Browsing by Subject "Nephrology"

Now showing 1 - 10 of 10
  • Thumbnail Image
    Item
    Open Access
    An audit of acute kidney injury : a prospective study of the epidemiology, management and outcome of patients with acute kidney injury, over a 12 month period at Groote Schuur Hospital, Cape Town, South Africa
    (2014) Dlamini, Thandiwe Angela Lerato; Rayner, Brian L
    Introduction: Acute kidney injury results from a rapid decline in kidney function. There are many potential causes, some of which are preventable. It carries the risks of mortality, progression to chronic kidney disease and worsening of pre-existing chronic kidney disease. There is a scarcity of data on the epidemiology of acute kidney injury in sub-Saharan Africa. The aims of this study were to describe the epidemiology of acute kidney injury at Groote Schuur hospital, and factors associated with mortality and renal recovery. Methods: This was a prospective observational study of patients with acute kidney injury, referred to Groote Schuur Hospital Renal Unit from the 8th of July 2012 to the 8th of July 2013. Ethics approval was granted by the University of Cape Town Human Research Ethics Committee. We excluded patients younger than 13 years, kidney transplant patients, and those not fulfilling the consensus definition of acute kidney injury according to the Kidney Disease: Improving Global Outcomes (KDIGO) group. Data on patient demographics, medical history, clinical observations, investigations, and cause of acute kidney injury was collected from a clerking sheet designed for the study. Patients were followed up at, or after 3 months (90 days) for assessment of survival and renal recovery. The main outcomes were recovery of renal function and mortality at 3 months. Data was entered into an Excel spreadsheet, and imported onto Stata 12.1 for analysis. Results: A total of 366 patients were included. The median age was 44 years (IQR 14-82). Of these 214 were male (58.5%). Referrals were from medical, surgical and obstetrics and gynaecology departments. The majority, 217 (59.3%) were medical referrals. Most, 265 (72.4%) had community acquired acute kidney injury. The majority of the 101 patients with hospital acquired acute kidney injury, 72 (71.3%) had severe, stage 3 acute kidney injury. Hypertension was the commonest co-morbidity, present in 152 (41.5%) of the patients. There were 75 (20.6%) HIV positive patients. Acute tubular necrosis was the most common cause of acute kidney injury, identified in 251 (68.6%) patients. Renal biopsies were carried out in 36 (9.8%) patients. More than half, 202 (55.2%), of the patients were in the intensive care unit, while 204 (55.7%) were dialysed. Fluid input was recorded in 140 patients (38.3%). Overall 3 month mortality was 38.8% (142 patients). Of the 224 surviving patients, 119 (53.1%) had a follow up serum creatinine. Of these, 95 (80.5%) had full renal recovery, and 4 (3.4%) went on to end stage renal disease. On multivariate analysis, mechanical ventilation was strongly associated with mortality at 3 months (OR 2.46, p-value 0.0 19, 95% CI 1.41-4.03). Sepsis had a borderline significant association with 3 month mortality (OR 1.83, P-value 0.066, 95%CI 1.02 – 3.27), as did prolonged time to dialysis (OR 1.93, p-value 0.080, 95% CI 0.93 – 4.03). HIV was not associated with mortality on univariate analysis (OR 1.07, p-value 0.801, 95%CI 0.64-1.80). Conclusions: Acute kidney injury carries a high mortality risk, most significant in mechanically ventilated patients. Sepsis and, in those dialysed, late dialysis, may be associated with a high risk of mortality. Efforts to reduce hospital acquired acute kidney injury and to improve patient fluid balance chart records should be made.
  • Thumbnail Image
    Item
    Open Access
    Bedside rationing and moral distress in nephrologists in sub- Saharan Africa
    (BioMed Central, 2022-05-25) Ashuntantang, Gloria; Miljeteig, Ingrid; Luyckx, Valerie A
    Background Kidney diseases constitute an important proportion of the non-communicable disease (NCD) burden in Sub-Saharan Africa (SSA), though prevention, diagnosis and treatment of kidney diseases are less prioritized in public health budgets than other high-burden NCDs. Dialysis is not considered cost-effective, and for those patients accessing the limited service available, high out-of-pocket expenses are common and few continue care over time. This study assessed challenges faced by nephrologists in SSA who manage patients needing dialysis. The specific focus was to investigate if and how physicians respond to bedside rationing situations. Methods A survey was conducted among a randomly selected group of nephrologists from SSA. The questionnaire was based on a previously validated survey instrument. A descriptive and narrative approach was used for analysis. Results Among 40 respondents, the majority saw patients weekly with acute kidney injury (AKI) or end-stage kidney failure (ESKF) in need of dialysis whom they could not dialyze. When dialysis was provided, clinical compromises were common, and 66% of nephrologists reported lack of basic diagnostics and medication and > 80% reported high out-of-pocket expenses for patients. Several patient-, disease- and institutional factors influenced who got access to dialysis. Patients’ financial constraints and poor chances of survival limited the likelihood of receiving dialysis (reported by 79 and 78% of nephrologists respectively), while a patient’s being the family bread-winner increased the likelihood (reported by 56%). Patient and institutional constraints resulted in most nephrologists (88%) frequently having to make difficult choices, sometimes having to choose between patients. Few reported existence of priority setting guidelines. Most nephrologists (74%) always, often or sometimes felt burdened by ethical dilemmas and worried about patients out of hospital hours. As a consequence, almost 46% of nephrologists reported frequently regretting their choice of profession and 26% had considered leaving the country. Conclusion Nephrologists in SSA face harsh priority setting at the bedside without available guidance. The moral distress is high. While publicly funded dialysis treatment might not be prioritized in essential health care packages on the path to universal health coverage, the suffering of the patients, families and the providers must be acknowledged and addressed to increase fairness in these decisions.
  • Thumbnail Image
    Item
    Open Access
    Characteristics and allocation outcomes of patients assessed for the renal replacement therapy at Groote Schuur Hospital (2008-2012)
    (2014) Kilonzo, Kajiru; Rayner, Brian L
    End Stage Kidney Disease (ESKD) is a global public health problem with an enormous economic burden. In resource limited settings like South Africa management of End Stage Kidney Diseases is rationed to the most transplantable candidates. Racial and socio-economic inequalities in selecting candidates have been documented in a South Africa despite the availability of guidelines. No data is available on selection outcomes using the current 2010 prioritization guidelines of Western Cape. We audited the outcome of patients assessed for the renal replacement therapy at Groote Schuur hospital. A retrospective analytic study of patients presented to the renal replacement therapy committee was conducted in the renal unit of Groote Schuur Hospital. Outcome letters, proceedings from the committee meetings and the hospital database were sources of data used. All new patients presented between 2008 and 2012 were included in the study. Data entry and statistical analysis was done using SPSS v.22. A total of 734 ESKD patients were assessed for renal replacement therapy between January, 2008 and December, 2012. During that period, there were 564 new patients, of which more than half (53.9%) were not selected for the program. Following the introduction of the new prioritization criteria a trend towards increasing number of patients presented and accepted was noted. More males were presented (M: F = 1.3) and most patients were below the age of 50yrs (n=478, 84.8%). Half of the patients came from low socioeconomic areas. There were no significant differences in socio-demographic factors before and after introduction of the new guidelines. Clinically they had advanced disease with either uremic (n=181, 44.4%) or fluid overload (n=179, 43.9%) symptoms as their major presentation. The underlying causes were Hypertension (40.6%), Diabetes (14.4%) and chronic Glomerulonephritis (15.8%). Predictors of rejection from the program included age above 50 years, unemployment and a poor psychosocial assessment. Substance abuse and Diabetes also showed a statistical significant association with the likelihood of being rejected. Race and marital status were not predictors. Efforts to allocate more resources should continue in view of the loss of young and potential productive life. Advanced presentation of patients with ESRD represents challenges in early diagnosis and referral in the current system. Community screening programs and improved access to knowledgeable clinicians at the primary level is advocated. The use of new selection guidelines have not led to an increase in selection inequalities.
  • Thumbnail Image
    Item
    Open Access
    Chronic kidney disease in HIV populations: prevalence, risk factors and role of transforming growth factor beta (TGF-߀1) polymorphisms
    (2019) Ekrikpo, Udeme Ekpenyong; Okpechi, Ikechi; Kengne, Andre Pascal; Bello, Aminu; Dandara, Collet; Wonkam, Ambroise
    Background and purpose: With the advent of antiretroviral therapy, HIV-infected individuals now live longer and are at increased risk of chronic kidney disease (CKD). Also, recent studies indicate a genetic predisposition to CKD in the African HIV population. This work investigated the prevalence of CKD (and its correlates) in the global and local HIV population and proceeded to investigate the diagnostic utility of urinary transforming growth factor-beta-1 (TGF-β1) for CKD in the HIV population and determine the association between polymorphisms of TGF-β1 gene and prevalent CKD. Methods: A meta-analysis was performed to document the prevalence of CKD in the global HIV population. From the local HIV population in Nigeria, the prevalence of CKD and traditional risk factors for cardiovascular disease was determined. Using ELISA, TGF-β1 levels was assayed in the urine samples of HIV patients with or without CKD to investigate the ability of urinary TGF-β1 to diagnose early CKD. SNP genotyping of rs1800469, rs1800470, rs1800471, rs121918282 in TGF-β1, rs60910145 (APOL1), rs73885319 (APOL1), rs71785313 (APOL1) and rs743811 (HMOX1) was performed using predesigned TaqMan genotyping assays. Results: Using meta-analytic methods, the global pooled CKD prevalence was 6.4% (95%CI 5.2–7.7%) with MDRD, and 4.8% (2.9–7.1%) with CKD-EPI. Among the WHO regions, Africa had the highest MDRD-based prevalence, 7.9% (5.2-11.1%) with the West African subregion carrying the heaviest burden, 14.6% (9.9- 20.0%). Among the local HIV population, using the CKD-EPI equation, the prevalence of CKD was 13.4% (11.6- 15.4%). Hypertension prevalence was 26.7% (25.5-28.0%); diabetes 5.6% (4.5-6.7%); obesity 8.3% (7.6-9.1%) and dyslipidaemia 29.1% (26.1-32.1%). HIV-infected individuals with CKD had significantly higher levels of urinary TGF-β1-creatinine ratio (uTGFβ1Cr) after controlling for potential confounding factors in regression models. However, within the CKD-HIV group, uTGFβ1Cr reduced as CKD stage worsened. The presence of APOL1 genetic risk independently increased the risk of CKD (OR 2.54, 95% CI 1.44-4.51) in the HIV population while the TGF-β1 SNP, rs1800470, appeared to have a protective effect (OR 0.44 (95% CI 0.20-0.97). There was no significant association between HMOX1 SNPs and CKD occurrence. Conclusion: There is a high prevalence of CKD (and other cardiovascular risk factors) in the adult HIVpopulation. Urinary TGF-β1 may be useful in the non-invasive detection of early CKD in the HIV population. Genetic testing may be used to predict the risk of CKD in the HIV population.
  • Thumbnail Image
    Item
    Open Access
    Clinico-pathological characteristics and outcomes of nephrology adolescents and young adults in Cape Town: a single centre study
    (2022) Barday, Zibya; Davidson, Bianca; Wearne, Nicola; Jones, Erika; McCulloch, Mignon
    Background Adolescents and young adults [AYA] are important users of the nephrology health care services. Worldwide, there is a paucity of data on AYA kidney disease and outcomes. This study evaluates kidney outcomes, survival and challenges faced by AYA in a South African setting. Methods This 5-year retrospective study included AYA [aged 10-24] with chronic kidney disease, at a tertiary nephrology service in South Africa. Descriptive analysis characterised the aetiology of kidney disease. A comparative analysis of baseline characteristics, outcomes and social challenges were performed between patients attending a dedicated AYA clinic and those attending the standard adult clinics [non-AYA clinics]. Primary composite outcome assessed included doubling of creatinine, reduction of eGFR >40%, end-stage kidney disease and death. Logistic regression evaluated associations between relevant variables, death and lost to follow up [LTFU]. Results The total AYA cohort consisted of 292 patients, 111 (38.0%) attended the AYA clinic and 181 (62.0%) the non-AYA clinics. The main aetiologies of disease were glomerular 212 (72.6%), congenital anomalies of the urinary tract 31 (10.6%), and hereditary conditions 24 (8.2%). There was a significantly lower mortality (p=0.007) and reduction in LTFU (p=0.012) in the cohort attending the AYA clinic. A statistically significant composite outcome (p=0.018), with improved kidney survival was found in the AYA clinic group. High proportions of nonadherence (33.9%) and substance use (25.0%) was demonstrated in both cohorts. Conclusion This study adds to the dearth of literature on AYA kidney disease. A dedicated nephrology AYA clinic is shown to have lower mortality, less LTFU and improved kidney outcomes, which is essential in a resource-limited setting where access to kidney replacement therapy is restricted.
  • Thumbnail Image
    Item
    Open Access
    Complications of percutaneous native kidney biopsies in adults in low and middle-income countries: A Systematic review and meta-analysis
    (2021) Kajawo, Shepherd; Okpechi, Ikechi G
    Introduction: Kidney biopsy supports diagnoses, choice of treatment and prognostication in management of kidney diseases. Complications associated with this procedure varies among countries depending on several clinical and technical factors. This Systematic review and meta-analysis aims to report on these complications in low and middle-income countries (LMIC) and compare the burden of complications across different regions. Methods: Two independent reviewers searched studies from 1st January 1980 to 31st December 2017 in PubMed, Cochrane Reviews and African Journals Online. The study-specific estimates were pooled through a random-effects model meta-analysis to obtain an overall summary estimate of major complications across studies. Statistical heterogeneity was evaluated by the Cochrane's Q statistic. Results: 35 studies reporting on 18,456 kidney biopsies met the inclusion criteria. The overall rate of kidney biopsy complications was 14.0% (95% CI 10.0-18.0%).Major complications occurred in 1.3% (95% CI 0.8 – 2.4%) whilst minor complications were 10.9% (95% CI 0.07.4-14.9%). LMIC in Europe and Central Asia had the highest complications 21.4% (95% CI 19.1 – 23.8%) while East Asia and the Pacific had the least rates 7.9% (95% CI 1.8 – 17.7%); p< 0.001. Blind procedures had the highest overall complications, 21.2% (95% CI 17.6 – 25.0%), followed by pre-marking using ultrasound [13.9% (95% CI 7.8-21.3%) and least complications with real-time ultrasound (p=0.003). Death occurring post kidney biopsy was reported in 2 patients. Conclusion: Major complications associated with kidney biopsies in LMIC were low. However, minor complications still occur in significant proportions. Ultrasound-guided kidney biopsies and appropriate training will mitigate some of these risks.
  • Thumbnail Image
    Item
    Open Access
    Epidemiology and clinical outcomes of patients with idiopathic membranous glomerulonephritis at Groote Schuur Hospital over a ten year period
    (2015) Ameh, Oluwatoyin Idaomeh; Okpechi, Ikechi G
    BACKGROUND: Glomerulonephritis is a common cause of end-stage renal disease (ESRD) in developing countries. Idiopathic membranous nephropathy (IMGN) is an identified cause of nephrotic syndrome in South Africa. Early attainment of complete remission (CR) or partial remission (PR) in patients with IMGN has been shown to slow progression to ESRD. There is a dearth of outcome studies in Africa on IMGN. METHODS: This study was approved by the institution's Human Research Ethics Committee. It was a retrospective review of patients diagnosed (biopsy-proven) with IMGN at the Division of Nephrology and Hypertension, Groote Schuur Hospital, Cape Town, over a 10-year period. Secondary causes of MN were excluded in this study. Demographic, clinical, biochemical and histological records of such patients were retrieved for analysis. The trends in clinical and biochemical parameters over the course of follow-up from baseline were also determined. The primary outcome of interest was the attainment of a CR or PR at the last date of follow-up. Predictors of the composite of CR and PR at the last follow-up visit were assessed using univariate and multivariate Cox-Regression analysis. The trend in estimated glomerular filtration rate over the median duration of follow-up was evaluated as a secondary outcome. RESULTS: There were 56 patients with histologic and clinical parameters compatible with the diagnosis of IMGN. There were 26/56 females (46.4%) with an overall mean age of 41.5±14.6 years. Forty-three (43) patients had subsequent follow-up care at our centre with a median duration of follow-up of 23.0 (13.0, 48.0) months. Sixteen patients (37.2%) were treated with immunosuppression (ISP)-combination of steroids and cyclophosphamide, and 81.4% received renin-angiotensin system (RAS) blockade. There were no statistically significant differences in demographic and clinical features of patients treated with or without ISP. Trends in level of proteinuria, estimated GFR and serum albumin concentrations were also not significantly different between the two groups. Eighteen patients (41.9%) reached CR or PR at the last visit. There were also no statistically significant differences in demographic, clinical, histological, and biochemical characteristics of patients who had or had not achieved remission. The median time-to-remission of patients treated with or without ISP was similar - 48.6 and 48.7 months respectively (p=0.13) while the proportions of patients not reaching CR/PR at 1 year and 2 years were 94.6% and 80.8% respectively by Kaplan-Meier analysis. Gender, race and u se of immunosuppression did not influence remission status (log rank p>0.05). On regression analysis, the predictors of CR/PR at last follow up visit were GFR [OR 1.01 (95%CI: 1.00 - 1.02); p=0.041] and systolic BP (OR 0.97 [95%CI: 0.95 – 0.99); p=0.036]. CONCLUSION: Remission outcomes with the current immunosuppressive treatment protocol for I M G N are delayed and poor. There is a need for its re-evaluation and also for longitudinal, multicenter studies to assess the best treatment approach (-es) to IMGN in South Africa.
  • Thumbnail Image
    Item
    Open Access
    Patient outcomes in a PD First Program in Cape Town, South Africa
    (2017) Davidson, Bianca; Wearne, Nicola
    Background: South Africa [SA] currently performs the most peritoneal dialysis [PD] in Africa. Yet, outcome data is limited. With the collision of epidemics of communicable and non-communicable diseases in Africa the need for chronic dialysis is escalating. PD remains a life-saving modality especially as haemodialysis is limited in the state sector. Methods: We retrospectively analysed all patients undergoing PD at Groote Schuur Hospital from January 2008 until June 2014 and thereafter prospectively until June 2015. Variables included demographics, adequacy, modality, fluid, cardiovascular risk and diabetes. The influences of these variables on peritonitis rate, technique and patient survival were assessed. Results: 230 patients were initiated on PD, 31 were excluded as they were on PD for < 90 days. The mean age was 39.7 +/- 10.4 years [SD], 49.8% were male and 63.8% were mixed ancestry. 9.8 % were diabetic at dialysis initiation. The average length of time on PD was 17 months (IQR 8 - 32). The peritonitis rate was 0.87 events per patient years. One, 2 and 5 year patient and technique survival was 94.4%, 84.3% and 60.2% and 82.5%, 69.0% and 37.4% respectively. Fluid overload (p=0.019) and low haemoglobin (p=0.001) were independent risk factors for poor survival. African race (HR 1.97, 95% CI (1.16 - 3.37) and fluid overload (p= 0.002) were both predictors of technique failure. Conclusions: In our PD-First programme the results are encouraging, despite lack of home visits due to safety, resource limitations and a high disease burden. Technique failure in African race needs further evaluation. Peritoneal dialysis remains a viable, life-saving alternative in an African setting.
  • Thumbnail Image
    Item
    Open Access
    Technology in nephrology
    (Health and Medical Publishing Group, 2003) Pascoe, M D; Halkett, J
    Early nephrological referral allows for uncomplicated transition to dialysis and improves long-term survival. Peripheral veins require careful preservation for future vascular access in patients with renal disease. Improved biocompatibility of modern polysulphone and other membranes reduces the inflammatory response to dialysis. The increased permeability of these modern membranes improves the clearance of solutes but does require volumetrically controlled machines. Volumetric dialysis equipment allows the patient’s fluid balance to be very precisely controlled. Continuous dialysis therapies for acute renal failure allow for dialysis for acutely ill patients who would not tolerate standard intermittent haemodialysis. Continuous dialysis for acute renal failure allows for intensive nutritional support and improved and more stable metabolic and volume control than standard dialysis. Continuous dialysis is the treatment of choice for patients with raised intracranial pressure. Bicarbonate-buffered dialysis fluid provides better acid-base control than standard acetate dialysis. Advances in technology are expensive and cost control is of increasing importance.
  • Thumbnail Image
    Item
    Open Access
    Using urinary MCP-1 and TWEAK to assess disease activity in a cohort of South African patients with lupus nephritis
    (2020) Rusch, Jody Alan; Okpechi, Ikechi Gareth; Omar, Fierdoz
    Background: Renal involvement is common in systemic lupus erythematosus (SLE) and can lead to chronic kidney disease (CKD). Diagnosis of lupus nephritis (LN) is dependent on renal biopsy. Due to its invasiveness, repeat renal biopsy for monitoring disease activity is not recommended, thus creating a need for noninvasive and accurate biomarkers. Monocyte chemoattractant protein-1 (MCP-1) and tumour necrosis factor-like weak inducer of apoptosis (TWEAK) have been implicated in the pathogenesis of LN and are thus potential biomarkers for disease activity monitoring. Methods: In this study urinary MCP-1 (uMCP-1) and TWEAK (uTWEAK), together with standard markers of disease activity, were analysed in a cohort of 50 biopsy-proven LN patients at baseline, after sixmonths of induction therapy, and at one-year. Results: Throughout the study there was correlation between uMCP-1 and uTWEAK (r=0.52, p< 0.001). Both biomarkers also correlated with standard of care tests and clinical scores. The median [interquartile range] of uMCP-1 and uTWEAK were significantly increased in the active group when compared to the quiescent group (1440 [683–2729] vs 256 [175–477] pg/mL, p< 0.0001, and 209 [117–312] vs 74 [11– 173] pg/mL, p=0.0008, respectively). After completion of induction therapy in the active group, there was no significant difference in biomarker results between the groups. The sensitivity and specificity for indicating disease activity was 95% and 73% for uMCP-1 (area under curve [AUC]=0.875), and 60% and 90% for uTWEAK (AUC=0.783), respectively. Conclusion: uMCP-1 and uTWEAK reflect LN disease activity, and correlate with standard of care biomarkers in a South African cohort. Further studies are needed to assess additional clinical benefit.