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Introduction: Sickle cell disease (SCD) is a common cause of Chronic kidney disease (CKD) and microalbuminuria is a predictor of CKD. Aims: To determine the prevalence of microalbuminuria (MA) in SCD patients as well as the clinical correlates of MA in these individuals. Study Design: A hospital-based cross-sectional study. Place and Duration of Study: Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State and Federal Medical Centre, Owo, Ondo State, between May 2016 to April 2017 Methodology: This cross-sectional study involved a total of 100 individuals with SCD. Blood and urine samples were obtained for haematology, chemistry and urine albumin/ creatinine ratio (UACR). Results: All the 100 studied subjects completed the study. The SCD group comprises both HbSS (86%) and HbSC (14%) subjects. The percentage of individuals with MA in the SCD subjects was 61%. The mean age of individuals with MA was 30.5(11.3) years compared to mean age of 25.3(6.8) years in those without MA (p= 0.012). In SCD subjects with microalbuminuria, eGFR was found to be significantly lower (p=0.044). The reticulocyte index, serum aspartate aminotransferase and serum albumin are the clinical correlates associated with MA in individuals with SCD. Conclusions: MA is prevalent among subjects with SCD and should be a routine method of detecting early onset of sickle cell nephropathy.

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race — a socio-political construct that mediates the effect of structural racism — as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations., Here, the authors discuss how structural racism underlies many of the health disparities that affect individuals from minority racial groups. They also examine how the use of race coefficients in estimated glomerular filtration rate equations might contribute to health inequities in Black patients with kidney disease., Key points Race and ethnicity are socio-political constructs that are inextricably tied to health outcomes for individuals from racial and ethnic minority groups worldwide.Historically, science has developed and relied on racial frames to artificially organize people into presumed homogeneous and genetically distinct racial groups, to suggest that inherent biological differences exist between the groups.The use of race coefficients in estimated glomerular filtration rate equations reinforces flawed assumptions of race essentialism and potentially perpetuates health inequities for Black individuals with kidney disease.Valid and race-free methods of kidney function estimation should be used to promote high-quality science, guide clinical management decisions and decrease racial bias.

Chronic kidney disease (CKD) particularly in its most severe form, end-stage renal disease (ESRD), is highly prevalent globally. Although both the incidence and prevalence appears to be increasing, the rate of increase is far higher in developing countries, probably as a result of underdevelopment, high incidence of communicable and noncommunicable diseases, poverty as well as inaccessible, unavailable, or unaffordable treatment modalities. The epidemiology differs remarkably between developing and developed economies - it afflicts the young and middle-aged in the former and older individuals in the latter. The etiologies also differ significantly, and the outcome is mainly determined by accessibility and availability of renal replacement therapies. While the three modalities of treatment namely hemodialysis, peritoneal dialysis, and kidney transplantation are available in sub-Saharan Africa, affordability of care remains a major challenge due to nonavailability of healthcare insurance in many of the countries, and where state support is available, dialysis and transplant rationing based on certain criteria remains a major limitation. Data on CKD and ESRD are largely unreliable because of a lack of renal registries in most countries, but the reactivation of the South African Renal Registry and its extension to cover other African countries may improve data quality. .

Variants in the Apolipoprotein L1 (APOL1) gene (G1-rs60910145, rs73885319, G2-rs71785313) are common in Africans and in individuals of recent African ancestry and are associated with an increased risk of non-diabetic chronic kidney disease (CKD) and in particular of HIV associated nephropathy (HIVAN). In light of the significantly increased risk of HIVAN in carriers of two APOL1 risk alleles, a role in HIV infectivity has been postulated in the mechanism of APOL1 associated kidney disease. Herein, we aim to explore the association between HIV viremia and APOL1 genotype. In addition, we investigated interaction between BK and JC viruria, CKD and HIV viremia. A total of 199 persons living with HIV/AIDS (comprising 82 CKD cases and 117 controls) from among the participants in the ongoing Human Heredity and Health in Africa (H3Africa) Kidney Disease Research Network case control study have been recruited. The two APOL1 renal risk alleles (RRA) genotypes were associated with a higher risk of CKD (OR 12.6, 95% CI 3.89–40.8, p < 0.0001). Even a single APOL1 RRA was associated with CKD risk (OR 4.42, 95% CI 1.49–13.15, p = 0.007). The 2 APOL1 RRA genotypes were associated with an increased probability of having HIV viremia (OR 2.37 95% CI 1.0–5.63, p = 0.05). HIV viremia was associated with increased CKD risk (OR 7.45, 95% CI 1.66–33.35, P = 0.009) and with a significant reduction of JC virus urine shedding (OR 0.35, 95% CI 0.12–0.98, p = 0.046). In contrast to prior studies, JC viruria was not associated with CKD but was restricted in patients with HIV viremia, regardless of CKD status. These findings suggest a role of APOL1 variants in HIV infectivity and emphasize that JC viruria can serve as biomarker for innate immune system activation.

Vasculopathy, as occurring in sickle cell disease (SCD), can affect celiac and mesenteric arteries and result in stenosis, with elevated peak systolic velocity (PSV) on Doppler ultrasonography. In six subjects with confirmed SCD in steady state, routine Doppler ultrasonographic examination discovered features of celiac artery (CA) or superior mesenteric artery (SMA) stenosis with CA PSV >200 cm/s (median = 222.8 cm/s; range = 201.5-427.1 cm/s) and/or SMA PSV >275 cm/s (median 183.2 cm/s; range = 87.8-289.3 cm/s). Among the six subjects, five had elevated soluble P-selectin values (median 72.55 ng/mL), while all six (100%) had elevated cystatin C levels (median 4.15 mg/L). Peripheral oxygen saturation was suboptimal in five subjects. All subjects had low hemoglobin concentration levels (median 8.5 g/dL) while four had elevated white blood cell count. Although vaso-occlusive crises result from microvessel occlusion, these findings at the macrovascular level suggest that SCD patients may also be vulnerable to mesenteric ischemic injury, especially in the setting of anemic heart failure from hemolysis.

Introduction: Mineral and bone disorders (MBD) are among the important complications of chronic kidney disease (CKD) including end-stage renal disease. In addition to the higher rate of all-cause and cardiovascular-related mortality, MBD is also a cause of significant morbidity in CKD patients. Materials and Methods: This is a cross-sectional study of all consenting patients on hemodialysis at Aminu Kano Teaching Hospital, between December 2011 and June 2012. With the aid of an interviewer-administered questionnaire, the demographic profile and clinical features of the patients were obtained. After a general physical examination, blood sample was taken for the determination of calcium, phosphate, intact parathyroid hormone, 25 hydroxy (25[OH]) Vitamin D3, packed cell volume, serum creatinine, and potassium. Results: Forty-eight patients on maintenance hemodialysis were recruited for the study, 39 (81.3%) were male and 9 (18.8%) were female. The age range was 40–59 years, with a mean of 45.96 ± 13.7 years. Chronic glomerulonephritis was the predominant cause of CKD (25%). Hyperphosphatemia was noted in 19 (39.5%) of the patients, whereas 22 (46%) had hypocalcemia. In 26 (54.1%) of the patients, the calcium-phosphate product was >4.55 mmol2/L2. We found that 58% of the patients had CKD-MBD, of which 15 (31%) had secondary hyperparathyroidism, whereas 13 (27%) had features suggestive of adynamic bone disease. None of the patient had normal serum 25(OH) Vitamin D3 (mean: 43.79 ± 21 ng/ml). Conclusion: CKD-MBD is common among patients on hemodialysis in our center. Screening for CKD-MBD and appropriate use of phosphate binder and Vitamin D when indicated are highly recommended.

Despite positive economic forecasts, stable democracies, and reduced regional conflicts since the turn of the century, Africa continues to be afflicted by poverty, poor infrastructure, and a massive burden of communicable diseases such as HIV, malaria, tuberculosis, and diarrheal illnesses. With the rising prevalence of chronic kidney disease and kidney failure worldwide, these factors continue to hinder the ability to provide kidney care for millions of people on the continent. The International Society of Nephrology Global Kidney Health Atlas project was established to assess the global burden of kidney disease and measure global capacity for kidney replacement therapy (dialysis and kidney transplantation). The aim of this second iteration of the International Society of Nephrology Global Kidney Health Atlas was to evaluate the availability, accessibility, affordability, and quality of kidney care worldwide. We identified several gaps regarding kidney care in Africa, chief of which are (i) severe workforce limitations, especially in terms of the number of nephrologists; (ii) low government funding for kidney care; (iii) limited availability, accessibility, reporting, and quality of provided kidney replacement therapy; and (iv) weak national strategies and advocacy for kidney disease. We also identified that within Africa, the availability and accessibility to kidney replacement therapy vary significantly, with North African countries faring far better than sub-Sahara African countries. The evidence suggests an urgent need to increase the workforce and government funding for kidney care, collect adequate information on the burden of kidney disease from African countries, and develop and implement strategies to enhance disease prevention and control across the continent.

The practice of Nephrology in Nigeria dates back to the 1960s when the country gained independence from the UK. The University College Hospital (UCH) in Ibadan, as a college of the University of London, had the first recognised Nephrology unit. Several other units have been established over the years countrywide in federal, state and private institutions, although these units are mainly restricted to the urban parts of the country where an estimated 51.9% of the population now live. These units mainly have the capacity to carry out haemodialysis, with much fewer units having the capacity to carry out peritoneal dialysis and kidney transplantation. Haemodialysis has been consistently carried out in the country since 1982 with expanding capacity, and renal transplantation since March 2000. Peritoneal dialysis, however, despite being first performed in the early 1960s at UCH Ibadan, is done only in few centres and as acute intermittent peritoneal dialysis due to various challenges which are addressed in this chapter. The chapter also details a summary of the spectrum of kidney diseases, therapies and related research that are available in the country. The peculiarities and challenges faced by those engaged in the care of these patients are also outlined.

Acute kidney injury (AKI) is prevalent and is associated with high morbidity and mortality globally. The epidemiology differs remarkably between developing and developed economies. Infections, diarrheal illnesses, obstetric causes and nephrotoxins are very rampant in the tropics. Even though the etiologies are different, the final common pathway in the pathogenesis is similar - tubular damage or necrosis, tubular blockage, and back leak of glomerular filtrate. The mechanism of AKI in infections could be through ischemic insult consequent to hypovolemia and/or hemoglobinuria, as seen in malaria and viral hemorrhagic fevers, interstitial inflammation, or nephrotoxicity. On the contrary, the mechanism of nephrotoxin-induced AKI includes direct toxic effect on the renal tubules, intratubular precipitation of substances like djenkolic and oxalic acids (crystalluria) as well as intratubular obstruction and AKI. Toxicity could also be indirect by interacting with the pharmacokinetic profile of other coadministered medications. Bites and envenomation as well as obstetric complications also induce AKI through hypovolemia, interstitial nephritis, and other unclear mechanisms in eclampsia and preeclampsia. Outcome is variable and dependent on etiology. Prognosis appears to be significantly better in hypovolemic or prerenal and/or obstructive AKI compared to intrarenal or intrinsic AKI.

Introduction: Hypertension is a cause and consequence of chronic kidney disease globally. The other factors that work in concert with hypertension to cause CKD are yet to be clearly elucidated. Studies have identified proteinuria, dyslipidemia, obesity, smoking and family history of CKD as renal risk factors. Due to the high morbidity and mortality associated with occurrence of CKD including the enormous financial burden involved in its management, the knowledge of prevention and understanding of the risk factors for development of CKD is highly essential. Therefore, Identifying well defined risk factors that display strong graded association with the occurrence and progression of CKD can help in elucidating potential targets for disease modification. Objective: The aim of this study was to determine the prevalence of renal risk factors and their impact on kidney function in newly diagnosed hypertensive Nigerians.Methods: This was a case control study of two hundred and fifty newly diagnosed hypertensive Nigerians recruited from two contiguous hospitals in an urban setting in south western Nigeria. Another group of two hundred and fifty apparently healthy age and sex matched normotensive Nigerians in the same community were recruited as controls.Results: Seventy (28%) of the newly diagnosed hypertensives had estimated glomerular filtration rate of less than 60ml/min, while 42.4% and 18.8% of the subjects and the controls had microalbuminuria respectively. The newly diagnosed hypertensives had significantly higher prevalence of analgesic use (86.4% versus 41.6%, p < 0.001), alcohol consumption (20.8% versus 12%, p = 0.008), use of canned salted food (18.8% versus 8.4%, p= 0.001) and central obesity (36.1% versus 26.8%, p= 0.025) compared to controls.Conclusion: There is a significant occurrence of modifiable renal risk factors in newly diagnosed hypertensives and this offers a platform for instituting preventive strategies in the community.Keywords: Renal risk, hypertensives, urban population, Nigeria.

Evidence-based cinical practice guidelines improve delivery of uniform care to patients with and at risk of developing kidney disease, thereby reducing disease burden and improving outcomes. These guidelines are not well-integrated into care delivery systems in most low- and middle-income countries (LMICs). The KDIGO Controversies Conference on Implementation Strategies in LMIC reviewed the current state of knowledge in order to define a road map to improve the implementation of guideline-based kidney care in LMICs. An international group of multidisciplinary experts in nephrology, epidemiology, health economics, implementation science, health systems, policy, and research identified key issues related to guideline implementation. The issues examined included the current kidney disease burden in the context of health systems in LMIC, arguments for developing policies to implement guideline-based care, innovations to improve kidney care, and the process of guideline adaptation to suit local needs. This executive summary serves as a resource to guide future work, including a pathway for adapting existing guidelines in different geographical regions.

Kidney diseases have assumed epidemic proportions in both developed and developing countries, particularly chronic kidney disease (CKD). While treatment modalities are available and accessible in developed economies with improvement in outcomes, survival, and quality of life, they are either unavailable or inaccessible in nations with emerging economies, particularly in sub-Saharan Africa (SSA), with an attendant worsening outcome and survival for CKD patients. The epidemiology of CKD in SSA has revealed that it preferentially affects adults in their economically productive years, usually below the age of 50 years, with consequent drain on the economy. This derives mainly from the major etiologies in the region, which are infection-induced chronic glomerulonephritis and hypertension, compounded by poverty as well as societal and health underdevelopment, poor resource allocation to health, and underdeveloped health infrastructures. This has made preventive nephrology a major goal in the sub-region, although those who have already developed CKD must be managed up to tertiary levels. In this review, we assessed the contributions of parasitic diseases (i.e., malaria and schistosomiasis), sickle cell disease and nephrotoxins with the aim of espousing their contributions to the burden of kidney disease, and proposing management options with the goal of ultimately reducing the burden of kidney disease in these disadvantaged populations.

Background: Renal and ocular vessels are some of the major vessels affected in patients with diabetes, and the involvement of these vessels is independent risk factors for other complications. Hemodynamic flow in arteries may be assessed by using measures such as resistive index, which is a non-invasive measure of the resistance in vessels. The association between retinopathy and nephropathy has been conflicting. This study assessed the relationship between resistive index of the central retinal artery and indices of nephropathy in type 2 diabetes. Method: This cross-sectional study examined 74 Nigerian diabetics who were selected consecutively from the out-patient diabetic clinic of a tertiary hospital in South-West Nigeria. Doppler ultrasound was used to determine the resistive index of the central retinal artery along with the right renal artery. The urinary and serum biochemical parameters were also done to determine the urinary albumin excretion and the glomerular filtration rate. Results: The mean age of participants was 59.62 ± 9.55 years. The mean central retinal artery resistive index (CRARI) was 0.77 ± 0.06, with 65 (87.8%) of the participants having elevated CRARI. There was no statistical difference between patients with normal CRARI and elevated CRARI in respect of their urinary albumin excretion (p = 0.796). There was no significant correlation between CRARI and estimated glomerular filtration rate (r = 0.120; p = 0.309) and right renal artery resistive index (r = 0.068; p = 0.564). Conclusion: This study demonstrates that central retinal artery resistive index (CRARI) may not be a predictor of renal function in diabetics.

Introduction: Autosomal Dominant Polycystic Kidney Disease (ADPKD) is presumably rare in Africa. Knowledge about the disease in Nigeria is limited as demonstrated by scanty articles on the subject. Objectives: To determine the pattern of clinical presentation and outcome of ADPKD among ADPKD patients. Method: ADPKD subjects were prospectively studied between January 1996 and December 2010. Their demographics, clinical and investigation parameters were documented. Dependency on dialysis, renal transplant and death were the final outcomes. Results: Forty one patients (M:F=1.3:1) with mean age of 48.6±4.6 years were studied. ADPKD was diagnosed at 2.73 cases per annum. Family history of ADPKD and hypertension were present in 56.1% and 82.9% respectively. Their mean systolic and diastolic blood pressures were 166.9 ±23.6 and 104 ±21.2 respectively. Nocturia (78.0%) and loin pain (68.3%) were the most common presenting symptoms. Liver cysts (31.7%) and aortic regurgitation (22.0%) were the predominant extra-renal manifestations. Twenty three (56.1%) received haemodialysis; no renal transplantation. Death rate was 51.2%. Presence of uraemia and intra-cerebral aneurysm contributed significantly to mortality. Conclusion: ADPKD may not be so rare in Nigeria. Awareness campaign to change attitude of family members to screening and further studies using newer criteria for diagnosis of ADPKD should be conducted. Keywords: Clinical presentation, autosomal dominant polycystic, kidney disease, Nigeria.

HIV-positive individuals are at increased risk for kidney disease, including HIV-associated nephropathy, non-collapsing focal segmental glomerulosclerosis, immune-complex kidney disease, and comorbid kidney disease, as well as kidney injury resulting from prolonged exposure to antiretroviral therapy or from opportunistic infections. Clinical guidelines for kidney disease prevention and treatment in HIV-positive individuals are largely extrapolated from studies in the general population, and do not fully incorporate existing knowledge of the unique HIV-related pathways and genetic factors that contribute to the risk of kidney disease in this population. We convened an international panel of experts in nephrology, renal pathology, and infectious diseases to define the pathology of kidney disease in the setting of HIV infection; describe the role of genetics in the natural history, diagnosis, and treatment of kidney disease in HIV-positive individuals; characterize the renal risk-benefit of antiretroviral therapy for HIV treatment and prevention; and define best practices for the prevention and management of kidney disease in HIV-positive individuals.

Objective To better define the prevalence of protein-energy wasting (PEW) in kidney disease is poorly defined. Methods We performed a meta-analysis of PEW prevalence from contemporary studies including more than 50 subjects with kidney disease, published during 2000-2014 and reporting on PEW prevalence by subjective global assessment or malnutrition-inflammation score. Data were reviewed throughout different strata: (1) acute kidney injury (AKI), (2) pediatric chronic kidney disease (CKD), (3) nondialyzed CKD 3-5, (4) maintenance dialysis, and (5) subjects undergoing kidney transplantation (Tx). Sample size, period of publication, reporting quality, methods, dialysis technique, country, geographical region, and gross national income were a priori considered factors influencing between-study variability. Results Two studies including 189 AKI patients reported a PEW prevalence of 60% and 82%. Five studies including 1776 patients with CKD stages 3-5 reported PEW prevalence ranging from 11% to 54%. Finally, 90 studies from 34 countries including 16,434 patients on maintenance dialysis were identified. The 25th-75th percentiles range in PEW prevalence among dialysis studies was 28-54%. Large variation in PEW prevalence across studies remained even when accounting for moderators. Mixed-effects meta-regression identified geographical region as the only significant moderator explaining 23% of the observed data heterogeneity. Finally, two studies including 1067 Tx patients reported a PEW prevalence of 28% and 52%, and no studies recruiting pediatric CKD patients were identified. Conclusion By providing evidence-based ranges of PEW prevalence, we conclude that PEW is a common phenomenon across the spectrum of AKI and CKD. This, together with the well-documented impact of PEW on patient outcomes, justifies the need for increased medical attention.

This review addresses the development of dialysis services in Africa in the face of past and contemporary challenges. Maintenance dialysis treatment programs developed in 29 countries over the past 50 years, usually many years after their independence and the end of subsequent territorial and civil wars. Eight countries had the resources to launch national dialysis programs, conventionally defined as those accommodating at least 100 patients per million population. Additionally, based on information obtained from international and local publications, conference proceedings, and personal communications, it appears that limited short-term dialysis therapy currently is available in most African countries. Currently, the prevalence of and outcomes associated with dialysis in Africa are influenced significantly by the following: (1) local health indexes, including the prevalence of undernutrition and chronic infections; (2) per capita gross domestic product; (3) national expenditures on health and growth of these expenditures with incremental demand; (4) availability and adequate training of health care providers; and (5) literacy. In an attempt to reduce the socioeconomic burden of maintenance dialysis treatment, 12 countries have adopted active transplantation programs and 5 are striving to develop screening and prevention programs. Our recommendations based on these observations include optimizing dialysis treatment initiatives and integrating them with other health strategies, as well as training and motivating local health care providers. These steps should be taken in collaboration with regulatory authorities and the public.

Objective Despite being a Critical Intervention in the WHO Near-miss concept, the indications and clinical outcomes of patients with Pregnancy-Related Acute Kidney Injury (PRAKI) requiring dialysis at the Obafemi Awolowo University Teaching Hospitals Complex, Nigeria remain unknown. This retrospective review was conducted to facilitate counselling, prognostication and introduction of preventative measures by providing contemporary data on the aetiology and clinical outcomes of women with PRAKI. Study design A retrospective review. The indications for dialysis and feto-maternal outcomes of women with PRAKI requiring dialysis between January 2007 and December 2016 were reviewed. Analysis was performed with IBM SPSS 21.0. Results There were 43 patients with PRAKI that required dialysis and 11,242 live births, with Maternal Near Miss Ratio (MNMR) of 3.8/1000 live births. Preeclampsia/ecclampsia (40%), Sepsis (37.5%) and Haemorrhage (20%) were the leading aetiologies of kidney injury, while oligo-anuria (100%) was the commonest clinical presentation. Majority (78%) of them had ≤four dialysis sessions before recovery of renal function. The mean (±SD) gestational age and birth weight at delivery were 36 (±3.1) weeks and 2.9 (±0.6)kg, while the Maternal Mortality Index and Perinatal mortality rates were 18% and 34% respectively. Delayed referral, and lower number of dialysis sessions were the significant predictors of mortality, while four women discontinued care due to cost. Conclusion The high rate of Pregnancy-related acute kidney injury requiring dialysis, with its attendant morbidity and mortality are largely preventable. The prognosis is however good with standardised care. Functional emergency obstetric services, and a review of the Nigerian healthcare financing system are advocated.

Summary Background The burden of end-stage kidney disease (ESKD) in sub-Saharan Africa is unknown but is probably high. Access to dialysis for ESKD is limited by insufficient infrastructure and catastrophic out-of-pocket costs. Most patients remain undiagnosed, untreated, and die. We did a systematic literature review to assess outcomes of patients who reach dialysis and the quality of dialysis received. Methods We searched PubMed, African Journals Online, WHO Global Health Library, and Web of Science for articles in English or French from sub-Saharan Africa reporting dialysis outcomes in patients with ESKD published between Jan 1, 1990, and Dec 22, 2015. No studies were excluded to best represent the current situation in sub-Saharan Africa. Outcomes of interest included access to dialysis, mortality, duration of dialysis, and markers of dialysis quality in patients with ESKD. Data were analysed descriptively and reported using narrative synthesis. Findings Studies were all of medium to low quality. We identified 4339 studies, 68 of which met inclusion criteria, comprising 24 456 adults and 809 children. In the pooled analysis, 390 (96%) of 406 adults and 133 (95%) of 140 children who could not access dialysis died or were presumed to have died. Among those dialysed, 2747 (88%) of 3122 adults in incident ESKD cohorts, 496 (16%) of 3197 adults in prevalent ESKD cohorts, and 107 (36%) of 294 children with ESKD died or were presumed to have died. 2508 (84%) of 2990 adults in incident ESKD cohorts discontinued dialysis compared with 64 (5%) of 1364 adults in prevalent ESKD cohorts. 41 (1%) of 4483 adults in incident ESKD cohorts, 2280 (19%) of 12 125 adults in prevalent ESKD cohorts, and 71 (19%) of 381 children with ESKD received transplants. 16 studies reported on management of anaemia, 17 on dialysis frequency, eight on dialysis accuracy, and 22 on vascular access for dialysis Interpretation Most patients with ESKD starting dialysis in sub-Saharan Africa discontinue treatment and die. Further work is needed to develop equitable and sustainable strategies to manage individuals with ESKD in sub-Saharan Africa. Funding None.

Therapeutic apheresis (TA) refers to a group of extracorporeal blood treatment modalities with clinical indications for which the clinicians' knowledge, availability and applicability vary widely worldwide. Therapeutic plasma exchange (TPE), the most common TA technique, is neither readily available nor affordable in many parts of Africa. This article focuses on the challenges of starting a TPE program in a resource-constrained economy and the result of a survey of Nigerian nephrology professionals on TPE. A critical appraisal of published manuscripts from Nigeria on TA was undertaken to assess uses, methods, and challenges encountered followed by a survey of the perceptions of Nigerian nephrology professionals on TPE. Survey results: 56.7% of respondents had very little or no knowledge of TPE; 40.5% moderate and only 2.7% admitting to having a good knowledge. Only 18.9% of respondents have ever participated or observed a TPE procedure with the remaining 81.1% not having any exposure to the procedure. A vast majority of the respondents 97.3% felt they needed better exposure and training in TPE and its applications. Among consultants, 56% had little knowledge, 88% had never participated or observed the TPE procedure, and 94% felt they needed better exposure and training. There is significant limitation in accessibility, availability, and use of TPE in Nigeria; knowledge of TPE and its applications is minimal among nephrology professionals. Efforts should be concentrated on improving the knowledge and availability of TPE in resource-constrained economy like Nigeria. Centers that would be able to manage cases requiring TA should be developed.

The incidence and prevalence of chronic kidney disease and end-stage renal disease (ESRD) have continued to increase exponentially all over the world in both developed and developing countries. While the majority of patients in developed countries benefit from various modalities of renal replacement therapies, those from developing economies suffer untimely deaths from uremia and cardiovascular disease. Kidney transplantation (KT) leads to improvement in both the quantity and quality of life. Unfortunately, it is not exploited to its full potential in most countries and this is particularly the case in developing economies. Only a very small fraction of the ESRD population in emerging countries ever gets transplanted because of the many constraints. This review focuses on KT in Nigeria between 2000 and 2010 and assessed particular challenges that need be addressed for KT potential to be fully harnessed in such resource-constrained settings. A total of 143 KTs were performed in 5 transplant centers, some of which have only recently opened. One-year graft and patient survival was 83.2% and 90.2%, respectively, while the 5-year graft and patient survival was 58.7% and 73.4%, respectively. Mortality was reported in 38 (27%) of recipients. The complications recorded included acute rejection episodes in 15–30%, chronic allograft nephropathy in 21(14.7%) and malignancies, particularly Kaposi Sarcoma, which was reported in 8 (5.6%) recipients. It was concluded that KT has led to an improved survival but is bedevilled with unaffordability, inaccessibility, a shortage of donor organs and poor legislative support. Enactment of relevant organ transplant legislation, subsidization of renal care, and further development of local capacities would improve KT utilization and thus lead to better outcomes.

Background: Chronic kidney disease (CKD) patients who experience superimposed acute kidney injury (AKI) have been shown to be at higher risk of long-term sequelae of AKI when compared to those who do not experience AKI. It remains unclear whether the need for temporary dialysis intervention following superimposed AKI in patients with CKD has any effect on the long-term major adverse cardiovascular events (MACE). This study examines the relationship between temporary dialysis therapy following AKI and long-term major cardiovascular events in patients with background CKD. Methods: The study population consists of adults who developed AKI while on admission at the University of Virginia Medical Center between January 1, 2002 and December 31, 2012, and who had preadmission estimated glomerular filtration rate (eGFR) between 20 and 60 mL/min/1.73 m2 and survived beyond 30 days of AKI. Demographic and baseline clinical variables were used to generate propensity score. Survivors who had temporary dialysis were matched to those managed conservatively according to the propensity score in a ratio of 1:3. Results: Overall, 6,634 (n = 381 and 6,253 in the temporary dialysis-requiring AKI and non-dialysis AKI groups respectively) met entry criteria for the full cohort. Of these, 381 (5.7%) received temporary dialysis. There were 3,147 (47.4% of all patients) MACE events during the study period. The crude incidence for MACE after 30 days of AKI was similar in both dialyzed and non-dialyzed patients. After the propensity score matching, the adjusted hazard ratio for MACE in dialyzed versus non dialyzed patients was 1.162 (95% CI 0.978-1.381). Conclusions: Treatment of AKI with temporary dialysis in hospitalized patients with baseline eGFR between 20 and 60 mL/min/1.73 m2 was not associated with an increased risk for subsequent admission for MACE. If confirmed by prospective studies, clinicians may not need to worry that the dialysis procedure may contribute to additional risk for long-term MACE in CKD patients with superimposed AKI.

Background: The prevalence of depression and its relationship to poor outcomes in chronic kidney disease are established facts. Such prognostic impact in acute kidney injury (AKI) is not known. This study determines the prognostic implication of a diagnosis of depression on renal recovery and major adverse cardiovascular events (MACE), a new diagnosis of myocardial infarction, cerebrovascular disease (CVD, stroke or transient ischemic attack) or congestive heart failure (CHF) after hospitalization with AKI. Methods: The study population comprises adults admitted to the University of Virginia Medical Center between January 1, 2002 and December 31, 2012 who suffered AKI during admission. Long-term outcomes, MACE and all-cause mortality, were compared between 2 groups; patients with preexisting diagnosis of major depression and those without. Risk adjusted multivariable Cox proportional hazards regression examined the association between major depression and these outcomes. Results: Patients with AKI numbering 11,425 survived beyond 90 days and had data available. Of these patients, 2,519 (22%) were majorly affected by depression; more often, younger patients, females, African Americans, and those with more comorbid conditions, especially CHF, CVD, diabetes, peptic ulcer disease, chronic pulmonary disease and liver disease were found to be affected with depression. Crude hazard ratio for MACE was 1.245, 95% CI 1.150-1.348 and for all-cause mortality 1.186, 95% CI 1.091-1.290; p < 0.001, that is, the cohort with major depression had a long-term risk for MACE and all-cause mortality increased by 24 and 18%, respectively. Conclusion: Patients who develop AKI in hospital and have preexisting major depression are at greater long-term risk of MACE and all-cause mortality.

Background and objectives The incidence of acute kidney injury (AKI) in hospitalized patients is increasing. Many of these patients survive the immediate post-AKI period and may be prone to developing long-term complications of AKI. This study aimed to determine whether complete recovery following an episode of AKI is associated with a lower risk of long-term major adverse cardiovascular events (MACE). Design Retrospective cohort study. Setting and participants Adults admitted to the University of Virginia Medical Center between January 1, 2002 and December 31, 2012 who developed hospital-acquired AKI. Predictor AKI was defined as an increase in serum creatinine (SCr) by ≥ 0.3 mg/dL from the baseline and or requirement for acute dialysis during index hospitalization. Complete recovery was defined as a return of SCr to less than 1.25 times the baseline value and not dialysis dependent. Outcome and measurement: MACE was defined as subsequent admission for myocardial infarction, stroke or transient ischemic attach and heart failure using ICD- 9-CM codes. Results Overall, 11,538 patients survived beyond 90 days of AKI and had data available for analysis. Of the 9,673 survivors of AKI in whom recovery could be assessed, 7170 (74.12%) had complete renal recovery. MACE occurred in 27.28% of our study population over a median follow-up period of 399 days. 28.19% of patients who completely recovered renal function developed MACE, while only 32.48% did in those who did not recover completely. Patients who had complete recovery had a lower risk of long-term MACE when compared with those without complete recovery (adjusted hazard ratio 95% confidence interval (CI): 0.774 (0.713, 0.842)). Limitation Measurement of albuminuria was not available. Conclusion Complete renal recovery after an episode of AKI in patients with normal baseline kidney function is associated with a lower risk of long-term MACE when compared with those who did not fully recover.

Prevalence of chronic kidney disease (CKD) in Nigeria is on the increase and it is associated with increasing caregiving burden for both the professionals and informal caregivers. This study evaluated the burden experienced by nurses caring for CKD patients, identified the procedures causing the caregiving burden and factors associated with burden in two hospitals in Ondo State, Nigeria. Two hundred and forty nurses caring for renal patients were selected from two health institutions in Ondo State. Information on sociodemographic data was obtained using a self-administered questionnaire. The burden of care was evaluated using the Zarith Burden of Life Instrument (ZBI), with aggregate score ranged from 0–88. A score of 21–40 indicates mild-to-moderate burden while a score >40 indicates high burden. The mean age of the respondents was 33.7 ± 7.5 years (age range: 20–67 years). Forty percent experienced no burden, 48.3% experienced mild-to-moderate burden, 10.4% experienced severe burden while only 1.3% experienced very severe burden. Dialysis procedure (65.5%) was identified as posing the greatest caregiving burden. Factors identified as responsible for caregiving burden were shortage of staff (68%), followed by lack of funds on the part of the patients (67.1%). Caregiving burden was not associated with age, gender, or years of experience. Prevalence of caregiving burden was very high among the respondents and dialysis was identified as causing greatest burden. Government should fund and improve staffing of dialysis units to reduce caregiving burden.

Background: Chronic kidney disease (CKD) is a global public health problem, with a greater burden and prohibitive cost of care particularly indeveloping countries. This study determined the prevalence of chronic kidney disease and identified its associated risk factors in patients attending the Family Practice Clinic, Wesley Guild Hospital, Ilesa, Nigeria.Method: Consecutive newly-registered patients who attended the Family Practice Clinic of Wesley Guild Hospital, Ilesa from August 2005 to January2006 were recruited and studied. Relevant data were collected by using an interviewer-administered questionnaire, and determining the spot urinaryACR (albumin-creatinine ratio) of the subjects by using Microalbustix™ reagent strips and using their serum creatinine concentration. The glomerular filtration rate (GFR) of each subject was estimated using the Modification of Diet in Renal Disease (MDRD) formula. A repeat urine test was done three months after the initial screening to identify subjects with persistent microalbuminuria.Results: The age of the study subjects ranged from 20 to 74 years, with a mean age of 50.52 + 13.03 years. There were 68 males and 182 females in the sample population, showing a male to female ratio of 1:2.7. One hundred and thirteen of the 250 subjects (45.2%) were found to have pathologic albuminuria at the initial screening, while 31 (12.4%) had persistent albuminuria three months later. Also, 51 subjects (20.4%) had estimated low GFR at the initial screening and 26 (10.4%) had persistent low GFR three months later. Significant risk factors for CKD in the study subjects were increasing age, elevated blood pressure, history of diabetes mellitus (DM), habitual intake of analgesics and herbs, and an abnormal waist to hip ratio (p < 0.05). The association between persistent abnormal ACR and low GFR did not reach statistical significance (p = 0.053). Habitual analgesic intake (p = 0.002) and age group (p = 0.0027) were true predictors of CKD among the study subjects.Conclusions: The prevalence of CKD in the study population was high and its association with modifiable risk factors was demonstrated. Familyphysicians have a unique opportunity to identify and address these factors in their patients. Routine screening for CKD in family practice clinics isindicated to reduce the burden of renal disease in the population.

In order to determine the pattern of renal disease and risk factors for renal disease in HIV-infected Nigerians, we studied 400 consecutive HIV/AIDS patients (210 males, 190 females) aged between 18 and 65 years (mean +/- SD; 34.6 +/- 9.4 years), and examined renal disease factors attributable to the infection. Diagnosis of renal disease was based on the consistent presence of at least 1+ albuminuria and/or elevated serum creatinine (>132 micromol/l) as well as the absence of other identifiable causes of chronic kidney disease (CKD). We determined socio-demography and clinical findings, as well as full laboratory work-ups including haemogram, CD4+ cell count, serum electrolytes, urea, creatinine, protein, cholesterol and urine analysis. Renal biopsies were taken in 10 patients who had moderate to massive proteinuria and had consented to the procedure. Finally, we compared HIV/AIDS cases with and without renal disease to determine the risk factors for nephropathy. We observed a high prevalence of renal disease (proteinuria and/or elevated serum creatinine), which was present in 152 (38%) of the patients. This subgroup included 74 males and 78 females with a M:F ratio of 1:1. The mean age (+/-SD) was 35.8 (+/-10.01) years. Systolic and/or diastolic hypertension was seen in 13.2% of these patients while the mean (+/- SD) body mass index (BMI) and packed cell volume (PCV) were 18.5 (+/-3.1) kg/m(2) and 25.26 (+/-6.81)%, respectively. The mean (+/-SD) CD4+ count was 246.49 (+/-192.8) cells/microl, while the mean (+/-SD) serum creatinine and 24-h urine protein excretion rates were 210.11 (+/-337.8) micromol/l and 2.57 (+/- 2.42) g/day, respectively. In subjects with and without nephropathy, there were significant differences in age, BMI, serum cholesterol, serum albumin and CD4+ counts, suggesting that these parameters may be risk factors for nephropathy. Histology revealed mainly focal glomerulosclerosis (FGS) with glomerular collapse. We conclude that the prevalence of proteinuria in HIV-seropositive patients is high in Nigeria. Such subjects show an equal male:female distribution, and glomerular histology revealed that a majority of biopsied patients had the collapsing FSGS variant. The risk factors for renal disease included severity of the HIV infection (inferred from the generally low CD4+ count), anaemia, malnutrition and increasing age.

There is a dearth of data on end-stage renal disease (ESRD) in Africa. Several national renal registries have been established but have not been sustainable because of resource limitations. The African Association of Nephrology (AFRAN) and the African Paediatric Nephrology Association (AFPNA) recognize the importance of good registry data and plan to establish an African Renal Registry. This article reviews the elements needed for a successful renal registry and gives an overview of renal registries in developed and developing countries, with the emphasis on Africa. It then discusses the proposed African Renal Registry and the first steps towards its implementation. A registry requires a clear purpose, and agreement on inclusion and exclusion criteria, the dataset and the data dictionary. Ethical issues, data ownership and access, the dissemination of findings and funding must all be considered. Well-documented processes should guide data collection and ensure data quality. The ERA-EDTA Registry is the world's oldest renal registry. In Africa, registry data have been published mainly by North African countries, starting with Egypt and Tunisia in 1975. However, in recent years no African country has regularly reported national registry data. A shared renal registry would provide participating countries with a reliable technology platform and a common data dictionary to facilitate joint analyses and comparisons. In March 2015, AFRAN organized a registry workshop for African nephrologists and then took the decision to establish, for the first time, an African Renal Registry. In conclusion, African nephrologists have decided to establish a continental renal registry. This initiative could make a substantial impact on the practice of nephrology and the provision of services for adults and children with ESRD in many African countries.

Dialysis-requiring acute kidney injury (D-AKI) is common in hospitalized patients. Many patients survive the immediate post AKI period, thus at risk of suffering long-term sequelae of AKI. Prior studies examining long term outcomes lack non-dialyzed AKI control groups. Without non-dialyzed AKI control group, these studies cannot provide relevant information on long-term risks or benefits associated with dialysis intervention following AKI. The study cohort comprises of adults admitted to the University of Virginia Medical Center between January 1, 2002 and December 31, 2012 with baseline eGFR ≥60 ml/min per 1.73 m2, who developed AKI during hospitalization and survived beyond 30 days of the AKI event. Follow up was done until MACE, death or through Dec 31, 2013 (n = 11,779). AKI was defined according to KDIGO definition. MACE was defined as subsequent admission for Myocardial Infarction (MI), cerebrovascular disease (CVD) and heart failure using ICD 9-CM codes. The date of MACE was defined as the date of the first qualifying event. Demographic and premorbid clinical variables were used to generate propensity score. Patients who had temporary dialysis were matched with those managed conservatively according to propensity score in a ratio of 1:3. After the propensity score match, the adjusted hazard ratio for MACE, all-cause mortality and composite end point “all-cause mortality or MACE” in dialyzed versus non dialyzed patients were 1.081 (95 % CI 0.848–1.378), 1.107 (95 % CI 0.869–1.410) and 1.107 (95 % CI 0.880–1.307), respectively. Management of AKI with temporary dialysis in hospitalized patients with baseline eGFR of ≥60 ml/min per 1.73 m2 was NOT associated with an increased risk for subsequent admission for MACE or all-cause mortality. Clinicians may not need to worry that the dialysis procedure itself may confer additional risk for long-term MACE and all-cause mortality in AKI patients with normal pre-hospitalization GFR.

H3Africa is developing capacity for health-related genomics research in Africa

Therapeutic apheresis (TA) refers to a group of extracorporeal blood treatment modalities with clinical indications for which the clinicians' knowledge, availability and applicability vary widely worldwide. Therapeutic plasma exchange (TPE), the most common TA technique, is neither readily available nor affordable in many parts of Africa. This article focuses on the challenges of starting a TPE program in a resource-constrained economy and the result of a survey of Nigerian nephrology professionals on TPE. A critical appraisal of published manuscripts from Nigeria on TA was undertaken to assess uses, methods, and challenges encountered followed by a survey of the perceptions of Nigerian nephrology professionals on TPE. Survey results: 56.7% of respondents had very little or no knowledge of TPE; 40.5% moderate and only 2.7% admitting to having a good knowledge. Only 18.9% of respondents have ever participated or observed a TPE procedure with the remaining 81.1% not having any exposure to the procedure. A vast majority of the respondents 97.3% felt they needed better exposure and training in TPE and its applications. Among consultants, 56% had little knowledge, 88% had never participated or observed the TPE procedure, and 94% felt they needed better exposure and training. There is significant limitation in accessibility, availability, and use of TPE in Nigeria; knowledge of TPE and its applications is minimal among nephrology professionals. Efforts should be concentrated on improving the knowledge and availability of TPE in resource-constrained economy like Nigeria. Centers that would be able to manage cases requiring TA should be developed.

These case reports demonstrated the diagnostic dilemma encountered in patients with systemic lupus erythematosus and thrombotic thrombocytopenic purpura particularly in settings with limited diagnostic facilities and laboratory support. The similarities in the diagnostic criteria for both conditions make clear distinction as well as management decisions difficult. We present the difficulties encountered with both the diagnosis and the management of these two patients that were managed in our facility.

To determine the risk factors predisposing Nigerian diabetics to overt nephropathy with a view to developing strategies for its prevention.case control study.Tertiary care hospital, a major nephrology referral centre in Nigeria.30 diabetic nephropathy (DN) patients and 32 age and sex-matched diabetic patients without nephropathy.30 diabetic nephropathy (DN) patients with chronic renal failure who have been diabetic for a minimum of five years and satisfied the inclusion criteria for the study were compared with 32 age and sex-matched diabetic patients without nephropathy. Their socio-demographic parameters, clinical and laboratory profiles were determined and compared. RESULTS were analysed using the statistical package for social sciences version 10. Chi-square test, logistic regression analysis and Spearman's rank correlation coefficient were used, p-value0.05 was considered as significant.The study sought to compare socio-demographic, clinical and biochemical data between diabetic patients with overt nephropathy and those without.Duration of diabetes, blood pressures and blood sugar levels were significantly higher in DN patients than the controls (p0.05). A family history of renal disease, socio-economic status, cigarette smoking, body mass index and total serum cholesterol did not distinguish between DN patients from controls (p0.05). Systolic blood pressure positively correlated with serum creatinine (r = 0.057, p0.001) and duration of DM (r = 0.284, p = 0.02). There was a constellation of clinical features viz: retinopathy, peripheral neuropathy and left ventricular hypertrophy, which were significantly associated with DN (p0.05).Prolonged duration of diabetes, hypertension, retinopathy, and peripheral neuropathy, left ventricular hypertrophy and poor glycaemic control were the major risk factors for overt nephropathy among Nigerian diabetics. Apreventive strategy should include adequate blood pressure and glycaemic control.

Acute renal failure, a relatively common clinical condition, is still associated with a high mortality rate in both developed and developing countries despite the differences in the epidemiology, clinical characteristics and therapeutic modalities offered to affected patients. The various modalities of renal replacement therapy are still largely inaccessible, unaffordable and unavailable in most parts of sub-Saharan Africa, hence the need to judiciously utilise available resources. Consequently we studied patients with acute renal failure to critically appraise the factors that influence survival and determine the usefulness or otherwise of available renal replacement therapies (Acute HD and Acute PD). A total of 46 (34 (73.9%) males and 12 (26.1%) females) patients satisfied the inclusion criteria. Their ages ranged between 15 and 76 years (mean +/- SD; 38.2 +/-16.3 years). The commonest causes were gastro-enteritis (cholera) and septicaemia in 36.9% and 30.5% respectively. Twenty six (56.5%) of all the patients survived while the remaining 20 (43.5%) died. Twenty four (52.2%) patients had different complications of which pulmonary oedema was singularly found to significantly influence survival. Other factors that were found to significantly influence survival included availability of renal replacement therapy, the aetiology of ARF; gender; age of the patients and the duration of oliguria. We further compared the patients managed with haemodialysis with those managed with peritoneal dialysis and found no difference(s) in the age; duration of oliguria or hospitalisation; survival figures; effect of pulmonary oedema and the aetiology of ARF. However, the number of sessions for HD and the duration of PD significantly influenced survival. We conclude that ARF is still associated with a high mortality rate and prompt institution of available renal replacement therapy and aggressive management of complications would assist in reducing the trend.