Community-acquired acute kidney injury in Asia

Megalin-related mechanism of hemolysis-induced acute kidney injury and the therapeutic strategy

Hemolysis-induced acute kidney injury (AKI) is attributed to heme-mediated proximal tubule epithelial cell (PTEC) injury and tubular cast formation due to intratubular protein condensation. Megalin is a multiligand endocytic receptor for proteins, peptides, and drugs in PTECs and mediates the uptake of free hemoglobin and the heme-scavenging protein α1-microglobulin. However, understanding of how megalin is involved in the development of hemolysis-induced AKI remains elusive. Here, we investigated the megalin-related pathogenesis of hemolysis-induced AKI and a therapeutic strategy using cilastatin, a megalin blocker. A phenylhydrazine-induced hemolysis model developed in kidney-specific mosaic megalin knockout (MegKO) mice confirmed megalin-dependent PTEC injury revealed by the co-expression of kidney injury molecule-1 (KIM-1). In the hemolysis model in kidney-specific conditional MegKO mice, the uptake of hemoglobin and α1-microglobulin as well as KIM-1 expression in PTECs was suppressed, but tubular cast formation was augmented, likely due to the nonselective inhibition of protein reabsorption in PTECs. Quartz crystal microbalance analysis revealed that cilastatin suppressed the binding of megalin with hemoglobin and α1-microglobulin. Cilastatin also inhibited the specific uptake of fluorescent hemoglobin by megalin-expressing rat yolk sac tumor-derived L2 cells. In a mouse model of hemolysis-induced AKI, repeated cilastatin administration suppressed PTEC injury by inhibiting the uptake of hemoglobin and α1-microglobulin and also prevented cast formation. Hemopexin, another heme-scavenging protein, was also found to be a novel ligand of megalin, and its binding to megalin and uptake by PTECs in the hemolysis model were suppressed by cilastatin. Mass spectrometry-based semiquantitative analysis of urinary proteins in cilastatin-treated C57BL/6J mice indicated that cilastatin suppressed the reabsorption of a limited number of megalin ligands in PTECs, including α1-microglobulin and hemopexin. Collectively, cilastatin-mediated selective megalin blockade is an effective therapeutic strategy to prevent both heme-mediated PTEC injury and cast formation in hemolysis-induced AKI. © 2024 The Pathological Society of Great Britain and Ireland.

Access to Dialysis for Acute Kidney Injury in Low-Resource Settings

Acute kidney injury (AKI) is estimated to occur in approximately 13.3 million patients per year with an estimated mortality of 1.7 million. Approximately 85% of cases occur in low-resource settings where access to kidney replacement therapy (KRT) may be limited or nonexistent. The true extent of AKI, including access to KRT in developing countries, is largely unknown because appropriate systems are not in place to detect AKI or report it. Barriers to provision of KRT in low-resource settings revolve around systems management and funding, however, there also are region-specific issues. This review focuses on the epidemiology, obstacles, and solutions to improving access to KRT for AKI.

Histopathological profile of fatal snake bite autopsy cases in a tertiary care center in South India

Background

Snake bite is a major public health problem, especially in the tropical areas of the world, which the World Health Organization aims to eradicate. According to the National Crime Records Bureau in India, where agriculture is the mainstay of employment attributes about 8660 mortalities in a year. Histopathological results are of immense help in establishing the cause of death in those snake bite cases where other circumstantial shreds of evidence are lacking.

Results

An autopsy-based prospective study was conducted on fatal cases of snake bite reported at a tertiary care center in south India over a period of 2 years. A total of 38 fatal snake bite cases were included in the study. Epidemiological data were collected and analyzed. Histopathological findings of the kidneys, heart, and endocrine glands (pituitary, adrenals, thyroid, and pancreas) were analyzed. The significant findings of the kidneys were distinct corticomedullary demarcation on the gross surface (65.8%) and congestion and acute tubular necrosis (55.3%) on histology. On the other hand, in the set of endocrine glands, adrenals and pituitary showed predominantly hemorrhagic infarction on the histological analysis (18.4% and 52.6%) respectively.

Conclusion

The results of the current study enlighten the findings such as distinct corticomedullary demarcation and acute tubular necrosis in the kidneys and hemorrhagic infarction in the endocrine glands in a case of snake bite. It highlights the need for histopathological analysis in the cases of a fatal snake bite when other circumstantial and gross features become indecisive. This can aid immensely in a medico-legal investigation of snake bite cases.

Community-Acquired AKI in Asia: An Update

Community-acquired acute kidney injury (CA-AKI) is the dominant form of AKI encountered in developing countries in Asia. Economic disparities, variations in access to health care services, geographic conditions, environmental risk factors, and sociocultural circumstances shape the causes and outcomes of CA-AKI. Infections, drugs, plant and chemical toxins, envenomations, and obstetric complications are common causes of CA-AKI. Previously healthy young individuals who often work outdoors in fields or farms are exposed to a wide variety of work-related or environmental risk factors for CA-AKI. Improving disease definitions, better data, and evolving host-pathogen interactions have changed disease descriptions and presentations over the past 20 years. Among infections, although the incidence of malaria has decreased, the number of cases with dengue and scrub typhus have increased sharply. The recognition of AKI in relation to Plasmodium knowlesi, Plasmodium vivax, scrub typhus, and leptospirosis in areas not traditionally considered at risk, association of infections with the future development of chronic kidney disease, and the role of complement dysregulation in infection-associated AKI are important new findings. Snake-bite-related toxic envenomation continues to be an important cause of AKI in some counties and is a neglected public health problem. On the other hand, significant decreases in the incidence of AKI related to acute diarrheal illness or obstetric causes are signs of hope. Coordinated efforts between administrative stakeholders, society, and health care delivery services at all levels have the potential to propel research and improve outcomes in CA-AKI.

Prevention and Therapy of AKI in Asia: A Big Challenge

Asia is the largest and most populous continent and has huge differences in socioeconomic status, development, and health care between the different countries and regions within each country. This manifests in the varied causes of acute kidney injury (AKI), particularly higher rates of community-acquired AKI and in the differential access to health care for the population. Because of resource limitations, prevention and treatment of AKI is a difficult challenge. This review highlights the differences in AKI in Asia compared with the developed world and discusses prevention and treatment of AKI within the context of resource limitations.

Epidemiology and short-term outcomes of acute kidney injury among patients in the intensive care unit in Laos: a nationwide multicenter, prospective, and observational study

BACKGROUND

Acute kidney injury (AKI) has become a global health issue. Little is known about the disease burden in Laos. We aimed to evaluate the burden and outcomes of AKI as well as assess the availability of AKI treatment in Laos.

METHODS

We performed a multicentric prospective observational study in adult patients who had been admitted to 5 intensive care units (ICU) in Laos. The data was serially collected on the first 28 days of ICU admission. Patients were diagnosed by the KDIGO 2012 criteria for AKI. We used AKI occurrence as the primary outcome and explored risk factors on the development and outcomes of AKI.

RESULTS

We enrolled 1480 patients from 5 ICU centers across Laos from January to December 2016. After excluding patients with end-stage renal disease and those with incomplete data, AKI occurred in 508 of the 1460 enrolled patients (34.8%). Overall, the rates of maximum AKI staging were 4% for stage 1, 10.3% for stage 2, and 20.5% for stage 3. Risk factors for AKI were older age, obesity, cardiovascular diseases, respiratory diseases, renal diseases, oncologic diseases, and chronic kidney diseases. Only 1.8% of all participants received RRT. The mortality rate was 28.4% in non-AKI patients compared to 44.5% in AKI patients, which increased according to the stage of AKI (stage 1, 4.9%; stage 2, 28.3%; stage 3 66.8%; P < 0.001). There were 13.6% who were discharged against medical advice.

CONCLUSIONS

AKI is a huge burden in Laos with under-recognition and poor outcomes.

Clinical spectrum of community-acquired acute kidney injury: A prospective study from central India

The aim is to study the epidemiology of acute kidney injury (AKI), since it differs from country to country and varies from center to center within a country. Owing to the absence of a central registry, data on overall epidemiology of AKI are scanty from India. This study was conducted in an urban tertiary care center in central India with the aim to identify the etiology and outcomes as well as the factors associated with in-hospital mortality of community-acquired AKI (CAAKI) patients. A two-year prospective study of all patients with CAAKI admitted to the Nephrology Department from January 2014 to December 2015 was performed. Of the 9800 admitted patients, 286 patients (2.9%), with a mean age of 48 ± 17.1 years, were diagnosed to have CAAKI as per our specified criteria. The most common cause of CAAKI was medical (77.27%), followed by obstetrical (13.98%) and surgical (9%) causes. Among the medical causes, hypoperfusion (57.4%) was the most common, followed by sepsis (26.69%), glomerulonephritis (8.14%), and drugs (7%). Nephrolithiasis was the most common surgical cause. Puerperal sepsis (52.5%), preeclampsia (20%), hemorrhage (17.5%), and thrombotic microangiopathy (10%) were the obstetric causes of CAAKI. The overall in-hospital mortality among patients with CAAKI was 20% and 8% of patients became dialysis dependent. Sepsis had the highest in-hospital mortality (44%). The epidemiological characteristics of CAAKI are changing rapidly. There has been an increase in the overall incidence of AKI with changing etiology in recent years. In contrast to developed nations, CAAKI is more common in developing countries. It often affects younger individuals. For early diagnosis of kidney injury and reducing the risk of poor outcome, patients should be referred to nephrologists early in the course of disease.

Scrub typhus-associated acute kidney injury: A study from a South Indian Tertiary Care Hospital

Infections including scrub typhus contribute to a significant proportion of community-acquired acute kidney injury (AKI) in the tropics. Scrub typhus infection now requires global attention since disease outbreaks are being reported across continents. We intended to study the clinical profile, renal involvement, and parameters predicting renal involvement in scrub typhus infection. This is a retrospective study. The medical records of all patients who were admitted and treated for scrub typhus infection for a study period of two years (from September 2015 to August 2017) were analyzed, and salient clinical features and laboratory results were collected from the hospital data. Statistical analysis was done from the collected data. Our study had 272 patients including 81 children. Adults constituted 70.96% (n = 193) and the remaining 29.04% (n = 81) were pediatric population. Among adults, females constituted 62.7% (n = 121) and males 37.3% (n = 72). The mean age of the adult population was 45.7 ± 15 years and that of pediatric patients was 8.56 ±5.1 years. 18.7% of adult cases and 3.70% of pediatric cases had AKI. Renal replacement therapy was required in 3.67% of adult cases. Mortality was 4.14% in adults and 1.23% in children. Hypotension, pulmonary involvement, central nervous system involvement, multiorgan dysfunction syndrome, increased total counts, elevated aspartate transaminase levels, and hypoalbuminemia predicted AKI in our adult population. Scrub typhus should be considered as a differential in cases presenting with fever and AKI. Outcomes of scrub typhus infection in terms of mortality seem to be improving in this region.

Epidemiology and outcome of acute kidney injury due to venomous animals from a subtropical region of India

AIM

To study the epidemiology and outcome of acute kidney injury (AKI) caused by venomous animals.

METHODS

A retrospective study of patients admitted at Indira Gandhi Medical College Hospital, Shimla, with AKI due to venomous animals over a period of 15 years (January 2003-December 2017). Medical records were evaluated for patient information on demographic factors, clinical characteristics, complications, and outcome. Outcomes of requirement for intensive care unit (ICU) support, treatment with dialysis, survival, and mortality were analyzed. The survival and non-survival groups were compared to see the difference in the demographic factors, laboratory results, clinical characteristics, and complications.

RESULTS

One hundred and eighty-one patients were diagnosed with AKI caused by venomous creatures. Mean age was 44 ± 15.4 years, and the majority (54.1%) was women. Snakebite (77.9%) and wasp stings (19.9%) were the leading causes of AKI. Clinical details were available in 148 patients. The median duration of arrival at hospital was two days. 81.8% had oliguria, and 54.7% had a history of hematuria or having passed red or brown colored urine. The hematological and biochemical laboratory abnormalities were as follows: anemia (75%), leukocytosis (75.7%), hyperkalemia (35.8%), severe metabolic acidosis (46.6%), hepatic dysfunction (54.7%), hemolysis (85.8%), and rhabdomyolysis (65.5%). Main complications were as follows: gastrointestinal bleed (9.5%), seizure/encephalopathy (10.8%), and pneumonia/acute respiratory distress syndrome (ARDS) (11.5%). 82.3% of the patients required dialysis. 154 (85.1%) patient survived, and 27 (14.9%) patients died. As compared to the survival group, the white blood cell count, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, creatine kinase, and lactate dehydrogenase were significantly higher, and serum albumin levels were significantly lower in patients who died. The proportion of patients with leukocytosis, hyperkalemia, metabolic acidosis, pneumonia/ARDS, seizure/encephalopathy, need for ICU support, and dialysis was significantly higher in patients who died.

CONCLUSIONS

Snakebite and multiple Hymenoptera stings (bees and wasps) were the leading causes of AKI due to venomous animals. AKI was severe, a high proportion required dialysis, and the mortality was high.

Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases

Pregnancy-related acute kidney injury (pAKI), preeclampsia (PE), and the hypertensive disorders of pregnancy are closely related conditions, which are, in turn, frequently linked to pre-existing and often non-diagnosed chronic kidney disease (CKD). The current literature and research mainly underline the effects of pregnancy complications on the offspring; this review strongly emphasizes the maternal health as well. These conditions not only negatively affect pregnancy outcomes, but have a relevant effect on the future health of affected mothers and their children. Therefore, dedicated diagnostic and follow-up programs are needed, for optimizing materno-foetal health and reducing the impact of pregnancy-related problems in the mothers and in the new generations. This narrative review, performed on the occasion of the 2018 World Kidney Day dedicated to women’s health, focuses on three aspects of the problem. Firstly, the risk of AKI in the hypertensive disorders of pregnancy (the risk is the highest in developing countries; however PE is the main cause of pregnancy related AKI worldwide). Secondly, the effect of AKI and the hypertensive disorders of pregnancy on the development of CKD in the mother and offspring: long-term risks are increased; the entity and the trajectories are still unknown. Thirdly, the role of CKD in the pathogenesis of AKI and the hypertensive disorders of pregnancy: CKD is a major risk factor and the most important element in the differential diagnosis; pregnancy is a precious occasion for early diagnosis of CKD. Higher awareness on the importance of AKI in pregnancy is needed to improve short and long term outcomes in mothers and children.

Infections and the kidney: a tale from the tropics

Tropical infections are caused by a variety of bacteria, viruses and parasitic organisms across varying geographical regions and are more often reported in adults than in children. Most of the infections are acute, presenting as a febrile illness with involvement of multiple organ systems, including the kidney. The gamut of renal manifestations extends from asymptomatic urinary abnormalities to acute kidney injury and-albeit rarely-chronic kidney disease. Tropical infections can involve the glomerular, tubulointerstitial and vascular compartments of the kidney. Leptospirosis, malaria, dengue, rickettsial fever and schistosomiasis are the most prevalent tropical infections which affect the kidneys of children living in the tropics. In this review we discuss renal involvement in these most prevalent tropical infections.

Cross-sectional survey on adult acute kidney injury in Chinese ICU: the study protocol (CARE-AKI)

INTRODUCTION

Acute kidney injury (AKI) is one of the most serious syndromes in intensive care unit (ICU) patients, and is a mysterious problem in clinical practice worldwide. Due to unknown aetiology and mechanism, awareness of AKI diagnosis and treatment in China varies, resulting in underestimated incidence and poor prognosis. To solve this problem, we design this national survey of AKI in adult ICUs. Various indexes are included and analysed to classify the epidemiology of adult AKI in Chinese ICUs, including AKI aetiology, risk factors, mortality, prognosis, therapeutic strategies and cognition of ICU medical staff.

METHODS

A multicentre, cross-sectional survey, which will involve about 35 hospitals and 6147 patients from 23 provinces, 4 municipalities and 5 autonomous regions, is planned. All patients who meet the inclusion criteria are eligible to apply for enrolment in the study, which cover baseline demographics, clinical performance, and follow-up related to diagnosis and treatment.

CONCLUSION

The study is expected to fill the gap between China and developed countries, and to provide a theoretical foundation for developing more scientific and standardised approaches to AKI diagnosis and treatment.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the ethics committee of Harbin Medical University Cancer Hospital (registration number KY2017-21). The findings of this review will be communicated through peer-reviewed publications and scientific presentations.

TRIAL REGISTRATION NUMBER

ChiCTR-EOC-17013133; Pre-results.

Acute Kidney Injury of Infectious Etiology in Monsoon Season: A Prospective Study Using Acute Kidney Injury Network Criteria

The epidemiological pattern of acute kidney injury (AKI) in tropical countries during monsoon reflects infectious disease as the most important cause. AKI is a confounding factor and may be overlooked by primary health-care providers and underreported in health statistics. The present study prospectively helps estimate the burden of disease and analyze etiology, clinical profile, and outcome in a tertiary care hospital of a metropolitan city in a tropical country. The study period included monsoon season of 2012 and 2013, a total of 8 months. AKI staging was done as per the AKI Network (AKIN) criteria. Patients were treated for primary disease. Renal replacement therapy (RRT) was given as required. Patients were followed up during hospitalization till recovery/death. Out of a total of 9930 admissions during this period, 1740 (17.52%) were for infections and 230 (2.31%) had AKI secondary to infectious diseases during monsoon. The incidence of AKI (230/1740) in infectious diseases during monsoon was 13.21%. The study population (n = 230) comprised 79.5% of males and the mean age was 40.95 ± 16.55 years. Severe AKI: AKIN Stage III was seen in 48.26% of patients and AKIN Stage I in 41.74%. The most common etiology of AKI was malaria (28.3%) followed by acute gastroenteritis (23%), dengue (16.5%), leptospirosis (13%), undifferentiated fever (10.4%), more than one etiology (5.4%), and enteric fever (3.5%). RRT was required in 44.78% of patients. Requirement for RRT was maximum in patients with more than one etiology followed by leptospirosis, malaria, dengue, and least in typhoid. The overall mortality was 12.17%. In multivariate analysis, vasopressor support and assisted ventilation were risk factors for mortality.

Clinical and laboratory parameters associated with acute kidney injury in patients with snakebite envenomation: a prospective observational study from Myanmar

Background

Snakebite-related acute kidney injury (AKI) is a common community-acquired AKI in tropical countries leading to death and disability. The aims of this study were to (1) determine the occurrence of snakebite-related AKI, (2) assess factors at presentation that are associated with snakebite-related AKI, and (3) determine the outcomes of patients with snakebite-related AKI.

Methods

We conducted a prospective observational study of patients with snake envenomation at the three academic tertiary care hospitals in Yangon, Myanmar between March 2015 and June 2016. Patient data including baseline characteristics, clinical and laboratory findings, hospital management, and outcomes were recorded in a case report form. A stepwise multivariate logistic regression analysis using a backward selection method determined independent factors significantly associated with AKI.

Results

AKI was observed in 140 patients (54.3%), the majority of whom were AKI stage III (110 patients, 78.6%). AKI occurred at presentation and developed during hospitalization in 88 (62.9%) and 52 patients (37.1%), respectively. Twenty-seven patients died (19.3%), and 69 patients (49.3%) required dialysis. On multivariate logistic regression analysis, (1) snakebites from the Viperidae family (odds ratio [OR]: 9.65, 95% confidence interval [CI]: 2.42–38.44; p = 0.001), (2) WBC >10 × 10³ cells/μL (OR: 3.55, 95% CI: 1.35–9.34; p = 0.010), (3) overt disseminated intravascular coagulation (OR: 2.23, 95% CI: 1.02–4.89; p = 0.045), (4) serum creatine kinase >500 IU/L (OR: 4.06, 95% CI: 1.71–9.63; p = 0.001), (5) serum sodium <135 mmol/L (OR: 4.37, 95% CI: 2.04–9.38; p < 0.001), (6) presence of microscopic hematuria (OR: 3.60, 95% CI: 1.45–8.91; p = 0.006), and (7) duration from snakebite to receiving antivenom ≥2 h (OR: 3.73, 95% CI: 1.48–9.37; p = 0.005) were independently associated with AKI. Patients bitten by Viperidae with normal renal function who had serum sodium <135 mmol/L had a significantly higher urine sodium-to-creatinine ratio than those with serum sodium ≥135 mmol/L (p < 0.001).

Conclusions

Identifying factors associated with snakebite-related AKI might help clinicians to be aware of snakebite patients who are at risk of AKI, particularly patients who demonstrate renal tubular dysfunction after Viperidae bites.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0510-0) contains supplementary material, which is available to authorized users.

Community-Acquired Acute Kidney Injury: A Nationwide Survey in China

BACKGROUND

This study aimed to describe the burden of community-acquired acute kidney injury (AKI) in China based on a nationwide survey about AKI.

STUDY DESIGN

Cross-sectional and retrospective study.

SETTING & PARTICIPANTS

A national sample of 2,223,230 hospitalized adult patients from 44 academic/local hospitals in Mainland China was used. AKI was defined according to the 2012 KDIGO AKI creatinine criteria or an increase or decrease in serum creatinine level of 50% during the hospital stay. Community-acquired AKI was identified when a patient had AKI that could be defined at hospital admission.

PREDICTORS

The rate, cause, recognition, and treatment of community-acquired AKI were stratified according to hospital type, latitude, and economic development of the regions in which the patients were admitted.

OUTCOMES

All-cause in-hospital mortality and recovery of kidney function at hospital discharge.

RESULTS

4,136 patients with community-acquired AKI were identified during the 2 single-month snapshots (January 2013 and July 2013). Of these, 2,020 (48.8%) had cases related to decreased kidney perfusion; 1,111 (26.9%), to intrinsic kidney disease; and 499 (12.1%), to urinary tract obstruction. In the north versus the south, more patients were exposed to nephrotoxins or had urinary tract obstructions. 536 (13.0%) patients with community-acquired AKI had indications for renal replacement therapy (RRT), but only 347 (64.7%) of them received RRT. Rates of timely diagnosis and appropriate use of RRT were higher in regions with higher per capita gross domestic product. All-cause in-hospital mortality was 7.3% (295 of 4,068). Delayed AKI recognition and being located in northern China were independent risk factors for in-hospital mortality, and referral to nephrology providers was an independent protective factor.

LIMITATIONS

Possible misclassification of AKI and community-acquired AKI due to nonstandard definitions and missing data for serum creatinine.

CONCLUSIONS

The features of community-acquired AKI varied substantially in different regions of China and were closely linked to the environment, economy, and medical resources.

Acute kidney injury due to tropical infectious diseases and animal venoms: a tale of 2 continents

South and Southeast Asia and Latin American together comprise 46 countries and are home to approximately 40% of the world population. The sociopolitical and economic heterogeneity, tropical climate, and malady transitions characteristic of the region strongly influence disease behavior and health care delivery. Acute kidney injury epidemiology mirrors these inequalities. In addition to hospital-acquired acute kidney injury in tertiary care centers, these countries face a large preventable burden of community-acquired acute kidney injury secondary to tropical infectious diseases or animal venoms, affecting previously healthy young individuals. This article reviews the epidemiology, clinical picture, prevention, risk factors, and pathophysiology of acute kidney injury associated with tropical diseases (malaria, dengue, leptospirosis, scrub typhus, and yellow fever) and animal venom (snakes, bees, caterpillars, spiders, and scorpions) in tropical regions of Asia and Latin America, and discusses the potential future challenges due to emerging issues.

Acute Kidney Injury in Asia

BACKGROUND

Acute kidney injury (AKI) is a common disorder and is associated with a high morbidity and mortality worldwide. The diversity of the climate and of the socioeconomic and developmental status in Asia has a great influence on the etiology and presentation of AKI in different regions. In view of the International Society of Nephrology's 0by25 initiative, more and more attention has been paid to AKI in Asian countries.

SUMMARY

In this review, we summarize the recent achievements with regard to the prevalence and clinical patterns of AKI in Asian countries. Epidemiological studies have revealed the huge medical and economic burden of AKI in Eastern Asian countries, whereas the true epidemiological picture of AKI in the tropical areas is still not well understood. In high-income Asian regions, the presentation of AKI resembles that in other developed countries in Europe and North America. In low-income regions and tropical areas, infections, environmental toxins, and obstetric complications remain the major culprits in most cases of AKI. Preventive opportunities are missed because of failure to recognize the risk factors and early signs of AKI. Patients often present late for treatment or are recognized late by physicians, which leads to more severe kidney injury, multiorgan involvement, and increased mortality. There is significant undertreatment of AKI in many regions, and medical resources for renal replacement therapy are not universally available.

KEY MESSAGES

More efforts should be made to increase public awareness, establish preventive approaches in communities, educate health-care practitioner entities to achieve better recognition, and form specialist renal teams to improve the treatment of AKI. The choice of renal replacement therapy should fit patients' needs, and peritoneal dialysis can be practiced more frequently in the treatment of AKI patients.

FACTS FROM EAST AND WEST

(1) More than 90% of the patients recruited in AKI studies using KDIGO-equivalent criteria originate from North America, Europe, or Oceania, although these regions represent less than a fifth of the global population. However, the pooled incidence of AKI in hospitalized patients reaches 20% globally with moderate variance between regions. (2) The lower incidence rates observed in Asian countries (except Japan) may be due to a poorer recognition rate, for instance because of less systematically performed serum creatinine tests. (3) AKI patients in South and Southeastern Asia are younger than in East Asia and Western countries and present with fewer comorbidities. (4) Asian countries (and to a certain extent Latin America) face specific challenges that lead to AKI: nephrotoxicity of traditional herbal and less strictly regulated nonprescription medicines, environmental toxins (snake, bee, and wasp venoms), and tropical infectious diseases (malaria and leptospirosis). A higher incidence and less efficient management of natural disasters (particularly earthquakes) are also causes of AKI that Western countries are less likely to encounter. (5) The incidence of obstetric AKI decreased globally together with an improvement in socioeconomic levels particularly in China and India in the last decades. However, antenatal care and abortion management must be improved to reduce AKI in women, particularly in rural areas. (6) Earlier nephrology referral and better access to peritoneal dialysis should improve the outcome of AKI patients.

Snakebite mediated acute kidney injury, prognostic predictors, oxidative and carbonyl stress: A prospective study

Snake bite is an occupational hazard in India and important preventable cause of acute kidney injury (AKI). This study was done to estimate the magnitude of snakebite-induced AKI (SAKI) who required renal replacement therapy, prognostic predictors, and final outcome, and to measure the oxidative and carbonyl stress (CS) level in SAKI patient who underwent hemodialysis (HD). All SAKI patients dialyzed between April 2010 and July 2011 in NRS Medical College were included. Demographical, clinical, and biochemical data were analyzed, and patients are followed to discharge or death. Oxidative and CS markers (advanced oxidation protein product [AOPP], advanced glycation end product, pentosidine, dityrosine, thioberbituric acid reactive substance, and methylglyoxal [MG]) were measured in 48 SAKI patient requiring HD. About 155 SAKI patients (M: F 2.2:1) received HD. Of them. The age was 36.2 (range 4–74) years. The most common site of the bite was lower limb (88.7%). Oliguria and bleeding manifestation were the common presentation. Hypotension was found in 52 (33.5%) cases, cellulitis and inflammation were found in about 63%. Mean creatinine was 4.56 ± 0.24 mg/dl. About 42 (27.1%) had disseminated intravascular coagulation (DIC). 36 (78.2%) had cellulites, 24 (52.2%) had hypotension or shock at initial presentation (P < 0.05), bleeding manifestation was found in 37 (80.4%), and 22 (47.8%) had DIC (P < 0.05). Forty-six (29.7%) patient died. DIC and hypotension/shock at initial presentation came out as an independent predictor of death. Among all markers measured for oxidative and CS (n = 48) AOPP and MG came out as an independent predictor (P < 0.05) of adverse outcome. Hypotension, DIC, AOPP, and MG were a poor prognostic marker in SAKI patients requiring dialysis.

Scorpion sting nephropathy

Scorpion envenomations are ubiquitous, but nephropathy is a rare manifestation, reported mainly from the Middle East and North Africa. Rapid venom redistribution from blood, delayed excretion from the kidneys, direct toxicity of venom enzymes, cytokine release and afferent arteriolar constriction have been seen in experimental animals. Haemoglobinuria, acute tubular necrosis, interstitial nephritis and haemolytic–uraemic syndrome have been documented in human victims of scorpion envenomation. Epidemiology, venom components and toxins, effects on the laboratory mammals especially the kidneys and reports of renal failure in humans are reviewed in this article.

Eliminating treatable deaths due to acute kidney injury in resource-poor settings

Acute kidney injury (AKI) is imposing a severe burden of morbidity and mortality both in developed and developing countries. Also AKI has a major economic impact on healthcare expenditure. This is particularly so in poor countries where AKI especially impacts young productive people, imposing severe penury upon their families. The mission is to lessen the high burden in terms of death consequent to this disorder in low-resource regions, which in many cases is preventable and treatable with simple measures. The International Society of Nephrology has launched a long-term program, called "0 by 25", which advocates that zero people should die of untreated AKI in the poorest part of Africa, Asia, and Latin America by 2025. This paper illustrates how the project will be developed.

Predictors of mortality in leptospirosis: an observational study from two hospitals in Kolkata, eastern India

BACKGROUND

Leptospirosis has a mortality rate of 5-20%. Poor prognostic factors are older age; oliguria; elevated potassium, creatinine and/or bilirubin levels; and altered mental status. We conducted this retrospective study to analyse the predictors of mortality among Indian patients with leptospirosis.

METHODS

Clinical, biochemical, demographic and treatment related data (time between onset of symptoms and commencement of leptospira specific antibiotics) of 101 leptospirosis patients were reviewed. Predictors identified by univariate analysis were analysed by multivariable Cox regression for survival analysis.

RESULTS

Prominent clinical features were: fever (101/101, 100%), jaundice (62, 62.4%), vomiting (42, 41.6%), oliguria (35, 34.7%), cough (18, 17.8%) and dyspnoea (10, 10.0%). Common complications were acute kidney injury (22, 21.8%), cardiovascular collapse (13, 12.9%), haemorrhages (10, 10.0%), meningitis (7, 6.9%), acute respiratory distress syndrome and pancreatitis (5, 5.0% each). Seventeen patients died (16.8%). Univariate predictors of mortality were older age, delayed antibiotic therapy, higher bilirubin, aspartate aminotransferase, alkaline phosphatase, leucocyte count and aspartate/alanine aminotransferase ratio (AAR). Only AAR (HR 1.208, 95% CI 1.051-1.388) and number of days the patient was symptomatic before access to specific antibiotic therapy (HR 1.304, 95% CI 1.081-1.574) remained significant predictors after Cox regression.

CONCLUSIONS

Multivariate analysis showed high AAR and delayed antibiotic therapy might be associated with fatality.

Role of neutrophil gelatinase-associated lipocalin for early detection of acute kidney injury

Acute kidney injury (AKI) is characterized by abrupt or rapid decline of renal function and is usually associated with the development of serious complications as well as an independent risk of mortality in hospitalized patients. Emergency physicians play a critical role in recognizing early AKI, preventing iatrogenic injury, and reversing the course of AKI. Among the various available biomarkers for AKI, reliable and automated assay methods are commercially available for only cystatin-C and neutrophil gelatinase-associated lipocalin (NGAL). NGAL appears to be a promising marker for early detection of AKI and is likely to be adapted for wide-scale clinical use in patient management as a point-of-care test. Use of NGAL along with panel of other renal biomarkers can improve the rate of early detection of AKI. Large, multicenter studies demonstrate the association between biomarkers and hard end points such as need for renal replacement therapy (RRT), cardiovascular events, hospital stay, and death, independent of serum creatinine concentrations.

The report of sustained low-efficiency dialysis (SLED) treatment in fifteen patients of severe snakebite

To investigate the therapeutic efficacy of sustained low-efficiency dialysis (SLED) in severe snakebite patients. Fifteen patients of severe snakebite was treated with SLED from July 2005 to August 2009 were included in the study. Central venous access was established in all patients. SLED was administered using Dialog(+) dialyzer (B. Braun, Germany). SLED sessions were 6-12 h in duration at a blood flow rate of 200 ml/min and a dialysate flow rate of 300 ml/min. Heparin or low molecular weight heparin was used as anticoagulant. Biochemical indicators, APACHE II scores before and after SLED, and clinical outcomes were evaluated. The levels of serum creatinine, glutamic-oxaloacetic transaminase, glutamic-pyruvic transaminase, creatine kinase isozyme MB, and creatine kinase were significantly lower than the level before SLED (P < 0.05); the level of cholinesterase was significantly higher after SLED (P < 0.01); the APACHE II score before SLED was 14.1 ± 3.8, but decreased significantly to 7.9 ± 1.4, 6.2 ± 1.1, and 4.2 ± 0.8 on days 1, 2, and 7 after SLED, respectively (P < 0.01). Three patients died on days 1, 3, and 4 after SLED, respectively. The remaining twelve patients were either cured or showed improvement at the time of discharge. The survival rate was 80 % where as mortality was 20 %. SLED may be an effective treatment option in severe snakebite patients. It can reduce mortality, thereby, resulting in increased survival rates.

Community-acquired acute kidney injury in tropical countries

Community-acquired acute kidney injury (AKI) in developing tropical countries is markedly different from AKI in developed countries with a temperate climate, which exemplifies the influence that environment can have on the epidemiology of human diseases. The aetiology and presentation of AKI reflect the ethnicity, socioeconomic factors, climatic and ecological characteristics in tropical countries. Tropical zones are characterized by high year-round temperatures and the absence of frost, which supports the propagation of infections that can cause AKI, including malaria, leptospirosis, HIV and diarrhoeal diseases. Other major causes of AKI in tropical countries are envenomation; ingestion of toxic herbs or chemicals; poisoning; and obstetric complications. These factors are associated with low levels of income, poor access to treatment, and social or cultural practices (such as the use of traditional herbal medicines and treatments) that contribute to poor outcomes of patients with AKI. Most causes of AKI in developing tropical countries are preventable, but strategies to improve the outcomes and reduce the burden of tropical AKI require both improvements in basic public health, achieved through effective interventions, and increased access to effective medical care (especially for patients with established AKI).

Postrenal transplant Plasmodium vivax malaria: neglected and not benign

Plasmodium vivax is causing increasingly more cases of severe malaria worldwide. We reported a case of postrenal transplantation acute kidney injury (AKI) associated with P. vivax, a neglected human malaria parasite. The diagnosis of P. vivax monoinfection was confirmed by direct visualization of the parasite in blood smear and rapid diagnostic test. On admission, serum creatinine (SCr.) increased from 1.45 to 3.7 mg/dl. The other etiologies of fever and AKI were ruled out. He responded to prompt therapy with antimalarial drugs. There was no change in tacrolimus trough level before and after antimalarial drugs. Two weeks after discharge, his SCr. was 1.43 mg/dl. Our patient lived in an endemic malarial area and the transplant took place in December 2010. The patient subsequently presented with clinical malaria in June 2012, so we thought that posttransplantation transmission by the mosquito was a possibility and very less likely that other dormant form of the parasite had been the source of the clinical infection. P. vivax can lead to as AKI in renal transplant recipient. P. vivax should be considered in the differential diagnosis of fever in transplant recipients who had received organs or blood products from malaria-endemic area to facilitate a prompt diagnosis and adequate treatment.

Acute kidney injury due to acute cortical necrosis following a single wasp sting

Acute kidney injury (AKI) can develop after multiple wasp or bee stings. The etiology is the acute tubular necrosis secondary to shock, pigment toxicity, interstitial nephritis, or direct nephrotoxicity of venom. We report a 40-year-old female who presented with oliguric AKI after a single wasp sting on her hand. Her history, examination, and investigations did not support any of the established causes of AKI in such settings. She did not improve with supportive management and dialysis, and kidney biopsy showed acute cortical necrosis (ACN). This is the first report of ACN after a single wasp sting.

Pathogenesis of malaria in tissues and blood

The clinical manifestations of severe malaria are several and occur in different anatomical sites. Both parasite- and host-related factors contribute to the pathogenicity of the severe forms of the disease. Cytoadherence of infected red blood cells to the vascular endothelium of different organs and rosetting are unique features of malaria parasites which are likely to contribute to the vascular damage and the consequent excessive inflammatory/immune response of the host. In addition to cerebral malaria or severe anaemia, which are quite common manifestation of severe malaria, clinical evidences of thrombocytopenia, acute respiratory distress syndrome (ARDS), liver and kidney disease, are reported. In primigravidae from endemic areas, life threatening placental malaria may also be present.

In the following pages, some of the pathogenetic aspects will be briefly reviewed and then data on selected and less frequent manifestation of severe malaria, such as liver or renal failure or ARDS will be discussed.

Outcome and prognostic factors of malaria-associated acute kidney injury requiring hemodialysis: A single center experience

Acute kidney injury (AKI) is one of the most dreaded complications of severe malaria. We carried out prospective study in 2010, to describe clinical characteristics, laboratory parameters, prognostic factors, and outcome in 59 (44 males, 15 females) smear-positive malaria patients with AKI. The severity of illness was assessed using Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA) score, Multiple Organ Dysfunction Score (MODS), and Glasgow Coma Scale (GCS) scores. All patients received artesunate and hemodialysis (HD). Mean age of patients was 33.63 ± 14 years. Plasmodium falciparum malaria was seen in 76.3% (n = 45), Plasmodium vivax in 16.9% (n = 10), and mixed infection in 6.8% (n = 4) patients. Presenting clinical features were fever (100%), nausea-vomiting (85%), oliguria (61%), abdominal pain/tenderness (50.8%), and jaundice (74.5%). Mean APACHE II, SOFA, MODS, and GCS scores were 18.1 ± 3, 10.16 ± 3.09, 9.71 ± 2.69, and 14.15 ± 1.67, respectively, all were higher among patients who died than among those who survived. APACHE II ≥20, SOFA and MODS scores ≥12 were associated with higher mortality (P < 0.05). 34% patients received blood component transfusion and exchange transfusion was done in 15%. Mean number of HD sessions required was 4.59 ± 3.03. Renal biopsies were performed in five patients (three with patchy cortical necrosis and two with acute tubular necrosis). 81.3% of patients had complete renal recovery and 11.8% succumbed to malaria. Prompt diagnosis, timely HD, and supportive therapy were associated with improved survival and recovery of kidney functions in malarial with AKI. Mortality was associated with higher APACHE II, SOFA, MODS, GCS scores, requirement of inotrope, and ventilator support.

Collapsing glomerulopathy and hemolytic uremic syndrome associated with falciparum malaria: completely reversible acute kidney injury

Acute kidney injury (AKI) is one of the most dreaded complications of severe malaria. Herein, we report a case of spontaneous resolution of AKI due to collapsing glomerulopathy (CG) and hemolytic-uremic syndrome (HUS) associated with P. falciparum malaria. Our case report highlights the fact that early intervention on the triggering cause of CG without a long course of steroids may obtain a remission of this severe subset of CG and may obtain a remission of HUS without therapeutic plasmapheresis The etiologic treatment of CG and HUS may avoid progression to end-stage renal disease.