Prevalence of microalbuminuria and associated factors among HIV - infected ART naïve patients at Mulago hospital: a cross-sectional study in Uganda.

BACKGROUND: HIV infection affects multiple organs and the kidney is a common target making renal disease, one of the recognized complications. Microalbuminuria represents an early, important marker of kidney damage in several populations including HIV-infected antiretroviral therapy (ART) naïve patients. Early detection of microalbuminuria is critical to slowing down progression to chronic kidney disease (CKD) in HIV-infected patients, however, the burden of microalbuminuria in HIV-infected antiretroviral therapy (ART) naïve patients in Uganda is unclear. METHODS: A cross-sectional study was conducted in the Mulago Immune suppression syndrome (ISS) clinic among adult HIV - infected ART naïve outpatients. Data on patient demographics, medical history was collected. Physical examination was performed to assess body mass index (BMI) and hypertension. A single spot morning urine sample from each participant was analysed for microalbuminuria using spectrophotometry and colorimetry. Microalbuminuria was defined by a urine albumin creatinine ratio (UACR) 30-299 mg/g and macroalbuminuria by a UACR > 300 mg/g. To assess the factors associated with microalbuminuria, chi-square, Fisher's exact test, quantile regression and logistic regression were used. RESULTS: A total of 185 adult participants were consecutively enrolled with median age and CD4+ counts of 33(IQR = 28-40) years and 428 (IQR = 145-689) cells/μL respectively. The prevalence of microalbuminuria was 18.9% (95% CI, 14-25%). None of the participants had macroalbuminuria. CD4+ count <350cells/μL was associated with increased risk of microalbuminuria (OR: 0.27, 95% CI: 0.12-0.59), P value = 0.001). Diabetes mellitus, hypertension, smoking, alcohol intake were not found to be significantly associated with microalbuminuria. CONCLUSION: Microalbuminuria was highly prevalent in adult HIV - infected ART naive patients especially those with low CD4+ count. There is need to study the effect of ART on microalbuminuria in adult HIV - infected patients

Thirty years old lady with nephrotic syndrome: a case of biopsy proven lupus nephritis in Tanzania

We describe a case of a 30 years old female patient who presented with nephrotic syndrome and impaired renal function which was diagnosed to have systemic lupus erythematosus (SLE) with lupus nephritis. This is the first biopsy proven lupus nephritis in Tanzania. SLE is common among females and is reported be more common among Africans as compared to other races. This patient presented with nephrotic syndrome, pleural effusion and pericardial effusion which depicts the multisystem effects of SLE. This patient was treated with cyclophosphamide in combination with steroid as induction therapy and attained remission after one month of treatment. Systemic lupus erythematosus should be considered in patients with nephrotic syndrome and these patients should have renal biopsy to determine renal involvement

Flow diagram of mid-level practitioners who attended the Integrated Management of Infectious Diseases course.

<p>The figure shows the selection and random allocation of health facilities to two arms. Participants in arm A attended the Integrated Management of Infectious Disease (IMID) training program and On-Site Support. Participants in arm B attended IMID.</p

Capacity-Building and Clinical Competence in Infectious Disease in Uganda: A Mixed-Design Study with Pre/Post and Cluster-Randomized Trial Components

<div><h3>Trial Design</h3><p>Best practices for training mid-level practitioners (MLPs) to improve global health-services are not well-characterized. Two hypotheses were: 1) Integrated Management of Infectious Disease (IMID) training would improve clinical competence as tested with a single arm, pre-post design, and 2) on-site support (OSS) would yield additional improvements as tested with a cluster-randomized trial.</p> <h3>Methods</h3><p>Thirty-six Ugandan health facilities (randomized 1∶1 to parallel OSS and control arms) enrolled two MLPs each. All MLPs participated in IMID (3-week core course, two 1-week boost sessions, distance learning). After the 3-week course, OSS-arm trainees participated in monthly OSS. Twelve written case scenarios tested clinical competencies in HIV/AIDS, tuberculosis, malaria, and other infectious diseases. Each participant completed different randomly-assigned blocks of four scenarios before IMID (t0), after 3-week course (t1), and after second boost course (t2, 24 weeks after t1). Scoring guides were harmonized with IMID content and Ugandan national policy. Score analyses used a linear mixed-effects model. The primary outcome measure was longitudinal change in scenario scores.</p> <h3>Results</h3><p>Scores were available for 856 scenarios. Mean correct scores at t0, t1, and t2 were 39.3%, 49.1%, and 49.6%, respectively. Mean score increases (95% CI, p-value) for t0–t1 (pre-post period) and t1–t2 (parallel-arm period) were 12.1 ((9.6, 14.6), p<0.001) and −0.6 ((−3.1, +1.9), p = 0.647) percent for OSS arm and 7.5 ((5.0, 10.0), p<0.001) and 1.6 ((−1.0, +4.1), p = 0.225) for control arm. The estimated mean difference in t1 to t2 score change, comparing arm A (participated in OSS) vs. arm B was −2.2 ((−5.8, +1.4), p = 0.237). From t0–t2, mean scores increased for all 12 scenarios.</p> <h3>Conclusions</h3><p>Clinical competence increased significantly after a 3-week core course; improvement persisted for 24 weeks. No additional impact of OSS was observed. Data on clinical practice, facility-level performance and health outcomes will complete assessment of overall impact of IMID and OSS.</p> <h3>Trial Registration</h3><p>ClinicalTrials.gov <a href="http://www.clinicaltrials.gov/ct2/show/NCT01190540">NCT01190540</a></p> </div

Inclusion and exclusion criteria for health facilities and mid-level practitioners.

<p>Inclusion and exclusion criteria for health facilities and mid-level practitioners.</p

Aggregate Mean New Scenario Scores and Score Changes by Arm and Time.

<p>Abbreviations. t0: Pretest (baseline); t1: End of 3-week core course; t2: End of 2^nd boost course (24 weeks after t1).</p

Scenario Content Description; Evolution of Scores on New Scenarios by Scenario and Block.

<p>Abbreviations. AIDS: acquired immune deficiency syndrome; ART: antiretroviral therapy; HIV: human immunodeficiency virus; IRIS: immune reconstitution inflammatory syndrome; PMCT: prevention of mother to child transmission (of HIV); TB: tuberculosis.</p>*<p>Although they did not focus on pregnancy, these scenarios also addressed antenatal and post-partum PMTCT protocols.</p

Allocation of case scenarios across testing points.

<p>The 72 IDCAP participants (36 from arm A, 36 from arm B) were randomly assigned to three groups, which contained 12 participants from each arm. The 12 clinical case scenarios were distributed across three, 4-scenario blocks (A, B, and C), and each group was assigned to a different sequence of blocks.</p