Nephrology

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This collection contains data collected in the course of clinical work in Nephrology across several hospitals In particular , the CMJAH Living Donor Clinic has a long history . You can see that the work of the unit has inspired or directly produced many thesis. We also have a selection of work on transplants. This collection also includes data on kidney disease from other tertiary hospitals in gauteng

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PARTICIPANT NOTICE OF DATA SHARING FOR STUDY TITLED ‘EVALUATION OF POTENTIAL KIDNEY DONORS AND OUTCOMES POST-DONATION AT CHARLOTTE MAXEKE JOHANNESBURG ACADEMIC HOSPITAL (1983-2015)’.

Good day, The Division of Nephrology at Charlotte Maxeke Johannesburg Academic Hospital ( Previously JHB GEN)conducted a research study in the unit’s Living Donor Clinic. The study assessed clinical data of all individuals who presented to this clinic from January 1983 to July 2015. Written permission to access clinical records was obtained from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand, Johannesburg. The purpose of the study was to analyze living kidney donation in the South African setting with the hope that the clinical findings of this research may contribute toward the future betterment of care for all potential kidney donors and that this data may expand upon the limited information available in this important field of study. As a patient belonging to this Living Donor Transplant Community, you have the right to direct how your information is shared for use by research platforms. You may engage with the principal investigator of this study should you have any queries regarding how the data from this study is being applied. You may also withdraw consent to share any information you feel is potentially identifying at any point. Should you require any further information regarding the study, please feel free to contact the principal investigator, Dr Chandni Dayal via email

chandni.dayal@wits.ac.za

or telephonically on 011 489 0467. Please note that prior to accessing your clinical records, approval was obtained from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand, Johannesburg. A principal function of this Committee is to safeguard the rights and dignity of all individuals who are a part of research projects and the integrity of the research. If you have any complaints or concerns over the way the study was conducted, please contact the Chairperson of this Committee who is Dr. Clement Penny, on telephone number 011 717 2301, or by e-mail

Clement.Penny@wits.ac.za

The telephone numbers for the Committee secretariat are 011 717 2700/1234 and the e-mail addresses are Zanele.Ndlovu@wits.ac.za and Rhulani.Mukansi@wits.ac.za Thank you for reading this notice. 11 March 2022 Dr Chandni Dayal

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New onset diabetes post renal transplantation
(2009-02-12T11:43:48Z) Harrichund, Pretissha
ABSTRACT Diabetes mellitus is a major cause of morbidity and mortality and is the leading cause of end-stage renal disease worldwide. New onset diabetes post renal transplantation is associated with reduced graft function, decreased patient survival and increased risk of graft loss. The immunosuppressive regimes used and dosage of corticosteroid therapy appear to impact on the incidence of new onset diabetes post renal transplantation. The objectives of this study were: to ascertain the prevalence of new onset diabetes post transplantation; to determine the association between new onset diabetes with immunosuppressive regimens and ethnicity; and to assess outcomes in terms of morbidity and mortality. The study design consisted of a retrospective analysis of 398 patient files transplanted between 01/07/1994 and 30/06/2004. Information retrieved from the files consisted of patient demographics ( age, race, gender ), weight, date of onset of diabetes, immunosuppressive regimens used, infections, cardiovascular and overall morbidity and mortality. The diagnosis of diabetes was based on the American Diabetes Association (ADA) criteria or the requirement for anti-diabetic agents. Results obtained showed that 15.58% (62/398) of patients became diabetic. The mean time to onset of diabetes was 22.9 months ( range 1 week to 100 months ). 20.21% Black patients (p=0.100), 9.42% White, 12.5% Coloured and 12% Indian patients became diabetic. Treatment with Cyclosporine( CyA) had an incidence of diabetes of 14.44%, Tacrolimus 20.25% p = 0.228, Rapamune 11.36% and Mycophenolate Mofetil 11.97%. Infections occurred in 96.77% of diabetic patients, p = <0.0001. Cardiovascular morbidity and mortality was 11.29%, p = 0.82. Overall mortality was 79.3% in the diabetic group p = 0.237, HR 1.45. In conclusion, the incidence of new onset diabetes is significant as it confers a higher risk of infections and overall mortality. Black patients are more affected, with an increased risk for those treated with Tacrolimus.
An analysis of reasons for exclusion of potential live kidney donors
(2009-03-23T07:34:50Z) Levy, Cecil Steven
Enhancing the doctor-patient relationship: living, dying and use of the living will
(2009-10-21T10:58:09Z) Etheredge, Harriet
The research aims to establish whether processes around the consideration and execution of the living will help enhance the doctor-patient relationship. Studies have shown that the living will is not used frequently, and that the doctor-patient relationship is often deficient. The research explores the two primary topics – the living will, and the doctor-patient relationship – separately. Each primary topic is approached via a consideration of the relevant literature, and each is then analyzed from a theoretical–ethical point of view. A synthesis of these separate investigations is presented. This synthesis concludes that the living will can help enhance the doctor-patient relationship.
Analysis and interpretation of Iron studies and Vitamin C levels in paediatric patients with chronic renal failure
(2010-08-24) Lutz, Tracey Leigh
This prospective observational study analysed iron studies and vitamin C levels in patients with chronic kidney disease attending Johannesburg Hospital Paediatric Nephrology Clinic. The rationale behind this study was to determine the extent of iron deficiency among patients in chronic renal failure. Vitamin C deficiency is common among dialysis patients, it is easy to test for and easy to prevent. This study may assist in guiding future management with regards to vitamin C supplementation in patients with chronic renal insufficiency on dialysis. The study contained 45 patients of which 27 (60 %) were male and 18 (40 %) were female. The ages of the children varied from 2 years 1 month to 19 years and 7 months. The study included patients from all ethnic groups; 9 were Caucasian, 33 African, 2 Indian and 1 Coloured. Two male patients did not have Vitamin C levels analyzed. The patients were divided into 3 distinct groups; firstly those patients on haemodialysis (12 patients), those on peritoneal dialysis (22 patients) and those not yet dialysed (11 patients). In all patients who were not yet on dialysis the GFR ranged between 18.1 and 45 ml/min/1.73m2. There were no statistically significant differences between the three groups when the results of the iron studies were analysed. However, despite iron treatment 26.6 % of patients were iron deficient as indicated by their transferrin saturation which was less than 20 %. Vitamin C levels were also analysed in this study. Forty one percent of children in chronic renal failure were vitamin C deficient. There was no statistically significant variability among the three groups. Two patients (4.6%) were noted to be Vitamin C toxic. One of these patients was haemodialysed; the other was not yet on dialysis. Vitamin C deficiency in chronic renal insufficient patients on dialysis is easily correctable when identified. Vitamin C in specific well documented doses is safe to administer to this group of patients. It will also enhance the absorption of iron and thereby have an indirect effect on anaemia.
A review of patterns of renal disease at Chris Hani Baragwanath Academic Hospital from1982 to 2011
(2014) Vermeulen, Alda
This study reports a review of biopsy-confirmed renal pathology from Soweto Gauteng. A retrospective analysis was conducted of 1848 adult native renal biopsy reports from Chris Hani Baragwanath Academic Hospital from 1 January 1982 to 31 December 2011. The mean age of all patients biopsied was 33.5 ± 12.6 years and the majority of patients (96.4%) were black. The most frequent histological findings were secondary glomerular diseases (SGNs) (49.3%) and primary glomerular diseases (PGNs) (39.7%). SGNs increased, while PGNs decreased over time (p<0.001). The main contributors to SGN were lupus nephritis (31.0%) and HIV associated nephropathy (HIVAN) (13.3%) while for PGN it was focal segmental glomerulosclerosis (FSGS) (29.6%). HIV positive biopsies constituted 19.7% of all biopsies with a dominant diagnosis of HIVAN (32.7%). Changing patterns of renal disease are evident in the data. The increased SGNs likely reflect the influence of renal pathology secondary to HIV and lupus nephritis.
Establishment of a flow cytometric assay in the setting of renal transplant for T and B cell crossmatching
(2014-02-17) Ramparsad, Narisha
Donor specific crossmatching is performed prior to renal transplantation in order to determine the presence of pre-existing antibodies against donor HLA antigens which can result in hyperacute rejection. Flow cytometric crossmatching is reported in the literature to be a more sensitive and objective method of testing than the complement dependent cytotoxicity (CDC) method that is currently used in the Gauteng Province. A prospective analysis of the flow cytomeric crossmatch (FCXM) assay using the Luminex technology as the reference method was conducted. Forty-three samples were analysed. The T cell crossmatch (using a cutoff value of 2) revealed a sensitivity of 66.7%, a specificity of 83.8%, a positive predictive value (PPV) of 40% and negative predictive value (NPV) of 93.9%. The B cell crossmatch (using a cutoff value of 5) gave a sensitivity of 100%, specificity of 92.7%, and a PPV and NPV of 40 and100%, respectively. In addition, a retrospective analysis of clinical data for all patients transplanted during the period January 2008 to May 2009 was performed. Of a total of 50 patients assessed post transplant, none of the patients showed signs of hyperacute rejection, while twelve percent (12%) of patients revealed signs and symptoms suggestive of acute rejection. The validation of the flow cytometric crossmatch analysis was complex as there is no gold standard reference method. The assay was validated based on the clinical relevance of its high negative predictive value and the absence of hyperacute rejections in the clinical follow up. The rate of acute rejection found in this study is similar to that reported in literature.
Outcome in kidney transplant recipients receiving kidneys from renal donors screened using 51CR-EDTA to determine glomerular filtration rate
(2014-04-10) Malan, Nico
There is a global preponderance of renal disease and many of these conditions are associated with renal failure. A significant proportion of these patients will develop advanced kidney disease with ultimately end stage renal failure. Kidney transplantation is the most successful treatment of patients in end stage renal failure. Currently, the majority of transplantations in the University of the Witwatersrand (WITS) Academic complex (which comprises Charlotte Maxeke Academic, Helen Joseph and Chris Hani Baragwanath Academic Hospitals) are performed with cadaveric donor kidneys. With the worldwide shortage of kidneys required for patients in renal failure, living kidney donation has increased the availability of donor kidneys. Potential renal donors (PRD) are subjected to a battery of investigations prior to being considered for donation, amongst other, glomerular filtration rate (GFR). Potential renal donors at the WITS Academic Complex undergo GFR assessment using 51Cr-ethylene-diamine-tetra-acetic acid (EDTA). Some PRD, potentially those on a vegetarian diet, have a “low” GFR (≤80ml/min/1.73m2) and do not meet criteria for renal donation. These potential renal donors are requested to follow a novel protocol, following a diet high in animal protein (beef and fish) for one week after which time the GFR is determined again. Potential renal donors where the GFR increases (thus showing good renal reserve), subsequently donate a kidney. We do not know the outcome of recipients receiving kidneys in which the GFR “normalized” following a protein load. To the best of our knowledge, the outcome of such recipients is also not described in the current available body of literature. The aim is to determine the outcome in recipients receiving kidneys from protein loaded donors versus recipients of non-protein loaded (“normal” GFR) kidneys. Methods The study follows a retrospective record analysis of patient demographics and work-up results (cross-matching, GFR, infectious diseases, renal anatomy etc.) and outcomes in: i. All potential renal donors (PRDs) from 1997 to July 2012 who had GFR determined by clearance of 51Cr-EDTA ii. The subset of those who donated a kidney iii. Donors with “low” (≤80ml/min/1.73m2) baseline GFR and subsequent protein-loaded GFR iv. Donors with a “normal” (>80ml/min/1.73m2) GFR v. The recipients receiving the grafts – outcome, complications, creatinine over time and survival Results In this study it was shown that 51Cr-EDTA clearance correlates with calculated creatinine clearance (r2=0.44) within the range of 51Cr-EDTA clearance between 40 and 180ml/min (uncorrected for BSA). It was also shown that reproducibility of 51Cr-EDTA clearance in 7 donor patients was excellent (r2=0.86), suggesting a robust method. Two hundred and forty nine patients were screened using 51Cr-EDTA clearance. Two hundred and twelve potential donors had good GFR and were not protein loaded. Of these potential renal donors, one hundred and twenty four were well matched and donated to recipients, with complete follow up in 85 cases. A total of 88 potential donors were excluded for various reasons. In this non-protein loaded group that donated kidneys, overall graft and recipient survival over 16 years was 64%. Thirty seven potential renal donors were protein loaded since their initial GFR was ≤80ml/min/1.73m2. Of these 37 potential donors, 15 were excluded. Twenty two potential donors donated kidneys in this group, with outcomes available in 13 recipients. Overall graft and recipient survival over 14 years was 58.3% for this group. This was not significantly different from the recipients receiving grafts from non-protein loaded donors (p=0.14; log rank test). For potential donors, upon protein loading, GFR increased significantly to 89.3±18.4 ml/min/1.73m2 (p<0.0001), with a mean percentage increase of 26.0±24.4% (median 22.2%; range: -12.9% to +103.4%). Furthermore, when comparing only patient survival between recipients of grafts from donors that were protein loaded and donors that were not protein loaded, there is still no significant difference between the two groups. The pre-protein loaded GFR correlated with the post-protein loaded GFR measurement. There was a negative correlation between pre-protein load (baseline) GFR and percentage increase in GFR following protein loading. In all donors, GFR declined from pre-transplant determination of 97.7±18.1ml/ min/1.73m2 to 75.2±16.4ml/min/1.73m2 (p<0.005). Discussion and conclusion 51Cr-EDTA is a reliable, reproducible technique to assess the GFR of potential renal donors. The novel protein loading technique developed in our institution is a convenient way to assess the functional renal reserve of potential renal donors that have a suboptimal estimated GFR of ≤80ml/min/1.73m2. Although the patient numbers in this study are small, there is no significant difference between the outcome of recipients of renal grafts from non-protein loaded and protein loaded donors. The inclusion of potential donors that show a normal GFR post protein load may increase the pool of available kidney grafts and assist greatly in the treatment of many patients with end stage renal disease. Further research in this area is encouraged, and multicenter studies may yield results that with larger number of patients that may ratify the results of this study.
Cardiovascular risk profile of kidney transplant recipients at the Charlotte Maxeke Johannesburg Academic Hospital.
(2014-04-25) Muhammad, Aminu Sakajiki
INTRODUCTION Cardiovascular diseases (CVD) are more common in kidney transplant recipients (KTRs) than in the general population. The high incidence of CVD in the KTRs can be attributed to traditional risk factors, additional risk factors associated with graft dysfunction and those specifically related to transplantation. Carotid intima-media thickness (cIMT) is a proven surrogate of atherosclerosis; it correlates with vessel pathology and is precisely imaged using ultrasound technology. This study was aimed at determining the prevalence and predictors of cardiovascular risk among KTRs at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and to examine the relationship between cardiovascular risk factors and carotid intima media thickness. METHODS Patients aged 18 years and above who received a kidney transplant at the CMJAH between January 2005 and December 2009 were recruited. A questionnaire that captured cardiovascular risk factors was administered. Patients records were assessed for information on their post transplant follow up. All patients had echocardiography and carotid doppler done for measurement of intima-media thickness. The Framingham Risk Score was used to categorize patients into low, moderate, high risk and very high risk groups. Results were analyzed using statistical package for social sciences (SPSS) version 17, p value of 0.05 was considered significant. RESULTS One hundred (KTRs) 63 male (63%) and 37 female (37%) were recruited ranging in age from 19 to 70 years, with a mean age of 42.2 ± 12.42. Thirty six patients (36%) were found to have high cardiovascular risk. Multiple regression showed proteinuria (p = 0.022), higher cumulative steroid dosage (p = 0.028), elevated serum triglycerides (p = 0.04) and the presence of plaques in the carotid artery (p = 0.012) as predictors of higher cardiovascular risk.Carotid intima-media thickness correlates with higher CVD risk. Fourteen patients (14%) had a carotid artery plaque. Twenty five patients (25%) had cIMT of >0.7 mm. CONCLUSION Kidney transplant recipients in CMJAH were found to have high cardiovascular risk (36%) and carotid intima-media thickness correlates with this high CVD risk. Routine follow up of KTRs should include measurement of cIMT as it provides a simple non-invasive assessment of subclinical atherosclerosis.
Combined paediatric liver-kidney transplantation: analysis of our experience
(2014-08-27) Strobele, Bernd
Background. Renal insufficiency is increasingly common in end-stage liver disease and allocation of livers to this category of patient has escalated. The frequency of combined liver-kidney transplantation (CLKT) has consequently increased. Indications for CLKT in children differ from those for adults and typically include rare congenital conditions; subsequently limited numbers of this procedure have been performed in paediatric patients worldwide. Scant literature exists on the subject. Methods. Subsequent to institutional approval, a retrospective chart analysis of all paediatric CLKTs performed at the Transplant Unit, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa between January 2005 and July 2013 was conducted. Results. Defining children as younger than 18 years of age, 43 patients had received a liver transplant since 2005, of whom 8 received a CLKT. Indications included autosomal recessive polycystic kidney disease (n=3), primary hyperoxaluria type 1 (n=4) and heterozygous factor H deficiency with atypical haemolytic uraemic syndrome (n=1). Graft combinations included whole liver and one kidney (n=5), whole liver and two kidneys (n=1) and left lateral liver segment and one kidney (n=2), all from deceased donors. Patient age ranged from 4 to 17 years (median 9) and included 4 females and 4 males. Weight ranged from 13 to 42 kg (median 22.5). We describe one in-hospital mortality. The remaining 7 patients were long-term survivors with a survival range from 6 to 65 months. Conclusions. Although rarely indicated in children, CLKT is an effective treatment option, appropriately utilising a scarce resource and significantly improving quality of life in the recipient.
Haemoglobin levels in the chronic dialysis population in the Nephrology Unit at Chris Hani Baragwanath Academic Hospital
(2015-09-07) Kara, Reena
Chronic kidney disease (CKD) is an increasingly important cause of morbidity and mortality worldwide and it is in developing countries, such as South Africa, that bears the greatest portion of the burden of CKD. Anaemia is a frequent complication of CKD that has significant implications in terms of progression of the disease, as well as on the quality of life. It is for that reason that we have reviewed the demographics and causes of CKD; as well the prevalence, contributors to and management of anaemia of the chronic dialysis population at Chris Hani Baragwanath Academic Hospital (CHBAH). Methods A retrospective review of the chronic dialysis population at CHBAH in January 2012 was conducted. Patients’ records, using both paper-based records and electronic records in the form of Bara Active Renal Tracking (BART) programme were analyzed. Data was captured electronically using the REDCap (Research Electronic Data Capture) tool and exported to Microsoft Excel and GraphPad InStat programmes to compile the statistics, figures and tables. Chi-square test was used for comparisons between groups with categorical variables and an unpaired t test was used to compare groups with normally distributed variables. To compare proportions between the two groups a Fishers exact test was performed. A P-value of < 0.05 was taken as significant. Results The chronic dialysis population consisted of a total of 140 patients in January 2012. Based on exclusion criteria, 4 patients were excluded. The mean age of the patients was 45 ± 13 years, with the peritoneal dialysis (PD) cohort being slightly older as compared to the haemodialysis (HD) cohort. A larger proportion of the cohort were male (56.6%) and 87% percent of the cohort were Black patients. The cause of CKD was unknown in the majority of the patients – 72% in the HD group and 56% in the PD group. The other causes noted were hypertension (17%), primary glomerulonephritis (5.9%), and diabetes mellitus (5.9%). None of the causes of CKD were associated with more severe rates or degrees of anaemia. Suboptimal haemoglobin levels were present in 40% of the patients, with higher rates and increased severity of anaemia noted among the patients on haemodialysis. Among the HD patients, those patients with an arteriovenous fistula or a permanent cuffed venous catheter had higher haemoglobin levels. Other factors associated with lower levels of haemoglobin included younger age of the patients, the presence of hyperparathyroidism, sepsis and inflammation (indicated by C - reactive protein and ferritin levels) and Hepatitis C seropositivity. Approximately 85 % of the patients were receiving erythropoiesis stimulating agents, with higher rates and doses noted in the HD group, as compared to the PD group (p˂0.001). Only 40% of the HD patients and 16% of the PD patients received intravenous iron as part of the regular prescription. Discussion Our findings that the mean age in the chronic dialysis population CHBAH is substantially lower than in developed countries is in keeping with the finding that that end stage renal disease (ESRD) patients on dialysis are younger in the developing world, where the delay in detection of renal disease and the failure to institute timely preventative measures results in a faster deterioration of renal function and the development of ESRD at a young age. A factor that may also affect the mean age of our study population are the selection criteria for patients to be enrolled on the chronic dialysis programme in the public sector in South Africa. The patients need to qualify for a renal transplant. In our population and in the developing world the cause in a large proportion of patients with ESRD remains unknown because of late presentation or referral of patients, inadequacy of medical care facilities and shrunken kidneys, as is represented by the more than 65% of patients in the study, for whom there was no attributable cause of ESRD stated. Suboptimal correction of anaemia is present in a significant portion of our chronic dialysis population with a variety of contributing factors. This complication is inadequately managed, both in terms of addressing contributing factors and the prescription of the correct treatment. Rates of erythropoietin use in our population were comparable to international studies; however hyporesponsiveness to ESA therapy in our population is a concern based on the suboptimal rates of usage of intravenous iron. Conclusion CKD is a major problem in South Africa, where a double burden of disease is present- diseases of lifestyle and infectious diseases. Renal replacement therapy is a scarce resource and complications such as anaemia need to be aggressively managed in patients on this therapy, so as to maximise the benefit and improve outcomes. In conclusion, there is much room for improvement in the management of this grave consequence of ESRD by more stringent application of the available recent international and local guidelines.
Malignancy in renal transplant recipients at Charlotte Maxeke Johannesburg academic hospital: 1990-2010
(2016) Ziki, Joyce Tukayi
Introduction Post transplant malignancy (PTM) is a recognized long term complication in renal transplant recipients. Many studies have been conducted on this group of patients over the last 50 years to assess the impact of various immunosuppressant drug regimens, geographical locations, ethnicity, and age at the time of transplant on the risk of developing a PTM. The incidence of PTM has been shown from these studies to vary from 3% to 11%. Many inconsistencies exist in these studies, but the one common finding is that the incidence of malignancy is increased in renal transplant recipients compared to the general population. Aims and Objectives The objectives of this study were to determine the incidence of PTM at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in the period from 1990 to 2010; to calculate the mean time to diagnosis of PTM; determine the association of PTM and immunosuppressive drug regimens and identify risk factors associated with developing a malignancy post renal transplant. Methods The study design was a retrospective review of the medical records of patients transplanted between 01/01/1990 and 31/12/2010 at CMJAH, South Africa. All recipients above 18years of age transplanted during this study period were included in the review. All recipients who rejected, died or were transferred to other centres within six months of transplantation were excluded. A total of 668 records were included in this study for analysis. Information retrieved from the files included patient demographics (age at transplantation; gender; ethnic group, year of transplantation), aetiology of end-stage renal disease, the source of graft, the number of times treated for rejection, oncogenic viruses diagnosed, immunosuppressant regimens and outcomes of the recipients. For those recipients who developed a malignancy, the time from transplantation to diagnosis of cancer was calculated and the histological diagnoses documented. Results The incidence of PTM in this study was 7.0% (95% CI 5.2-9.4) for the era under review. The cumulative incidence of cancer from transplantation increased with follow-up time. The mean time to diagnosis of malignancy was: 3.4 years, 6.6 years, 7.4 years and 8.1 years for Kaposi Sarcoma (KS), post transplant lymphoproliferative disorder (PTLD), skin and solid organ malignancy, respectively. The distribution of post transplant malignancy (PTM) was skin cancers 44.7%; KS 23.4%; PTLD 14.9%; solid organ tumours 17.0 %. The recipients who developed cancer were significantly older at transplantation with a mean age of 42.9 years compared to those without PTM whose mean age was 36.3 years. Age and year of transplantation period 1996-2000 were independent risk factors for developing a malignancy in this cohort. Discussion There was no change in the incidence of PTM at CMJAH, occurring in 7% of the transplant recipients in the period of review (1990-2010) compared to 7.0% reported for the period 1966-1989, despite the change in the demographic patterns of the patients, immunosuppressive regimens and improved surveillance for cancers. No individual immunosuppressant drug appears to pose a risk for cancer significantly, instead, the prolonged general state of immune suppression in this group of patients seems to be the main risk factor of note. Recipients transplanted at an older age and those with long post renal transplantation follow-up should be closely monitored and routine surveillance for cancers done.
Urinary tract infection in children with congenital anomalies of the kidney and urinary tract attending the division of paediatric nephrology at Charlotte Maxeke Johannesburg academic hospital, South Africa
(2016) Okoronkwo, Nneka Chioma
Background: Both CAKUT and UTI can independently cause renal insufficiency with ultimate progression to ESRD, and CAKUT is a well-documented risk factor for UTI in children. Aim: To describe CAKUT in a cohort of children, between 2 weeks and 18 years of age, and to document the patterns of UTI in this group. Method: A retrospective medical record review was performed on all patients with documented CAKUT managed between January 2005 and December 2014. Results: The prevalence of CAKUT was 20% and the male: female ratio was 4.4:1. The median age at presentation was 8.4 months and the median duration of follow up was 39 months. At presentation 57% were under the age of one year and 21% were above the age of 5 years. PUV was the commonest type of CAKUT and a very low rate of VUR was noted. The incidence of UTI was 41.8% and the odds of getting a UTI were significantly increased among children with bladder anomalies, PUV and collecting system anomalies. Escherichia coli and Klebsiella pneumonia were the commonest bacteria isolated and, although more than 90% of both E. coli and Klebsiella pneumoniae were sensitive to amikacin, meropenem, imipenem and ertapenem, more than 40% were resistant to commonly used oral antibiotics such as amoxicillin/clavulanate and trimethoprim-sulphamethoxazole. Prophylactic antibiotic use was highest among patients with PUV (35%) and, overall, patients who were not on a prophylactic antibiotic were five times more likely to have a UTI. The association between antibiotic prophylaxis and the development of antibiotic resistance could not be explored but there was a statistically significant association between the type of bacteria isolated and the use of antibiotic prophylaxis. Conclusion: Delayed presentation, the high rate of UTI and the high rate of antibiotic resistance to many first line oral antibiotics are all of concern. The study highlights the effectiveness of antibiotic prophylaxis in this group. Future research topics include determining the long term outcome, and the long term effects of antibiotic prophylaxis on renal function, in our cohort.
"Toxic thoughts"- impact of chronic kidney disease on cognitive functioning and pyschological well-being
(2016) Ansell, Glen
Background Chronic Kidney Disease (CKD) is a reality faced by many around the world. There has been much physiological study around factors associated with CKD, as well as many studies surrounding the psychosocial impacts of the disease, with relatively less attention given to neuropsychological effects the disease can have on sufferers. This paper investigates the cognitive impacts as well as psychological impacts simultaneously, impacting on sufferers of End Stage Kidney Disease (ESKD). Methods Sixteen medically stable patients aged (M = 40.56, SD = 12.52) years with ESKD, were investigated. Eight of the patients were evaluated before and after six months of successful kidney transplant, using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), which assessed immediate memory, visuospatial / constructional, language, and attention. They were also tested on a brief symptom inventory (BSI 18) to assess depression and anxiety in these patients. A further eight who remained on dialysis, and had not undergone renal transplant were evaluated in the same manner for comparative purposes. Results Between-group comparisons showed a statistically significant improvement in overall cognitive functioning, as well as in the specific cognitive domains of visuospatial / constructional, language and attention for participants who had undergone renal transplant surgery compared to their counterparts who had not. Results also found that there were no statistically significant differences between the levels of anxiety experienced between patients in the two groups. When assessing the differences in cognitive improvement within the transplant patient group before and after transplant, improvement in the delayed memory function of renal transplant patients post-transplant was found. Conclusion These data show improvements in delayed memory function of patients having undergone renal transplant therapy, while also highlighting a continued decline of overall cognitive functioning in patients remaining on hemodialysis therapy.
Knowledge of nephrology nurses on evidence based guidelines for prevention of haemodialysis catheter related infections
(2016) Ntlhokoe, Mphanye Joseph
The purpose of the study was to determine knowledge of nephrology nurses’ on evidence based guidelines for the prevention of haemodialysis catheter related infections. The study was done in 5 haemodialysis units from two university-affiliated, public sector and tertiary level hospitals in Gauteng which are: “Baragwanath Hospital and Charlotte Maxeke Academic Hospital”. Face and content validation of the research instrument “Evaluation questionnaire concerning nurses’ knowledge of interventions for prevention of haemodialysis catheterrelated bloodstream infections” was done by a panel of experts to ensure applicability of the instrument to the South African context. Prior to commencement of the study, ethical clearance and permission to conduct the study was obtained from the relevant authorities and the university committee. A non-experimental, descriptive, prospective study design was utilised in order to meet the objectives of the study. Descriptive and comparative statistics were used to analyse the data which was done in consultation with a statistician. Knowledge was reorganised as poor (0-50%), average (50-70%) and good (71% and above). Overall, participants performed well in the second part of the questionnaire where their knowledge was tested regarding evidence based guidelines in prevention of vascular access infection; the majority 72.50% (n=58) scored more than 71%, indicating they have knowledge of evidence based guidelines on prevention of vascular access infection, 20% of participants scored between 51 and 70%, whilst only 2% scored below 50%. A positive correlation (with moderate strength) between age and experience (r=0.563) was established indicating that as age increases the experience will also increase moderately. A slight negative correlation, which was very weak (null correlation) was also established between years of experience and performance as most respondents were above and below the regression line. Therefore years of experience has no influence over performance.
"Hey sister! where's my kidney?" : exploring ethics and communication in organ transplantation in Gauteng, South Africa
(2016) Etheredge, Harriet Rosanne
Introduction South Africa is characterised by numerous dichotomies and diversities, within which its two-tier healthcare system operates. An under-resourced state sector serves a majority of the population and a resource-intensive private sector serves a small minority. Within the constitutional framework of human rights and distributive justice there are nevertheless expectations of fair and equal access to healthcare services. There is furthermore an expectation of quality care across the health system, in spite of a number of systemic challenges related to staff and equipment shortages, unrealistic working hours and poor working conditions. Organ transplant is available to different degrees within the South African healthcare sector. Whilst transplant programmes are burgeoning internationally, cadaver transplant numbers in South Africa have decreased over recent years as donor organs have become increasingly scarce. Current research suggests that these challenges to transplant in South Africa arise from aspects of personal and cultural beliefs, illegal transplant practices and resource constraints - which all serve to compromise the ethical implementation of transplant services in the two-tier healthcare system. The impact of interprofessional communication and transplant professional–patient communication has not been previously researched in South Africa. However, research into other healthcare issues has shown that communication is vital to the ethical provision of healthcare services, especially those which involve patient-centeredness and multidisciplinary interaction. Transplant involves a significant amount of communication within a particularly large network of recipients and their families, cadaver donor families, living donors and a range of transplant professionals. This communication seems a vital part of the transplant process, disseminating information which role-players need in order to promote favourable outcomes. Given the extensive networks involved in the transplant process, communication would seem to be a fertile area for research. This study aimed to explore communication in organ transplant in Gauteng province, South Africa. It considered both interprofessional communication and communication with patients as this took place within the hierarchical healthcare system and throughout the transplant process. An ethics of care framework was utilised in order to account for the expectations of care which South Africans confer upon their health system. Methods The study took place in the Gauteng province of South Africa across six healthcare institutions. Both the state and the private sector were equally represented. Altogether, thirty in-depth interviews with transplant professionals, two focus groups with transplant coordinators, two interviews with cadaver donor families, and one focus group with living kidney donors, were conducted. Thematic analysis and triangulation of the data utilising Braun and Clarke’s (2006) principles revealed three main themes relating to context, communication with patients, and interprofessional communication Findings The South African transplant context is complex and multifaceted, shaped by both the patients’ expectations of care and the transplant professionals’ perceptions of care. These expectations and perceptions are influenced by personal beliefs, suspicions of biomedicine, the media, and resource inequalities which pose challenges to accessing transplant services. The transplant context is characterised by ethical dilemmas relating to distributive justice, as questions about resource distribution and allocation of donor organs are raised. Transplant communication is influenced by context and varies depending upon role-players in transplant and the different phases of transplant. Demands for care by those hoping to receive an organ had a noticeable influence on transplant professional-potential recipient communication in the pre-transplant phase, a period when emotions of desperation and uncertainty were prominent. By the time recipients had received their organ and entered the more stable post-transplant phase, a relationship of trust developed in which communication was regular and caring roles seemed fulfilled. The opposite trend was evident in communication between transplant professionals and donor families. This was characterised by notions of care in the pre-transplant phase, contrasting with a perception amongst donor families that care was sometimes overlooked in the post-transplant phase - a time often imbued with chronic uncertainty. Even in the pre-transplant phase numerous ethical issues surrounding autonomy, decision-making and informed consent proved to complicate and challenge transplant communication. Interprofessional communication was shaped by hierarchical institutional organisation, a lack of continuity of care, and resource constraints, all of which challenged transplant professionals seeking to provide care, and sometimes resulted in aggressive interchanges. The pressure to procure an organ timeously – which could result in patient care and professional respect being somewhat disregarded – could so compromise interprofessional communications that moral distress was created. Furthermore, as a result of miscommunications, an ethical vacuum where the best interests of patients in the transplant process were not, apparently, a foremost consideration, was identified. Conclusion Transplant is a highly complex process requiring a number of different communication styles and skills and accompanied by intricate ethical challenges. Although transplant professionals seemed cognisant of the need for careful communication, inequalities, resource scarcity and conflict intervened to create a space for moral distress and uncertainty in which communication was affected, and the provision of care was the casualty. Appraising results within an ethics of care framework suggests that transplant in Gauteng cannot be considered to be a process fully informed by the imperative of care. The ethics of care proved to be a helpful framework for understanding transplant communication in Gauteng because of the way it accounts for interpersonal relationships - fundamental to the transplant process - whilst also emphasising the importance of resources necessary to provide good care. It was concluded that in the current environment, where there is little legal direction or political buy-in, transplant in Gauteng will be unable to reach its full potential.
Attitudes and beliefs of patients with chronic kidney disease in the Rustenburg area, North west regarding kidney dysfunction
(2016-02-10) Njoro, Mmampu Magdeline
Aim: The aim of this study was to investigate the attitudes and beliefs of patients with chronic kidney disease regarding kidney dysfunction in the Rustenburg area. Background: Kidney disease is still regarded as a low risk disease in Rustenburg, particularly among the rural community with low literacy level. Some of the people believe that chronic kidney is caused by driving heavy duty vehicles and hard labour whilst some associate the symptoms of chronic kidney disease with cultural disease resulting from failure to undergo cultural practices after the death of spouse or life partner. Low awareness of kidney disease results in patients seeking traditional cure that may cause further deterioration of their kidney dysfunction and progress to end stage renal disease, and therefore need lifelong dialysis or kidney transplantation. Research Methods: An explorative, descriptive qualitative research method was chosen for this study. Participants were patients with chronic kidney disease attending haemodialysis treatment at a dialysis unit of a level II public sector hospital. This dialysis unit provides both acute and chronic haemodialysis treatment and peritoneal dialysis training, and has eight chronic and two acute haemodialysis machines. Individual, face-to-face, semi-structured interviews were conducted using an interview guide (Appendix A). Participants were conveniently sampled until point of saturation was reached, and nine participants constituted the sample. Inclusion criteria were 18 years old and above, men and women, on haemodialysis for more than six months and willing to be interviewed. Patients who did not attend haemodialysis on the day of the interviews were excluded from the study. The interviews were audio-taped, transcribed verbatim and analysed according to Tesch’s method of qualitative data analysis. Significance of the study: This study uncovered the attitudes and beliefs of patients with chronic kidney disease regarding kidney dysfunction. Uncovering their attitudes and beliefs has enlightened nephrology nurses on future renal care initiatives that may improve both patients and the community’s attitudes and beliefs regarding kidney disease. Findings: The study has shown that chronic kidney disease has a profound and devastating impact on the patient, his family and significant others. The study further revealed that traditional healing and cultural health is still widely practiced by most of the patients with chronic kidney disease particularly in the rural areas. There is poor awareness of kidney disease as well as risk factors associated with kidney disease among this community. Conclusion: This rural population was not knowledgeable about kidney disease nor the risk factors associated with this condition. Nephrology nurses should conduct kidney awareness campaigns in order to educate the patients and public about kidney disease order to correct their attitudes and beliefs towards chronic kidney disease.
Outcomes of cadaveric renal transplantation in patients using mycophenolate mofetil or azathioprine
(2016-10-12) Gathara, Linda
Introduction: Mycophenolate Mofetil (MMF) has replaced Azathioprine (AZA) in immunosuppressive regimens worldwide in the prevention of acute allograft rejection. Whether long term treatment with MMF is superior to treatment with AZA is a matter of debate. There are no studies in South Africa that have been done to show that MMF is superior to AZA. Objectives: To describe the outcomes of cadaveric renal transplantation in patients using Mycophenolate Mofetil or Azathioprine over a five year period at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Design: This was a retrospective comparative study. Setting: The CMJAH Renal Transplant Unit in Johannesburg, Republic of South Africa. Patients: A convenience sample of all eligible patients, 208 in total, was recruited from the Renal Transplant Unit at CMJAH. Methods: The study was approved by the University of the Witwatersrand Human Research Ethics Committee (Medical) (Protocol Number: M130434). The data source was clinical records of renal transplant recipients at the Renal Transplant Unit at CMJAH from 1985-2013, who were treated with one of the two immunosuppressive agents required for analysis in the study. The data were entered in Microsoft Excel Spreadsheets and transferred to STATA version 14 for statistical analysis. Results: Of the 208 patients, 101 patients were treated with Azathioprine and 107 patients treated with Mycophenolate Mofetil, in addition to corticosteroids and cyclosporine. A total of 16 patients developed acute allograft rejection 12-52 weeks after cadaveric transplantation. Of these, 6% were in the AZA group and 10 % in the MMF group. There was a mortality rate of 1% in the MMF and 16.8% in the AZA group respectively (p= 0.0001). The serum creatinine at 3 months was found to be a strong predictor of allograft function in patients on Mycophenolate Mofetil (p<0.001). After adjusting for the confounders, serum creatinine at 3 months remained a strong predictor of outcome. Patients experiencing abdominal pain while on treatment with Mycophenolate Mofetil were 62% less likely to develop acute allograft rejection than patients on treatment with Azathioprine [unadjusted HR = 0.38(0.14-1.05)]. This finding however, is not statistically significant (p=0.06). After adjusting for the other confounders the association with abdominal pain was marginally significant (adjusted HR 0.18(0.01-1.02) p=0.05). Conclusions: Patient survival was superior in the longterm in cadaveric renal transplant patients receiving Mycophenolate Mofetil therapy.
A cross-sectional observational study of the vitamin D status in children with chronic kidney disease at Charlotte Maxeke Johannesburg academic hospital
(2016-11-04) Raga, Shirika V
Introduction Vitamin D has numerous important functions in the human body. There is limited data available regarding vitamin D status in children with Chronic Kidney Disease (CKD) in South Africa. Objectives To determine the vitamin D status, as well as factors that affect it, in children with CKD in Johannesburg, South Africa. Methods A cross-sectional observational study was performed on 69 patients who attended the Renal Outpatient Clinic, and required routine phlebotomy, at Charlotte Maxeke Johannesburg Academic Hospital, Division of Paediatric Nephrology, between 20/08/2013 and 20/05/2014. Results 71% (n=49) of patients in our study sample were vitamin D sufficient. Significant factors that influenced vitamin D status included albumin levels and the presence of Nephrotic syndrome with relapse. There was a statistically significant positive correlation between albumin and vitamin D (p=0.00). As albumin levels increased so did the vitamin D levels. Patients with Nephrotic Syndrome with relapse had significantly lower vitamin D levels compared to patients with Nephrotic Syndrome in remission (p=0.00). Conclusion The majority of children with Chronic Kidney Disease in Johannesburg, South Africa, are vitamin D sufficient. This is reassuring as it implies that there is no need for routine vitamin D supplementation in this sample of children. However patients, especially those with nephrotic syndrome with relapse, still need to be screened for vitamin D deficiency and insufficiency and supplemented if necessary.
Data Set : Prevalence, characterization and response to chronic kidney disease in an urban and rural setting in South Africa
(2016-11-18) Naicker, Saraladevi; Fabian, June; Jaya A George; Harriet R Etheredge; Manuel van Deventer; Robert Kalyesubula; Alisha N Wade; Laurie A Tomlinson; Stephen Tollman
Globally, chronic kidney disease (CKD) is an emerging public health challenge but accurate data on its true prevalence are scarce, particularly in poorly resourced regions such as sub-Saharan Africa (SSA). Limited funding for population-based studies, poor laboratory infrastructure and the absence of a validated estimating equation for kidney function in Africans are contributing factors. Consequently, most available studies used to estimate population prevalence are hospital-based, with small samples of participants who are at high risk for kidney disease. While serum creatinine is most commonly used to estimate glomerular filtration, there is considerable potential bias in the measurement of creatinine that might lead to inaccurate estimates of kidney disease at individual and population level. To address this, the Laboratory Working Group of the National Kidney Disease Education Program published recommendations in 2006 to standardize the laboratory measurement of creatinine. The primary objective of this review was to appraise implementation of these recommendations in studies conducted in SSA after 2006. Secondary objectives were to assess bias relating to choice of estimating equations for assessing glomerular function in Africans and to evaluate use of recommended diagnostic criteria for CKD. This study was registered with Prospero (CRD42017068151), and using PubMed, African Journals Online and Web of Science, 5845 abstracts were reviewed and 252 full-text articles included for narrative analysis. Overall, two-thirds of studies did not report laboratory methods for creatinine measurement and just over 80% did not report whether their creatinine measurement was isotope dilution mass spectroscopy (IDMS) traceable. For those reporting a method, Jaffe was the most common (93%). The four-variable Modification of Diet in Renal Disease (4-v MDRD) equation was most frequently used (42%), followed by the CKD Epidemiology Collaboration (CKD-EPI) equation for creatinine (26%). For the 4-v MDRD equation and CKD-EPI equations, respectively, one-third to one half of studies clarified use of the coefficient for African-American (AA) ethnicity. When reporting CKD prevalence, <15% of studies fulfilled Kidney Disease: Improving Global Outcomes criteria and even fewer used a population-based sample. Six studies compared performance of estimating equations to measured glomerular filtration rate (GFR) demonstrating that coefficients for AA ethnicity used in the 4-v MDRD and the CKD-EPI equations overestimated GFR in Africans. To improve on reporting in future studies, we propose an 'easy to use' checklist that will standardize reporting of kidney function and improve the quality of studies in the region. This research contributes some understanding of the factors requiring attention to ensure accurate assessment of the burden of kidney disease in SSA. Many of these factors are difficult to address and extend beyond individual researchers to health systems and governmental policy, but understanding the burden of kidney disease is a critical first step to informing an integrated public health response that would provide appropriate screening, prevention and management of kidney disease in countries from SSA. This is particularly relevant as CKD is a common pathway in both infectious and non-communicable diseases, and multimorbidity is now commonplace, and even more so when those living with severe kidney disease have limited or no access to renal replacement therapy.
Mycophenalate mofetil in renal transplant recipients: predisposition to gastrointestinal intolerance
(2017) Chen, Min-Shien
Objective Renal transplantation is the ideal therapeutic option for patients that reach end-stage renal failure. However, patients require long term immunosuppression following surgical transplantation to prevent graft rejection [1,2,4]. Mycophenolate mofetil (MMF) had proven to be an effective immunosuppressant in transplant patients[8,9,10], although it is associated with an increase in gastrointestinal adverse effects, which may result in dose adjustment or termination of use [22]. There is a paucity of data regarding gastrointestinal side effects of MMF in South Africa. This study attempts to describe the incidence of gastrointestinal complications, incidence of dose adjustment and discontinuation of MMF due to side effects, to compare the incidence of GI complications between those that had prior gastrointestinal ailments and those that had no prior gastrointestinal ailments and finally to determine possible risk factors (age, gender, ethnicity, donor type, pre-transplant GI diagnosis, pre-transplant diabetes and combination of MMF with tacrolimus) of gastrointestinal adverse effects. Method Data was collected retrospectively from the file records of the renal transplant unit at CMJAH (Charlotte Maxeke Johannesburg Academic Hospital) on adult patients who had received kidney transplants between 1998 and 2010 and who had received MMF as part of the immunosuppressive regimen for at least the one year post-transplant. Relevant data was captured in an anonymous fashion on a collection sheet. Descriptive analysis of the data was carried out. Time-to-event data were analysed by Kaplan-Meier survival analysis. The assessment of the effect of prior gastrointestinal ailments, as well as risk factors, was carried out by Cox Proportional Hazards regression to estimate the Hazard Ratios. Results A total of 188 patients were included in the study group, which comprised 65.4% males and 32.4% females (2.1% missing data). The mean age at transplant was 38.1 years. The patients were predominantly black (69.1%). Donors were predominantly deceased donors. Of the 24.5% of donors who were living donors, 76.1% were related living donors, while the rest were non-related living donors. The majority of patients (82%) were induced with MMF dose of 2 grams per day. After 5 years, 13.8% of patients discontinued MMF while 86.2% of the patients were still on MMF. 48.1% had a dose adjustment due to gastrointestinal side effects. 61% of patients had had a diarrhoeal adverse event by 5 years. 21.8% of the patients had gastrointestinal side effects other than diarrhoea by 5 years. The combination of tacrolimus and MMF was found to be a significant risk factor for diarrhoeal adverse events (Hazard Ratio 1.82; 95% CI 1.21-2.73). Having a living donor graft reduced the chance of non-diarrhoeal gastrointestinal adverse event (Hazard Ratio 0.33; 95% CI 0.13-0.84, p<0.02). A trend towards significance was seen in living donors having less diarrhoeal events although it did not reach statistical significance (Hazard Ratio 1.32; 95% CI 0.87-2.00, p=0.20). Conclusion As far as the authors are aware, this is the first local study on MMF and GIT adverse effect. We found the combination of MMF and tacrolimus is associated with increased risk of having diarrhoeal adverse events, which is consistent with international data[34,35]. Living donor graft is associated with a lower risk of developing non-diarrhoeal gastrointestinal events. Although non-significant, data suggest the same trend favoring living donor graft with regards to diarrhoeal events.

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