Acute kidney injury among hospitalised patients who died due to COVID-19 in the Eastern Cape, South Africa

Background: Acute kidney injury (AKI) commonly occurs in coronavirus disease 2019 (COVID-19) patients who have been hospitalised and is associated with a poor prognosis. This study aimed to determine the incidence of AKI among COVID-19 patients who died in a regional hospital in South Africa. Methods: This retrospective record review was conducted at the Mthatha Regional Hospital in South Africa's Eastern Cape province. Data were collected between 10 July 2020 and 31 January 2021. Results: The incidence of AKI was 38% among the hospitalised patients who died due to COVID-19. Most study participants were female, with a mean age of 63.3 ± 16 years. The most common symptom of COVID-19 at the time of hospitalisation was shortness of breath, followed by fever and cough. Half of the patients had hypertension, while diabetes, human immunodeficiency viruses (HIV) and tuberculosis (TB) were other comorbidities. At admission, the average oxygen saturation was 75.5% ± 17. Conclusion: The study revealed a high incidence of AKI among hospitalised patients who died due to COVID-19. It also found that those received adequate crystalloid fluids at the time of admission had a lower incidence of AKI. Contribution: Acute kidney injury can be prevented by adequate fluid management during early stage of COVID-19. Majority of COVID-19 patients were referred from lower level of care and primary care providers have their first encounter with these patients. Adequate fluid resuscitation in primary care settings can improve the outcome of hospitalised COVID-19 patients.

Les facteurs associés aux morbi-mortalités maternelles de l'éclampsie à la maternité de Befelatanana / Factors associated with maternal eclampsia morbidity and mortality at the maternity hospital of Befelatanana

L'éclampsie est une complication neurologique majeure de la pré-éclampsie sévère, responsable d'une lourde morbidité et mortalité maternelle. L'objectif de cette étude était de déterminer les facteurs associés aux morbimortalités maternelles de l'éclampsie. Patients et Méthodes : Il s'agissait d'une étude rétrospective, transversale, descriptive et analytique ; sur une période de 36 mois, allant de Janvier 2019 à Décembre 2021, réalisée à la maternité de Befelatanana. Les paramètres cliniques et obstétricales, la prise en charge, les complications et l'évolution maternelle ont été les paramètres étudiés. Résultats : Sur 21 514 accouchements, 461 cas (2,14%) d'éclampsie ont été recensé dont 288 cas inclus dans l'étude. L'âge moyen était de 23,29±6 ans ; l'âge gestationnel était > 37 semaine d'aménorrhée dans 60,10% (n= 173) des cas et la grossesse étaient mal suivies dans 49,70% (n=143) des cas. Les complications maternelles dominées par : la détresse respiratoire aigüe sur pneumopathie d'inhalation; le coma prolongé ; une hémorragie intracérébrale et l'association à d'autres complications tel que : un HELLP syndrome, un hématome rétroplacentaire et une insuffisance rénale oligo-anurique aigue. Les facteurs associés aux décès étaient : l'existence de trouble de la conscience postcritique (p=0,026 ; OR=3,2 [1,09-9,37]), l'existence de coma prolongé ≥24h (p=10-8 ; OR=34 [11,47-100,71]), l'existence d'une insuffisance rénale aigue (p=10-4 ; OR=4,42 [2,08-9,4]) et l'association à un HELLP syndrome (p=10-8 ; OR=29,16 [12,08-70,41]). Conclusion : La morbi-mortalité de l'éclampsie reste encore très élevé à Madagascar ; une éducation de la population Malagasy doit être renforcer sur le suivi médical rapproché de la grossesse

An Evaluation of Risk Factors Associated with Pregnancy Related Acute Kidney Injury in Women Admitted to the High Dependency Care Unit at Women and Newborn Hospital, Lusaka-Zambia

Objective:To evaluate factors associated with Pregnancy-related KidneyInjury(PRAKI) inwomen admitted to high dependency care unit at Women and Newborn Hospital in Lusaka, ZambiaMethodology:This was an unmatched case-control study conducted in the high-dependency care unit at Women and Newborn Hospital in Lusaka. Study participantswererecruitedconsecutivelybyconveniencesampling.Participants'medicalrecords were reviewed to capture serum creatinine levels;whileastructuredquestionnairewasadministeredto eligible andconsentedstudy participants to capture data on sociodemographic, obstetric, and medical factors. Serum creatinine levels above 84µmol/l were used as criteria for classifying PRAKI. Excel was used for data cleaningandStatav13usedforanalysis.Descriptive statistics were done for all variables followed by univariate and multivariable logistic regression to determine association. 95% CI was usedand p value of<0.05 was consideredsignificant.Results:Thestudy comprised of185 study participants, split into 85 women with PRAKI (cases) and 100 women without PRAKI (controls). The median age was 29 years with 11years interquartile range. 75.3%of the study participants wereinmarriagerelationships.Pre-existinghypertension was the most prevalent medical condition in both the cases (51.8%) and the controls (38%). Sickle celldisease was much less common at 1.2% in cases and 8% in controls. Among the obstetric conditions, preeclampsia was the most common condition at 77.6% and 60% in cases and controls respectively. Eclampsia was found in 38.8% of cases and 11% of controls. Sepsis was least common at 4.7% of cases. This study found that obstetricfactorssuch as eclampsia (AOR = 5.12, 95% CI [2.14 ­ 12.23]; p≤0.0001), preeclampsia (AOR = 2.46, 95% CI [1.12 ­ 5.39]; p = 0.025), and postpartum haemorrhage were associated with the development of PRAKI. Medical conditions were not associated with PRAKI.

Risk factors and outcomes of sepsis-associated acute kidney injury in intensive care units in Johannesburg, South Africa

Background. Sepsis-associated acute kidney injury (SA-AKI) has been shown to be a significant contributor to morbidity and mortality in both children and adults with critical illness. In sub-Saharan Africa, there is a lack of information on factors associated with development of SA-AKI and outcomes after intensive care unit (ICU) admission. Objectives. To assess the rate of SA-AKI, factors associated with its development, and predictors of mortality at 90 days in critically ill patients admitted to the ICU with sepsis. Methods. This was a prospective observational study conducted at two of the biggest teaching hospitals in Johannesburg, South Africa, from 15 February 2016 to 15 February 2020. The study included consecutive patients with confirmed sepsis who were admitted to the ICU within 24 hours of admission to hospital. The primary outcome of the study was development of SA-AKI (defined according to Kidney Disease Improving Global Outcome (KDIGO) criteria), and secondary outcomes were risk factors for SA-AKI and predictors of mortality at 90 days. Multivariate logistic regression analysis was employed to determine the factors associated with SA-AKI and 90-day mortality. Results. In total, 327 critically ill patients with sepsis admitted to the ICUs were included in the study. The median (interquartile range) age was 39 (30 - 52) years, and 185 patients (56.6%) developed SA-AKI. Of these patients, blacks and whites comprised 91.0% and 6.1%, respectively, and the prevalent comorbidities were HIV/AIDS (19.3%), hypertension (14.2%) and diabetes mellitus (10.1%). Patients with SA-AKI were likely to be older and of male gender, and to have cardiovascular disease, malignancies, hypotension and a low serum albumin level. In multivariate analysis, the predictors of SA-AKI were age ≥55 years (odds ratio (OR) 2.43; 95% confidence interval (CI) 1.27 - 4.65), inotropic support (OR 3.61; 95% CI 2.18 - 5.96) and a low serum albumin level (OR 2.93; 95% CI 1.40 - 6.13). SA-AKI and need for inotropic support were respectively associated with 1.9-fold and 1.7-fold increased mortality at 90 days after ICU admission. Conclusion. SA-AKI was found to be frequent in this study in two tertiary hospital ICUs in Johannesburg, and the need for inotropic support predicted mortality after ICU admission.

Early detection of acute renal lesions by serum cystatin C in children at hospital and university Centre of Brazzaville

Acute Kidney Injury (AKI) is considered one of the main public health problems. The effective management of these alterations is based on the early detection of renal lesions. The objective of this study was to evaluate the contribution of the Cystatin C (CysC) assay in the early diagnosis of acute kidney injury (AKI) in children hospitalized in pediatric intensive care units in Brazzaville. MATERIALS AND METHODS Sixty children at high risk of developing AKI were included. Consent form signed was obtained from parents, socio-demographic data, weight and height of children recorded. Creatinine (Cr), CysC and urea were assayed in serum 24 hours after admission. Glomerular filtration clearance was estimated using serum creatinine and CysC. Glomerular filtration rate (GFR) was calculated from CysC and Cr. The diagnostic accuracy was determined by comparing the results of CysC to those of Cr (considered as a reference biomarker). RESULTS The median age was 5 years (with extremes ranging from 1 month to 17 years). Cr, CysC, urea, and GFR/Cr (mean ± standard deviation [range]) were 0.94±1.17 (0.2­ 1.4 mg/dl), 0.14 ± 0.062 (0.053-0.095 mg/l), 46.65±47.75 (15.0­45.0 mg/dl), 81.85±31.90 (≥190 ml/min per 1.73 m2 , respectively. The level of CysC in patients with ARL was significantly higher than that of children with normal renal function (p<0.001). Our results show that the performance of serum CysC in detecting AKI early was superior to that of serum Cr in children hospitalized in pediatric intensive care units in Brazzaville

Prevalence and associated factors for kidney dysfunction in hospitalized patients with COVID-19 pneumonia in Zambia

Abstract Background: A significant link has been reported between COVID-19 pneumonia, disease severity and development of kidney dysfunction. This study assessed the prevalence and correlated factors for kidney impairment in hospitalized patients with COVID-19 infection Methods: This nested retrospective study examined medical files of patients with confirmed COVID-19 pneumonia. The outcome variable was kidney dysfunction ( defined as functional renal indexes beyond the normal range) and associated factors. Multivariate logistic regression was employed to establish factors associated with renal dysfunction. Results: 179 patients were included in this nested study and the mean age was 58.3 years (SD 16.5) and 49.0% were female. The prevalence of renal dysfunction was 51.9% and 39.3% these patients renal had eGFR<60 mL/min/1.73m2 The proportion of kidney impairment was higher in males than females (59.3% vs.44.3 %), patients with underlying hypertension than normotensive (60.5% vs. 39.5 %) and those with chronic kidney disease (CKD) than those without (90% vs. 10%). After adjusting for age, male gender, critical COVID-19 disease, and raised white cell count, hypertension was an independent predictor of kidney impairment with a AOR 1.54 (95% CI [1.06-2.23],p=0.022). Presence of HIV or diabetes mellitus showed a non statistical significance with renal dysfunction. Conclusion: The study demonstrated a high prevalence of kidney dysfunction in hospitalized patients with COVID-19 pneumonia and presence of hypertension predicted nearly 2-fold development renal impairment.

Insuffisance rénale aïgue à COVID-19: à propos de 02 cas au Mali / Acute renal failure due to covid-19: about the two cases in Mali

Le rein est une des cibles de Covid-19.L'atteinte peut se présenter sous forme d'une insuffisance rénale aigue (5-35% des patients), d'une hématurie (30-40%) et/ou d'une protéinurie (40-65%). Nous rapportons deux cas d'insuffisance rénale aigue due au Covid-19 au Mali. Il s'agit d'une femme de 63 ans et d'un homme de 60 ans, de race noire et tous deux diabétiques. Les circonstances de découverte de l'insuffisance rénale ont été l'oligurie dans les deux cas et l'hématurie macroscopique totale dans le deuxième cas. Conclusion : Les atteintes rénales deviennent de plus de plus fréquentes au cours de l'infection à Covid-19. Nous suggérons de les rechercher systématiquement dès que le diagnostic de cette infection est posé.

Early prediction of acute kidney injury in patients with acute on chronic liver failure by measuring kidney injury Molecule-1 level in Urine at Zagazig University Hospitals

Background and study aim: Some of patients with decompensated cirrhosis will exhibit newly developed acute liver failure. This condition is called acute-on-chronic liver failure (ACLF). Acute kidney injury (AKI) is common with ACLF. Kidney injury Molecule-1 (KIM-1) is an ideal biomarker of AKI. The aim of this study was to evaluate role of KIM-1 in prediction of AKI in ACLF patients. Patients and Methods: Eighty four patients were included in this study. They were selected from hospitalized patients with acute decompensated cirrhosis. They were allocated into two groups; group I: patients with no acute-on-chronic liver failure (ACLF), group II: patients with ACLF. Results: KIM-1 was significantly higher in the ACLF (group II). KLM-1 median was 2.4 in group I vs 7.35 in group II with p value <0.001. We found that at cut off value of ≥0.5 KLM-1 can predict the presence of AKI with sensitivity of 85.7%, specificity 88.1%, positive predictive value 87.8%, negative predictive value 86%, accuracy 86.9% and AUC= 0.867 p <0.001. Conclusion: KLM-1 rises significantly in patients with ACLF. KLM-1 can be reliable in prediction of the presence of acute kidney injury in decompensated cirrhosis

Prevalence of hyperhomocysteinemia and hypovitaminosis B12 among acute ischemic stroke patients

Background: Deficiency of Vitamin B12 can lead to hyperhomocysteinemia. Hyperhomocysteinemia constitutes an abnormally high level of homocysteine in the serum, above the upper limit of normal for an environment. The two conditions are significant risk factors for the development of stroke. There is a paucity of data on the prevalence of these biochemical risk factors in stroke patients in our environment which brought about this study. Objective: The objective of the study was to determine how prevalent hyperhomocysteinemia and hypovitaminosis B12 are in acute ischemic stroke patients in Zaria. Materials and Mthods: This is a cross­sectional prospective study conducted from February 2014 to March 2015 in ABUTH Zaria. One hundred patients with clinical diagnosis of first­ever ischemic stroke confirmed by brain computed tomography scan, and another apparently healthy age­ and sex­matched one hundred controls were recruited. Their fasting serum homocysteine and Vitamin B12 were determined using the enzyme­linked immunosorbent assay technique. Prevalence of high homocysteine and low Vitamin B12 was determined.Results: Thirty­four percent (34%) of patients had high and 66% patients had normal serum homocysteine, whereas 81% of patients had low and 19% of patients had normal serum Vitamin B12, and the difference was found to be statistically significant (P < 0.05).There was significant negative correlation between serum homocysteine and Vitamin B12 among cases with P = 0.04 and r = −0.198.Conclusion: The Prevalence rates of hyperhomocysteinemia and hypovitaminosis B12 among ischemic stroke pateints were 34% and 81%, respectively

Factors associated with acute kidney injury recovery in a tertiary hospital in Ghana: a prospective study

Introduction: acute kidney injury (AKI) is a challenging problem in developing countries due to late presentation of its victims to health care facilities. Data on the pattern of AKI, its outcome and factors associated with its recovery is scanty in developing countries therefore impeding AKI management. Aim: to study AKI recovery rate and its associated factors.Methods: an observational study conducted from September 2013 to June 2014 at Korle-Bu Teaching Hospital (KBTH). Participants were adults, admitted with AKI at KBTH. Kidney Disease: Improving Global Outcomes (KDIGO) criteria was used to diagnose and stage AKI.Results: mean age (SD) of the participants was 41.9 (± 19.2) years. About a third of the patients (34.6%) were less than 29 years with 30-39 years and 40-60 years constituting 23.0% and 23.6% respectively. Females were in the majority (56.0%). AKI stages I, II and III accounted for 11.0%, 6.8% and 70.7% respectively. Majority, 82.2% of the patients recovered their kidney function. Stage III AKI was significantly associated with decreasing odds of recovery [OR = 0.4, 95%CI = 0.4-2.6, p = 0.002]. In addition, normal blood sodium was associated with recovery from AKI [OR, 95%CI = 2.3, (1.1-5.3), p = 0.043]. Almost half (45.5%) presented with fever whereas 32.5% and 22.5% presented with peripheral oedema and pulmonary oedema respectively.Conclusion: the study demonstrated high kidney function recovery following AKI. Dominant clinical features were fever, peripheral and pulmonary oedema. Advanced stage was associated with poor recovery whereas normal serum sodium level improves kidney function recovery

Atteintes renales chez l'adulte drepanocytaire ivoirien

Introduction. L'atteinte renale est precoce et frequente chez le drepanocytaire. Elle a ete peu decrite chez les drepanocytaires africains. L'objectif de notre etude etait de decrire les aspects epidemiologique; clinique; therapeutique et evolutif des manifestations renales observees chez les adultes drepanocytaires ivoiriens. Population et methodes. Etude retrospective descriptive monocentrique incluant tout patient drepanocytaire ayant une nephropathie tubulaire; interstitielle; glomerulaire ou vasculaire. Resultats. Vingt un cas ont ete colliges. Il s'agissait de 13 hommes et 8 femmes ages en moyenne de 26;42 ans; 17 patients etaient porteurs de l'hemoglobine SS. L'atteinte renale etait tubulaire dans 6 cas; interstitielle dans 3 cas et glomerulaire dans 9 cas. 3 patients avaient une hypertension arterielle. On notait 15 cas d'insuffisance renale aigue et 6 cas d'insuffisance renale chronique. Le traitement a comporte la transfusion de concentres erythrocytaires chez 17 patients; l'utilisation d'inhibiteur de l'enzyme de conversion chez 12 malades et l'epuration extra renale etait indiquee dans 11 cas. 7 patients ont pu beneficier du traitement de suppleance. L'evolution a ete marquee par la guerison de 6 patients; 3 malades sont sortis et perdus de vue et 5 malades etaient vus en consultation de nephrologie. 7 patients sont decedes. Conclusion : L'atteinte renale est dominee par des manifestations glomerulaires compliquees d'une insuffisance renale chronique. Nous recommandons la recherche systematique d'une proteinurie a la bandelette urinaire et l'evaluation de la fonction renale dans le suivi du patient drepanocytaire et au cours des crises vaso-occlusives

Insuffisance renale aigue compliquant un paludisme grave a plasmodium falciparum: prise en charge dans un milieu peu equipe

Les auteurs rapportent un cas d'insuffisance renale aigue classe F selon le critere RIFLE compliquant un paludisme grave chez un enfant de 7 ans; de sexe masculin; pris en charge dans un milieu logistiquement pauvre. La goutte epaisse etait positive avec une Hyperparasitemie a plasmodium falciparum; l'uremie a 143 mg/dl et la creatininemie a 5;0mg/dl. Par manque de dialyse; l'association furosemide a forte dose et dopamine a dose dopaminergique avait permis de controler la surcharge hydrosodee en attendant la resolution de l'insuffisance renale

Causes and Outcome of Acute Kidney Injury: Gezira Experience

Introduction: A precise operational definition of acute kidney injury remains elusive. Conceptually; acute kidney injury is defined as the loss of renal function; measured by decline in acute kidney injury (AKI) are highly variable; in some patients; the only manifestation may be biochemical abnormalities on routine blood sampling; while other patients will present with overt uremic signs or symptoms. Objectives: We evaluated the aetiology and the clinical outcome of all patients admitted to Gezira Hospital for Renal diseases and Surgery with AKI. Methods: Clinical data of patients admitted from January 2008 through December 2009 were reviewed and analysed. Results: Total number of patients included in this study was 122. Out of them 39.3(48) were females. The mean age was 51.34 (SD 22.18) years. The most common causes of acute kidney injury are ischemic acute tubular necrosis; followed by sepsis and obstruction respectively. Mortality rate was 18.9. Conclusion: Mortality rate of AKI in our set up was 18.9

Atteintes rénales associées au gène de la drépanocytose dans le service de néphrologie et d'hémodialyse du CHU Point G

But : identifier les manifestations rénales associées au gène de la drépanocytose. Patients et méthodes : il s'agissait d'une étude transversale descriptive allant de juin 1995 à janvier 2004. Ont été inclus les patients drépanocytaires vus en consultation ou hospitalisés présentant une des manifestations rénales: hématurie, protéinurie, leucocyturie, uroculture positive, augmentation de l'urée et/ou de la créatinine sanguines. L'analyse et la saisie des données ont été effectuées sur SPSS 11.0. Le test statistique a été le Khi carré avec un seuil de signification p≤0,05. Résultats : les dossiers de 30 patients (18 H et 12 F) ont été colligés. L'âge moyen était de 31,4 ans (5 et 64 ans). Les motifs d'hospitalisation les plus rencontrés étaient le syndrome œdémateux (26,7%) et l'hématurie totale (20%). La majorité des patients étaient hétérozygote 93,33%. Les atteintes rénales rencontrées étaient : l'IRA 40%, l'hématurie macroscopique 20%, le syndrome néphrotique 20%, l'IRC 13,4%, l'infection urinaire 3,3% et l'hématurie microscopique 3,3%. Conclusion : le gène drépanocytaire au Mali est associé à une morbidité rénale. La fréquence élevée des porteurs du trait drépanocytaire doit être confirmée par d'autres études afin d'élaborer une stratégie de prise en charge de cette pathologie

Facteurs pronostiques de l'insuffisance renale aigue aux Cliniques Universitaires de Kinshasa

Cette etude a recherche les facteurs pronostiques de l'insuffisance renale aigue (IRA) en vue d'ameliorer la survie des patients. Methode : Ont ete collectees sur base d'une fiche ad hoc; les caracteristiques demographiques (age; sexe); cliniques (delai d'admission et au cours de l'hospitalisation; differents facteurs etiologiques; types de traitement applique) et biologiques (creatinemie; clairance de la creatinine; uree sanguine; ionogramme sanguin; hemogramme) des patients admis au Service de Nephrologie des Cliniques Universitaires de Kinshasa pour IRA; entre 1996et 2003. L'analyse multivariee a utilise le modele de regression logistique par la methode de trainage avant (pas a pas) pour identifier les facteurs pronostiques de cette affection. L'etude de la survie a recouru a la courbe de Kaplan Meier et a la regression de COX. Resultats : Trois cents vingt cas d'IRA ont ete enregistres (5des admissions en Medecine Interne); avec un sex-ration H/F de 2 et l'age moyen de 33 ans. Seuls 18des patients ont pu beneficier de la dialyse. Le taux de mortalite etait de 29;4. Les facteurs de mauvais pronostic ont ete : le coma (p0;01); l'anemie (p0;01); la kaliemie (p0;01); le sepsis (p0;05); le delai d'admission a l'hopital (p0;05) et l'age (p

Morbidité et mortalité hospitalières dans le service de nephrologie de l'Hôpital National Donka

Il s'agit d'une étude rétrospective de type descriptif sur une période de 4 ans, allant du 01Avril 1999 au 31 Mars 2003. L'objectif était de déterminer les facteurs liés à la morbidité et à la mortalité des affections rénales dans le service de Néphrologie du CHU de Conakry. L'étude a portésur 606 patients hospitalisés dont 21 dialysés. Les paramètres de l'étude étaient l'âge, le sexe, lafréquence des affections rénales, la mortalité, les pathologies associées, le délai de consultation, laprise en charge, le traitement reçu avant l'hospitalisation, la durée d'hospitalisation, les horaires de décès et certains facteurs de risque cardio-vasculaires (tabac, alcool). Les malades ayant réponduaux critères de sélection étaient 365 hommes (60,23%) et 241 femmes (39,77%) avec un sex-ratio de1,51. La moyenne d'âge était de 44 ± 17 ans avec des extrêmes de 15 et 95 ans ; 16,34% des patients étaient âgés de moins de 25 ans et 14,03% avaient plus de 65 ans. Selon la prise en charge, 462 (76,24%) étaient à la charge de leur entourage, seuls 144 (23,76%) pouvaient se prendre en charge pour les soins. Selon le traitement reçu avant l'hospitalisation, 357 avaient consommé des décoctions de feuilles et de racines, 86 avaient consulté un centre de santé. La durée moyenne d'hospitalisation a été de 13 ± 9 jours avec des extrêmes de 1 et 80 jours. Le tabagisme avait été observé chez 183 malades dont 181 hommes et l'alcoolisme chez 134 malades dont 122 hommes. Les affections rénales étaient l'insuffisance rénale chronique (51%), l'hypertension artérielle (30,36%), les glomérulonéphrites chroniques (8,09%), l'insuffisance rénale aiguë (7,59%), les infections urinaires (1,65%) les glomérulonéphrites aiguës (0,99%) et le cancer du rein (0,33%). Parmi eux, 130 décès avaient été observés soit 21,45%. Selon le délai écoulé avant la consultation, 24 décès étaient survenus 2 semaines après le premier symptôme et 106 après plus d'un mois.Suivant les horaires, 33 décès (25,38%) étaient survenus entre 8h et 16h et 63 décès (48,47%) entre 16h et 8h ; dans 34 cas, l'heure n'était pas précisée. La mortalité était due à l'insuffisance rénale chronique dans 97 cas, soit 74,61%, à l'hypertension artérielle dans 19 cas, soit 14,62% et aux autres affections dans 14 cas, soit 0,77%. Les infections, le diabète, l'hypertension artérielle et la drépanocytose étaient les facteurs de risque rénal. Les facteurs de morbidité et de mortalité étaient nombreux et variés à savoir : le retard à la consultation, le traitement traditionnel, le faiblerevenu des malades, l'absence de couverture sanitaire, le manque de prise en charge correct au cours des gardes, le manque d'équipement adéquat et l'absence d'éducation sanitaire populaire