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 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 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 DayalBrowse
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Item Analysis and interpretation of Iron studies and Vitamin C levels in paediatric patients with chronic renal failure(2010-08-24) Lutz, Tracey LeighThis 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.Item An analysis of reasons for exclusion of potential live kidney donors(2009-03-23T07:34:50Z) Levy, Cecil StevenItem An argument for a paid and regulated living-unrelated kidney donation system in South Africa(2021) Ewing (Naude), Susan LesleyOne of the biggest challenges that global healthcare is experiencing is the shortage of kidney organ donors. Globally, the demand for organs is far greater than the supply and as a result, people who are on waiting lists will not get a chance to receive a kidney. Those who are waiting for transplants will require ongoing dialysis to survive (Nath & Fervenza, 2018). Dialysis is extremely costly and burdens the healthcare systems. Given the enormous gaps between supply and demand, this report seeks to answer the question: “Should South Africa follow the model of a paid and regulated living unrelated kidney donation system?” I begin with an analysis of South Africa’s current structure, the effects of this system and ultimately seeing the need for a different solution. I analyzed the various models globally in kidney donation, including the only country that allows for a paid system and the objections thereto. Currently, the sale of organs is prohibited in South Africa. My view is that our current South African model is lacking in solutions to the shortage of organ donors, particularly kidneys. There is a need for a better solution as the current system is failing to meet the needs of patients. In this paper, I use the principlism framework consisting of the four bioethical principles namely, autonomy, beneficence, non-maleficence and justice, to highlight the constitutional conflicts and the ethical dilemmas when considering a paid donation system. As I am arguing for a paid system in South Africa, I have included the ubuntu theory to show why objections to a paid and regulated system would fail. In conclusion, a paid and regulated living-unrelated kidney donation system is argued to be the most ethically and practically appropriate system in South Africa, to improve kidney donation rates and the livelihoods of the peopleItem Assessment of GFR in the evaluation of potential living kidney donors at the Wits Donald Dordon Medical Center (WDGMC) and Charlotte Maxeke Johannesburg Academic Hospital (CMJAH)(2018) Okuthe, Jacktone OdhiamboEquations that estimate GFR (eGFR) are widely used in clinical practice to estimate kidney function in sub-Saharan Africa, but have not been validated for use in this region. This study assessed the performance of eGFR equations in adults evaluated for suitability for live kidney donation against a gold standard radionuclear GFR measurement (mGFR) and determined their usefulness for screening live kidney donors in South Africa. This study was a retrospective record review of 350 adults evaluated for living kidney donation from 1996 – 2013 at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Wits Donald Gordon Medical Centre (WDGMC). Their eGFR was calculated using CG, 4-v MDRD and CKD-EPI equations. Plasma clearance of 51Cr-EDTA was used as a reference method for mGFR. The 4-v MDRD (with and without ethnicity adjustment) and the CKD-EPI (without ethnicity adjustment) equations underestimated the mGFR (negative bias of -8 mL/min/1.73m2, -16 mL/min/-1.73m2 and -6.4 mL/min/1.73m2 respectively).However, the bias associated with the average mGFR using the CG and CKD-EPI (with ethnicity adjustment) equations was not significant (2.3 mL/min/1.73m2 and 0.6 respectively).Use of the ethnicity factor resulted in overestimation of mGFR for both the 4v-MDRD equation (by 24.2ml/min/1.73m2 compared to 6.8 ml/min/1.73m2 without it) and the CKD-EPI equation (by 21.8ml/min/1.73m2, compared to 7.6ml/min/1.73m2, without the ethnicity factor). In conclusion, this study showed that almost half of adults screened for living donation in Johannesburg were not eligible due to comorbid hypertension, diabetes and unexplained kidney disease. In addition, the error statistics worsened as mGFR increased and all four prediction equations had a low sensitivity for determining individuals with a GFR <80 ml/min/1.73m2. Based on the findings in this study, use of a gold standard measured GFR should be the preferred method for assessing kidney function in potential living kidney donors in South Africa.Item Attitudes and beliefs of patients with chronic kidney disease in the Rustenburg area, North west regarding kidney dysfunction(2016-02-10) Njoro, Mmampu MagdelineAim: 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.Item Audit of acute rejection in renal allografts(2020) Thomas, Riju MathewAcute graft rejection is acknowledged to have a negative impact on graft survival in renal transplantation. South Africa provides for limited renal transplantation amidst the increasing burden of chronic kidney disease in the local context. Despite this suboptimal provision and limited resources, amongst many other concerns, the role of acute graft rejection on graft survival has not been characterized in the context of South Africa, as well as the African continent. This study is an audit, characterising acute graft rejection diagnosed at the Charlotte Maxeke Johannesburg Academic Hospital over a ten-year period (2003-2012). The study revealed the incidence of acute rejection in renal transplants to be 34.5%, similar to that reported in international studies. The majority of acute rejections occurred within the first year of transplantation (53.8%), which was lower than that reported in other studies, with 40% of patients having recurrence of acute rejection. The main form of rejection diagnosed was acute cellular rejection (predominantly BANFF grades 1A and 1B), followed by Borderline acute cellular rejection, the combination of which comprised the majority (86.9%) of all rejections diagnosed. This population was found to be a male dominant and Black African dominant study group, in keeping with the racial distribution of the dialysis population of South Africa, commonly influenced by treatment-seeking behaviour. Cadaveric donor grafts were engrafted in 77.7% of this population and 77.8% of the population had less than 40% of HLA antigens in common with their donor. Delayed graft function was observed in 22.4% of recipients with a significant association with more severe acute graft rejection. Hypertension was the most dominant primary aetiology leading to chronic kidney disease of native kidneys in this population. Immunosuppressive regimen, including cyclosporin, mycophenolate mofetil and prednisone, was used in 80% of recipients, with 97.6% of recipients on mycophenolate mofetil and prednisone. The five-year survival of grafts developing acute rejection was 61.7%. Graft function deteriorated more dramatically amongst recipients who progressed to graft loss, with recovery of graft function observed to be more prominent amongst recipients with surviving grafts. This study adds to the literature on this topic, and also describes the characteristics and outcomes of this entity.Item Cardiovascular risk profile of kidney transplant recipients at the Charlotte Maxeke Johannesburg Academic Hospital.(2014-04-25) Muhammad, Aminu SakajikiINTRODUCTION 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.Item Challenges faced by Gauteng nephrology nurses regarding implementing evidence based practice(2020) Dube, Elizabeth LeratoIntroduction: Evidence-based practice is an expected core competence of all health care clinicians regardless of discipline. Melnyk and Fineout-Overholt (2014) noted that although there is an explosion of scientific evidence available to guide clinical practice, the implementation of evidence-based care by health professionals is typically not the norm in many healthcare systems across the globe. The researcher undertook this study to gain an understanding of what is preventing the nurses from implementing EBP in the nephrology nursing departments in Gauteng. Purpose of the study was to describe challenges related to EBP implementation that were faced by nephrology nurses in clinical practice and to describe the recommendations that will assist them to successfully implement. Methods. This study followed a qualitative, exploratory, descriptive and contextual approach and was conducted in nephrology units in Gauteng Province. The population of this study included trained nephrology nurses registered with the South African Nursing Council (SANC) and meeting the eligibility criteria. Data was collected from three phases and analysed using Hsieh and Shannon (2005) conventional data analysis method. Results: Sixteen sub categories emerged which were condensed to three categories of Management Practices, Perceived organizational support and leadership practices and Training and Development. Results included studies recommending the middle manager to be the link between nurses at the operational level and top management, who can successfully drive EBP and assist in alleviating experienced challenges. Recommendations were describedItem Combined paediatric liver-kidney transplantation: analysis of our experience(2014-08-27) Strobele, BerndBackground. 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.Item 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 VIntroduction 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.Item Enhancing the doctor-patient relationship: living, dying and use of the living will(2009-10-21T10:58:09Z) Etheredge, HarrietThe 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.Item Establishment of a flow cytometric assay in the setting of renal transplant for T and B cell crossmatching(2014-02-17) Ramparsad, NarishaDonor 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.Item Evaluation of potential kidney donors and outcomes post-donation at Charlotte Maxeke Johannesburg acdemic hospital (1983 - 2015) a(2019) Dayal, ChandniBackground Living kidney donation has emerged as a key therapeutic modality for end-stage kidney disease due to the global chronic shortage of renal allografts. However, the potential benefits to the recipient of a living donor kidney must be balanced against donor safety. In demographically diverse populations, there is a paucity of data regarding the living donor evaluation process and outcomes following donation. Objectives This study was undertaken to describe donation patterns, characterise reasons for nondonation and evaluate long-term morbidity and mortality following living kidney donation in the South African context. Methods A retrospective analysis of all Potential Living Donors (PLDs) evaluated at a single centre over a 32-year period was conducted. Of the total cohort of 1208 PLDs, 298 were Accepted Living Donors (ALDs), resulting in 910 Failed Living Donors (FLDs). Data collected included donor demographics. In addition, in the ALD group, clinical and laboratory parameters at various points in donor follow-up, as well as mortality data was noted. In the FLD group reason for donor exclusion was documented. Results Of the 1208 PLDs, 697 (58%) were female. The majority (559; 46%) were of Black African descent, and related to the intended recipient (991; 82%). Outcome of PLD evaluation varied significantly by race (p<0.001), with only a third of Black PLDs being accepted for donation. Black vs. Caucasian PLDs were more likely to fail workup (52.1% vs. 39.3%; p<0.001) and be excluded for medical reasons (44% vs. 35%; p<0.001). Leading medical exclusions included hypertension, HIV and obesity. In the ALD cohort, median follow-up time was 44 months (IQR 13.8 – 93.5 months). Hypertension was documented in 12.8% of ALDs at most recent follow-up compared to 4.7% of ALDs pre-donation (p=0.06). There was a significant increase in Albumin Excretion Rate (AER) following donation (p<0.001). There was a significant decline in the CKD-EPI eGFR between pre-donation (91.7 ± 19.1 ml /min/1.73 m2) and the most recent visit postdonation (72.5 ± 20 ml/min/1.73 m2; p<0.001). 27% of ALDs had a CKD-EPI eGFR<60 ml/min/1.73 m2 at most recent visit, however none required renal replacement therapy. There were 5 documented deaths, all unrelated to the development of renal dysfunction. Black ethnicity was not associated with increased risk of adverse outcome following donation. Conclusions There is a high exclusion rate for PLDs. Black PLDs are more likely to be excluded than Caucasian counterparts due to significant comorbidity. Although limited by high rates of donors lost to follow-up, it is concerning that a quarter of ALDs developed an eGFR<60 ml/min/1.73 m2 at last follow-up, with a significant increase in AER.Item Factors influencing CD4+ T cell counts in people living with HIV with end-stage kidney disease(2020) Pretorius, MelanieIntroduction: In South Africa, it is estimated that ~7 million people are living with Human Immunodeficiency Virus (HIV). HIV is associated with an increased risk of kidney disease. For people living with HIV (PLWH) who develop end-stage kidney disease (ESKD), access to renal replacement therapy can be difficult. Kidney transplantation is a cost-effective option, with improved overall survival and better quality of life. Eligibility criteria for kidney transplantation in Johannesburg includes a sustained CD4+ T cell count of >200 cells/μl and suppressed HIV replication. This study aimed to investigate the influence of hemodialysis on the lymphocyte subsets in PLWH with ESKD. Methods: Study participants and controls were recruited from renal dialysis centres in Johannesburg. Demographic data, social data, serial CD4+ T cell counts, serial HIV viral load measurements and blood samples were collected (before and after a haemodialysis session). Lymphocyte subsets were then measured. Results: Our cohort showed a statistically significant increase in the post-dialysis % of CD4+ T cells and the absolute CD4+ T cell counts. The longitudinal trend analysis for the % of CD4+ T cells revealed a significant increase in five participants and a single patient had a significant decrease in the longitudinal trend analysis for the absolute CD4+ T cell counts. The longitudinal trend analysis for HIV viral load revealed the majority of our participants were not virologically suppressed. Conclusion: This study showed that haemodialysis does not negatively impact CD4+ T cell count, suggesting that immunologic recovery is not impeded by treatment of the underlying ESKD.Item Graft survival in South African renal transplant patients during the transition period at Charlotte Maxeke Johannesburg Academic Hospital (graft-sat study)(2020) Chhiba, Priya DarshaniIntroduction: In the developed world, studies performed on the transition of adolescent renal transplant patients have noted high rates of rejection, non-adherence and graft loss. However, there is paucity of data in developing countries, and none in a South African setting. Objectives: The purpose of this study was to assess the rates of acute and chronic rejection, graft and patient survival in adolescents at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Methods:This study was a retrospective analysis of patients who received a renal transplant from 1 January 1990 to 31 December 2010, in the Paediatric Nephrology Department at CMJAH, in Parktown, Johannesburg, and entered the adolescent period (10 to 19 years old) with a functioning graft. Patients were included whether or not they were transferred to the Adult Nephrology Department at CMJAH.Results: 162 recipients were patients were transplanted during the study period, of which 80 (49.4%) were of black race, 63 (38.9%) were white, 10 (6.2%) were Asian and 9 (5.5%) were of mixed race. 65 (40.1%) were female and 97 (59.9%) were male. The median age at transplant was 13.8 years old (Interquartile range (IQR): 10.6 to 15.9). One hundred, twenty-eight (79.0%) patients received a renal transplant during the adolescent period and 34 (21.0%) were transplanted prior to adolescence. Fifty-four (33.3%) patients were transferred to the adult unit during adolescence. Graft failure occurred in 60 (37.0%) of the patients during the adolescent period, of which 54 (90.0%) occurred in the paediatric unit and 6 (10.0%) occurred in the adult unit. The median age at graft failure in the adolescent period was 16.1 years old (IQR: 14.5 to 17.9). Kaplan-Meier curves were used to analyse graft and patient survival. The following factors were identified as statistically significant in contributing to graft failure: if the transplant occurred during adolescence, previous renal transplant,non-compliance and rejection episodes in the adult unit, (p value <0.05). The 1, 3, 5, and 10-year patient survival rates were 98.8%, 97.6%, 95.1% and 93.9% respectively. Conclusion: This study revealed high rates of graft rejection and loss in South African renal transplant recipients in the adolescent period highlighting the vulnerability of this population group. Consideration should be given to the creation of transition clinics to potentially improve the graft outcomes of this vulnerable group. Further studies are needed on the transition period of adolescent renal transplant patients.Item Haemoglobin levels in the chronic dialysis population in the Nephrology Unit at Chris Hani Baragwanath Academic Hospital(2015-09-07) Kara, ReenaChronic 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.Item "Hey sister! where's my kidney?" : exploring ethics and communication in organ transplantation in Gauteng, South Africa(2016) Etheredge, Harriet RosanneIntroduction 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.Item The influence of dialysis modality on post-transplant outcomes(2020) Boosi, ReeceIntroduction: Renal transplantation is the therapy of choice for end stage kidney disease, offering mortality risk reduction and improved morbidity over dialytic therapies. Limited data is available evaluating the effect of pre-engraftment dialysis modality on transplant outcomes. Methods: A retrospective review was conducted of all adult patients undergoing renal transplantation at Charlotte Maxeke Johannesburg Academic Hospital for the period 01/01/2006 – 31/12/2011 (n=103). Transplant outcomes were assessed by dialysis modality. c2 testing was used to compare dialysis modalities; Cox proportional hazard modelling was used to assess effect on graft outcomes. A p < 0.05 was deemed statistically significant. Results: Antecedent dialytic modality was as follows: 55 patients (53.4%) received haemodialysis (HD), 35 (34%) received peritoneal dialysis (PD), and 13 (12.6%) received a combination of both (HD+PD, defined as either modality for > 3 months). Acute rejection (AR) was documented in 43.7% of patients; 54.3% of PD patients developed AR compared to 38.2% of HD patients and 38.5% of HD+PD patients (p=0.29). No significant difference in the number of episodes of AR was detected between modality groups (p=0.44). Chronic rejection (CR) developed in 22.3% of patients overall; 21.8% of HD patients, 25.8% of PD and 15.9% of HD+PD patients (p=0.74). PD was associated with an increased risk of developing any rejection (HR=2.4, 95% CI 0.9–6.4, p=0.02). Whereas dialysis modality did not affect graft survival (for HD b= 0.57, SE=0.5, Wald=1.2, 95% CI -0.4-1.6, p=0.27; for PD b=0.58, SE=0.5, Wald = 1.4, 95% CI -0.4-1.6, p=0.24), AR was found to be associated with futuregraft loss (b=1.29, SE=0.3, Wald = 18.1, 95% CI 0.7-1.9, p<0.001).Conclusions: Antecedent PD is associated with an increased risk of graft rejection. Although AR is associated with graft loss, antecedent dialysis modality does not directly predict graft survival, likely reflecting the multifactorial nature of cumulative allograft injury.Item Kidney transplant related knowledge and health education needs of patients with chronic kidney failure in two academic hospitals in Gauteng(2021) Nkadimeng, Mmabje CalvinBackground: Patients living with chronic kidney failure endure a lot of stress, as they have to adjust their lifestyle, stop smoking, eat a healthy diet, and refrain from self-medication. Currently, South Africa has dearth in literature regarding the knowledge of these patients about kidney transplant, which is so far the best treatment for chronic kidney failure. Patients are provided with health education before any transplant, this is done to equip them with adequate knowledge regarding the disease and its management. However, there are no methods to examine whether the patient comprehended the information or not. Purpose: The purpose of this study was to describe the kidney transplant related knowledge and health education needs of patients with Chronic Kidney Failure on haemodialysis awaiting kidney transplant in two hospitals in Gauteng. Methods: The study was a quantitative, descriptive and cross-sectional survey and data was collected using a kidney transplant understanding tool (K-TUT) questionnaire. Data analysis: Data was analysed using the statistical package for Social Science computer Programme and quantitative content analysis. Setting: The setting for this study was the renal units at two academic hospitals in Gauteng, South Africa. Results: Of the n=124 aimed sample size, n=70 patients gave consent to participate in the study, based on the set objective of describing the knowledge of patients on dialysis about their knowledge on kidney transplant, a large number n=58 (82.86%) scored above 50% indicating adequate knowledge and n=12 (17.14%) scored below 50%, which is regarded as inadequate knowledge. However, at the mean score of 55%, only half (n=35; 50%) of the participants had adequate knowledge. When considering the 55% as adequate knowledge indicator, half of the participants had inadequate knowledge regarding kidney transplant. The health education needs revealed three themes: firstly, the health education needs related to kidney transplant (quality of life, reproductive health and risks and side effects). Secondly the additional information needs to understand kidney transplant process such as donors and support system and lastly the family member involvement theme which entailed their family member understanding of the risk of rejection and infectionItem Knowledge of nephrology nurses on evidence based guidelines for prevention of haemodialysis catheter related infections(2016) Ntlhokoe, Mphanye JosephThe 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.