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Saudi J Kidney Dis Transpl 2012;23(2):391-396

2012 Saudi Center for Organ Transplantation

Saudi Journal
of Kidney Diseases
and Transplantation

Renal Data from Asia Africa

Factors Influencing Hemodialysis and Outcome in Severe Acute Renal
Failure from Ilorin, Nigeria
A. Chijioke, A. M. Makusidi, M.O. Rafiu
Renal Unit, Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
ABSTRACT. The epidemiology of acute renal failure (ARF) varies between nations and even
within the same country because of differences in diagnostic criteria, causes, mode of presentation, and cost of therapy. To determine the factors influencing hemodialysis and outcome of
severe ARF in Ilorin, Nigeria, we studied ARF patients on hemodialysis in our center between
January 1989 and December 2009. There were 138 (58 males and 80 females) patients with age
range between 18 and 69 years and a mean of 29.4 11.9 years. Major etiologies of ARF
included septicemia, acute glomerulonephritis, septic abortion, herbal remedies, post-partum
bleeding, and gastroenteritis. The mean duration of illness and waiting time before dialysis was
11.7 8.14 days and 3.28 1.86 days, respectively. The mean number of dialysis was 2.24 1.13
sessions and 89% of the patients received a maximum of three sessions before recovery.
Hypotension, twitching of muscles, and back pains were common intradialysis complications. The
factors that influenced hemodialysis and outcome were late presentation, severity of ARF, and
financial constraints. The etiological agents are preventable and treatable conditions. The short
duration of hospital stay, waiting time before dialysis, and total duration of illness influenced the
outcome positively. We strongly recommend early referral of patients with severe ARF to
nephrologists for proper management in a bid to reduce mortality from this disease.
Introduction
Ilorin is located in the Guinea savannah area
of Nigeria and the university of Ilorin teaching
hospital (UITH) serve as a referral center for
most states in both North central and South west
Correspondence to:
Dr. Adindu Chijioke,
Renal Unit, Department of Medicine,
University of Ilorin Teaching Hospital,
Ilorin, Nigeria.
E-mail: drchijiokeady@yahoo.com

zones. Our dialysis center was established in

the year 1987 with the aim of caring for patients with acute and chronic renal failure.
Acute renal failure (ARF) is a syndrome characterized by rapid and possibly reversible
deterioration in renal function following a
variety of insults to previously normal kidneys.1-5 It may be difficult to distinguish between acute-on-chronic renal failure and acute
renal failure because most of the CRF patients
in the tropics present in acute setting.6-10
The epidemiology of ARF varies between
countries and even within the same country

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392

Chijioke A, Makusidi AM, Rafiu MO

because of differences in the diagnostic criteria.11-16 In developed countries, elderly patients predominate17,18 in contrast to tropical
environment where acute renal failure is a
disease of children and young adults.19-23 In
developing countries such as Nigeria, the leading causes of ARF include volume depletion,l8,23,24 infection,8,25,26 obstetric,2 and toxic
agents.28-32 Simple interventions like early oral
rehydration,33-34 improvement in obstetric practice,35,36 and use of potent antibiotics in the
treatment of infection37-38 can dramatically reduce the incidence and severity of ARF.33-36
Prevention of ARF is often the realistic way
to decrease its morbidity and mortality since
the cost of renal replacement therapy (RRT) is
prohibitively high, especially in the tropics.19,3941
Early commencement, appropriate dosage
and frequency of RRT are among factors associated with good outcome.42-48
The aim of our study was to document our
experience on ARF with specific reference to
causes, mode of presentation, factors affecting
initiation of dialysis, duration of hospital stay,
and outcome.
Patients and Methods
We studied all the cases of ARF treated at
our center from January 1989 to December
2009. All the patients met the RIFLE criteria
for diagnosis of ARF.2,3 The inclusion criteria
comprised some or all of the following features: short duration of illness in days and
weeks, unusual weakness, vomiting, diarrhea,
anorexia, malaise, hiccups, altered sensorium,
body swelling, pruritus, polyuria, loin pains,
urine output below 0.3 mL/kg/24 h and blood
biochemistry that showed tripling of creatinine
or creatinine levels greater than 355 mmol/L.
All patients had glomerular filtration rate
(GFR) reduced to greater than 75% in the presence of normal-sized kidneys. Patients with
previous history of renal disease, more than
three months duration of illness, ultrasonographic evidence of shrunken kidneys and
those who had suggestive clinical features but
could not be investigated due to poor finances
were excluded from the study. Also excluded

were patients with ARF and who had treatment with peritoneal dialysis.
The majority of the etiological factors were
obtained from clinical features. All patients
with suspected infections had septic work-up
and complete blood count, which showed
leucocytosis and toxic granulations with vacuolization of neutrophils. The diagnosis of
acute glomerulonephritis was confirmed in the
presence of facial/ankle edema, macroscopic
hematuria, hypertension, and mild proteinuria.
None of the patients had renal biopsy for
histological diagnosis. Dialysis was instituted
on severely uremic patients who could afford
the procedure. Most of the patients received
two to three, four hourly sessions of hemodialysis before recovery of ARF. Survivors
were followed up after discharge in the
nephrology clinic till they achieved normal
renal function based on clinical and laboratory
parameters. Data were analyzed using SPSS
version 16.
Results
There were 138 (58 males and 80 females)
out of 342 ARF patients (40.35%) who were
dialyzed because of their disease, with a maleto-female ratio of 1:33. The age range was
from 18 to 69 years with a mean of 29.4 11.9
years, and 76% of the patients were below 40
years. The etiological factors are shown in
Figure 1; the most frequent causes included
septicemia (35.5%), acute glomerulonephritis
(15.5%), and septic abortion. The duration of
ARF before dialysis ranged from 1 to 30 days
with a mean of 11.7 8.14 days, and 80% of
the cases were below 14 days. The waiting
time before commencing dialysis ranged from
1 to 9 days with a mean of 3.28 1.86 days,
and the majority were less than seven days
(91.1%). The majority of patients were traders
and students followed by civil servant and
housewives. Blood transfusion ranged between
1 and 6 units, with a mean of 2.24 1.13 units,
and 65% of the patients received at least three
units. Hemodialysis sessions ranged between 1
and 6 times with a mean of 2.24 1.13 times,
and 89% of the patients received a maximum of

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Factors influencing HD and outcome in severe ARF from Nigeria

393

Etiological factors

Figure 1. Causes of acute renal failure in the study patients.

three sessions before recovery.

The major factors influencing hemodialysis
and outcome were late presentation, severity
of ARF, and financial constraints. The duration of hospitalization was less than 21 days in
96% of the cases with a mean of 20.1 9.69
days. Hypotension, twitching of muscle, cramps,
and back pains were the common intradialysisencountered complications (Figure 2). The
outcome was favorable with six deaths (13.3%
of the cases).
Discussion
The majority of acute renal failure patients in
this study presented in a setting of a septicemic
illness with the females in their productive age,

Figure 2. Intradialysis complications.

constituting 58% of cases. Most of these

females, had sepsis complicating abortion, urinary tract infection in pregnancy, prepartum
and postpartum bleeding. Anemia was a common associated feature at presentation as 65%
of cases received at least three unit of blood
transfusion before recovery. The finding of
severe anemia necessitating blood transfusion
is not surprising as the etiology of ARF was
multifactorial and late presentation was very
common. Many of these patients had septicemia, septic abortion, obstetric bleeding, and
acute glomerulonephritis in varying combinations, which can individually cause severe
anemia. Although duration of illness before
presentation was less than two weeks, the very
poor condition of many of them casts doubt on

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394

Chijioke A, Makusidi AM, Rafiu MO

the reliability of such information.

The waiting time before commencement of
dialysis was less than a week in most of these
patients. This was encouraging as the usual
delay in raising funds for cost of laboratory
work-up and treatment of the patients was not
uncommon and might have impacted on the
favorable outcome. The prevalence of anemia
among the patients was comparable to reports
from other centers.7,8,10,17 The widespread prevalence of anemia in tropical developing countries due to multiple causes preclude the use of
this important clinical feature in distinguishing
between acute renal failure and acute-onchronic renal failure.6,7,8,30-32 However, the
availability and increased utilization of renal
ultrasonography have helped considerably in
making this distinction in recent times.
The duration of hospital stay was less than
three weeks in the majority of our patients.
This is not surprising as the predisposing
factors were mainly preventable prerenal conditions and the waiting time before initiating
dialysis was considerably short, which contributed to the low mortality rate of 13%. The observed intra-dialysis complications were similar
to those reported by other authors.8,12,19,48-49
Most of the identified complications are preventable and treatable conditions.8,48,49
We conclude from our study that ARF was a
common cause of morbidity and mortality in
our environment. The implicated etiological
agents were preventable and treatable conditions with majority of them presenting in septicemic illness. A short duration of hospital stay,
waiting time before commencing dialysis, and
duration of illness before presentation had
positive influence on the outcome. We strongly
recommend early referral of patients with
severe ARF to nephrologists for proper management in order to further reduce mortality
from this highly preventable and treatable
condition.
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