High risk of acute kidney injury in Malawian trauma patients: a prospective observational cohort study.

BACKGROUND: Trauma is a common cause of acute kidney injury (AKI). Yet little data exist regarding trauma-related-AKI in low-resourced settings, where the majority of deaths from AKI and trauma occur. We prospectively evaluated epidemiology of AKI in hospitalized Malawian trauma patients. METHODS: AKI was defined by creatinine-only Kidney Disease Improving Global Outcomes (KDIGO) criteria. Those with AKI were followed up 3-6 months later to determine persistent kidney abnormalities. We calculated univariate statistics with Wilcoxon rank sum tests, Fisher's exact, and chi-square tests to compare those with and without AKI. Multivariate log-risk regression modelling was used to determine risk ratios (RR) and 95% confidence intervals (CI) for AKI development. RESULTS: Of 223 participants, 14.4% (n = 32) developed AKI. Most patients were young (median age 32) males (n = 193, 86.5%) involved in road traffic injuries (n = 120, 53.8%). After adjusting for confounders, those with severe anemia during their admission were 1.4 times (RR 1.4, 95% CI 1.1-1.8) more likely to develop AKI than those without. Overall mortality was 7.6% (n = 17), and those who developed AKI were more likely to die than those who did not (18.8% vs 5.6%, p-value = 0.02). Almost half of those with AKI (n = 32) either died (n = 6) or had persistent kidney dysfunction at follow-up (n = 8). CONCLUSION: In one of the few African studies on trauma-related AKI, we found a high incidence of AKI (14.4%) in Malawian trauma patients with associated poor outcomes. Given AKI's association with increased mortality and potential ramifications on long-term morbidity, urgent attention is needed to improve AKI-related outcomes.

Validity of Urine NGALds Dipstick for Acute Kidney Injury in a Malawian Trauma Cohort.

INTRODUCTION: Acute kidney injury (AKI) is a major cause of mortality worldwide, particularly in low-resource settings with limited diagnostic testing. Neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in predicting AKI. Nested within a larger, prospective cohort study evaluating AKI incidence in admitted trauma patients, our objective was to evaluate a novel dipstick, NGALds, for the prediction of AKI in Malawi, Africa. METHODS: Participants were >6 months of age. Spearman rank correlation coefficients (R) assessed NGAL categories (negative [≤50 ng/ml], low risk [51-149 ng/ml], moderate risk [150-299 ng/ml], and high risk [≥300 ng/ml]) for the urine NGALds dipstick and laboratory-based NGAL Test. RESULTS: We enrolled 285 participants (one-third children). Thirteen percent developed AKI. The dipstick captured 45 of 52 participants (86.5%) with moderate- or high-risk NGAL values on laboratory-based testing (R = 0.74). The dipstick had sensitivity of 44.4%, specificity of 73.5%, positive predictive value of 19.5%, and negative predictive value of 90.2% for predicting AKI. Acute kidney injury was associated with an increased risk of mortality (relative risk [RR] = 3.9, 95% confidence interval [CI] = 1.9-8.2), but mortality risk greatly increased among children who first had a positive (≥150 ng/ml) NGALds result (RR = 12.0, 95% CI = 1.8-78.4). CONCLUSIONS: The NGALds dipstick performed similarly to the NGAL Test in this low-resource setting and may be a useful tool to rule out AKI. It may be even more important in predicting high mortality risk among children.

Incidence and epidemiology of acute kidney injury in a pediatric Malawian trauma cohort: a prospective observational study.

BACKGROUND: Acute kidney injury (AKI) is highly associated with mortality risk in children worldwide. Trauma can lead to AKI and is a leading cause of pediatric death in Africa. However, there is no information regarding the epidemiology of pediatric, trauma-associated AKI in Africa. METHODS: Prospective cohort study of pediatric trauma patients admitted to a tertiary referral hospital in Malawi. Participants enrolled at admission were followed prospectively throughout their hospitalization. AKI was defined by creatinine-only Kidney Disease Improving Global Outcomes criteria. We calculated descriptive statistics and univariate relative risks (RR) for hypothesis-generation of potential risk factors associated with AKI. RESULTS: We analyzed data from 114 participants. Depending on baseline creatinine definition, AKI incidence ranged from 4 to 10%. The new Schwartz equation estimated baseline creatinine values best and yielded an AKI incidence of 9.7%. Almost one in ten children died during hospitalization, but those with AKI (n = 4) were at significantly higher risk of death compared to those without AKI (40.0% vs 6.2%; RR 6.5, 95% CI 2.2-19.1). Burn injuries were most commonly associated with AKI (63.6%). Other potential AKI risk factors included multiple injuries, trunk or facial injuries, and recent consumption of herbal remedies. CONCLUSIONS: AKI occurs in up to 10% of admitted pediatric trauma patients in Malawi and increases the risk of death 7-fold compared to those without AKI. This large unrecognized burden in trauma requires further investment by researchers, clinicians and policymakers to develop evidenced-based triage, recognition, and management approaches to prevent the associated sequelae and potential mortality from AKI.

Cardiovascular risk factors in adult Malawians on long-term antiretroviral therapy.

Around 225,000 patients currently receive antiretroviral therapy (ART) in the Malawi scale-up programme that uses the public health approach to ART. There are concerns that cardiovascular disease risk factors are common in ART patients, but few data exist from sub-Saharan Africa, and none from Malawi. We did a cross-sectional study of cardiovascular risk factors in urban, adult, Malawian ART patients, with the WHO STEP-wise surveillance tool. We enrolled 174 long-term (>1 year) ART patients during routine clinic visits, mean age 40.8 years (range 18-69), 61.5% female, 97.1% on first-line regimens, median duration ART 35.5 months. Insufficient fruit and vegetable diet (67.6%), raised blood pressure (45.9%), increased waist-hip ratio (45.4%), raised total cholesterol levels (31.0%) and low physical activity level (27.0%) were common, while current smoking (0.6%), current alcohol consumption (2.3%) and elevated glucose levels (1.2%) were rare. In multivariable analyses, higher age was associated with low physical activity, raised blood pressure, being overweight, and increased waist-hip ratio. Longer duration of ART was not associated with any risk factor and was protective for being overweight. Cardiovascular risk factors were common among long-term ART patients in Malawi. This requires more attention and further study in programmes using the public health approach to ART.