Significance, definition, classification and risk factors of chronic kidney disease in South Africa

Renal dysfunction or chronic kidney disease (CKD) is found in 10% of the global population and is classified into five stages according to the estimated glomerular filtration rate (eGFR). No matter where a patient lives, estimation of the GFR is mandatory for decision-making and obtained by the simple measurement of a serum creatinine level. The objective of diagnosing CKD lies in its future prevention, early detection and proper treatment, which will prevent or delay functional deterioration. Primary hypertension (PH) occurs in 25% of South Africa (SA)’s black population and is the putative cause of stage 5 CKD in 40 - 60% of these patients. Moreover, in this group, stage 5 CKD occurs at a relatively young age (35 - 45 years) compared with other population groups in whom stage 5 CKD resulting from PH usually occurs between 60 and 70 years of age. In the cohort study, PH has been found in 12 - 16% of black school learners (mean age 17 years) compared with 1.8 - 2% of other ethnic groups (mixed race, Asian, white). End-stage renal failure (ESRF) is the fifth most common cause of death in SA, excluding post-traumatic cases. In addition, undiagnosed or poorly controlled PH is a potent risk factor for other cardiovascular disease (CVD), e.g. congestive cardiac failure, myocardial infarction, stroke. Significant protein is also associated with CVD and protein >1 g/d is a significant risk factor for ESRF

Drugs and the kidney

This article on drug nephrotoxicity is detailed, as it is important to be fully aware of renal side effects of drugs with regard to prevention and early diagnosis in order to manage the condition correctly. Many therapeutic agents are nephrotoxic, particularly when the serum half-life is prolonged and blood levels are raised because of decreased renal excretion. Distal nephrotoxicity is markedly enhanced when the glomerular filtration rate (GFR) is reduced and is a particular threat in elderly patients with so called ‘normal’ creatinine levels. In patients of 45 - 55 years of age the GFR is reduced by about 1 mL/min/year, so that an otherwise healthy person of 80 may have an estimated GFR (eGFR) of <60 mL/min or <50 mL/min, i.e. stage 2, 3 or 3b chronic kidney disease (CKD). Furthermore, other effects related to kidney dysfunction may be seen, e.g. worsening of hypertension with the use of non-steroidal anti inflammatory drugs, increased bruising or bleeding tendency with aspirin, and hyponatraemia hypertension acidosis with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Digoxin is contraindicated in stage 3 CKD, even in a reduced dosage. Other drugs can cause the direct formation of kidney stones, e.g. topiramate (used in the prophylaxis of resistant migraine). Levofloxacin (Tavanic) can cause rupture of the Achilles tendon and other tendons.Radiocontrast media must be used with care. Occasionally, strategies to prevent acute kidney insufficiency cause irreversible CKD, especially in patients with diabetes and those with myeloma who have stage 4 - 5 CKD. Gadolinium in its many forms (even the newer products) used as contrast medium for magnetic resonance imaging is best avoided in patients with stages 4 and 5 CKD

Paediatric chronic kidney disease

Doctors use various guidelines on paediatric chronic kidney disease (CKD) for managing their patients according to the availability of resources. As with adolescent and adult patients, CKD in children can also progress to end-stage renal failure – the time course being influenced by several modifiable factors. Decline in renal failure is best categorised in stages, which determine management and prognosis. Staging is based on three categories, i.e. cause, glomerular filtration rate and proteinuria. Early diagnosis of CKD allows for the institution of renoprotective treatment of modifiable factors and treatment to prevent the development of complications. The two most important modifiable factors that can be treated successfully are hypertension and proteinuria. The objective of this article is to provide information on the diagnosis and treatment of CKD in children. Early identification and treatment of modifiable risk factors of CKD decreases the burden of disease and delays or prevents the need for renal replacement therapy

Clinical aspects of chronic kidney disease

Any patient seeking any form of medical advice at any clinic or hospital, or from a doctor or other healthcare worker, should have their blood pressure recorded and a urine dipstick test done. The most useful indication of a diagnosis of any stage of chronic kidney disease, is the presence of either hypertension, urinary dipstick abnormality or both. Many practitioners frequently refer such patients to urologists, which must be discouraged. Referral should be to a nephrologist or specialist physician

Diagnostic approach to chronic kidney disease

Chronic kidney disease (CKD) can be considered to be present if a patient has a glomerular filtration rate <60 mL/min or markers of kidney disease that have been present for >3 months. These include proteinuria, haematuria and radiological abnormalities. Regardless of the stage of CKD, the approach is mainly similar. As stated in the South African Renal Society Guidelines for the early detection and management of CKD, early and appropriate investigation and timeous referral of these patients enable one to establish a specific diagnosis; treat reversible diseases; optimise management to slow the progression of CKD; identify and optimally manage comorbid conditions; and plan renal replacement therapy well before the patient develops end-stage kidney disease

Building a comprehensive mentoring academy for schools of health.

Formal mentoring programs are increasingly recognized as critical for faculty career development. We describe a mentoring academy (MA) developed for faculty across tracks (i.e., researchers, clinicians, educators) within a "school of health" encompassing schools of medicine and nursing. The program is anchored dually in a clinical and translational science center and a school of health. The structure includes the involvement of departmental and center mentoring directors to achieve widespread uptake and oversight. A fundamental resource provided by the MA includes providing workshops to enhance mentoring skills. Initiatives for junior faculty emphasize establishing and maintaining strong mentoring relationships and implementing individual development plans (IDPs) for career planning. We present self-report data on competency improvement from mentor workshops and data on resources and barriers identified by junior faculty (n = 222) in their IDPs. Mentors reported statistically significantly improved mentoring competency after workshop participation. Junior faculty most frequently identified mentors (61%) and collaborators (23%) as resources for goal attainment. Top barriers included insufficient time and time-management issues (57%), funding limitations (18%), work-life balance issues (18%), including inadequate time for self-care and career development activities. Our MA can serve as a model and roadmap for providing resources to faculty across traditional tracks within medical schools

Management of patients with chronic kidney disease

Co-operation between primary healthcare workers (clinic staff and general practitioners) and nephrologists is essential and the ability to refer patients timeously should be on a pre-negotiated and organised basis. This article deals with these aspects, including follow-up guidelines and management and treatment strategies, including lifestyle changes where indicated and referral for end-stage renal failure, i.e. for dialysis and transplantation

Important complications of chronic kidney disease

The complications of chronic kidney disease (CKD) are dyslipidaemia, hyperkalaemia, metabolic acidosis, anaemia, and bone and mineral disorders. Dyslipidaemia may be treated with low-density lipoprotein lowering agents. Statins are ineffective in stages 4 and 5 CKD, but are indicated for preventing the progression of disease in the earlier stages. Chronic acidosis has recently been shown to be a risk factor in the progression of CKD renal dysfunction. Therefore, treatment is mandatory. Practically, this should  consist of 1 - 2 heaped teaspoons of sodium bicarbonate 2 - 3 times per day, which is an inexpensive and safe therapy that does not raise the blood pressure in spite of the increased sodium level. Target levels of haemoglobin, according to international guidelines, are between 10 g/dL and 12 g/dL. The serum phosphate level is raised in stage 4 CKD, and especially in stage 5 CKD, which is associated with coronary carotid and other vascular calcifications and may result in ischaemic heart disease, myocardial infarction and stroke. A raised parathyroid hormone level (secondary hyperparathyroidism) is also a major risk factor for cardiovascular disease and is associated with increased hypertension and resistance to the treatment of CKD-associated anaemia

Important causes of chronic kidney disease in South Africa

In hypertensive patients without chronic kidney disease (CKD) the goal is to keep blood pressure (BP) at ≤140/90 mmHg. When CKD is present, especially where there is proteinuria of ≥0.5 g/day, the goal is a BP of ≤130/80 mmHg. Lifestyle measures are mandatory, especially limitation of salt intake, ingestion of adequate quantities of potassium, and weight control. Patients with stages 4 - 5 CKD must be carefully monitored for hyperkalaemia and deteriorating kidney function if angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are used, especially in patients >60 years of age with diabetes or atherosclerosis. BP should be regularly monitored and, where possible, home BP-measuring devices are recommended for optimal control.Guidelines on the use of antidiabetic agents in CKD are presented, with the warning that metformin is contraindicated in patients with stages 4 - 5 CKD.There is a wide clinical spectrum of renal disease in the course of HIV infection, including acute kidney injury, electrolyte and acid-base disturbances, HIV-associated glomerular disease, acute-on-chronic renal disease and side-effects related to the treatment of HIV

Experience with chronic haemodialysis in Johannesburg

Since 1966 the treatment for patients with end-stage renal disease in Johannesburg has primarily been renal transplantation. This has required an adequate programme of regular dialysis. All patients were treated at the central hospital or at two small satellite units. A total of 158 patients, mean age 34,2 years (88 males) have been dialysed. The mean duration on dialysis prior to transplantation was 5,6 months (range 1 week - 23 months). The commonest cause of renal failure in males was chronic glomerulonephritis (63%), whereas in females it was analgesic nephropathy (39%). Twenty-seven patients (17%) died while on dialysis, including 6 who had had unsuccessful transplantations. Renal osteodystrophy was diagnosed in 30% of the patients. Hepatitis has been endemic among both patients and staff. Nephrectomies were done in 106 patients. Ten patients had operations for peptic ulcer and 5 parathyroidectomies were performed. The number of patients unsuccessfully transplanted, or who died, was less than the number of new patients requiring treatment. In addition, an increasing proportion of patients have become 'relatively untransplaotable'. This has led to overloading of facilities.S. Afr. Med. J., 48, 1821 (1974