Acute Renal Failure in Children at the University Hospital of Brazzaville

Introduction: Acute renal failure (ARF) is a medical emergency that does not spare children. Its interest lies in the search for etiologies and management made difficult by the poor quality of hospital technical platform in Africa. Objectives: To improve the management of ARF in children, determine its prevalence, and identify the causes and factors associated with mortality. Patients and Methods: We reviewed the records of children from one month to 17 years hospitalized between January 2016 and December 2018 in every pediatric department at the University Hospital of Brazzaville and included those whose discharge diagnosis included the item “ARF”. Study variables were age, sex, source, (para)clinical signs, stage and type of ARF, etiology and evolutionary profile. Results: Included were 18952 hospitalized children out of whose 253 had ARF 1.3%. There were 145 (57.3%) boys and 108 (42.7%) girls with an average age of 71.5 months. The mean time to consultation was 8.1 days. ARF was at failure stage in 147 cases (58.1%). It was functional in 210 cases (83.0%), out of which 95.1% re-sulted from severe dehydration. No extra-renal treatment was performed. Lethality was 34.4%. Hypovolemic shock (56.3%), severe sepsis (18.4%) and severe malaria (14.9%) were the main causes. Young age, provenance of the child, severe dehydration, deep coma, oligoanuria, stage of failure, hyperkalemia, absence of an extra-renal purification center were factors associated with mortality (p < 0.0002). Conclusion: The high prevalence of ARF and its lethality re-quires public health actions including proper management of dehydration and malaria but also the creation of an extra-renal purification center.


Operational Definitions
ARF was defined as a rapid and usually reversible decrease in the glomerular filtration rate leading to uremia and fluid and electrolyte disturbances. It is characterized by a recent elevation (<3 months) of serum creatinine, which may display preserved diuresis (>500 ml/24h) or oliguria (100 -500 ml/24h) or anuria (<100ml/24h) [13].
The staging of the ARF used was that of the modified RIFLE (Table 1) classification for pediatrics (pRIFLE) [14]. The estimated clearance of creatinine is calculated according to Schwartz's pediatric formula [15] and compared to a reference value of 100 ml/min/1.73m 2 in the absence of a known prior value.
Acute renal failure is called functional or pre-renal, when there is a decrease in glomerular perfusion; organic or intrinsic, a dysfunction of different renal structures (tubules, glomeruli, interstitium or vessels) and obstructive or post-renal, when there is an obstacle on the urinary tract [16].
Complete recovery of renal function: was defined by the normalization of serum creatinine and blood urea output.
Partial recovery of renal function: was defined as resumption of diuresis with improvement of renal function without normalization of serum creatinine and/or blood urea. Chronicity: was defined by the lack of normalization of renal function beyond three months.

Statistical Analysis
The data were entered and processed using SPSS version 20.0 and Microsoft Excel 2010. The qualitative and quantitative variables were expressed in percentages ± standard deviation, respectively. The comparison of the means between variables was performed by Pearson's chi-square for qualitative variables, the Student's test for quantitative variables. The Odd Ratio (OR) calculation and their confidence interval (CI) were required. The threshold of significance was set at 0.05. The socio-economic level specified in 220 cases (87%), was low in 135 cases (61.4%), average in 64 cases (29.1%) and high in 21 cases (9.5%).

Anamnestic Data
The mean time from onset of symptoms to hospitalization was 8.1 ± 10.1 days (range 1 to 60 days).

Clinical Data
The symptoms leading to hospitalization and those found on the examination are recorded in Table 2 and Table 3.
The causes of ARF are shown in Table 4.

Treatment
The treatment was conservative and function of etiology in all cases. Hemodialysis was indicated and not performed in 63 cases.

Unified Analysis
Relationship between socio-demographic Characteristics and mortality: Table 6.
The young age of the children, the facility of reference and low socioeconomic level of the parents have been identified as risk factor for death.
Relationship between clinical data and mortality: Table 7.
Relationship between para-clinical data and mortality: Table 8.

Multi-Varied Analysis
Relationship between mortality and socio-demographic characteristics: Table 9.
Relationship between evolutionary data and mortality: Table 10.
Relationship between mortality and clinical characteristics are recorded in Table 11.
The existence of a current complication of hospitalization, the non-completion of hemodialysis and short hospital stay were risk factors for death.

Discussion
The purpose of this study was to improve the management of children with ARF hospitalized at the Brazzaville University Hospital, and to describe epidemiological aspects, identify the causes, describe the evolutionary profile and identify the factors associated with death. This study, although hospital and mono-centric, has the advantage of being carried out in the only Pediatric Intensive Care Unit in Brazzaville. But, it presents some pitfalls; the most important is the retrospective nature of the study source of bias, lost sight of but also in the collection of   [32]- [37]. The definitive diagnosis is provided by creatinine, which has been significantly contributive to this study. If medical treatment: Duration of treatment: <7 days / _ /; 7 and 14 Days / _ / ≥ 15 Days / _ / ATB: aminoglycoside /C3G / metronidazole / quinolone / Amoxi + ac clav / / Amoxicillin / _ / macrolide / _ / cotrimoxazole / _ / Antipalust: A + L / _ / quinine / _ / arthemether / _ / artesunate / _ / NSAID / _ / corticosteroid / _ / diazepam / _ / diarrhea / / Specify the delay between taking the medication and hospitalization: Interval: <7days / _ /; 7 and 14Days / _ / ≥ 15Days / _ / Family history: Sibling: