Characteristics and allocation outcomes of patients assessed for the renal replacement therapy at Groote Schuur Hospital (2008-2012)

Includes bibliographical references.End Stage Kidney Disease (ESKD) is a global public health problem with an enormous economic burden. In resource limited settings like South Africa management of End Stage Kidney Diseases is rationed to the most transplantable candidates. Racial and socio-economic inequalities in selecting candidates have been documented in a South Africa despite the availability of guidelines. No data is available on selection outcomes using the current 2010 prioritization guidelines of Western Cape. We audited the outcome of patients assessed for the renal replacement therapy at Groote Schuur hospital. A retrospective analytic study of patients presented to the renal replacement therapy committee was conducted in the renal unit of Groote Schuur Hospital. Outcome letters, proceedings from the committee meetings and the hospital database were sources of data used. All new patients presented between 2008 and 2012 were included in the study. Data entry and statistical analysis was done using SPSS v.22. A total of 734 ESKD patients were assessed for renal replacement therapy between January, 2008 and December, 2012. During that period, there were 564 new patients, of which more than half (53.9%) were not selected for the program. Following the introduction of the new prioritization criteria a trend towards increasing number of patients presented and accepted was noted. More males were presented (M: F = 1.3) and most patients were below the age of 50yrs (n=478, 84.8%). Half of the patients came from low socioeconomic areas. There were no significant differences in socio-demographic factors before and after introduction of the new guidelines. Clinically they had advanced disease with either uremic (n=181, 44.4%) or fluid overload (n=179, 43.9%) symptoms as their major presentation. The underlying causes were Hypertension (40.6%), Diabetes (14.4%) and chronic Glomerulonephritis (15.8%). Predictors of rejection from the program included age above 50 years, unemployment and a poor psychosocial assessment. Substance abuse and Diabetes also showed a statistical significant association with the likelihood of being rejected. Race and marital status were not predictors. Efforts to allocate more resources should continue in view of the loss of young and potential productive life. Advanced presentation of patients with ESRD represents challenges in early diagnosis and referral in the current system. Community screening programs and improved access to knowledgeable clinicians at the primary level is advocated. The use of new selection guidelines have not led to an increase in selection inequalities

Ten-year plateau phase in human immunodeficiency virus induced motor neuron disease upon antiretroviral therapy: a first case from Eastern Africa.

We report an individual with rapidly progressive motor neuron disease (MND), phenotypically compatible with amyotrophic lateral sclerosis (ALS). The patient described in this case report proved positive for human immunodeficiency virus (HIV) and was initiated on antiretroviral therapy (ART). Following ART he clinically stabilised over 10 years and deteriorated again due to noncompliance or ART resistance. HIV infection can give rise to an MND mimic, HIV-ALS. The improvement in response to ART supports the notion that HIV-ALS is a treatable entity also in Africa. This is the first case report of a patient with HIV-ALS and long term follow up in Sub-Saharan Africa. The report raises the suggestion that an additional (retro)virus can play a role in the aetiology of ALS

Risks, precipitants and clinical presentation of gastro-oesophageal reflux disease at the Kilimanjaro Christian Medical Centre in Tanzania

Introduction: Risk factors and precipitants of gastro-oesophageal disease (GERD) differ widely in  communities. We conducted an observational study to describe these risks, precipitants and clinical  presentation of GERD patients at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania.Methods: We consecutively recruited 92 GERD patients who were referred for endoscopy at KCMC from March to November 2008. By using structured questionnaire we enquired: risk factors, precipitants and symptoms of GERD and upper gastrointestinal endoscopic findings. Their upper gastrointestinal  endoscopic findings were as well documented.Results: The mean (± SD) age of the study population was 47.32 (±17) years. Reported symptoms  included water brash (37%), dyspepsia (6%), chronic cough (11%) and hemoptysis (5%). More than half (56%) of the patients surveyed identified food precipitants for their GERD symptoms. Triggers of GERD symptoms were boiled beans 19%, spicy food 11%, sour/fermented meals 10%, roasted tomato 9%,  silver cyprinid fish (dagaa) 5%, beans with cooked green banana (matoke) 2% and fermented milk 1%.  Most of the studied patients had normal body mass index (52%), and 25% admitted to be consuming  alcohol though they didn’t associate it with their GERD symptoms. The most common endoscopy finding was “loose lower oesophageal sphincter” (85%).Conclusion: Most GERD patients referred for endoscopy at KCMC were found to have water brash and  “loose lower oesophageal sphincters” as described by endoscopists to denote mechanical abnormality of the lower oesophageal sphincter. GERD symptoms were precipitated by common locally available food and spices.Key words: GERD, precipitating food, risk factors, loose lower ooesophageal sphincter, upper  gastrointestinal endoscopy

Developing nephrology services in low income countries: A case of Tanzania

Background: The burden of kidney diseases is reported to be higher in lower- and middle-income countries as compared to developed countries, and countries in sub-Saharan Africa are reported to be most affected. Health systems in most sub-Sahara African countries have limited capacity in the form of trained and skilled health care providers, diagnostic support, equipment and policies to provide nephrology services. Several initiatives have been implemented to support establishment of these services. Methods: This is a situation analysis to examine the nephrology services in Tanzania. It was conducted by interviewing key personnel in institutions providing nephrology services aiming at describing available services and international collaborators supporting nephrology services. Results: Tanzania is a low-income country in Sub-Saharan Africa with a population of more than 55 million that has seen remarkable improvement in the provision of nephrology services and these include increase in the number of nephrologists to 14 in 2018 from one in 2006, increase in number of dialysis units from one unit (0.03 unit per million) before 2007 to 28 units (0.5 units per million) in 2018 and improved diagnostic services with introduction of nephropathology services. Government of Tanzania has been providing kidney transplantation services by funding referral of donor and recipients abroad and has now introduced local transplantation services in two hospitals. There have been strong international collaborators who have supported nephrology services and establishment of nephrology training in Tanzania. Conclusion: Tanzania has seen remarkable achievement in provision of nephrology services and provides an interesting model to be used in supporting nephrology services in low income countries.publishedVersio

Knowledge, Attitudes, and Practices Associated with Chronic Kidney Disease in Northern Tanzania: A Community-Based Study.

Non-communicable diseases (NCDs) are a leading cause of death among adults in sub-Saharan Africa, and chronic kidney disease (CKD) is a growing public health threat. Understanding knowledge, attitudes, and practices associated with NCDs is vital to informing optimal policy and public health responses in the region, but few community-based assessments have been performed for CKD. To address this gap, we conducted a cross-sectional survey of adults in northern Tanzania using a validated instrument. Between January and June 2014, we administered a structured survey to a random sample of adults from urban and rural communities. The validated instrument consisted of 25 items designed to measure knowledge, attitudes, and practices associated with kidney disease. Participants were also screened for CKD, diabetes, hypertension, and human immunodeficiency virus. We enrolled 606 participants from 431 urban and rural households. Knowledge of the etiologies, symptoms, and treatments for kidney disease was low (mean score 3.28 out of 10; 95% CI 2.94, 3.63). There were no significant differences by CKD status. Living in an urban setting and level of education had the strongest independent associations with knowledge score. Attitudes were characterized by frequent concern about the health (27.3%; 20.2, 36.0%), economic (73.1%; 68.2, 77.5%), and social impact (25.4%; 18.6, 33.6%) of kidney disease. Practices included the use of traditional healers (15.2%; 9.1, 24.5%) and traditional medicines (33.8%; 25.0, 43.9%) for treatment of kidney disease as well as a willingness to engage with mobile-phone technology in CKD care (94.3%; 90.1, 96.8%). Community-based adults in northern Tanzania have limited knowledge of kidney disease. However, there is a modest knowledge base upon which to build public health programs to expand awareness and understanding of CKD, but these programs must also consider the variety of means by which adults in this population meet their healthcare needs. Finally, our assessment of local attitudes suggested that such public health efforts would be well-received

Neurological disorders in Northern Tanzania: A 6-year prospective hospital-based case series

Background: The burden of neurological disorders is large and altered by the HIV epidemic. Objectives: We describe the pattern of neurological disorders and their association with HIV infection in adult patients attending a consultant hospital in Northern Tanzania. Methods: In this prospective cross-sectional study, we collected data on adult neurological referrals over a 6-year period between 2007-13. The odds of HIV infection, across neurological categories adjusted for age and sex, was calculated. Results: Of 2037 participants, 54.8% were male and 45.2% were female. The median age of participants was 43 years. The results for HIV screening were available for 992/2037 (48.7%) patients, of whom 306 (30.8%) were seropositive. The most frequent neurological disorders were cerebrovascular disease (19.9%), paraplegia (13.6%), and peripheral neuropathies (8%). Taken together CNS infection accounted for 278/2037 (13.6%). The adjusted odds (aOR) of HIV infection was highest amongst infections; brain abscesses (aOR 107, 95% CI 35.1-470.4) and meningitis/encephalitis (aOR 40.1, 95% CI 13.6-172.9), but also raised in cerebrovascular disease, paraplegia, peripheral neuropathies, cranial nerve palsies, seizures, cerebllar disorders, movement disorders, motor neuron disease and headache. Conclusion: The main pattern of neurological disorders in Northern Tanzania is presented. The odds of HIV infection was highest in CNS infections and in a wide range of non-communicable neurological disorders.publishedVersio

Post-Partum Pituitary Insufficiency and Livedo Reticularis Presenting a Diagnostic Challenge in a Resource Limited Setting in Tanzania: A Case Report, Clinical Discussion and Brief Review of Existing Literature.

Pituitary disorders following pregnancy are an important yet under reported clinical entity in the developing world. Conversely, post partum panhypopituitarism has a more devastating impact on women in such settings due to high fertility rates, poor obstetric care and scarcity of diagnostic and therapeutic resources available. A 37 year old African female presented ten years post partum with features of multiple endocrine deficiencies including hypothyroidism, hypoadrenalism, lactation failure and secondary amenorrhea. In addition she had clinical features of an underlying autoimmune condition. These included a history of post-partum thyroiditis, alopecia areata, livedo reticularis and deranged coagulation indices. A remarkable clinical response followed appropriate hormone replacement therapy including steroids. This constellation has never been reported before; we therefore present an interesting clinical discussion including a brief review of existing literature. Post partum pituitary insufficiency is an under-reported condition of immense clinical importance especially in the developing world. A high clinical index of suspicion is vital to ensure an early and correct diagnosis which will have a direct bearing on management and patient outcome

Estimating the prevalence, quality of life, economic and societal impact of arthritis in Tanzania: protocol for a mixed methods study [Protocol]

Introduction: Musculoskeletal (MSK) disorders are one of the major causes of disability globally. A 2010 Global Burden of Disease study reported that MSK diseases account for 20% of all Years Lived with Disability (YLDs) in Low- and Middle-Income countries. This study will use mixed methods to generate new findings on the prevalence, quality of life, economic and societal impact of musculoskeletal disorders (including arthritis) in the Hai district in Tanzania. Methods and analysis: In this mixed-methods study funded by the UK’s National Institute for Health Research (NIHR) Global Health Research Units and Groups (Award no: 17/63/35) we will conduct quantitative, community-based (urban, peri - urban and rural) and hospital based prospective surveys, supported by rapid ethnographic assessments (REAs), in-depth interviews, focus group discussions (FGDs) and clinical diagnostic screening to estimate the prevalence, economic and societal impact of arthritis. A retrospective medical records baseline review at the Kilimanjaro Christian Medical Centre (KCMC) will also be conducted to assess prevailing documentation and management of arthritis. Ethics and dissemination: Ethical approval has been obtained through Kilimanjaro Christian Medical University College (KCMUCo) Research Ethics and Review committee (CRERC) in Moshi, National Health Research Ethics Committee (NatHREC) of the National Institute for Medical research (NIMR) in Tanzania and the Medical Veterinary and Life Sciences (MVLS) Ethics committee at the University of Glasgow, UK (MVLS ethics project number:20018010). We will disseminate the findings in clinical, epidemiological, and economic peer reviewed journals. Other dissemination modalities include professional conferences, short reports, community leaflets, policy briefs and dissemination events to communities and various stakeholders including the Ministry of health in Tanzania

A roadmap for kidney care in Africa: An analysis of International Society of Nephrology–Global Kidney Health Atlas Africa data describing current gaps and opportunities

Delivery of kidney care in Africa is significantly constrained by various factors. In this review, we used International Society of Nephrology–Global Kidney Health Atlas (ISN–GKHA) data for Africa to address sub-regional differences in care delivery in the continent with focus on infrastructure, workforce, and the economic aspects of kidney care. Forty two African countries participated in the survey conducted in 2018. North Africa had the highest proportions of nephrologists [12.53 per million population (pmp)], nephrology trainees (2.19 pmp) and haemodialysis (HD) centres (8.58 pmp); whereas southern Africa had the highest proportions of peritoneal dialysis (PD) centres (0.89 pmp) and kidney transplant (KT) centres (0.29 pmp); West Africa had the greatest nephrology workforce shortages. The annual median costs of HD (US$22,731 [interquartile range (IQR): US$1,560–43,902]) and PD (US$34,165 [US$34,165–34,165]) were highest in Central Africa and only Algeria, Egypt and South Africa reported zero co-payment for all modalities of kidney replacement therapy in the public sector. Policies on chronic kidney disease and non-communicable diseases were scarcely available across all African sub-regions. The ISN–GKHA African data highlight a stark difference in kidney care measures between North and sub-Saharan Africa and also suggest the need for a more cohesive approach to policy formulations that support and protect patients with kidney disease in the continent, especially from the excessive costs associated with care. Using the World Health Organization (WHO) Global Action Plan for noncommunicable diseases, this paper proposes an African roadmap for optimal kidney care

Establishing a core outcome set for peritoneal dialysis : report of the SONG-PD (standardized outcomes in nephrology-peritoneal dialysis) consensus workshop

Outcomes reported in randomized controlled trials in peritoneal dialysis (PD) are diverse, are measured inconsistently, and may not be important to patients, families, and clinicians. The Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) initiative aims to establish a core outcome set for trials in PD based on the shared priorities of all stakeholders. We convened an international SONG-PD stakeholder consensus workshop in May 2018 in Vancouver, Canada. Nineteen patients/caregivers and 51 health professionals attended. Participants discussed core outcome domains and implementation in trials in PD. Four themes relating to the formation of core outcome domains were identified: life participation as a main goal of PD, impact of fatigue, empowerment for preparation and planning, and separation of contributing factors from core factors. Considerations for implementation were identified: standardizing patient-reported outcomes, requiring a validated and feasible measure, simplicity of binary outcomes, responsiveness to interventions, and using positive terminology. All stakeholders supported inclusion of PD-related infection, cardiovascular disease, mortality, technique survival, and life participation as the core outcome domains for PD