Incidence Epidemiology Acute Kidney Injury Tertiary Care Centre

SSR Inst. Int. J. Life Sci. ISSN (O): 2581-8740 | ISSN (P): 2581-8732 Kumar et al., 2019 DOI:10.21276/SSR-IIJLS.2019.5.6.3 Research Article Incidence and Epidemiology of Acute Kidney Injury in Tertiary Care Centre in Gwalior Chambal Region Krishan Kumar1, Neelima Singh2*, Sushma Trikha3, Nitin Kr. Srivastava4, Archana Kansal3, Sutakshee Sonowani5 1 Junior Resident III, Department of Medicine, G. R. Medical College, Gwalior, India Associate Professor, Department of Medicine, G. R. Medical College, Gwalior, India 3 Professor, Department of Medicine, G. R. Medical College, Gwalior, India 4 Junior Resident III, Department of Medicine, Lalit Narayan Mishra Railway Hospital, Gorakhpur, India 5 Senior Resident, Department of Medicine, G. R. Medical College, Gwalior, India 2 *Address for Correspondence: Dr. Neelima Singh, Associate Professor, Department of Medicine, G. R. Medical College, Gwalior, Madya Pradesh-474002, India E-mail: [email protected] Received: 25 Aug 2019/ Revised: 28 Oct 2019/ Accepted: 04 Nov 2019 ABSTRACT Background: Acute kidney injury (AKI) is a commonly encountered syndrome associated with various aetiologies and pathophysiological processes leading to decreased kidney function. This study was designed to assess the incidence and epidemiology of AKI of patients in a tertiary care centre in the Intensive Care Unit (ICU) of Gwalior, Madhya Pradesh, India. Methods: This was a prospective study of AKI patients, admitted in the Intensive Care Unit (ICU) of the Department of Medicine from September 2017 to February 2018. In total 100 AKI patients, which included 54 males and 46 females, male (44.20±8.54) and females (47.56±10.20) were collected and then subjected to the classification and arrangements data on the basis of general characteristics of patients; nature of disease and etiology of AKI amongst patients reported. Statistical data were collected using a self-administered questionnaire. Results: Total of 100 AKI patients with the mean age of male (44.20±8.54) and female (47.56±10.2) found. Cases of AKI causes were characteristics of AKI patients most prominent of co-mortality diabetic (18%) then hypertension (12%). Etiology of cases among the pneumonia was (13%), pylonephritis/ urosepsis (11%), acute gastrointestinal tract pathology (8%), meningitis (5%), bacterial gastroenteritis (5%), soft tissue injury (4%), and septic arthritis (3%) found. Female was risked to AKI majorly due to acute gastrointestinal tract pathology (8%). Hair dye (4%) was the first major poisonous cause of occurrence of AKI, followed by Organophosphorous (1%), celphos (3%), Datura (1%), and rat killer (1%). Conclusion: AKI was an increasing concern and potentially catastrophic complication in hospitalized patients and frequently observed in our study due to sepsis post-trauma and heart failure as well as it carries a poor prognosis. Key-words: Acute kidney injury, AKI, Acute kidney failure, Chronic disease, Cardiac failure, Hemorrhage INTRODUCTION Acute kidney injury (AKI) is a syndrome (or more accurately a group of syndromes) [1] defined by an abrupt decrease in glomerular filtration. AKI is a common condition in all countries of the world, regardless of economic status. How to cite this article Kumar K, Singh N, Trikha S, Srivastava NK, Kansal A, Sonowani S. Incidence and Epidemiology of Acute Kidney Injury in Tertiary Care Centre in Gwalior Chambal Region. SSR Inst. Int. J. Life Sci., 2019; 5(6): 2428-2435. Access this article online https://iijls.com/ The syndrome is associated with considerable morbidity, mortality and high costs. As an episode of AKI can lead to the development of chronic kidney disease (CKD) or endstage renal disease (ESRD), and the incidence of AKI is increasing, the impact of AKI on long-term health and cost is far greater than formerly acknowledged [2,3]. Annual prevalence of patients with AKI in need of one of the replacement methods has been reported to be about 200 to 300 cases in 1 million populations [4,5]. The causes of AKI are different based on various geographical regions and there is a significant difference in its prevalence between developing and developed countries [6] . Most affected population was 60–79 year old men and common co-morbidities in this group of patients Copyright © 2015 - 2019| SSR-IIJLS by Society for Scientific Research under a CC BY-NC 4.0 International License Volume 05 | Issue 06 | Page 2428 SSR Inst. Int. J. Life Sci. ISSN (O): 2581-8740 | ISSN (P): 2581-8732 Kumar et al., 2019 DOI:10.21276/SSR-IIJLS.2019.5.6.3 include surgery, diabetes, pneumonia, cardiac failure, stroke, and history of CKD [7]. Definitions and diagnosis of AKI- Loss of kidney function is classically defined by increases in serum creatinine level; however, in community settings and circumstances in which a patient’s volume status is closely monitored for example, in ICU-oliguria or anuria might be the only recognizable sign of AKI [8]. Accordingly, in the Improving Global Outcomes (KDIGO) guideline, AKI stages are classified into three stages on the basis of either the increase in serum creatinine level or the duration and extent of oliguria [9-11]. Epidemiology and risk factors of AKI patients- The widespread adoption of standardized criteria to define the presence of AKI have facilitated comparisons of the epidemiology and outcomes of AKI across hospital settings [12]. However, this standardization should not imply that AKI is a single entity. Rather, AKI is a syndrome that encompasses a multitude of clinical scenarios, underlying etiologies, co-morbidities, drug exposures and severities of renal dysfunction. AKI also involves several different patho-physiological processes; in experimental models, gene expression in the kidney in response to intrinsic renal tubular injury differs from that seen in homeostatic responses to volume contraction, even when each mechanism results in similar changes in serum creatinine concentration [13]. These factors are important to consider when evaluating studies describing the epidemiology of AKI in hospitalized patients (or indeed, in any group of patients), especially given that most epidemiologic studies use serum creatinine criteria alone to define AKI and generally do not report the etiology of AKI or the characteristics of the hospitals studied [14]. Therefore, the present study was done with the aim of evaluating the incidence and epidemiology of AKI in patients presenting to emergency department as a sample of ICU. MATERIALS AND METHODS A prospective study was done from September 2017 to February 2018 in a 1200 bed strength tertiary care centre (G. R. Medical College) located in Gwalior, Madhya Pradesh, India. The study protocol was approved by the Institute Ethics Committee. Total numbers of 100 AKI patients (i.e. 54 male and 46 female) were collected for this study. Obtained data were then subjected to the classification and arrangements on the basis of general characteristics of patients; nature of the disease, etiology of the septicemic cause of AKI amongst patients, nephrotoxins, and poisonous causes of AKI amongst population reported. Inclusion criteria  Presence of uremic symptoms or oliguria or anuria of recent onset,  AKI as defined using the kidney disease- KDIGO criteria based on serum creatinine (increase in serum creatinine by ≥0.3 mg/dL within 48 h or increase in serum creatinine to ≥1.5 times baseline), which is known or presumed to have occurred within the prior 7 days. Staging of AKI was serum creatinine 1.5 to 1.9 times base-line or ≥0.3 mg/dL increase (stage 1); 2.0 to 2.9 times baseline (stage 2) and 3.0 time baseline or increase in serum creatinine to ≥4.0 mg/dL or initiation of renal replacement therapy (stage 3). It was presumed that the patient had normal renal function, if the serum creatinine was 1.5 mg/dL. Exclusion criteria  Pre-existing kidney disease (serum creatinine >1.5 mg/dL or ultrasonography of the abdomen suggestive of bilateral small kidneys/loss of corticomedullary differentiation (CMD)/obstructive nephropathy/other renal pathology)  Patients with AKI in CKD. Statistical Analysis- The results were presented in mean±SD and percentage. Chi-square test was used to compare the categorical variables between cases and controls. Unpaired t-test was used to compare the study parameters between cases and controls. The Pearson correlation coefficient was calculated among the study parameters. The p-value i.e. <0.05 was considered as significant. All the analysis was carried out by using SPSS (IBM) 21.0 version (Chicago, Inc., USA). RESULTS A total of 1795 patients were admitted in ICU of the Department of Medicine at G. R. Medical College, Gwalior during the study period, screened for inclusion into the study. In which, a total of 100 patients were suffered from AKI and the incidence rate of AKI in the present study was 5.57% (Table 1). Copyright © 2015 - 2019| SSR-IIJLS by Society for Scientific Research under a CC BY-NC 4.0 International License Volume 05 | Issue 06 | Page 2429 SSR Inst. Int. J. Life Sci. ISSN (O): 2581-8740 | ISSN (P): 2581-8732 Kumar et al., 2019 DOI:10.21276/SSR-IIJLS.2019.5.6.3 Table 1: Incidence rate of AKI in present study cohort Number Percentage (%) Total Admission at study place 1795 100 Incidence rate of AKI 100 5.57 Majority of the patients had AKI stage II (74%) followed by AKI stage I (13%) and AKI stage III (13%) shown in Table 2. Table 2: Distribution of acute kidney injury classification AKI classification Frequency Percentage (%) Stage I 13 13 Stage II 74 74 Stage III 13 13 Fig. 1: Distribution according to AKI classification General characteristics of AKI patients- In the total studied population male were in majority. The average age of AKI patients was found 45.74±9.45 years whereas, male was found 3 years younger with average age of 44.20±8.54 and female with average age of 47.56±10.20 (Fig. 3). Fig. 2: Comparing mean of age between Gender Copyright © 2015 - 2019| SSR-IIJLS by Society for Scientific Research under a CC BY-NC 4.0 International License Volume 05 | Issue 06 | Page 2430 SSR Inst. Int. J. Life Sci. ISSN (O): 2581-8740 | ISSN (P): 2581-8732 Kumar et al., 2019 DOI:10.21276/SSR-IIJLS.2019.5.6.3 Total 20% of patients were subjected to internal medicine ward whereas, 80% were found to be admitted into ICU. The majority of patients were in ICU ward, which indicated that patients were being treated for some chronic diseases. Total 8% patients were suffering from hypertension as co-morbidity of which 14.81% were male and 8.69% were female. Diabetes mellitus was found to one of the major chronic disease in 18% of total population, in which 16.66% were male and 19.56% were female. Blood pressure recordings indicated that of the total population 24% were suffering from hypotension, 14% were normal and 8% had hypertension. It was observed that occurrence of The 8% of the population was suffering from HIV, 6% with cancer, 4% with hepatitis B and hepatitis C, 4% with heart failure and 2% with CKD (Table 3). Table 3: General characteristics of AKI patients Variables Age (years) Total (%) N=100 45.74±9.45 Male (%) N=54 44.20±8.54 Female (%) N=46 47.56±10.20 Unit of hospitalization Internal medicine ICU 20(20) 80(80) 12(22.22) 42(77.77) 8(17.39) 38(82.60) Co-morbidity Hypertension Diabetes mellitus 12(12) 18(18) 8 (14.81) 9(16.66) 4(8.69) 9(19.56) Blood pressure (mmHg) Hypotension Normal Hypertension 24(24) 14(14) 8(8) 18(33.33) 9(16.66) 6(11.11) 6(13.04) 5(10.86) 2(4.34) HIV 8(8) 5(9.25) 3(6.52) Cancer 6(6) 4(7.47) 2(4.34) Hepatitis B/C 4(4) 3(5.55) 1(2.17) Heart failure Known CKD 4(4) 2(2) 3(5.55) 1(1.85) 1(2.17) 1(2.17) Etiology of AKI amongst patients- Among the studied population the septicemic cause of occurrence of AKI was different amongst different patients. Sepsis post trauma was one of the biggest causes of AKI in the study population followed by the pneumonia (13%), pylonephritis/ urosepsis (11%), meningitis (5%), soft tissue (4%), bacterial gastroenteritis (5%) and septic arthritis (3%). Female was risked to AKI majorly due to acute gastrointestinal tract pathology (8%) (Table 4). Nephrotoxins causes of AKI amongst patients- The hair dye (4%) was the first major poisonous cause of occurrence of AKI, followed by Organophosphorous (1%), celphos (3%), Datura (1%) and rat killer (1%) in this study population. It was also found that the males were at higher risk of poisoning than that of female almost in all the enlisted poisoning cases (Table 4). Copyright © 2015 - 2019| SSR-IIJLS by Society for Scientific Research under a CC BY-NC 4.0 International License Volume 05 | Issue 06 | Page 2431 SSR Inst. Int. J. Life Sci. ISSN (O): 2581-8740 | ISSN (P): 2581-8732 Kumar et al., 2019 DOI:10.21276/SSR-IIJLS.2019.5.6.3 Table 4: Nature and etiology of AKI amongst patients Variables Etiologies (Septicemia) Total (%) N=100 Male (%) N=54 Female (%) N=46 Pneumonia Acute gastrointestinal tract pathology 13(13) 8(8) 8(14.81) 3(5.55) 5(10.86) 5(10.86) Meningitis Pyelonephritis/Urosepsis 5(5) 11(11) 2(3.70) 7(15.21) 3(6.52) 4(8.69) Sepsis post trauma Septic arthritis Soft tissue injury Bacterial gastroenteritis Post-operative cases Sepsis abortion Post parter hemorrhage Congestive cardiac failure Acute pancreatitis Nephrotoxins Hair dye Organophosphorous Rat killer Celphos Datura 12(12) 3(3) 4(4) 5(5) 7(7) 6(6) 5(5) 4(4) 4(4) 10(18.51) 1(1.85) 3(5.55) 4(7.40) 4(7.40) 0(0.00) 0(0.00) 2(3.70) 3(5.55) 2(4.34) 2(4.34) 1(2.17) 1(2.17) 3(6.52) 6(13.04) 5(10.86) 2(4.34) 1(2.17) 4(4) 1(1) 1(1) 3(3) 1(1) 1(1.85) 1(1.85) 0(0.00) 2(3.70) 1(1.85) 3(6.52) 0(0.00) 1(2.17) 1(2.17) 0(0.00) Others 3(3) 9(16.66) 4(8.69) Fig. 3 Nature and Etiology of AKI amongst patients Copyright © 2015 - 2019| SSR-IIJLS by Society for Scientific Research under a CC BY-NC 4.0 International License Volume 05 | Issue 06 | Page 2432 SSR Inst. Int. J. Life Sci. ISSN (O): 2581-8740 | ISSN (P): 2581-8732 Kumar et al., 2019 DOI:10.21276/SSR-IIJLS.2019.5.6.3 DISCUSSION In the present study, the average age of the population was 45.74±9.45 years, which were younger than the studies reported [15-17]. It is also reported that the AKI mostly occurs at old age or a disease of senility [15]. In our study AKI suffered male were also found three years younger than the average age of female, which clearly indicates male is at higher risk at early age than females. This may be due to rapidly changing life style and consumption of fast food in busy lifestyle. It was reported that consumption of fast food and increased dietary intake of foods with high oxalate content such as cocoa will lead to CKD [18]. Such chronic disease many a times leads to development of AKI [18]. The majority of studied population was admitted in internal medicine ward with chronic history of disease and prolonged intensive treatment. Hypotension was found to be the main co-morbidity in present study, which found in majority in sample population suffering AKI. Hypotension lowers the rate of flow of blood throughout the body which, leads to reduce in the rate of filtration of toxic component in the kidney. Non-filtered toxic component remains in the body majorly in accumulating in the kidney prone to AKI. It is also reported that patients with CKD, congestive heart failure, hypertension, renovascular disease and diabetes were more likely to develop AKI [15,19] . In our study 4% population was found to be suffering from heart failure and 2% with CKD [16,19]. In study population diabetes mellitus was found to one of the major chronic disease affecting 18% of total population of which 16.66% were male and 19.56% were female. Hypotension as well as hypertension was also observed in the AKI patients. In male population occurrence of AKI with normal blood pressure was higher 16.66%, as compared to females 10.86%, which again indicative of food habits and stress [16,18]. Along with it the patient were suffering from the infectious causes like affecting total 8% HIV was higher in 9.25% male as compared to females 6.52%, total 6% cancer was higher 7.47% as compared to females 4.32%, 4% as well as total hepatitis B and hepatitis C was higher 5.55% as compared to females 2.17%. Heart failure 4% total and known CKD 2% of higher as 5.55% of male compared than 1% of female. It was reported that sepsis is one of the major cause of AKI and septicemic causes to occurrence of AKI was different amongst different patients. With respect to the observations made in the present study most literature report a similar total Incidence of hospitalization in ICU ward ranging from 55.60% to 84% [20-25]. Certain reports, have however documented a highest Incidence of hospitalization in Internal medicine ward the range 37.1% [26]. Similarly ICU admitted patients, sepsis was one of the major causes in our finding of with 77.77% of male and 82.60% of female were at risk, whereas, in Internal medicine ward cases, our finding was 22.22% of male and 17.39% of female [27]. The majority of studied population was admitted in ICU with chronic history of disease and prolonged intensive treatment. Other septicemia causes though do not directly relate to the AKI indirectly contributing the aggravation of condition. Those includes infections like pneumonia, pylonephritis/ urosepsis, acute gastro-intestinal tract pathology, meningitis, soft tissue, bacterial gastroenteritis, septic arthritis and other unidentified cause. In our study it is also found that the female with infectious causes are greater risk relating poor health and hygiene of females. Infectious causes like pneumonia, for male was 14.81% and 10.86% for female, gastrointestinal tract pathology (10.86%) and meningitis (6.52%) were the main disease associated with the occurrence of AKI in females. In all the toxic origin of occurrence of AKI male population was suffered greatly than the females, which clearly indicate the toxigenic occurrences of AKI related to job profile [21]. Male population was found at higher risk in all the toxic incidences. All other toxicities of hair dye, methanol, organophosphate, paraquat, celphos, and rat killer are either industrial origin or the risk jobs preferably performed by the male candidates at home and socially; hence male was clearly at major risk. CONCLUSIONS The incidence of AKI is high in ICU admitted patients and the development of AKI is associated with poor outcome and reduced survival. AKI significantly increases the period of hospital stay, and this is likely to increase to the healthcare burden and morbidity. The epidemiology of present study concluded, the risk of AKI was high among critically ill patients with co-morbidities. Most of the risk factors of AKI can be prevented with early diagnosis and interventions such as health education on oral rehydration, quality prenatal and emergency obstetric care, appropriate management of infections Copyright © 2015 - 2019| SSR-IIJLS by Society for Scientific Research under a CC BY-NC 4.0 International License Volume 05 | Issue 06 | Page 2433 SSR Inst. Int. J. Life Sci. ISSN (O): 2581-8740 | ISSN (P): 2581-8732 Kumar et al., 2019 DOI:10.21276/SSR-IIJLS.2019.5.6.3 and taking proper precautions, when prescribing nephrotoxic medications. Future study may be also benefitted by better identifying modifiable risk factors to prevent the development of AKI from the outset and timely and aggressive management will certainly reduce the incidence of AKI. Treatment of AKI is largely supportive and further research is urgently needed to improve AKI diagnosis and patient’s outcomes. CONTRIBUTION OF AUTHORS Research concept- Prof. Sushma Trikha, Prof. Archana Kansal, Dr. Neelima Singh Research design- Dr. Krishan Kumar Supervision- Prof. Sushma Trikha Materials- Dr. Krishan Kumar Data collection- Dr. Krishan Kumar Data analysis and Interpretation- Dr. Krishan Kumar, Dr. Sutakshee Sonowani Literature search- Dr. Krishan Kumar Writing article- Dr. Krishan Kumar, Dr. Nitin Kr. Srivastava Critical review-Prof. Sushma Trikha, Prof. Archana Kansal, Dr. Neelima Singh Article editing- Dr. Krishan Kumar Final approval- Prof. Sushma Trikha REFERENCES [1] Kellum JA. Why are patients still getting and dying from acute kidney injury? Curr. Opin. Crit. Care, 2016; 22(6): 513–19. [2] Lameire NH, Bagga A, Cruz D, De Maeseneer J, Endre Z, et al. Acute kidney injury: an increasing global concern. Lancet, 2013; 382(9887): 170–79. [3] Mehta RL, Cerdá J, Burdmann EA, Tonelli M, GarciaGarcia G, et al. International Society of Nephrology’s by 25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology. Lancet, 2015; 385(9987): 2616–43. [4] Metcalfe W, Simpson M, Khan IH, Prescott GJ, Simpson K, et al. Acute renal failure requiring renal replacement therapy: incidence and outcome. QJM: An Int. J. Med., 2002; 95(9): 579-83. [5] Hoste EA, Schurgers M. Epidemiology of acute kidney injury: how big is the problem? Crit. Care Med., 2008; 36(4): S146-S51. [6] Susantitaphong P, Cruz DN, Cerda J, Abulfaraj M, Alqahtani F, et al. World incidence of AKI: a meta- analysis. Clinical J. Am. Soc. Nephrol., 2013; 8(9): 1482-93. [7] Xu X, Nie S, Liu Z, Chen C, Xu G, Zha Y, et al. Epidemiology and clinical correlates of AKI in Chinese hospitalized adults. Clin. J. Am. Soc. Nephrol., 2015; 10(9): 1510-18. doi: 10.2215/CJN.02140215. [8] Kellum JA, Sileanu FE, Murugan R, Lucko N, Shaw AD, et al. Classifying AKI by urine output versus serum creatinine level. J. Am. Soc. Nephrol., 2015; 26: 2231–38. doi: 10.1681/ASN.2014070724. [9] Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, et al. Acute renal failure-definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit. Care, 2004; 8(4): R204–R12. [10]Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit. Care; 2007; 11(2): R31. [11]Kidney Disease Improving Global Outcomes (KDIGO). Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int., 2012; Suppl. 2: 01–138. [12]Hsu CY, McCulloch CE, Fan D, Ordonez JD, Chertow GM, et al. Community- Based incidence of acute renal failure. Kidney Int., 2007; 72(2): 208–12. [13]Xu K, Rosenstiel P, Paragas N, Hinze C, Gao X, et al. Unique transcriptional programs identify subtypes of AKI. J. Am. Soc. Nephrol., 2017; 28(6): 1729–40. doi: 10.1681/ASN.2016090974. [14]Susantitaphong P, Cruz DN, Cerda J, Abulfaraj M, et al. World incidence of AKI: a meta-analysis. Clin. J. Am. Soc. Nephrol., 2013; 8(9): 1482–93. [15]Coca SG. Acute kidney injury in elderly persons. Am. J. Kidney Dis., 2010; 56(1): 122-31. [16]Haynes RJ, Read S, Collins GP, Darby SC, Winearls CG. Presentation and survival of patients with severe acute kidney injury and multiple myeloma: a 20-year experience from a single centre. Nephrology Dialysis Transplantation, 2009; 25(2): 419-26. [17]Uchino S, Bellomo R, Goldsmith D, Bates S, Ronco C. An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Critical care med., 2006; 34(7): 1913-17. Copyright © 2015 - 2019| SSR-IIJLS by Society for Scientific Research under a CC BY-NC 4.0 International License Volume 05 | Issue 06 | Page 2434 SSR Inst. Int. J. Life Sci. ISSN (O): 2581-8740 | ISSN (P): 2581-8732 Kumar et al., 2019 DOI:10.21276/SSR-IIJLS.2019.5.6.3 [18]Albersmeyer M, Hilge R, Schrottle A, Weiss M, Sitter T, et al. Acute kidney injury after ingestion of rhubarb: secondary oxalate nephropathy in a patient with type 1 diabetes. BMC nephrology, 2012; 13(1): 141. [19]Wu VC, Wu CH, Huang TM, Wang CY, Lai CF, Shiao CC. and Chu TS. Long-term risk of coronary events after AKI. Journal of the American Society of Nephrology, 2014; 25(3): 595-605. [20]Liborio AB, Leite TT, Neves FM, et al. AKI complications in critically ill patients: association with mortality rates and RRT. Clin. J. Am. Soc. Nephrol., 2015; 10: 21. [21]Mandelbaum T, Scott DJ, Lee J, et al. Outcome of critically ill patients with acute kidney injury using the Acute Kidney Injury Network criteria. Crit. Care Med., 2011; 39: 2659. [22]Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med., 2015; 41: 1411. [23]Hoste EA, Clermont G, Kersten A, et al. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit. Care, 2006; 10: R73. [24]Kellum JA, Sileanu FE, Murugan R, et al. Classifying AKI by Urine Output versus Serum Creatinine Level. J. Am. Soc. Nephrol., 2015; 26: 2231. [25]Vasanth G, Surendrakumar P, Catherine P, Venu G. A study of factors determining outcome of acute kidney injury patients requiring hemodialysis. Int. J. Res. Med. Sci., 2018; 6: 2974-82. [26]Cheng X, Wu B, Liu Y, Mao H, Xing C. Incidence and diagnosis of acute kidney injury in hospitalized adult patients: a retrospective observational study in a tertiary teaching Hospital in Southeast China. BMC Nephrol., 2017: 18: 203. doi: 10.1186/s12882-0170622-6. [27]Schrier RW, Wang W. Acute renal failure and sepsis. New England J. Med., 2004; 351(2): 159-69. doi: 10.1056/NEJMra032401. Open Access Policy: Authors/Contributors are responsible for originality, contents, correct references, and ethical issues. SSR-IIJLS publishes all articles under Creative Commons Attribution- Non-Commercial 4.0 International License (CC BY-NC). https://creativecommons.org/licenses/by-nc/4.0/legalcode Copyright © 2015 - 2019| SSR-IIJLS by Society for Scientific Research under a CC BY-NC 4.0 International License Volume 05 | Issue 06 | Page 2435