Capacity for the management of kidney failure in the International Society of Nephrology Africa region: report from the 2023 ISN Global Kidney Atlas (ISN-GKHA)

The burden of chronic kidney disease and associated risk of kidney failure are increasing in Africa. The management of people with chronic kidney disease is fraught with numerous challenges because of limitations in health systems and infrastructures for care delivery. From the third iteration of the International Society of Nephrology Global Kidney Health Atlas, we describe the status of kidney care in the ISN Africa region using the World Health Organization building blocks for health systems. We identified limited government health spending, which in turn led to increased out-of-pocket costs for people with kidney disease at the point of service delivery. The health care workforce across Africa was suboptimal and further challenged by the exodus of trained health care workers out of the continent. Medical products, technologies, and services for the management of people with nondialysis chronic kidney disease and for kidney replacement therapy were scarce due to limitations in health infrastructure, which was inequitably distributed. There were few kidney registries and advocacy groups championing kidney disease management in Africa compared with the rest of the world. Strategies for ensuring improved kidney care in Africa include focusing on chronic kidney disease prevention and early detection, improving the effectiveness of the available health care workforce (e.g., multidisciplinary teams, task substitution, and telemedicine), augmenting kidney care financing, providing quality, up-to-date health information data, and improving the accessibility, affordability, and delivery of quality treatment (kidney replacement therapy or conservative kidney management) for all people living with kidney failure.

Clinicopathologic Study of Sickle Cell-associated Kidney Disease: A Nigerian Experience

BACKGROUND

Improvements in sickle cell disease (SCD) care have resulted in the survival of many patients into adulthood, although this is accompanied by the increased incidence of end-organ damage, including chronic kidney disease (CKD).

OBJECTIVES

This study assessed the prevalence, pattern and predictors of renal dysfunction in SCD patients and investigated the associated renal histopathologic changes.

METHODS

We evaluated 105 patients with SCD, for proteinuria, estimated glomerular filtration rate (eGFR), and tubular dysfunction. Renal biopsy was conducted on 22 patients who qualified. Data were analysed using SPSS package version 23.

RESULTS

Thirty-seven (35.2%) of the 105 patients had CKD, as defined by an eGFR of 60 ml/min/1.73 m2 and/or proteinuria. The fractional excretion of potassium (FEK) was elevated in all patients, whereas the fractional excretion of sodium (FENa) was elevated in 98.1%. Glomerular filtration rate was negatively correlated with irreversible percentage sickle cell count (r = -0.616, P = 0.0001), FEK (r = -0.448, P = 0.0001) and FENa (r = -0.336, P = 0.004). Age, irreversible percentage sickle cell count, haemoglobin levels and FENa were the major predictors of CKD. The histological pattern in the 22 patients who had biopsies was consistent with mesangioproliferative glomerulonephritis 11 (50%), minimal change disease 6 (27.3%), focal segmental glomerulosclerosis 3 (13.6%) and interstitial nephritis 2 (9.1%).

CONCLUSIONS

CKD was prevalent in SCD patients, and it was characterised by tubular dysfunction and mesangioproliferative glomerulonephritis. The main predictors of CKD were increased age, severity of vaso-occlusive crisis, worsening anaemia and tubular dysfunction.

Comparative Evaluation of Prevalence, Risk Factors, and Pathologic Features of Kidney Disease in Highly Active Antiretroviral Therapy-Naive and Highly Active Antiretroviral Therapy-Experienced Patients at a Tertiary Health Facility in Maiduguri, Northeastern Nigeria

Infection of the kidneys by human immunodeficiency virus (HIV) is known to cause kidney disease. HIV-associated nephropathy occurs with variable prevalence rates in various communities and is found to be higher among sub-Saharan Africans. The disease has not been studied in Northeastern Nigeria. This study was aimed at comparing the prevalence, clinical and histo-pathologic features of kidney disease among highly active antiretroviral therapy (HAART)-experienced and HAART-naive patients in northeastern Nigeria. Four hundred HIV-infected (200 HAART-experienced and 200 HAART-naïve) patients were recruited consecutively from the ART clinic. Their socio-demographic and laboratory data including CD4+ cell counts and viral loads were obtained and documented. Out of the 200 study participants in the HAART-experienced arm, 21 (10.5%) had kidney disease whereas 61 (30.5%) participants in the HAART-naïve group had kidney disease. Their mean ages were 41.43 ± 11.04 years and 37.42 ± 9.96 years in the HAART-experienced and HAART-naïve groups, respectively. The mean serum creatinine (SCr), CD4⁺ cell counts, and viral load were 185.67 ± 221.80 μmol/L, 493.26 ± 241.97/mm³, and 8,856.79 ± 19,747.11/mL in the HAART-experienced group, respectively. In the HAART-naïve group, the mean SCr, CD4⁺ cell count, and viral load were 141.88 ± 130.56 μmol/L, 270.00 ± 154.65 cells/mm³, and 139,217.70 ± 12,598.50/mL. Focal segmental glomerulosclerosis (FSGS) was the most common histologic diagnosis in 64.7% of kidney biopsies. Risk factors for chronic kidney disease among the study population included age, low weight and body mass index, high human immunodeficiency virus (HIV)-1 viral load, low CD4+ cell counts, low hemoglobin (Hb), and proteinuria. The prevalence of kidney disease is higher among HAART-naïve HIV-infected patients than in patients who are HAART-experienced patients. Factors associated with development of kidney disease included advanced age, low CD4⁺ cell counts, high viral load, proteinuria, and HAART-naivety. FSGS is the most common histologic diagnosis in our study population.

Detection of Early Renal Disease In Children With Sickle Cell Anaemia Using Microalbuminuria As A Surrogate Marker

EDITORIAL.

The Prevalence and Pattern of Malnutrition in Pre-Dialytic Chronic Kidney Disease Patients at a Tertiary Care Facility in Nigeria

BACKGROUND

Malnutrition is a common problem in chronic kidney disease contributing to adverse outcomes in terms of morbidity and mortality and overall poor quality of life. In our environment and indeed most other developing countries, the prevalence of malnutrition in the general population is high. The high cost and dearth of renal replacement therapy in developing countries underscores the need for identification of factors that if adequately addressed will lead to slowing down of the progression to End Stage Renal Disease.

AIMS AND OBJECTIVES

To determine the prevalence and pattern of malnutrition in pre-dialytic CKD patients at a tertiary care renal unit in a developing country.

METHODOLOGY

One hundred and two consecutive patients attending the nephrology clinic of a tertiary care facility along with apparently healthy age and sex-matched subjects were studied. Demographic data, social classification and aetiology of CKD were obtained from patients. Multiple tools were used for assessment of the nutritional status of patients in stages 2-5 CKD who are not yet on dialysis. Clinical examination, anthro-pometric measurements triceps skin fold (TSF), Body Mass Index (BMI), Mid-upper Arm Circumference (MUAC), biochemical assessment (serum albumin and serum cholesterol) and Subjective Global Assessment (SGA) were used as tools for nutritional assessment for patients and compared with controls. The proportion of patients that met the International Society of Renal Nutrition and Metabolism (ISRNM) criteria for malnutrition was also determined.

RESULTS

The mean age of the CKD patients was 47±11 years with a male to female ratio of 1.2:1. Prevalence of malnutrition in the CKD patients using clinical assessment was 8.8% (control=none), Body Mass Index was 31.4% (control=7.8%), Triceps skin fold thickness 46.6% (control=14.7%), serum albumin 46.1% (control=5.9%), Mid-upper arm circumference was 30.4% (control=11.18%), serum cholesterol 11.8% (control=3.9%), Subjective Global Assessment, 5.9% (control = none) and International Study of Renal Nutrition and Metabolism criteria 31.4% (control=none). The Prevalence of malnutrition increased significantly across CKD stages 2 to 5 with the use of clinical assessment (p=0.001), SGA (p value =0.001), serum albumin (p value =0.001) and BMI (p value =0.012).

CONCLUSION

Malnutrition is common in pre-dialytic CKD patients in Nigeria and possibly other developing countries. There is a need to identify those who may need nutritional intervention early as this will impact positively on the final outcome of the disease as well as reduce the number of patients progressing to ESRD.

The burden of caring for renal patients: The nurses perspective

Prevalence of chronic kidney disease (CKD) in Nigeria is on the increase and it is associated with increasing caregiving burden for both the professionals and informal caregivers. This study evaluated the burden experienced by nurses caring for CKD patients, identified the procedures causing the caregiving burden and factors associated with burden in two hospitals in Ondo State, Nigeria. Two hundred and forty nurses caring for renal patients were selected from two health institutions in Ondo State. Information on sociodemographic data was obtained using a self-administered questionnaire. The burden of care was evaluated using the Zarith Burden of Life Instrument (ZBI), with aggregate score ranged from 0-88. A score of 21-40 indicates mild-to-moderate burden while a score >40 indicates high burden. The mean age of the respondents was 33.7 ± 7.5 years (age range: 20-67 years). Forty percent experienced no burden, 48.3% experienced mild-to-moderate burden, 10.4% experienced severe burden while only 1.3% experienced very severe burden. Dialysis procedure (65.5%) was identified as posing the greatest caregiving burden. Factors identified as responsible for caregiving burden were shortage of staff (68%), followed by lack of funds on the part of the patients (67.1%). Caregiving burden was not associated with age, gender, or years of experience. Prevalence of caregiving burden was very high among the respondents and dialysis was identified as causing greatest burden. Government should fund and improve staffing of dialysis units to reduce caregiving burden.

Prevalence and Pattern of Chronic Kidney Disease and its Associated Risk Factors in a Rural Community in South Western Nigeria

BACKGROUND

Chronic kidney disease (CKD) has now become a disease of public health importance. The increased prevalence in the population of patients with end stage renal disease (ESRD) is partly related to the failure of early detection of the pre-clinical stages of the disease and its associated risk factors. This study aimed to determine the prevalence of chronic kidney disease and its associated risk factors in Aiyepe community in Ogun state, south western Nigeria as well as determining the awareness level of the population about CKD.

MATERIALS AND METHODS

It was a cross-sectional community-based study involving 456 participants recruited through cluster and simple random sampling techniques.Participants were screened for urinary albumin by dipstick and/or albumin creatinine ratio. Serum creatinine, fasting blood sugar and serum lipid profile were determined while glomerular filtration rate was estimated using Cockroft and Gault formula from serum creatinine.

RESULTS

The mean age ± standard deviation (SD) of the study population was 48.09(±15.7) years, and the age range was 18-80 years. Hypertension was seen in 28.9% of studied participants while only 4.2% were diabetic. The mean waist-hip ratio (WHR) of the participants was 0.94(±0.55). The mean BMI of the participants was 26.62(±6.0) kg/m2 with a range of 15.04 to 48.68 kg/m2. The prevalence of overweight and obesity was found to be 24.4% and 30% respectively. The prevalence of proteinuria was 16.3% while 3.7% of the participants had history of haematuria. The prevalence of CKD was 27.6%. Age (OR-1.080, CI-95%, 1.059-1.102), female gender (OR-0.550, CI-95%, 0.320-0.945), BMI (OR-0.832, CI-95%, 0.785-0.882) and dyslipidaemia (OR-1.007, CI-95%, 0.978-1.037) were found to be predictive of CKD in this study.

CONCLUSION

The prevalence of CKD and its associated risk factors is high in Aiyepe community in Ogun state, south western Nigeria. If this is true for other rural communities generally, it will pose huge challenges on the available healthcare resources.

Prevlaence of chronic kidney disease markers in Kumbotso rural Northern Nigeria

BACKGROUND

Data- on the epidemiology of Chronic Kidney Disease (CKD) from sub-SaharanAfrica are sparse. We investigated the prevalence of CKD and its early markers in Kumbotso, a rural community in northern Nigeria.

METHODS

A total of 480 individuals were randomly selected from the general population using multistage stratified random sampling. Relevant- demographic and clinical data were obtained using a structured questionnaire. Biological samples (urine and blood) were drawn for relevant investigations.

RESULTS

CKD (estimated glomerular filtration rate [eGFR <60 mls/min) was found in 117 participants (26%). Proteinuria was present in 106 persons (23.6%) and haematuria in 7 individuals (1.6%). The most common CKD stage was stage 1 (20%). CKD was associated with hypertension (P=0.002), diabetes (P=0.001), high cholesterol (P=0.030), smoking (P=0.015), increasing BMI (P=0.020), and increasing age (P=0.003). After adjusting for potential confounding with logistic regression modeling we found BMI, family history of hypertension, history of diabetes mellitus and family history of renal disease to be independent predictors of CKD.

CONCLUSIONS

Early markers of CKD are common among rural inhabitants of northern Nigeria and this call for concerted efforts towards institution of preventive measures.

Preliminary report of HLA (DNA) typing of Nigerians using sequence-specific primer technique

AIMS AND OBJECTIVES

This communication is an attempt to present the experience and a preliminary report of results over a one-year period.

PATIENTS AND METHODS

From December 2011 to December 2012, a prospective determination of the HLA types of 20 individuals referred to the Tissue Typing Laboratory of the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife was done. These consisted of prospective transplant recipients, their donors, and a migrant pair for kinship determination. DNA was extracted from the client's peripheral blood sample, using the QIAmp Blood DNA Mini kit, (Qiagen). PCR was done using OlerupR low-resolution PCR-SSP typing kit. The PCR product was resolved in 2% agarose gel, and the bands visualised under UV light. The HLA types were determined using provided tables and/or Helmberg software. Data were presented using descriptive statistics whileHLA antigen frequency (AF) was expressed in percentage and gene frequency (GF) was determined using square root method (1-(1-AF)1/2).

RESULTS

A total of 20 individuals (13males and 7females) consisting of seven renal transplant recipients and seven prospective donors; a stem cell recipient and three donors and a migrant pair for kinship determination were typed. Age ranged from 4-65 years. 44 HLA alleles were detected, while HLA-A, B, C, DRB1 and DQB1 were 7, 10, 11, 8, 8 alleles respectively. The alleles were heterogeneous in distribution while 6 antigens (HLA-A*02, B*30, C*15, DRB1*03, DRB1*08 and DQB1*06) were having frequencies e"25%.

CONCLUSION

This report confirms that DNA-based HLA typing is feasible locally, andit was observed that renal transplantation procedure is the most frequent indication. The HLA antigens observed to have very high frequencies (e"25% frequency) in this population were HLA-A*02, B*30, C*15, DRB1*03, DRB1*08 and DQB1*06. There is a strong need to develop a broad-based HLA data bank for Nigeria to further strengthening her transplantation programmes.

Iron status and benefit of the use of parenteral iron therapy in pre-dialysis Chronic Kidney disease patients

AIMS AND OBJECTIVES

Anaemia is a major cardiovascular risk factor in chronic kidney disease (CKD). Treatment and correction of anaemia leads to improvement of cardiovascular status and quality of life of patients with CKD. This interventional open labeled randomised controlled study comparing the effect of intravenous and oral iron therapy in improving red cell indices and iron status in anaemic pre-dialysis Chronic Kidney Disease was carried out to determine iron status in anaemic pre-dialysis CKD patients to assess the benefit of parenteral iron supplementation as against empirical oral iron in CKD patients with iron deficiency.

PATIENTS AND METHODS

Sixty consecutive pre-dialysis chronic kidney disease patients attending the renal clinic over a six month period were screened. Forty- one subjects (68.3%) were found to be anaemic and were subsequently studied.

RESULTS

The ages of the patients ranged between 19 and 71 years with a mean age of 39 years. The mean serum creatinine and mean creatinine clearance were 201.80 (70.25)?mol/L and 37.90 (± 12.17)ml/minute respectively. The haematocrit concentration was found to correlate inversely with the level of serum creatinine and 56.1% of the anaemic patients had iron deficiency. The mean PCV rise in the intravenous iron group was 2.42 (± 1.98)% and this was statistically significant (p=0.002) while the mean PCV difference was 0.909 (± 0.94)% in the oral iron group. Intravenously administered iron alone permitted anaemia correction in about one-third of these patients without any life threatening adverse drug event.

CONCLUSION

Anaemia is very common in the pre-dialysis CKD population and the prevalence of iron deficiency is high. Intravenous iron supplementation is an effective and safe treatment for the anaemia in the pre-dialysis CKD patients. Response to oral iron was poor.

Kidney transplantation in a low-resource setting: Nigeria experience

The incidence and prevalence of chronic kidney disease and end-stage renal disease (ESRD) have continued to increase exponentially all over the world in both developed and developing countries. While the majority of patients in developed countries benefit from various modalities of renal replacement therapies, those from developing economies suffer untimely deaths from uremia and cardiovascular disease. Kidney transplantation (KT) leads to improvement in both the quantity and quality of life. Unfortunately, it is not exploited to its full potential in most countries and this is particularly the case in developing economies. Only a very small fraction of the ESRD population in emerging countries ever gets transplanted because of the many constraints. This review focuses on KT in Nigeria between 2000 and 2010 and assessed particular challenges that need be addressed for KT potential to be fully harnessed in such resource-constrained settings. A total of 143 KTs were performed in 5 transplant centers, some of which have only recently opened. One-year graft and patient survival was 83.2% and 90.2%, respectively, while the 5-year graft and patient survival was 58.7% and 73.4%, respectively. Mortality was reported in 38 (27%) of recipients. The complications recorded included acute rejection episodes in 15-30%, chronic allograft nephropathy in 21(14.7%) and malignancies, particularly Kaposi Sarcoma, which was reported in 8 (5.6%) recipients. It was concluded that KT has led to an improved survival but is bedevilled with unaffordability, inaccessibility, a shortage of donor organs and poor legislative support. Enactment of relevant organ transplant legislation, subsidization of renal care, and further development of local capacities would improve KT utilization and thus lead to better outcomes.

A community study of the prevalence, risk factors and pattern of chronic kidney disease in Osun State, South West Nigeria

BACKGROUND

Chronic kidney disease (CKD) is a global public health concern. Nigeria, like other African countries has paucity of hard data derived from community based studies.

AIMS

We set out to determine the awareness, level of knowledge, prevalence of chronic kidney disease and its associated risk factors in Nigerian community.

METHODS

We used a pre-tested structured questionnaire to draw information on sociodemography, knowledge and risk factors of CKD from 468 residents aged ≥ 18 years. Clinical examination, blood glucose, serum creatinine, urinalysis and urinary albumin: creatinine ratio (ACR) was carried out. Glomerular filtration rate (eGFR) was estimated using Modification for Diet in Renal Disease equation. CKD was defined as eGFR < 60 ml/min and/or macroalbuminuria (ACR ≥ 300 mg/g or dipstick proteinuria).

RESULTS

A total of 454 residents, mainly farmers, with a mean age of 45.8 ± 19.0 years and M: F ratio of 0.8:1 completed the study. Only 33.7% had heard of kidney disease; the level of knowledge of CKD was adjudged good, fair and poor in 25.5%, 42.2% and 30.6% respectively. There was higher prevalence of CKD in those with poor knowledge (p=0.023). Smoking habit, habitual analgesic intake, alcohol and herbal concoction use was 7%, 20%, 19% and 75% respectively. The prevalence of hypertension was 30%, diabetes mellitus (3.7%), obesity by waist circumference (14.6%) and haematuria (3.1%). Estimated GFR < 60 ml/min was present in 12.3% while macroalbuminuria was present in 8.9%. The overall prevalence of CKD was 18.8%, with CKD stages 1, 2, 3 and 4 accounting for 2.4%, 4.1%, 11.8% and 0.5% respectively. Age (p=0.00; OR 1.09), female gender (p=0.006; OR 4.87), systolic blood pressure P<0.001; OR 1.04) and diabetes (p=0033; OR 15.76) were predictive of CKD.

CONCLUSION

The prevalence of CKD and its risk factors are high in this rural community of South Western Nigeria. Majority had moderately impaired kidney function. This underscores the need for primary and secondary preventive programmes.

Calciphylaxis causing digital, gangrene in end stage renal disease: a case report and review

Calcific uraemic arteriolopathy (CUA), a potentially life-threatening vasculopathy of the skin and subcutaneous tissues is rarely associated with advanced chronic kidney disease (CKD) particularly in patients on haemodialysis. It is more frequently reported in whites than in blacks and commonly accompanies hyperphosphataemia, elevated calcium-phosphate product and marked secondary hyperparathyroidism. We report a rare case of CUA that complicated end stage renal disease secondary to obstructive uropathy in a 68 year old Nigerian. The risk factors for CUA, diagnosis, management and our peculiar limitations were reviewed and discussed.

C-reactive protein in healthy adult Nigerians

BACKGROUND

C-reactive protein (CRP) is an acute phase reactant produced in the liver in response to tissue injury or systemic inflammation, its release is stimulated by cytokines (interleukin-6 and tumour necrosis factor-alpha). Elevated CRP levels have been linked to an increased risk of later development of diabetes mellitus and systemic hypertension. Baseline level of C-reactive protein in apparently healthy men and women predict long-term risk of a first myocardial infarction.

METHOD

The study design was cross-sectional conducted among apparently healthy adult relative of patients and hospital staff of the Obafemi Awolowo University Teaching Hospitals complex (OAUTHC) Ile Ife, Osun State south western Nigeria. Serum lipids and fasting blood glucose were measured, while C-reactive protein measurement was based on the principle of solid phase enzyme-linked immunosorbent assay (ELISA).

RESULTS

Atotal of 50 apparently healthy consecutive adult subjects were recruited into the study comprising 19 male and 31 female. There was no significant difference in mean Fasting blood glucose and serum lipids between the male and female study subjects. However, C-reactive protein was found to be higher in female compared to male, but the difference was not statistically significant.

CONCLUSION

This study showed that apparently healthy adult female Nigerians have higher level of C-reactive protein compared to male, but with no significant difference.

The pattern, clinical characteristics and outcome of ESRD in Ile-Ife, Nigeria: is there a change in trend?

BACKGROUND

The prevalence of chronic renal failure and End Stage Renal Disease (ESRD) has remained high worldwide and the epidemiology has changed significantly in the last decade in industrialised countries. While there have been significant improvements in these patient's outcomes in developed countries, their state and survival is still appalling in developing countries.

OBJECTIVE

To determine the clinical pattern, presentation and management outcomes in our ESRD population over a 19-year period (1989-2007).

METHODS

Seven hundred and sixty patients' records were reviewed. Data on major causes, clinical presentation, management and survival were retrieved and collated. Data was analysed using SPSS package version 16.

RESULTS

Their ages ranged between 15-90 years (mean ± SD; 39.9±1.67years) with male preponderance (70.3%). Major presenting complaints were body swelling and uraemic symptoms in most studied patients. The predisposing conditions included chronic glomerulonephritis, hypertension, obstructive uropathy and diabetes mellitus. Renal replacement therapy offered included HD in 556(73.2%), Continous Ambulatory Peritoneal Dialysis (CAPD) in only 9(1.2%) patients and renal transplantation in only 7(0.9%). Only 38(6.8%) survived on HD for longer than three months while 7(77.8%) CAPD patients and all transplanted patients survived for between six months and four years (p<0.00001). Median duration of survival after diagnosis for all the patients was 2 weeks (range 0-50 months).

CONCLUSION

End stage renal disease is still prevalent with chronic glomerulonephritis and hypertension being the common causes. Prognosis is still grave hence subsidized renal replacement therapy and preventive nephrology should be targeted in such underserved populations.

Serum C-reactive protein in Nigerians with type 2 diabetes mellitus

BACKGROUND

C-reactive protein is an acute-phase proteins, produce in the liver, its release is stimulated by cytokines (interleukin 6 and tumour necrosis factor alpha). Elevated level of it is a risk factor for coronary heart disease. Baseline levels of C-reactive protein in apparently healthy men and women predict long-term risk of a first myocardial infarction. Diabetics are at increased risk for coronary heart disease, data from the Framingham Study showed a two- to three-fold elevation in the risk of clinically evident atherosclerotic disease in patients with type II diabetes compared to those without diabetes. However, but data regarding CRP in Nigerian diabetic is lacking.

METHOD

A cross-sectional study conducted among patients attending out patient clinic of the Obafemi Awolowo University Teaching Hospitals complex OAUTHC) Ile Ife, Osun State south western Nigeria. Measurement of C-reactive protein was based on the principle of solid phase enzyme-linked immunosorbent assay (ELISA).

RESULTS

A total of 125 consecutive subjects were recruited comprising 75 patients with type II diabetes mellitus with or without hypertension and 50 apparently healthy age-and-sex comparable controls. There was a significant difference between the mean systolic and diastolic blood pressures of the patients and controls. The fasting blood glucose and C-reactive protein were significantly higher in diabetics compared to controls. there was a positive and significant correlation between FBG and CRP in both patients and controls.

CONCLUSION

This study showed that diabetics have significantly higher serum C-reactive protein compared to the apparently controls. Also there was a positive and significant correlation between C-reactive protein and fasting blood glucose among both patients and controls.

An appraisal of kidney dysfunction and its risk factors in patients with sickle cell disease

Sickle cell disease (SCD), a genetically inherited disease of blacks, often presents with disabling acute complications which can occasionally be fatal. Its renal manifestations are increasingly being recognized as affected patients now survive to middle and rarely old age. We set out to determine the magnitude of kidney dysfunction in our SCD patient population and evaluate its predictive factors. We reviewed the available case records of SCD patients managed in our hospital. Information on socio-demographic, clinical and laboratory data were retrieved and collated. A total of 374 (99.46%) were reviewed with complete data; the median age was 23 years (range 7-62), while median age at diagnosis of SCD was 4 years (range 0.25-31). 235 patients (68.2%) had no kidney disease while the remaining 139 (37.2%) had proteinuria, hematuria or reduced glomerular filtration rate (GFR) <60 ml/min. The age of patients was a significant predictor of kidney disease (p = 0.002) and correlated with the level of serum creatinine (r = 0.188, p < 0.001), GFR (r = 0.245, p < 0.0001) and the degree of proteinuria (r = 0.174, p = 0.006). Patients with kidney disease had a significantly higher number of crises/hospitalizations (p < 0.001). Seven patients died in all and 4 (57%) of them had end-stage renal disease. We concluded that kidney disease is a common complication of SCD and significantly contributes to mortality. The age of the patients, duration of SCD and frequency of crises/hospitalizations are strong predictors of development of kidney disease.

Serum C-reactive protein in Nigerians with type II diabetes mellitus

BACKGROUND

C-reactive protein is an acute-phase proteins, produce in the liver, its release is stimulated by cytokines (interleukin 6 and tumour necrosis factor alpha). Elevated level of it is a risk factor for coronary heart disease. Baseline levels of C-reactive protein in apparently healthy men and women predict long-term risk of a first myocardial infarction. Diabetics are at increased risk for coronary heart disease, data from the Framingham Study showed a two-to three-fold elevation in the risk of clinically evident atherosclerotic disease in patients with type II diabetes compared to those without diabetes. However, but data regarding CRP in Nigerian diabetic is lacking.

OBJECTIVES

The study was to determine serum C-reactive protein in Nigerian with Type II diabetes mellitus.

METHODS

The study design was cross-sectional conducted among patients attending out patient clinic of the Obafemi Awolowo University Teaching Hospitals complex (OAUTHC) Ile Ife, Osun State south western Nigeria. Measurement of C-reactive protein was based on the principle of solid phase enzyme-linked immunosorbent assay (ELISA).

RESULTS

A total of 125 consecutive subjects were recruited comprising 75 patients with type II diabetes mellitus with or without hypertension and 50 apparently healthy age-and-sex comparable controls. There was a significant difference between the mean systolic and diastolic blood pressures of the patients and controls. The fasting blood glucose and C-reactive protein were significantly higher in diabetics compared to controls. There was a positive and significant correlation between FBG and CRP in both patients and controls.

CONCLUSION

This study showed that diabetics have significantly higher serum C-reactive protein compared to the apparently controls. Also there was a positive and significant correlation between C-reactive protein and fasting blood glucose among both patients and controls.

Prevalence and pattern of renal bone disease in end stage renal disease patients in Ile-Ife, Nigeria

BACKGROUND

Information on renal bone disease (RBD) is sparse in Nigeria. The prevalence of RBD in a dialysis population worldwide ranges between 33% and 67% and it increases with progression of renal insufficiency.

OBJECTIVE

To determine the prevalence and magnitude of RBD in patients with end stage renal disease (ESRD).

METHODS

Thirty consecutive ESRD patients were recruited. They had thorough clinical evaluation and investigations which included serum calcium, phosphate, alkaline phosphatase, albumin and skeletal survey. The serum iPTH, osteocalcin, and 1,25 (OH2) D3 were assessed in 20 patients.

RESULTS

The patients were aged 18-72 years with a mean of 38.93+/-15.7 years. There was a male:female ratio of 4:1. Uraemic symptoms were the major presenting complaints. None of the patients complained of bone pain or fracture. The mean values for serum creatinine, urea, creatinine clearance, calcium, phosphate, albumin, alkaline phosphatase, iPTH, osteocalcin and 1,25 (OH)2 Vit D3 were 1478.96 +/- 771.12 micromol/L, 22.33 +/- 7.42 mmol/L, 3.38 +/-2.22 mls/min, 1.8 +/- 0.5 mmol/L, 1.61 +/- 0.65 mmol/L, 30.2 +/- 6.1 g/L, 124.33 +/- 63.37 IU/L, 22.66 +/- 24.72, 45.14 +/- 43.8, 37.7 +/- 22.3 respectively. There were hypocalcaemia and hyper-phosphataemia in 80% and 60% of the patients respectively. Alkaline phosphatase was elevated in 44% of the patients while 11.8% had hyperparathyroidism. Level of 1,25 (OH)2 Vit D3 was low in 83.3% of the patients. There was a significant negative correlation between serum calcium and iPTH levels (r = -0.915, p=0.029). There was also significant negative correlation between alkaline phosphatase and 1,25 (OH)2 Vit D3 and serum albumin. Radiological evidence of RBD occurred in only 16.7% of the patients.

CONCLUSION

Renal bone disease is common in our patients with ESRD associated most commonly with low bone turnover while occurrence of hyperparathyroid bone disease appears low.

Acute renal failure (ARF) in developing countries: which factors actually influence survival

Acute renal failure, a relatively common clinical condition, is still associated with a high mortality rate in both developed and developing countries despite the differences in the epidemiology, clinical characteristics and therapeutic modalities offered to affected patients. The various modalities of renal replacement therapy are still largely inaccessible, unaffordable and unavailable in most parts of sub-Saharan Africa, hence the need to judiciously utilise available resources. Consequently we studied patients with acute renal failure to critically appraise the factors that influence survival and determine the usefulness or otherwise of available renal replacement therapies (Acute HD and Acute PD). A total of 46 (34 (73.9%) males and 12 (26.1%) females) patients satisfied the inclusion criteria. Their ages ranged between 15 and 76 years (mean +/- SD; 38.2 +/-16.3 years). The commonest causes were gastro-enteritis (cholera) and septicaemia in 36.9% and 30.5% respectively. Twenty six (56.5%) of all the patients survived while the remaining 20 (43.5%) died. Twenty four (52.2%) patients had different complications of which pulmonary oedema was singularly found to significantly influence survival. Other factors that were found to significantly influence survival included availability of renal replacement therapy, the aetiology of ARF; gender; age of the patients and the duration of oliguria. We further compared the patients managed with haemodialysis with those managed with peritoneal dialysis and found no difference(s) in the age; duration of oliguria or hospitalisation; survival figures; effect of pulmonary oedema and the aetiology of ARF. However, the number of sessions for HD and the duration of PD significantly influenced survival. We conclude that ARF is still associated with a high mortality rate and prompt institution of available renal replacement therapy and aggressive management of complications would assist in reducing the trend.

Acute renal failure in the intensive care unit: aetiological and predisposing factors and outcome

BACKGROUND

Acute renal failure (ARF) in the intensive care unit (ICU) complicates 20 to 35% of admissions worldwide. There is no information on the pattern of ARF in our ICU and factors that influence survival.

OBJECTIVE

To determine the magnitude of acute renal failure, and outcome among patients at an ICU in Nigeria.

METHODS

Adult patients requiring intensive care, and with ARF were recruited. Severity of ARF was assessed using the Liano prognostic scoring system and a modified version of APACHE II prognostic scores. Haemodialysis was offered when indicated. Management outcomes were noted while a relationship was sought between severity of ARF and outcome.

RESULTS

Forty (19.6%) of the 204 patients managed during the period had ARF. These included 28 (70%) males and 12 (30%) females. Twelve (30%) of the patients had head injury while eight (20%) had major burns. Surgical sepsis accounted for seven (17.5%), while six (15%) patients had advanced metastatic carcinoma. Multiple fractures accounted for four (10%) while other causes accounted for the remaining 16 (40%). The mean serum creatinine and urea were 863.3+95umol per litre and 19.45(4.1) mmol per litre respectively. The Liano scores ranged from 33% to 99% , mean of 61 + or - 4.2%) while modified APACHE II score ranged from 5-19 (mean of 11 + or - 3.2). There was a significant correlation between the Liano scores and outcome (p<0.007) while the modified APACHE II score did not influence the outcome (P>0.05). Eighty percent of patients who had two or more organ failure died compared to 20% of the patients with less than two organ failure. Eight (20%) patients survived. Dialysis therapy significantly influenced outcome as 100% of the dialysed patients survived compared to 80% of those who were not.

CONCLUSION

Acute renal failure presents a continuing challenge in the ICU setting with attendant of high morbidity and mortality. Dialysis significantly influences survival, hence, the service should be provided in every intensive care unit.

Which factors actually influence the development and progression of overt nephropathy in Nigerian diabetics?

OBJECTIVE

To determine the risk factors predisposing Nigerian diabetics to overt nephropathy with a view to developing strategies for its prevention.

DESIGN

case control study.

SETTING

Tertiary care hospital, a major nephrology referral centre in Nigeria.

SUBJECTS

30 diabetic nephropathy (DN) patients and 32 age and sex-matched diabetic patients without nephropathy.

MATERIALS AND METHODS

30 diabetic nephropathy (DN) patients with chronic renal failure who have been diabetic for a minimum of five years and satisfied the inclusion criteria for the study were compared with 32 age and sex-matched diabetic patients without nephropathy. Their socio-demographic parameters, clinical and laboratory profiles were determined and compared. RESULTS were analysed using the statistical package for social sciences version 10. Chi-square test, logistic regression analysis and Spearman's rank correlation coefficient were used, p-value < 0.05 was considered as significant.

MAIN OUTCOME MEASURES

The study sought to compare socio-demographic, clinical and biochemical data between diabetic patients with overt nephropathy and those without.

RESULTS

Duration of diabetes, blood pressures and blood sugar levels were significantly higher in DN patients than the controls (p < 0.05). A family history of renal disease, socio-economic status, cigarette smoking, body mass index and total serum cholesterol did not distinguish between DN patients from controls (p > 0.05). Systolic blood pressure positively correlated with serum creatinine (r = 0.057, p < 0.001) and duration of DM (r = 0.284, p = 0.02). There was a constellation of clinical features viz: retinopathy, peripheral neuropathy and left ventricular hypertrophy, which were significantly associated with DN (p < 0.05).

CONCLUSIONS

Prolonged duration of diabetes, hypertension, retinopathy, and peripheral neuropathy, left ventricular hypertrophy and poor glycaemic control were the major risk factors for overt nephropathy among Nigerian diabetics. Apreventive strategy should include adequate blood pressure and glycaemic control.

Adult nephrectomy: our experience at Ile-Ife

OBJECTIVES

To determine indications for adult nephrectomy in our community and the outcome of the procedure in our Institution.

MATERIALS AND METHOD

Records of adult patients scheduled for nephrectomy at Obafemi Awolowo University Teaching Hospital from January 1993 to December 2004 were reviewed. Information extracted and analysed included age of patient, sex, presentation, investigations, indication, type and outcome of nephrectomy, histopathology result and duration of follow up.

RESULTS

During the period, thirty adult patients mean age 42.73 yrs (range 16-80 yrs, M:F = 2:1) were scheduled for nephrectomy. Indications included suspicion of malignancy in 19 (63.3%) patients, protracted loin pain in non-functioning kidney in 2 (6.7%), uncontrollable bleeding in a patient with bilateral polycystic kidney (3.3%), pyonephrosis with septicaemia in a patient (3.3%), kidney injury (grade 5) in 2(6.7%) and kidney donation for transplantation in 3(10%). Ultrasound and intravenous urography were useful in the patients' evaluation. Twenty-seven (90%) patients were operated upon, but only 25 (83.3%) had nephrectomy. Sixteen (53.3%) had radical nephrectomy, 5 (16.7%) had simple nephrectomy, 3 (10%) had nephro-ureterectomy, and one (3.3%) had partial nephrectomy. Major surgical complications included wound sepsis (18.5%) and primary haemorrhage (7.4%). The overall morbidity and mortality rates were 7.4% and 3.7% respectively. Postuninephrectomy, patients' renal function remained stable after an average of 34.05 months follow-up.

CONCLUSION

Renal tumours constitute the main indication for adult nephrectomy in our community. Kidney injury, kidney donation, and pyonephrosis are relatively uncommon indications. Open nephrectomy, which remains our local practice, is safe and unilateral nephrectomy is compatible with normal life.

Complete recovery of renal allograft function after sixty days of delay following living related transplantation

Delayed graft function (DGF), a term employed when a newly transplanted organ does not function efficiently is commonly observed following cadaveric renal transplantation but is very rare after living related transplants. We present a 31-year-old female recipient of a related donor kidney (mother) who had DGF following trans-plantation due to acute tubular necrosis, probably caused by partial allograft arterial thrombosis, which recovered function after 60 days. Appropriate use of allograft biopsy should be encouraged even in resource-limited settings lest the allograft be assumed to have failed irreversibly.

Malignant renal tumors in adults: a ten-year review in a Nigerian hospital

This study was undertaken to determine the age, sex, pattern of presentation, histopathology and outcome of management of adult patients with malignant renal tumors (MRT) in Nigeria. Using hospital records, a retrospective study was performed covering the period between January 1997 and December 2006. A total of 18 adult patients had been diagnosed to have MRT during this period. Information extracted and analyzed included the age of the patient, sex, presentation, investigations, type of histopathology, management and duration of follow-up. The mean age of the study patients was 47.5 years (range 16-80 yrs). The male: female ratio was 13 : 5 and the mean duration of symptoms was 43.6 weeks (range 2-104 wks). Sixteen patients (88.9%) presented in advanced stage. Symptoms included loin pain in 17 (94.4%), abdominal swelling in 15 (83.3%), weight-loss in 13 (72.2%) and hematuria in nine (50.0%). Ultrasound and intravenous urography assisted greatly in making the diagnosis. Thirteen patients (72.2%) underwent radical nephrectomy, tumors were not resectable in two (11.1%) and three others (16.7%) were deemed unfit to undergo surgery. The average tumor mass removed at surgery was 1.884 Kg (range 0.48-3.82 Kg). Renal cell carcinoma (RCC) accounted for 13 of the tumors (72.2%). Surgical complications include primary-hemorrhage, septicemia and tumor recurrence in one patient each (7.6%). Morbidity and mortality rates were 7.6% each. The average post-operative hospital stay and follow-up duration were 9.3 days and 37.5 months respectively. Our study suggests that RCC is the major MRT in our community. Most cases still present late with loin pain and swelling, weight loss and hematuria. This late presentation and sarcomatous type of tumor have negative influence on prognosis. Radical nephrectomy is beneficial in operable, locally advanced, non-metastatic MRT.

Internal jugular and subclavian catheterisation: indications, problems and prospects in a Nigerian dialysis centre

AIMS AND OBJECTIVES

To highlight the indications, problems and prospects of bedside non-surgically inserted jugular and subclavian dual lumen catheters.

PATIENTS AND METHODS

Renal failure patients being managed in our centre with indications for central catheterisation were consecutively recruited at presentation. They had bedside non-surgical jugular and subclavian insertion of central catheters using modified Seldinger wire technique and the performance of the catheters monitored.

RESULTS

Sixteen patients aged between 23 and 65 years had 32 central catheterizations during the 12-month period. The indications included its use as haemodialysis access in all catheterisations, additional indications were CVP monitoring in 5, and parenteral hyperalimentation in 1. Three catheterisations were in right subclavian vein, 4 in left internal jugular vein and 25 in right internal jugular vein. The duration of use ranged between 3 days and 11 weeks and blood flow rate used ranged between 250 and 350 mls/min. Nine (28.1%) catheterisations were complicated with exit site and systemic infection. Catheter blockage and accidental catheter removal were recorded in 3 patients each. Carotid artery puncture was recorded in 2 patients but haemostasis was maintained with direct digital compression.

CONCLUSION

We conclude that percutaneous bedside internal jugular and subclavian (venous) catheterisation using dual lumen catheter is safe and devoid of major complications.

Kidney transplantation in a developing economy: challenges and initial report of three cases at Ile Ife

BACKGROUND

Kidney transplantation (KT) is globally adjudged the best alternative treatment for end stage renal disease (ESRD) in preference to life-long dialysis. This form of therapy was hitherto unavailable in Nigeria until our hospital and a private hospital embarked on a KT programme despite our depressed economy, and inadequate facilities. We present the initial report of KT performed in our hospital and the challenges of KT in our developing society.

CASE REPORTS

Three patients with ESRD had living related KT between June 2002 and April 2003. The first patient died with functioning graft six and a half months post transplantation from complications of Diabetes mellitus and sepsis, while the remaining two still enjoy a good quality of life 35 months post transplantation. There were problems with procurement and monitoring of immunosuppressive drugs in the three patients. This report also illustrates the common causes of ESRD in Nigeria and some of the complications of KT. To our knowledge, these are the first reported cases of KT in Nigeria.

CONCLUSION

Kidney transplantation is cost effective and offers a good quality of life for ESRD patients. Poverty, inadequate facilities and lack of donors are major problems facing KT in our society. Although KT requires high technical and material resources, with proper training, commitment and adequate funding, it is feasible, safe and cheaper on a long term basis for the management of patients with ESRD in a developing economy like ours. There is a need for government funding of KT programmes in developing countries.

An analysis of the effectiveness and benefits of peritoneal dialysis and haemodialysis using Nigerian made PD fluids

Haemodialysis (HD) and peritoneal dialysis (PD) remains the cornerstone of management of patients with renal failure in developing countries as renal transplantation is just developing in most. Although both HD and PD are cost intensive, specific advantages and disadvantages have been identified with either of them. Comparative assessment of their effectiveness, benefits and cost will assist in providing a rational basis for preference of one or the other especially in third world countries where renal replacement therapy remains unaffordable and therefore relatively inaccessible to majority of patients. We therefore conducted this prospective randomised study to compare the effectiveness, benefits, cost and complications of acute or intermittent PD (IPD) and HD using locally manufactured PD fluids. Two groups of twenty patients with renal failure matched for age and clinical diagnosis were managed with IPD and HD and the effectiveness, costs and complications of both modalities compared. We found that both were comparably effective in the control of uraemia with significant reductions in the serum urea, creatinine and potassium from 29.2 +/- 7.2 mmol/L, 1693.7 +/- 580.5micromol/L and 4.8 +/- 1.2 mmol/L to 13.2 +/- 4.6 mmol/L, 796.0 +/- 458.0micromol/ L and 3.3 +/- 0.6 mmol/L respectively for IPD (P<0.05) and 34.4 +/- 9.0mmol/L, 1536.0 +/- 832.5 micromol/L and4.8 +/- 1.3 mmoV L to 14.6 +/- 7.5 mmol/L, 830.0 +/- 570.7 micromol/L and 3.9 +/- 0.8 mmol/L respectively for HD (P<0.05). In addition, there were significant improvements in serum bicarbonate in both groups. There was no significant difference in percentage reduction in serum urea, creatinine and serum potassium in both groups (P>0.05). However, HD managed patients required more blood transfusion (P<0.05). There were also comparably significant reductiohs in systolic, diastolic and mean arterial blood pressures in both groups (P<0.05). The costs of dialysis as well as the total cost of hospitalization were found to be significantly lower in patients managed with IPD (P<0.05). The commonest complication observed in patients managed with IPD was peritonitis while in patients managed with HD it was dialysis-induced hypotension. The clinical outcome was equally good in all the ARF patients as all of them recovered irrespective of the treatment modality; CRF patients did not fare as well with 37.5% mortality observed. We conclude that IPD and HD are effective renal replacement therapies with the former being significantly cheaper. IPD should be encouraged in our patients with ARF or acute exacerbation of chronic renal failure.

Health-related quality of life in emotionally related kidney transplantation: deductions from a comparative study

The health related quality of life (HRQOL) has not been compared between live related and un-related donations. We set out to assess the HRQOL in 52 recipients and compare them to 68 HD patients using the Karnofsky performance status scale. Statistical package for social sciences (SPSS) was used for data analysis. The duration of end-stage renal disease was 7.14 + 3.8 years and 5.30 + 4.15 years for transplant and HD patients respectively. The HRQOL was similar in both living and emotionally related recipients but both were significantly better than that of HD patients (P < 0.0001). There was significant negative correlation between HRQOL and age (r = -0.363, P < 0.0001), serum creatinine (r = -0.502, P = 0.0001), serum urea (r = -0.493, P < 0.0001), serum phosphate (r = -0.363, P = 0.003) and calcium-phosphate product (r = -0.305, P < 0.0001). There was significant positive correlation between HRQOL and haemoglobin (r = +0.495, P < 0.0001) and serum calcium (r = +0.247, P = 0.017). Age of the patients appears to be the most important determinant of HRQOL in the studied population. HRQOL was similar in the related and unrelated donors and was better than in hemodialysis patients.

Patterns of presentation and mortality in tetanus: a 10-year retrospective review

BACKGROUND

Tetanus, an ubiquitous disease still ravages our population despite the fact that it is totally preventable. The mortality had remained high with its attendant socio-economic implications as it affects mainly farmers in their prime of life. We conducted this retrospective review to be able to determine pattern of presentation, case fatality rate and factors influencing mortality with a view to mapping out control strategies.

PATIENTS, MATERIALS AND METHODS

The case records of all managed patients aged 16 and above over a ten-year period (1992-2001) were retrieved and socio-demographic and clinical data as well as results of laboratory investigations were collated. Analysis was done using SPSS package. Chi-square analysis and student t-test were used for comparison of means as appropriate. P-values of <0.05 were taken as significant.

RESULTS

There were a total of 114 patients managed during the period, which comprised 85 males and 29 females. The mean age (+/- SD) was 35.96 years (+/- 17.76). Sixty-six (57.89% ) patients are either jobless or farmers. Majority of the patients had injuries in the lower limb (59.65% ) when compared with 20.18% that had theirs in the upper limb. 107 (93.86% ) of the patients presented with trismus while only 82 (71.93% ) had opsthotomus. Only 51 (44.73% ) patients survived while 61(53.5% ) died. The mean age (+/- SD) of the survivors was 32.35 (+ 14.45) years while that of those that died was 39.4 (+/- 19.89) years (P = 0.036). Other factors that significantly influenced survival included severity of spasms (P = 0.003), tachycardia (P = 0.044), and degree of sedation (P<0.0001). No association was found between survival and incubation period, period of onset, site of injury and associated medical conditions.

CONCLUSIONS

Tetanus is still associated with high mortality rate. Factors such as severity of spasms, age, sedation and tachycardia were found to significantly influence mortality. It is recommended that prophylactic life immunisation against tetanus be given to all Nigerians.

Gastro-oesophageal reflux disease: a review of clinical features, investigations and recent trends in management

BACKGROUND

Gastro-oesophageal reflux disease, though a common digestive disorder worldwide, is scarcely reported with very sparse literature in oursetting.

AIM

To review the clinical features, investigations and recent developments in the management of gastro-oesophageal reflux disease.

METHODS

We retrieved publications from local and international journals. We also searched Medline particularly for local references. Other sources of our data include Up-to-date in Medicine and standard texts in medicine and pathology.

RESULTS

Local literature is generally lacking; while the classical symptoms of gastro-oesophageal reflux disease are heartburn, dysphagia and acid regurgitation, clinical examination is usually silent except when there are complications. There is no gold standard investigation but oesophageal pH monitoring, Bernstein test, oesophagoscopy and oesophageal manometry have been established to be useful in the evaluation of affected patients. Radiologic investigations, though insensitive in the diagnosis, are invaluable in diagnosing complications. Response to 14-day treatment with omeprazole (20 mg daily) has now been established to have a high sensitivity and specificity in diagnosing the condition. Management strategies include lifestyle modification, medical and surgical therapies. Proton pump inhibitors are now recognized as first line therapy in management.

CONCLUSION

The prevalence and behaviour of this condition in Nigeria is not known and local references are scanty. This review article focused on the worldwide epidemiology, pathogenesis and recent trends in management to stimulate our interest in this area.

Patterns of presentation and mortality in tetanus: a 10-year retrospective review

AIMS AND OBJECTIVES

To highlight the indications, problems and prospects of bedside non-surgically inserted jugular and subclavian dual luman catheters.

PATIENTS AND METHODS

Renal failure patients being managed in our centre with indications for central catheterisation were consecutively recruited at presentation. They had bedside non-surgical jugular and subclavian insertion using modified seldinger wire technique and the performance of the Gatheters monitored.

RESULTS

Sixteen patients aged between 23 and 65 years had 32 central catheterisations during the 12-month period. The indications included its use as haemodialysis access in all patients, additional indications were CVP monitoring in 5, and parenteral hyperalimentation in 1. Three catheterisations were in right subclavian vein, 4 in let internal jugular vein and 25 in right internal jugular vein. The duration of use ranged between 3 days and 11 weeks and blood flow rate used ranged between 50 and 350ml/min. Nine (28.1%) catheterisations were complicated with exit site and systemic infection. Catheter blockage and accidental catheter removal were recorded in 3 patients each. Carotid artery puncture was recorded in 2 patients but haemostasis was maintained with direct digital compression.

CONCLUSION

We conclude that percutaneous bedside internal jugular and subclavian (venous) catheterisation using dual lumen catheter is safe and devoid of major complications.

BACKGROUND

Tetanus, an ubiquitous disease still ravages our population despite the fact that it is totally preventable. The mortality had remained high with its attendant socio-economic implications as it affects mainly farmers in their prime of life. We conducted this retrospective review to be able to determine pattern of presentation, case fatality rate and factors influencing mortality with a view to mapping out control strategies.

PATIENTS, MATERIALS AND METHODS

The case records of all managed patients aged 16 and above over a ten-year period (1992-2001) were retrieved and socio-demographic and clinical data as well as results of laboratory investigations were collated. Analysis was done using SPSS package. Chi-square analysis and student t-test were used for comparison of means as appropriate. P-values of <0. 05 was taken as significant.

RESULTS

There were a total of 114 patients managed during the period, which comprised of 85 males and 29 females. The means age (+/- SD) was 35.96 (+/-17.76). Sixty six (57.89%) patients are either jobless or farmers. Majority of the patients had injuries in the lower limb 59.65% when compared with 20.18% that had theirs in the upper limb. 107 (93.86%) of the patients presented with trismus while only 82 (71.93%) had opsthotonus. Only 51 (44.73%) patients survived while 61 (53.5%) died. The mean age (+/- SD) of the survivors was 32.35 (+ 14.45) years while that of those that died was 39.4 (+/- 19.89) years (P = 0.036). Other factors that significantly influenced survival included severity of spasms (P = 0/003), tachycardia (P = 0.044), and degree of sedation (P <0.0001). No association was found between survival and incubation period, period of onset, site of injury and associated medical conditions.

CONCLUSIONS

Tetanus is still associated with high mortality rate. Factors such as severity of spasma, age, sedation and tachycardia were found to significantly influence mortality. It is recommended that prophylactic life immunisation against tetanus be given to all Nigerians.

Cancer Antigen (CA) 125, a Novel Peritoneal Membrane Marker in CAPD Patients

Chronic renal failure (CRF) remains a major cause of morbidity and mortality world-wide and consumes substantial percentage of health budgets in the developed countries. Dialysis, in particular, continuous ambulatory peritoneal dialysis (CAPD), as a form of therapy in the management of CRF, has its own side effects and can contribute to the morbidity and mortality. The end result of these side effects is loss of effective surface area consequent on the development of peritoneal sclerosis. Peritoneal sclerosis in CAPD occurs gradually over repeated number of dialysis sessions. Serial observations of changes in the peritoneum, as a dialyzing surface, are difficult and it is only available by peritoneal biopsy, which is an invasive procedure. However, the discovery of some markers in the effluents of CAPD patients as a measure of peritoneal membrane status has reduced the need for this invasive procedure. In particular, the discovery of cancer antigen 125 (CA 125) in the effluent has provided a much-needed tool to follow the changes in peritoneal membrane of CAPD patients and prevent the occurrence of much dreaded peritoneal sclerosis.

Factors influencing compliance in patients with tuberculosis on directly observed therapy at Ile-Ife, Nigeria

BACKGROUND

Increased morbidity and mortality of tuberculosis have been blamed on neglect of the human dimension of tuberculosis control. One of such factors included in human dimension is non-compliance, a behavioural parameter, which has led to the emergence of multi-drug resistant tuberculosis, and poor treatment outcome.

OBJECTIVE

To explore the impact of directly observed therapy (DOT) on compliance and the factors influencing it.

DESIGN

A retrospective study.

SETTING

Chest clinic of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.

METHODS

Directly observed therapy (DOT) was employed. Records of the socio-demographic characteristics, treatment categories, complications developed, results of investigations, level of compliance and treatment outcome for the patients were kept. The data for the patients seen between May 1996 and April 1997 were retrieved and analysed. Those that complied were compared with those that did not comply.

RESULTS

One hundred and ninety nine patients comprising ninety one males and 108 females, were seen during the period. They were mostly between the ages of 16 years and 45 years (mean +/- SD = 31.7+/-14.98). One hundred and fifty eight (73%) complied and all of them were cured. The only factor that significantly influenced rate of compliance was proximity to the chest clinic.

CONCLUSION

DOT improves the rate of compliance. No socio-demographic factors considered significantly influenced the rate of compliance under DOT, and as such they are not reliable predictive factors. Locating chest units in the existing primary health care facilities will improve the rate of compliance with antituberculosis therapy. More attention should be paid to behavioural aspect of tuberculosis control.