Predictors of Fatal Outcome in Hospitalised Adult Patients with Acute Kidney Injury at Two Tertiary Hospitals in Sub-Saharan Africa

Introduction: Data on mortality in acute kidney injury (AKI) derives from high-income countries where AKI is hospital-acquired and occurs in elderly patients with a high burden of cardiovascular disease. In sub-Saharan Africa (SSA), AKI is community-acquired occurring in healthy young adults. We aimed to identify predictors of fatal outcomes in patients with AKI in two tertiary hospitals in Cameroon. Methods: Medical records of adults with confirmed AKI, from January 2018 to March 2020 were retrieved. The outcomes of interest were in-hospital deaths and presumed causes of death. We used multiple logistic regressions modeling to identify predictors of death. The study was approved by the ethics boards of both hospitals. Values were considered significant for a p-value of 0.05. Results: We included 285 patient records (37.2% females). The mean (SD) age was 50.1 (19.0) years. Hypertension (n = 97, 34.0%), organ failure (n = 88, 30.9%), and diabetes (n = 60, 21.1%) were the main comorbidities. The majority of patients had community-acquired AKI (78.6%, n = 224), were KDIGO stage 3 (88.8%, n = 253), and needed dialysis (52.6%, n = 150). Up to 16.7% (n = 25) did not receive what was needed. The in-hospital mortality rate was 29.1% (n = 83). Lack of access to dialysis (OR = 27.8;CI: 5.2 - 149.3, p = 0.001), hypotension (OR = 11.8;CI: 1.3 - 24.8;p = 0.001) and ICU admission (OR = 5.7;CI: 1.3 - 24.8, p = 0.001) were predictors of mortality. The presence of co-morbidities or underlying diseases (n = 46, 55%) were the main causes of death. Conclusions: In-hospital AKI mortality is high, as in other low- and middle-income economies. Lack of access to dialysis and the severity of the underlying illness are major predictors of death.

Paraquat poisoning from accidental ingestion leading to fatal outcome:A case report

Rationale:Paraquat,a highly toxic bipyridyl herbicide lacking a specific antidote,poses severe risks upon ingestion.However,the diagnosis of paraquat poisoning is complicated by its nonspecific initial symptoms,particularly when a detailed exposure history is not provided.Patient’s Concern:A 33-year-old man inadvertently ingested an unknown liquid and presented to medical services a day later with complaints of ongoing nausea,vomiting,and diarrhea.The assessment revealed elevated serum creatinine,signaling acute kidney injury,initially thought due to gastroenteritis and dehydration.Diagnosis:Acute renal insufficiency due to paraquat poisoning.Interventions:The treatment involved fluid resuscitation and antibiotics,but his decline led to intensive care unit transfer.Subsequent chest computed tomography scans indicated lung changes indicative of paraquat poisoning.A detailed history review and comprehensive blood and urine toxicology screens confirmed the diagnosis.Subsequently,aggressive interventions such as hemoperfusion and continuous renal replacement therapy were initiated,yet there was a further decline in respiratory function,necessitating mechanical ventilation.The prognosis was poor,and ultimately,the family chose to withdraw care.Outcomes:The patient succumbed to his illness.Lessons:This case underscores the importance of promptly and accurately diagnosing paraquat poisoning,as its vague early signs can lead to diagnostic delays,crucial due to the condition’s rapid progression.Alertness to paraquat poisoning is essential in patients with sudden gastrointestinal and renal symptoms post-exposure.Additionally,it underscores the necessity for public health measures to avert paraquat ingestion and advance therapeutic approaches.

Fatal liver failure due to reactivation of lamivudine-resistant HBV mutant

We report a case of fatal liver failure due to reactivation of lamivudine-resistant HBV. A 53-year-old man was followed since 1998 for HBV-related chronic hepatitis. Serum HBV-DNA was 150 MEq/mL (branched DNA signal amplification assay) and ALT levels fluctuated between 50-200 IU/L with no clinical signs of liver cirrhosis. Lamivudine (100 mg/d) was started in May 2001 and serum HBV-DNA subsequently decreased below undetectable levels. In May 2002, serum HBV-DNA had increased to 410 MEq/mL, along with ALT flare (226 IU/L). The YMDD motif in the DNA polymerase gene had been replaced by YIDD. Lamivudine was continued and ALT spontaneously decreased to the former levels. On Oct 3 the patient presenting with general fatigue, nausea and jaundice was admitted to our hospital. The laboratory data revealed HBV reactivation and liver failure (ALT: 1828 IU/L, total bilirubin: 10 mg/dL, and prothrombin INR: 3.24). For religious reasons, the patient and his family refused blood transfusion, plasma exchange and liver transplantation. The patient died 10 d after admission. The autopsy revealed remarkable liver atrophy.

Pseudoaneurysm of gastroduodenal artery following radical gastrectomy for gastric carcinoma patients

We report a rare case of postoperative pseudoaneurysm of the gastroduodenal artery following radical gastrectomy.Surgical trauma to the gastroduodenal artery during regional lymphadenectomy was considered as the cause of the postoperative pseudoaneurysm. The pseudoaneurysm was successfully managed by ligating the bleeding vessel. We should consider the possibility of pseudoaneurysm formation in a patient with gastrointestinal bleeding in the postoperative period following radical gastrectomy with regional lymph node and perivascular lymphatic dissection.

Case report of acute-on-chronic liver failure secondary to diffuse large B-cell lymphoma

Acute liver failure is a rare presentation of hematologic malignancy. Acute on chronic liver failure(ACLF) is a newly recognized clinical entity that describes acute hepatic decompensation in persons with preexisting liver disease. Diffuse large B-cell lymphoma(DLBCL) is an aggressive non-Hodgkin's lymphoma(NHL) with increasing incidence in older males, females and blacks. However, it has not yet been reported, to present with acute liver failure in patients with preexisting chronic liver disease due to human immunodeficiency virus(HIV)/hepatitis C virus(HCV) co-infection. We describe a case of ACLF as the presenting manifestation of DLBCL in an elderly black man with HIV/HCV coinfection and prior Hodgkin's disease in remission for three years. The rapidly fatal outcome of this disease is highlighted as is the distinction of ACLF from decompensated cirrhosis. Due to the increased prevalence of HIV/HCV co-infection in the African American 1945 to 1965 birth cohort and the fact that both are risk factors for chronic liver disease and NHL we postulate that the incidence of NHL presenting as ACLF may increase.

Fathal pulmonary hypertension after distal splenorenal shunt in schistosomal portal hypertension

Mansonic schistosomiasis is the main cause of portal hypertension in Brazil. Hepatosplenic (HS) form is manifested by hepatomegaly mainly on the left hepatic lobe associated with large splenomegaly and bleeding due to esophageal varices with high mortality rates.

Effect of in-hospital medical complications on case fatality post-acute ischemic stroke： data from the China National Stroke Registry

Background In-hospital medical complications are associated with poorer clinical outcomes for stroke patients after disease onset. However, few studies from China have reported the effect of these complications on the mortality of patients with acute ischemic stroke. In this prospective work, the China National Stroke Registry Study, we investigated the effect of medical complications on the case fatality of patients with acute ischemic stroke. Methods From September 2007 to August 2008, we prospectively obtained the data of patients with acute stroke from 132 clinical centers in China. Medical complications, case fatality and other information recorded at baseline, during hospitalisation, and at 3, 6, and 12 months after stroke onset. Multivariable Logistic regression was performed to analyze the effect of medical complications on the case fatality of patients with acute ischemic stroke. Results There were 39741 patients screened, 14526 patients with acute ischemic stroke recruited, and 11 560 ischemic stroke patients without missing data identified during the 12-month follow-up. Of the 11 560 ischemic patients, 15.8% （1826） had in-hospital medical complications. The most common complication was pneumonia （1373; 11.9% of patients）, followed by urinary tract infection and gastrointestinal bleeding. In comparison with patients without complications, stroke patients with complications had a significantly higher risk of death during their hospitalization, and at 3, 6 and 12 months post-stroke. Having any one in-hospital medical complication was an independent risk factor for death in patients with acute ischemic stroke during hospital period （adjusted OR=6.946; 95% CI 5.181 to 9.314）, at 3 months （adjusted OR=3.843; 95% C/3.221 to 4.584）, 6 months （adjusted OR=3.492; 95% CI 2.970 to 4.106）, and 12 months （adjusted OR= 3.511; 95% CI 3.021 to 4.080）. Having multiple complications strongly increased the death risk of patients. Conclusion Short-term and long-term outcomes of acute stroke patients are affected by in-hospital medical complications.

Complications of button battery ingestion or insertion in children:a systematic review and pooled analysis of individual patient-level data

Background Button battery(BB)exposures are common in children and can have devastating consequences.We reviewed current evidence on the complications associated with BB exposure and identified predictors of outcomes using individual patient-level data.Data sources We carried out a systematic review and pooled analysis by searching MEDLINE,Embase,and Scopus up to May 19,2023.Included studies describe complications following BB exposures in children(aged<18 years).Odds ratios(ORs)were calculated using binary logistic regression to measure associations between predictive factors and different outcomes.Results Two-hundred seventeen studies(439 children)were included.The median age at presentation was 1.75[interquartile range(IQR)1.00–3.00]years and 399(90.9%)exposures were ingestions.Of the 380 cases reporting sex,162(42.6%)were female.Feeding(192,48.1%)and respiratory difficulties(138,34.6%)were common presenting features for ingestions,while symptomatology was site-specific for insertions.Common complications included oesophageal mucosal damage alone(105,26.3%)and tracheooesophageal fistula(93,23.3%)for ingestions,and nasal septal perforation(22,55.0%)and mucosal damage alone(13,32.5%)for insertions.Intestinal perforation occurred in 2.5%of ingestion cases,including perforation of Meckel's diverticulum,peritonitis,and jejunocolic fistula.Vascular complications were common among children who died.Age(≤2 years),battery exposure duration(>6 hours),and battery diameter(≥20 mm)were associated with common and severe complications of ingestions.Conclusion BB injuries are time-critical,with severe sequelae predominantly affecting young children.Diagnosis is challenging.Preventative work through regulation and safer battery design are required to eliminate this problem.