version 21. Statistical analysis was performed in both descriptive and inferential forms.
The study revealed the following main results:
A. Description of the study patients:
• The age of studied patients ranged from 18 to 90 years with a mean of 53±17 years. Patients aged from 18 years to less than 35 years constituted 15.8 percent. More than half (54.3%) of the studied patients aged from 35 years to less than 65 years. AKI patients tended to be older than non-AKI patients with mean± SD, 56±16 years and 48±16 years, respectively.
• The percentage of males was slightly higher than females (51.4% versus 48.6%, respectively).
• About three quarters (74.5%) of the studied patients were married. Single patients constituted 16.6% of the studied patients. Widowed patients accounted for 7.2% of the studied patients. Only 5 patients were divorced.
• About one third (30.7%) of the studied patients were illiterate. Those who read and write constituted 10.3%. Secondary and university graduates represented 22.7% and 15.9%, respectively.
• More than half (59.7%) of the studied patients were living in Alexandria. About one fifth (20.8%) came from Beheira while the remaining patients (19.5%) were from other governorates.
• More than one third (35.2%) of the studied patients were not working while housewives constituted 27.6% of the studied patients. Those who were working constituted 34.8%. Only 2 patients were students.
B. Concerning history of clinical diseases:
• Diabetes mellitus (DM) constituted 39% of the studied patients. Those patients who were having a positive history of DM for five to less than 10 years constituted approximately a quarter (25.7%) of the diabetic patients enrolled in the study. Nearly one third (31.9%) of the diabetic patients included in the study were having DM for 10 to less than 15 years. Also about one third (32%) of the diabetic patients included in the study were having a positive history of DM over a period of 15 to less than 25 years. The percentage of DM among AKI patients 48.5% was significantly higher than among non-AKI patients 25.2%.
• Nearly two thirds of the studied patients (66.6%) gave a positive history of hypertension (HTN). Those patients who reported a positive history of HTN over a duration of five years to less than 10 years and a duration of 10 years to less than 15 years accounted for approximately half (51.9%) of the hypertensive patients included in the study (25.4% and 26.5%, respectively). Around a quarter (25.3%) of hypertensive patients included in the study were having hypertension for 15 years to less than 25 years. Most of the hypertensive patients (89.1%) were receiving antihypertensive drugs.
• More than half (51.4%) of the studied patients gave a positive history of at least one cardiovascular disease (CVD); coronary heart disease, heart failure, atrial fibrillation, angina and peripheral vascular disease. The percentage of the presence of at least one cardiovascular disease was significantly different among AKI versus non-AKI patients (62.6% versus 35.3%, respectively) (p˂0.001).
C. Concerning history of drug intake:
• More than a quarter (26.9%) of the studied patients gave a positive history of diuretic use. AKI and non-AKI patients differed significantly (36.3% versus 13.4%, respectively) regarding the history of diuretic use and (p<0.001).
• A positive history of non-steroidal anti-inflammatory drugs (NSAIDs) use was given by about one fifth (22.4%) of patients enrolled in the study. there was a significant difference between AKI and non-AKI patients (28.1% versus 14.3%, respectively) regarding the history of NSAIDs use (p=0.006).
• A positive history of angiotensin converting enzyme (ACE) inhibitors treatment was given by 15.9% of the studied patients. The AKI and non-AKI patients tended to be different regarding the history of ACE inhibitors treatment (p=0.1).
• Nine patients gave a positive history of receiving a contrast agent. AKI and non- AKI patients did not differ significantly regarding the history of receiving a contrast agent (p=0.3).
• Only 5.5% of the study patients reported a positive history of Angiotensin receptors blockers (ARBs) use. ARBs showed no significant difference among AKI and non-AKI patients (p=0.07).
D. As regards clinical characteristics:
• About three quarters (75.2%) of the studied patients were mechanically ventilated. The percentage of AKI patients who were on mechanical ventilation on admission was significantly different from non-AKI patients (81.3% versus 66.4, respectively) (p=0.006).
• Those patients admitted with a presence of sepsis constituted 43.4% of the studied patients. Patients with AKI had a higher percentage of sepsis at the time of critical care unit admission compared to non-AKI patients (60.2% and 17.6%, respectively) (p<0.001).
E. The frequency of AKI among critically ill patients:
• Among the critically ill patients admitted in medical critical care units included in the study, AKI was detected in 171 patients (58.9 %). Community-acquired AKI was predominant and constituted 69% of the AKI patients.
F. As regards the staging of AKI:
• Among AKI patients, 45.1 % were in stage 1 while those in stage 3 constituted 40.9%. Only 14% (24 AKI cases) were in stage 2.
G- Factors associated with AKI:
• In univariate analysis: age, marital status, educational level, occupation, body mass index, DM, CVD, malignancy, liver disease, neurologic diseases, gastrointestinal diseases, renal/urologic diseases, diuretics, NSAIDs, mechanical ventilation, presence of sepsis, presence of chronic kidney disease, APACHE II score and low hemoglobin level were significantly associated with AKI.
H- Concerning predictors of AKI:
• In multivariate logistic regression analysis: APACHE II score, CVD and sepsis were significant predictors of AKI among critically ill patients.
I- Regarding the outcome:
• Patients with AKI had significantly longer length of critical care unit stay than non-AKI patients 12(8-18) days versus 7(5-12) days, respectively.
• The need for renal replacement therapy (RRT) before discharge constituted 15.5% of the studied patients. There was a significant difference between AKI and non- AKI patients (26.3% versus 0%, respectively) as regards the need for RRT at discharge.
• The mortality percentage was significantly higher in the AKI than the non-AKI patients (48% versus 25.2%, respectively).
Based on the results of the current study, the following could be concluded:
• The frequency of acute kidney injury (AKI) among the critically ill patients admitted to the medical critical care units was about 60% with a predominance of community acquired acute kidney injury.
• The presence of sepsis is proved to be a significant predictor for AKI among critically ill patients and appeared to be predominant among AKI patients.
• Cardiovascular diseases and APACHE II score are significant predictors for AKI among critically ill patients.
• Mortality rate is higher among AKI patients than non-AKI patients in the medical critical care setting.
Recommendations:
For the Ministry of Health and Population:
1. Raising awareness among all health care providers and the population about risk factors and consequences of acute kidney injury (AKI) through planning and implementing public health educational programs and campaigns using all media means.
2. Training of health care providers as well as supplying tools to record and convey information about high risk individuals for AKI.
3. Developing standardized written AKI prevention policies and procedures appropriate for the services provided by the health care facilities in Egypt.
4. Provision of regular AKI screening program for early detection as a part of public health preventive programs.
5. Establishing continuous community-based AKI surveillance system for both community-acquired and hospital-acquired AKI.
6. Developing an accurate recording system within each health care facility for all cases of AKI.
• For health care providers:
1. Considering doing renal function tests when prescribing nephrotoxic drugs and agents and applying risk benefit analysis for each case.
2. Planning and applying a clear system for early detection and management of AKI patients within each health care facility based on a multidisciplinary approach.
3. Establishing and implementing an effective system for early detection and proper management of sepsis.
• For the Community:
1. Comply with screening programs provided by the Ministry of Health.
2. Regular medical check-up in individuals with multiple co-morbid diseases is recommended.
3. Averting the irrational use of over the counter nephrotoxic drugs.
• For the researchers:
1. Implementing further studies that focus on long- term survival, renal recovery and quality of life beyond hospital discharge.