3
98
tive management with none requiring dialysis. It is
likely that the appropriate treatment of the underlying
malaria contributed to this good outcome. Similarly, the
use of appropriate antibiotics to treat sepsis would have
also contributed to the good outcome. The bottom line
therefore is that the fatal progression of these two ill-
nesses can be interrupted with the use of appropriate
potent pharmacologic agents. Once this is done, the con-
sequent AKI is reversed in most cases if acute cortical
necrosis has not developed.
the best option. Mean serum potassium were on the
higher level of normal in both the conservative and di-
alysis group but the difference in both groups was not
statistically significant even though there were individ-
ual cases of hyperkalemia as shown in Tables 2&3. The
serum sodium was comparably low in both groups be-
cause of the consequent fluid retention common to both
groups. Of all the biochemical determinants of modality
of management, only serum creatinine may be consid-
ered in isolation. The others must be considered relative
to the serum creatinine. In other words, if the serum urea
is elevated and the serum creatinine is not proportion-
ately elevated, it may be of no effect as other conditions
such as dehydration may have contributed to that.
In contrast, renal replacement therapy was required in
the glomerulopathies whose cou8 rse sometimes carry
1
poor prognosis once AKI sets in. The causes of AKI in
the glomerulopathies may include the disease process
itself which are irreversible in some cases and the effect
of drug used in the management of the condition such as
frusemide which could cause interstitial nephritis.
The most significant determinant of modality of treat-
ment in this study was the urine output. It had an appre-
ciable sensitivity and specificity, however, the positive
and negative predictive value was marginal. This is in
tandem with the RIFLE and AKIN recommendation
which uses both (urine output and GFR) and (urine out-
put and serum creatinine) respectively as criteria for
determ1, 3ining severity and hence mode of management of
AKI. Therefore, if the mean lowest urine output in
both groups (shown in Table 4) is approximated to one
decimal place, it would give (0.6±0.4ml/kg/hr for the
conservative group) and (0.1±0.1 ml/kg/hr for the dialy-
sis group). The implication therefore is that children
with urine output of ≥0.6ml/kg/hr would benefit from
conservative management, while children with urine
output of ≤0.1ml/kg/hr would require dialysis.
A close look at the serum creatinine of the conservative
group shows that it was lower when compared with the
dialysis group even though it was not statistically sig-
nificant. Hence as serum creatinine rises, the corre-
sponding most appropriate intervention must be offered
immediately. However in resource poor countries of
Africa, conservative management are more readily of-
fered because of limited facilities and uneven distr1i9bu-
tion and availability of renal replacement therapy. In
Nigeria, the spread and availability of dialysis facilities
is gradually improving. However there are still chal-
lenges of ability of caregivers to pay for the services and
when19-t2h0ey can pay, certain logistics may be unavail-
able.
Our study indicated that offering conservative
There is the group in between >0.1ml/kg/hr (benchmark
for dialysis group) and <0.6ml/kg/hr (benchmark for the
conservative group) i.e. 0.11-0.59ml/kg/hr which is left
hanging. It is our opinion that any urine output between
0.11-0.59ml /kg/hr may be offered a “trial of conserva-
tive management” when all other biochemical parame-
ters are considered. However to minimize risk to the
patients, the best form of intervention available should
be promptly offered.
management may not be a bad option at serum
creatinine ≤676.79µmol/l. However at serum creatinine
>
676.7µmol/l, dialysis remains the best option, even
though there may still be a few patients that may benefit
from conservative management as evidenced by six pa-
tients in Table 2 with elevated serum creatinine due
mainly to severe malaria. As earlier indicated, AKI re-
verses in most cases of severe malaria once appropriate
antimalaria is administered. Similarly at serum urea
≤
sidered, while at serum urea above that, dialysis remains
37.34mmol/l, conservative management may be con-
Conflict of interest: None
Funding: None
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