Modification of Association of Cystatin C With Kidney and Cardiovascular Outcomes by Obesity

RATIONALE & OBJECTIVE

Cystatin C-based estimated glomerular filtration rate (eGFRcys) has stronger associations with adverse clinical outcomes than creatinine-based eGFR (eGFRcr). Obesity may be associated with higher cystatin C levels, independent of kidney function, but it is unknown whether obesity modifies associations of eGFRcys with kidney and cardiovascular outcomes.

STUDY DESIGN

Cohort study.

SETTING & PARTICIPANTS

27,249 US adults in the Reasons for Geographic and Racial Differences in Stroke Study.

PREDICTORS

eGFRcys, eGFRcr, waist circumference, and body mass index (BMI).

OUTCOME

All-cause mortality, kidney failure, incident atherosclerotic cardiovascular disease (ASCVD), and incident heart failure (HF).

ANALYTICAL APPROACH

Multivariable Cox and Fine-Gray models with multiplicative interaction terms were constructed to investigate whether waist circumference quartiles or BMI categories modified associations of eGFRcys with risks of 4 clinical outcomes.

RESULTS

Participants had a mean age of 65 years; 54% were women, 41% were Black, and 21% had an eGFRcys<60mL/min/1.73m2. The baseline prevalence of abdominal obesity (waist circumference≥88cm for women or≥102cm for men) was 48% and obesity was 38%. In multivariable adjusted analyses, each 15mL/min/1.73m2 lower eGFRcys was associated with higher HR and 95% CI of mortality in each waist circumference quartile (first quartile, 1.19 [1.15-1.24]; second quartile, 1.22 [1.18-1.26]; third quartile, 1.20 [1.16-1.24]; fourth quartile, 1.19 [1.15-1.23]) as well as within each BMI category (BMI<24.9: 1.21 [1.17-1.25]; BMI 25.0-29.9: 1.21 [1.18-1.25]; BMI 30.0-34.9: 1.20 [1.16-1.25]; BMI≥35: 1.17, [1.12-1.22]). Neither waist circumference nor BMI modified the association of eGFRcys with mortality, kidney failure, incident ASCVD, or incident HF (all Pinteraction>0.05).

LIMITATIONS

Included only Black and White persons in the United States.

CONCLUSION

Obesity did not modify the association of eGFRcys with all-cause mortality, kidney failure, incident ASCVD, or incident HF. Among individuals with obesity, cystatin C may be used to provide eGFR-based risk prognostication for adverse outcomes.

PLAIN-LANGUAGE SUMMARY

Cystatin C is increasingly used in clinical practice to estimate kidney function, and cystatin C-based eGFR (eGFRcys) may be used to determine risk for adverse clinical outcomes. Adiposity may increase serum levels of cystatin C, independent of kidney function. This cohort study investigated whether associations of eGFRcys with adverse kidney and cardiovascular outcomes are modified by measures of obesity, waist circumference, and body mass index. We found that obesity does not modify associations of eGFRcys with 4 clinical outcomes and conclude that among individuals with obesity, cystatin C may be used to provide eGFR-based risk prognostication for adverse outcomes.

Patients' Perspectives on Race and the Use of Race-Based Algorithms in Clinical Decision-Making: a Qualitative Study

BACKGROUND

Clinical algorithms that incorporate race as a modifying factor to guide clinical decision-making have recently been criticized for propagating racial bias in medicine. Equations used to calculate lung or kidney function are examples of clinical algorithms that have different diagnostic parameters depending on an individual's race. While these clinical measures have multiple implications for clinical care, patients' awareness of and their perspectives on the application of such algorithms are unknown.

OBJECTIVE

To examine patients' perspectives on race and the use of race-based algorithms in clinical decision-making.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

Twenty-three adult patients recruited at a safety-net hospital in Boston, MA.

APPROACH

Interviews were analyzed using thematic content analysis and modified grounded theory.

KEY RESULTS

Among the 23 study participants, 11 were women and 15 self-identified as Black or African American. Three categories of themes emerged: The first theme described definitions and the individual meanings participants ascribed to the term race. The second theme described perspectives on the role and consideration of race in clinical decision-making. Most study participants were unaware that race has been used as a modifying factor in clinical equations and rejected the incorporation of race in these equations. The third theme related to exposure to and experience of racism in healthcare settings. Experiences described by non-White participants ranged from microaggressions to overt acts of racism, including perceived racist encounters with healthcare providers. In addition, patients alluded to a deep mistrust in the healthcare system as a major barrier to equitable care.

CONCLUSIONS

Our findings suggest that most patients are unaware of how race has been used to make risk assessments and guide clinical care. Further research on patients' perspectives is needed to inform the development of anti-racist policies and regulatory agendas as we move forward to combat systemic racism in medicine.

Socioeconomic Parameters and Well Being of Sickle Cell Anaemic Patients in Southwestern Nigeria

BACKGROUND

The financial and educational status of individuals living with sickle-cell anaemia contributes to their general well-being. It is widely known that education is closely linked with positive health-seeking behaviors i.e., the more educated a person is, the better the person is likely to seek medical attention when needed, and take care of themselves before the crisis. It is considered that a relatively well-educated person with a means of livelihood would purchase the required drugs for prophylactic use. In most African countries where poverty is acute, it becomes a problem when the resource for education and finance needed for the treatment is not available. This study assessed the socioeconomic parameters (financial and educational status) of individuals living with the disorder within the Ibadan metropolis, southwest Nigeria.

METHODS

This study is a descriptive cross-sectional study using quantitative methods that assessed individuals' financial and educational status with sickle cell anaemia. Respondents were recruited from federal and state hospitals, non-governmental foundations, worship centers, and schools. The individuals' educational and financial statuses were accessed using standardized data collection and assessment tools, while the data were analyzed using SPSS (v22). Presentation of inferential statistics was done at a 5% level of significance.

RESULTS

The study recruited 253 participants, of which more than half (58.1%) were females. Those between 12-28 years were 64.4%, and the mean age was approximately 27.7±10.3 years. Also, 67.2% had tertiary education, 74.7% were neither engaged nor married at the time of this study, 88.5% were Yoruba, 73.5% of the participants were from a monogamous family, and 73.1% were Christians. A significant directly proportional association was found between financial status, educational status, and general well-being.

CONCLUSION

Sociodemographic, as well as educational factors, contributed to the general well-being of the individual participants. Thus, finance, level of exposure, and the environment were found to contribute significantly to well-being. More than half of the participants had tertiary education or are currently in school compared to those without tertiary education. There is an association between those with tertiary education and the number of hospital visits in the selected participants. While no association exists between those with buoyant financial status compared to those without a stable source of income.

Individual and ecological analyses of antenatal care: Prospects for delivery assistance and use of modern family planning in Nigeria

Despite the availability of healthcare centres for the provision of antenatal care (ANC) services in Nigeria, the services are still underutilized by pregnant women. ANC services not only reduce maternal mortality and birth defects, but also have a strong link to many causes of maternal deaths. This study explored the individual and ecological relationships between antenatal care, skilled birth assistance during delivery, and family planning use across states in Nigeria. This study was a secondary analysis of data from the 2018 National Nutrition and Health Survey (NNHS) carried out among 24,985 women aged 15-49 years in the 36 states and the Federal Capital Territory (FCT) in Nigeria. Analysis was carried out at the level of individual women and at the ecological level. Only 68.3% visited a health professional (doctors, nurses, midwives, community health extension workers, and community health officers) for ANC in the most recent pregnancy before the survey. At delivery, 44.9% were assisted by delivery attendants with about half (50.1%) assisted by non-professional (traditional birth attendants, relatives and friends) during delivery. There was a significant variation in use of modern family planning (FP) across types of ANC provider. There was a strong positive correlation between ANC utilisation and skilled birth attendance (SBA) (r=0.706, p <0.001), and between SBA and FP (r=0.730, p <0.001). These results have implications for the design of appropriate interventions for strengthening the role of healthcare providers to enhance ANC patronage, utilization of safe delivery services and sustained use of reproductive health services.

Prevalence and predictive factors for early initiation of breastfeeding in Nigeria: Evidence from the Nigerian demographic and health survey (2003-2018)

Early initiation of breastfeeding (EIBF) is an essential first step in exclusive breastfeeding that is expected to commence within an hour after childbirth. This study examined the prevalence and the factors associated with EIBF among nursing mothers in Nigeria based on an analysis of the 2003, 2008, 2013, and 2018 Nigerian Demographic Health Survey (NDHS) data. The prevalence of early breastfeeding initiation by women's demographic, socio-economic and reproductive characteristics were computed for each of the survey rounds. The differences in the prevalence estimates for early breastfeeding initiation between the last two survey periods were calculated. A crude and adjusted model to examine association between explanatory variables and early breastfeeding initiation were fitted using Poisson regression model. The mean age of respondents was 29 years (SD=7.3). The prevalence of EIBF increased from 31.5% in 2003 (95% CI 28.4-34.5) to 43.8% in 2018 (95% CI 42.6-45.0), with a decline to 35.3% in 2013 (95% CI 34.0-36.7). The identified risk factors associated with EIBF were being 35-39 years, having at least a primary education, lower wealth quintiles, multiparity, and delivery in a public hospital. EIBF was lower among women that had skilled occupation, access to media, decided to delay pregnancy, history of previous caesarean section, small size baby at birth, and women who received antenatal care. The results indicate that the proportion of women with EIBF in Nigeria is low. Addressing the barriers identified in this paper will help promote EIBF practices in the country.

Assessment of diagnostic accuracy and adherence to maternal and child health guidelines as a measure of clinical competence of frontline healthcare workers in Nigeria

Clinical competence of primary healthcare (PHC) workers is important in the delivery of maternal and child health care and services. In this cross-sectional study, we investigated the diagnostic accuracy and adherence to clinical guidelines for the management of some clinical conditions such as malaria, diarrhea, pneumonia, neonatal asphyxia and postpartum hemorrhage, as a proxy to measure the clinical competence of frontline health workers in PHCs in selected states in Nigeria. Ninety PHC facilities were randomly selected in each State and the FCT. Of the 3330 health workers, only 36.0% were able to correctly diagnose the five selected medical conditions. There was a significant difference in the diagnostic accuracy of the health workers with the doctors having highest diagnostic accuracy (65.5%) compared to other health workers (p <0.001). Adherence to the management guidelines was generally poor across all cadres of health workers and this pattern appear similar across the geopolitical regions in the country. The highest adherence to guidelines was observed among medical doctors (38.2%). The diagnostic accuracy and adherence to national guidelines for managing patients was poor among health workers, particularly, among other cadres except doctors. PHC workers in Nigeria need continuous training to enhance their clinical competence to improve quality of maternal and child health care.

Prevalence and patterns of anthropometric failure among under-five children in Nigeria: Evidence from the National nutrition and health survey, 2018

Globally, malnutrition among under-five children remains a public health concern. There is increasing concern at research and policy levels about anthropometric failure and the double burden of child malnutrition across different groups of children. The objective of this study was to describe the magnitude and distribution of various forms of anthropometric failure (AF) among children under age five in Nigeria. We used the 2018 National Nutrition and Health Survey data collected among 19,471 under-five children in Nigeria. The most prevalent AF was stunting only (17.7%) followed by stunting and underweight (13.9%). Wasting, stunting and underweight was found among 3.5% of the sample. Wasting, stunting and underweight was most common in age 6-11 months (7.0%) and 12-23 months (6.9%). Overall, about 1 out of 5 under-five children has multiple anthropometric failure. The peak age group for multiple AFs was between six months and 35 months. Multiple AF was less likely among females compared to males (RR=0.74, CI: 0.69, 0.80). The risk of multiple AF was higher in both North East (RR=2.15, CI: 1.78, 2.59) and North West (RR=2.98, CI: 2.51, 3.55) relative to the North Central. In contrast, the risk was lesser in the South East (RR=0.75, CI: 0.59, 0.95) and other southern regions. The study showed that multiple anthropometric failure is a common problem among children in Nigeria. Programmes that will support prevention and early identification of different types of malnutrition among under-five children across States in Nigeria are recommended.

Genetics of Chronic Kidney Disease in Low-Resource Settings

Advances in kidney genomics in the past 20 years has opened the door for more precise diagnosis of kidney disease and identification of new and specific therapeutic agents. Despite these advances, an imbalance exists between low-resource and affluent regions of the world. Individuals of European ancestry from the United States, United Kingdom, and Iceland account for 16% of the world's population, but represent more than 80% of all genome-wide association studies. South Asia, Southeast Asia, Latin America, and Africa together account for 57% of the world population but less than 5% of genome-wide association studies. Implications of this difference include limitations in new variant discovery, inaccurate interpretation of the effect of genetic variants in non-European populations, and unequal access to genomic testing and novel therapies in resource-poor regions. It also further introduces ethical, legal, and social pitfalls, and ultimately may propagate global health inequities. Ongoing efforts to reduce the imbalance in low-resource regions include funding and capacity building, population-based genome sequencing, population-based genome registries, and genetic research networks. More funding, training, and capacity building for infrastructure and expertise is needed in resource-poor regions. Focusing on this will ensure multiple-fold returns on investments in genomic research and technology.

End-stage kidney disease and COVID-19 in an urban safety-net hospital in Boston, Massachusetts

Introduction

End-stage kidney disease (ESKD) patients are at a high risk for Coronavirus Disease 2019 (COVID-19). In this study, we compared characteristics and outcomes of ESKD and non-ESKD patients admitted with COVID-19 to a large safety-net hospital.

Methods

We evaluated 759 adults (45 with ESKD) hospitalized with COVID-19 in Spring of 2020. We examined clinical characteristics, laboratory measures and clinical outcomes. Logistic regression analyses were performed to investigate the associations between ESKD status and outcomes.

Results

73% of ESKD and 47% of non-ESKD patients identified as Black (p = 0.002). ESKD patients were older and had higher rates of comorbidities. Admission ferritin was approximately 6-fold higher in ESKD patients. During hospitalization, the rise in white blood cell count, lactate dehydrogenase, ferritin and C-reactive protein, and the decrease in platelet count and serum albumin were all significantly greater in ESKD patients. The in-hospital mortality was higher for ESKD [18% vs. 10%; multivariable adjusted odds ratio 1.5 (95% CI, 0.48–4.70)], but this did not reach statistical significance.

Conclusions

Among hospitalized COVID-19 patients, ESKD patients had more co-morbidities and more robust inflammatory response than non-ESKD patients. The odds ratio point estimate for death was higher in ESKD patients, but the difference did not reach statistical significance.

INFLUENCE OF COVID-19 PANDEMIC ON MEDICAL CONSULTATIONS IN OUTPATIENTS CLINICS, SOUTHWESTERN NIGERIA - A COMMENTARY

Coronavirus Disease (COVID-19) is the largest outbreak of severe acute respiratory syndrome (SARS). It was declared a pandemic by the World Health Organization (WHO) on 11 March 2019, and it has since disrupted many health systems and a threat to the fragile, unprepared health care services in LMICs. Many patients avoided the health facilities despite battling with chronic non-communicable diseases which needed medical attention. Hence, the healthcare providers had to devise means of ensuring the running of essential medical services amidst the pandemic. Scheduled patients' appointments and medical consultations through telemedicine were adopted. A scrutiny of the adjustment in the routine medical consultations in a limited resource country like Nigeria will help to identify the strength and limitations in sustaining safe consultations even after COVID-19 pandemic.

NUTRITION-RELATED KNOWLEDGE AND ATTITUDE OF PRACTISING NIGERIAN MEDICAL DOCTORS TO NUTRITION COUNSELLING DURING THE COVID-19 PANDEMIC 2020

OBJECTIVE

Adequate nutrition is needed to enhance the immune system, especially at the time of COVID-19 pandemic for disease prevention and treatment.

OBJECTIVE

The study aimed to assess physicians' knowledge to nutrition-related issues of COVID-19 infection and explore their attitudes to offering nutritional counselling to patients.

METHODOLOGY

This was a cross-sectional online study conducted among doctors in private and public institutions across the six (6) geo-political zones in Nigeria using the social media online platforms of the Nigerian Medical Association (NMA) from August 17 to September 26, 2020. A categorisation of the knowledge score into sufficient and insufficient was done using the mean (sd) knowledge score. The attitude score was categorised into positive and negative using the median (IQR) attitude score, and bivariate analysis was used to test for associations.

RESULTS

Responses were gotten from a total of 176 doctors over six weeks of data collection. Majority 97(55.1%) were females, and 84 (47.7%) had practised between 11 and 20 years. Majority 95(54.0%) had insufficient knowledge, while 128(72.7%) of the respondents had a negative attitude to nutrition counselling of patients regarding COVID-19. Females had significantly better knowledge about nutrition-related issues of COVID-19 (p=0.004). However, there was no significant difference in the respondents' attitude based on professional cadre, gender, place of practice, and years of practice.

CONCLUSION

Respondents were deficient in the knowledge of common food items containing relevant nutrients essential for boosting immunity. Hence, there is a need to encourage physicians training in nutrition and nutritional counselling.

KNOWLEDGE, ATTITUDE AND PRACTICE OF NIGERIAN MEDICAL STUDENTS TOWARDS COMPLEMENTARY AND ALTERNATIVE MEDICINE IN COVID-19 MANAGEMENT

OBJECTIVE

Complementary and alternative medicine (CAM) is commonly used, but many physicians have limited knowledge of CAM despite its widespread use. Therefore, this study sought to assess the knowledge, attitude, and practice of medical students on complementary and alternative medicine in the management of COVID-19.

METHODOLOGY

A descriptive cross-sectional study was conducted among 150 medical students from three Federal Universities in South West, Nigeria. A self-administered semi-structured online Google Forms questionnaire was used to collect information. Chi-squared and Fisher's exact test was used to analyze the bivariate relationship between KAP status and sociodemographic characteristics. Spearman's correlation coefficient matrix was computed to determine the association between knowledge, attitude, CAM, age, and religiosity practice.

RESULTS

The median age was 22 years (interquartile range: [IQR]: 21-23 years). Median self-rated score for religion was 4.00 (IQR: 3.00-4.25). Median knowledge score was 4.00 (IQR: 3.75-5.00), median attitude score 2.75 (IQR: 2.38-3.00) and median practice score 2.00 (IQR: 1.00-2.00). Thirty-seven respondents (24.7%) were considered to have poor knowledge about CAM use in COVID-19 while the rest (75.3%) had good knowledge. Thirty-eight (25.3%) had a poor attitude towards using CAM in COVID-19 and 112 (74.7%) had a good attitude.

CONCLUSION

Medical students have good knowledge and a positive attitude towards CAM modalities as adjunct management for COVID-19. However, their practices do not reflect wide acceptability. There is a need for clinical trials on the efficacy of CAM as an adjunct treatment for COVID-19 to further inform its use.

INTEREST IN FAMILY MEDICINE SPECIALIZATION AMONG MEDICAL UNDERGRADUATES OF THE UNIVERSITY OF IBADAN, NIGERIA

BACKGROUND

One of the strategies adopted to improve interest in family medicine (FM) by many regions was the introduction of undergraduate family medicine training into the Medical School Curriculum. However, medical students' interest in FM has been reportedly low ranging from 3 - 29%.

OBJECTIVES

This study described the pattern of medical students' specialty choices and assessed factors associated with interest in FM specialization among them.

METHODS

Using a cross-sectional study design, total sampling of fourth to sixth-year medical students undergoing family medicine rotation as of November 2017 (N= 412) was done. The response rate was 75% (N=309). A pre-validated semi-structured, self-administered questionnaire was utilized to assess factors associated with respondents' interest in 12 medical specialties including FM.

RESULTS

The respondents were predominantly male (67.3%), with a mean age of 23 (± 7.9) years. Most (83.4%) of them had at least one parent with tertiary school education. Fifteen (4.9%) of the respondents indicated a current interest in specializing in FM while 112 (36.2%) would consider FM in the future. A higher proportion of those with family members with FM specialization (28.6%) expressed current interest in FM while the female gender was associated with future consideration of FM.

CONCLUSION

There is a low interest in FM specialization among medical students and this may be attributable to the fact that FM undergraduate training is relatively new in Nigeria. Further research on the role of mentorship and preceptorship on specialty choices of medical students needs to be carried out.

Kidney Mentoring and Assessment Program for Students: a guide for engaging medical students in nephrology

Background

The American Society of Nephrology's (ASN) Workforce Committee created a unique program called the Kidney Mentoring and Awareness Program for Students to engage medical students in the fight against kidney diseases and interest them in careers in nephrology.

Methods

The program provided a framework and 2 years of funding to three medical schools to organize and carry out health screenings in underserved areas of their communities as well as a structure for student mentoring by the practicing nephrologists.

Results

The Workforce Committee identified three medical schools (Emory University, Atlanta, GA; Indiana University, Indianapolis, IN and University of Louisville, Louisville, KY) and engaged faculty at each school to serve as advisors. The ASN committed funding to the groups for 2 years, after which the groups became self-sufficient. Three nephrologists participated in each chapter, building on existing relationships with community groups to identify sites and carry out kidney screening events.

Conclusions

We report here the experience of those chapters and a blueprint for other schools interested in setting up a similarly structured program to interest students in nephrology while working with community groups to spread awareness of the major underlying causes of kidney disease.

Burden of chronic kidney disease on the African continent: a systematic review and meta-analysis

Background

Accurate contemporary data on the burden of Chronic Kidney Disease (CKD) on the African continent are lacking. We determined the prevalence of CKD in adult populations living in Africa, and variations by stage, gender, estimated Glomerular Filtration Rate (eGFR) equation, and residence.

Methods

For this systematic review, we searched multiple electronic databases for original studies on CKD prevalence reported from January 1, 2000 to December 31, 2016. Two reviewers independently undertook quality assessment and data extraction. We stabilized the variance of study-specific estimates with the Freeman-Turkey single arcsine transformation and pooled the data using a random effects meta-analysis models.

Results

A total of 98 studies involving 98,432 individuals were included in the final meta-analysis. The overall prevalence was 15.8% (95% CI 12.1–19.9) for CKD stages 1–5 and 4.6% (3.3–6.1) for CKD stages 3–5 in the general population. Equivalent figures were greater at 32.3% (23.4–41.8) and 13.3% (10.7–16.0) in high-risk populations (people with hypertension, diabetes, HIV). CKD prevalence was higher in studies based on the Cockcroft-Gault formula than MDRD or CKD-EPI equations; and in studies from sub-Saharan Africa compared with those from North Africa (17.7, 95% CI 13.7–22.1 vs 6.1, 95% CI 3.6–9.3, p < 0.001). There was substantial heterogeneity across studies (all I² > 90%) and no evidence of publication bias in main analyses.

Conclusion

CKD is highly prevalent across Africa, inviting efforts into prevention, early detection and control of CKD in adults living on the African continent which is particularly important in a resource limited environment.

Trial Registration

Prospero Registration ID: CRD42017054445.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-0930-5) contains supplementary material, which is available to authorized users.

Functional health of patients with knee osteoarthritis in a family medicine clinic in Ibadan

BACKGROUND

Patients with knee osteoarthritis experience pain and functional impairment, which impacts upon activities of daily living ultimately leading to a loss of functional independence and low quality- of-life. This study therefore aimed at evaluating the functional health status of patients with knee osteoarthritis in the Family Medicine clinic, University College Hospital, Ibadan, Nigeria.

METHODS

A cross-sectional study was conducted on 270 eligible respondents between January and March 2011. The Ibadan Knee/Hip Osteoarthritis Measure (IKHOAM) was administered after screening with the knee pain screening tool (KNEST). Respondents'Socio- demographic characteristics and knee pain intensity ratings were also recorded.

RESULTS

The age range of respondents in the study was from 28 years to 85 years with a female: male ratio 5:1. Out of the 270 respondents studied, 146 (54.1%) reported restriction in performing duties at work. One hundred and twenty seven respondents (47.0%) needed some assistance in walking outside the house for 15 to 20 minutes, whilst 195 (72.2%) required some assistance in climbing stairs. Thirty four (12.6%) of Muslims and 77 (28.5%) of Christians could not kneel to pray. Males are twice more likely to have a better functional health than females (OR= 2.1, 95% CI= 1.0- 4.6, p=0.046).

CONCLUSION

Knee osteoarthritis significantly impairs activities of daily living, especially some socio-cultural and religious practices of respondents. Therefore in addition to treating the knee symptoms, removing environmental barriers may reduce immobility within and outside the home thereby improving functionality.