A retrospective review of the profile and clinical course of patients requiring acute dialysis at Chris Hani Baragwanath Academic Hospital over a 2 year period

A Research Report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree Of Master of Medicine Johannesburg, 2014Acute kidney injury (AKI) is a condition with high rates of mortality and morbidity in the hospital setting. Various factors, such as social, political and ethical dilemmas are closely associated with scarce resources in the management of AKI in Africa. We therefore reviewed the demography, causes and outcomes of AKI at Chris Hani Baragwanath Academic Hospital (CHBAH). Methods A retrospective review of 324 patients with renal failure who were initiated on acute dialysis at the CHBAH over the periods of 1 July 2009 to 30 June 2011 was done. Results The mean age at presentation with AKI was 40±13 years. Males accounted for 57% whist 92% of the total cohort were Black. HIV positivity occurred in 26% of patients, whilst 4% and 2% of the cohort had Hepatitis B and C infection respectively. The leading causes for initiation of acute dialysis included decompensated chronic kidney disease (38.9%), acute tubular necrosis (ATN) (38.3%), HIV related kidney disease (13.6%), pregnancy-related kidney disease (7.4%), glomerulonephritis (7.4%) and malaria (5.7%). Acute tubular necrosis due to sepsis was the predominant cause of AKI in HIV positive patients. Decompensated chronic kidney disease was present in a large proportion of patients, suggesting that chronic co-morbid diseases such as hypertension and diabetes mellitus occurred in a large proportion of the general population. Medical referrals accounted for 78% of the patients presenting with AKI. Renal recovery occurred in patients presenting with a lower average pre-dialysis blood urea level of 34±19 mmol/l, compared to higher levels seen in patients with poorer outcomes (p <0.0001). Pregnancy- related kidney injury had the lowest average pre-dialysis blood urea levels of 20±6 mmol/l. The average pre-dialysis serum creatinine in patients with renal recovery was 804±467 μmol/l compared to those with poorer outcomes, that had average serum creatinine levels of greater than 1000 μmol/l at initiation of dialysis (p <0.0001). The overall renal recovery rate was 31%, with a mortality rate of 23%. Failure to regain renal function with subsequent chronic consequences occurred in 44.6% of patients, of which 23% were transferred to chronic renal replacement therapy and the remaining 21.6% of patients were transferred to Renal out patients department with cessation of acute dialysis. HIV positive patients had a greater renal recovery rate (36% vs 26%); however they had a higher mortality rate compared to their HIV negative counterparts (34% vs 19%); (p <0.0001). HIV positive patients with CD4 counts greater than 200 cells/μl had a 46% renal recovery rate compared to 30% in patients with CD4 counts less than 200 cells/μl (p=0.1894). Mortality with CD4 counts less than 200 cells/μl was 38% compared to 26% in patients with CD4 counts greater than 200 cells/μl (p=0.1894). Mortality rates were similar in HIV positive patients treated with antiretrovirals (ARVs) compared to those that were ARV-naive (p =0.5857). Pregnancy-related kidney injury and malaria both had high rates of renal recovery, 92% and 79% respectively. Discussion The mean age of presentation of AKI were consistent with other studies in developing countries but was substantially lower than in developed countries such as the United Kingdom and Spain. The underlying aetiology of AKI at CHBAH resembles that of other developing nations with ATN, malaria and pregnancy-induced kidney injury being amongst the leading causes. Acute tubular necrosis still remains a common cause of AKI in South Africa as previously documented by Seedat et al. Malignancy and obstructive uropathy occurs at a much lower frequency compared to developed nations. The leading cause in HIV positive patients is ATN secondary to sepsis. Mortality occurred in 23% of the cohort, with HIV positive patients having a much higher mortality of 34%, concurring with a Johannesburg-based study by Vachiat et al. Initiating dialysis at lower blood urea and serum creatinine levels in all patent groups had a much better outcome, including in HIV positive patients. Conclusion AKI remains a common presentation that frequently requires dialysis, a scarce resource in an already overburdened health system, with a high mortality rate. HIV positive patients had a higher mortality rate compared to HIV negative patients; however a higher renal recovery rate was observed in this group. CD4 count and ARV status had no statistical significant effect on outcomes, probably due to the small sample size

A retrospective review of the relationship between peritonsillar abscess and HIV

MMed (Otorhinolaryngology), Faculty of Health Sciences, University of the WitwatersrandHIV/AIDS continues to be an important public health challenge in sub Saharan Africa. It is estimated that approximately 68% of people living with HIV in the world are from this region [1]. South Africa has the largest infected population in the world, the adult (15-49 years) HIV prevalence is estimated at 17.64% [2]. It has been estimated that 40 - 70% of such HIV positive individuals present with head and neck manifestations, which include infection, inflammation and tumours, and are often the only and initial presenting sign [3,4]. Peritonsillar abscess is the most common deep infection of the head and neck in young adults and can occur in all age groups, but the highest incidence is in adults 20 to 40 years of age [5]. The aim of this study was to assess the relationship between peritonsillar abscess and the HIV status of patients. Method: An analytical cross sectional study utilising retrospective clinical data from ward registers, patient records, treatment registers and National Health Laboratory System (NHLS) databases. This study was conducted in the adult ENT ward at the Chris Hani Baragwanath Hospital and sample consisted of patient records over a 4 year period from January 2005 to December 2008. All patients admitted to the ENT ward with the discharge diagnosis of peritonsillar abscess that have been tested for HIV were included in this study. In this study period 450 patient files were reviewed of which 291 fulfilled the inclusion criteria. The demographic details, clinical presentation which included head and neck manifestations of HIV, the HIV status, management and complications of peritonsillar abscess were recorded. This data was analysed using STATA-10 software. Results: The age ranged from 15 to 63 years with a mean (SD) 29.3 years (9.58). From the 291 patients, 86 (29.55%) were HIV positive. This is significantly higher than the adult (15-49years) HIV prevalence rate of 17.64% [6]. The male: female ratio of HIV positive patients 1:1.53. Forty-nine (16.84%) patients presented with cervical lymph nodes of which 65.31% were HIV positive (P< 0.001). From the 86 HIV positive patients oral candida was present in 15.12% (P<0.001), lymphoma in 6.98% (P<0.001), oral hairy leukoplakia in 2.33%, Kaposi’s sarcoma in 1.16% and complications (parapharyngeal abscess) 3.48%. There was no statistical significance in the management of HIV positive patients, however hospital stay was longer with a mean of 3.802 days (P<0.001). From this study sample the HIV prevalence of 29.55% suggests that peritonsillar abscess may be an early clinical marker of HIV infection. Due to the high incidence of head and neck manifestations in HIV positive patients identifying a clinical marker (quinsy) in the earlier stages of HIV infection would allow for better screening, earlier diagnosis and treatment of HIV infection

Neuroendocrine tumour in a patient with neurofibromatosis type 1 and HIV

We report the case of an HIV-positive female patient with neurofibromatosis type 1 who was treated for recurrent peptic ulcer disease and later developed diabetes mellitus and chronic diarrhoea. A metastasising somatostatinoma was histologically proven and evidence of a concomitant gastrin-producing neuroendocrine tumour was found. Neuroendocrine tumours (NETs) are very rare neoplasms originating from a wide variety of endocrine and nervous system tissue with the ability to produce different hormones. A somatostatin- and gastrinsecreting NET in a patient with HIV has not been reported in the literature, to the best of our knowledge. We discuss oncogenic pathomechanisms related to the underlying conditions and propose stringent monitoring for tumours in HIV-positive patients with phakomatoses as well as initiation of antiretroviral therapy.http://www.sajhivmed.org.za/am201

Tuberculosis and Hepatic Steatosis Are Prevalent Liver Pathology Findings among HIV-Infected Patients in South Africa

Liver disease epidemiology in sub-Saharan Africa has shifted as a result of HIV and the increased use of antiretroviral therapy leading to a need for updated data on common causes of liver disease. We retrospectively reviewed records from all hospitalized patients who had liver biopsy at a single hospital in South Africa from 2001 to 2009 and compared diagnosis by HIV status. During the period of study 262 patients had liver biopsy, 108 (41%) were HIV-infected, 25 (10%) were HIV-sero-negative, and 129 (49%) had unknown or unrecorded HIV status. Overall 81% of biopsies provided additional diagnostic data. Malignancy was the most common finding reported on 56 (21%) biopsies followed by granuloma or TB, hepatic steatosis, and fibrosis or cirrhosis. HIV-infected patients were more likely to have granulomas and steatosis. Half of patients with granulomas were already on TB treatment, suggesting paradoxical reactions or drug induced liver injury may have been important causes of liver inflammation among these patients. We note that TB, paradoxical reactions during TB treatment, possible drug induced liver injury, and hepatic steatosis are important causes of liver pathology among HIV-infected hospitalized patients with unclear etiology of liver disease after initial assessment. Among HIV sero-negative patients, malignancy was the major cause of liver disease. Our findings re-enforce the importance of TB as a diagnosis among HIV-infected individuals.\ud \u

Prevalence and risk factors for latent tuberculosis infection among household contacts of index cases in two South African provinces: Analysis of baseline data from a cluster-randomised trial.

INTRODUCTION: Household contacts of patients with active pulmonary tuberculosis (TB) often have latent TB infection, and are at risk of progression to disease. We set out to investigate whether index TB case HIV status was linked to a higher probability of latent TB infection among household contacts. MATERIALS AND METHODS: Data were collected prospectively from participants in the intervention arm of a household cluster-randomised trial in two South Africa provinces (Mangaung, Free State, and Capricorn, Limpopo). In intervention group households, TB contacts underwent HIV testing and tuberculin skin testing (TST). TST induration was estimated at two cut-offs (≥5mm, ≥10mm). Multilevel Bayesian regression models estimated posterior distributions of the percentage of household contacts with TST induration ≥5mm and ≥10mm by age group, and compared the odds of latent TB infection by key risk factors including HIV status index case age and study province. RESULTS: A total of 2,985 household contacts of 924 index cases were assessed, with most 2,725 (91.3%) undergoing TST. HIV prevalence in household contacts was 14% and 10% in Mangaung and Capricorn respectively. Overall, 16.8% (458/2,725) had TST induration of ≥5mm and 13.1% (359/2,725) ≥10mm. In Mangaung, children aged 0-4 years had a high TST positivity prevalence compared to their peers in Capricorn (22.0% vs. 7.6%, and 20.5% vs. 2.3%, using TST thresholds of ≥5mm and ≥10mm respectively). Compared to contacts from Capricorn, household contacts living in Mangaung were more likely to have TST induration ≥5mm (odds ratio [OR]: 3.08, 95% credibility interval [CI]: 2.13-4.58) and ≥10mm (OR: 4.52, 95% CI: 3.03-6.97). There was a 90% and 92% posterior probability that the odds of TST induration ≥5mm (OR: 0.79, 95% CI: 0.56-1.14) and ≥10mm (OR: 0.77, 95% CI: 0.53-1.10) respectively were lower in household contacts of HIV-positive compared to HIV-negative index cases. CONCLUSIONS: High TST induration positivity, especially among young children and people living in Mangaung indicates considerable TB transmission despite high antiretroviral therapy coverage. Household contact of HIV-positive index TB cases were less likely to have evidence of latent TB infection than contacts of HIV-negative index cases

Origine sociale et comportement politique

Les conséquences politiques de la mobilité sociale intergénérationnelle sur les comportements et les attitudes politiques des individus ont fait l'objet, depuis une vingtaine d'années, d'une série de recherches en particulier aux Etats-Unis et en Angleterre. A la suite de ces travaux une conclusion majeure semble s'imposer : les « mobiles sociaux » adopteraient un comportement politique intermédiaire entre leur groupe d'origine et leur groupe d'arrivée. Dans cette recherche, qui se fonde sur l'analyse d'un échantillon représentatif de cadres moyens et supérieurs, l'origine sociale paraît effectivement déterminer pour partie les comportements et attitudes politiques des individus appartenant aux couches moyennes salariées. Toutefois, une étude plus précise de ce mécanisme montre que l'effet de l'origine sociale sur le comportement et les attitudes politiques n'est pas seulement fonction de la distance entre la position sociale du père et celle du fils mais se diversifie également selon la nature et les conditions du trajet social effectué par l'individu.The political consequences of intergenerational social mobility on individuals' political attitudes and behavior have been studied in a series of inquiries over the past twenty years, especially in the United States and England. As a result of this work, it seems that one major conclusion may be drawn: the "socially mobile" seem to adopt a political behavior which is intermediate to that of the group from which they started out and that into which they are arriving. In this study based on a representative sample of middle — and upper — level executives, social origin indeed seems to be in part a determining factor in the political behavior and attitudes of individuals belonging to the middle range of the wage scale. However, a closer study of this mechanism shows that the effect of social origin upon political behavior and attitudes is not only a function of the distance between the father's and the son's social positions, but also differs according to the nature and conditions of the individual's social ascension