A case of refractory thrombotic thrombocytopenic purpura treated with plasmapheresis and rituximab

 Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder with no prevalence or incidence studies in sub-Saharan Africa. Acquired TTP has several causes, all of which lead to decreased activity of von Willebrand factor cleaving protease (ADAMTS13) due to autoantibodies that are directed towards ADAMTS13. We report a case of a 46-year-old man who presented with most of the classic clinical manifestations of TTP

A case of refractory thrombotic thrombocytopenic purpura treated with plasmapheresis and rituximab

Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder with no prevalence or incidence studies in sub-Saharan Africa. Acquired TTP has several causes, all of which lead to decreased activity of von Willebrand factor cleaving protease (ADAMTS13) due to autoantibodies that are directed towards ADAMTS13. We report a case of a 46-year-old man who presented with most of the classic clinical manifestations of TTP

Perceived Barriers to Peritoneal Dialysis Among Kenyan Nephrologists: A Cross-Sectional Descriptive Study

Background: Peritoneal dialysis (PD) is a well-recognized technique of renal replacement therapy (RRT), with similar efficacy as well as survival outcomes as hemodialysis (HD). Despite its advantages including prolonged preservation of residual renal function, potentially lower cost and advances with automated techniques, and commercialization of more biocompatible solutions, the overall prevalence of patients treated with PD is still very low in developed countries and even more so in Africa and low-middle income countries like Kenya. According to our knowledge, no local studies have been done on prevalence of peritoneal dialysis or on potential barriers to utilization of PD as an RRT modality. Objective: To explore perceptive barriers of nephrologists to PD utilization. Methodology: A computer-base, 22-question questionnaire was formulated using the Delphi technique and sent out to all the nephrologists via emails. There were 30 nephrologists, in clinical practice in Kenya, at the time when the study was conducted. This is according to the registry maintained by the Kenya Renal Association (KRA). Their contacts were obtained from the registry. Design: A cross-sectional descriptive study. Setting: A computer based 22-question questionnaire was administered to 23 nephrologists in Kenya. Results: Among the total number of 23 nephrologists, 39% reported to be looking after patients maintained on PD despite 59% of them reporting that they think patients should be maintained on PD. Only 21% of respondents felt limited training in PD limited their use of PD and only 23% felt poor personal experience contributed to limited use. Other barriers that came up with a relative majority of the respondents included lack of nursing expertise, concerns with PD catheter placement, concerns about long-term viability of continuous peritoneal dialysis, concerns about technique failure and peritonitis, lack of facility support for PD, and lack of dialysis education programs. Conclusion: A significant proportion of nephrologists in this survey felt PD, as a modality of RRT, was underutilized and reported systemic and technical factors as being potential barriers

Association between dialysate sodium concentration and interdialytic weight gain in patients undergoing twice weekly haemodialysis

Abstract Background Chronic kidney disease is highly prevalent across the globe with more than 2 million people worldwide requiring renal replacement therapy. Interdialytic weight gain is the change in body weight between two sessions of haemodialysis. Higher interdialytic weight gain has been associated with an increase in mortality and adverse cardiovascular outcomes. It has long been questioned whether using a lower dialysate sodium concentration during dialysis would reduce the interdialytic weight gain and hence prevent these adverse outcomes. Methods This study was a single blinded cross-over study of patients undergoing twice weekly haemodialysis at the Aga Khan University Hospital, Nairobi and Parklands Kidney Centre. It was conducted over a twelve-week period and patients were divided into two groups: dialysate sodium concentration of 137 meq/l and 140 meq/l. These groups switched over after a six-week period without a washout period. Univariate analysis was conducted using Fisher’s exact test for categorical data and Mann Whitney test for continuous data. Results Forty-one patients were included in the analysis. The mean age was 61.37 years, and 73% were males. The mean duration for dialysis was 2.53 years. The interdialytic weight gain was not significantly different between the two groups (2.14 for the 137 meq/l group and 2.35 for the 140 meq/l group, p = 0.970). Mean blood pressures were as follows: pre-dialysis: DNa 137 meq/l: systolic 152.14 ± 19.99, diastolic 78.99 ± 12.20, DNa 140 meq/l: systolic 156.95 ± 26.45, diastolic 79.75 ± 11.25 (p = 0.379, 0.629 respectively). Post-dialysis: DNa 137 meq/l: systolic 147.29 ± 22.22, diastolic 77.85 ± 12.82 DNa 140 meq/l: systolic 151.48 ± 25.65, diastolic 79.66 ± 15.78 (p = 0.569, 0.621 respectively). Conclusion There was no significant difference in the interdialytic weight gain as well as pre dialysis and post dialysis systolic and diastolic blood pressures between the two groups. Therefore, using a lower dialysate sodium concentration does not appear useful in altering the interdialytic weight gain or blood pressure although further studies are warranted with a larger sample size, taking into account residual renal function and longer duration for impact on blood pressures

A Case Report of Concurrent Cryptococcal and Tuberculous Meningitis in an Immunosuppressed Renal Transplant Patient

Infections after renal transplant are a common cause of morbidity and are commonly due to Cytomegalovirus (CMV), Cryptococcus, Mycobacterium tuberculosis, and Aspergillus. Concurrent infections with both cryptococcal and tuberculous aetiologies are rare within the central nervous system (CNS). We present a case of a 67-year-old male patient who presented with three weeks of headaches, confusion, unsteady gait, and seizures. He had type 2 diabetes mellitus and hypertension. He had a kidney transplant three years prior and was on three immunosuppressive agents. He was HIV-negative. He was evaluated and found to have cryptococcal meningitis and received appropriate treatment with liposomal amphotericin B, flucytosine, and serial lumbar punctures. He also had treatment for CMV viremia with valganciclovir. Three weeks later, after an initial good clinical response, he deteriorated with worsening confusion and persistent seizures. We re-evaluated him and found him to have brain imaging suggestive of tuberculosis. We started him on anti-tuberculous medication, and he improved significantly and was alert and seizure free at discharge home one month later. This case highlights that concurrent CNS infections with cryptococcus and tuberculosis do occur especially in patients who are severely immunosuppressed such as after a renal transplant. Failure to improve while on treatment for one CNS opportunistic infection should prompt one to investigate for other concurrent causes

Associated Factors and Outcomes of Acute Kidney Injury in COVID-19 Patients in Kenya.

Background; Corona Virus Disease 2019 (COVID-19), an infection caused by the SARS-CoV-2 virus, has been the largest global pandemic since the turn of the 21st century. With emerging research on this novel virus, studies from the African continent have been few. Corona Virus Disease 2019 has been shown to affect various organs including the lungs, gut, nervous system, and the kidneys. Acute kidney injury (AKI) is an independent risk factor for mortality and increases the health care burden for patients with persistent kidney dysfunction and maintenance dialysis. Sub-Saharan Africa has a high number of poorly controlled chronic illnesses, economic inequalities, and health system strains that may contribute to higher cases of kidney injury in patients with COVID-19 disease. Objectives: The objective of this study was to determine the incidence, associated factors, and outcomes of AKI in patients hospitalized with COVID-19 in Kenya. Methods: This retrospective cohort study included 1366 patients with confirmed COVID-19 illness hospitalized at the Aga Khan University Hospital in Nairobi, Kenya, between April 1, 2020 and October 31, 2021. Data were collected on age, sex, the severity of COVID-19 illness, existing pregnancy and comorbid conditions including human immunodeficiency virus (HIV), diabetes mellitus, hypertension, and functioning kidney transplant patients. Univariate analysis was carried out to determine the association of clinical and demographic factors with AKI. To determine independent associations with AKI incidence, a logistic regression model was used and the relationship was reported as odds ratios (ORs) with a 95% confidence interval (CI). The outcomes of AKI including the in-hospital mortality rate, renal recovery rate at hospital discharge, and the duration of hospital stay were reported and stratified based on the stage of AKI. Results: The median age of study patients was 56 years (interquartile range [IQR] = 45-68 years), with 67% of them being male (914 of 1366). The AKI incidence rate was 21.6% (n = 295). Patients with AKI were older (median age = 64 years vs 54 years; P \u3c .001), majority male (79% of men with AKI vs 63.6% without AKI; P \u3c .001), and likely to have a critical COVID-19 (OR = 8.03, 95% CI = 5.56-11.60; P \u3c .001). Diabetes and hypertension, with an adjusted OR of 1.75 (95% CI = 1.34-2.30; P \u3c .001) and 1.68 (95% CI = 1.27-2.23; P \u3c .001), respectively, were associated with AKI occurrence in COVID-19. Human immunodeficiency virus, pregnancy, and a history of renal transplant were not significantly associated with increased AKI risk in this study. Patients with AKI had significantly higher odds of mortality, and this effect was proportional to the stage of AKI (OR = 11.35, 95% CI = 7.56-17.03; P \u3c .001). 95% of patients with stage 1 AKI had complete renal recovery vs 33% of patients with stage 3 AKI. Of the patients with stage 3 AKI (n = 64), 10 underwent hemodialysis, with 1 recovery in renal function and 3 patients requiring ongoing dialysis after discharge. Conclusions: This study was conducted at a single private tertiary-level health care facility in Kenya and only up to the time of hospital discharge. It is one of the first large studies from sub-Saharan Africa looking at the associated factors and outcomes of AKI in COVID-19 and forms a foundation for further analysis on the long-term consequences of COVID-19 on the kidneys. A major limitation of the study is the lack of baseline pre-admission creatinine values for most patients; thus, the impact of chronic kidney disease/baseline creatinine values on the incidence of AKI could not be established

Helicobacter pylori eradication: A randomised comparative trial of 7-day versus 14-day triple therapy

Background. Helicobacter pylori is associated with several upper gastrointestinal conditions including chronic gastritis, peptic ulcer disease, and gastric malignancy. Proton pump inhibitor-based triple therapies are considered the standard regimens for H. pylori eradication, but the optimal duration of therapy is controversial. To prevent infection and complications, local studies should be undertaken to evaluate H. pylori eradication rates in a country.Objectives. We compared 7-day and 14-day regimens to determine the optimum duration of triple therapy for H. pylori eradication.Methods. We undertook a prospective randomised comparative trial of 7-day and 14-day triple therapy regimen for H. pylori eradication at the Aga Khan University Hospital, Nairobi; 120 patients with dyspepsia and H. pylori infection were randomised to receive esomeprazole, amoxicillin and clarithromycin for either 7 days (EAC 7) or 14 days (EAC 14). Compliance and side-effects were assessed 2 weeks after the start of therapy and H. pylori eradication was assessed by stool antigen tests 4 weeks after treatment.Results. Both the intention-to-treat (ITT; N=120) and per protocol (PP; N=97) analyses showed no significant differences between the eradication rates of EAC 7 (ITT 76.7%; PP 92%) and EAC 14 (ITT 73.3%; PP 93.6%) (ITT p=0.67; PP p=0.76). Poor compliance was reported in one patient in the EAC 14 group. The incidence of adverse events was comparable in the two groups.Conclusion. One-week and 2-week triple treatments for H. pylori eradication are similar in terms of efficacy, safety and patient compliance.S Afr Med J 2012;102(6):368-371

A randomised comparative trial of seven versus fourteen day triple therapy for helicobacter pylori eradication at The Aga Khan University Hospital, Nairobi

Background: Helicobacter is associated with a number of important upper gastrointestinal conditions including chronic gastritis, peptic ulcer disease, and gastric malignancy. Proton pump inhibitor -based triple therapies are considered the standard regimens for Helicobacter pylori eradication, but the optimal duration of these regimens is still controversial. Local studies are required to evaluate the H. pylori eradication rates in a country for adequate eradication to prevent H. pylori infection and complications Objectives: The main objective of this study was to compare 7 day and 14 day regimens and determine the optimum duration of triple therapy for H. pylori eradication. Methods: A prospective randomised comparative trial of 7 and 14 day H. pylori eradication triple therapy at the Aga Khan University Hospital Nairobi. One hundred and twenty patients with dyspepsia and H. pylori infection were randomized to receive esomeprazole, amoxicillin and clarithromycin for either 7 days (EAC 7) or 14 days (EAC 14). Compliance and side affects were assessed two weeks after start of therapy and H. pylori eradication was assessed by H. pylori stool antigen done four weeks after treatment. Results: Both the intention-to-treat (ITT; n = 120) and per protocol (PP; n = 97) analyses showed no significant differences between the eradication rates of EAC 7 (ITT 76.7%; PP 92%) and EAC 14 (ITT 73.3%; PP 93.6%; ITT p = 0.67; PP p = 0.76). Poor compliance was reported in only one patient who was in EAC 14 group. Incidences of adverse events were comparable. Conclusion: 1-week and 2-week triple treatments for H. pylori eradication are similar in terms of efficacy, safety and patient compliance

Treatment of steroid-resistant focal segmental glomerulosclerosis with rituximab: A case report and review of literature

Various immunomodulating agents have been tried for the treatment of steroid-resistant focal segmental glomerulosclerosis (FSGS) in the native kidney. A few case series and small studies have reported mixed results with the use of Rituximab for this indication. We report on the case of a 76-year-old male with steroid-resistant FSGS successfully treated with rituximab and remained in remission at the end of six months. A review of the literature highlights the paucity of data on this subject. We conclude that rituximab is a potentially useful treatment for steroid resistant FSGS and larger controlled studies are needed to further define its role in this setting

A delay in diagnosis: thrombotic thrombocytopenia purpura occurring in systemic lupus erythematous

Thrombotic thrombocytopenia purpura (TTP) in the background of systemic lupus erythematous (SLE) remains rare with an incidence of about 2%. Both conditions have overlapping features and can thus be difficult to differentiate and diagnose. A careful review of the peripheral blood smear remain essential often providing many clues. The diagnosis of TTP is a medical emergency and therapy should be instituted immediately. We present one such challenging case where a delay in diagnosis due to limited resources could have proven fatal for our patient