Acute Kidney Injury Among Children Likely Associated with ..

Investigation and Results

In July 2022, a pediatric nephrologist at the Edward Francis Small Teaching Hospital in The Gambia’s capital city of Banjul alerted MoH to a cluster of AKI cases among children. Data on AKI incidence are not routinely collected in The Gambia; thus, the baseline AKI rate was unknown. However, the treating nephrologist expressed concern that the number of cases and deaths were well above baseline: through August 12, a total of 30 pediatric deaths among 37 AKI cases had been reported from facilities throughout the country (case fatality rate = 81%). In response to a request for assistance, a multidisciplinary CDC team, including an epidemiologist, an anthropologist, an infectious disease physician, and an environmental health scientist, arrived on September 16 to assist the Field Epidemiology Training Program (FETP) and MoH in characterizing the illness and identifying exposures. MoH collaborated separately with the World Health Organization (WHO) to test medications that might have been used by patients.

Active surveillance was conducted through reoccurring communication with the teaching hospital and other regional hospitals, inquiring about admissions of pediatric patients with kidney failure. As of September 29, 2022, MoH had identified 78 clinically suspected AKI cases. Among these patients, 66 (85%) had died. Most patients (75%) were aged <2 years, and 60% were male. Cases were reported from six of the country’s seven health regions.* Among the 78 cases reported to MoH, symptom onset date was available for 67 (86%) (Figure).

CDC, MoH, and FETP investigators developed a standardized case report form to gather data about pediatric patients with AKI identified by MoH. Data collection consisted of a review of the patient’s medical records and caregiver interview data. For this investigation, a confirmed case of pediatric AKI was defined as anuria (no urine output) of unknown etiology in a child aged ≤8 years, persisting for ≥24 hours, during June 21–September 29, 2022. June 21 was chosen as the start date because medications suspected to have possibly caused the AKI outbreak had been imported into the country on June 21. Investigators first reviewed the medical records of 52 (67%) of the 78 MoH-identified patients with suspected AKI who were treated by the teaching hospital. Next, interviews with at least one caregiver of each of 27 patients were conducted by investigators in local languages, including the caregivers of 20 patients whose children’s hospital medical records were reviewed and seven patients whose medical records could not be located. Investigators selected a convenience sample of caregivers for interview based on their location of residence. Because of resource limitations and reluctance on the part of some caregivers to be interviewed, not all medical records could be located, and not all invited caregivers participated. In addition, interview data were collected in only two of the six health regions (Western Regions 1 and 2). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^†

Caregivers were asked about the child’s recent medical history, including disease course, experiences with the health care system, and possible exposures, including medications, foods, and experience of flooding, among others. All participating caregivers were interviewed in their homes. All four (15%) living patients whose caregivers were interviewed had been discharged at the time of interview. Among patients who had died, the mean interval between date of death and date caregivers were contacted for interview was 33 days. Information from medical records and interviews was used to determine whether patients on the MoH line list met the confirmed case definition. After data from the 27 caregiver interviews and 52 medical record reviews were combined, 59 case report forms were completed, representing 76% of the 78 cases reported to MoH, and 88% of the 67 patients with a symptom onset date. Among these 59 patients, 56 (95%) met the confirmed case definition and were included in the analysis.^§

Among the 56 included patients, more than one half (54%) experienced fever as their first signs or symptoms, and 50% experienced vomiting (Table 1). Approximately one third (34%) had diarrhea or loose stool as the first symptom. During the course of illness, all patients experienced anuria and fever, 95% experienced vomiting, and 73% experienced diarrhea. Nearly one half (48%) experienced anorexia or reduced feeding. The median interval from symptom onset to anuria was 5 days (IQR = 2–7 days); among the 26 patients who died, the median interval from onset of anuria to death was 6 days (IQR = 3–7 days).

Abnormal laboratory test results were received by 66%–100% of patients, including impaired renal and liver function, thrombocytosis, and mild to moderate anemia (Table 2). Fourteen patients underwent peritoneal dialysis, and one patient underwent hemodialysis; all 15 patients who received dialysis died.

Among the 26 patients with a caregiver interview, 100% of caregivers reported that the child consumed a prescription or over-the-counter syrup-based medication (including paracetamol, known in the United States as acetaminophen, commonly administered for fever) before the onset of anuria. Twelve patients (47%) had consumed four or more medications before being hospitalized. Although many caregivers were unable to recall the names of medications that they administered to their children, caregivers of 14 (54%) of these 26 patients identified the manufacturer name of at least one medication administered to their child before inpatient hospitalization. A single international manufacturer that produced a syrup-based medication was reported in eight of 14 (57%) interviews in which caregivers identified the manufacturer name of at least one medication administered to their child before inpatient hospitalization.