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Galson SW, Pesambili M, Vissoci JRN, Manavalan P, Hertz JT, Temu G, Staton CA, Stanifer JW. Hypertension in an Emergency Department Population in Moshi, Tanzania; A Qualitative Study of Barriers to Hypertension Control. PLoS One 2023; 18:e0279377. [PMID: 36608026 PMCID: PMC9821488 DOI: 10.1371/journal.pone.0279377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Sub-Saharan Africa has a high prevalence of hypertension with a low rate of awareness, treatment adherence, and control. The emergency department (ED) may represent a unique opportunity to improve hypertension screening, awareness, and linkage to care. We conducted a qualitative study among hypertensive patients presenting to the ED and their healthcare providers to determine barriers to hypertension care and control. METHODS In northern Tanzania, between November and December 2017, we conducted three focus group discussions among patients with hypertension presenting to the emergency department and three in-depth interviews among emergency department physicians. In our study, hypertension was defined as a single blood pressure of ≥160/100 mm Hg or a two-time average of ≥140/90 mm Hg. Barriers to care were identified by thematic analysis applying an inductive approach within the framework method. RESULTS We enrolled 24 total patients into three focus groups and performed three in-depth interviews with individual providers. Thematic analysis identified two major domains: 1) patient knowledge, attitudes, and practices, and 2) structural barriers to hypertension care. Four major themes emerged within the knowledge, attitudes, and practices domain, including disease chronicity, provider communication, family support, and fear-based attitudes. Within the structural domain, several themes emerged that identified barriers that impeded hypertension follow-up care and self-management, including cost, access to care, and transportation and wait time. CONCLUSION Patients and physicians identified multiple barriers and facilitators to hypertension care. These perspectives may be helpful to design emergency department-based interventions that target blood pressure control and linkage to outpatient care.
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Affiliation(s)
- Sophie W. Galson
- Duke Emergency Medicine, Duke Global Health Institute, Durham, NC, United States of America
- * E-mail:
| | | | | | - Preeti Manavalan
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Julian T. Hertz
- Duke Emergency Medicine, Duke Global Health Institute, Durham, NC, United States of America
| | - Gloria Temu
- Kilimanjaro Christian Medical Center, Kilimanjaro, Tanzania
| | - Catherine A. Staton
- Duke University Medical Center, Duke Global Health Institute, Durham, NC, United States of America
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Pham TV, Beasley CM, Gagliardi JP, Koenig HG, Stanifer JW. Spirituality, Coping, and Resilience Among Rural Residents Living with Chronic Kidney Disease. J Relig Health 2020; 59:2951-2968. [PMID: 31392626 DOI: 10.1007/s10943-019-00892-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Spirituality, an established resource within rural America, serves as an important coping mechanism for crises of chronic illness. We examined the effects of spirituality on chronic kidney disease (CKD) maintenance in the rural community of Robeson County, North Carolina. We conducted nine focus group discussions and 16 interviews involving 80 diverse key informants impacted by CKD. As disenfranchised patients, they locally engaged in spirituality which mobilized personal and social resources and elicited support from a transcendent authority. Our participants developed a heuristic and aesthetic understanding of disease, built resilience and self-care skills, and improved overall coping and survival.
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Affiliation(s)
- Tony V Pham
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27701, USA.
| | - Cherry M Beasley
- Department of Nursing, University of North Carolina, Pembroke, Pembroke, NC, USA
| | - Jane P Gagliardi
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke Health, Durham, NC, USA
| | - Harold G Koenig
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27701, USA
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - John W Stanifer
- Munson Nephrology, Munson Healthcare, Traverse City, MI, USA
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Stanifer JW, Pokorney SD, Chertow GM, Hohnloser SH, Wojdyla DM, Garonzik S, Byon W, Hijazi Z, Lopes RD, Alexander JH, Wallentin L, Granger CB. Apixaban Versus Warfarin in Patients With Atrial Fibrillation and Advanced Chronic Kidney Disease. Circulation 2020; 141:1384-1392. [DOI: 10.1161/circulationaha.119.044059] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background:
Compared with the general population, patients with advanced chronic kidney disease have a >10-fold higher burden of atrial fibrillation. Limited data are available guiding the use of nonvitamin K antagonist oral anticoagulants in this population.
Methods:
We compared the safety of apixaban with warfarin in 269 patients with atrial fibrillation and advanced chronic kidney disease (defined as creatinine clearance [CrCl] 25 to 30 mL/min) enrolled in the ARISTOTLE trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation). Cox proportional models were used to estimate hazard ratios for major bleeding and major or clinically relevant nonmajor bleeding. We characterized the pharmacokinetic profile of apixaban by assessing differences in exposure using nonlinear mixed effects models.
Results:
Among patients with CrCl 25 to 30 mL/min, apixaban caused less major bleeding (hazard ratio, 0.34 [95% CI, 0.14–0.80]) and major or clinically relevant nonmajor bleeding (hazard ratio, 0.35 [95% CI, 0.17–0.72]) compared with warfarin. Patients with CrCl 25 to 30 mL/min randomized to apixaban demonstrated a trend toward lower rates of major bleeding when compared with those with CrCl >30 mL/min (
P
interaction=0.08) and major or clinically relevant nonmajor bleeding (
P
interaction=0.05). Median daily steady-state areas under the curve for apixaban 5 mg twice daily were 5512 ng/(mL·h) and 3406 ng/(mL·h) for patients with CrCl 25 to 30 mL/min or >30 mL/min, respectively. For apixaban 2.5 mg twice daily, the median exposure was 2780 ng/(mL·h) for patients with CrCl 25 to 30 mL/min. The area under the curve values for patients with CrCl 25 to 30 mL/min fell within the ranges demonstrated for patients with CrCl >30 mL/min.
Conclusions:
Among patients with atrial fibrillation and CrCl 25 to 30 mL/min, apixaban caused less bleeding than warfarin, with even greater reductions in bleeding than in patients with CrCl >30 mL/min. We observed substantial overlap in the range of exposure to apixaban 5 mg twice daily for patients with or without advanced chronic kidney disease, supporting conventional dosing in patients with CrCl 25 to 30 mL/min. Randomized, controlled studies evaluating the safety and efficacy of apixaban are urgently needed in patients with advanced chronic kidney disease, including those receiving dialysis.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT00412984.
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Affiliation(s)
- John W. Stanifer
- Munson Nephrology, Munson Healthcare, Traverse City, MI (J.W.S.)
| | - Sean D. Pokorney
- Division of Cardiology, Department of Medicine, Duke Health (S.D.P., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, CA (G.M.C.)
| | | | - Daniel M. Wojdyla
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
| | - Samira Garonzik
- Clinical Pharmacology and Pharmacometrics, Bristol-Myers Squibb Company, Princeton, NJ (S.G.)
| | - Wonkyung Byon
- Global Product Development Clinical Pharmacology, Pfizer, Inc, Groton, CT (W.B.)
| | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center (Z.H., L.W.), Uppsala University, Sweden
| | - Renato D. Lopes
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
| | - John H. Alexander
- Division of Cardiology, Department of Medicine, Duke Health (S.D.P., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center (Z.H., L.W.), Uppsala University, Sweden
| | - Christopher B. Granger
- Division of Cardiology, Department of Medicine, Duke Health (S.D.P., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute (S.D.P., D.M.W., R.D.L., J.H.A., C.B.G.), Duke University School of Medicine, Durham, NC
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Lunyera J, Stanifer JW, Davenport CA, Mohottige D, Bhavsar NA, Scialla JJ, Pendergast J, Boulware LE, Diamantidis CJ. Life Course Socioeconomic Status, Allostatic Load, and Kidney Health in Black Americans. Clin J Am Soc Nephrol 2020; 15:341-348. [PMID: 32075808 PMCID: PMC7057315 DOI: 10.2215/cjn.08430719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/07/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Low socioeconomic status confers unfavorable health, but the degree and mechanisms by which life course socioeconomic status affects kidney health is unclear. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined the association between cumulative lifetime socioeconomic status and CKD in black Americans in the Jackson Heart Study. We used conditional process analysis to evaluate allostatic load as a potential mediator of this relation. Cumulative lifetime socioeconomic status was an age-standardized z-score, which has 1-SD units by definition, and derived from self-reported childhood socioeconomic status, education, and income at baseline. Allostatic load encompassed 11 baseline biomarkers subsuming neuroendocrine, metabolic, autonomic, and immune physiologic systems. CKD outcomes included prevalent CKD at baseline and eGFR decline and incident CKD over follow-up. RESULTS Among 3421 participants at baseline (mean age 55 years [SD 13]; 63% female), cumulative lifetime socioeconomic status ranged from -3.3 to 2.3, and 673 (20%) had prevalent CKD. After multivariable adjustment, lower cumulative lifetime socioeconomic status was associated with greater prevalence of CKD both directly (odds ratio [OR], 1.18; 95% confidence interval [95% CI], 1.04 to 1.33 per 1 SD and OR, 1.45; 95% CI, 1.15 to 1.83 in lowest versus highest tertile) and via higher allostatic load (OR, 1.09; 95% CI, 1.06 to 1.12 per 1 SD and OR, 1.17; 95% CI, 1.11 to 1.24 in lowest versus highest tertile). After a median follow-up of 8 years (interquartile range, 7-8 years), mean annual eGFR decline was 1 ml/min per 1.73 m2 (SD 2), and 254 out of 2043 (12%) participants developed incident CKD. Lower cumulative lifetime socioeconomic status was only indirectly associated with greater CKD incidence (OR, 1.04; 95% CI, 1.01 to 1.07 per 1 SD and OR, 1.08; 95% CI, 1.02 to 1.14 in lowest versus highest tertile) and modestly faster annual eGFR decline, in milliliters per minute (OR, 0.01; 95% CI, 0.00 to 0.02 per 1 SD and OR, 0.02; 95% CI, 0.00 to 0.04 in lowest versus highest tertile), via higher baseline allostatic load. CONCLUSIONS Lower cumulative lifetime socioeconomic status was substantially associated with CKD prevalence but modestly with CKD incidence and eGFR decline via baseline allostatic load.
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Affiliation(s)
- Joseph Lunyera
- Division of General Internal Medicine, Department of Medicine,
| | | | | | | | | | - Julia J Scialla
- Division of Nephrology, Department of Medicine.,Duke Clinical Research Institute, and
| | - Jane Pendergast
- Division of General Internal Medicine, Department of Medicine.,Department of Biostatistics and Bioinformatics
| | | | - Clarissa Jonas Diamantidis
- Division of General Internal Medicine, Department of Medicine.,Division of Nephrology, Department of Medicine.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Lunyera J, Davenport CA, Jackson CL, Johnson DA, Bhavsar NA, Sims M, Scialla JJ, Stanifer JW, Pendergast J, McMullan CJ, Ricardo AC, Boulware LE, Diamantidis CJ. Evaluation of Allostatic Load as a Mediator of Sleep and Kidney Outcomes in Black Americans. Kidney Int Rep 2019; 4:425-433. [PMID: 30899870 PMCID: PMC6409364 DOI: 10.1016/j.ekir.2018.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 01/18/2023] Open
Abstract
Introduction Poor sleep associates with adverse chronic kidney disease (CKD) outcomes yet the biological mechanisms underlying this relation remain unclear. One proposed mechanism is via allostatic load, a cumulative biologic measure of stress. Methods Using data from 5177 Jackson Heart Study participants with sleep measures available, we examined the association of self-reported sleep duration: very short, short, recommended, and long (≤5, 6, 7–8, or ≥9 hours per 24 hours, respectively) and sleep quality (high, moderate, low) with prevalent baseline CKD, and estimated glomerular filtration rate (eGFR) decline and incident CKD at follow-up. CKD was defined as eGFR <60 ml/min per 1.73 m2 or urine albumin-to-creatinine ratio ≥30 mg/g. Models were adjusted for demographics, comorbidities, and kidney function. We further evaluated allostatic load (quantified at baseline using 11 biomarkers from neuroendocrine, metabolic, autonomic, and immune domains) as a mediator of these relations using a process analysis approach. Results Participants with very short sleep duration (vs. 7–8 hours) had greater odds of prevalent CKD (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.03–1.66). Very short, short, or long sleep duration (vs. 7–8 hours) was not associated with kidney outcomes over a median follow-up of 8 years. Low sleep quality (vs. high) associated with greater odds of prevalent CKD (OR 1.26, 95% CI 1.00–1.60) and 0.18 ml/min per 1.73 m2 (95% CI 0.00–0.36) faster eGFR decline per year. Allostatic load did not mediate the associations of sleep duration or sleep quality with kidney outcomes. Conclusions Very short sleep duration and low sleep quality were associated with adverse kidney outcomes in this all-black cohort, but allostatic load did not appear to mediate these associations.
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Affiliation(s)
- Joseph Lunyera
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Correspondence: Joseph Lunyera, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, North Carolina 27701, USA.
| | - Clemontina A. Davenport
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chandra L. Jackson
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina, USA
| | - Dayna A. Johnson
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nrupen A. Bhavsar
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mario Sims
- Jackson Heart Study, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Julia J. Scialla
- Duke Clinical Research Institute, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - John W. Stanifer
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jane Pendergast
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ciaran J. McMullan
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - L. Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Clarissa J. Diamantidis
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Galson SW, Stanifer JW, Hertz JT, Temu G, Thielman N, Gafaar T, Staton CA. The burden of hypertension in the emergency department and linkage to care: A prospective cohort study in Tanzania. PLoS One 2019; 14:e0211287. [PMID: 30682173 PMCID: PMC6347227 DOI: 10.1371/journal.pone.0211287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/10/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Globally, hypertension affects one billion people and disproportionately burdens low-and middle-income countries. Despite the high disease burden in sub-Saharan Africa, optimal care models for diagnosing and treating hypertension have not been established. Emergency departments (EDs) are frequently the first biomedical healthcare contact for many people in the region. ED encounters may offer a unique opportunity for identifying high risk patients and linking them to care. METHODS Between July 2017 and March 2018, we conducted a prospective cohort study among patients presenting to a tertiary care ED in northern Tanzania. We recruited adult patients with a triage blood pressure ≥ 140/90 mmHg in order to screen for hypertension. We explored knowledge, attitudes and practices for hypertension using a questionnaire, and assessed factors associated with successful follow-up. Hypertension was defined as a single blood pressure measurement ≥ 160/100 mmHg or a three-time average of ≥ 140/90 mmHg. Uncontrolled hypertension was defined as a three-time average measurement of ≥ 160/100 mmHg. Successful follow-up was defined as seeing an outpatient provider within one month of the ED visit. RESULTS We enrolled 598 adults (mean age 59.6 years), of whom 539 (90.1%) completed the study. The majority (78.6%) of participants were aware of having hypertension. Many (223; 37.2%) had uncontrolled hypertension. Overall, only 236 (43.8%) of participants successfully followed-up within one month. Successful follow-up was associated with a greater understanding that hypertension requires lifelong treatment (RR 1.11; 95% CI 1.03,1.21) and inversely associated with greater anxiety about the future (RR 0.80; 95% CI 0.64,0.99). CONCLUSION In a northern Tanzanian tertiary care ED, the burden of hypertension is high, with few patients receiving optimal outpatient care follow-up. Multi-disciplinary strategies are needed to improve linkage to care for high-risk patients from ED settings.
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Affiliation(s)
- Sophie W. Galson
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
| | - John W. Stanifer
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Division of Nephrology, Duke University, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Gloria Temu
- Department of Medicine, Kilimanjaro Christian Medical College Hospital, Kilimanjaro, Tanzania
| | - Nathan Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Temitope Gafaar
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Catherine A. Staton
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Neurosurgery, Division of Global Neurosurgery and Neuroscience, Durham, North Carolina, United States of America
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Stanifer JW, Stapleton HM, Souma T, Wittmer A, Zhao X, Boulware LE. Perfluorinated Chemicals as Emerging Environmental Threats to Kidney Health: A Scoping Review. Clin J Am Soc Nephrol 2018. [PMID: 30213782 DOI: 10.2215/an.04670418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Per- and polyfluoroalkyl substances (PFASs) are a large group of manufactured nonbiodegradable compounds. Despite increasing awareness as global pollutants, the impact of PFAS exposure on human health is not well understood, and there are growing concerns for adverse effects on kidney function. Therefore, we conducted a scoping review to summarize and identify gaps in the understanding between PFAS exposure and kidney health. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We systematically searched PubMed, EMBASE, EBSCO Global Health, World Health Organization Global Index, and Web of Science for studies published from 1990 to 2018. We included studies on the epidemiology, pharmacokinetics, or toxicology of PFAS exposure and kidney-related health, including clinical, histologic, molecular, and metabolic outcomes related to kidney disease, or outcomes related to the pharmacokinetic role of the kidneys. RESULTS We identified 74 studies, including 21 epidemiologic, 13 pharmacokinetic, and 40 toxicological studies. Three population-based epidemiologic studies demonstrated associations between PFAS exposure and lower kidney function. Along with toxicology studies (n=10) showing tubular histologic and cellular changes from PFAS exposure, pharmacokinetic studies (n=5) demonstrated the kidneys were major routes of elimination, with active proximal tubule transport. In several studies (n=17), PFAS exposure altered several pathways linked to kidney disease, including oxidative stress pathways, peroxisome proliferators-activated receptor pathways, NF-E2-related factor 2 pathways, partial epithelial mesenchymal transition, and enhanced endothelial permeability through actin filament modeling. CONCLUSIONS A growing body of evidence portends PFASs are emerging environmental threats to kidney health; yet several important gaps in our understanding still exist.
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Affiliation(s)
- John W Stanifer
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; and
- Duke Global Health Institute
| | | | - Tomokazu Souma
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; and
| | | | | | - L Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
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8
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Stanifer JW, Stapleton HM, Souma T, Wittmer A, Zhao X, Boulware LE. Perfluorinated Chemicals as Emerging Environmental Threats to Kidney Health: A Scoping Review. Clin J Am Soc Nephrol 2018; 13:1479-1492. [PMID: 30213782 PMCID: PMC6218824 DOI: 10.2215/cjn.04670418] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/27/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Per- and polyfluoroalkyl substances (PFASs) are a large group of manufactured nonbiodegradable compounds. Despite increasing awareness as global pollutants, the impact of PFAS exposure on human health is not well understood, and there are growing concerns for adverse effects on kidney function. Therefore, we conducted a scoping review to summarize and identify gaps in the understanding between PFAS exposure and kidney health. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We systematically searched PubMed, EMBASE, EBSCO Global Health, World Health Organization Global Index, and Web of Science for studies published from 1990 to 2018. We included studies on the epidemiology, pharmacokinetics, or toxicology of PFAS exposure and kidney-related health, including clinical, histologic, molecular, and metabolic outcomes related to kidney disease, or outcomes related to the pharmacokinetic role of the kidneys. RESULTS We identified 74 studies, including 21 epidemiologic, 13 pharmacokinetic, and 40 toxicological studies. Three population-based epidemiologic studies demonstrated associations between PFAS exposure and lower kidney function. Along with toxicology studies (n=10) showing tubular histologic and cellular changes from PFAS exposure, pharmacokinetic studies (n=5) demonstrated the kidneys were major routes of elimination, with active proximal tubule transport. In several studies (n=17), PFAS exposure altered several pathways linked to kidney disease, including oxidative stress pathways, peroxisome proliferators-activated receptor pathways, NF-E2-related factor 2 pathways, partial epithelial mesenchymal transition, and enhanced endothelial permeability through actin filament modeling. CONCLUSIONS A growing body of evidence portends PFASs are emerging environmental threats to kidney health; yet several important gaps in our understanding still exist.
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Affiliation(s)
- John W. Stanifer
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; and
- Duke Global Health Institute
| | | | - Tomokazu Souma
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; and
| | | | | | - L. Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
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Lunyera J, Kirenga B, Stanifer JW, Kasozi S, van der Molen T, Katagira W, Kamya MR, Kalyesubula R. Geographic differences in the prevalence of hypertension in Uganda: Results of a national epidemiological study. PLoS One 2018; 13:e0201001. [PMID: 30067823 PMCID: PMC6070243 DOI: 10.1371/journal.pone.0201001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 07/07/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hypertension accounts for more than 212 million global disability-adjusted life-years, and more than 15 million in sub-Saharan Africa. Identifying factors underlying the escalating burden of hypertension in sub-Saharan Africa may inform delivery of targeted public health interventions. METHODS As part of the cross-sectional nationally representative Uganda National Asthma Survey conducted in 2016, we measured blood pressure (BP) in the general population across five regions of Uganda. We defined hypertension as systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg, or on-going use of medications for the purpose of lowering BP among adults (≥18 years of age); pre-hypertension as systolic BP between 120 and 140 mmHg and/or diastolic BP bteween 80 and 90 mmHg among adolescents and adults (≥12 years of age). FINDINGS Of 3416 participants who met inclusion criteria, 38.9% were male, and mean age ± SD was 33.8 ± 16.9 years. The age- and sex-adjusted prevalence of hypertension was 31.5% (95% confidence interval [CI] 30.2 to 32.8). The adjusted prevalence of hypertension was highest in the Central Region (34.3%; 95% CI 32.6 to 36.0), and it was comparable to that in the West and East Regions. However, compared with the Central Region, hypertension was significantly less prevalent in the North (22.0%; 95 CI 19.4 to 24.6) and West Nile Regions (24.1%; 95% CI 22.0 to 26.3). Adjustment for demographic characteristics (occupation, monthly income, and educational attainment) of participants did not account for the significantly lower prevalence of hypertension in the North and West Nile Regions. The prevalence of pre-hypertension was 38.8% (95% CI 37.7 to 39.8), and it was highly prevalent among young adults (21-40 years of age: 42.8%; 95% CI 41.2-44.5%) in all regions. CONCLUSIONS Hypertension is starkly prevalent in Uganda, and numerous more people, including young adults are at increased risk. The burden of hypertension is highest in the Central, Western, and Eastern regions of the country; demographic characteristics did not fully account for the disparate regional burden of hypertension. Future studies should explore the potential additional impact of epidemiological shifts, including diet and lifestyle changes, on the development of hypertension.
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Affiliation(s)
- Joseph Lunyera
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, United States of America
- * E-mail:
| | - Bruce Kirenga
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Lung Institute, Kampala, Uganda
| | - John W. Stanifer
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | | | - Thys van der Molen
- Department of General Practice and Elderly Care, and Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen (UMCG), The Netherlands
| | | | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Kalyesubula
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Physiology, Makerere University College of Health Sciences, Kampala, Uganda
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10
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Stanifer JW, Landerman L, Pieper CF, Huffman KM, Kraus WE. Relations of established aging biomarkers (IL-6, D-dimer, s-VCAM) to glomerular filtration rate and mortality in community-dwelling elderly adults. Clin Kidney J 2018; 11:377-382. [PMID: 29942503 PMCID: PMC6007338 DOI: 10.1093/ckj/sfx097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/22/2017] [Indexed: 12/11/2022] Open
Abstract
Background Biomarkers improving risk prediction for elderly populations with chronic kidney disease (CKD), an independent predictor of mortality, could be particularly useful. We previously observed that interleukin-6 (IL-6), D-dimer and soluble vascular adhesion molecule (s-VCAM) were independent biomarkers of mortality in elderly individuals. Therefore, we investigated whether these established biomarkers were independently associated with both estimated glomerular filtration rate (eGFR) and mortality. Methods The Established Populations for Epidemiologic Studies of the Elderly (EPESE) is a longitudinal cohort of community-dwelling elderly individuals. We investigated the association among eGFR, the biomarkers (IL-6, D-dimer and s-VCAM) and 4-year all-cause mortality using restricted cubic splines within Cox proportional hazards models. Results Among 1907 participants in EPESE, 1342 had available creatinine and biomarker measures. Incidence of all-cause mortality was 21.6%. eGFR was associated with all-cause mortality (P < 0.01); individuals at the lowest (<30 mL/min/1.73 m2) levels had the highest mortality rates. D-dimer and s-VCAM were associated (P < 0.01) with mortality, and after adjustment for IL-6, D-dimer and s-VCAM, the mortality risk varied by eGFR level. Conclusions In community-dwelling elderly individuals, we observed an association among eGFR, 4-year mortality and IL-6, D-dimer and s-VCAM. eGFR was independently associated with mortality, and the relation between eGFR and mortality was modified by IL-6, D-dimer and s-VCAM, which was most notable in individuals with severely reduced eGFR. These findings suggest that IL-6, D-dimer and s-VCAM may be useful biomarkers for improving risk prediction, but further studies are needed examining the role of these biomarkers in elderly individuals with CKD.
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Affiliation(s)
- John W Stanifer
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Landerman
- Duke University Older Americans Independence Center; Duke University School of Medicine; Duke University; Durham, NC, USA
| | - Carl F Pieper
- Duke University Older Americans Independence Center; Duke University School of Medicine; Duke University; Durham, NC, USA
| | - Kim M Huffman
- Department of Medicine, Division of Rheumatology, Duke University School of Medicine, Durham, NC, USA.,Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, USA
| | - William E Kraus
- Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, USA.,Department of Medicine, Division of Cardiology, Duke University School of Medicine, Duke University, Durham, NC, USA
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11
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Stanifer JW, Hall YN. Are County Codes More Indicative of Kidney Health Than Genetic Codes? Am J Kidney Dis 2018; 72:4-6. [PMID: 29937026 DOI: 10.1053/j.ajkd.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 03/06/2018] [Indexed: 11/11/2022]
Affiliation(s)
- John W Stanifer
- Division of Nephrology, Department of Medicine, Duke Global Health Institute, Durham, NC; Duke Clinical Research Institute, Duke University, Durham, NC
| | - Yoshio N Hall
- Division of Nephrology & Kidney Research Institute, University of Washington, Seattle, WA.
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12
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Luyckx VA, Tonelli M, Stanifer JW. The global burden of kidney disease and the sustainable development goals. Bull World Health Organ 2018; 96:414-422D. [PMID: 29904224 PMCID: PMC5996218 DOI: 10.2471/blt.17.206441] [Citation(s) in RCA: 388] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/23/2018] [Accepted: 03/23/2018] [Indexed: 12/16/2022] Open
Abstract
Kidney disease has been described as the most neglected chronic disease. Reliable estimates of the global burden of kidney disease require more population-based studies, but specific risks occur across the socioeconomic spectrum from poverty to affluence, from malnutrition to obesity, in agrarian to post-industrial settings, and along the life course from newborns to older people. A range of communicable and noncommunicable diseases result in renal complications and many people who have kidney disease lack access to care. The causes, consequences and costs of kidney diseases have implications for public health policy in all countries. The risks of kidney disease are also influenced by ethnicity, gender, location and lifestyle. Increasing economic and health disparities, migration, demographic transition, unsafe working conditions and environmental threats, natural disasters and pollution may thwart attempts to reduce the morbidity and mortality from kidney disease. A multisectoral approach is needed to tackle the global burden of kidney disease. The sustainable development goals (SDGs) emphasize the importance of a multisectoral approach to health. We map the actions towards achieving all of the SDGs that have the potential to improve understanding, measurement, prevention and treatment of kidney disease in all age groups. These actions can also foster treatment innovations and reduce the burden of such disease in future generations.
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Affiliation(s)
- Valerie A Luyckx
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| | | | - John W Stanifer
- Department of Medicine, Duke University, Durham, United States of America
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13
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Stanifer JW, Kilonzo K, Wang D, Su G, Mao W, Zhang L, Zhang L, Nayak-Rao S, Miranda JJ. Traditional Medicines and Kidney Disease in Low- and Middle-Income Countries: Opportunities and Challenges. Semin Nephrol 2018; 37:245-259. [PMID: 28532554 DOI: 10.1016/j.semnephrol.2017.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Traditional medicines are a principal form of health care for many populations, particularly in low- and middle-income countries, and they have gained attention as an important means of health care coverage globally. In the context of kidney diseases, the challenges and opportunities presented by traditional medicine practices are among the most important considerations for developing effective and sustainable public health strategies. However, little is known about the practices of traditional medicines in relation to kidney diseases, especially concerning benefits and harms. Kidney diseases may be caused, treated, prevented, improved, or worsened by traditional medicines depending on the setting, the person, and the types, modes, and frequencies of traditional medicine use. Given the profound knowledge gaps, nephrology practitioners and researchers may be uniquely positioned to facilitate more optimal public health strategies through recognition and careful investigation of traditional medicine practices. Effective implementation of such strategies also will require local partnerships, including engaging practitioners and users of traditional medicines. As such, practitioners and researchers investigating kidney diseases may be uniquely positioned to bridge the cultural, social, historical, and biologic differences between biomedicine and traditional medicine, and they have opportunities to lead efforts in developing public health strategies that are sensitive to these differences.
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Affiliation(s)
- John W Stanifer
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC; Duke Global Health Institute, Duke University, Durham, NC; Duke Clinical Research Institute, Duke University, Durham, NC.
| | | | - Daphne Wang
- Duke Global Health Institute, Duke University, Durham, NC
| | - Guobin Su
- Department of Nephrology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Traditional Chinese Medicine, Guangzhou, China; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; National Clinical Research Base for Chronic Kidney Disease and Traditional Chinese Medicine, Nephrology Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Wei Mao
- Department of Nephrology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Traditional Chinese Medicine, Guangzhou, China; National Clinical Research Base for Chronic Kidney Disease and Traditional Chinese Medicine, Nephrology Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Lei Zhang
- Department of Nephrology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Traditional Chinese Medicine, Guangzhou, China; National Clinical Research Base for Chronic Kidney Disease and Traditional Chinese Medicine, Nephrology Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - La Zhang
- Department of Nephrology, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Traditional Chinese Medicine, Guangzhou, China; National Clinical Research Base for Chronic Kidney Disease and Traditional Chinese Medicine, Nephrology Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China; School of Health and Biomedical Science, Royal Melbourne Institute of Technology, Melbourne, Australia
| | - Shobhana Nayak-Rao
- KS Hedge Medical Academy, Medical Sciences Complex, Derlakatte Mangalore, Karnataka, India
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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14
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Stanifer JW, Von Isenburg M, Chertow GM, Anand S. Chronic kidney disease care models in low- and middle-income countries: a systematic review. BMJ Glob Health 2018; 3:e000728. [PMID: 29629191 PMCID: PMC5884264 DOI: 10.1136/bmjgh-2018-000728] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/15/2018] [Accepted: 02/20/2018] [Indexed: 01/29/2023] Open
Abstract
Introduction The number of persons with chronic kidney disease (CKD) living in low- and middle-income countries (LMIC) is increasing rapidly; yet systems built to care for them have received little attention. In order to inform the development of scalable CKD care models, we conducted a systematic review to characterise existing CKD care models in LMICs. Methods We searched PubMed, Embase and WHO Global Health Library databases for published reports of CKD care models from LMICs between January 2000 and 31 October 2017. We used a combination of database-specific medical subject headings and keywords for care models, CKD and LMICs as defined by the World Bank. Results Of 3367 retrieved articles, we reviewed the full text of 104 and identified 17 articles describing 16 programmes from 10 countries for inclusion. National efforts (n=4) focused on the prevention of end-stage renal disease through enhanced screening, public awareness campaigns and education for primary care providers. Of the 12 clinical care models, nine focused on persons with CKD and the remaining on persons at risk for CKD; a majority in the first category implemented a multidisciplinary clinic with allied health professionals or primary care providers (rather than nephrologists) in lead roles. Four clinical care models used a randomised control design allowing for assessment of programme effectiveness, but only one was assessed as having low risk for bias; all four showed significant attenuation of kidney function decline in the intervention arms. Conclusions Overall, very few rigorous CKD care models have been reported from LMICs. While preliminary data indicate that national efforts or clinical CKD care models bolstering primary care are successful in slowing kidney function decline, limited data on regional causes of CKD to inform national campaigns, and on effectiveness and affordability of local programmes represent important challenges to scalability.
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Affiliation(s)
- John W Stanifer
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, USA.,Duke Global Health Institute, Duke University, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Megan Von Isenburg
- Medical Center Library, Duke University School of Medicine, Durham, North Carolina, USA
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, California, USA
| | - Shuchi Anand
- Division of Nephrology, Stanford University School of Medicine, Stanford, California, USA
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Abstract
INTRODUCTION Sub-Saharan Africa is particularly vulnerable to the growing global burden of hypertension, but epidemiological studies are limited and barriers to optimal management are poorly understood. Therefore, we undertook a community-based mixed-methods study in Tanzania to investigate the epidemiology of hypertension and barriers to care. METHODS In Northern Tanzania, between December 2013 and June 2015, we conducted a mixed-methods study, including a cross-sectional household epidemiological survey and qualitative sessions of focus groups and in-depth interviews. For the survey, we assessed for hypertension, defined as a single blood pressure ≥160/100 mm Hg, a two-time average of ≥140/90 mm Hg or current use of antihypertensive medications. To investigate relationships with potential risk factors, we used adjusted generalised linear models. Uncontrolled hypertension was defined as a two-time average measurement of ≥160/100 mm Hg irrespective of treatment status. Hypertension awareness was defined as a self-reported disease history in a participant with confirmed hypertension. To explore barriers to care, we identified emerging themes using an inductive approach within the framework method. RESULTS We enrolled 481 adults (median age 45 years) from 346 households, including 123 men (25.6%) and 358 women (74.4%). Overall, the prevalence of hypertension was 28.0% (95% CI 19.4% to 38.7%), which was independently associated with age >60 years (prevalence risk ratio (PRR) 4.68; 95% CI 2.25 to 9.74) and alcohol use (PRR 1.72; 95% CI 1.15 to 2.58). Traditional medicine use was inversely associated with hypertension (PRR 0.37; 95% CI 0.26 to 0.54). Nearly half (48.3%) of the participants were aware of their disease, but almost all (95.3%) had uncontrolled hypertension. In the qualitative sessions, we identified barriers to optimal care, including poor point-of-care communication, poor understanding of hypertension and structural barriers such as long wait times and undertrained providers. CONCLUSIONS In Northern Tanzania, the burden of hypertensive disease is substantial, and optimal hypertension control is rare. Transdisciplinary strategies sensitive to local practices should be explored to facilitate early diagnosis and sustained care delivery.
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Affiliation(s)
- Sophie W Galson
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - Catherine A Staton
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
- Division of Global Neurosurgery and Neuroscience, Department of Neurosurgery, Duke Global Health Institute, Durham, North Carolina, USA
| | - Francis Karia
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Kajiru Kilonzo
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Joseph Lunyera
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Uptal D Patel
- Department of Medicine, Duke Clinical Research Institute , Duke University, Durham, North Carolina, USA
| | - Julian T Hertz
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - John W Stanifer
- Duke Global Health Institute, Durham, North Carolina, USA
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, USA
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16
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Stanifer JW, Charytan DM, White J, Lokhnygina Y, Cannon CP, Roe MT, Blazing MA. Benefit of Ezetimibe Added to Simvastatin in Reduced Kidney Function. J Am Soc Nephrol 2017; 28:3034-3043. [PMID: 28507057 PMCID: PMC5619955 DOI: 10.1681/asn.2016090957] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 04/10/2017] [Indexed: 12/23/2022] Open
Abstract
Efficacy of statin-based therapies in reducing cardiovascular mortality in individuals with CKD seems to diminish as eGFR declines. The strongest evidence supporting the cardiovascular benefit of statins in individuals with CKD was shown with ezetimibe plus simvastatin versus placebo. However, whether combination therapy or statin alone resulted in cardiovascular benefit is uncertain. Therefore, we estimated GFR in 18,015 individuals from the IMPROVE-IT (ezetimibe plus simvastatin versus simvastatin alone in individuals with cardiovascular disease and creatinine clearance >30 ml/min) and examined post hoc the relationship of eGFR with end points across treatment arms. For the primary end point of cardiovascular death, major coronary event, or nonfatal stroke, the relative risk reduction of combination therapy compared with monotherapy differed by eGFR (P=0.04). The difference in treatment effect was observed at eGFR≤75 ml/min per 1.73 m2 and most apparent at levels ≤60 ml/min per 1.73 m2 Compared with individuals receiving monotherapy, individuals receiving combination therapy with a baseline eGFR of 60 ml/min per 1.73 m2 experienced a 12% risk reduction (hazard ratio [HR], 0.88; 95% confidence interval [95% CI], 0.82 to 0.95); those with a baseline eGFR of 45 ml/min per 1.73 m2 had a 13% risk reduction (HR, 0.87; 95% CI, 0.78 to 0.98). In stabilized individuals within 10 days of acute coronary syndrome, combination therapy seemed to be more effective than monotherapy in individuals with moderately reduced eGFR (30-60 ml/min per 1.73 m2). Further studies examining potential benefits of combination lipid-lowering therapy in individuals with CKD are needed.
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Affiliation(s)
- John W Stanifer
- Division of Nephrology, Department of Medicine,
- Duke Clinical Research Institute, and
| | - David M Charytan
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and
- The Baim Institute, Boston, Massachusetts
| | | | | | - Christopher P Cannon
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and
- The Baim Institute, Boston, Massachusetts
| | - Matthew T Roe
- Duke Clinical Research Institute, and
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - Michael A Blazing
- Duke Clinical Research Institute, and
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
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17
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Stanifer JW, Sharma A. Life-sustaining technologies in resource-limited settings. Lancet 2017; 390:1024. [PMID: 28901932 DOI: 10.1016/s0140-6736(17)31953-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
- John W Stanifer
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC 27705, USA; Duke Global Health Institute, Duke University, Durham, NC 27705, USA; Duke Clinical Research Institute, Duke University, Durham, NC 27705, USA.
| | - Abhinav Sharma
- Duke Clinical Research Institute, Duke University, Durham, NC 27705, USA; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
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18
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Stanifer JW, Karia F, Maro V, Kilonzo K, Qin X, Patel UD, Hauser ER. APOL1 risk alleles among individuals with CKD in Northern Tanzania: A pilot study. PLoS One 2017; 12:e0181811. [PMID: 28732083 PMCID: PMC5521837 DOI: 10.1371/journal.pone.0181811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/09/2017] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION In sub-Saharan Africa, approximately 100 million people have CKD, yet genetic risk factors are not well-understood. Despite the potential importance of understanding APOL1 risk allele status among individuals with CKD, little genetic research has been conducted. Therefore, we conducted a pilot study evaluating the feasibility of and willingness to participate in genetic research on kidney disease, and we estimated APOL1 risk allele frequencies among individuals with CKD. METHODS In 2014, we conducted a community-based field study evaluating CKD epidemiology in northern Tanzania. We assessed for CKD using urine albumin and serum creatinine to estimate GFR. We invited participants with CKD to enroll in an additional genetic study. We obtained dried-blood spots on filter cards, from which we extracted DNA using sterile punch biopsies. We genotyped for two single nucleotide polymorphisms (SNPs) defining the APOL1 G1 risk allele and an insertion/deletion polymorphism defining the G2 risk allele. Genotyping was performed in duplicate. RESULTS We enrolled 481 participant, 57 (12%) of whom had CKD. Among these, enrollment for genotyping was high (n = 48; 84%). We extracted a median of 19.4 ng of DNA from each dried-blood spot sample, and we genotyped the two APOL1 G1 SNPs and the APOL1 G2 polymorphism. Genotyping quality was high, with all duplicated samples showing perfect concordance. The frequency of APOL1 risk variants ranged from 7.0% to 11.0%, which was similar to previously-reported frequencies from the general population of northern Tanzania (p>0.2). DISCUSSION In individuals with CKD from northern Tanzania, we demonstrated feasibility of genotyping APOL1 risk alleles. We successfully genotyped three risk variants from DNA extracted from filter cards, and we demonstrated a high enrollment for participation. In this population, more extensive genetic studies of kidney disease may be well-received and will be feasible.
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Affiliation(s)
- John W. Stanifer
- Department of Medicine, Duke University; Durham, NC United States of America
- Duke Global Health Institute, Duke University; Durham, NC United States of America
- Duke Clinical Research Institute, Duke University; Durham, NC United States of America
| | - Francis Karia
- Kilimanjaro Christian Medical College; Moshi, Tanzania
| | - Venance Maro
- Kilimanjaro Christian Medical College; Moshi, Tanzania
| | | | - Xuejun Qin
- Duke Molecular Physiology Institute, Duke University School of Medicine; Durham NC United States of America
| | - Uptal D. Patel
- Department of Medicine, Duke University; Durham, NC United States of America
| | - Elizabeth R. Hauser
- Department of Medicine, Duke University; Durham, NC United States of America
- Duke Molecular Physiology Institute, Duke University School of Medicine; Durham NC United States of America
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine; Durham, NC United States of America
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Crowley MJ, Diamantidis CJ, McDuffie JR, Cameron CB, Stanifer JW, Mock CK, Wang X, Tang S, Nagi A, Kosinski AS, Williams JW. Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease: A Systematic Review. Ann Intern Med 2017; 166:191-200. [PMID: 28055049 PMCID: PMC5293600 DOI: 10.7326/m16-1901] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Recent changes to the U.S. Food and Drug Administration boxed warning for metformin will increase its use in persons with historical contraindications or precautions. Prescribers must understand the clinical outcomes of metformin use in these populations. PURPOSE To synthesize data addressing outcomes of metformin use in populations with type 2 diabetes and moderate to severe chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment. DATA SOURCES MEDLINE (via PubMed) from January 1994 to September 2016, and Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015. STUDY SELECTION English-language studies that: 1) examined adults with type 2 diabetes and CKD (with estimated glomerular filtration rate less than 60 mL/min/1.73 m2), CHF, or CLD with hepatic impairment; 2) compared diabetes regimens that included metformin with those that did not; and 3) reported all-cause mortality, major adverse cardiovascular events, and other outcomes of interest. DATA EXTRACTION 2 reviewers abstracted data and independently rated study quality and strength of evidence. DATA SYNTHESIS On the basis of quantitative and qualitative syntheses involving 17 observational studies, metformin use is associated with reduced all-cause mortality in patients with CKD, CHF, or CLD with hepatic impairment, and with fewer heart failure readmissions in patients with CKD or CHF. LIMITATIONS Strength of evidence was low, and data on multiple outcomes of interest were sparse. Available studies were observational and varied in follow-up duration. CONCLUSION Metformin use in patients with moderate CKD, CHF, or CLD with hepatic impairment is associated with improvements in key clinical outcomes. Our findings support the recent changes in metformin labeling. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs. (PROSPERO: CRD42016027708).
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Affiliation(s)
- Matthew J. Crowley
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Clarissa J. Diamantidis
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jennifer R. McDuffie
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - C. Blake Cameron
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - John W. Stanifer
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Clare K. Mock
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Xianwei Wang
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Shuang Tang
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Avishek Nagi
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Andrzej S. Kosinski
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - John W. Williams
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
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Stanifer JW, Cleland CR, Makuka GJ, Egger JR, Maro V, Maro H, Karia F, Patel UD, Burton MJ, Philippin H. Prevalence, Risk Factors, and Complications of Diabetes in the Kilimanjaro Region: A Population-Based Study from Tanzania. PLoS One 2016; 11:e0164428. [PMID: 27711179 PMCID: PMC5053499 DOI: 10.1371/journal.pone.0164428] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 09/25/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, diabetes is a growing burden, yet little is known about its prevalence, risk factors, and complications. To address these gaps and help inform public health efforts aimed at prevention and treatment, we conducted a community-based study assessing diabetes epidemiology. METHODS AND FINDINGS We conducted a stratified, cluster-designed, serial cross-sectional household study from 2014-2015 in the Kilimanjaro Region, Tanzania. We used a three-stage cluster probability sampling method to randomly select individuals. To estimate prevalence, we screened individuals for glucose impairment, including diabetes, using hemoglobin A1C. We also screened for hypertension and obesity, and to assess for potential complications, individuals with diabetes were assessed for retinopathy, neuropathy, and nephropathy. We enrolled 481 adults from 346 urban and rural households. The prevalence of glucose impairment was 21.7% (95% CI 15.2-29.8), which included diabetes (5.7%; 95% CI 3.37-9.47) and glucose impairment with increased risk for diabetes (16.0%; 95% CI 10.2-24.0). Overweight or obesity status had an independent prevalence risk ratio for glucose impairment (2.16; 95% CI 1.39-3.36). Diabetes awareness was low (35.6%), and few individuals with diabetes were receiving biomedical treatment (33.3%). Diabetes-associated complications were common (50.2%; 95% CI 33.7-66.7), including renal (12.0%; 95% CI 4.7-27.3), ophthalmic (49.6%; 95% CI 28.6-70.7), and neurological (28.8%; 95% CI 8.0-65.1) abnormalities. CONCLUSIONS In a northern region of Tanzania, diabetes is an under-recognized health condition, despite the fact that many people either have diabetes or are at increased risk for developing diabetes. Most individuals were undiagnosed or untreated, and the prevalence of diabetes-associated complications was high. Public health efforts in this region will need to focus on reducing modifiable risk factors, which appear to include obesity, as well as early detection that includes increasing awareness. These findings highlight a growing urgency of diabetes prevention in this region as well as the need for treatment, including management of complications.
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Affiliation(s)
- John W. Stanifer
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | - Joseph R. Egger
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Venance Maro
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Honest Maro
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Francis Karia
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Uptal D. Patel
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Moorfields Eye Hospital, London, United Kingdom
| | - Heiko Philippin
- Eye Department, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Lunyera J, Wang D, Maro V, Karia F, Boyd D, Omolo J, Patel UD, Stanifer JW. Traditional medicine practices among community members with diabetes mellitus in Northern Tanzania: an ethnomedical survey. Altern Ther Health Med 2016; 16:282. [PMID: 27514380 PMCID: PMC4982437 DOI: 10.1186/s12906-016-1262-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Diabetes is a growing burden in sub-Saharan Africa where traditional medicines (TMs) remain a primary form of healthcare in many settings. In Tanzania, TMs are frequently used to treat non-communicable diseases, yet little is known about TM practices for non-communicable diseases like diabetes. METHODS Between December 2013 and June 2014, we assessed TM practices, including types, frequencies, reasons, and modes, among randomly selected community members. To further characterize TMs relevant for the local treatment of diabetes, we also conducted focus groups and semi-structured interviews with key informants. RESULTS We enrolled 481 adults of whom 45 (9.4 %) had diabetes. The prevalence of TM use among individuals with diabetes was 77.1 % (95 % CI 58.5-89.0 %), and the prevalence of using TMs and biomedicines concurrently was 37.6 % (95 % CI 20.5-58.4 %). Many were using TMs specifically to treat diabetes (40.3 %; 95 % CI 20.5-63.9), and individuals with diabetes reported seeking healthcare from traditional healers, elders, family, friends, and herbal vendors. We identified several plant-based TMs used toward diabetes care: Moringa oleifera, Cymbopogon citrullus, Hagenia abyssinica, Aloe vera, Clausena anisata, Cajanus cajan, Artimisia afra, and Persea americana. CONCLUSIONS TMs were commonly used for diabetes care in northern Tanzania. Individuals with diabetes sought healthcare advice from many sources, and several individuals used TMs and biomedicines together. The TMs commonly used by individuals with diabetes in northern Tanzania have a wide range of effects, and understanding them will more effectively shape biomedical practitices and public health policies that are patient-centered and sensitive to TM preferences.
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Stanifer JW, Turner EL, Egger JR, Thielman N, Karia F, Maro V, Kilonzo K, Patel UD, Yeates K. Knowledge, Attitudes, and Practices Associated with Chronic Kidney Disease in Northern Tanzania: A Community-Based Study. PLoS One 2016; 11:e0156336. [PMID: 27280584 PMCID: PMC4900616 DOI: 10.1371/journal.pone.0156336] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 05/12/2016] [Indexed: 11/18/2022] Open
Abstract
Background Non-communicable diseases (NCDs) are a leading cause of death among adults in sub-Saharan Africa, and chronic kidney disease (CKD) is a growing public health threat. Understanding knowledge, attitudes, and practices associated with NCDs is vital to informing optimal policy and public health responses in the region, but few community-based assessments have been performed for CKD. To address this gap, we conducted a cross-sectional survey of adults in northern Tanzania using a validated instrument. Methods Between January and June 2014, we administered a structured survey to a random sample of adults from urban and rural communities. The validated instrument consisted of 25 items designed to measure knowledge, attitudes, and practices associated with kidney disease. Participants were also screened for CKD, diabetes, hypertension, and human immunodeficiency virus. Results We enrolled 606 participants from 431 urban and rural households. Knowledge of the etiologies, symptoms, and treatments for kidney disease was low (mean score 3.28 out of 10; 95% CI 2.94, 3.63). There were no significant differences by CKD status. Living in an urban setting and level of education had the strongest independent associations with knowledge score. Attitudes were characterized by frequent concern about the health (27.3%; 20.2, 36.0%), economic (73.1%; 68.2, 77.5%), and social impact (25.4%; 18.6, 33.6%) of kidney disease. Practices included the use of traditional healers (15.2%; 9.1, 24.5%) and traditional medicines (33.8%; 25.0, 43.9%) for treatment of kidney disease as well as a willingness to engage with mobile-phone technology in CKD care (94.3%; 90.1, 96.8%). Conclusions Community-based adults in northern Tanzania have limited knowledge of kidney disease. However, there is a modest knowledge base upon which to build public health programs to expand awareness and understanding of CKD, but these programs must also consider the variety of means by which adults in this population meet their healthcare needs. Finally, our assessment of local attitudes suggested that such public health efforts would be well-received.
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Affiliation(s)
- John W. Stanifer
- Department of Medicine, Duke University, DUMC Box 3182, Durham, NC, 27710, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, 27710, United States of America
- Duke Clinical Research Institute, Duke University, DUMC Box 3646, Durham, NC, 27710, United States of America
- * E-mail:
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, NC, 27710, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, DUMC Box 2721, Durham, NC, 27710, United States of America
| | - Joseph R. Egger
- Duke Global Health Institute, Duke University, Durham, NC, 27710, United States of America
| | - Nathan Thielman
- Department of Medicine, Duke University, DUMC Box 3182, Durham, NC, 27710, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, 27710, United States of America
| | - Francis Karia
- Kilimanjaro Christian Medical College, Sokoine Road, Moshi, Tanzania
| | - Venance Maro
- Kilimanjaro Christian Medical College, Sokoine Road, Moshi, Tanzania
| | - Kajiru Kilonzo
- Kilimanjaro Christian Medical College, Sokoine Road, Moshi, Tanzania
| | - Uptal D. Patel
- Department of Medicine, Duke University, DUMC Box 3182, Durham, NC, 27710, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, 27710, United States of America
- Duke Clinical Research Institute, Duke University, DUMC Box 3646, Durham, NC, 27710, United States of America
| | - Karen Yeates
- Department of Medicine, Queen’s University, 76 Stuart Street, Kingston, Ontario, Canada K7L 2VL
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Stanifer JW, Egger JR, Turner EL, Thielman N, Patel UD. Neighborhood clustering of non-communicable diseases: results from a community-based study in Northern Tanzania. BMC Public Health 2016; 16:226. [PMID: 26944390 PMCID: PMC4779220 DOI: 10.1186/s12889-016-2912-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/01/2016] [Indexed: 12/31/2022] Open
Abstract
Background In order to begin to address the burden of non-communicable diseases (NCDs) in sub-Saharan Africa, high quality community-based epidemiological studies from the region are urgently needed. Cluster-designed sampling methods may be most efficient, but designing such studies requires assumptions about the clustering of the outcomes of interest. Currently, few studies from Sub-Saharan Africa have been published that describe the clustering of NCDs. Therefore, we report the neighborhood clustering of several NCDs from a community-based study in Northern Tanzania. Methods We conducted a cluster-designed cross-sectional household survey between January and June 2014. We used a three-stage cluster probability sampling method to select thirty-seven sampling areas from twenty-nine neighborhood clusters, stratified by urban and rural. Households were then randomly selected from each of the sampling areas, and eligible participants were tested for chronic kidney disease (CKD), glucose impairment including diabetes, hypertension, and obesity as part of the CKD-AFRiKA study. We used linear mixed models to explore clustering across each of the samplings units, and we estimated absolute-agreement intra-cluster correlation (ICC) coefficients (ρ) for the neighborhood clusters. Results We enrolled 481 participants from 346 urban and rural households. Neighborhood cluster sizes ranged from 6 to 49 participants (median: 13.0; 25th–75th percentiles: 9–21). Clustering varied across neighborhoods and differed by urban or rural setting. Among NCDs, hypertension (ρ = 0.075) exhibited the strongest clustering within neighborhoods followed by CKD (ρ = 0.440), obesity (ρ = 0.040), and glucose impairment (ρ = 0.039). Conclusion The neighborhood clustering was substantial enough to contribute to a design effect for NCD outcomes including hypertension, CKD, obesity, and glucose impairment, and it may also highlight NCD risk factors that vary by setting. These results may help inform the design of future community-based studies or randomized controlled trials examining NCDs in the region particularly those that use cluster-sampling methods.
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Affiliation(s)
- John W Stanifer
- Department of Medicine, Duke University, DUMC Box 3182, Durham, NC, 27710, USA. .,Duke Global Health Institute, Duke University, Durham, NC, 27710, USA. .,Duke Clinical Research Institute, Duke University, DUMC Box 3646, Durham, NC, 27710, USA. .,Duke University Medical Center, Box 3182, Durham, NC, 27710, USA.
| | - Joseph R Egger
- Duke Global Health Institute, Duke University, Durham, NC, 27710, USA
| | - Elizabeth L Turner
- Duke Global Health Institute, Duke University, Durham, NC, 27710, USA.,Department of Biostatistics and Bioinformatics, Duke University, DUMC Box 2721, Durham, NC, 27710, USA
| | - Nathan Thielman
- Department of Medicine, Duke University, DUMC Box 3182, Durham, NC, 27710, USA.,Duke Global Health Institute, Duke University, Durham, NC, 27710, USA.,Duke University Medical Center, Box 3182, Durham, NC, 27710, USA
| | - Uptal D Patel
- Department of Medicine, Duke University, DUMC Box 3182, Durham, NC, 27710, USA.,Duke Global Health Institute, Duke University, Durham, NC, 27710, USA.,Duke Clinical Research Institute, Duke University, DUMC Box 3646, Durham, NC, 27710, USA.,Duke University Medical Center, Box 3182, Durham, NC, 27710, USA
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Lunyera J, Stanifer JW, Ingabire P, Etolu W, Bagasha P, Egger JR, Patel UD, Mutungi G, Kalyesubula R. Prevalence and correlates of proteinuria in Kampala, Uganda: a cross-sectional pilot study. BMC Res Notes 2016; 9:97. [PMID: 26879636 PMCID: PMC4755001 DOI: 10.1186/s13104-016-1897-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the increasing prevalence of chronic kidney disease (CKD) in sub-Saharan Africa, few community-based screenings have been conducted in Uganda. Opportunities to improve the management of CKD in sub-Saharan Africa are limited by low awareness, inadequate access, poor recognition, and delayed presentation for clinical care. Therefore, the Uganda Kidney Foundation engaged key stakeholders in performing a screening event on World Kidney Day. METHODS We conducted a cross-sectional pilot study in March 2013 from a convenience sample of adult, urban residents in Kampala, Uganda. We advertised the event using radio and television announcements, newspapers, billboards, and notice boards at public places, such as places of worship. Subsequently, we screened for proteinuria, hypertension, fasting glucose impairment, and obesity in a central and easily-accessible location. RESULTS We enrolled 141 adults most of whom were female (57 %), young (64 %; 18-39 years), and had a professional occupation (52 %). The prevalence of proteinuria (13 %; 95 % confidence interval [CI] 7-19 %), hypertension (38 %; 95 % CI 31-47 %), and impaired fasting glucose (13 %; 95 % CI 9-20 %) were high in this study population. Proteinuria was most prevalent among young (18-39 years) adults (n = 14; 16 %) and among those who reported a history of alcohol intake (n = 10; 32 %). CONCLUSIONS The prevalence of proteinuria was high among a convenience sample of urban residents in a sub-Saharan African setting. These results represent an important effort by the Ugandan Kidney Foundation to increase awareness and recognition of CKD, and they will help formulate additional epidemiological studies on NCDs in Uganda which are urgently needed and now feasible.
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Affiliation(s)
- Joseph Lunyera
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, USA. .,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
| | - John W Stanifer
- Department of Medicine, Duke Clinical Research Institute and Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Prossie Ingabire
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Wilson Etolu
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Peace Bagasha
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Joseph R Egger
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, USA.
| | - Uptal D Patel
- Department of Medicine, Duke Clinical Research Institute and Duke Global Health Institute, Duke University, Durham, NC, USA. .,Departments of Medicine and Pediatrics, Duke Clinical Research Institute and Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Gerald Mutungi
- Section of Non-communicable Diseases, Ministry of Health, Kampala, Uganda.
| | - Robert Kalyesubula
- Department of Medicine, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda. .,Department of Physiology, Makerere University College of Health Sciences, Kampala, Uganda.
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Stanifer JW, Muiru A, Jafar TH, Patel UD. Chronic kidney disease in low- and middle-income countries. Nephrol Dial Transplant 2016; 31:868-74. [PMID: 27217391 DOI: 10.1093/ndt/gfv466] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/30/2015] [Indexed: 12/25/2022] Open
Abstract
Most of the global burden of chronic kidney disease (CKD) is occurring in low- and middle-income countries (LMICs). As a result of rapid urbanization in LMICs, a growing number of populations are exposed to numerous environmental toxins, high infectious disease burdens and increasing rates of noncommunicable diseases. For CKD, this portends a high prevalence related to numerous etiologies, and it presents unique challenges. A better understanding of the epidemiology of CKD in LMICs is urgently needed, but this must be coupled with strong public advocacy and broad, collaborative public health efforts that address environmental, communicable, and non-communicable risk factors.
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Affiliation(s)
- John W Stanifer
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC, USA Duke Global Health Institute, Duke University, Durham, NC, USA Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Anthony Muiru
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tazeen H Jafar
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | - Uptal D Patel
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC, USA Duke Global Health Institute, Duke University, Durham, NC, USA Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Abstract
For most of the 19th century, Germany was the centre of the medical world. From there the most innovating research came and many of the physicians of that era are known to nearly every medical student and physician of today. Virchow, Kussmaul, Quincke, von Recklinghausen, Müller and Schönlein are familiar names in today's medicine but insofar as they are merely eponyms associated with signs, symptoms, disease and anatomy. The story of their lives, their research and their influence on each other has been little examined. This is an essay about Virchow's relationship with his mentors Müller and Schönlein and how these relationships shaped the development of Kussmaul, Quincke and von Recklinghausen as students of Virchow and their work in medicine and clinical observation after leaving Virchow's laboratory.
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Affiliation(s)
- John W Stanifer
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Lunyera J, Mohottige D, Von Isenburg M, Jeuland M, Patel UD, Stanifer JW. CKD of Uncertain Etiology: A Systematic Review. Clin J Am Soc Nephrol 2015; 11:379-85. [PMID: 26712810 DOI: 10.2215/cjn.07500715] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 11/12/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Epidemics of CKD of uncertain etiology (CKDu) are emerging around the world. Highlighting common risk factors for CKD of uncertain etiology across various regions and populations may be important for health policy and public health responses. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched PubMed, Embase, Scopus and Web of Science databases to identify published studies on CKDu. The search was generated in January of 2015; no language or date limits were used. We used a vote-counting method to evaluate exposures across all studies. RESULTS We identified 1607 articles, of which 26 met inclusion criteria. Eighteen (69%) were conducted in known CKDu-endemic countries: Sri Lanka (38%), Nicaragua (19%), and El Salvador (12%). The other studies were from India, Japan, Australia, Mexico, Sweden, Tunisia, Tanzania, and the United States. Heavy metals, heat stress, and dietary exposures were reported across all geographic regions. In south Asia, family history, agrochemical use, and heavy metal exposures were reported most frequently, whereas altitude and temperature were reported only in studies from Central America. Across all regions, CKDu was most frequently associated with a family history of CKDu, agricultural occupation, men, middle age, snake bite, and heavy metal exposure. CONCLUSIONS Studies examining etiologies of CKDu have reported many exposures that are heterogeneous and vary by region. To identify etiologies of CKDu, designing consistent and comparative multisite studies across high-risk populations may help elucidate the importance of region-specific versus global risk factors.
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Affiliation(s)
| | | | | | - Marc Jeuland
- Duke Global Health Institute, Sanford School of Public Policy, and Institute of Water Policy, Lee Kwan Yew School of Public Policy, National University of Singapore, Singapore
| | - Uptal D Patel
- Duke Global Health Institute, Departments of Medicine and Pediatrics, Duke Clinical Research Institute, Duke University, Durham, North Carolina; and
| | - John W Stanifer
- Duke Global Health Institute, Departments of Medicine and Duke Clinical Research Institute, Duke University, Durham, North Carolina; and
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Stanifer JW, Lunyera J, Boyd D, Karia F, Maro V, Omolo J, Patel UD. Traditional medicine practices among community members with chronic kidney disease in northern Tanzania: an ethnomedical survey. BMC Nephrol 2015; 16:170. [PMID: 26499070 PMCID: PMC4619231 DOI: 10.1186/s12882-015-0161-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/09/2015] [Indexed: 11/29/2022] Open
Abstract
Background In sub-Saharan Africa, chronic kidney disease (CKD) is being recognized as a non-communicable disease (NCD) with high morbidity and mortality. In countries like Tanzania, people access many sources, including traditional medicines, to meet their healthcare needs for NCDs, but little is known about traditional medicine practices among people with CKD. Therefore, we sought to characterize these practices among community members with CKD in northern Tanzania. Methods Between December 2013 and June 2014, we administered a previously-developed survey to a random sample of adult community-members from the Kilimanjaro Region; the survey was designed to measure traditional medicine practices such as types, frequencies, reasons, and modes. Participants were also tested for CKD, diabetes, hypertension, and HIV as part of the CKD-AFRiKA study. To identify traditional medicines used in the local treatment of kidney disease, we reviewed the qualitative sessions which had previously been conducted with key informants. Results We enrolled 481 adults of whom 57 (11.9 %) had CKD. The prevalence of traditional medicine use among adults with CKD was 70.3 % (95 % CI 50.0–84.9 %), and among those at risk for CKD (n = 147; 30.6 %), it was 49.0 % (95 % CI 33.1–65.0 %). Among adults with CKD, the prevalence of concurrent use of traditional medicine and biomedicine was 33.2 % (11.4–65.6 %). Symptomatic ailments (66.7 %; 95 % CI 17.3–54.3), malaria/febrile illnesses (64.0 %; 95 % CI 44.1–79.9), and chronic diseases (49.6 %; 95 % CI 28.6–70.6) were the most prevalent uses for traditional medicines. We identified five plant–based traditional medicines used for the treatment of kidney disease: Aloe vera, Commifora africana, Cymbopogon citrullus, Persea americana, and Zanthoxylum chalybeum. Conclusions The prevalence of traditional medicine use is high among adults with and at risk for CKD in northern Tanzania where they use them for a variety of conditions including other NCDs. Additionally, many of these same people access biomedicine and traditional medicines concurrently. The traditional medicines used for the local treatment of kidney disease have a variety of activities, and people with CKD may be particularly vulnerable to adverse effects. Recognizing these traditional medicine practices will be important in shaping CKD treatment programs and public health policies aimed at addressing CKD. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0161-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John W Stanifer
- Department of Medicine, Duke University, Durham, NC, USA. .,Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Joseph Lunyera
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - David Boyd
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Francis Karia
- Kilimanjaro Christian Medical College, Moshi, Tanzania, Africa.
| | - Venance Maro
- Kilimanjaro Christian Medical College, Moshi, Tanzania, Africa.
| | - Justin Omolo
- National Institute for Medical Research, Dar es Salaam, Tanzania, Africa.
| | - Uptal D Patel
- Department of Medicine, Duke University, Durham, NC, USA. .,Duke Global Health Institute, Duke University, Durham, NC, USA. .,Duke Clinical Research Institute, Duke University, Durham, NC, USA.
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Stanifer JW, Maro V, Egger J, Karia F, Thielman N, Turner EL, Shimbi D, Kilaweh H, Matemu O, Patel UD. The epidemiology of chronic kidney disease in Northern Tanzania: a population-based survey. PLoS One 2015; 10:e0124506. [PMID: 25886472 PMCID: PMC4401757 DOI: 10.1371/journal.pone.0124506] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 03/03/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, kidney failure has a high morbidity and mortality. Despite this, population-based estimates of prevalence, potential etiologies, and awareness are not available. METHODS Between January and June 2014, we conducted a household survey of randomly-selected adults in Northern Tanzania. To estimate prevalence we screened for CKD, which was defined as an estimated glomerular filtration rate ≤ 60 ml/min/1.73m2 and/or persistent albuminuria. We also screened for human immunodeficiency virus (HIV), diabetes, hypertension, obesity, and lifestyle practices including alcohol, tobacco, and traditional medicine use. Awareness was defined as a self-reported disease history and subsequently testing positive. We used population-based age- and gender-weights in estimating prevalence, and we used generalized linear models to explore potential risk factors associated with CKD, including living in an urban environment. RESULTS We enrolled 481 adults from 346 households with a median age of 45 years. The community-based prevalence of CKD was 7.0% (95% CI 3.8-12.3), and awareness was low at 10.5% (4.7-22.0). The urban prevalence of CKD was 15.2% (9.6-23.3) while the rural prevalence was 2.0% (0.5-6.9). Half of the cases of CKD (49.1%) were not associated with any of the measured risk factors of hypertension, diabetes, or HIV. Living in an urban environment had the strongest crude (5.40; 95% CI 2.05-14.2) and adjusted prevalence risk ratio (4.80; 1.70-13.6) for CKD, and the majority (79%) of this increased risk was not explained by demographics, traditional medicine use, socioeconomic status, or co-morbid non-communicable diseases (NCDs). CONCLUSIONS We observed a high burden of CKD in Northern Tanzania that was associated with low awareness. Although demographic, lifestyle practices including traditional medicine use, socioeconomic factors, and NCDs accounted for some of the excess CKD risk observed with urban residence, much of the increased urban prevalence remained unexplained and will further study as demographic shifts reshape sub-Saharan Africa.
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Affiliation(s)
- John W. Stanifer
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Venance Maro
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Joseph Egger
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Francis Karia
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Nathan Thielman
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
| | - Dionis Shimbi
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | | | - Oliver Matemu
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Uptal D. Patel
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
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Stanifer JW, Patel UD, Karia F, Thielman N, Maro V, Shimbi D, Kilaweh H, Lazaro M, Matemu O, Omolo J, Boyd D. The determinants of traditional medicine use in Northern Tanzania: a mixed-methods study. PLoS One 2015; 10:e0122638. [PMID: 25848762 PMCID: PMC4388565 DOI: 10.1371/journal.pone.0122638] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 02/23/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction Traditional medicines are an important part of healthcare in sub-Saharan Africa, and building successful disease treatment programs that are sensitive to traditional medicine practices will require an understanding of their current use and roles, including from a biomedical perspective. Therefore, we conducted a mixed-method study in Northern Tanzania in order to characterize the extent of and reasons for the use of traditional medicines among the general population so that we can better inform public health efforts in the region. Methods Between December 2013 and June 2014 in Kilimanjaro, Tanzania, we conducted 5 focus group discussions and 27 in-depth interviews of key informants. The data from these sessions were analyzed using an inductive framework method with cultural insider-outsider coding. From these results, we developed a structured survey designed to test different aspects of traditional medicine use and administered it to a random sample of 655 adults from the community. The results were triangulated to explore converging and diverging themes. Results Most structured survey participants (68%) reported knowing someone who frequently used traditional medicines, and the majority (56%) reported using them themselves in the previous year. The most common uses were for symptomatic ailments (42%), chronic diseases (15%), reproductive problems (11%), and malaria/febrile illnesses (11%). We identified five major determinants for traditional medicine use in Northern Tanzania: biomedical healthcare delivery, credibility of traditional practices, strong cultural identities, individual health status, and disease understanding. Conclusions In order to better formulate effective local disease management programs that are sensitive to TM practices, we described the determinants of TM use. Additionally, we found TM use to be high in Northern Tanzania and that its use is not limited to lower-income areas or rural settings. After symptomatic ailments, chronic diseases were reported as the most common reason for TM use which may be particularly important in Northern Tanzania where non-communicable diseases are a rapidly growing burden.
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Affiliation(s)
- John W. Stanifer
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
| | - Uptal D. Patel
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
| | - Francis Karia
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Nathan Thielman
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Venance Maro
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Dionis Shimbi
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | | | - Matayo Lazaro
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Oliver Matemu
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | | | - David Boyd
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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Stanifer JW, Karia F, Voils CI, Turner EL, Maro V, Shimbi D, Kilawe H, Lazaro M, Patel UD. Development and validation of a cross-cultural knowledge, attitudes, and practices survey instrument for chronic kidney disease in a Swahili-speaking population. PLoS One 2015; 10:e0121722. [PMID: 25811781 PMCID: PMC4374886 DOI: 10.1371/journal.pone.0121722] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 02/03/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Non-communicable diseases are a growing global burden, and structured surveys can identify critical gaps to address this epidemic. In sub-Saharan Africa, there are very few well-tested survey instruments measuring population attributes related to non-communicable diseases. To meet this need, we have developed and validated the first instrument evaluating knowledge, attitudes and practices pertaining to chronic kidney disease in a Swahili-speaking population. Methods and Results Between December 2013 and June 2014, we conducted a four-stage, mixed-methods study among adults from the general population of northern Tanzania. In stage 1, the survey instrument was constructed in English by a group of cross-cultural experts from multiple disciplines and through content analysis of focus group discussions to ensure local significance. Following translation, in stage 2, we piloted the survey through cognitive and structured interviews, and in stage 3, in order to obtain initial evidence of reliability and construct validity, we recruited and then administered the instrument to a random sample of 606 adults. In stage 4, we conducted analyses to establish test-retest reliability and known-groups validity which was informed by thematic analysis of the qualitative data in stages 1 and 2. The final version consisted of 25 items divided into three conceptual domains: knowledge, attitudes and practices. Each item demonstrated excellent test-retest reliability with established content and construct validity. Conclusions We have developed a reliable and valid cross-cultural survey instrument designed to measure knowledge, attitudes and practices of chronic kidney disease in a Swahili-speaking population of Northern Tanzania. This instrument may be valuable for addressing gaps in non-communicable diseases care by understanding preferences regarding healthcare, formulating educational initiatives, and directing development of chronic disease management programs that incorporate chronic kidney disease across sub-Saharan Africa.
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Affiliation(s)
- John W. Stanifer
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
| | - Francis Karia
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Corrine I. Voils
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, North Carolina, United States of America
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
| | - Venance Maro
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Dionis Shimbi
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | | | - Matayo Lazaro
- Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Uptal D. Patel
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
- Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States of America
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Inrig JK, Califf RM, Tasneem A, Vegunta RK, Molina C, Stanifer JW, Chiswell K, Patel UD. The landscape of clinical trials in nephrology: a systematic review of Clinicaltrials.gov. Am J Kidney Dis 2013; 63:771-80. [PMID: 24315119 DOI: 10.1053/j.ajkd.2013.10.043] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 10/16/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Well-designed trials are of paramount importance in improving the delivery of care to patients with kidney disease. However, it remains unknown whether contemporary clinical trials within nephrology are of sufficient quality and quantity to meet this need. STUDY DESIGN Systematic review. SETTING & POPULATION Studies registered with ClinicalTrials.gov. SELECTION CRITERIA FOR STUDIES Interventional (ie, nonobservational) studies (both randomized and nonrandomized) registered between October 2007 and September 2010 were included for analysis. Studies were reviewed independently by physicians and classified by clinical specialty. PREDICTOR Nephrology versus cardiology versus other trials. OUTCOMES Select clinical trial characteristics. RESULTS Of 40,970 trials overall, 1,054 (2.6%) were classified as nephrology. Most nephrology trials were for treatment (75.4%) or prevention (15.7%), with very few diagnostic, screening, or health services research studies. Most nephrology trials were randomized (72.3%). Study designs included 24.9% with a single study group, 64.0% that included parallel groups, and 9.4% that were crossover trials. Nephrology trials, compared with 2,264 cardiology trials (5.5% overall), were more likely to be smaller (64.5% vs 48.0% enrolling≤100 patients), phases 1-2 (29.0% vs 19.7%), and unblinded (66.2% vs 53.3%; P<0.05 for all). Nephrology trials also were more likely than cardiology trials to include a drug intervention (72.4% vs 41.9%) and less likely to report having a data monitoring committee (40.3% vs 48.5%; P<0.05 for all). Finally, there were few trials funded by the National Institutes of Health (NIH; 3.3%, nephrology; 4.2%, cardiology). LIMITATIONS Does not include all trials performed worldwide, and frequent categorization of funding source as university may underestimate NIH support. CONCLUSIONS Critical differences remain between clinical trials in nephrology and other specialties. Improving care for patients with kidney disease will require a concerted effort to increase the scope, quality, and quantity of clinical trials within nephrology.
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Affiliation(s)
- Jula K Inrig
- Duke University Medical Center, Durham, NC; Quintiles Global Clinical Research Organization, Morrisville, NC
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Stanifer JW, George R, Keenan RT, Massey EW. What started this? Debilitating longitudinally-extensive myelitis. Am J Med 2012; 125:1071-3. [PMID: 23098863 DOI: 10.1016/j.amjmed.2012.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 07/23/2012] [Accepted: 07/25/2012] [Indexed: 11/19/2022]
Affiliation(s)
- John W Stanifer
- Department of Medicine, Duke University Hospital, Durham, NC 27710, USA.
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Whitted AD, Stanifer JW, Dube P, Borkowski BJ, Yusuf J, Komolafe BO, Davis RC, Soberman JE, Weber KT. A dyshomeostasis of electrolytes and trace elements in acute stressor states: impact on the heart. Am J Med Sci 2010; 340:48-53. [PMID: 20610973 DOI: 10.1097/maj.0b013e3181e5945b] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute stressor states are associated with a homeostatic activation of the hypothalamic-pituitary-adrenal axis. A hyperadrenergic state follows and leads to a dyshomeostasis of several intra- and extracellular cations, including K, Mg, and Ca. Prolongation of myocardial repolarization and corrected QT interval (QTc) of the ECG are useful biomarkers of hypokalemia and/or hypomagnesemia and should be monitored to address the adequacy of cation replacement. A dyshomeostasis of several trace elements, including Zn and Se, are also found in critically-ill patients to compromise metalloenzyme-based antioxidant defenses. Collectively, dyshomeostasis of these electrolytes and trace elements have deleterious consequences on the myocardium: atrial and ventricular arrhythmias; induction of oxidative stress with reduced antioxidant defenses; and adverse myocardial remodeling, including cardiomyocytes lost to necrosis and replaced by fibrous tissue. To minimize such consequences during hyperadrenergic states, systematic surveillance of electrolytes and trace elements, together with QTc, are warranted. Plasma K and Mg should be maintained at > or =4.0 mEq/L and > or =2.0 mg/dL, respectively (the 4 and 2 rule).
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Affiliation(s)
- Anthony D Whitted
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
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