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Year : 2021  |  Volume : 10  |  Issue : 6  |  Page : 2423-2427  

The requirement of hemodialysis in patients with acute gastroenteritis–induced acute kidney injury

General Medicine, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India

Date of Submission24-Sep-2020
Date of Decision02-Dec-2020
Date of Acceptance05-Jan-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. R Prithviraj
Prestige Bella Vista, Tower 20C, Flat 201211, Mount Poonamalle High Road, Iyyapanthangal, Chennai - 600 056, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfmpc.jfmpc_1979_20

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Acute gastroenteritis is an important cause of preventable acute kidney injury (AKI). Inadequate or delayed restoration of diarrheal losses results in a very high incidence of AKI. Diarrheal illness is a major reason for hospitalization, but data on consequent acute kidney injury are sparse. The objective of the study is to determine the incidence of AKI in infectious and noninfectious diarrheal illness requiring hospitalization and to identify correlates and outcomes of diarrhea-associated AKI. None of the patients had any organism isolated in stool, probably due to prompt initiation of antibiotics/inadequate culture growth. Three out of our 6 cases did not require hemodialysis (HD) and AKI resolved on conservative management alone (fluids, electrolyte management, and antibiotics). Three out of 6 cases had nonresolving AKI and were dependent on renal replacement therapy (RRT) even at 1 month after discharge as they remained oliguric. One recent paper has reported the recovery of renal function after a period of dialysis. Frequent electrolyte abnormalities, risk of (catheter-related/bloodstream) infections, and severity of the primary disease are the chief reasons for the persistently high morbidity. Although, there was no mortality in our study.

Keywords: ABG – arterial blood gas, AGE – acute gastroenteritis, AKI – acute kidney injury, BUN – blood urea nitrogen, DM – diabetes mellitus, HD – hemodialysis, HTN – hypertension, LFT – liver function test, RFT – renal function test

How to cite this article:
Bhakthavatchalam S, Srinivasan D, Prithviraj R. The requirement of hemodialysis in patients with acute gastroenteritis–induced acute kidney injury. J Family Med Prim Care 2021;10:2423-7

How to cite this URL:
Bhakthavatchalam S, Srinivasan D, Prithviraj R. The requirement of hemodialysis in patients with acute gastroenteritis–induced acute kidney injury. J Family Med Prim Care [serial online] 2021 [cited 2021 Sep 26];10:2423-7. Available from: https://www.jfmpc.com/text.asp?2021/10/6/2423/320453

  Introduction Top

Acute diarrheal diseases are an important cause of preventable acute kidney injury (AKI) in India. Inadequate or delayed restoration of diarrheal losses results in a very high incidence of AKI.[1] AKI is characterized by abrupt deterioration in kidney function, manifested by an increase in serum creatinine level with or without reduced urine output.[2] The spectrum of injury ranges from mild to advanced, sometimes requiring renal replacement therapy (RRT).[3]

The present case series focuses on AKI, offset by hypovolemia, secondary to extrarenal losses such as acute gastroenteritis (AGE). A study conducted by Carpenter CCJ, Mondal A, Sack RB, et al.[4] shows that rapid and effective restoration of extracellular fluid (ECF) volume within 4 h can prevent acute renal failure (ARF). Similar results were found in Mahajan et al., wherein it was noted that volume depletion was the most common precipitating factor for ARF, and in Jayakumar et al., it was found that among the medical causes of ARF acute diarrheal disease was the most common. [5],[6]

Approximately 70% of community-acquired cases of AKI are attributed to prerenal causes. In a study conducted by Kaufman J, Dhakal M, Patel B, Hamburger R. Community-acquired acute renal failure. American Journal of Kidney Disease. 1991;17(2):191–198, AGE was the most common cause of AKI followed by ischemic acute tubular necrosis (ATN). In these cases, underlying kidney function may be normal, but decreased renal perfusion associated with intravascular volume depletion (e.g., from vomiting or diarrhea) or decreased arterial pressure (e.g., from sepsis) results in a reduced glomerular filtration rate.

  Case Description Top

The present case series was conducted on 6 patients, in the medical ICU of Sri Ramachandra Institute of Higher Education and Research Centre, Chennai, over a period of 3 months, i.e., 1st January 2020–31st March 2020. Outcomes in patients were studied who developed AKI secondary to AGE. AKI was diagnosed according to any of the following criteria (1) Increase in serum creatinine (SCr) by X 0.3 mg/dL within 48 h; or increase in SCr to X 1.5 times baseline, which is known or presumed to have occurred within the prior 7 days or (2) Urine volume <0.5 mL/kg/h for 6 h, (3) normal kidneys on ultrasound/absence of pre-existing renal disease.

Once the diagnosis of AKI was made, the underlying etiology was determined by combining history, examination, and investigative data. Risk factors of AKI such as chronic kidney disease (CKD), hypertension and diabetes mellitus, use of nephrotoxic drugs/contrast agents administered in the past were ruled out on admission. At the same time, patients were started on appropriate conservative treatment.

Cases were followed up telephonically at 1 month after their discharge to assess recovery for AKI caused by diarrheal illness and/or requirement of HD. It was conferred that 3 out of the 6 AKI cases were requiring maintenance HD at 1 month follow up, following which we terminated our study to prevent superimposing of COVID-19 infection, which could make the purpose of the case series inconclusive.

[Table 1] - Title (Relevant Patient Details since the time of admission & discharge & follow up at one month post discharge) it is original patient data taken after patient consent at intensive care unit (ICU) of Sri Ramachandra Institute of Higher Education and Research.[19]
Table 1: Relevant patient details since the time of admission upto discharge and one month follow up

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  Discussion Top

ARF, also referred to as AKI, is characterized by sudden kidney function impairment leading to nitrogenous and other waste products retention, which are normally cleared by kidneys.[2] The present case series consists of 6 patients, of which all were male, of age range between 38 and 75 years. A similar age and gender distribution are seen in Mahajan et al., and Kumar et al., studies. Diarrhea, nausea, and vomiting were the predominant complaints in all patients and oliguria, anuria, hypotension, and tachycardia were other symptoms observed among a few. Investigations revealed proteinuria noted in four of our cases with no comorbidities, except for two patients with a history of hypertension and diabetes mellitus. Also, the increased neutrophil-lymphocyte ratio (NLR) was highly peculiar in our case as there was no significant infection or another underlying cause was noted. This pattern of NLR elevation[7] and proteinuria with AKI,[8] in few patients were being observed in COVID-19 infection nowadays which gives a suspicion of prevalence during the study period before the announcement of the pandemic.

In India, ARF occurs mainly due to acute diarrheal disease[1] similarly in our case food poisoning might be one of the reasons leading to such an entity. The high incidence of ARF is mainly due to delay in reporting to the hospital and delayed or inadequate restoration of diarrheal losses.[9] This can be highly related to our case as the patients reported late due to their negligence and were found to have severe uremia, and renal failure was detected. About 40% of cases of AKI in India are caused by acute diarrheal disease, malaria, leptospirosis, snakebite, insect stings, intravascular hemolysis due to septicemia, chemical poisonings such as copper sulphate and vasmol, and pregnancy.[10],[11] Mehta et al., in their prospective study, related climatic influence on AKI of infectious etiology.[12] Basu et al. reported a 41.1% incidence of AKI among the tropical acute febrile illnesses.[9] These infections present mostly with fever as a cardinal sign, which was not seen in any of our patients presented in this case series. However, on a microbiological investigation, few organisms isolated were Pseudomonas and E-coli which was evident in 2 of our patients. AKI, in these infections, may be a result of direct invasion of renal parenchyma by microbial agents, tubular necrosis due to hemodynamic disturbances, renal inflammation due to immune response, or iatrogenic renal injury associated with treatment.[9] Most studies to date have highlighted the causes of AKI in tropics or individual disease with AKI due to microbial infections, which was insignificant in our cases.

Prakash et al., noted that the main etiological factor for ARF encountered was volume depletion secondary to gastrointestinal fluid loss (35.2%).[5] Similar results were found in Mahajan et al., where it was noted that the volume depletion was the most common precipitating factor for ARF[10] and in Jayakumar et al., study it was found that among the medical causes of ARF acute diarrheal disease was the most common.[6]

It calls for greater awareness about the management of AKI among primary care physicians. In the last few years, various concepts have emerged regarding the prevention and management of AKI.[13] The different components of this approach (risk assessment, recognition, response, renal support, and rehabilitation) coincide with various points of contact in the health care system.[14] Knowing when to call for help and a timely referral to the nephrologist are important.

  Conclusion Top

The optimal timing of renal support is still a matter of debate. According to the Kidney Disease: Improving Global Outcomes (KDIGO) review, delayed RRT was associated with increased mortality, longer duration of hospital stays, and dependency on RRT.[15]

A holistic approach by the physician by treating the comorbid conditions may not only halt the progression to CKD but will also improve the quality of life.[16] AKI being the most common entity in a developing country like India, awareness of such potential renal complications and their prevention and early hospitalization, being the single most cost-effective life-saving measure should be emphasized among people.[17] The mortality has been dramatically brought down due to hemodialysis therapy and appropriate medical management,[18] and this has been reflected in the above case series.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Carpenter CC. Cholera. In. Weatherall DJ, Ledingham JG, Warrell DA, editors. Oxford Text Book of Medicine.Oxford: Oxford University Press; 1983. p. 195-8.  Back to cited text no. 1
Muthusethupathi MA. Shiva Kumar S. Acute renal failure in South India, J Assoc Physicians India 1987;35:504-7.  Back to cited text no. 2
Nunan TO. Stevens EA, Eroft DN, Hilton PJ, Jones NF, Wing AJ, et al. Recovery of renal function after prolonged dialysis and transplantation. Br Med J 1983;287:248-9.  Back to cited text no. 3
Carpenter CC, Mondal A, Sack RB, Mitra PP, Dans PE, Wells SA, et al. Clinical studies in Asiatic cholera II. Development of 2:1 Saline – Lactate regimen. Comparison of this regimen with traditional methods of treatment between April and May 1963. Bull Johns Hopkins Hosp 1966;118;174-96.  Back to cited text no. 4
Prakash J, Tripathi K, Malhotra V, Kumar O, Srivastava PK. Acute renal failure in Eastern India. Nephrol Dial Transplant 1995;10:2009-12.  Back to cited text no. 5
Jayakumar M, Prabahar MR, Fernando EM, Manorajan R, Venkatraman R, Balaraman V. Epidemiologic trend changes in acute renal failure – A tertiary center experience from South India. Ren Fail 2006;28:405-10.  Back to cited text no. 6
Qin C, Zhou L, Hu Z, Zhang S, Yang S, Tao Y, et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clin Infect Dis 2020;71:762-8.  Back to cited text no. 7
Yang X, Jin Y, Li R, Zhang Z, Sun R, Chen D. Prevalence and impact of acute renal impairment on COVID-19: A systematic review and meta-analysis. Crit Care 2020;24:1-8.  Back to cited text no. 8
Basu G, Chrispal A, Boorugu H, Gopinath KG, Chandy S, Prakash JA, et al. Acute kidney injury in tropical acute febrile illness in a tertiary care centre – RIFLE criteria validation. Nephrol Dial Transplant 2011;26:524-31.  Back to cited text no. 9
Dan LL, Kasper DL, Jameson JL, Fauci AS, Hause SL, Loscalzor, et al. Harrison's Principles of Internal Medicine. 18th ed. New York: The McGraw-Hill Companies, Inc; 2012. p. 2293-308.  Back to cited text no. 10
Ahuja MM. Progress in Clinical Medicine in India. 3rd ed. New Delhi: Arnold-Heinemann Publishers; 1979. p. 312-26.  Back to cited text no. 11
Mehta RL, Pascual MT, Soroko S, Savage BR, Himmelfarb J, Ikizler TA, et al. Spectrum of acute renal failure in the Intensive Care Unit: The PICARD experience. Kidney Int 2004;66:1613-21. Kumar SS, Paramananthan R, Muthusethupathi MA. Acute renal failure due to acute diarrhoeal Diseases. JAPI 1990;38:164-6.  Back to cited text no. 12
Lewington AJ, Cerda J, Mehta RL. Raising awareness of acute kidney injury: A global perspective of a silent killer. Kidney Int 2013;84:457-67.  Back to cited text no. 13
Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney injury: A KDIGO summary (Part 1). Crit Care 2013;17:204.  Back to cited text no. 14
Harty J. Prevention and management of acute kidney injury. Ulster Med J 2014;83:149-57.  Back to cited text no. 15
Zarbock A, Kellum JA, Schmidt C, Van Aken H, Wempe C, Pavenstadt H, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: The ELAIN randomized clinical trial. JAMA 2016;315:2190-9.  Back to cited text no. 16
Godin M, Bouchard J, Mehta RL. Fluid balance in patients with acute kidney injury: Emerging concepts. Nephron Clin Pract 2013;123:238-45.  Back to cited text no. 17
Xu Y, Gao J, Zheng X, Zhong B, Na Y, Wei J. Timing of initiation of renal replacement therapy for acute kidney injury: A systematic review and meta-analysis of randomized-controlled trials. Clin Exp Nephrol 2017;21:552-62.  Back to cited text no. 18
Ortiga, B., Salazar, A., Jovell, A. et al. Standardizing admission and discharge processes to improve patient flow: A cross sectional study. BMC Health Serv Res 12, 180 (2012). https://doi.org/10.1186/1472-6963-12-180  Back to cited text no. 19


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