Prevention of Hepatitis B Virus and Hepatitis C Virus Transmission in Hemodialysis Centers: Review of Current International Recommendations

Introduction: Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in hemodialysis (HD) patients are associated with adverse outcomes, especially after kidney transplantation. Review: In the HD setting, cross-contamination to patients via environmental surfaces, supplies, equipment, multiple-dose medication vials and staff members is mainly responsible for both HBV and HCV transmission. The incidence and prevalence of HBV in HD centers have dropped markedly as a result of isolation strategy for HBsAg positive patients, the implementation of infection control measures and the introduction of HBV vaccine. The incidence and prevalence of HCV infection among HD patients remain higher than the corresponding general population. There is ongoing debate as to whether isolation of HCV infected patients is needed to combat high anti-HCV seroconversion rates. The current guidelines do not recommend isolation or the use of dedicated machines for HCV infected patients, and rely on strict adherence to infection control measures for the prevention of HCV transmission in the HD setting. Investigations of dialysis associated outbreaks of HCV infection indicate that transmission most likely occurs because of inadequate infection control practices. Routine screening of anti-HCV negative patients, with HCV-antibody testing, and monthly monitoring of ALT levels is recommended to monitor transmission within centers. Conclusion: Prevention of transmission of HBV and HCV in the HD setting warrants a multi-faceted approach. Not enough stress can be placed on the importance of adequate infection control practices for the prevention of both infections. Prevention of HBV transmission is augmented by correct implementation of isolation strategies and the universal vaccination of susceptible patients. Keywords: Hemodialysis; Hepatitis B Virus; Hepatitis C Virus; Infection Control; Isolatio

Reaching Target Hemoglobin Level and Having a Functioning Arteriovenous Fistula Significantly Improve One Year Survival in Twice Weekly Hemodialysis

Introduction: This is a prospective study of a cohort of 1011 patients maintained on regular hemodialysis (HD) in Khartoum, Sudan, studied in the year 2009 and reevaluated one year later. Their survival rates in November 2010 were related to their baseline characteristics.Methods: Demographic and clinical data of studied patients was collected by direct patient interviews and dialysis records revision. Survival rates were calculated using the Kaplan Meier method.Results: Patients had a median age of 45 years and a median duration on dialysis of 25 months. Two thirds of patients were males and 4.2% were children. Studied patients had a one-year survival rate of 86%. Mostpatients (74.8%) received twice weekly HD, and their survival rate was lower than patients receiving thrice weekly HD (85% versus 89%, P = 0.06). The strongest independent predictors of mortality were lack of adocumented measure of dialysis adequacy (HR = 2.7, P =0.00), poor functional capacity (HR = 2.4, P = 0.00), lack of a functioning AV fistula (HR = 2.0, P = 0.00), age . 65 years (HR = 1.6, P = 0.02) and  cardiovascular disease (HR = 1.5, P = 0.04). Patients with hemoglobin level < 10 g/dl had significantly lower survival rates (81% versus 92%, P = 0.00) compared to other patients. HD patientsf perception of their own general health was also significantly correlated to their survival rates (P = 0.00).Conclusion: Patients on thrice weekly HD did marginally better than those on twice weekly HD. In the latter group, however, having an AV fistula and a hemoglobin level of > 10 g/dl appeared to have a positive effect on theirsurvival. Twice weekly HD could be acceptable for many patients provided other aspects of renal care are cared for adequately

Chronic Kidney Disease in Police Forces Households in Khartoum, Sudan: Pilot Report

Introduction: In the Police Forces Hypertension, Diabetes, Renal Insufficiency and Thyroid Derangement (HyDRIT) pilot study we explored the prevalence, risk factors, awareness, treatment adequacy and complications of chronic kidney disease (CKD) and other non-communicable diseases among adult Police Forces households in two housing complexes in Khartoum, Sudan. Methods: Serum creatinine measurements and urine dipstick testing were performed for 273 individuals. The glomerular filtration rate (GFR) was estimated using the standardized Cockroft-Gault and the four variable MDRD formulas. CKD was defined as an estimated GFR of less than 60 ml/min/1.73m2 and/or proteinuria. Results: The overall prevalence of CKD was 11% (30/273) using the standardized Cockroft-Gault equation and 7.7% (21/273) using the four variable MDRD equation. According to the standardized Cockroft-Gault formula, 14 subjects had reduced GFR with negative urine dipstick testing, two subjects had both proteinuria and reduced GFR, and 14 subjects had proteinuria without reduction in GFR. None of those subjects was aware of his kidney problem. According to the standardized Cockroft-Gault formula, 14 of the identified CKD cases were hypertensive (46.7%); eight of them (57.1%) had a prior diagnosis of hypertension but none achieved therapeutic targets. Four of the identified CKD cases were diabetic (13.3%), three of whom had a prior diagnosis of diabetes mellitus with reasonably controlled blood sugar levels. Only age above 50 years and low educational level proved to be independent risk factors for CKD in multivariate analysis. Conclusion: The prevalence of CKD in the study population seems to be comparable to other countries. Keywords: awareness, chronic kidney disease, diabetes mellitus, hypertension, prevalence, Suda

Renal Replacement Therapy in Sudan, 2009

Introduction: Despite an early start, the provision of renal replacement therapy (RRT) in Sudan is constrained by economic factors. This report describes the ESRD population and the available renal replacement therapy (RRT) services in Sudan in 2009. Current status: In June 2009, there were 2858 patients on hemodialysis (HD) in Sudan, 122 patients on continuous ambulatory peritoneal dialysis (CAPD), and 1168 kidney transplant recipients. The overall prevalence of treated ESRD was 106 patients per million population. All forms of RRT were funded by the government. The mean age of HD, CAPD and kidney transplant patients was 46±17, 42±22 and 39±13 years respectively. Males constituted 66%, 67.7% and 79.5% and children constituted 3.9%, 25.3% and 6.6% of HD, CAPD and kidney transplant patients respectively. The commonest reported cause of kidney failure was hypertension (26.1%), followed by diabetes mellitus (DM) (10.4%), obstructive uropathy (7.6%), glomerulonephritis (GN) (5.5%), polycystic kidney disease (2.6%), and pyelonephritis (1.1%). The majority of HD patients (83.8%) are offered twice-weekly HD, 83.6% had a functioning arterio-venous (AV) fistula, 6.4% were positive for hepatitis B virus (HBV) infection, 6.5% were positive for hepatitis C virus (HCV) infection, and 0.7% were positive for both HBV and HCV. Target blood pressure, hemoglobin and phosphorus levels were achieved by 26.5%, 23.1% and 28.5% of HD patients compared to 41.8%, 20.6% and 63.5% of CAPD patients respectively. Kidney transplant recipients had their transplant operation performed in Sudan (33.1%), Egypt (20.7%), KSA (18.2%), Jordan (14.8%), Pakistan (8.4%) and other countries. Conclusion: The prevalence of RRT in Sudan remains low. Hypertension and diabetes mellitus are the most commonly reported cause of kidney failure. Keywords: End stage renal disease; Hemodialysis; Kidney transplant; Peritoneal dialysis; Renal replacement therapy; Suda

Renal Replacement Therapy Resources in Africa

Background: Africa is the world’s second-largest and most-populous continent. It is also the world’s poorest inhabited continent. Regarding chronic kidney disease (CKD), there are no reliable statistics in most African countries. However, there is a general impression that it is at least three to four times more frequent than in more developed countries Methods: a survey on renal replacement therapy in Africa was conducted in the context of the African Association of Nephrology (AFRAN) Congress 2007. A questionnaire was sent to leading African nephrologists, and data were also collected from the main dialysis supply companies and by personal communication. Data have been obtained from 32 out of 54 countries, representing 89% of the total population. Results: There are no reliable statistics regarding CKD in most African countries. The total number of nephrologists in the continent is 1154 (1-4 pmp). The total number of patients on hemodialysis (HD) is just over 60000 patients

The Potential Role of Nursing Students in the Implementation of Community-Based Hypertension Screening Programs in Sudan

Introduction: Hypertension (HTN), diabetes mellitus (DM) and chronic kidney disease (CKD) are important health problems worldwide, and it is possible to reduce their burden through effective HTN screening and treatment programs. It may be feasible to incorporate such programs in the community outreach activities of nursing and medical schools in Sudan. Methods: Village inhabitants in the Northern state of Sudan were invited to attend a free clinic for screening of hypertension as well as for follow up and treatment of persons with previously diagnosed hypertension. Fourth year nursing students from the National Ribat University were asked to record demographic data and blood pressure measurements for the attendants of the clinic. Results: A total of 389 adults were screened, their mean age was 41±15 years and 83.8% of them were females. Family history of HTN, DM and CKD was reported by 52.7%, 40.4% and 12.9% respectively. Personal history of HTN, DM and CKD was reported by 28.5%, 17% and 6.4% respectively. The overall prevalence of HTN was 39.6%. Among persons previously diagnosed as hypertensive, 80.2% were on antihypertensive medication but only 48.6% had blood pressure < 140/90 mmHg. Among the 278 persons with no personal history of HTN, 19.1% had blood pressure ≥ 140/90 mmHg. Variables significantly and independently associated with the presence of HTN were family history of HTN (OR: 6.4, P: 0.005), less than 10 years of formal education (OR: 3.5, P: 0.000) and age ≥ 40 years (OR: 2.4, P: 0.005). Conclusion: With proper coordination, nursing and medical students can effectively contribute to the implementation of hypertension screening programs. Keywords: Hypertension; Nursing Students; Screening; Suda

Active Tuberculous Infection among Adult Sudanese Patients on Long Term Peritoneal Dialysis

Introduction: The prevalence of tuberculosis in Sudan is 209 cases per 100,000 populations. There are no reports available regarding the prevalence of tuberculosis among the end-stage kidney disease and dialysis populations.Methods: We reviewed the medical records of all adults who were on peritoneal dialysis (PD) in the Sudan Peritoneal Dialysis Program, during the period from June 2005 to December 2011. Those diagnosed ashaving active tuberculous infections were retrospectively studied regarding their demography, clinical presentation and outcomes.Results: Out of 350 patients in our program, 19 were diagnosed as having active tuberculosis (5.4%). All patients were diagnosed during their first year on peritoneal dialysis, 74% were males; the mean age was37 &#177; 11 years, extrapulmonary tuberculosis was seen in 16/19 (84%) patients and it was abdominal in nine of the 16 (47%) patients. In addition to high clinical suspicion, the diagnosis of active tuberculosis was supported by tissue biopsy findings in 16%, positive polymerase chain reaction in 26%, exudative ascites with suggestive radiological features in 21%, strongly positive tuberculin test in 21% and a favourable response to empirical antituberculous therapy in 26% of patients. HIV test wasnegative in all 19 patients and only one patient tested positive for hepatitis B viral infection. Antituberculous drugs side effects were seen in 68% of patients. Forty seven percent of patients showed complete recovery and continued on peritoneal dialysis. Our case fatality was 32%.Conclusion: Abdominal tuberculosis is common among PD patients and its diagnosis should always be considered in suspected patients

Recurrent Transvaginal Leak of Dialysate as a Complication of Peritoneal Dialysis Catheter Tip Capture by Fallopian Tube after Tubal Occlusion

Introduction: Peritoneal dialysis (PD) catheter malfunction may result from obstruction by various intra-peritoneal structures. Such obstruction may rarely be caused by fallopian tubes, in which case it may present as out flow failure and/or per vaginum (PV) leak of dialysate. Case report: A 46 years old female developed early out-flow obstruction while maintaining adequate dialysate inflow soon after PD catheter insertion. The patient also had PV leak of the dialysate that was misinterpreted by the patient as urine incontinence. Fluoroscopic catheterogram confirmed catheter patency and outlined the right fallopian tube. Magnetic Resonance Imaging (MRI) revealed the presence of fluid in vagina with no obvious peritoneo-vaginal fistulous track. Laparoscopy was performed, at which time examination under anesthesia excluded the presence of peritoneo-vaginal fistula. During laparoscopy, the catheter tip was found to be captured by the fimbriae of the right fallopian tube. The catheter tip was released and right tubal occlusion was performed, after which adequate flow was restored. Three month later, the catheter was replaced because of fungal peritonitis. Vaginal leak recurred six weeks after insertion of the new catheter through the same occluded tube. Mini laparotomy and tubal ligation with catheter removal were done and the patient was maintained on hemodialysis until she received a kidney transplant four months later. Conclusion: Vaginal leak of dialysate can occur as an early complication of PD secondary to fallopian tube capture of PD catheter tip. It is important to distinguish between tubal capture of the catheter tip which can be treated laparoscopically and peritoneo-vaginal fistula which often requires laparotomy for fistulous tract debridement and repair. Key words: Peritoneal Dialysis, Dialysate, Transvaginal leak, Fallopian tub

Encysted Fluid Collections after Catheter Removal for Peritonitis in Peritoneal Dialysis Patients

Introduction: Peritonitis is a frequent complication of continuous ambulatory peritoneal dialysis (CAPD). This case series describes episodes of peritoneal dialysis (PD) related fungal or Pseudomonas peritonitis that were complicated by the formation of encysted intra abdominal fluid collections despite prompt catheter removal and appropriate therapy. Case series: The first patient presented with fever and abdominal pain two weeks after removing his PD catheter because of fungal peritonitis. Examination revealed fluid collection in the former catheter tunnel. This turned out to be pus on surgical drainage. Abdominal computed tomography (CT) scan revealed another extensive encysted extra-peritoneal fluid collection that was aspirated and found to be clear transudate fluid. The second patient presented with abdominal pain and distention seven weeks after removing her PD catheter because of fungal peritonitis. She had a large intra abdominal encysted fluid collection that was drained under ultra sound guidance. The third patient presented with painless abdominal distention one month after removing the PD catheter because of Pseudomonas peritonitis. He had two encysted extra peritoneal fluid collections that were aspirated under ultra sound guidance. This occurred despite three weeks of treatment with oral fluconazole in the case of the first two patients and appropriate antibiotic therapy in the case of the third patient. Key Words: CAPD, Fungal peritonitis, Pseudomonas peritonitis, Encysted abdominal fluid collection, Suda