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\def\runningtitle{Etiological Factors and Clinical Profile of Acute Kidney Injury in MICU}
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\title{\textbf{Etiological Factors and Clinical Profile of Acute Kidney Injury in~MICU}}
\articletype{}
\author{{Dr. Mekha K. Mathew{\color{blue}\thanks{Corresponding author.}}\ \textsuperscript{,}{\color{blue}\thanks{Email: drmekhamathew333@gmail.com}}\ \textsuperscript{,}\textsuperscript{1}, 
            Dr. T. R. Radha\textsuperscript{2}}~\\[.3pc]~\\[.1pc]\itshape \raggedright {\fontsize{8pt}{10.5pt}\selectfont \textsuperscript{1}Senior Resident, Department Of General Medicine, Government Medical College, Kottayam, Kerala, India}~\\[.1pc]\itshape \raggedright {\fontsize{8pt}{10.5pt}\selectfont \textsuperscript{2}Additional Professor, Department Of General Medicine, Government Medical College, Kottayam, Kerala, India}~\\[.5pc]\fontsize{8pt}{10.5pt}\selectfont\normalfont{\color{blue}{\ifx\cmDoi\empty\else DOI: \fi}}\url{\cmDoi} ~\\[.5pc] \ifx\cmAccepted\empty\else Accepted \fi\cmAccepted\ifx\cmReceived\empty\else\ifx\cmAccepted\empty\else ;\ \fi Received \fi\cmReceived\ifx\cmPublishedOnline\empty\else; Publish Online \cmPublishedOnline\fi}\vspace{-2pc}
  
\twocolumn[{\maketitle\parbox[t]{.22\textwidth}{\sffamily\fontsize{12pt}{14pt}\selectfont\raggedright \ifx\reviewauthor\empty\else Reviewed By: \fi\reviewauthor~\\ \ifx\reviewerdep\empty\else Department: \fi\reviewerdep}\hfill
\parbox[t]{.74\textwidth}{\fontsize{9pt}{12pt}\selectfont\textbf{{\color{airforceblue}ABSTRACT}\\}\fontsize{10pt}{10.5pt}\selectfont \textbf{Background} \textbf{ and Objectives:}

Data on the etiology, management practices and outcome in patients admitted to intensive care units in Kerala has not been studied in depth. The etiology and patterns of AKI, as well as management practices are likely to differ in countries with resource limitations and variations in disease patterns. The present study was undertaken to identify the etiologic factors and outcome of patients with Acute Kidney Injury admitted in Medical ICU.

\textbf{Methods:}

The study is a cross sectional study, done in 150 consecutive patients admitted to Medical Intensive Care Unit, Government Medical College, Kottayam meeting the AKIN creatinine criteria for acute kidney injury over a period of 12 months.

\textbf{Results and Discussion:}

The most common diagnosis in the patients admitted with AKI in MICU was Leptospirosis (22\%) followed by undifferentiated fever (21\%) and sepsis seen in 17\%. Dialysis was required in 81.3\% among those with undifferentiated febrile illness and 78.8\% among those with leptospirosis. Significant association was identified between etiology of AKI and the need for dialysis. The most common stage of AKI in the patients in this study group on admission to the medical intensive care unit was stage 3 in 64.7\%. 45\% of the patients required dialysis, among which 24\% underwent CRRT while the 76\% underwent hemodialysis.

Out of 150 cases 59\% survived and 41\% expired. Mortality was more in the patients in this study with undifferentiated acute febrile illness, 43.8\% and leptospirosis, 36.4\%. Mortality was 48.5\% in those who underwent dialysis. But no significant association was identified between requirement of dialysis or diagnosis and mortality. Significant association was identified between patients with breathlessness, basal crepitations, later stage of AKI, inotropic support, ventilator support and mortality with p value {\textless}0.05.

By logistic regression analysis of the factors having association with mortality, requirement of ventilator support and inotropic supports were independent predictors of mortality.

\textbf{Conclusion:}

The most common etiology was leptospirosis (22\%) followed by undifferentiated fever (21\%). Mortality was 41\% in the patients in the study group. Requirement of ventilator support and inotropic supports were independent predictors of mortality.

\def\keywordstitle{Keywords}}}\vspace{3pc}]\saythanks 

\baselineskip=\the\baselineskip plus.25pt minus.25pt

    
\section{Introduction:}
Acute kidney injury (AKI) complicates 5{\textendash}7\% of acute care hospital admissions and up to 30\% of admissions to the intensive care unit.\unskip~\cite{634105:14853759}  4\% to 6\% of ICU patients will need dialysis. 

The tropical zone which is geographically limited by the Tropics of Cancer and Capricorn, is an area with extreme heterogeneity in terms of ethnic composition, as well as the socioeconomic and developmental status. Acute kidney injury remains one of the most enigmatic problems in these regions with high incidence rates (25\% - 80\%) especially in the intensive care units. 

There are very few studies on the etiologic factors of acute kidney injury in the intensive care units in South India. Unlike in the developed nations, were sepsis is a predominant etiologic factor, in high rainfall receiving regions of the tropics like in Kerala, infections like leptospirosis form a major cause of AKI. 

The identification of the common etiological agents in a region can help in the formulation of a better protocol for the early diagnosis and management. This can in turn help in reduction of mortality and morbidity. 
    
\section{\textbf{Objective:}}
To study the etiologic factors, clinical profile and outcome of patients with Acute Kidney Injury admitted in Medical intensive care unit
    
\section{\textbf{Material and Methods:}}
\textbf{Study Design} \textbf{ : }Cross sectional Analytical study

\textbf{Study Setting} \textbf{ : }Medical Intensive Care Unit\textbf{, }

Government Medical College, Kottayam

\textbf{Duration of Study} \textbf{ : }12 Months

\textbf{Study Population: }

Patients admitted in Medical Intensive Care Unit, Government Medical College, Kottayam with a diagnosis of AKI. 

\textbf{Sample Size:}

n = (Z \ensuremath{\alpha }) \ensuremath{^2} pq/d\ensuremath{^2} 

Z \ensuremath{\alpha } = 1.96 for \ensuremath{\alpha } at 5\% level of significance

 p = prevalence of sepsis causing AKI- 38.6\%

(Based on Eswarappa et al on spectrum of AKI in critically ill patients [6])

 q = 100 {\textendash} p

 d = absolute precision (8) 

(4x38.6x61.4)/8x8=148

Minimum required sample size - 150

\textbf{Study Tool:}

Performa based on case records

\textbf{Inclusion Criteria:}

Patients admitted to this hospital within the study period with diagnosis of Acute Kidney Injury by AKIN creatinine criteria

\textbf{Exclusion Criteria:}

Patients with Chronic Kidney disease

\textbf{Study Procedure:}

150 consecutive patients admitted to Medical Intensive Care Unit during my study period meeting AKIN creatinine criteria for acute kidney injury was included in this study. All patients or their relatives were interviewed as per the prepared Performa and then complete clinical examination was done.

The following investigations were performed: blood routine, random blood sugar, renal function tests, liver function tests, serum electrolytes, serum uric acid, INR, blood pH, urine analysis, ECG, chest X ray, ultrasonography of abdomen for all cases and specific tests for diagnosis in special cases. Patients were classified into several diagnostic categories based on the diagnosis documented at the point of admission. The data collected was entered in Microsoft excel and analyzed using SPSS software.

\textbf{Ethical consideration:}

The above mentioned study was conducted in this institution after obtaining due ethical clearance from the Ethical Committee of Government Medical College, Kottayam and Department of General Medicine, Government Medical College, Kottayam. Informed consent was obtained from cases in the study. 

\textbf{Data management and analysis:}

The data was coded and entered in Microsoft excel and further statistical analysis were done using SPSS software. Associations between various factors were assessed using chi square test for qualitative variables and t test/ANOVA for quantitative variables. Appropriate non parametric tests were applied wherever required. The level of statistical significance was taken as p value less than 0.05.
    
\section{\textbf{Theory:}}
AKI affects patients worldwide, leading to decreased survival, and sometimes to new onset of CKD. Outcomes in AKI are influenced by the underlying disease, the severity and duration of renal impairment and by the baseline characteristics of the patient.  

The cause of AKI is often multi-factorial. Sepsis is a leading precipitating cause of AKI. 45-75\% of all AKI is associated with sepsis. Sepsis is associated with high burden of illness, greater abnormality in acute physiology \& laboratory findings \& greater non-renal organ failure\unskip~\cite{634105:14853760,634105:14853761,634105:14853762}

Sepsis is reported to be the most common cause of death in Intensive Care Unit (ICU). It is an increasingly common cause of mortality and morbidity particularly in elderly, immune compromised and critically ill patients. Approximately 25-35\% of patients with severe sepsis and 40-55\% of patients with septic shock die within 30 days \unskip~\cite{634105:14853759,634105:14853760}

Other causes include acute gastroenteritis, nephrotoxic drugs, cardiac causes and hepatic causes. Hypertension, diabetes and coronary artery disease are predominant comorbid conditions. Early detection \& aggressive management of sepsis \& its complications is necessary to bring down the mortality in patients admitted in ICU\unskip~\cite{634105:14853759}  . The role of sepsis in AKI has been well documented in western literature, causing nearly 50\% of the AKI cases in few studies. \unskip~\cite{634105:14853759}\unskip~\cite{634105:14853763,634105:14853764}

Fidel Barrantes et al concluded that the Acute Kidney Injury Network (AKIN) definition of acute kidney injury predicts hospital mortality, need for renal replacement therapy and prolonged hospital stay in critically ill patients.\unskip~\cite{634105:14853762}

The true picture of AKI in the tropics is poorly understood due to the late presentation of patients to tertiary centres. Infections remain the major culprit in most cases causing high mortality rates in the tropics. Acute kidney injury is one of the most challenging problems faced by clinicians in the tropics owing to its fast-changing burden.

Tropical infectious diseases are an important cause of admission to ICU in Kerala, and diseases like leptospirosis have a high propensity to cause AKI. Data on the etiology, management practices and outcome in patients admitted to intensive care units in Kerala has not been studied in depth.
    
\section{ C\textbf{ase Definitions:}}
\textbf{Acute Kidney Injury:}

Defined by AKIN Creatinine Criteria 

Stage 1: Increase of S Cr \ensuremath{\geq }0.3 mg/dl / increase of S Cr \ensuremath{\geq }150\% to 200\% over 48 hrs

 Oliguria urine output {\textless}0.5 ml/ kg / hr over 6 hrs

Stage 2: Increase of S Cr \ensuremath{\geq }200\% to 300\% over 48 hours 

 Oliguria urine output {\textless}0.5 ml/ kg / hr over 12 hrs

Stage 3: Increase of S Cr \ensuremath{\geq } 300\% 

 S Cr \ensuremath{\geq }4 mg/dl and acute rise \ensuremath{\geq }0.5mg/dl

 Initiation of RRT \unskip~\cite{634105:14853765}

Several diagnostic categories were formulated based on the diagnosis documented at the point of admission by the treating clinician.

A diagnosis of sepsis/septic shock was made where the primary reason for admission was a sepsis related illness, and included sepsis associated with pneumonia, gastrointestinal disease, urinary tract infections, central nervous system infections, soft tissue infections and sepsis of undetermined source based on a qSOFA score {\textgreater}2 in presence of documented infection.Figure~\ref{f-383d7d7347c8}


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\caption{{Quick SequentialOrgan Failure Assessment Score}}
\label{f-383d7d7347c8}
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\egroup
 A cardiac diagnosis was made where the primary reason for admission was cardiogenic shock, cardiac arrest, congestive cardiac and acute myocardial infarction (rise in troponin and either ischemic chest pain, new ST-T wave changes).

 A respiratory diagnosis encompassed aspiration syndrome, exacerbations of chronic obstructive pulmonary disease or asthma. A diagnosis of gastrointestinal diagnosis included chronic liver disease, pancreatitis and acute diarrheal disease. 

Metabolic/poisoning diagnoses included causes of metabolic coma, diabetic ketoacidosis, drug overdose or other endocrinopathies. Primary neurologic diagnoses included stroke or other neurological causes for coma. 

A diagnosis of Dengue by IgM Dengue ELISA test. 

A diagnosis of probable Leptospirosis based on System of scoring using the Modified Faine's Criteria\unskip~\cite{634105:14853766}\ensuremath{^{}}
    
\section{\textbf{Results:}}
\textbf{1. Gender Distribution:}

73.3\% of the patients in the study group were males and 26.7\% were females.

\textbf{2. Age Distribution:}Table~\ref{tw-db524e53a680}Figure~\ref{f-ac4d0857192e}


\begin{table*}[!htbp]
\caption{{\textbf{Age distribution}} }
\label{tw-db524e53a680}
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\centering \small 
\begin{tabulary}{\linewidth}{LLLL}
\hline~\\[-8pt] 
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{Age group (years.) }} &
  \multicolumn{2}{p{\dimexpr(\mcWidth{2}+\mcWidth{3})}}{SEX} &
  \multicolumn{1}{p{\dimexpr(\mcWidth{3})}}{\multirow{2}{\linewidth}{Total}}\\
 &
  Male &
  Female &
  \\
{\textless}24 &
  11 (10.0\%) &
  2 (5.0\%) &
  13 (8.7\%)\\
25-34 &
  14 (12.7\%) &
  5 (12.5\%) &
  19 (12.7\%)\\
35-44 &
  20 (18.2\%) &
  4 (10.0\%) &
  24 (16.0\%)\\
45-54 &
  20(18.2\%) &
  10(25.0\%) &
  30(20.0\%)\\
55-64 &
  22(20.0\%) &
  9(22.5\%) &
  31(20.7\%)\\
65-74 &
  15(13.6\%) &
  8(20.0\%) &
  23(15.3\%)\\
75 \&above &
  8(7.3\%) &
  2(5.0\%) &
  10(6.7\%)\\
Total &
  110(100.0\%) &
  40(100.0\%) &
  150(100.0\%)\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/9b1b6ea2-66dd-45a7-9d90-57a3b7520df8-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/9b1b6ea2-66dd-45a7-9d90-57a3b7520df8-uimage.png}{\includegraphics{images/9b1b6ea2-66dd-45a7-9d90-57a3b7520df8-uimage.png}}{}
\makeatother 
\caption{{Age distribution }}
\label{f-ac4d0857192e}
\end{figure*}
\egroup
Mean age was 49.6 years with a standard deviation of 16.5. Youngest and the oldest of the study population had 15 and 88 years of age respectively.

\textbf{3. Presenting Symptoms:}Table~\ref{tw-a39cfda15155}Figure~\ref{f-2220381e8fa2}


\begin{table*}[!htbp]
\caption{{\textbf{Presenting symptoms}} }
\label{tw-a39cfda15155}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
Symptoms &
  Frequency &
  Percentage\\
Fever &
  108 &
  72 \%\\
Decreased urine output &
  72 &
  48 \%\\
Breathlessness &
  68 &
  45.3 \%\\
Myalgia &
  64 &
  42.70\%\\
Headache &
  35 &
  23.30\%\\
Cough &
  30 &
  20 \%\\
Altered sensorium &
  28 &
  18.7 \%\\
Abdominal pain &
  28 &
  18.7 \%\\
Vomiting &
  24 &
  16 \%\\
Diarrhea &
  17 &
  11.3 \%\\
Chest pain &
  12 &
  8 \%\\
Hemoptysis &
  10 &
  6.7 \%\\
Pedal edema &
  10 &
  6.7 \%\\
Abdominal distension &
  6 &
  4 \%\\
Bleeding manifestation &
  5 &
  3.3 \%\\
Seizure &
  5 &
  3.3 \%\\
Injury &
  3 &
  2 \%\\
Snake bite &
  1 &
  0.70\%\\
Poisoning &
  1 &
  0.70\%\\
Weakness &
  1 &
  0.70\%\\
Dysuria &
  1 &
  0.70\%\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/fa43e42c-3c2b-4eb8-93c4-c3a1e62f2b18-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/fa43e42c-3c2b-4eb8-93c4-c3a1e62f2b18-uimage.png}{\includegraphics{images/fa43e42c-3c2b-4eb8-93c4-c3a1e62f2b18-uimage.png}}{}
\makeatother 
\caption{{Presenting symptoms}}
\label{f-2220381e8fa2}
\end{figure*}
\egroup
Fever was the most common presenting symptom seen in 108 (72\%) patients, decreased urine output in 72 (48\%) patients, breathlessness in 68 (45.3\%) patients, and myalgia in 64(42.7\%) patients.

Other common presenting symptoms were headache, cough, altered sensorium and abdominal pain seen in 35 (23.3\%), 30 (20\%), 28 (18.7\%) and 28 (18.7\%) respectively.

\textbf{4. Nephrotoxic Drug Intake:Table~\ref{tw-7fdf80a6c71a}}


\begin{table*}[!htbp]
\caption{{\textbf{Nephrotoxic drug intake}} }
\label{tw-7fdf80a6c71a}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
Drugs &
  Frequency &
  Percentage\\
No &
  140 &
  93.3 \%\\
NSAID &
  4 &
  2.7 \%\\
Lithium &
  2 &
  1.3 \%\\
ARB &
  2 &
  1.3 \%\\
Herbal &
  1 &
  0.7 \%\\
Cocaine &
  1 &
  0.7 \%\\
Total &
  150 &
  100 \%\\
\hline 
\end{tabulary}\par 
\end{table*}
Only 10 patients that accounts for 7 \% had h/o nephrotoxic drug usage. NSAID (2.7\%) was the most common one implicated used by 4 patients prior to development of AKI.

\textbf{5. Etiologic Factors:Table~\ref{tw-43b753460f5d}Figure~\ref{f-c0d587c3c35c}}


\begin{table*}[!htbp]
\caption{{\textbf{Etiologic factors}} }
\label{tw-43b753460f5d}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
Etiologic factors &
  Frequency &
  Percentage\\
Leptospirosis &
  33 &
  22 \%\\
Undifferentiated acute febrile illness &
  32 &
  21.3 \%\\
Sepsis  &
  26 &
  17.3 \%\\
Respiratory diagnosis  &
  17 &
  11.3 \%\\
Cardiac diagnosis  &
  14 &
  9.3 \%\\
Gastrointestinal  &
  13 &
  8.7 \%\\
Metabolic/poisoning diagnoses &
  7 &
  4.7 \%\\
Primary neurologic diagnoses  &
  3 &
  2 \%\\
Dengue &
  3 &
  2 \%\\
Drug &
  1 &
  0.7 \%\\
Snake bite &
  1 &
  0.7 \%\\
Total &
  150 &
  100.0 \% \\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/3185c884-c8b6-4f1c-b283-412e8b313269-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/3185c884-c8b6-4f1c-b283-412e8b313269-uimage.png}{\includegraphics{images/3185c884-c8b6-4f1c-b283-412e8b313269-uimage.png}}{}
\makeatother 
\caption{{Etiologic factors}}
\label{f-c0d587c3c35c}
\end{figure*}
\egroup
\textbf{6. Stage of Acute Kidney Injury by The Akin Creatinine Criteria:  Table~\ref{tw-38c51ca5be72}Figure~\ref{f-89f1a5bb05dc}}


\begin{table*}[!htbp]
\caption{{\textbf{Stage of Acute Kidney Injury }} }
\label{tw-38c51ca5be72}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
 &
  Frequency &
  Percent\\
Stage 1 &
  7 &
  4.7\\
Stage 2 &
  46 &
  30.7\\
Stage 3 &
  97 &
  64.7\\
Total &
  150 &
  100\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/984c3fcf-6414-4607-93a2-472f612e311f-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/984c3fcf-6414-4607-93a2-472f612e311f-uimage.png}{\includegraphics{images/984c3fcf-6414-4607-93a2-472f612e311f-uimage.png}}{}
\makeatother 
\caption{{Stage of acute kidneyinjury }}
\label{f-89f1a5bb05dc}
\end{figure*}
\egroup
The most common stage of AKI in the patients in this study group on admission to the medical intensive care unit was stage 3 seen in 97 patients which accounts to 64.7\%.

\textbf{7. Dialysis Requirement:}

68 out of the 150 patients in the study group required dialysis, which accounts to \textbf{45\%}. Among the patients in the study group who underwent dialysis 52 patients (76.5\%) underwent intermittent hemodialysis while 16 patients (23.5\%) underwent CRRT. Table~\ref{tw-2d2a05e15c46}Figure~\ref{f-1d6e7eef3f4d}


\begin{table*}[!htbp]
\caption{{\textbf{Dialysis type}} }
\label{tw-2d2a05e15c46}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
 &
  Frequency &
  Percentage\\
CRRT &
  16 &
  23.5 \% \\
Intermittent hemodialysis &
  52 &
  76.5 \% \\
Total &
  68 &
  100.0 \% \\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/dca22231-0636-47b2-b2f5-704f354c9375-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/dca22231-0636-47b2-b2f5-704f354c9375-uimage.png}{\includegraphics{images/dca22231-0636-47b2-b2f5-704f354c9375-uimage.png}}{}
\makeatother 
\caption{{Dialysis type}}
\label{f-1d6e7eef3f4d}
\end{figure*}
\egroup
\textbf{ 8. Indication for Dialysis:Table~\ref{tw-ac411e2e73bd}}


\begin{table*}[!htbp]
\caption{{\textbf{Indication for dialysis}} }
\label{tw-ac411e2e73bd}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
 &
  Frequency &
  Percentage\\
Metabolic acidosis alone &
  9 &
  13.2\%\\
Hyperkalemia &
  1 &
  1.5\%\\
Anuria alone &
  22 &
  32.4\%\\
Metabolic acidosis and anuria &
  36 &
  52.9\%\\
Total &
  68 &
  100.00\%\\
\hline 
\end{tabulary}\par 
\end{table*}
The predominant indication for dialysis in the patients in the study group was metabolic acidosis and anuria in 52.9\% of the patients.

9. \textbf{Ventilation Requirement:}Table~\ref{tw-d43852d095cd}Figure~\ref{f-083e13a337a0}


\begin{table*}[!htbp]
\caption{{\textbf{Ventilation requirement}} }
\label{tw-d43852d095cd}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
 &
  Frequency &
  Percentage\\
No &
  66 &
  44.00\%\\
Yes &
  84 &
  56.00\%\\
Total &
  150 &
  100.00\%\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/1200468d-1ece-46e6-9189-7b8d6ab54d2b-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/1200468d-1ece-46e6-9189-7b8d6ab54d2b-uimage.png}{\includegraphics{images/1200468d-1ece-46e6-9189-7b8d6ab54d2b-uimage.png}}{}
\makeatother 
\caption{{Ventilation requirement}}
\label{f-083e13a337a0}
\end{figure*}
\egroup
66 out of the 150 patients which accounts to 56\% required invasive ventilation.

\textbf{9. Inotrope Requirement: Table~\ref{tw-12834a6ddf92}Figure~\ref{f-3feecf8189e5}}


\begin{table*}[!htbp]
\caption{{\textbf{: Inotrope requirement}} }
\label{tw-12834a6ddf92}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
 &
  Frequency &
  Percentage\\
No &
  25 &
  16.70\%\\
Yes &
  125 &
  83.30\%\\
Total &
  150 &
  100.00\%\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/ed79037f-2388-4784-b0be-7eb7fad57e69-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/ed79037f-2388-4784-b0be-7eb7fad57e69-uimage.png}{\includegraphics{images/ed79037f-2388-4784-b0be-7eb7fad57e69-uimage.png}}{}
\makeatother 
\caption{{Inotrope requirement}}
\label{f-3feecf8189e5}
\end{figure*}
\egroup
125 of the 150 patients in the study group which accounts for 83\% required inotropic support.

\textbf{ 10. Mortality:Table~\ref{tw-b9becd9e6def}Figure~\ref{f-78386eb06c06}}


\begin{table*}[!htbp]
\caption{{\textbf{Mortality:}} }
\label{tw-b9becd9e6def}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLL}
\hline~\\[-8pt] 
 &
  Frequency &
  Percentage\\
No &
  88 &
  58.70\%\\
Yes &
  62 &
  41.30\%\\
Total &
  150 &
  100.00\%\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/963aa619-e284-4e83-b1ae-e9c15aeaf3d2-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/963aa619-e284-4e83-b1ae-e9c15aeaf3d2-uimage.png}{\includegraphics{images/963aa619-e284-4e83-b1ae-e9c15aeaf3d2-uimage.png}}{}
\makeatother 
\caption{{Mortality }}
\label{f-78386eb06c06}
\end{figure*}
\egroup
Mortality was 41\% in the patients in the study group, 62 patients out of 150 expired.

\textbf{11. Association between AKI Stage and Mortality: Table~\ref{tw-749880eed350}Figure~\ref{f-dd4c1963e47a}}


\begin{table*}[!htbp]
\caption{{Association between AKI stage and mortality} }
\label{tw-749880eed350}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLLL}
\hline~\\[-8pt] 
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{}} &
  \multicolumn{2}{p{\dimexpr(\mcWidth{3}+\mcWidth{4})}}{Outcome }\\
 &
   &
  Survived &
  Expired\\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{6}{\linewidth}{AKI stage}} &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Stage 1}} &
  5 &
  0\\
 &
   &
  100.0\% &
  0\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Stage 2}} &
  28 &
  0\\
 &
   &
  100.0\% &
  0\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Stage 3}} &
  55 &
  62\\
 &
   &
  47.0\% &
  53.0\%\\
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{Total}} &
  No &
  62\\
 &
   &
  \% &
  41.3\%\\
\hline 
\end{tabulary}\par 
\end{table*}
 53\% of those with stage 3 AKI expired compared to no mortality in the stage 1or2. Significant association could be identified between stage of AKI and mortality by chi square test with a p value less than 0.05. 


\bgroup
\fixFloatSize{images/04c6c3bd-0ed3-4d31-a6b1-524a563670c9-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/04c6c3bd-0ed3-4d31-a6b1-524a563670c9-uimage.png}{\includegraphics{images/04c6c3bd-0ed3-4d31-a6b1-524a563670c9-uimage.png}}{}
\makeatother 
\caption{{Association between AKI stage and mortality }}
\label{f-dd4c1963e47a}
\end{figure*}
\egroup
\textbf{12. Association between Inotrope Use and Mortality:  Table~\ref{tw-e8fa526bce87}Figure~\ref{f-ed7194b931a4}}


\begin{table*}[!htbp]
\caption{{Association between inotrope useand mortality} }
\label{tw-e8fa526bce87}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLLLLL}
\hline~\\[-8pt] 
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{}} &
  \multicolumn{3}{p{\dimexpr(\mcWidth{2}+\mcWidth{3}+\mcWidth{4})}}{Outcome} &
  \multicolumn{2}{p{\dimexpr(\mcWidth{5}+\mcWidth{6})}}{\multirow{2}{\linewidth}{Total}}\\
 &
  Survived &
  \multicolumn{2}{p{\dimexpr(\mcWidth{3}+\mcWidth{4})}}{Expired} &
   &
  \\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{Inotropic support absent}} &
  23 &
  2 &
  \multicolumn{2}{p{\dimexpr(\mcWidth{4}+\mcWidth{5})}}{25} &
  \\
 &
  92.0\% &
  8.0\% &
  \multicolumn{2}{p{\dimexpr(\mcWidth{4}+\mcWidth{5})}}{100.0\%} &
  \\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{Inotrope support present}} &
  65 &
  60 &
  \multicolumn{2}{p{\dimexpr(\mcWidth{4}+\mcWidth{5})}}{125} &
  \\
 &
  52.0\% &
  48.0\% &
  \multicolumn{2}{p{\dimexpr(\mcWidth{4}+\mcWidth{5})}}{100.0\%} &
  \\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{Total}} &
  88 &
  62 &
  \multicolumn{2}{p{\dimexpr(\mcWidth{4}+\mcWidth{5})}}{150} &
  \\
 &
  58.7\% &
  41.3\% &
  \multicolumn{2}{p{\dimexpr(\mcWidth{4}+\mcWidth{5})}}{100.0\%} &
  \\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/3edea250-82be-440d-85de-a072da83180e-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/3edea250-82be-440d-85de-a072da83180e-uimage.png}{\includegraphics{images/3edea250-82be-440d-85de-a072da83180e-uimage.png}}{}
\makeatother 
\caption{{Association betweeninotrope use and mortality}}
\label{f-ed7194b931a4}
\end{figure*}
\egroup
Mortality was more in the patients in this study requiring inotrope support. 48\% of those with inotropic support expired.

Significant association was identified between inotropic support and mortality with p value{\textless}0.05

\textbf{13. Association Between Ventilation And Mortality:Figure~\ref{f-10efef688ef8}Table~\ref{tw-a29c052aad56}}


\begin{table*}[!htbp]
\caption{{Association between ventilation andmortality} }
\label{tw-a29c052aad56}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLLL}
\hline~\\[-8pt] 
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{}} &
  \multicolumn{2}{p{\dimexpr(\mcWidth{2}+\mcWidth{3})}}{Outcome} &
  \multicolumn{1}{p{\dimexpr(\mcWidth{3})}}{\multirow{2}{\linewidth}{Total}}\\
 &
  Survived &
  Expired &
  \\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{Ventilator support absent }} &
  63 &
  3 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{4})}}{\multirow{2}{\linewidth}{66}}\\
 &
  95.5\% &
  4.5\% &
  \\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{Ventilator support present}} &
  25 &
  59 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{4})}}{\multirow{2}{\linewidth}{84}}\\
 &
  29.8\% &
  70.2\% &
  \\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{2}{\linewidth}{ Total}} &
  88 &
  62 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{4})}}{\multirow{2}{\linewidth}{150}}\\
 &
  58.7\% &
  41.3\% &
  \\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/7974c303-f442-427e-85a0-92ea724c59e6-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/7974c303-f442-427e-85a0-92ea724c59e6-uimage.png}{\includegraphics{images/7974c303-f442-427e-85a0-92ea724c59e6-uimage.png}}{}
\makeatother 
\caption{{Association betweenventilation and mortality}}
\label{f-10efef688ef8}
\end{figure*}
\egroup
Mortality was more in the patients in this study requiring ventilator support. Significant association was identified between ventilator support and mortality. Of the patients with ventilator support 70.2\% expired

\textbf{14. Association between Diagnosis and Outcome:Table~\ref{tw-0d5753411725}Figure~\ref{f-d92b01b476f7}}


\begin{table*}[!htbp]
\caption{{Association between Diagnosis and Outcome:} }
\label{tw-0d5753411725}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLLL}
\hline~\\[-8pt] 
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{}} &
  \multicolumn{2}{p{\dimexpr(\mcWidth{3}+\mcWidth{4})}}{Outcome}\\
 &
   &
  Survived &
  Expired\\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{22}{\linewidth}{Diagnosis}} &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Sepsis }} &
  16 &
  10\\
 &
   &
  61.50\% &
  38.50\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Cardiac diagnosis }} &
  7 &
  7\\
 &
   &
  50.00\% &
  50.00\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Respiratory diagnosis }} &
  11 &
  6\\
 &
   &
  64.70\% &
  35.30\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Gastrointestinal }} &
  9 &
  4\\
 &
   &
  69.20\% &
  30.80\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Metabolic/poisoning Diagnoses}} &
  3 &
  4\\
 &
   &
  42.90\% &
  57.10\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Primary neurologic Diagnoses}} &
  1 &
  2\\
 &
   &
  33.30\% &
  66.70\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Undifferentiated acute Febrile illness}} &
  18 &
  14\\
 &
   &
  56.30\% &
  43.80\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Leptospirosis}} &
  21 &
  12\\
 &
   &
  63.60\% &
  36.40\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Dengue}} &
  2 &
  1\\
 &
   &
  66.70\% &
  33.30\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Drug}} &
  0 &
  1\\
 &
   &
  0.00\% &
  100.00\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Snake bite}} &
  0 &
  1\\
 &
   &
  0.00\% &
  100.00\%\\
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{Total}} &
  88 &
  62\\
 &
   &
  58.70\% &
  41.30\%\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/389a7313-b4df-4ff0-a849-9d8f3181a421-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/389a7313-b4df-4ff0-a849-9d8f3181a421-uimage.png}{\includegraphics{images/389a7313-b4df-4ff0-a849-9d8f3181a421-uimage.png}}{}
\makeatother 
\caption{{Association between diagnosis andOutcome}}
\label{f-d92b01b476f7}
\end{figure*}
\egroup
Mortality was more in the patients in this study with undifferentiated acute febrile illness, 43.8\% and leptospirosis, 36.4\%. No significant association was identified between the etiology of AKI and mortality.

\textbf{15. Association Between Diagnosis And Stage Of AKI: Table~\ref{tw-acfb83e057ec}Figure~\ref{f-4166b236480e}}


\begin{table*}[!htbp]
\caption{{Association betweendiagnosis and stage of AKI} }
\label{tw-acfb83e057ec}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLLLL}
\hline~\\[-8pt] 
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{}} &
  \multicolumn{3}{p{\dimexpr(\mcWidth{3}+\mcWidth{4}+\mcWidth{5})}}{AKI stage}\\
 &
   &
  1 &
  2 &
  3\\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{22}{\linewidth}{DIAGNOSIS}} &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Sepsis }} &
  1 &
  8 &
  17\\
 &
   &
  3.8\% &
  30.8\% &
  65.4\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Cardiac diagnosis }} &
  2 &
  10 &
  2\\
 &
   &
  14.3\% &
  71.4\% &
  14.3\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Respiratory diagnosis }} &
  2 &
  7 &
  8\\
 &
   &
  11.8\% &
  41.2\% &
  47.1\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Gastrointestinal }} &
  0 &
  5 &
  8\\
 &
   &
   &
  38.5\% &
  61.5\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Metabolic/poisoning Diagnoses}} &
  0 &
  5 &
  2\\
 &
   &
   &
  71.4\% &
  28.6\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Primary neurologic Diagnoses}} &
  1 &
  2 &
  0\\
 &
   &
  33.3\% &
  66.7\% &
  0.0\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Undifferentiated acute Febrile illness}} &
  1 &
  3 &
  28\\
 &
   &
  3.1\% &
  9.4\% &
  87.5\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Leptospirosis}} &
  0 &
  3 &
  30\\
 &
   &
   &
  9.1\% &
  90.9\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Dengue}} &
  0 &
  2 &
  1\\
 &
   &
   &
  66.7\% &
  33.3\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Drug}} &
  0 &
  0 &
  1\\
 &
   &
   &
   &
  100.0\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Snake bite}} &
  0 &
  1 &
  0\\
 &
   &
   &
  100.0\% &
  \\
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{Total}} &
  7 &
  46 &
  97\\
 &
   &
  4.7\% &
  30.7\% &
  64.7\%\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/bb7e9a71-59c0-40d8-8d75-c3b71924ad53-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/bb7e9a71-59c0-40d8-8d75-c3b71924ad53-uimage.png}{\includegraphics{images/bb7e9a71-59c0-40d8-8d75-c3b71924ad53-uimage.png}}{}
\makeatother 
\caption{{Association between diagnosis and stage of AKI}}
\label{f-4166b236480e}
\end{figure*}
\egroup
90.9\% of those with leptospirosis and 87.5\% of those with undifferentiated febrile illness presented in AKI stage 3. Significant association was identified between the etiology of AKI and the stage of presentation on admission to the medical intensive care unit.

\textbf{16. Association between etiology of AKI and dialysis requirement: Table~\ref{tw-13f921da0eca}Figure~\ref{f-e1d6fb0d322b}}


\begin{table*}[!htbp]
\caption{{Association between etiology of AKI and dialysis requirement:} }
\label{tw-13f921da0eca}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLLL}
\hline~\\[-8pt] 
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{}} &
  \multicolumn{2}{p{\dimexpr(\mcWidth{3}+\mcWidth{4})}}{Dialysis}\\
 &
   &
  Not done &
  Done\\
\multicolumn{1}{p{\dimexpr(\mcWidth{1})}}{\multirow{22}{\linewidth}{ Etiology}} &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Sepsis }} &
  17 &
  9\\
 &
   &
  65.40\% &
  34.60\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Cardiac diagnosis }} &
  14 &
  0\\
 &
   &
  100.00\% &
  0.00\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Respiratory diagnosis }} &
  14 &
  3\\
 &
   &
  82.40\% &
  17.60\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Gastrointestinal }} &
  11 &
  2\\
 &
   &
  84.60\% &
  15.40\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Metabolic/poisoning diagnoses}} &
  7 &
  0\\
 &
   &
  100.00\% &
  0.00\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Primary neurologic diagnoses }} &
  3 &
  0\\
 &
   &
  100.00\% &
  0.00\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Undifferentiated acute febrile illness}} &
  6 &
  26\\
 &
   &
  18.80\% &
  81.30\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Leptospirosis}} &
  7 &
  26\\
 &
   &
  21.20\% &
  78.80\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Dengue}} &
  2 &
  1\\
 &
   &
  66.70\% &
  33.30\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Drug}} &
  0 &
  1\\
 &
   &
  0.00\% &
  100.00\%\\
 &
  \multicolumn{1}{p{\dimexpr(\mcWidth{2})}}{\multirow{2}{\linewidth}{Snake bite}} &
  1 &
  0\\
 &
   &
  100.00\% &
  0.00\%\\
\multicolumn{2}{p{\dimexpr(\mcWidth{1}+\mcWidth{2})}}{\multirow{2}{\linewidth}{Total}} &
  82 &
  68\\
 &
   &
  54.70\% &
  45.30\%\\
\hline 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/0a7e5c0b-6db7-4e3e-b9fb-1eb206509d4c-uimage.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/0a7e5c0b-6db7-4e3e-b9fb-1eb206509d4c-uimage.png}{\includegraphics{images/0a7e5c0b-6db7-4e3e-b9fb-1eb206509d4c-uimage.png}}{}
\makeatother 
\caption{{Association between etiology of AKI and dialysisrequirement}}
\label{f-e1d6fb0d322b}
\end{figure*}
\egroup
Significant association was identified between etiology of AKI and the need for dialysis. Dialysis was required in 81.3\% among those with undifferentiated febrile illness and 78.8\% among those with leptospirosis and the association was significant by Chi square test.

\textbf{17. Logistic regression analysis of outcome predictors:Table~\ref{tw-b3f16e06304c}}


\begin{table*}[!htbp]
\caption{{Logistic regression analysis of outcome predictors:} }
\label{tw-b3f16e06304c}
\def\arraystretch{1}
\ignorespaces 
\centering \small 
\begin{tabulary}{\linewidth}{LLLLLLL}
\hline~\\[-8pt] 
 &
   &
  S.E. &
  Wald &
  df &
  Sig. &
  Exp(B)\\
Basal crepitations &
  -.416 &
  .654 &
  .405 &
  1 &
  .525 &
  .660\\
Breathlessness &
  .989 &
  .643 &
  2.364 &
  1 &
  .124 &
  2.687\\
AKI stage &
  20.905 &
  5237.667 &
  .000 &
  1 &
  .997 &
  1199225957.801\\
Ventilation &
  3.535 &
  .726 &
  23.717 &
  1 &
  .000 &
  34.291\\
Inotrope &
  2.102 &
  1.043 &
  4.059 &
  1 &
  .044 &
  8.186\\
Indication for dialysis  &
  -.170 &
  .118 &
  2.050 &
  1 &
  .152 &
  .844\\
Constant &
  -66.870 &
  15713.000 &
  .000 &
  1 &
  .997 &
  .000\\
\hline 
\end{tabulary}\par 
\end{table*}
By logistic regression analysis of the factors having association with mortality, requirement of ventilator support and inotropic supports were independent predictors of mortality. 
    
\section{Discussion:}
\textbf{AGE AND GENDER}

A trend towards an increasing number of AKI cases among male patients was observed compared to female patients [73\% and 27 \% respectively] in this study.

\textit{Compared with all ICU admissions, patients with AKI were found in male gender in Basu et al, Cruz et al and Daher et al \unskip~\cite{634105:14853767,634105:14853768,634105:14853769}}The reasons for such gender differences are unclear but are likely associated with work activities. 

Majority of patients in this study belonged to 55-65 years (21\%) followed by 45-55 years (20\%). Mean age was 49.6 years with standard deviation 16.5. \textit{The population of patients with AKI in developing tropical countries is younger (30{\textendash}40 years of age) than that reported in developed temperate countries (60{\textendash}70 years of age) like Angus et al\unskip~\cite{634105:14853771}}

\textbf{CLINICAL FEATURES}

Fever was the most common presenting symptom (72\%) followed by decreased urine output (48\%), breathlessness (45.3\%), and myalgia (42.7\%). \textit{Predominant presenting features included fever (89.6\%), oliguria (70.4\%), and breathlessness (40.4\%) as in Mehta et al \unskip~\cite{634105:14853772}}

Only 7 \% of the patients in this study had h/o nephrotoxic drug usage. NSAID (2\%) being the most common one implicated. 

The most common general examination finding in the patients in this study was icterus (52\%) followed by conjunctival congestion (22\%). The most common systemic examination finding in patients in this study was basal crepitations (40 \%). \textit{In Eswarappa et al, edema was seen in 28.0\%, pallor in 20.0\% and icterus in 21.0\% of the patients \unskip~\cite{634105:14853764}}

The mean serum creatinine in the patients in this study on admission to the Medical ICU was 3.72 mg/dL with a standard deviation of 1.65. \textit{Mean serum creatinine was 3.64 with SD of 3.1 in a study by Maulita et and 10.18 \ensuremath{\pm} 5.19 mg/dl in a study by Ahmed et al  \unskip~\cite{634105:14853773}}

\textbf{DIAGNOSIS }

The most common diagnosis in the patients in this study was leptospirosis (22\%) followed by undifferentiated fever (21\%) and sepsis seen in 17\%.

\textit{In contrast to sepsis, drugs and cardiogenic shock in the developed world, acute tubular necrosis (ATN) due to community-acquired infections remains the commonest cause of AKI in the tropics. Chug, Medve and Angus et al \unskip~\cite{634105:14853774,634105:14853775,634105:14853776,634105:14853777,634105:14853778}}

\textit{The main causes of ICU hospitalization were acquired immunodeficiency syndrome (AIDS)-related diseases (28 .6\%), pneumonia 13\%), leptospirosis (11.6\%) in Daher et al \unskip~\cite{634105:14853775} . It was scrub typhus (51.2\%), falciparum malaria (10.4\%), and enteric fever (8.7\%) in study by } \textit{Basu et al \unskip~\cite{634105:14853773} .}Unlike in our study the predominant cause of AKI in most studies in tropical areas was due to malaria. 

90.9\% of those with leptospirosis and 87.5\% of those with undifferentiated febrile illness presented in AKI stage 3. Significant association was identified between the etiology of AKI and the stage of presentation on admission to the medical intensive care unit. 

Significant association was identified between etiology of AKI and the need for dialysis. Dialysis was required in 81.3\% among those with undifferentiated febrile illness and 78.8\% among those with leptospirosis and the association was significant by Chi square test. 

\textit{Leptospirosis with AKI admitted to ICU had a significantly higher frequency of severe AKI 73.2 \% and a higher prevalence of dialysis requirement (57.3 \%) in a study by } \textit{De Francesco et al\unskip~\cite{634105:14853779}}

\textbf{MANAGEMENT}

The most common stage of AKI in the patients in this study group on admission to the medical intensive care unit was stage 3 in 64.7\%. \textit{Unlike in a study by lopes et al in which AKI occurred in 50.4\% of patients {\textendash} 21.1\% with Stage 1, 10.1\% with Stage 2 and 19.2\% with Stage 3 .}

45\% of the patients in the study group required dialysis, among which 24\% underwent CRRT while the 76\% underwent hemodialysis.

\textit{In a study conducted by Bernieh b et al. 58\% of patients were managed conservatively while 42\% patient were managed with dialysis which is comparable with present study.\unskip~\cite{634105:14853771}}

The predominant indication for dialysis in the patients in this study group was metabolic acidosis with anuria. \textit{The most common indication for dialysis was refractory fluid overload (89.4 \%), followed by uremic signs and symptoms (61.1 \%) in study by Ibrahim et al [23], probably because CKD patients were also included.}

\textbf{MORTALITY}

Mortality was 41\% in the patients in the study group. \textit{The ICU mortality rate was 39.3\% (44/112) in study by Medve et al\unskip~\cite{634105:14853777}   which is comparable with our study.}

Maximum mortality was seen in the age group 55-65years - 22.6\% and 45-55 years. - 17.7\%. Mortality was more, 72.6\% in the male patients in this study group compared to females. 

59.7\% of the patients in this study who died had no associated comorbidities.

Mortality was more, 71 \% in the patients with fever in this study. However, no significant association was identified between age group, gender, patients with comorbidities, fever as presenting symptom and mortality.

\textit{Age, gender or the presence of co-morbidities was not associated with a higher risk of AKI as in Wijikerma et al \unskip~\cite{634105:14853772}\ensuremath{^{}}}

Among those with breathlessness as presenting symptom, 58.8\% expired compared to only 26.8\% among those with no breathlessness on admission to the Medical ICU. Significant association was identified mortality and breathlessness as the presenting symptom, with p value {\textless}0.05. 

Among those with Basal Crepitations, 53.3\% expired compared to only 33.3\% among those with no Basal Crepitations on admission to the Medical ICU. Significant association was identified mortality and breathlessness as the presenting symptom, with p value {\textless}0.05. 

\textit{Respiratory involvement, along with AKI had statistically significant chances of poor outcome (p{\textless}0.05) in a study by Bhadade et al \unskip~\cite{634105:14853780}}

Mortality was more in the patients in this study with undifferentiated acute febrile illness, 43.8\% and leptospirosis, 36.4\%. \textit{No significant association was identified between the etiology of AKI and mortality unlike in study by Eswarappa et al which identified significant difference in mortality due to medical versus surgical etiology of AKI. }

53\% of those with stage 3 AKI expired compared to no mortality in the stage 1 or 2. Significant association could be identified between stage of AKI and mortality by chi square test with a p value less than 0.05. \textit{AKIN stages based on creatinine criteria predicted mortality as in a study by Lopez et al\unskip~\cite{634105:14853781} .}

Mortality was more in the patients in this study who underwent dialysis 48.5\% compared to those who did not require it. This may be because of the fact that they are more hemodynamically compromised. But no significant association was identified between dialysis and mortality. 

\textit{The need for dialysis treatment has been associated with a higher mortality rate (50-70\%) than among patients with AKI who did not require RRT in study by} \textit{Bhadade et al \unskip~\cite{634105:14853780}}

Significant association was identified between indication for dialysis and mortality. 60\% of the patients who underwent dialysis and died had both metabolic acidosis and anuria. \textit{Significant association was identified between patients with metabolic acidosis and anuria and mortality in Kumar et al.\unskip~\cite{634105:14853781}\ensuremath{^{}}}

Mortality was more in the patients in this study requiring inotrope support. 48\% of those with inotropic support expired. Significant association was identified between inotropic support and mortality with p value{\textless}0.05.

Mortality was more in the patients in this study requiring ventilator support. Significant association was identified between ventilator support and mortality. Of the patients with ventilator support 70.2\% expired.

\textit{Vasopressor support and assisted ventilation were predictors for mortality in a study by Mathew George et al. \unskip~\cite{634105:14853780}}

By multivariate logistic regression analysis of the factors having association with mortality, requirement of ventilator support and inotropic supports were independent predictors of mortality. \textit{Significant association was identified between patients with ventilator support and mortality in Saxena et al \ensuremath{^{47}}and Liano et al. \unskip~\cite{634105:14853774}\unskip~\cite{634105:14853782,634105:14853783,634105:14853784}}
    
\section{\textbf{Conclusion:}}
150 consecutive patients diagnosed to have acute kidney injury admitted to the medical ICU of a tertiary care center in Kerala were studied. The main burden of diseases were due to infective etiologies. The most common was leptospirosis (22\%) followed by undifferentiated fever (21\%) and sepsis seen in 17\%. This is unlike to studies done in developed countries. This reflects mainly the trend in tropical regions with higher rainfall. Mortality was 41\% in the study and requirement of ventilator support and inotropic supports were independent predictors of mortality. 

In the tropics, diseases like leptospirosis have a high propensity to be the cause of AKI. So a high degree of suspicion should be kept to aid in the diagnosis and early referral to centers with intensive care facilities.
    
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