Concordance between bio-impedance analysis and clinical score in fluid-status assessment of maintenance haemodialysis patients: A single centre experience.

BACKGROUND: The burden of chronic kidney disease (CKD) is rising rapidly globally. Fluid overload (FO), an independent predictor of mortality in CKD, should be accurately assessed to guide estimation of the volume of fluid to be removed during haemodialysis (HD). Clinical score (CS) and bio-impedance analysis (BIA) have been utilized in assessment of FO and BIA has demonstrated reproducibility and accuracy in determination of fluid status in patients on HD. There is need to determine the performance of locally-developed CSs in fluid status assessment when evaluated against BIA. AIM: To assess the hydration status of patients on maintenance HD using BIA and a CS, as well as to evaluate the performance of that CS against BIA in fluid status assessment. METHODS: This was a single-centre, hospital-based cross-sectional study which recruited adult patients with CKD who were on maintenance HD at Kenyatta National Hospital. The patients were aged 18 years and above and had been on maintenance HD for at least 3 mo. Those with pacemakers, metallic implants, or bilateral limbs amputations were excluded. Data on the patients' clinical history, physical examination, and chest radiograph findings were collected. BIA was performed on each of the study participants using the Quantum® II bio-impedance analyser manufactured by RJL Systems together with the BC 4® software. In evaluating the performance of the CS, BIA was considered as the gold standard test. A 2-by-2 table of the participants' fluid status at each of the CS values obtained compared to their paired BIA results was constructed (either ++, +-, -- or -+ for FO using the CS and BIA, respectively). The results from this 2-by-2 table were used to compute the sensitivity and specificity of the CS at the various reference points and subsequently plot a receiver operating characteristic (ROC) curve that was used to determine the best cut-off point. Those above and below the best CS cut-off point as determined by the ROC were classified as being positive and negative for FO, respectively. The proportions of participants diagnosed with FO by the CS and BIA, respectively, were computed and summarized in a 2-by-2 contingency table for comparison. McNemar's chi-squared test was used to assess any statistically significant difference in proportions of patients diagnosed as having FO by CS and BIA. Logistic regression analysis was conducted to assess whether the variables for the duration of dialysis, the number of missed dialysis sessions, advisement by health care professional on fluid or salt intake, actual fluid intake, the number of anti-hypertensives used, or body mass index were associated with a patient's odds of having FO as diagnosed by BIA. RESULTS: From 100 patients on maintenance HD screened for eligibility, 80 were recruited into this study. Seventy-one (88.75%) patients were fluid overloaded when evaluated using BIA with mean extracellular volume of 3.02 ± 1.79 L as opposed to the forty-seven (58.25%) patients who had FO when evaluated using the CS. The difference was significant, with a P value of < 0.0001 (95% confidence interval: 0.1758-0.4242). Using CS, values above 4 were indicative of FO while values less than or equal to 4 denoted the best cut-off for no FO. The sensitivity and specificity for the CS were 63% and 78% respectively. None of the factors evaluated for association with FO showed statistical significance on the multivariable logistic regression model. CONCLUSION: FO is very prevalent in patients on chronic HD at the Kenyatta National Hospital. CS detects FO less frequently when compared with BIA. The sensitivity and specificity for the CS were 63% and 78% respectively. None of the factors evaluated for association with FO showed statistical significance on the multivariable logistic regression model.

Chronic kidney disease, pregnancy and haemodialysis: Case reports from a single centre in Kenya and literature review.

Chronic kidney disease (CKD) and end stage kidney disease are prevalent even in women of reproductive age. These are known to reduce fertility and successful pregnancy. There are chances of conception even in advanced CKD, though laden with complications. We present two cases of women who conceived in advanced CKD and were on haemodialysis in a tertiary hospital in Kenya, and review of literature.

Hemodialysis vascular accesses in patients on chronic hemodialysis at the Kenyatta National Hospital in Kenya.

INTRODUCTION: The objective of our study was to document the level of preparedness for renal replacement therapy assessed by incident hemodialysis vascular access and the access at least 3 months after initiation of hemodialysis at Kenyatta National Hospital, Nairobi. METHODS: Between June and July 2018, we carried out a cross-sectional descriptive study on the preparedness for hemodialysis by patients who were on chronic hemodialysis in the Kenyatta National Hospital Renal Department. Sociodemographic, medical history, duration of follow-up, and state of preparedness parameters were obtained through interview and entered into the questionnaire. The data were entered in preprogrammed format in the Statistical Package for the Social Sciences (SPSS) version 20.0 for analyses. RESULTS: Eighty-two patients were enrolled. Males were 50% (41). The mean age was 45.39 ± 15.96 years but females were 5 years younger than their male counterparts. About 85.4% of the patients were drawn from the hypertension and diabetes clinics, and the mean, mode, and median of the duration of follow-up were 41, 0, and 0 months, respectively, in these clinics. Almost three in every four patients (74.4%) were initiated on hemodialysis as emergency (p value < 0.001). About 80% were initiated hemodialysis via acute catheters placed in the jugular and subclavian veins (p value < 0.001). At least 3 months later, 40% still had acute catheters on the same veins (p value < 0.001). Acute venous catheters in the femoral veins were in 9.2% at initiation and 6.6% of the patients at least 3 months later. Less than 2% of the patients had arteriovenous fistulae at initiation, which rose to 14.5% in 3 months. Tunneled catheters were placed in 11.8% initially and at least 3 months, were almost in 40% of the patients. CONCLUSION: In conclusion, our young hemodialysis population mainly drawn from hypertension and diabetes clinic requires more input in hemodialysis vascular access planning. Focused individualized follow-up and early referrals to nephrologists are required. Uptake of arteriovenous grafts for hemodialysis might reduce the prevalence of hemodialysis catheters. As it is, this population is threatened with iterative vascular accesses complications as well as real danger of exhaustion of their vascular capital. There is real danger of increase in mortality from access complications.

Changes in Blood Pressure Levels and Antihypertensive Medication Use before and after Renal Transplantation among Patients in Nairobi, Kenya: A Comparative Cross-Sectional Study.

Objectives. To determine the changes in blood pressure levels and antihypertensive medication use in the postrenal transplantation period compared to pretransplantation one. Methods. A comparative cross-sectional study was carried out on renal transplant recipients at the Kenyatta National Hospital, a national referral hospital in Kenya. Sociodemographic details, blood pressure levels, and antihypertensive medication use before and after renal transplantation were noted. Changes in mean blood pressure levels and mean number of antihypertensive medications after renal transplantation were determined using paired t-test. Results. 85 subjects were evaluated. Mean age was 42.4 (SD ± 12.2) years, with a male : female ratio of 1.9 : 1. Compared to the pretransplant period, significantly lower mean systolic and diastolic blood pressure levels after transplantation were noted (mean SBP 144.5 mmHg versus 131.8 mmHg; mean DBP 103.6 mmHg versus 83.5 mmHg in the pre- and posttransplant periods, respectively, p < 0.001). Mean number of antihypertensive medications also reduced significantly after transplantation, with an average of 3.3 (±1.6) versus 2.1 (±0.9) in the pre- and posttransplant periods, respectively (p < 0.001). Conclusion. There is a significant reduction in blood pressure levels and number of antihypertensive medications used after renal transplantation. The positive impact of renal transplantation on blood pressure control should be confirmed using prospective cohort studies of patients with end stage renal disease who then undergo renal transplantation.

Factors Associated with Uncontrolled Hypertension among Renal Transplant Recipients Attending Nephrology Clinics in Nairobi, Kenya.

Objective. To determine the factors associated with poor blood pressure control among renal transplant recipients in a resource-limited setting. Methods. A cross-sectional study was carried out on renal transplant recipients at the Kenyatta National Hospital. Sociodemographic details, blood pressure, urine albumin : creatinine ratio, and adherence using the MMAS-8 questionnaire were noted. Independent factors associated with uncontrolled hypertension were determined using logistic regression analysis. Results. 85 subjects were evaluated. Mean age was 42.4 (SD ± 12.2) years, with a male : female ratio of 1.9 : 1. Fifty-five patients (64.7%) had uncontrolled hypertension (BP ≥ 130/80 mmHg). On univariate analysis, male sex (OR 3.7, 95% CI 1.4-9.5, p = 0.006), higher levels of proteinuria (p = 0.042), and nonadherence to antihypertensives (OR 18, 95% CI 5.2-65.7, p < 0.001) were associated with uncontrolled hypertension. On logistic regression analysis, male sex (adjusted OR 4.6, 95% CI 1.1-19.0, p = 0.034) and nonadherence (adjusted OR 33.8, 95% CI 8.6-73.0, p < 0.001) were independently associated with uncontrolled hypertension. Conclusion. Factors associated with poor blood pressure control in this cohort were male sex and nonadherence to antihypertensives. Emphasis on adherence to antihypertensive therapy must be pursued within this population.

Immunosuppression in renal transplantation: current status and application in developing countries.

Renal transplantation has become the most effective treatment for end stage renal failure. The numbers and survival rates of patients undergoing renal transplantation have increased immensely over the past decade. The use of immunosuppressive drugs has contributed greatly to the success of transplantation. Drugs such as azathioprine, corticosteroids, cyclosporin, FK 506, ATG/ALG and OKT3 are being used in several countries on a daily basis. New drugs and other modalities of immunosuppression are under investigation. This paper reviews these medications with respect to dosing, administration and adverse effects. Drugs being relatively expensive, the use of these drugs in developing counties is discussed.

Gromerular diseases in Kenya-another look at diseases characterised by nephrotic proteinura.

Renal biopsies were evaluated in 422 patients with nephrotic syndrome at the Kenyatta National Hospital between 1982 and 1993. Three hundred and fifty five (84.1%) of the patients were less than 30 years old (range: 7 months to 66 years; mean=SD: 28.4 - 9.2 years). The commonest histological lesions were mesangial proliferative glomerulonephritis (25.1%), minimal change nephropathy (17.5%) and focal segmental glomerulosclerosis (15.2%). Poststreptococcal aetiology was implicated in diffuse proliferative glomerulonephritis while use of skin lightening cosmetics appeared to play a role in the aetiology of minimal change nephrophathy in females. No aetiological role was apparent for hepatitis B virus, human immunodeficiency virus, malarial or schistosomal infection. All patients with minimal change nephropathy, focal segmental glomerulosclerosis and mesangial proliferative glomerulonephritis were treated with steroids and/or cytotoxics with a variable response.