Acute Kidney Injury (AKI) affects more than 13 million people and causes nearly 2 million deaths worldwide every year [1] . In the intensive care setting, its frequency can be as high as 60%, and it is consistently associated with mortality in excess of 40% [1] . Nearly 80% of the socio-economic burden of this disease occurs in developing countries [2] . In Africa, despite the 0by25 initiative of International Society of Nephrology (ISN), which called for a reduction in avoidable deaths due to AKI, research on the subject still shows dramatic results [3] . In Zambia, a study carried out in an intensive care unit revealed a 59% mortality rate in a group of patients with acute kidney injury [4] .

The mechanisms of AKI are multiple and often interrelated. AKI occurs most frequently in visceral failure, trauma or sepsis leading to hypovolemia, but also in kidney damage caused by exogenous or endogenous toxic agents [5] . The prognostic factors identified for AKI in the ICU are age, previous health status and severity on admission or inclusion [6] . However, these data are purely for developed countries, whereas African populations are less elderly and less comorbid. Sub-Saharan Africa has few data on the incidence of acute kidney injury in intensive care units, and even less on the factors associated with mortality. In the north of Togo, there are no dialysis centers. As a result, the management of patients with acute renal failure is laborious, especially in intensive care units; mortality appears to be high and the risk factors unknown.

In order to guide public policy in responding to this scourge, this study was carried out with the aim of determining the factors associated with mortality from acute kidney Injury in intensive care units in northern Togo.

The incidence of AKI in intensive care units in northern Togo was 12.6%. These

*OR = Odds Ratio, CI = Confidence Interval, KDIGO = Kidney Disease Improval Global Outcomes.

*OR = Odds Ratio, CI = Confidence Interval, ¹ORa = Adjusted Odds ratio, ICa = adjusted Confidence Interval.

data seem similar to those of Touré in Mali and Bennis in Morocco, who found a frequency of 12.3% and 14% of AKI respectively [7] [8] . However, they are quite different from the results of Banda, who found a frequency of 59% in Zambian intensive care units [4] . It has been established that the incidence of AKI in the ICU varies according to the type of patient recruitment (general ICU, medical ICU, surgical ICU) and the diagnostic criteria used [7] . In our study, the majority (67%) of patients came directly from their homes. In addition, the diagnostic criteria for acute renal failure were not the same. In sub-Saharan Africa, the diagnostic criteria for AKI are largely based on creatinine levels. Yet creatinine is a biomarker of renal function, and lags behind renal injury by several hours [9] . What’s more, its determination, which is not always available, is still carried out by the Jaffe method, which remains inaccurate, as chromogens other than creatinine interfere with the result, leading to errors [10] . In our study, not only was the diagnosis of AKI based on elevated creatinine in 82.7% of cases, but also the method used to measure creatinine was the Jaffe method. This may constitute a bias in patient recruitment.

Several studies have demonstrated that the development of AKI in the intensive care unit (ICU) or intensive care unit (ICU) is associated with increased morbidity and mortality. In a study of 279 ICU patients, mortality was 71.7% versus 14.4% (p < 0.001) in the AKI group compared with the non-AKI group [11] . In this study, the development of AKI was an independent predictor of mortality, increasing the risk of death by a factor of 10 [11] . In our series, the mortality rate was 44.3%. According to the multivariate model, mortality was associated with several factors: the number of visceral failures, respiratory distress, MAP < 60 mmHg, altered consciousness, and hemorrhage as etiology.

The number of visceral failures or dysfunctions associated with AKI is a major prognostic factor [6] . The more organ dysfunctions there are, the higher the risk of AKI.

The excess mortality associated with respiratory failure, hypotension and shock has been mentioned since the earliest studies of AKI [12] . This is illustrated by the correlation between mortality and the use of mechanical ventilation in most series [13] [14] . Indeed, mechanical ventilation may suggest the presence of respiratory or circulatory distress, and hence low mean arterial pressure. In his series, Consentino reported a mortality rate of 80% in the group requiring mechanical ventilation versus 57% in the non-ventilated group (p = 0.006) [14] . The most serious complications of AKI are PAO and metabolic acidosis, which result in respiratory distress. These complications are responsible for the majority of deaths.

In terms of treatment, dialysis was indicated in 59.4% of cases, but was carried out in only 3%. In a meta-analysis of 41 studies involving 1,401 adults and 1937 children, of the 70% of adults who required dialysis, only 33% had access to it [15] . According to the authors, the inaccessibility of dialysis facilities contributes to increased mortality in sub-Saharan Africa [15] . Although we did not find this associated factor in statistical analysis, it is easy to understand that the absence of this treatment is a major handicap. The treatment of serious complications such as hyperkalemia (16.4%), acute pulmonary edema (APO) and acidosis remains ineffective in our series. This raises the problem of under-equipped intensive care units in Africa [16] . Hypovolemia remains the primary mechanism of AKI in intensive care units [17] .

A closer look at the factors associated with mortality reveals a number of features specific to our population. The study population is young, rural, with a predominance of community-acquired renal failure.

Contrary to Western data [6] , age is not a factor associated with ICU mortality in our setting. In sub-Saharan Africa, AKI mainly affects young, economically active adults aged around 40 [18] [19] . The average age of 49.7 ± 17.9 years in our population was similar to that of Bennis [7] , who also reported a male predominance. This data is common to several works except those that include several patients from obstetric gynecology departments [20] .

Since KDIGO 2012, the notion of community versus hospital-acquired AKI has emerged [21] . Hospital-acquired AKI is multifactorial and occurs in subjects associating several comorbidities with a poor prognosis. In our study, in which patients were recruited from the intensive care unit, the predominance of community-acquired AKI (67.6%) reflects the delay in transfer. According to Lengani in Burkina Faso, it is the severity of symptoms or the extent of disability that motivates referral to healthcare facilities in Africa [22] . In our series, the top three reasons for hospitalization were respiratory distress (24.2%), consciousness disorders (22.7%) and circulatory distress (22.7%). Altered consciousness was also found to be predictive of death in AKI (p = 0.004). A prospective multicenter study by Liano et al. in Spain showed that the prognosis of AKI in the ICU was particularly poor for comatose patients [23] . The clinical expression of AKI in the ICU is multifaceted. Anuria was the first functional sign in our series. It reflects the late referral of patients, as it has been established that it occurs several hours after renal aggression and leads to the classification of AKI as KDIGO stage 3. The majority of patients were in stages 2 and 3.

Several pathophysiological factors were found concomitantly in the same patients. Although statistically insignificant, drugs with nephrotoxic potential, including aminoglycosides and diuretics, were found in high proportions. Indeed, studies have shown that these drugs are misused in AKI, with the risk of aggravating the initial mechanism, either through direct toxicity of the drug, favored by the drop in blood volume and the concentration of free metabolites, or through disruption of intra-glomerular hemodynamics [24] . Several traditional toxicants were also found in our series, although the causal link has not been formally established. In Togo in particular, and in Africa in general, the course of treatment is marked by traditherapy (treatment with plants and unapproved root decoctions). There are two main reasons for this: the importance of cultural beliefs and the high cost of treatment in a poor population.

In sub-Saharan Africa, the etiology of AKI is predominantly infectious [9] [25] . Rural populations, like our own, are often confronted with precarious sanitary conditions and limited access to medical infrastructures [15] . As infectious pathologies are not controlled, most patients develop AKI associated with them [9] [26] . The majority of etiologies found in our work were septic, and this was reflected by the presence of an inflammatory syndrome with a mean leukocyte count of 16.1 ± 2.9 G/l.

The main limitation of this study is that the factors associated with mortality were not studied concomitantly in the group without renal failure. The diagnosis of AKI itself, based solely on creatinine measurement, remains controversial, as does the fact that diuresis is not used as a criterion, given the organization of intensive care units.

Acute Kidney Injury (A is common in intensive care units, with a poor prognosis. In our context, it occurs in young male subjects, with hypovolemia as the main mechanism. Its high mortality is associated with factors such as respiratory distress, altered consciousness, MAP < 60 mmHg, hemorrhage as etiology and the number of visceral failures. Identifying these factors associated with death in Acute Kidney Injury should enable us to anticipate prognosis and adapt specific management. Simple strategies for systematic screening of target groups in emergency departments, with early intervention, could be implemented and evaluated in a future study.

The authors declare no conflicts of interest regarding the publication of this paper.

Amekoudi, E.M.Y.Y., Sabi, K.A., Keoula, M.D., Dolaama, B., Assenouwe, S. and Mouzou, T. (2024) Risk Factors for Mortality in Acute Kidney Injury in Intensive Care Units in Togo. Open Journal of Nephrology, 14, 37-47. https://doi.org/10.4236/ojneph.2023.141005