Acute Kidney Injury And Electrolyte Abnormalities Among Patients Admitted With Cholera In Kenyatta National Hospital In Nairobi, Kenya, In The Year 2017

Abstract

Title: Acute Kidney Injury and electrolyte abnormalities among patients admitted with Cholera in Kenyatta National Hospital (KNH) in Nairobi, Kenya in the year 2017 Background: Cholera is an acute secretory diarrheal illness caused by toxin-producing strains of the gram-negative bacterium Vibrio cholera. Cholera primarily affects resource-limited settings where there is inadequate access to clean water sources and is endemic in many countries mostly in Africa and Asia. In Kenya, cholera still remains a cause of severe diarrhea in areas with poor sanitation conditions, with trends indicating translation of cholera to an endemic disease. Severe cholera is characterized by profound fluid and electrolyte losses in the stool and vomitus, volume depletion and the rapid development of hypovolemic shock. Complications such as acute renal failure, metabolic acidosis, circulatory failure, arrhythmias and death occur if timely treatment is not initiated. Epidemiologic data on the current cholera epidemic in Kenya is largely available but no study has evaluated these complications. The aim of this study is to evaluate acute kidney injury and electrolyte abnormalities among patients admitted with cholera in KNH during the year 2017. Broad objective: To describe the frequency of acute Kidney Injury (AKI) and electrolyte abnormalities among patients admitted with cholera in KNH during the months of July to December 2017 Specific objectives: 1. To determine the proportion of patients who developed AKI among patients admitted to the cholera isolation ward in KNH in the year 2017 2. To describe abnormalities in the Blood Urea Nitrogen (BUN): creatinine ratio and electrolytes among patients admitted in cholera isolation ward in KNH in the year 2017 7

3. To describe the association between patients’ clinical and demographic characteristics and acute kidney injury 4. To describe the association between patients’ clinical and demographic characteristics and death Study design: Cross sectional study: A retrospective review of records of patients admitted in KNH with cholera in the year 2017. Study population: Patients admitted to the cholera isolation ward in KNH during the year 2017 Methodology: Data collection: Records of patients admitted to the cholera isolation ward in KNH during the study period were retrieved and evaluated for eligibility. Social demographic data, clinical and laboratory parameters were reviewed and recorded in a data collection tool. Inclusion criteria: Patients that were admitted to the cholera isolation ward in KNH with a diagnosis of either suspected or confirmed cholera during the study period, whose records of at least one urea, creatinine, sodium and potassium measurements was available. Exclusion criteria: 1. Patients who from hospital records, are known to have chronic kidney disease 2. Patients who from hospital records, are known to have a condition that is recognized as a risk factor for renal impairment: Diabetes mellitus, Hypertension, acute glomerulonephritis, infection with Human Immunodeficiency Virus (HIV) 3. Incomplete records 4. Negative Cholera diagnosis test 8

Statistical Analysis: Descriptive statistics were carried out: Frequency tables, percentages and proportions were generated for categorical variables while Mean, Standard deviation, median and interquartile ranges were generated for continuous variables. Association analysis (chi square, student t-test) was carried out to determine the association between patients’ characteristics and AKI or death. Results: Of the 127 patients enrolled into the study, 67% were males and the mean age was 36years (±12.6). The mean duration of symptoms prior to admission was 2.1± 1.2 days. AKI was present in 60.6% and majority of these patients had AKI at the time of admission (97%), 17.6% of these patients received renal replacement therapy. Among those with AKI that did not receive renal replacement therapy, 56.2% had normal creatinine levels at the time of discharge. Among those with elevated serum creatinine levels, the mean BUN: Creatinine ratio (mg/dl) was 8.9(±3.7). On association analysis, there as a significant association (p value<0.001) between AKI and duration of hospital stay, total WBC counts, serum hemoglobin levels, cholera diagnosis and serum sodium levels at admission (p value=0.032).The most frequent electrolyte abnormality was hyponatremia at 40.2 %. Other electrolyte abnormalities seen were hypokalemia (26.8%), hyperkalemia (15.0%) and Hypernatremia (10.2%). Serum bicarbonate, chloride and PH were not assessed in majority of these patients (>90%). The in-hospital case fatality rate was 5.5 %. On bivariate analysis, there was a statistically significant association (p value<0.05) between death and age, duration of symptoms prior to admission, blood pressures at admission, total WBC counts and serum urea levels at admission. Conclusions and recommendations The prevalence of AKI among patients admitted in the cholera isolation ward during the cholera outbreak in Kenya in the year 2017 was high and was present at the time of admission in the 9

majority of patients. The frequency of electrolyte abnormalities was high and the in-hospital case fatality rate was also high. We recommend inclusion of a nephrologist to guide management and follow up of patients who develop AKI and electrolyte abnormalities. We also recommend close monitoring of serum electrolytes to include serum bicarbonate, PH, chloride and other electrolytes. It is worthwhile to enhance public awareness on the importance of seeking healthcare early during cholera epidemics for volume repletion to prevent progression to AKI.