Medical Nutrition Therapy in Renal Replacement Therapy

This chapter discusses Medical Nutrition Therapy in three modalities of renal replacement therapy (RRT), outlining the nutrient requirements for patients on maintenance hemodialysis, peritoneal dialysis, and kidney transplant in acute and chronic phases. The chapter takes note of the drastic impact of RRT on the patient’s nutrition status and overall well-being, which puts them at high risk of morbidity and mortality, and thus emphasizes timely and regular comprehensive nutrition assessment to enable appropriate intervention. Recognizing that there are different modalities of RRT and that patients have different physiological characteristics as well as different laboratory test values, which may also vary for individual patients each time tests are run, nutrition therapy is individualized each time. The chapter takes a closer look at protein-energy wasting, a condition common among patients undergoing RRT, which is a predictor of mortality, discussing its prevention and treatment measures. Finally, the chapter takes a closer look at electrolytes, specifically potassium, sodium, calcium, and phosphorous, in relation to mineral bone disease

Soybean farm-saved seed viability and vigor as influenced by agro-ecological conditions of Meru South Sub-County, Kenya

Objective: The experiment was conducted with the aim of assessing the soybean farm-saved seed viability and vigor as influenced by agro-ecological conditions of Meru South Sub-County, Kenya.Methodology and results: Within one month of harvest, soybean farm-saved-seed was randomly sampled from 30 households in February 2013 from areas representative of agro-ecological zones Upper Midlands II (Ann. Mean temp. (18.2-20.60C); Upper Midlands III (19.2-20.60C; Lower Midlands III (20.9-22.90C) and Lower Midlands IV (21-240C). Standard germination, electrical conductivity and moisture content tests were done according to ISTA rules (2007). Analysis of Variance was done using SAS (9.2) and means separated using LSD. Results revealed that seed moisture was lowest in the warmer LM4 (6.3%) than in the cooler LM3 (8%); UM3 (8.4%) and UM2 (10%). In addition, soybean seed from the cooler agro-ecologies - UM2 (94%), UM3 (86.6%) and LM3 (99.5%) had significantly higher germination than seed from the lower warmer LM4 (57%). Similarly, seed vigor was highest in the cooler UM2 (41.7 C/cm/g), UM3 (45.8C/cm/g) and LM3 (31.6C/cm/g) as shown by reduced seed leachates; indicative of better integrity of seed membranes than seed from the warmer LM4 (79.1C/cm/g). In addition, there was a strong negative correlation between electrical conductivity and germination, showing a faster deterioration due to leakage of electrolytes.Conclusions and applications of findings: The soybean farm-saved seed germination and vigor were significantly influenced by agro-ecological conditions. Considering that seed moisture content in the lower warmer agro-ecologies was significantly lower than those from higher cooler agro-ecologies the observed seed deterioration was attributable to the higher temperatures characteristic of lower altitudes agro-ecologies. Therefore, since the farm saved seed viability and vigor was better retained in the cooler higher agroecological zones (UM2, UM3 and LM3) of Meru South Sub-County, farmers should source better quality soybean seed from these areas. The results validate the need for ecological zoning of suitable areas for the production of high quality soybean seed in Kenya.Keywords: soybean farm-saved seed, agro-ecological zones, seed germination and vigo

Mothers' involvement in providing care for their hospitalised sick newborns in Kenya: a focused ethnographic account

Introduction: There is growing evidence that parental participation in the care of small and sick newborns benefits both babies and parents. While studies have investigated the roles that mothers play in newborn units in high income contexts (HIC), there is little exploration of how contextual factors interplay to influence the ways in which mothers participate in the care of their small and sick newborn babies in very resource constrained settings such as those found in many countries in sub-Saharan Africa. Methods: Ethnographic methods (observations, informal conversations and formal interviews) were used to collect data during 627 h of fieldwork between March 2017 and August 2018 in the neonatal units of one government and one faith-based hospital in Kenya. Data were analysed using a modified grounded theory approach. Results: There were marked differences between the hospitals in the participation by mothers in the care of their sick newborn babies. The timing and types of caring task that the mothers undertook were shaped by the structural, economic and social context of the hospitals. In the resource constrained government funded hospital, the immediate informal and unplanned delegation of care to mothers was routine. In the faith-based hospital mothers were initially separated from their babies and introduced to bathing and diaper change tasks slowly under the close supervision of nurses. In both hospitals appropriate breast-feeding support was lacking, and the needs of the mothers were largely ignored. Conclusion: In highly resource constrained hospitals with low nurse to baby ratios, mothers are required to provide primary and some specialised care to their sick newborns with little information or support on how undertake the necessary tasks. In better resourced hospital settings, most caring tasks are initially performed by nurses leaving mothers feeling powerless and worried about their capacity to care for their babies after discharge. Interventions need to focus on how to better equip hospitals and nurses to support mothers in caring for their sick newborns, promoting family centred care

Selected Factors Affecting Adoption of Improved Finger Millet Varieties by Small- Scale Farmers in the Semi-Arid Mogotio District, Kenya

Finger millet is one of the important traditional, nutritious and drought tolerant food crop grown by small scale farmers in most arid and semi-arid lands (ASALs) of the world. In the ASALs of Kenya, the small scale farmers mainly grow unimproved finger millet varieties of low yields. Despite availability of improved high yielding and recommended varieties, the farmer

Perceptions of the governance of the technological risks of food innovations for addressing food security

Food and nutrition insecurity continue to risk the lives and wellbeing of millions of people throughout the world today. Further, food and nutrition insecurity are still major challenges in Kenya and have triggered the adoption of a number of modern biotechnologies for agricultural transformation. Consequently, many food technologies have been approved to secure sustainable access to food for millions of people. This study investigated the perceptions and implementation of two technologies for addressing food insecurity in Kenya, namely, genetically modified organisms (GMOs) and the use of antibiotics in livestock production. In particular, the study explored how their implementation can be governed responsibly through approved legislation. Therefore, the knowledge, attitudes and practices, as well as the governance, of GMO technology and antibiotic resistance risks were assessed. In-depth key interviews were conducted for a qualitative survey with triangulation using quantitative data sources. The findings showed that 46% of the population have limited knowledge about GMO technology, with about 79% indicating that foods with GM ingredients were already being consumed in the country despite the government ban. The majority of respondents agree that GMOs can contribute to an increase in the global food supply (65%), make food affordable (57%) and produce more nutritious foods (50%). Further, most agree that GMOs can produce crops more resistant to pests and reduce pesticide use on food crop plants (89). The main concerns reported regarding GMO technology by most respondents included the impact on the environment and human health and the adverse effects on traditional farming practices. About 36% of these respondents indicated that the technology diminishes traditional farming technologies, and 32% reported that it contributes to loss of biodiversity. Notably, 64% reported that GMO technology is a solution to food security and that GM foods are safe. Regarding the use of antimicrobials mainly meant to prevent diseases and access better markets, respondents perceived their use to be associated with a “large level of risk” of antimicrobial resistance (score of 2 on a scale of 1–3) (M = 1.85, SD = 1.06). A total of 56% of the respondents reported that the efforts towards promoting awareness of antibiotic resistance risks and their associated effects on human health are relatively limited. Our findings show that most of the respondents have only observed minimal awareness campaigns. Regarding the governance of the two technologies, 71% and 50% of the respondents reported that scientists and elected officials, respectively, have the greatest roles in the governance of GMOs, with small-scale farmers playing a negligible role. These findings are crucial to the advancement of food innovations that are geared towards achieving food security in Kenya as they highlight the risks associated with the poor governance and implementation of technologies. Therefore, there is a need for a framework for technological risk governance that is sensitive to local values and socio-economic circumstances and that will facilitate the achievement of food security goals

Drop-offs in the isoniazid preventive therapy cascade among children living with HIV in western Kenya, 2015–2019

Introduction: Isoniazid preventive therapy (IPT) can reduce the risk of tuberculosis (TB) in children living with HIV (CLHIV), but data on the outcomes of the IPT cascade in CLHIV are limited. Methods: We evaluated the IPT cascade among CLHIV aged <15 years and newly enrolled in HIV care in eight HIV clinics in western Kenya. Medical record data were abstracted from September 2015 through July 2019. We assessed the proportion of CLHIV completing TB symptom screening, IPT eligibility assessment, IPT initiation and completion. TB incidence rate was calculated stratified by IPT initiation and completion status. Risk factors for IPT non-initiation and non-completion were assessed using Poisson regression with generalized linear models. Results: Overall, 856 CLHIV were newly enrolled in HIV care, of whom 98% ([95% CI 97–99]; n = 841) underwent screening for TB symptoms and IPT eligibility. Of these, 13 (2%; 95% CI 1–3) were ineligible due to active TB and 828 (98%; 95% CI 97–99) were eligible. Five hundred and fifty-nine (68%; 95% CI 64–71) of eligible CLHIV initiated IPT; median time to IPT initiation was 3.6 months (interquartile range [IQR] 0.5–10.2). Overall, 434 (78%; 95% CI 74–81) IPT initiators completed. Attending high-volume HIV clinics (aRR = 2.82; 95% CI 1.20–6.62) was independently associated with IPT non-initiation. IPT non-initiation had a trend of being higher among those enrolled in the period 2017–2019 versus 2015–2016 (aRR = 1.91; 0.98–3.73) and those who were HIV virally non-suppressed (aRR = 1.90; 95% CI 0.98–3.71). Being enrolled in 2017–2019 versus 2015–2016 (aRR = 1.40; 1.01–1.96) was independently associated with IPT non-completion. By 24 months after IPT screening, TB incidence was four-fold higher among eligible CLHIV who never initiated (8.1 per 1000 person years [PY]) compared to CLHIV who completed IPT (2.1 per 1000 PY; rate ratio [RR] = 3.85; 95% CI 1.08–17.15), with a similar trend among CLHIV who initiated but did not complete IPT (8.2/1000 PY; RR = 4.39; 95% CI 0.82–23.56). Conclusions: Despite high screening for eligibility, timely IPT initiation and completion were suboptimal among eligible CLHIV in this programmatic cohort. Targeted programmatic interventions are needed to address these drop-offs from the IPT cascade by ensuring timely IPT initiation after ruling out active TB and enhancing completion of the 6-month course to reduce TB in CLHIV

Individual and composite adverse pregnancy outcomes in a randomized trial on isoniazid preventative therapy among women living with human immunodeficiency virus

CITATION: Theron, G. et al. 2021. Individual and Composite Adverse Pregnancy Outcomes in a Randomized Trial on Isoniazid Preventative Therapy Among Women Living With Human Immunodeficiency Virus. Clinical infectious diseases, 72(11):e784–e790. doi:10.1093/cid/ciaa1482The original publication is available at https://academic.oup.com/cid/Background: International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1078, a randomized noninferiority study designed to compare the safety of starting isoniazid preventive therapy (IPT) in women living with human immunodeficiency virus (HIV) either during pregnancy or after delivery, showed that IPT during pregnancy increased the risk of composite adverse pregnancy outcomes, but not individual outcomes. Many known factors are associated with adverse pregnancy outcomes: these factors' associations and effect modifications with IPT and pregnancy outcomes were examined. Methods: Pregnant women living with HIV from 8 countries with tuberculosis incidences >60/100 000 were randomly assigned to initiate 28 weeks of IPT either during pregnancy or at 12 weeks after delivery. Using univariable and multivariable logistic regression and adjusting for factors associated with pregnancy outcomes, composite and individual adverse pregnancy outcome measures were analyzed. Results: This secondary analysis included 925 mother-infant pairs. All mothers were receiving antiretrovirals. The adjusted odds of fetal demise, preterm delivery (PTD), low birth weight (LBW), or a congenital anomaly (composite outcome 1) were 1.63 times higher among women on immediate compared to deferred IPT (95% confidence interval [CI], 1.15-2.31). The odds of fetal demise, PTD, LBW, or neonatal death within 28 days (composite outcome 2) were 1.62 times higher among women on immediate IPT (95% CI, 1.14-2.30). The odds of early neonatal death within 7 days, fetal demise, PTD, or LBW (composite outcome 3) were 1.74 times higher among women on immediate IPT (95% CI, 1.22-2.49). Conclusions: We confirmed higher risks of adverse pregnancy outcomes associated with the initiation of IPT during pregnancy, after adjusting for known risk factors for adverse pregnancy outcomes.https://academic.oup.com/cid/article/72/11/e784/5913421?login=truePublishers versio

Isoniazid Preventive Therapy in HIV-Infected Pregnant and Postpartum Women

CITATION: Gupta, A. et al. 2019. Isoniazid Preventive Therapy in HIV-Infected Pregnant and Postpartum Women. The New England Journal of Medicine, 381(14):1333-1346. doi:10.1056/NEJMoa1813060The original publication is available at https://www.nejm.org/BACKGROUND: The safety, efficacy, and appropriate timing of isoniazid therapy to prevent tuberculosis in pregnant women with human immunodeficiency virus (HIV) infection who are receiving antiretroviral therapy are unknown. METHODS: In this multicenter, double-blind, placebo-controlled, noninferiority trial, we randomly assigned pregnant women with HIV infection to receive isoniazid preventive therapy for 28 weeks, initiated either during pregnancy (immediate group) or at week 12 after delivery (deferred group). Mothers and infants were followed through week 48 after delivery. The primary outcome was a composite of treatment-related maternal adverse events of grade 3 or higher or permanent discontinuation of the trial regimen because of toxic effects. The noninferiority margin was an upper boundary of the 95% confidence interval for the between-group difference in the rate of the primary outcome of less than 5 events per 100 person-years. RESULTS: A total of 956 women were enrolled. A primary outcome event occurred in 72 of 477 women (15.1%) in the immediate group and in 73 of 479 (15.2%) in the deferred group (incidence rate, 15.03 and 14.93 events per 100 person-years, respectively; rate difference, 0.10; 95% confidence interval [CI], −4.77 to 4.98, which met the criterion for noninferiority). Two women in the immediate group and 4 women in the deferred group died (incidence rate, 0.40 and 0.78 per 100 person-years, respectively; rate difference, −0.39; 95% CI, −1.33 to 0.56); all deaths occurred during the postpartum period, and 4 were from liver failure (2 of the women who died from liver failure had received isoniazid [1 in each group]). Tuberculosis developed in 6 women (3 in each group); the incidence rate was 0.60 per 100 person-years in the immediate group and 0.59 per 100 person-years in the deferred group (rate difference, 0.01; 95% CI, −0.94 to 0.96). There was a higher incidence in the immediate group than in the deferred group of an event included in the composite adverse pregnancy outcome (stillbirth or spontaneous abortion, low birth weight in an infant, preterm delivery, or congenital anomalies in an infant) (23.6% vs. 17.0%; difference, 6.7 percentage points; 95% CI, 0.8 to 11.9). CONCLUSIONS: The risks associated with initiation of isoniazid preventive therapy during pregnancy appeared to be greater than those associated with initiation of therapy during the postpartum period. (Funded by the National Institutes of Health; IMPAACT P1078 TB APPRISE ClinicalTrials.gov number, NCT01494038. opens in new tab.)https://www.nejm.org/doi/full/10.1056/NEJMoa1813060Publisher’s versio

Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis.

INTRODUCTION Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. METHODS We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. RESULTS We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection-as compared with uninfected pregnant women-were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. CONCLUSIONS This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol

Facilitating war-affected young mothers\u27 reintegration: lessons from a participatory action research study in Liberia, Sierra Leone, and Uganda

Young women and girls formerly associated with armed forces and armed groups face multiple challenges. Many become pregnant or have children while they are associated and face stigma and marginalization upon reintegration into civilian communities. This article describes a multi-year participatory action research study that took place in twenty communities in Liberia, Sierra Leone, and northern Uganda from 2006 – 2009 and included more than 650 young mother participants. We find that this community-based approach to reintegration improved the wellbeing of young mother participants and their children. We discuss the challenges and limitations of conducting participatory action research with war-affected young people and make recommendations for future reintegration programming