Nephrotoxicity of amphotericin B in the treatment of cryptococcal meningitis in acquired immunodeficiency syndrome patients.

OBJECTIVES: To describe the incidence of renal dysfunction, hypokalaemia and hypomagnesaemia in AIDS patients with cryptococcal meningitis and on amphotericin B treatment. Secondary objective was to determine all-cause mortality in the same group. DESIGN: Prospective, observational study. SETTING: Kenyatta National Hospital (KNH), Nairobi, Kenya. SUBJECTS: Seventy consecutive patients with AIDS and cryptococcal meningitis on amphotericin B. RESULTS: About 58.6% of the patients had at least 100% rise in the creatinine level. Thirty eight point six per cent of patients experienced a rise in serum creatinine of at least 50%. Ninty three per cent of the patients developed hypokalaemia and 80% had hypomagnesaemia at trough magnesium level. Only 54.3% of patients completed the intended 14-day treatment. Thirty point five per cent of patients died within the two week follow-up period. CONCLUSION: The incidences of amphotericin B associated nephrotoxicity, hypokalemia and hypomagnesaemia were high in this studied population.

Type 2 diabetes mellitus: clinical and aetiologic types, therapy and quality of glycaemic control of ambulatory patients.

BACKGROUND: Type 2 diabetes is a heterogeneous disease with multiple causes revolving around beta cell dysfunction, insulin resistance and enhanced hepatic glucose output. Clinical judgement based on obesity status, age of onset and the clinical perception of residual beta cell insulin secretory function (hence insulin-requiring or not), has been used to determine therapeutic choices for each patient. Further laboratory testing of the clinically defined type 2 diabetes unmasks the various aetiologic types within the single clinical group. OBJECTIVE: To determine the aetiological types of the clinically defined type 2 diabetic patients, their chosen therapies at recruitment and the quality of glycaemic control achieved. DESIGN: Descriptive cross-sectional study. SETTING: Diabetes out-patient clinic of Kenyatta National Hospital, Nairobi, Kenya. RESULTS: A total of 124 patients with clinical type 2 diabetes were included, 49.2% were males. The mean duration of diabetes in males was 26.09 (20.95) months and that of females was 28.68 (20.54) months. The aetiological grouping revealed the following proportions: Type 1A-3.2%, Type 1B-12.1%, LADA-5.7%, and "true" type 2 diabetes 79.0%. All the patients with Type 1A were apparently, and rightly so, on "insulin-only" treatment even though they did not achieve optimal glycaemic control with HbA1c % = 9.06. However the study patients who were type 1B and LADA were distributed all over the treatment groups where most of them did not achieve optimal glycaemic control, range of HbA1c of 8.46 -10.6%. The patients with "true" type 2 were also distributed all over the treatment groups where only subjects on 'diet only' treatment had good HbA1c of 6.72% but those in other treatment groups did not achieve optimal glycaemic control of HbA1c, 8.07 - 9.32%. CONCLUSION: Type 2 diabetes is a heterogeneous disease where clinical judgement alone does not adequately tell the various aetiological types apart without additional laboratory testing of C-peptide levels and GAD antibody status. This may partly explain the inappropriate treatment choices for the various aetiological types with consequent sub-optimal glycaemic control of those patients.

Diabetic ketoacidosis: risk factors, mechanisms and management strategies in sub-Saharan Africa: a review.

BACKGROUND: Diabetic ketoacidosis is the most common hyperglycaemic emergency in patients with diabetes mellitus, especially type 1 diabetes. It carries very high mortality in sub-Saharan Africa, both in the treated patients and those who are presenting to hospital with diabetes for the first time. OBJECTIVE: To review the risk factors, mechanisms and management approaches in diabetes ketoacidosis in published literature and to discuss them in the context of why a significant proportion of patients who develop diabetic ketoacidosis in sub-Saharan Africa still have high mortality. DATA SOURCE: Literature review of relevant published literature from both Africa and the rest of the world. DATA SYNTHESIS: The main causes or precipitants of DKA in patients in SSA are newly diagnosed diabetes, missed insulin doses and infections. The major underlying mechanism is insulin deficiency. Treated patients miss insulin doses for various reasons, for example, inaccessibility occasioned by; unavailability and unaffordability of insulin, missed clinics, perceived ill-health and alternative therapies like herbs, prayers and rituals. Infections also occur quite often, but are not overt, like urinary tract, tuberculosis and pneumonia. Due to widespread poverty of individuals and nations alike, the healthcare systems are scarce and the few available centres are unable to adequately maintain a reliable system of insulin supply and exhaustively investigate their hospitalised patients. Consequently, there is little guarantee of successful outcomes. Poor people may also have sub-optimal nutrition, caused or worsened by diabetes, more so, at first presentation to hospital. Intensive insulin therapy in such individuals mimics 're-feeding syndrome', an acute anabolic state whose outcome may be unfavourable during the period of treatment of diabetic ketoacidosis. CONCLUSIONS: Although mortality and morbidity from diabetic ketoacidosis remains high in sub-Saharan Africa, improved healthcare systems and reliable insulin supply can reverse the trend, at least, to a large extent. Individuals and populations need empowerment through education, nutrition and poverty eradication to improve self-care in health and living with diabetes.