Professional Documents
Culture Documents
Jorge Cerda,* Norbert Lameire, Paul Eggers, Neesh Pannu, Sigehiko Uchino,
Haiyan Wang, Arvind Bagga,** and Adeera Levin
*Division of Nephrology, Albany Medical College, Albany, New York; Department of Internal Medicine, University
Hospital Ghent, Ghent, Belgium; Kidney and Urology Epidemiology, National Institute of Diabetes and Digestive and
Kidney Disease, National Institutes of Health, Bethesda, Maryland; Division of Nephrology, University of Alberta,
Edmonton, Alberta, Canada; Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama,
Japan; The First Hospital Institute of Nephrology, Beijing University, Beijing, China; **Division of Pediatric
Nephrology, All India Institute of Medical Sciences, New Delhi, India; and Division of Nephrology, University of
British Columbia, Vancouver, British Columbia, Canada
Background and objectives: The worldwide incidence of acute kidney injury is poorly known because of underreporting,
regional disparities, and differences in definition and case mix. New definitions call for revision of the problem with unified
criteria.
Design, setting, participants, & measurements: This article reports on the research recommendations of an international
multidisciplinary committee, assembled to define a research agenda on acute kidney injury epidemiology using a modified
three-step Delphi process.
Results: Knowledge of incidence and risk factors is crucial because it drives local and international efforts on detection and
treatment. Also, notable differences exist between developing and developed countries: Incidence seems higher in the former,
but underreporting compounded by age and gender disparities makes available data unreliable. In developing countries,
incidence varies seasonally; incidence peaks cause critical shortages in medical and nursing personnel. Finally, in developing
countries, lack of systematic evaluation of the role of falciparum malaria, obstetric mechanisms, and hemolytic uremic
syndrome on acute kidney injury hampers efforts to prevent acute kidney injury.
Conclusions: The committee concluded that epidemiologic studies should include (1) prospective out- and inpatient studies
that measure incidence of community and hospital acute kidney injury and postacute kidney injury chronic kidney disease;
(2) incidence measurements during seasonal peaks in developing and developed countries; and (3) whenever available, use of
reliable existing administrative or institutional databases. Epidemiologic studies using standardized definitions in community and institutional settings in developing and underdeveloped countries are essential first steps to achieving early detection
and intervention and improved patient outcomes.
Clin J Am Soc Nephrol 3: 881-886, 2008. doi: 10.2215/CJN.04961107
increase in worldwide incidence, large differences in the definition of AKI and case mix likely underlie such differences.
It is recognized that the epidemiology of AKI in developing
countries differs from that of the developed world in many
important ways (8 16). Whereas in developed regions elderly
patients predominate (4,5), in developing countries, AKI is a
disease of the young (14,17,18) and children (19,20), in whom
volume-responsive prerenal mechanisms are common (21
24). Although overall mortality seems to be lower than in
developed countries (2528), this finding is not true across all
age groups: In these regions, AKI affects predominantly the
young and children and mortality is high (29,30).
The difficulties of defining the incidence of AKI are especially
notable when one searches for data on developing countries
(8,13,15,16,25,3133), the place of residence of more than 50% of
the worlds population. No nationwide collection systems are
available, and data from isolated centers are not based on the
ISSN: 1555-9041/3030881
882
mittee, and a final ranking phase during which the research agenda
was developed.
Results
Global Perspectives
Local conditions in developing countries make underreporting an important problem (1,16). It is improbable that incidence
rates are so much lower in these regions than in developed
countries. The most likely explanation for the seemingly lower
incidence of AKI is that the majority of patients who develop
AKI never make it to large reporting centers: The condition is
underrecognized, distances are enormous, and the costs of
transportation and lost wages are prohibitive (3). Delayed referral as a result of transportation difficulties and traditional
cultural mores is still a formidable problem in many regions of
the world (61) associated with significantly worse outcomes, as
seen among children with hemolytic uremic syndrome in India
(30).
Gender disparities in seeking medical attention make available reports even more unreliable. Thus, in certain regions in
Africa and India, boys are more than twice as likely as girls to
be taken by their parents to see medical personnel (62 66).
Gender disparity is also expressed in the development of AKI
after septic abortion (41,67). In some African countries, the
problem has unfortunately worsened (41) despite nationwide
efforts.
In developing countries even at large centersthe availability of medical and nursing personnel is limited. This limitation becomes even more critical during seasonal variations in
incidence (10,68 70). For example, during the monsoon season
in Southeast Asia, the incidence of AKI may increase by 18 to
24% as a result of the increase in new cases of malaria, leptospirosis, acute gastroenteritis, and dysentery (71).
The causes and risk factors for AKI in developing countries
may be different from those in developed countries. Although
prerenal or toxic mechanisms predominate, specific etiologies
are important.
883
1 - FULL RECOVERY
2 - AKI TO CKD
RENAL FUNCTION
100
3 - ACUTE-ON-CHRONIC
KIDNEY DISEASE
4 - AKI TO ESRD
0
TIME
884
Research Recommendations
Conclusions
AKI is a worsening problem, but its true incidence is unknown. From a worldwide perspective, there is a clear need to
understand the epidemiology of AKI more accurately. Use of
standardized definitions and descriptions of existing at-risk
and high-risk populations, both in community and institutional
settings in developing and underdeveloped countries, are the
first steps to improve outcomes.
Disclosures
None.
References
1. Lameire N, Van Biesen W, Vanholder R: The changing
epidemiology of acute renal failure. Nat Clin Pract Nephrol
2: 364 377, 2006
2. Lameire N, Van Biesen W, Vanholder R: The rise of prevalence and the fall of mortality of patients with acute renal
failure: What the analysis of two databases does and does
not tell us. J Am Soc Nephrol 17: 923925, 2006
3. Lameire N, Van Biesen W, Vanholder R: Acute renal failure. Lancet 365: 417 430, 2005
4. Xue JL, Daniels F, Star RA, Kimmel PL, Eggers PW, Molitoris BA, Himmelfarb J, Collins AJ: Incidence and mortality
of acute renal failure in Medicare beneficiaries, 1992 to
2001. J Am Soc Nephrol 17: 11351142, 2006
5. Waikar SS, Curhan GC, Wald R, McCarthy EP, Chertow
GM: Declining mortality in patients with acute renal failure, 1988 to 2002. J Am Soc Nephrol 17: 11431150, 2006
6. Liano F, Pascual J: Epidemiology of acute renal failure: A prospective, multicenter, community-based study. Madrid Acute
Renal Failure Study Group. Kidney Int 50: 811818, 1996
7. Ali T, Khan I, Simpson W, Prescott G, Townend J, Smith W,
Macleod A: Incidence and outcomes in acute kidney injury:
A comprehensive population-based study. J Am Soc Nephrol 18: 12921298, 2007
8. Abraham G, Gupta RK, Senthilselvan A, van der Meulen J,
Johny KV: Cause and prognosis of acute renal failure in
Kuwait: A 2-year prospective study. J Trop Med Hyg 92:
325329, 1989
9. Jha V, Malhotra HS, Sakhuja V, Chugh KS: Spectrum of
hospital-acquired acute renal failure in the developing
countries: Chandigarh study. Q J Med 83: 497505, 1992
10. Noronha IL, Schor N, Coelho SN, Jorgetti V, Romao Junior JE,
Zatz R, Burdmann EA: Nephrology, dialysis and transplantation in Brazil. Nephrol Dial Transplant 12: 2234 2243, 1997
11. Thomas CN, Brann SH, Douglas AR, Thomas JM, Daniel
SC, Posthoff C, Rampersad KA, Angelini GD: Coronary
artery bypass graft outcome: The Trinidad and Tobago
experience. West Indian Med J 49: 290 293, 2000
12. Al-Homrany M: Epidemiology of acute renal failure in
hospitalized patients: Experience from southern Saudi
Arabia. East Mediterr Health J 9: 10611067, 2003
13. Vukusich A, Alvear F, Villanueva P, Gonzalez C, Francisco
O, Alvarado N, Zehnder C: Epidemiology of severe acute
renal failure in Metropolitan Santiago [in Spanish]. Rev
Med Chil 132: 13551361, 2004
14. Kohli HS, Bhat A, Jairam A, Aravindan AN, Sud K, Jha V,
Gupta KL, Sakhuja V: Predictors of mortality in acute renal
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
885
886
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.