Management of Renovascular Disease

Introduction: Renal artery stenosis (RAS) is not rare, but is often asymptomatic. In older individuals, atherosclerosis is the most common cause of RAS. Atherosclerotic RAS is usually one manifestation of wide spread atherosclerotic disease, and its presence increases the morbidity and mortality of other manifestations of atherosclerotic disease. Review: Renal arterial disease discovered incidentally can be managed expectantly as long as blood pressure and kidney function are well maintained. Revascularization can be considered with the prospect of improving blood pressure control or impaired kidney function, but its outcomes are heterogeneous. The potential for serious deterioration in kidney function after revascularization underscores the need to select patients carefully for vascular procedures in the kidney. Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are effective in treating most cases of hypertension in atherosclerotic RAS. In addition, clinical data suggest that the survival of patients with renovascular hypertension is better when ACE inhibitors are part of therapy than when they are not. This benefit may be in part due to the fact that ACE inhibitors reduce morbidity and mortality in congestive heart failure which is common co-morbidity in patients with RAS. Withdrawal of the ACE inhibitor in such patients should occur only when the rise in serum creatinine level exceeds 30% above baseline within the first two months of ACE inhibitor initiation, or if hyperkalemia develops. Conclusion: Renovascular hypertension is best managed with ACE inhibitors or ARBs as long as blood pressure and renal function are well maintained. Revascularization should be considered if blood pressure control is not adequate or if renal function deteriorates. Key words: renovascular disease, renal artery stenosis, renal artery occlusio

Restoration of Kidney Function after Prolonged (Four Months)Anuria Due to Bilateral Renal Artery Occlusion

Introduction: Atherosclerotic renal artery stenosis (RAS) is usually one manifestation of wide spread atherosclerotic disease and its presence has a grave impact on prognosis. RAS is a progressive condition that can remain asymptomatic for a long time, only to present later with accelerated hypertension or renal insufficiency. The first approach to the management of atherosclerotic RAS consists of medical therapy to control blood pressure and other atherosclerotic risk factors. However, surgical or percutaneous revascularization can be of substantial benefit in selected patient groups. Case Report: A 37 year old man who was a heavy smoker and known to have hypertension for the previous five years presented with acute anterior myocardial infarction (MI). His serum creatinine was 8.5 mg/dl and he needed a session of acute peritoneal dialysis to relieve severe pulmonary edema. Subsequent investigations revealed the presence of bilateral total occlusion of the renal arteries resulting in severe renal impairment and dialysis dependency. He underwent two unsuccessful attempts at angioplasty. Surgical revascularization of both renal arteries was eventually carried out after four months of anuria, and was immediately followed by dramatic improvement of his kidney function. The patient, however, continued to receive antihypertensive medication for adequate blood pressure control. Conclusion: This case reflects the ability of the kidney to adapt to chronic ischemia, and underscores the importance of considering renal revascularization in all patients with renal artery occlusion, even after long periods of kidney non-functioning. Key words: renal artery occlusion, renaovascular disease, renal revascularization, ischemic nephropath

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

Post Transplant Diabetes Mellitus in Ahmed Gasim Kidney Transplant Center, Sudan

Introduction: New onset post transplant diabetes mellitus (PTDM) is a common complication of kidney transplantation with a negative impact on patient and graft survival. Non-white ethnicity is a well known risk factor for PTDM. Methods: This is a retrospective study of 221 Sudanese patients who received live donor kidney transplantation in Ahmed Gasim kidney transplant center between December 2001 and December 2007, focusing on the incidence, clinical course and prognosis of PTDM during the first post transplant year, and relating this to calcineurin inhibitor use. Results: The 12 months cumulative incidence of PTDM in our transplant population was 17.6% and all cases required treatment with insulin. 53.8% of PTDM cases were transient with a median duration of 76 days; by 12 months post transplant only 6.2% of patients were receiving insulin. The 12 months cumulative incidence of PTDM was higher in the tacrolimus compared to cyclosporine groups (25.4% versus 6.6%; OR 4.8, 95% CI: 1.9-12.1; P=0.00). During the follow up period 57.6% of PTDM patients in the tacrolimus group were able to discontinue insulin compared to 33.3% of PTDM patients in the cyclosporine groups (OR 2.7, 95% CI: 0.4-17; P=0.3). By 12 months post transplant, the proportion of patients receiving insulin was not significantly different between the two groups (8.0% versus 4.0%; OR 2.1, 95% CI 0.5-8.4; P = 0.2). Conclusion: The incidence of PTDM in our transplant population is not different from that reported in published randomized controlled trials and similarly, in the majority of cases PTDM was transient. Key words: Post transplant diabetes mellitus, kidney transplantation, tacrolimus, cyclosporine, calcineurin inhibito

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

The Sudan Peritoneal Dialysis Program: Three Years of Momentum

Introduction: End stage renal disease (ESRD) is a significant social and economic burden on Africa. Continuous ambulatory peritoneal dialysis (CAPD) was introduced as a national service in the Sudan three years ago. An overview of the Sudan Peritoneal Dialysis Program is presented. Review: As a national scheme, the Sudan PD program was sequentially launched in seven centers in Sudan. CAPD was the modality exclusively utilized. The total number of patients enrolled by July 2008 was 232. Patients' mean age was 43 years, 23.5% were children, 63% were males, and 19% were diabetic. PD was the initial dialysis modality for 54.7% of patients, 43.5% were referred from HD, and 1.9% had a failed kidney transplant. The majority of patients (62.3%) chose PD as the preferred dialysis modality, while the remainder were referred from HD to PD because of vascular access problems or hemodynamic instability. One third of patients required assisted PD, and 17% needed urgent initiation of dialysis. The cumulative peritonitis rate was one episode per 10.8 patient months. Touch contamination, urgent initiation of dialysis and execution of dialysis by family members other than trained helpers were among the identified predisposing factors. Conclusion: The establishment and operation of the Sudan PD program over the past three years have indicated that it is a promising project with multifaceted success. There is, however, an ongoing need for retraining of patients and staff. Early selection and careful preparation for potential PD candidates is also of vital importance to reduce the need for urgent dialysis initiation. Key words: peritoneal dialysis, CAPD, renal replacement therapy, Sudan, Afric

Influence of Sugar Cane Mechanical Harvest on Clear Juice Quality at Elguneid Sugar Factory

This study aimed to investigate the influence of mechanical harvest on juice clarification in Elguneid sugar factory. Elguneid factory was designed to treat a hand cut cane more than a mechanical cut cane. So, the clarification system was tuned to meet this purpose. Color, turbidity, reducing sugar, sugar content, purity, pH, brix, temperature and phosphate content were determined. The results showed: the color has increased from 3910 to 13921 ICUMSA, turbidity from 3242 to 8496 and reducing sugar increased to 0.928%. Sucrose content decreased from 14.39 to 11.69% and purity from 88 to 83%. The results of Pol% and Purity% were taken at the beginning of crushing season, where the mechanical harvest was higher than hand cut. A comparative study between hand cut and mechanical harvest was made at the middle of the crushing season. The optimum brix in the clarifiers matched the turbidity decreased at brix 12%, 13% respectively. Also from the tests carried out it was shown that the flocculant and phosphoric acid, which were used by the factory personnel was lower than the standard values, phosphoric acid was 183ppm and the polymer was 1,6ppm. These low values affected the precipitation process. There is a relationship between the amount of mud and type of harvest. It was noticed that there is a relationship between sugar yield and type of harvest

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

Response of Banana "Williams Hybrid" to Nitrogen, Phosphorus and Potassium Fertilization

Field experiments were conducted at the National Institute for Promotion of Horticultural Exports (NIPHE) research farm during the period of 2001 to 2002 to determine the effects of nitrogen, phosphorus and potassium levels on growth parameters, earliness, nutrient uptake, yield and yield components of "William's hybrid" banana cultivar. Treatments included 5 N levels (0, 69, 138, 207 and 276g N/mat/year), 2 P levels (0 and 20 g P/mat/year) and 2 K levels (0 and 41 g K/mat/year) . The treatments were arranged in a randomized complete block design with 3 replications. Banana growth, yield and yield components were significantly increased by N and K application. The highest vegetative growth parameters, yield and yield components were obtained with the application of 207 g N/mat/year in combination with 41 g K/mat/year. Application of N in combination with K also resulted in a significant reduction in the period from plant-ing to shooting and from shooting to fruit maturation. The shortest number of days to shooting were obtained with the application of 276 g N/mat/year. Application of N, P and K also resulted in increased leaf N, P and K contents. Application of P alone or in combinations with N and K had no significant effects on growth or yield parameters