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

BACKGROUND

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

AIMS AND OBJECTIVES

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

METHODOLOGY

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Awareness, knowledge and perception of chronic kidney disease in a rural community of South-West Nigeria

BACKGROUND

Awareness and education on kidney disease impact on its effective management and will reduce the significant economic and public health burden. Knowledge of CKD and risk factors increases the perception of being at high risk and increasing health seeking behavior. We conducted a cross-sectional descriptive study to assess the level of awareness, knowledge and conventional risk factors of CKD in the community to strategize on preventive modalities using the information gathered from this population.

METHODS

We used a pretested structured questionnaire to draw information on sociodemography, knowledge and risk factors of CKD from 563 residents aged >18 years.

RESULTS

A total of 454 residents completed this study, mainly farmers, with a mean age of 45.8 ± 19.0 years and male: female ratio of 0.8:1. Only 33.7% had heard of kidney disease with 59.3% from the media and 35.3% from health workers; the level of knowledge of CKD was good in 27.1%. The majority (67.0%) do not know the correct location of the kidneys. Only 10.6% could mention at least one function of the kidneys with only 24.5% agreeing that NSAIDs can cause kidney disease. A laboratory test for kidney function was known by 4.4%; 45.9% and 47.8% believe that CKD can be cured by spiritual means and herbal concoctions respectively. Only 11.1% agreed that CKD can be hereditary. Abdominal obesity and cigarette smoking were seen in 14.6% and 16.6% respectively. Hypertension was seen in 26.5% while 17.8% actually knew they were hypertensive. Diabetes mellitus was found in 3.4%. None of the patients with CKD who had diabetes or hypertension was aware of kidney disease.

CONCLUSION

There are a misconception and low level of awareness and knowledge of CKD, including those with risk factors, in the community. Efforts should be made to create awareness and educate people on CKD and prevention of its risk factors.

Community Perspectives Associated With the African PsA-TT (MenAfriVac) Vaccine Trials

Background. The Meningitis Vaccine Project (MVP) was established to address epidemic meningitis as a public health problem in sub-Saharan Africa and, to that end, worked to develop a group A meningococcal conjugate vaccine, PsA-TT.

Methods. Experiences in 4 clinical trial sites are described. Culturally sensitive collaborative strategies were adopted to manage acceptable communication methods, peculiarities with the consent process, participant medical issues, community care, and death.

Results. The clinical trials were completed successfully through community acceptance and active community collaboration. The trials also strengthened the capacities in the participating communities, and actively worked to resolve community problems.

Conclusions. The understanding and integration of sociocultural realities of communities were major assets in the conduct and acceptance of these trials. MVP succeeded in these sites and provided a sound example for future clinical studies in Africa.

Clinical Trials Registration. ISRTCN78147026 (PsA-TT 002); ISRCTN87739946 (PsA-TT 003); ISRCTN82484612 (PsA-TT 004); PACTR ATMR2010030001913177 (PsA-TT 006); and PACTR201110000328305 (PsA-TT 007).

Ethical Challenges and Lessons Learned During the Clinical Development of a Group A Meningococcal Conjugate Vaccine

BACKGROUND

The group A meningococcal vaccine (PsA-TT) clinical development plan included clinical trials in India and in the West African region between 2005 and 2013. During this period, the Meningitis Vaccine Project (MVP) accumulated substantial experience in the ethical conduct of research to the highest standards.

METHODS

Because of the public-private nature of the sponsorship of these trials and the extensive international collaboration with partners from a diverse setting of countries, the ethical review process was complex and required strategic, timely, and attentive communication to ensure the smooth review and approval for the clinical studies. Investigators and their site teams fostered strong community relationships prior to, during, and after the studies to ensure the involvement and the ownership of the research by the participating populations. As the clinical work proceeded, investigators and sponsors responded to specific questions of informed consent, pregnancy testing, healthcare, disease prevention, and posttrial access.

RESULTS

Key factors that led to success included (1) constant dialogue between partners to explore and answer all ethical questions; (2) alertness and preparedness for emerging ethical questions during the research and in the context of evolving international ethics standards; and (3) care to assure that approaches were acceptable in the diverse community contexts.

CONCLUSIONS

Many of the ethical issues encountered during the PsA-TT clinical development are familiar to groups conducting field trials in different cultural settings. The successful approaches used by the MVP clinical team offer useful examples of how these problems were resolved.

CLINICAL TRIALS REGISTRATION

ISRCTN17662153 (PsA-TT-001); ISRTCN78147026 (PsA-TT-002); ISRCTN87739946 (PsA-TT-003); ISRCTN46335400 (PsA-TT-003a); ISRCTN82484612 (PsA-TT-004); CTRI/2009/091/000368 (PsA-TT-005); PACTR ATMR2010030001913177 (PsA-TT-006); PACTR201110000328305 (PsA-TT-007).

Clustering of cardiovascular risk factors in semi-urban communities in south-western Nigeria

BACKGROUND

In addition to poor socio-economic indices and a high prevalence of infectious diseases, there have been various reports of a rising prevalence of cardiovascular diseases, with associated morbidity and mortality in developing countries. These factors co-exist, resulting in a synergy, with serious complications, difficult-to-treat conditions and fatal outcomes. Hence this study was conducted to determine the clustering of cardiovascular disease risk factors and its pattern in semi-urban communities in south-western Nigeria.

METHODS

This was a cross sectional study over seven months in 11 semi-urban communities in south-western Nigeria.

RESULTS

The total number of participants was 1 285 but only 1 083, with 785 (65%) females, completed the data. Participants were 18 years and older, and 51.2% were over 60 years. The mean age was 55.12 ± 19.85 years. There were 2.6% current cigarette smokers, 22% drank alcohol and 12.2% added salt at the table, while 2% had been told by their doctors they had diabetes, and 23.6% had hypertension. The atherogenic index of plasma was at a high-risk level of 11.1%. Elevated total cholesterol and low-density lipoprotein cholesterol, and low high-density lipoprotein cholesterol levels were seen in 5.7, 3.7 and 65.1%, respectively. Prevalence of hypertension was 44.9%, diabetes was 5.2%, obesity with body mass index (BMI) > 30 kg/m2 was 5.7%, and abdominal circumference was 25.7%. Prevalence of clusters of two, three, and four or more risk factors was 23.1, 15.5 and 8.4%, respectively. Increasing age 2.94 (95% CI: 1.30-6.67), BMI 1.18 (95% CI: 1.02-1.37), fasting plasma glucose level 1.03 (95% CI: 1.00-1.05), albuminuria 1.03 (95% CI: 1.00-1.05), systolic blood pressure 1.07 (95% CI: 1.04-1.10), diastolic blood pressure 1.06 (95% CI: 1.00-1.11) and female gender 2.94 (95% CI: 1.30-6.67) showed increased odds of clustering of two or more cardiovascular risk factors.

CONCLUSION

Clustering of cardiovascular risk factors is prevalent in these communities. Patterns of clustering vary. This calls for aggressive and targeted public health interventions to prevent or reduce the burden of cardiovascular disease, as the consequences could be detrimental to the country.

Prevlaence of chronic kidney disease markers in Kumbotso rural Northern Nigeria

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIMS AND OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study

BACKGROUND

Diarrhoeal diseases cause illness and death among children younger than 5 years in low-income countries. We designed the Global Enteric Multicenter Study (GEMS) to identify the aetiology and population-based burden of paediatric diarrhoeal disease in sub-Saharan Africa and south Asia.

METHODS

The GEMS is a 3-year, prospective, age-stratified, matched case-control study of moderate-to-severe diarrhoea in children aged 0-59 months residing in censused populations at four sites in Africa and three in Asia. We recruited children with moderate-to-severe diarrhoea seeking care at health centres along with one to three randomly selected matched community control children without diarrhoea. From patients with moderate-to-severe diarrhoea and controls, we obtained clinical and epidemiological data, anthropometric measurements, and a faecal sample to identify enteropathogens at enrolment; one follow-up home visit was made about 60 days later to ascertain vital status, clinical outcome, and interval growth.

FINDINGS

We enrolled 9439 children with moderate-to-severe diarrhoea and 13,129 control children without diarrhoea. By analysing adjusted population attributable fractions, most attributable cases of moderate-to-severe diarrhoea were due to four pathogens: rotavirus, Cryptosporidium, enterotoxigenic Escherichia coli producing heat-stable toxin (ST-ETEC; with or without co-expression of heat-labile enterotoxin), and Shigella. Other pathogens were important in selected sites (eg, Aeromonas, Vibrio cholerae O1, Campylobacter jejuni). Odds of dying during follow-up were 8·5-fold higher in patients with moderate-to-severe diarrhoea than in controls (odd ratio 8·5, 95% CI 5·8-12·5, p<0·0001); most deaths (167 [87·9%]) occurred during the first 2 years of life. Pathogens associated with increased risk of case death were ST-ETEC (hazard ratio [HR] 1·9; 0·99-3·5) and typical enteropathogenic E coli (HR 2·6; 1·6-4·1) in infants aged 0-11 months, and Cryptosporidium (HR 2·3; 1·3-4·3) in toddlers aged 12-23 months.

INTERPRETATION

Interventions targeting five pathogens (rotavirus, Shigella, ST-ETEC, Cryptosporidium, typical enteropathogenic E coli) can substantially reduce the burden of moderate-to-severe diarrhoea. New methods and accelerated implementation of existing interventions (rotavirus vaccine and zinc) are needed to prevent disease and improve outcomes.

FUNDING

The Bill & Melinda Gates Foundation.

Health Care Utilization and Attitudes Survey: understanding diarrheal disease in rural Gambia

Diarrheal disease causes ∼1.34 million deaths per year among children under 5 years of age globally. We conducted a Health Care Utilization and Attitudes Survey of 1,012 primary caregivers of children aged 0–11, 12–23, and 24–59 months randomly selected from a Demographic Surveillance population in rural Gambia. Point prevalence of diarrhea was 7.7% (95% confidence interval [CI] = 6.1–9.8); 23.3% had diarrhea within the previous 2 weeks. Caregivers of 81.5% of children with diarrhea sought healthcare outside their home, but only 48.4% of them visited a health center. Only 17.0% (95% CI = 12.1–23.2) of children with diarrhea received oral rehydration solution (ORS) at home. Abbreviated surveys conducted on six occasions over the subsequent 2 years showed no change in prevalence or treatment-seeking behavior. Diarrhea remains a significant problem in rural young Gambian children. Encouraging care-seeking behavior at health centers and promoting ORS use can reduce mortality and morbidity in this population.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The immunogenicity and impact on nasopharyngeal carriage of fewer doses of conjugate pneumococcal vaccine immunization schedule

The immunogenicity and impact on carriage of fewer doses of pneumococcal conjugate vaccine (PCV7) followed by booster with pneumococcal polysaccharide vaccine (PPV) were investigated. 684 infants were assigned randomly to one of the three groups that received one (A), two (B) or three (C) doses of PCV7 between 2 and 4 months of age, plus PPV at 10 months. Following primary vaccination protective antibody titers of >0.35 μg/ml against the PCV7 serotypes combined increased significantly with the number of PCV7 doses, 44% vs. 77% vs. 94% (p<0.001), and correlated positively with the opsonophagocytic indices, but negatively with nasopharyngeal carriage of pneumococcus. The differences in antibody responses and pneumococcal carriage between the groups diminished following booster with PPV, implying that administration of one or two doses of PCV7, with a booster dose of PPV might lower the cost of protection against IPD in young children in resource poor countries.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Anaemia and its response to treatment with recombinant human erythropoietin in chronic kidney disease patients

BACKGROUND

The introduction of erythropoietin has transformed the management of anaemia in CKD, with considerable benefits which includes enhanced quality of life, increased exercise capacity and improved cardiac function. There is paucity of data on the beneficial effects of this treatment from this environment.

OBJECTIVE

The aim of this work was to study the pattern and response of anaemia and its response to treatment with recombinant human erythropoietin(r-HuEpo) in CKD patients in Nigeria.

METHODS

This was a prospective study in which 20 CKD patients who satisfied the inclusion criteria were recruited consecutively. Subcutaneous r-HuEpo was administered to each of the study patients, starting with a weekly dose of 50 iu per kg and titrated according to haemoglobin (Hb) response, which was monitored fortnightly throughout the study period with the aim of achieving a target Hb of 11g per dl.

RESULTS

The patients studied were anaemic with mean Hb of 7.36(1.05) g/dl. The anemia was normocytic normochromic in 85% of the patients. All the patients responded to treatment with r-HuEpo with the mean Hb rising from 6.74(0.70)g per dl to 11.64(0.37) g/dl and 7.64(1.19) to 11.98(0.45) g/dl in those on maintenance haemodialysis and pre-dialysis patients respectively. The patients reached the target Hb of 11g/dl within 8 weeks in predialytic CKD patients and within 10 weeks in those on maintenance haemodialysis.

CONCLUSION

Anaemia is mostly normocytic normochromic in CKD patients in our environment and r-HuEpo therapy is effective in correcting the anaemia.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Target organ damage and associated clinical conditions in newly diagnosed hypertensives attending a tertiary health facility

BACKGROUND

Despite the ease of detecting and making a diagnosis of hypertension, various population surveys have shown low awareness and treatment rates of hypertension. Failure to detect and make a diagnosis of hypertension leads to late presentation and institution of treatment with consequent development of target organ damage (TOD) and associated clinical conditions (ACC) which in turn are associated with increased cost of treatment, morbidity and mortality.

OBJECTIVE

This study was aimed at determining the presence and severity of TOD and ACC in newly diagnosed hypertensives with a view to ascertaining the magnitude of the problem.

METHOD

The study was carried out at Ladoke Akintola University of Technology Teaching Hospital Osogbo, Nigeria. Target organ damage (TOD) and associated clinical conditions (ACC) were determined in successive newly diagnosed hypertensives that presented at the centre during the study period.

RESULT

Of 147 newly diagnosed hypertensives seen at Ladoke Akintola University of Technology Teaching Hospital Osogbo, Nigeria, TOD and ACC were found in 98 (66.7%). The most prevalent TOD and ACC were LVH (42.2%), diabetes mellitus (14.3%), CVD (10.9%) and heart failure (8.8%). Patients with TOD andACC were significantly older (p = 0.028), had significantly higher SBP (p = 0.003), higher DBP (p = 0.022) and significantly lower BMI (p = 0.046) when compared with patients without TOD and ACC.

CONCLUSION

This study showed presence of TOD and ACC in two-thirds of newly diagnosed hypertensives. This underscores the need for improvement in the awareness, detection and treatment of hypertension in order to prevent TOD and ACC.

Association of hydrocarbon exposure with glomerulonephritis in nigerians: a case control study

Glomerulonephritis (GN) is a major cause of CRF in Nigerians. Experimental evidence and clinical studies mostly in Caucasian subjects have associated hydrocarbon (HC) exposure with GN. We conducted a case-control study using a questionnaire-based quantitative HC exposure measurement to compare lifetime HC exposure levels between Nigerian patients with GN-induced CRF and matched healthy control subjects. Fifty consecutive patients with CRF from GN were compared with age and sex matched group of 45 healthy controls. A questionnaire designed to assess the sources, duration and intensity of HC exposure was used to compute an HC exposure score (HES) for each participant and the scores for the two groups were then compared. The HES was significantly higher in the patients (score +/- SEM) of 2307.5 +/- 698.8 vs. 53.4 +/- 16.5; p < 0.001. The HES was dichotomised by classifying all study subjects within the upper third of scores as a high-exposure sub-group. A significantly higher proportion of patients had high exposure (p<0.002). Logistic regression analysis excluded age and gender as confounding factors and determined a greater than four-fold risk of GN-induced CRF with high HC exposure (OR 4.3; 95% CI 1.7 - 11). In conclusion, our findings suggest that HC exposure is a significant risk factor for GN in Nigerians with CRF. Exposure limitation could help to reduce the burden of CRF in the country.

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

AIMS AND OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND

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

PATIENTS, MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIMS AND OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

BACKGROUND

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

PATIENTS, MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Attitudes toward kidney donation

The Renal Unit of Obafemi Awolowo University Teaching Hospital Ile-Ife in Southwest Nigeria intends commencing a kidney transplantation program. This cross-sectional study aimed at examining the willingness of Nigerians to be living-related kidney donors. Three hundred and sixteen Nigerians (96 first-degree relatives of end-stage renal disease patients, 69 rural dwellers and 151 health workers) were interviewed regarding their willingness to donate kidneys using an interview schedule designed to elicit socio-demographic information, knowledge about kidney transplantation and attitude toward kidney donation. Sixty-two percent of health workers, 52.1% of the patients' relatives and 27.1% of rural dwellers expressed willingness to donate. Higher proportions of health workers and patients' relatives--compared with the rural dwellers--were willing to donate a kidney to their children, full-siblings and parents (P<0.05). The level of awareness about kidney transplantation was highest among health workers and least among rural dwellers (P<0.001). Altruism was the primary motivation for those willing to donate a kidney. The most important reason for refusal to donate was fear of adverse health consequences. Among the rural dwellers, never-married persons were more willing than the married to donate (P<0.05). Programs aimed at increasing awareness about the safety of kidney donation, reducing adverse beliefs about kidney donation, and encouraging altruistic tendencies will increase the availability of kidney donors.

Glomerular filtration rate in Nigerian children with homozygous sickle cell disease

The study proposed to assess glomerular filtration rate as determined by endogenous creatinine clearance in steady state Nigeria children with homozygous sickle cell disease and normal controls. Twenty-four hours urinary creatinine clearance was estimated over a 6-month period in 54 steady-state homozygous sickle cell disease and 57 normal control children aged 5 to 13 years. Each child was admitted and a 24-hour urine sample (8.00 am to 8.00 am) was collected both for volume measurement and creatinine concentration determination. Blood was also collected from each child 30 minutes to end of urine collection for plasma creatinine concentration determination, haematocrit and reticulocyte counts. The results were compared between the two groups of children using student's t-test and the chi (X2) square test where necessary. The mean glomerular filtration rates +/- SD (ml/min/1.73 M2) for homozygous sickle cell disease children and normal controls were not significantly different (p > 0.05). Glomerular filtration rate did not differ significantly between the age groups in both patients and normal controls; haematocrits correlated weakly with glomerular filtration rates in the patients (r = +0.213; p < 0.001). Nigerian children with homozygous sickle cell disease who are in steady states have normal glomerular filtration rate that is hardly influenced by increasing age and low haematocrit level.

What does the presence of hypertension portend in the Nigerian with non insulin dependent diabetes mellitus

132 Nigerians with Non Insulin -dependent diabetes mellitus (NIDDM) were divided into two groups (NIDDM) patients with hypertension and those without) and their clinico-laboratory parameters were studied and analyzed. Their mean age (SD) was 59.5+/-9 years. Body mass index (BMI) was 25.2+/-3.5 kg/m2 and the duration of DM was 6.9+/-6 years. The prevalence of hypertension was 55(41.6%) No significant difference were observed in the age, sex ratio and BMI of both groups but the duration of DM showed a statistical difference between the two groups. However, laboratory parameters such as fasting blood glucose, serum urea, creatinine clearance and degree of proteinuria all showed statistically significant difference between the hypertensive and normotensive groups. Also the hypertensive diabetic group were observed to have more end organ damage i.e peripheral neuropathy, diabetic retinopathy and diabetic nephropathy than the normotensive diabetics. We conclude that, hypertension in NIDDM patients has prognostic implications and so more aggressive efforts be made in detecting and controlling hypertension in DM patients.

Creatinine clearance estimation from serum creatinine values: evaluation and comparison of five prediction formulae in Nigerian patients

Predictability of creatinine clearance (CrCl) from serum creatinine would reduce the cost of renal care and obviate the need for 24-hours urine collection. Correlations have been established between serum creatinine (Scr) and 24-hour urinary creatinine clearance with derivation of various formulae. We have tested the applicability of these formulae in 34 Nigerian patients (22 males, 12 females) aged 18 to 58 years, (mean age 34.97 +/- 11.20 years) with established chronic renal failure (CRF) mean Scr level 742.26 +/- 388.15 mol/L. 32 age and sex matched healthy adults with serum creatinine values below 120 umol/l., served as controls. Serum creatinine and 24 hour CrCl levels were determined on two consecutive occasions. Creatinine clearance values were also derived from Scr using each of the established prediction formulae: Cockcrof and Gault [1] Gates [2] Hull et al [3]; Jelliffe [4]; and Mawer et al [5]. A relationship was sought between measured CrCl and the predicted values (derived) using the stated formulae. Regression equation were generated and correlation coefficient r, coefficient of determination r2, F-ration, prediction error, all defining the nature and strength of relationship were determined. We observed that good and statistically significant correlations exist between measured CrCl values and those predicated from the formulae (r ranging from 0.908 to 0.968 and r20.82 to 0.93 P = 0.000) and that a linear relationship exists in all cases. Cockcroft and Gault formula gave the highest coefficient of determination r2 = 0.94. It is concluded that the existing formulae are adequate for determining CrCl from Scr and should be frequently used in the long term follow-up of patients with Chronic Renal Failure (CRF) in our setting.

The haematological profile of Nigerians with chronic renal failure

In an attempt to add to existing sparse literature on the haematological profile in chronic renal failure (CFR) in Nigeria, we have undertaken a comprehensive haematological sturdy of 39 patients (male 27, female 12) age range 11-56 yr., (mean 28.8 +/- 11.8) who had established pre-dialytic CFR. The mean haematocrit was 24.1 +/- 6.7% (range 12-40%). Severe anaemia was found in seven (18%), mild to moderate anaemia in 27 (69%) whilst five patients were not anaemic. Haematocrit correlated inversely with the degree of renal failure as assessed by serum creatinine (r = -0.35, P < 0.05). Red cell morphology was variable but the majority of patients showed a normocytic, normochromic blood film. The reticulocyte counts/indices were low. The mean total white cell count was generally within normal limits, ranging from (2 to 10.5 x 10(9)/l), with a mean of 5.3 +/- 2.1 x 10(9)/l and striking eosinophilia in 5 patients. Platelet count ranged between 82 and 350 x 10(9)/l (mean 156.5 +/- 65.7 x 10(9)/l) with only 3 patients having a relatively low count of < 100 x 10/l. Prolonged bleeding time (BT) > 9 minutes occurred in 13 (25.6%). There was no significant correlation between platelet count and bleeding time r = 0.21, P = 0.34. No significant correlation was observed between serum creatinine and bleeding time r = 0.09, P > 05. The bone marrow showed predominantly normocellular marrow but 7 patients had hypocellularity. Myeloid: Erythroid ratio ranged between 1:1 and 10:1, (mean 3:6:1) and correlated positively with serum creatinine values. (r = 0.37, P = 0.048). Bone marrow storage iron was absent in two and reduced in six patients. Severe anaemia is a common feature in Nigeria patients with CRF and it strongly associated with the severity of the renal failure. The low reticulocyte count and the tendency for erythroid hpoplasia to occur with increasing severity of renal failure would necessitate the use of erythropietin in our patients. The increased bleeding tendency in some of the patients calls for caution in surgical procedures in these patient.

The pattern of acute toxic nephropathy in Ife, Nigeria

All cases of acute renal failure (ARF) seen over a two year (1993-94) period were evaluated. Those that had acute toxic nephropathy were further studied to determine the aetiologic agents involved, the clinical features and the effect of available treatment on its prognosis. Ten cases (33.3%) out of 30 ARF had toxins responsible for their renal failure. They were 8 males and 2 females. Agents responsible were green water in 2, naphthalene containing remedies in 2 and analgesic combination in 1 while herbal remedies were implicated in 5 cases. Anuria was a prominent feature occurring in 9 (90%) of the patients. The patients were uraemic with a mean serum creatinine of 1460 +/- 485.0 umol/1 and urea of 33.1 +/- 5.3 mmol/1 on admission. They were all anaemic with packed cell volume less than 18% in eight of the patients. Six (60%) of the patients required haemodialysis while 4 were managed conservatively. Prognosis was good as 8 (80%) of the patients survived and were followed up in the clinic for periods anging 6 to 18 months and their serum creatinine and urea levels normalised. It is concluded that acute toxic nephropathy is common in our practice, and it is eminently preventable. The prognosis is good if dialytic therapy is available.

Hypertension induced chronic renal failure: clinical features, management and prognosis

All consecutive cases of chronic renal failure (CRF) seen over a twelve-month period (January-December 1992) were evaluated. Those that fulfilled strict diagnostic criteria for hypertension induced CRF (HICRF) were further studied to determine peculiarities of its clinico-pathological features that may render this possibly preventable condition readily identifiable. Twenty one (23.1%) of the 91 cases of CRF satisfied these criteria. There was a male preponderance (M.F.4.3:1). Nocturia was a prominent symptom predating other symptoms of CRF in all. Throbbing frontal headache necessitating significant consumption of analgesic was found in 13(61.9%). Hypertension had been diagnosed in the patients for periods ranging from 2-15 years and compliance to therapy was adjudged poor. Ten smoked cigarette in significant quantities. Hypertension occurred in 8 of the families of the patients. Hypertension was severe in all, with evidence of accelerated phase in 19(90.5%). A majority (71.4%) presented with severe uraemia (serum creatinine > or = 100 umol/l). Target organ damage, evident in cardiomegaly with heart failure occurred in 15, while ultrasonographic features of bilateral shrunken kidneys was seen in all. Blood pressure control was largely inadequate with a combination of 3 drugs. Mortality rate was 51% in the first year. Renal histopathological findings of glomerular sclerosis, malignant arteriolar changes with absence of glomerular cellular proliferation were observed in renal biopsies and 6 autopsy tissues. It is concluded that HICRF is a major cause of mortality; renal failure is often advanced at presentation, and blood pressure is usually in the accelerated phase. Significant cigarette smoking, severe headache necessitating consumption of significant quantity of analgesics, and a family history of hypertension are striking features.

Rheumatoid factor and rheumatoid factor isotypes in loiasis with and without accompanying glomerulonephritis

We have studied the distribution of rheumatoid factor isotypes amongst patients with loiasis with and without accompanying glomerulonephritis to determine the possible role of rheumatoid factor antiglobulins in this disease. Our findings indicate an increase in both immunoglobulin (Ig) G and IgM rheumatoid factor isotypes in patients with filariasis alone as well as in patients with accompanying glomerulonephritis. No association with IgA rheumatoid factor was found. The raised IgG and IgM rheumatoid factor levels did not correlate with corresponding IgG and IgM levels.

The problem of follow-up of renal transplant patients in the tropics

A 40-year-old male Nigerian with end-stage renal disease (ESRD) received a renal allograft from a live related donor, in the United Kingdom in 1986. Subsequently, in Nigeria, he developed recurrent episodes suggestive of chronic allograft rejection or allograft nephritis which necessitated hospitalisation in our establishment. He subsequently died during one such episode. The peculiar management problems and challenges posed by the patient during his recent admission in our clinical setting are discussed.

Diabetes mellitus. II: Routine chest radiography

Chest radiographs of 43 consecutive diabetic patients were evaluated with a view to determine their role as a routine investigation of patients with diabetes mellitus. 22 (51.2%) patients had normal chest radiographs. The remaining 21 patients had 61 abnormalities found in their chest radiographs. 26 (42.6%) of these were significant abnormalities while 35 (57.4%) were non-significant. Of the former, 42.3% were due to cardiomegaly while in the latter group, aortic unfolding was the main finding. Radiological abnormalities were more commonly observed in patients aged 40 years and over, than in those below, with a ratio of 3:1. Chest radiographs corroborated clinical diagnosis in 19 of the 21 cases in whom abnormalities were observed. This study shows that routine chest radiograph in diabetic patients is useful in those with clinical symptoms and in older diabetics above the age of 40 years.

Diabetes mellitus. I: Routine plain abdominal radiography

The plain abdominal radiographs of 43 consecutive diabetic patients were studied. Disordered bowel motility which was unrelated to the severity of the diabetes mellitus occurred in 76.7% while artheriosclerosis occurred in 65%. Only 7% (3 patients) had pancreatic calcification; of these, one was a complication of urinary schistosomiasis (Schistosoma haematobium). All the patients with pancreatic calcification were above 45 years of age and had had diabetes mellitus for more than 7 years. This study shows that pancreatic calcification is uncommon among Nigerian diabetics, so plain abdominal radiography should be limited to patients who are above 45 years and who have had the illness for more than 7 years.

A common anti-DNA antibody idiotype and anti-phospholipid antibodies in sera from patients with schistosomiasis and filariasis with and without nephritis

The serum concentration of a public idiotype (16/6 ID), originally identified on a human hybridoma-derived monoclonal anti-DNA antibody, was raised in patients with S. mansoni and filariasis with or without nephritis, compared to patients with S. haematobium (in which nephritis does not occur) or idiopathic nephritis not associated with infection. There was no significant difference in 16/6 ID levels between patients with or without renal disease, whether associated with S. mansoni or filarial infection. The 16/6 ID-positive antibodies did not bind to native or denatured DNA, using competitive fluid-phase inhibition studies. Anti-cardiolipin antibody (ACA) concentration was increased in patients with either S. mansoni or filarial infection. In filariasis, both IgG and IgM ACA isotypes were elevated, irrespective of the presence of nephritis. In S. mansoni infection, IgA ACA were limited to patients with renal disease, and IgG ACA isotype to patients without overt nephritis. Both isotypes of anti-cardiolipin antibody correlated with levels of the 16/6 ID in patients with S. mansoni or filariasis. The 16/6 idiotype was therefore a feature of chronic helminthic infection, but was not related to anti-DNA antibody levels or specificity. The occurrence of nephritis as a complication of these infections was not related to the prevalence of the 16/6 idiotype.

Enalapril and hydrochlorothiazide in hypertensive Africans

The antihypertensive efficacy both of angiotensin converting enzyme (ACE) inhibitors and thiazide diuretics has been claimed to be influenced by plasma renin activity, which declines with age and is low in blacks. In a double-blind, placebo-controlled, double-dummy, randomized, parallel-group preliminary study, the antihypertensive efficacy and tolerability of the ACE inhibitor enalapril (20 mg day-1) and hydrochlorothiazide (50 mg day-1) were evaluated and compared for 4 weeks in 20 African patients with essential hypertension. The two groups had similar baseline clinical features and serum Na+ and K+ levels. Hydrochlorothiazide caused a significant and sustained fall in erect blood pressure with a reflex tachycardia. Enalapril exerted only a modest antihypertensive action, but significantly reduced erect heart rate. Direct comparison of hydrochlorothiazide- and enalapril-induced hypotension suggested a greater fall in subjects on the thiazide. The 95% confidence limits for the thiazide-enalapril difference in antihypertensive action at the end of the study was 39.5 to -7.5 mm Hg systolic and 22.0 to -6.6 mm Hg diastolic. The maximal blood pressure fall after hydrochlorothiazide was positively correlated with age (r = 0.50; p less than 0.05), whilst that of enalapril was inversely related age to (r = -0.57, p less than 0.05). The results are compatible with the notion that ACE inhibitor monotherapy may be less effective than thiazide diuretic treatment in African and black patients with essential hypertension. The findings also support the concept that age and racial factors may influence the response to antihypertensive treatment.

Prolonged prednisolone therapy in adult nephrotic syndrome: a preliminary study

Twenty-five adult Nigerian patients suffering from the nephrotic syndrome with normocomplementaemic mesangiocapillary glomerulonephritis were studied. Twelve of these were treated with prednisolone at a dose of 1.5 mg/kg body weight/day, with maximum dose of 90 mg/day initially for 2 weeks. Thereafter, a quarter of the daily dose was given on alternate days for a period varying from 6 to 12 months. The 13 others were similarly followed up on a dietary and diuretic regime alone. Oedema disappeared completely in all the steroid group except one, whilst it persisted in five of the controls. Proteinuria persisted in all the controls but remitted in five of the test patients. Renal function deteriorated with rising plasma creatinine in five of the controls, in contrast with one of the test patients. The beneficial effect of prednisolone observed here calls for further long-term studies.

Role of hepatitis Bs antigen in chronic glomerulonephritides in Nigerians

Using enzyme-linked immunosorbent assay technique (Boehring Institute Laboratory), eighty-one adult patients were studied for hepatitis Bs antigenaemia. Nine of the patients had asymptomatic persistent proteinuria, thirty-nine, nephrotic syndrome, and thirty-three had profuse proteinuria, azotoaemia and hypertension. The histopathology obtained in forty showed twenty-two with MCGN, four with focal glomerulosclerosis, three with proliferative glomerulonephritis, one with minimal change glomerulonephritis and ten with end-stage kidney disease. None of the patients had apparent clinical evidence of liver disease nor a past history of jaundice. One hundred and eighty apparently normal adults served as controls; 33.3% of the patients had positive hepatitis Bs antigenaemia, in contrast to 6% (P less than 0.001) in the normal controls. Hepatitis Bs antigenaemia was more prevalent in the groups with nephrotic syndrome and persistent asymptomatic proteinuria than in the group with advanced renal failure. Hepatitis Bs antigenaemia was detected in all histopathologic forms but was most prevalent in the MCGN (P less than 0.001) which is also the more commonly encountered lesion. The implications of these findings are discussed.

Serum immunoglobulins and complement in nephrotic syndrome

Serum concentrations of IgG, IgM and complement components C3 and C4 were estimated in thirty-one adult Nigerian patients with nephrotic syndrome; twenty-eight of whom had 'active' disease, while three were in remission. Eleven normal adults served as controls. The mean serum IgG was significantly lower, while the mean serum IgM was higher in the patients with active disease than in the controls. Similarly mean serum C3 and C4 levels were statistically significantly higher (P less than 0.05) in active disease than in normal controls. These findings in Nigerian patients are similar to those observed in Caucasians, and further support the role of a fundamental immunological defect in the pathogenesis of the nephrotic syndrome.

Recovery of renal function after 33 days of complete bilateral ureteric obstruction

Bilateral ureteric ligation is a rare complication of hysterectomy. We report a case of prompt recovery of renal function following release of bilateral ureteric ligation persisting for 33 days.