Access to Nephrology Care for Pregnancy-Related Acute Kidney Injury in Low- and Lower-Middle-Income Countries: A Perspective.

Pregnancy-related acute kidney injury (AKI) is a major public health problem with substantial maternal and fetal morbidity and mortality. Women with pregnancy-related AKI require immediate access to nephrology care to prevent deleterious kidney and health outcomes. Patients with pregnancy-related AKI in low-income and lower-middle-income countries experience disparities in access to comprehensive nephrology care for many reasons. In this perspective, we highlight the burden of pregnancy-related AKI and explore the challenges among different low-income and lower-middle-income countries. The lack of adequate nephrology workforce and infrastructure for kidney health care represents a fundamental component of the problem. A shortage of nephrologists hampers the care of patients with pregnancy-related AKI leading to poor outcomes. The lack of diagnostic tools and therapeutic options, including kidney replacement therapy, impedes the implementation of effective management strategies. International efforts are warranted to empower women to get the right services and support at the right time. Dedicated preventive and early care programs are urgently needed to decrease the magnitude of pregnancy-related AKI, a complication under-represented in the literature.

SARS-CoV2 mutations and impact on mortality: observational study in a sub-saharan Africa hospital.

BACKGROUND: One year after the coronavirus disease 2019 (COVID-19) pandemic, the focus of attention has shifted to the emergence and spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variants of concern (VOCs). The aim of the study was to assess the frequency of VOCs in patients followed for COVID-19 at Kinshasa university hospital (KUH) during the 3rd and 4th waves of the pandemic in Kinshasa. Hospital mortality was compared to that of the first two waves. METHOD: The present study included all patients in whom the diagnosis of SARS-CoV-2 infection was confirmed by the polymerase chain reaction (PCR). The laboratory team sequenced a subset of all SARS-CoV-2 positive samples with high viral loads define as Ct < 25 to ensure the chances to generate complete genome sequence. RNA extraction was performed using the Viral RNA Mini Kit (Qiagen). Depending on the platform, we used the iVar bioinformatics or artic environments to generate consensus genomes from the raw sequencing output in FASTQ format. RESULTS: During the study period, the original strain of the virus was no longer circulating. The Delta VOC was predominant from June (92%) until November 2021 (3rd wave). The Omicron VOC, which appeared in December 2021, became largely predominant one month later (96%) corresponding the 4th wave. In-hospital mortality associated with COVID-19 fell during the 2nd wave (7% vs. 21% 1st wave), had risen during the 3rd (16%) wave before falling again during the 4th wave (7%) (p < 0.001). CONCLUSION: The Delta (during the 3rd wave) and Omicron VOCs (during the 4th wave) were very predominant among patients followed for Covid-19 in our hospital. Contrary to data in the general population, hospital mortality associated with severe and critical forms of COVID-19 had increased during the 3rd wave of the pandemic in Kinshasa.

Circulating Proprotein Convertase Subtilisin/Kexin type 9 level independently predicts incident cardiovascular events and all-cause mortality in hemodialysis black Africans patients.

BACKGROUND: Cardiovascular (CV) disease is the leading cause of mortality in patients with end-stage kidney disease (ESKD). The aim of the present study was to determine whether Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) could be an independent predictor of CV events and all-cause mortality in black African haemodialysis patients. METHODS: We carried out a prospective cohort study of all consecutive hemodialysis (HD) patients between August 2016 and July 2020, admitted in six hemodialysis centers of Kinshasa, Democratic Republic of Congo. Independent determinants of plasma PCSK-9 measured by ELISA were sought using multiple linear regression analysis. Kaplan-Meier's method described the incidence of CV events while competitive and proportional risk models looked for independent risk factors for death at the .05 significance level. RESULTS: Out of 207 HD patients, 91 (43.9%) died; 116 (56.1%) have survived. PCSK9 level was significantly higher in deceased patients compared to survivors: 28.0 (24.0-31.0) ng/l vs 9.6 (8.6-11.6) ng/ml (p <  0.001). Patients with plasma PCSK9 levels in tertile 3 had a higher incidence of CV events and mortality compared to patients with plasma PCSK9 levels in tertile 2 or tertile 1 (p <  0.001). Tertile 3 negatively influence survival rates (26.6%) compared to tertile 2 (54.7%) and tertile 1 (85.3%). Patients in tertile 3 and tertile 2 had a 4-fold higher risk of death than patients in tertile 1. After adjustment for all parameters, competitive risk analysis showed that mortality was 2 times higher in patients with stroke. Similarly, serum albumin < 3.5 g/dL or PCSK9 in tertile 3 were respectively associated with 2 or 6 times higher rates of deaths. CONCLUSION: Elevated plasma PCSK9 level is an independent major predictor of incident CV events and all-cause mortality in black African HD patients.

SARS-CoV2 infection in symptomatic patients: interest of serological tests and predictors of mortality: experience of DR Congo.

BACKGROUND: In symptomatic patients, the diagnostic approach of COVID-19 should be holistic. We aimed to evaluate the concordance between RT-PCR and serological tests (IgM/IgG), and identify the factors that best predict mortality (clinical stages or viral load). METHODS: The study included 242 patients referred to the University hospital of Kinshasa for suspected COVID-19, dyspnea or ARDS between June 1st, 2020 and August 02, 2020. Both antibody-SARS-CoV2 IgM/IgG and RT-PCR method were performed on the day of admission to hospital. The clinical stages were established according to the COVID-19 WHO classification. The viral load was expressed by the CtN2 (cycle threshold value of the nucleoproteins) and the CtE (envelope) genes of SARS- CoV-2 detected using GeneXpert. Kappa test and Cox regression were used as appropriate. RESULTS: The GeneXpert was positive in 74 patients (30.6%). Seventy two patients (29.8%) had positive IgM and 34 patients (14.0%) had positive IgG. The combination of RT-PCR and serological tests made it possible to treat 104 patients as having COVID-19, which represented an increase in cases of around 41% compared to the result based on GeneXpert alone. The comparison between the two tests has shown that 57 patients (23.5%) had discordant results. The Kappa coefficient was 0.451 (p < 0.001). We recorded 23 deaths (22.1%) among the COVID-19 patients vs 8 deaths (5.8%) among other patients. The severe-critical clinical stage increased the risk of mortality vs. mild-moderate stage (aHR: 26.8, p < 0.001). The values of CtE and CtN2 did not influence mortality significantly. CONCLUSION: In symptomatic patients, serological tests are a support which makes it possible to refer patients to the dedicated COVID-19 units and treat a greater number of COVID-19 patients. WHO Clinical classification seems to predict mortality better than SARS-Cov2 viral load.

COVID-19 and Kidney Disease: Progress in Health Inequity From Low-Income Settings.

The acute coronavirus disease-2019 (COVID-19) pandemic has had a significant impact on the incidence and prevalence of acute kidney injury and chronic kidney disease globally and in low-income settings. Chronic kidney disease increases the risk of developing COVID-19 and COVID-19 causes acute kidney injury directly or indirectly and is associated with high mortality in severe cases. Outcomes of COVID-19-associated kidney disease were not equitable globally owing to a lack of health infrastructure, challenges in diagnostic testing, and management of COVID-19 in low-income settings. COVID-19 also significantly impacted kidney transplant rates and mortality among kidney transplant recipients. Vaccine availability and uptake remains a significant challenge in low- and lower-middle-income countries compared with high-income countries. In this review, we explore the inequities in low- and lower-middle-income countries and highlight the progress made in the prevention, diagnosis, and management of patients with COVID-19 and kidney disease. We recommend further studies into the challenges, lessons learned, and progress made in the diagnosis, management, and treatment of patients with COVID-19-related kidney diseases and suggest ways to improve the care and management of patients with COVID-19 and kidney disease.

Frequency and factors associated with proteinuria in COVID-19 patients: a cross-sectional study.

Proteinuria is a marker of severity and poor outcome of patients in intensive care unit (ICU). The objective of this study was to determine the frequency of proteinuria and the risk factors associated with proteinuria in Congolese COVID-19 patients. The present cross sectional study of proteinuria status is a post hoc analysis of data from 80 COVID-19 patients admitted at Kinshasa Medical Center (KMC) from March 10th to July 10th, 2020. The population under study came from all adult inpatients (≥18 years old) with a laboratory diagnosis by polymerase chain reaction (PCR) of COVID-19 were selected and divided into two groups (positive proteinuria and negative proteinuria group). Logistic regression models helped to identify the factors associated with proteinuria. The P value significance level was 0.05. Among 80 patients who tested positive for SARS-CoV-2 RT-PCR, 55% had proteinuria. The mean age was 55.2 ± 12.8 years. Fourty-seven patients (58.8%) had history of hypertension and 26 patients (32.5%) diabetes. Multivariable analysis showed age ≥ 65 years (aOR 5,04; 95% CI: 1.51-16.78), diabetes (aOR 3,15; 95% CI: 1.14-8.72), ASAT >40 UI/L (aOR 7,08; 95% CI: 2.40-20.87), ferritin >300 (aOR 13,47; 95% CI: 1.56-26.25) as factors independently associated with proteinuria in COVID-19 patients. Proteinuria is common in Congolese COVID-19 patients and is associated with age, diabetes, ferritin and aspartate aminotransferase (ASAT).

Circulating Proprotein Convertase Subtilisin/Kexin Type 9 Levels Predict Future Cardiovascular Event Risks in Hemodialyzed Black African Patients.

CONTEXT AND OBJECTIVE: Cardiovascular diseases are the leading cause of mortality in patients. In this context, proprotein convertase subtilisin/kexin type 9 (PCSK9) appears to be the new biomarker identified as interfering in lipid homeostasis. This study aimed to investigate the association between PCSK9, dyslipidemia, and future risk of cardiovascular events in a population of black Africans. METHODS: A cross-sectional study was conducted between August 2016 and July 2020 in six hemodialysis centers in the city of Kinshasa, Democratic Republic of the Congo. Serum PCSK9 was measured by ELISA; lipid levels of 251 chronic kidney disease grade 5 (CKD G5) hemodialysis patients and the Framingham predictive instrument were used for predicting cardiac events. RESULTS: Total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), and triglycerides (TG) were significantly increased in the tertile with the highest PCSK9. By contrast, high-density lipoprotein cholesterol (HDL-c) was significantly decreased in the same tertile. A strong positive and significant correlation was found between PCSK9 and TC, TG, and LDL-c. Negative and significant correlation was observed between PCSK9 and HDL-c. The levels of PCSK9, smoking, overweight, and atherogenic dyslipidemia were associated with future risks for cardiovascular events in univariate analysis. After adjustment, all these variables persisted as independent determinants of future risk for cardiovascular events. The probability of having a cardiovascular event in this population was independently associated with PCSK9 levels. Compared to the patients in the lowest PCSK9 tertile, patients with PCSK9 levels in the middle (aOR 5.9, 95% CI 2.06-17.3, P<0.001) and highest tertiles (aOR 8.9, 95% CI 3.02-25.08, P<0.001) presented a greater risk of cardiac event. CONCLUSION: Increased PCSK9 serum levels are associated with higher levels of TC, LDL-c, and TG and lower levels of HDL-c in black African hemodialysis patients. Serum PCSK9 levels in these patients predict increased risk of cardiovascular events, independent of traditional potential confounders.

Prognostic Significance of Abnormal Ankle-Brachial Index Among Long-term Hemodialysis Patients in Kinshasa, the Democratic Republic of the Congo.

OBJECTIVE: Early identification of atherosclerosis using a non-invasive tool like ankle-brachial index (ABI) could help reduce the risk for cardiovascular disease among long-term hemodialysis patients. The study objective was to assess the frequency and impact of abnormal ABI as a marker of subclinical peripheral artery disease (PAD) in chronic hemodialysis patients. METHODS: This was a historic cohort study of kidney failure patients on long-term hemodialysis for at least 6 months. The ABI, measured with two oscillometric blood pressure devices simultaneously, was used to assess subclinical atherosclerosis of low limb extremities. Abnormal ABI was defined as ABI <0.9 or >1.3 (PAD present). Survival was defined as time to death. Independent factors associated with abnormal ABI were assessed using multiple logistic regression analysis. Kaplan-Meier method (log-rank test) was used to compare cumulative survival between the two groups; a P value <0.05 was statistically significant. RESULTS: Abnormal ABI was noted in 50.6% (n=43) of the 85 kidney failure patients included in the study; 42.4% (n=36) had a low ABI, and 8.2% (n=7) had a high ABI. Factors associated with PAD present were cholesterol (adjusted odds ratio [AOR], 1.02; 95% confidence interval [CI], 1.01-1.04; P=0.019), inflammation (AOR, 9.44; 95% CI, 2.30-18.77; P=0.002), phosphocalcic product (AOR, 6.25; 95% CI, 1.19-12.87; P=0.031), and cardiac arrhythmias (AOR, 3.78; 95% CI, 1.55-7.81, P=0.009). Cumulative survival was worse among patients with PAD present (log-rank; P=0.032). CONCLUSION: The presence of PAD was a common finding in the present study, and associated with both traditional and emerging cardiovascular risk factors as well as a worse survival rate than patients without PAD.

Prevalence and factors associated with pulmonary arterial hypertension on maintenance hemodialysis patients in Kinshasa, Democratic Republic of Congo: a cross-sectional study.

BACKGROUND: Although cardiovascular diseases in particular Pulmonary Arterial Hypertension (PAH) is associated with, high morbid-mortality in chronic hemodialysis, but its magnitude remains paradoxically unknown in sub-Saharan Africa. The aim of this study was to evaluate the prevalence of PAH and associated factors in chronic hemodialysis in Sub-Saharan African population. METHOD: In a cross-sectional study, patients treated with HD for at least 6 months in 4 hemodialysis centers were examined. PAH was defined as estimated systolic pulmonary arterial pressure (sPAP) ≥ 35 mmHg using transthoracic Doppler echocardiography performed 24 h after the HD session. RESULTS: Eighty-five HD patients were included; their average age was 52.6 ± 15.9 years. Fifty-seven patients (67.1%) were male. Mean duration of HD was 13.3 ± 11 months. With reference to vascular access, 12 (14.1%), 29 (34.1%) and 44 (51.8%) patients had AVF, tunneled cuff and temporary catheter, respectively. The underlying cause of ESRD was diabetes in 30 patients (35.3%). The prevalence of PAH was 29.4%. Patients with PAH had more hyponatremia (11 (44%) vs 10 (16.7%), p = 0.010). In multivariate analysis, unsecured healthcare funding (aOR 4, 95% CI [1.18-6.018]), arrhythmia (aOR 3, 95% CI [1.29-7.34]), vascular access change (aOR 4, 95% CI [1.18-7.51]) and diastolic dysfunction (aOR 5, 95% CI [1.35-9.57] were independently associated with PAH. CONCLUSION: One third of hemodialysis patients exhibit PAH, which is independently associated with low socioeconomic status (unsecured funding, vascular access change) and cardiovascular complications (arrhythmia, diastolic dysfunction).

Response to single dose hepatitis B vaccine in Congolese non-HIV hemodialysis patients: a prospective observational study.

INTRODUCTION: Because of the cost, in the hemodialysis centers of Kinshasa, the double dose of hepatitis B (HBV) vaccine is administered only to HIV infected patients while other patients receive a single dose. This study aimed to evaluate the single-dose vaccination Protocol and identify determinants of seroconversion's lack of anti-HBs after vaccination schedule. METHODS: 56 non-HIV chronic hemodialysis patients serologically negative for HBs Ag, anti-HBs and anti-HBc were selected between January 2014 and December 2016. The recombinant DNA vaccine (Euvax B®20 µg) was administered intramuscularly in the deltoid muscle at days 0, 30, 60 and 180. Serum anti-HBs titer was assayed at day 240. The endpoint was seroconversion, defined as anti-HBs titer ≥ 10 IU/l (10-99 IU/l = low protective vaccine response; ≥ 100 IU/l = highly protective vaccine response). Anti-HBs titer < 10 IU/l defined a lack of seroconversion. A Logistic regression model was used to identify factors associated with the lack of seroconversion. RESULTS: In the study group (mean age 55.6± 15.1 years; 73 % men, 36% diabetic and 86% hypertensive), low and highly protective vaccine responses were seen in 32% and 50% respectively versus 18% of patient had a lack of seroconversion. CRP > 6 mg/L (aOR: 8.96), hypoalbuminemia (aOR: 6.50) and KT/V < 1.2 (aOR: 3.70) were associated with the lack of seroconversion. CONCLUSION: Half of the patients in the study had either a lack or low protective vaccine response. Patient-related factors and hemodialysis parameters were the main factors associated with the lack of anti-HbS seroconversion. These results highlight the need to maximize doses of vaccine in all patients.