The Use of Sustained Low-efficiency Dialysis in the Treatment of Sepsis-associated Acute Kidney Injury in a Low-income Country: A Prospective Cohort Study.

Background: Limited data are available regarding the management and outcomes of patients with sepsis-associated acute kidney injury (SA-AKI) requiring dialysis in Sudan. Continuous renal replacement therapy (CRRT) is a highly favored treatment modality in such patients. However, it stays unavailable and expensive treatment in most low-income countries. We aimed to evaluate the use of sustained low-efficiency dialysis (SLED) in the treatment of hemodynamically unstable patients with SA-AKI admitted to the intensive care unit (ICU). Materials and methods: A prospective cohort was conducted in Baraha Medical City, Khartoum, Sudan. Patients above 18 years of age, who were admitted to the ICU between January and September 2020 with SA-AKI, and required SLED or CRRT were enrolled. These were followed up till death or discharge from the ICU. They were observed regarding their dialysis tolerance, rate of renal recovery, ICU mortality, and cost of therapy. Data analysis was done using SPSS. Results: Fifty-three adults were enrolled. Their mean age was 62 ± 11 years, and 56.6% were males. Thirty-one patients (58.5%) received SLED and 22 (41.5%) underwent CRRT. Patients in the two groups were age and sex matched and showed no significant differences in their comorbid conditions, source of sepsis, sequential organ failure assessment (SOFA) score, and their indications for dialysis (p > 0.05). Patients treated with SLED showed similar dialysis tolerance, rate of renal recovery, length of ICU admission, and risk of death compared to those treated with CRRT (p > 0.05). Moreover, SLED treatments were less expensive than CRRT, and the costs of ICU admission among the SLED group were significantly less (p < 0.001). Conclusion: Our study shows that SLED is safe and effective. It is readily available and can be routinely performed in the treatment of hemodynamically unstable patients with SA-AKI at a significantly lower cost. How to cite this article: Taha AKA, Shigidi MMT, Abdulfatah NM, Alsayed RK. The Use of Sustained Low-efficiency Dialysis in the Treatment of Sepsis-associated Acute Kidney Injury in a Low-income Country: A Prospective Cohort Study. Indian J Crit Care Med 2024;28(1):30-35.

Molecular characterization and genotyping of hepatitis C virus from Sudanese end-stage renal disease patients on haemodialysis.

BACKGROUND: Hepatitis C virus (HCV) is a global public health problem, with ~ 11 million people in Africa infected. There is incomplete information on HCV in Sudan, particularly in haemodialysis patients, who have a higher prevalence compared to the general population. Thus, our objectives were to genotype and molecularly characterize HCV isolated from end-stage renal disease haemodialysis patients. METHODS: A total of 541 patients were recruited from eight haemodialysis centres in Khartoum and screened for anti-HCV. Viral loads were determined using in-house real-time PCR in seropositive patients. HCV was genotyped and subtyped using sequencing of amplicons of 5' untranslated (UTR) and non-structural protein 5B (NS5B) regions, followed by phylogenetic analysis of corresponding sequences. RESULTS: The HCV seroprevalence in the study was 17% (93/541), with HCV RNA-positive viremic rate of 7% (40/541). A low HCV load, with a mean of 2.85 × 104 IU/ml and a range of 2.95 × 103 to 4.78 × 106 IU/ml, was detected. Phylogenetic analyses showed the presence of genotypes 1, 3, 4, and 5 with subtypes 1a, 1b, 1 g, 3a, 4a, 4 l, 4 m, 4 s, and 4t. Sequences of HCV from the same haemodialysis units, clustered in similar genotypes and subtypes intimating nosocomial infection. CONCLUSION: HCV infection is highly prevalent in haemodialysis patients from Sudan, with phylogenetic analysis intimating nosocomial infection. HCV genotyping is useful to locate potential transmission chains and to enable individualized treatment using highly effective direct-acting antivirals (DAAs).

Risk factors associated with the development of diabetic kidney disease in Sudanese patients with type 2 diabetes mellitus: A case-control study.

BACKGROUND AND AIMS: Limited data are available regarding the risk factors associated with the development of diabetic kidney disease (DKD) among Sudanese adults with type 2 diabetes mellitus (T2DM). METHODS: A case-control study was conducted at Dr. Salma Center for Kidney Diseases between April and September 2019. Patients with T2DM and DKD were compared to age and sex-matched T2DM patients with no kidney disease (NKD). Socio-demographic features, clinical findings, and laboratory investigations of the study subjects and controls were analyzed using SPSS. RESULTS: A total of 372 patients with DKD were compared to 364 T2DM patients with NKD. The mean age of the DKD patients was 58 ± 13.4 years, their median eGFR was 37.3 ± 4.9 ml/min/1.73 m2; they had their T2DM at a significantly younger age compared to controls (P = 0.014). Logistic regression analysis revealed that a family history of diabetes mellitus, a family history of chronic kidney disease, the presence of hypertension, obesity, hypercholesterolemia, hyperuricemia, smoking, recurrent urinary tract infection, and the regular use of non-steroidal anti-inflammatory drugs were significantly associated with the development of DKD (P values < 0.05). CONCLUSION: A series of modifiable risk factors were found to be significant determinants for developing DKD. Primary care physicians are expected to pay considerable attention to their control.

An Overview of the Long-term Follow-up of the Adult Post-kidney Transplant Recipients in Sudan: A Single-Center Experience.

Kidney transplant remains the definitive treatment for patients with end-stage renal disease. A retrospective cohort was conducted in Dr. Selma Center for Kidney Diseases (DSCKD) to determine the pattern of follow-up and outcomes of adult kidney transplant recipients (KTRs) on long-term follow-up. Patients presented for follow-up during the period from January to June 2018 were studied regarding their demographic features, kidney transplant surgery, immunosuppressive therapy, graft function, and post-transplant complications. Data analysis was done using the Statistical Package for the Social Sciences version 16.0. During the study period, a total of 941 adult and pediatric KTR presented to DSCKD for follow-up. Only 792 KTRs were included in the study; those were adults, with their first kidney transplant, completed one year post-transplant, and agreed for enrollment. The mean age of the studied population was 47 ± 4.3 years. The majority were males, 74.2%. The median duration of follow-up was 7.4 years (interquartile range 3-11). Most transplants were through living-related donations, 78.8%. The combination of prednisolone, tacrolimus, and azathioprine remains the most common immunosuppressive regimen prescribed; delivered to 47.5% of recipients. Post-transplant complications were predominantly recurrent infections, diabetes mellitus, and hyperlipidemia seen in 54.5%, 42.4%, and 24.7% of recipients, respectively. On cross-comparisons living unrelated donor transplant recipients were found to have increased post-transplant complications, with a reduced kidney graft function at the end of the 1st year and throughout follow-up, when compared to living related donor transplant recipients. A prospective multi-center study with long-term follow-up remains essential for further evaluation of the long-term outcomes of the KTR in Sudan.

Clinical features and antinuclear antibodies profile among adults with systemic lupus erythematosus and lupus nephritis: a cross-sectional study.

INTRODUCTION: Limited data is available regarding the clinical manifestations and pattern of Systemic Lupus Erythematosus (SLE) in Sudan. This study aimed to determine the clinical manifestations and Antinuclear Antibodies (ANA) profile among Sudanese adults with SLE and lupus nephritis (LN). METHODS: A descriptive study was conducted in Omdurman Military Hospital, Sudan. It included all adults with SLE and on regular follow-up during the study period (December 2012 to May 2013). These were investigated regarding their demographic details, clinical features, and immunological profile (ANA, anti-double stranded DNA, and ANA profile 3 levels). Patients with LN had their pattern of renal involvement described; furthermore, associations between the various SLE reactive antibodies and the histological diagnosis of lupus were studied. RESULTS: Sixty-two Sudanese adults with SLE were included, their mean age was 31 ± 10.9 year. Females made 93.5% of patients. A clear predominance of those of Arab ancestry was seen, with most patients being from the Ja'alin and Shaigiya ethnic groups accounting for 29% and 12.9%, respectively. Arthritis was the dominant clinical manifestation seen in 85.5%, whereas renal involvement was seen in 66.1% of patients. Lupus nephritis class III was the dominant histological lesion, seen in 39% of patients. On correlating the ANA profile to the histopathological diagnosis of LN, anti-Nucleosomes and anti-AMA-M2 autoantibodies were found to be significantly associated with LN class IV and class VI, respectively (P values < 0.05). CONCLUSION: Further epidemiological studies regarding SLE and its ANA profile remain essential as they might help predicting the clinical patterns of the disease and its prognosis.

Pattern and outcome of acute kidney injury among Sudanese adults admitted to a tertiary level hospital: a retrospective cohort study.

INTRODUCTION: Little is known about the pattern and outcome of Acute Kidney injury (AKI) in Sudan. This study aimed to determine the etiology and outcome of AKI among Sudanese adults. METHODS: A retrospective cohort study was conducted in a tertiary level hospital, Soba University Hospital, Sudan. The medical records of all adults admitted to hospital from the 1st of January to 31st of December 2014 were reviewed. The diagnosis and severity of AKI was defined as per the Kidney Disease Improving Global Outcomes (KDIGO) recommendations. RESULTS: The medical records of 6769 patients were reviewed. AKI was diagnosed in 384 patients (5.7%); being community acquired in 82.6% of cases. Sepsis, volume depletion, obstructive uropathy, heart failure, acute glomerulonephritis and severe malaria were the commonest causes of AKI diagnosed in 44%, 38.5%, 8.9%, 5.7%, 4.7% and 3.1% of patients, respectively. Following treatment complete renal recovery was seen in 35.7% of patients; whereas 31.2% of patients died. Predictors of increased risk of death were old age [OR 1.03, 95% CI (1.01-1.057); P=0.003], presence of chronic liver disease [OR 2.877, 95% CI (1.5-5.5); P=0.001], sepsis [OR 2.51, 95% CI (1.912-4.493);P=0.002] and the severity of AKI [OR 3.873, 95% CI(1.498-10.013);P=0.005]. CONCLUSION: AKI was diagnosed in 5.7% of adults admitted to hospital. Most patients were having community acquired AKI. Old age, the presence of chronic liver disease, sepsis, and the severity of AKI as per KDIQO staging were significant predictors of mortality.

Parasite diversity in adult patients with cerebral malaria: a hospital-based, case-control study.

Thirty adult patients with cerebral malaria (CM) were recruited for this study. Two clinical groups were used as controls: those with mild malaria (n = 20) and asymptomatic volunteers (n = 20). Thick and thin blood smears were examined for detection of Plasmodium falciparum and estimating infection intensity. A nested polymerase chain reaction (PCR) using allele-specific primers for merozoite surface protein gene was used to determine the parasite diversity of Plasmodium falciparum causing CM. Plasmodium falciparum was detected in blood smears of all malaria patients. No significant difference in parasite count was found between the groups. Thirteen (65%) of the asymptomatic volunteers had a positive PCR for P. falciparum. Multiple alleles were found in 17 (58.6%) patients with CM, but only in 7 (35.6%) with uncomplicated malaria. Multiple alleles were also found in 6 (46.2%) of the 13 PCR-positive asymptomatic individuals. We could not identify a specific strain or strains of P. falciparum that showed a significant association with disease severity. Therefore, we assume that the development of CM in adults residing in endemic areas is more dependent on strain multiplicity rather than on a specific strain or strains of P. falciparum, and that the parasite intensity has no relationship with disease severity. Asymptomatic adults may repeatedly be exposed to low levels of a wide range of different strains during low transmission season and acquire sub-patent parasitemia. This may also confer premunition that renders them relatively resistant to CM.

Clinical presentation, treatment and outcome of paraphenylene-diamine induced acute kidney injury following hair dye poisoning: a cohort study.

INTRODUCTION: In Africa and Asia hair dye is applied together with henna to decorate the hands and feet. Paraphenylene-diamine (PPD), a highly toxic constituent of hair dye can lead to acute kidney injury (AKI). METHODS: A cohort study was conducted during the period from April 2012 to March 2013 in Khartoum Teaching Hospital, Sudan. It targeted adults presenting acutely with an evident history and clinical features of hair dye poisoning, together with AKI as per the RIFLE criteria. Analysis of data was done using SPSS. RESULTS: 30 adults were included, their mean age was 25.6 ± 4.2 years, 93.3% were females. Exposure to PPD was suicidal in 86.7%. The mean duration to onset of renal symptoms was 34.8 ± 7.6 hours, maximum median serum creatinine was 8.6 ± 2.3 mg/dl, 86.7% had loss of kidney function as per the RIFLE classification and required dialysis. Initial renal recovery was seen after a mean duration of 9.8 ± 2.2 days. One patient died, 3.3%; all others, 96.7%, recovered normal kidney function. The amount of ingested PPD correlated significantly to the severity of symptoms, number of dialysis sessions required and time for renal recovery with P values < 0.05. CONCLUSION: Hair dye poisoning was associated with prolonged hospital stay, requirement of dialysis and increased morbidity. The severity of symptoms directly correlates to the dose of PPD ingested, with the kidney damage being reversible in almost all survivors.

Adherence of healthcare professionals to evidence-based clinical practice guidelines in the management of hemodialysis patients, Khartoum State, Sudan.

INTRODUCTION: Hemodialysis (HD) is a complex procedure with many specifications and requires adherence to a set of particular clinical practice guidelines. These guidelines had already been established by globally acclaimed renal authorities and their implementation was shown to correlate with patients' morbidity and mortality. This study was conducted to evaluate the adherence of healthcare professionals to the evidence-based clinical practice patterns in Khartoum State HD units. METHODS: A cross-sectional study was conducted in Khartoum State HD units during the period from September 2010 to January of 2011. Data was collected from the healthcare professionals using a specially designed checklist. The checklist included the evidence-based clinical practice guidelines for the HD vascular access, HD adequacy, anemia of chronic kidney disease (CKD), nutrition, cardiovascular risk assessment, and hepatitis B and C virus infection control. Implementation of these guidelines was evaluated, and further graded using a Likert-type scale. RESULTS: Four randomly selected HD units were included in the study. The rate of implementation of the HD vascular access guidelines was 54.8%, adequacy guidelines 57%, anemia of CKD 68.8%, nutrition 58.4%, cardiovascular risk assessment 57%, and hepatitis B and C infection control guidelines was 79.2%. Overall, the four HD units assessed showed moderate deviations from the practice guidelines of anemia of CKD and hepatitis B and C infection control. Extreme deviations from the clinical practice guidelines were seen in HD vascular access practices, adequacy assessments, nutrition and cardiovascular risk assessment. CONCLUSION: Hemodialysis services in Khartoum State are in need of great improvements regarding adherence to protocols and the standards of care.

Barriers to kidney transplantation among adult Sudanese patients on maintenance hemodialysis in dialysis units in Khartoum State.

Kidney transplantation remains the preferred modality of treatment for patients with end-stage renal disease. In Sudan, kidney transplantation accounted for 28% of the total provided renal replacement therapies. A cross-sectional, hospital-based study was conducted in hemodialysis (HD) units in Khartoum State during the period from September 2010 to January 2011. It aimed to determine the main reasons for the currently low renal transplantation rate. Data were obtained by direct interviewing using a specifically pre-coded and pre-tested questionnaire following a pilot study. A total of 462 adult HD patients were randomly selected from the various HD units in Khartoum State; these patients accounted for 16.9% of the total HD population in Khartoum State. The mean age of the study patients was 48.5 ± 23.6 years and 312 (67.5%) were males. Upon interviewing, only 316 patients (68.4%) said that they had been counseled for kidney transplantation. One hundred and twenty-two patients (26.4%) were on the active transplant list; of these, 50% preferred to have their kidney transplantation performed abroad, mostly due to the availability of commercial transplantation and/or a presumed better outcome. The low renal transplantation rate was due to financial constraints in 112 patients (24.2%), lack of medical fitness in 97 patients (21%) and absence of a suitable kidney donor in 92 patients (20%), while 56 patients (12%) were still having misperceptions regarding transplantation and preferred to continue on dialysis. To improve the kidney transplantation rate in Khartoum State, the Sudan program for organ transplantation is expected to take more initiatives to promote and improve the outcome of kidney transplants inside the country and, accordingly, regain the patients' confidence on the health system.

Active tuberculous infection among adult Sudanese patients on long term peritoneal dialysis.

INTRODUCTION: The prevalence of tuberculosis in Sudan is 209 cases per 100,000 populations. There are no reports available regarding the prevalence of tuberculosis among the end-stage kidney disease and dialysis populations. METHODS: We reviewed the medical records of all adults who were on peritoneal dialysis (PD) in the Sudan Peritoneal Dialysis Program, during the period from June 2005 to December 2011. Those diagnosed as having active tuberculous infections were retrospectively studied regarding their demography, clinical presentation and outcomes. RESULTS: Out of 350 patients in our program, 19 were diagnosed as having active tuberculosis (5.4%). All patients were diagnosed during their first year on peritoneal dialysis, 74% were males; the mean age was 37 ± 11 years, extrapulmonary tuberculosis was seen in 16/19 (84%) patients and it was abdominal in nine of the 16 (47%) patients. In addition to high clinical suspicion, the diagnosis of active tuberculosis was supported by tissue biopsy findings in 16%, positive polymerase chain reaction in 26%, exudative ascites with suggestive radiological features in 21%, strongly positive tuberculin test in 21% and a favourable response to empirical antituberculous therapy in 26% of patients. HIV test was negative in all 19 patients and only one patient tested positive for hepatitis B viral infection. Antituberculous drugs side effects were seen in 68% of patients. Forty seven percent of patients showed complete recovery and continued on peritoneal dialysis. Our case fatality was 32%. CONCLUSION: Abdominal tuberculosis is common among PD patients and its diagnosis should always be considered in suspected patients.

The treatment of relapse in adults with minimal change nephrotic syndrome: myths and facts.

Few controlled trials have studied the treatment of relapse in adults with minimal change disease. Repeated courses of steroids, cyclophosphamide, cyclosporine and even mycophenolate mofetil (MMF), all seem to play a role. The aim of this study was to review and critically analyze the literature regarding the use of immunosuppressive therapy for the treatment of relapse in adults with minimal change nephrotic syndrome (MCNS). An intensive search was done for published trials in the general medical database. Retrieved studies were further sorted according to specific inclusion and exclusion criteria. Selected trials were critically analyzed and evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence, 2009 rating. Six studies were selected and systematically reviewed. One randomized controlled trial compared the use of cyclo-phosphamide versus cyclosporine (11 adults) and showed that both drugs are effective in the treatment of frequent relapses [level 1b evidence (grade B)]. Three trials (total of 20 patients) tested the use of cyclosporine therapy and showed that cyclosporine, though effective in the treatment of relapse, is associated with an extremely high incidence of subsequent relapses following drug with-drawal. A long-term follow-up cross-sectional study of 95 patients, with 69 relapsers, supported the use of steroids in the treatment of occasional relapses [level 2c evidence (grade C)]. One case series described the benefits of MMF [level 4 evidence (grade C)]. Most of the the clinical trials studied were heterogeneous, underpowered by small adult populations, open-labelled, non-randomized, with poor statistical analysis, validity and utility. We conclude that there is poor evidence that successful treatment of the first relapse of adult MCNS can be achieved with a second course of steroids or cyclosporine. Also, there is weak evidence that frequent relapses can be treated using cyclophosphamide, cyclosporine or MMF. Powered, multi-centered, randomized, blinded, controlled trials, with long-term follow-up are required to know the optimal treatment for relapsing adult MCNS.

Peritoneal dialysis, an expanding mode of renal replacement therapy in Qatar.

Qatar is one of the gulf countries with a current estimated population of 1.4 million. Diabetes mellitus, hypertension and chronic kidney diseases are major emerging epidemics, with an incidence of end-stage kidney disease (ESKD) of 202 patients per million population per year. Peritoneal dialysis (PD) was initiated in Qatar in 1997 with a rapid expansion in the number of patients. The study included all patients performing PD in Qatar, during the period from 1 January 2003 to 31 December 2007. Retrospective analysis of data included the records of 241 patients in terms of their demography, treatment, complications, and survival. During the study period, PD patients formed 23% of all the dialysis population in Qatar, with a mean annual expansion rate of 12%. Diabetic nephropathy was the commonest cause of ESKD seen in 43% of PD patients. All age groups were included in our program, with a mean age of 53 ± 13 years. Males represented 74%. Continuous ambulatory peritoneal dialysis remained the initial mode of PD, with significant numbers being changed to automated PD over the years. The 1- and 5-year survival rates were 91% and 26%, respectively, with cardiac causes being responsible for 86% of mortality. The rate of peritonitis was 0.24 ± 0.1 episodes per patient years, and technique survival at 1 and 5 year was 84% and 32%, respectively. We conclude that the components of the PD program in Qatar are comparable to that in other countries with a good outcome.

Microbial spectrum and outcome of peritoneal dialysis related peritonitis in Qatar.

Peritoneal dialysis therapy rapidly expanded in Qatar during the last decade. Peritoneal dialysis related peritonitis remains the leading cause of morbidity and technique failure. The objective of this study was to determine the incidence of peritoneal dialysis related peritonitis in Qatar, during a five year study period. The records of all patients on maintenance peritoneal dialysis from January 1, 2003 to December 31, 2007 were reviewed. Episodes of peritonitis, microbial profile, clinical course and outcome were analyzed. A total of 241 patients were included, males represented 74%, the mean age was 53 + or - 13 years, and 48% of patients were diabetics. During the study period 118 episode of peritonitis were observed, with a mean incidence of 0.24 + or - 0.1 episodes per patient year. Gram-positive organisms were isolated in 40% of episodes, with Staphylococcus epidermidis and Staphylococcus hemolyticus being the commonest organisms, isolated in 21% and 9% of infections, respectively. Escherichia coli was the commonest Gram-negative organism and was isolated in 9% of peritonitis episodes, whereas culture-negative peritonitis represented 28% of all diagnosed infections. Seventy nine percent of peritonitis episodes completely resolved with the use of intraperitoneal antimicrobial therapy. Peritoneal dialysis catheters were removed in 19% of episodes. Peritonitis related mortality rate was 3%, and it was due to Candida spp. and Pseudomonas aeruginosa. Despite its low incidence, peritonitis remained the leading cause of patient dropout. Prompt diagnosis and prudent management as well as psychological support to the patients remained essential to reduce the incidence of technique failure following peritonitis episodes.

Demographic data and hemodialysis population dynamics in Qatar: A five year survey.

Hemodialysis was initiated in Qatar in 1981, since then the hemodialysis population has been expanding rapidly. This report describes the demographics and outcome of our hemodialysis patients during a five years study period. Data of all the patients on regular hemodialysis from January 1 st , 2002 to December 31 st , 2006 were included in this study was collected from the medical records and entered into an especially designed questionnaire. The prevalence of end stage kidney disease in Qatar is 624 patients per million populations with an incidence of 202 patients per million populations per year. Currently, 278 patients are on hemodialysis, 65% of them are Qatari, males represent 51%, whereas 44.6% are between 65-74 years of age. Diabetic nephropathy is the commonest cause of end stage kidney disease (48%), followed by primary glomerulonephritis and hypertensive glomerulopathy. Arteriovenous fistula was the vascular access in 57% of patients. The incidence of Hepatitis B, C and Human immunodeficiency virus had been stable throughhout the study period though our hemodialysis population had increased by 1.5 fold. The first and five years survival rates of our patients were 84 and 53% respectively. Qatar has one of the highest rates of dialysis patients with a good long-term survival report. Peritoneal dialysis remained to be the key solution for the rapidly expanding patients' pool. Maintenance of national registry of dialysis patients and improving our organ transplant program is an essential goal.