Kidney function and clinical correlates in newly diagnosed hypertensives attending a university teaching hospital in southwest Nigeria.

Summary Hypertension is associated with development of cardiovascular and kidney complications. Low awareness of hypertension leads to late presentation and development of complications. Studies have also shown that chronic kidney disease is often undiagnosed and patients present late. In view of the aforementioned, the prevalence and clinical correlates of decreased kidney function in newly diagnosed hypertensives were assessed. The study was carried out at LAUTECH Teaching Hospital, Osogbo, Nigeria. One hundred and forty three patients satisfied the inclusion criteria. Hypertension was defined by SBP > or = 140 and/or DBP > or = 90 mm Hg. Kidney function was assessed by glomerular filtration rate (GFR) using Modification of Diet in Renal Disease (MDRD) formula. Patients with GFR < 60 mL/min were defined as having decreased kidney function. Determinants of decreased kidney function were assessed. Thirty three patients (23.1%) have decreased kidney function. On univariate analysis, age, educational status, BMI, SBP and DBP were significantly associated with decreased kidney function. After logistic regression, age and BMI were significantly associated with decreased kidney function. Decreased kidney function was present in 23.1% of the study population. These patients stand a higher risk of faster progression of kidney disease and cardiovascular complications. This finding underscores the need to improve the awareness of hypertension in the population.

Target organ damage and associated clinical conditions in newly diagnosed hypertensives attending a tertiary health facility.

BACKGROUND: Despite the ease of detecting and making a diagnosis of hypertension, various population surveys have shown low awareness and treatment rates of hypertension. Failure to detect and make a diagnosis of hypertension leads to late presentation and institution of treatment with consequent development of target organ damage (TOD) and associated clinical conditions (ACC) which in turn are associated with increased cost of treatment, morbidity and mortality. OBJECTIVE: This study was aimed at determining the presence and severity of TOD and ACC in newly diagnosed hypertensives with a view to ascertaining the magnitude of the problem. METHOD: The study was carried out at Ladoke Akintola University of Technology Teaching Hospital Osogbo, Nigeria. Target organ damage (TOD) and associated clinical conditions (ACC) were determined in successive newly diagnosed hypertensives that presented at the centre during the study period. RESULT: Of 147 newly diagnosed hypertensives seen at Ladoke Akintola University of Technology Teaching Hospital Osogbo, Nigeria, TOD and ACC were found in 98 (66.7%). The most prevalent TOD and ACC were LVH (42.2%), diabetes mellitus (14.3%), CVD (10.9%) and heart failure (8.8%). Patients with TOD andACC were significantly older (p = 0.028), had significantly higher SBP (p = 0.003), higher DBP (p = 0.022) and significantly lower BMI (p = 0.046) when compared with patients without TOD and ACC. CONCLUSION: This study showed presence of TOD and ACC in two-thirds of newly diagnosed hypertensives. This underscores the need for improvement in the awareness, detection and treatment of hypertension in order to prevent TOD and ACC.

Current concepts in the management of refractory cirrhotic ascites.

BACKGROUND: Ascites is the pathologic accumulation of fluid within the peritoneal cavity. This condition when refractory to treatment heralds more severe complications and a poor prognosis. The aim of this paper is to review literature on the pathogenesis and current management of refractory cirrhotic ascites. METHODS: An English language literature search using Medline and PubMed (1976-2006 March) was done to assess all research/review articles on the pathogenesis and management of refractory cirrhotic ascites. RESULTS: The onset of ascites in cirrhotic patients signifies poor prognosis. Only a small percentage of patients with cirrhotic ascites develop true resistance to diuretics. Serial therapeutic paracentesis remains the available option for the majority of patients. Liver transplantation is the only definitive therapy, but the use of this method is limited by the availability of the organ and the cost of such procedure. Transjugular intrahepatic portosystemic stent shunt is a useful procedure but limited by the complication of disseminated intravascular coagulopathy. The role of other alternatives is less clearly defined. CONCLUSION: Therapeutic options in patient with cirrhotic ascites remains serial therapeutic paracentesis with or without plasma expansion. Transjugular intrahepatic portosystemic stent-shunt is a useful alternative. The unavailability of liver donors serves as a barrier to liver transplantation.

The increasing prevalence of diabetic nephropathy as a cause of end stage renal disease in Nigeria.

The incidence of diabetic nephropathy, the leading cause of chronic kidney disease in the western world has increased by 150% in the past 10 years in the United States, with similar trends in Europe and Japan. It is apparent from the present study that diabetic nephropathy may be assuming an increasing role as a cause of chronic kidney disease in Nigeria.

Effects and outcome of haemodialysis on QT intervals and QT dispersion in patients with chronic kidney disease.

Cardiovascular complications and sudden cardiac death are common in patients with chronic kidney disease and those on haemodialysis. This is often associated with prolonged QT(c) and QT(c) dispersion intervals. Forty-two patients on haemodialysis were compared with 45 control subjects to study the effect of haemodialysis on these ECG parameters and to compare mortality rates of those with excessively prolonged QT(c) and QT(c) dispersion. Maximum QT(cd), QT(d) and QT(c) dispersion increased with dialysis although these did not reach statistical significance. The maximum QT(c) was longer than 440 ms in 71.4% of patients post-dialysis, with a mortality rate of 73.3%. This was not statistically different from a mortality of 66.7% for those patients with maximum QT(c) less than 440 ms. Some (40.4%) of the patients had a QT(c) dispersion longer than 80 ms; the mortality rate of these (70.5%) was not statistically different from 68.0% for those with shorter QT(c) dispersion. Arrhythmia was rare in all cases. Patients with left ventricular hypertrophy (LVH) had the longest QT(c) dispersion and a statistically higher mortality rate. The in-hospital mortality in our patients was high (69.0%) but this might have been related to late presentation and limited facilities and not necessarily to acute cardiovascular complications of prolonged QT(c) dispersion.

Profile of antihypertensive prescription in a developing country.

Data from pharmocoepidemiologic studies examining the patterns of antihypertensives prescription within a population are important for identifying any discordance between published recommendations and clinical practice. The aims of this article are to investigate the antihypertensive drug prescription pattern and utilization in the management of systemic hypertension among Nigerians, and to relate these to established guidelines. Within the population, the prescription pattern of antihypertensive drugs is still at variance with established guidelines.

Hepatitis B virus infection: implications in chronic kidney disease, dialysis and transplantation.

Hepatitis B virus (HBV) infection occurs worldwide but is most prevalent in Southeast Asia and sub-Saharan Africa with reported prevalence rates varying from 3 - 26 %. The higher prevalence of infection has been reported in patients with HBV and human immunodeficiency virus (HIV) co-infection. Hepatitis B virus not only affects the liver but has also been implicated in the pathogenesis of membranous, membranoproliferative and mesangial proliferative glomerulonephritides. Though controlling the spread of HBV infection in renal dialysis units has been one of the major triumphs in the management of end-stage renal disease, transmission of HBV can still occur through contamination of equipments and environmental surfaces and the use of multiple dose vials of drugs. Some reports have indicated that prior HBV infections have negative impact on graft and host survival following transplantation. Interferon can be used in the treatment of HBV-associated glomerulonephritides (HBV- GN) but is contraindicated in transplantation because of its immuno-modulatory effects. Despite the fact that patients with chronic kidney disease (CKD) have suboptimal response to HBV immunization, immunization is still beneficial to these patients. However, reports indicate that most patients with CKD were either not immunized or were given suboptimal doses. Control of HBV in the population by immunization can lead to a reduction in the prevalence of HBV- GN. In addition, immunization of patients with CKD will help in controlling HBV infection in dialysis settings and can lead to improved graft and host survival following transplantation.

Ruptured false iliac artery aneurysm--a case report from Nigeria.

A 23 year old male Nigerian presented to the Nephrology unit of the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria with features of chronic renal failure secondary to chronic glomerulonephritis. He was referred to the surgical department of the hospital on account of severe torrential uncontrollable bleeding from an infected cannulation site. He was maintained on regular hemodialysis but developed femoral triangle sepsis at the cannulation site and aneurysm of the external iliac artery. The aneurysm later ruptured with severe jet exsanguinations bleeding. Exploration revealed a-4 cm rent in the external iliac artery that was sutured with 6/0 prolene, interrupted, using clamp and suture technique. Perfusion was satisfactory in the immediate post-operative period. The patient was transfused with 11 pints of blood within 12 hours and had an uneventful post-operative period.

The global burden of chronic kidney disease and the way forward.

BACKGROUND: Chronic kidney disease (CKD) is increasing worldwide at an annual growth rate of 8%. Regional differences exist in the epidemiology of the condition, and non-Whites are more affected. METHODS: An English-language literature search using Medline (January 1984-October 2003) was done to assess research/review articles on burden and prevention of CKD. Particular attention was paid to epidemiology and prevention of chronic kidney diseases. RESULTS: The prevalence of CKD is higher in developing countries than in the developed world. The most common causes of CKD in the developing countries are chronic glomerulonephritis and systemic hypertension, diabetic nephropathy being the most common cause in Europe, the United States, and Japan. Factors contributing to the regional differences in the etiology and prevalence of CKD are race and ethnicity, genetic predisposition, increasing prevalence of type 2 diabetes, mortality caused by other disease, obesity, and possibly cigarette smoking. The control of hypertension, dyslipidemia, proteinuria, obesity, avoidance of low birth weight, smoking, and preventing ingesting of heavy metals such as lead are intervention strategies that retard or prevent progression of renal diseases. The magnitude of the existing burden of illness caused by renal failure, the projections for increasing incidence of CKD, and the limitations of our existing treatments for renal insufficiency all point to the need for clinical and population-based interventions aimed at prevention of CKD. CONCLUSIONS: A comprehensive health education campaign and screening of the general populace are needed in order to detect chronic kidney disease early. These measures will ensure appropriate and timely institution of proven measures to halt or reduce progression of CKD.

Target organ damage and associated clinical conditions among Nigerians with treated hypertension.

AIM: Systemic hypertension is the commonest noncommunicable disease in Nigeria. Hypertension is linked with certain target organ damage (TOD) and associated clinical conditions (ACC). This study assessed the extent, pattern and predictors of TOD/ACC in patients with hypertension in Nigeria. METHODS: The study was carried out at the medical outpatient department of a state hospital in Nigeria. Target organ damage was assessed in these patients. Predictors of TOD/ACC were also sought. RESULTS: A total of 203 patients [73 men (36.0%) and 130 women (64.0%)] constituted the study population. One hundred and twenty-two patients (60.1%) had TOD/ACC. The prevalent TOD/ACC were left ventricular hypertrophy (LVH) (31.0%), chronic kidney disease (18.2%), diabetic nephropathy (18.2%), heart failure (10.8%) and cerebrovascular disease (CVD) (8.9%). There was a statistically significant association between systolic blood pressure and TOD/ACC. Patients with over all blood pressure (BP) control (i.e. BP < 140/90 mmHg) had more TOD compared with those that had overall uncontrolled BP (i.e. BP > or = 140/90 mmHg) although the difference was not statistically significant (Chi2= 1.5, p > 0.05). The association between length of treatment and TOD/ACC approached significance ( Chi2= 9.35, p = 0.053). CONCLUSION: The study showed a high prevalence of TOD/ACC in treated hypertensives. A positive association was shown between systolic BP and TOD/ACC. Early detection of hypertension and strict blood pressure control should help in reducing TOD/ACC in the hypertensive population.

Reiter's syndrome--a case report and review of literature.

The occurrence of Reiter's Syndrome is rare and not commonly reported in Nigeria. This paper reports a case of a 35 yr old male Nigerian with Reiter's Syndrome, occurring 1-2 weeks after a bout of a dysenteric illness. The patient presented with fever, conjunctivitis, dysentery, urethritis and arthralgia. The joint pains involved the left wrist (which was swollen), the right knee and ankle joints. The patient was managed conservatively. The case is presented with a view to documenting the occurrence of Reiter's Syndrome in an African Nigerian.

Cardiovascular risk factors in type 2 diabetic Nigerians with clinical diabetic nephropathy.

This study aimed to assess the distribution of cardiovascular risk factors among subjects with type 2 clinical diabetic nephropathy, since in diabetic subjects, the excess mortality in cardiovascular events is primarily related to nephropathy. The study group consisted of 162 subjects with type 2 diabetes mellitus and persistent proteinuria, and the control group was 80 type 2 diabetic subjects without nephropathy. In the study group there were 81 male and 81 female subjects whose mean age was 53.4 +/- 6.3 years. There was no significant consumption of alcohol and cigarette use in the population. The mean waist-hip ratio (WHR) was 0.97 and 0.96 in male and female subjects, respectively. The mean body mass index (BMI) of the subjects was 25.5 +/- 5.2 (males: 24.4 +/- 4.3, females: 27.2 +/- 5.5). A total of 106 subjects, made up of 45 male (27.8%) and 61 female (37.7%) subjects, were hypertensive as compared with 16 controls (20%). There was a significant difference in systolic blood pressure (p < 0.05) between the obese and non-obese subjects. One hundred and thirty three subjects (82.1%) had serum total cholesterol below 200 mg% as compared with 74 (92.5% ) in the control. Seventy-eight subjects (48.1%) had left ventricular hypertrophy. Males had a higher tendency of developing left ventricular hypertrophy (p = 0.04). Stroke and peripheral vascular disease respectively occurred more commonly in type 2 diabetes mellitus subjects with nephropathy [7 (4%) and 44 (27.2%)] compared to type 2 diabetic subjects without nephropathy [0 (0% ) and 9 (11.3% )] (p < 0.05). We found that there is a high prevalence of cardiovascular risk factors among Nigerian subjects with clinical diabetic nephropathy.

Pattern of occurrence of microalbuminuria among dippers and non-dippers (essential hypertensives) in a Nigerian university teaching hospital.

OBJECTIVES: Hypertensives who fail to manifest the normal circadian nocturnal fall in blood pressure have a higher incidence of cardiovascular complications, early glomerular injury and microalbuminuria. This study aims to quantify the proportion of dippers and non-dippers among the essential hypertensive population, and determine the frequency of occurrence of micro-albuminuria among them. MATERIALS AND METHODS: Early morning urine specimens were taken from 50 patients with essential hypertension and 20 healthy, normotensive subjects. Combined negative results from albustic strip testing and sulfosalicylic acid tests were taken as excluding microalbuminuria. While collecting urine for 24-hour urinary protein and creatinine clearance, hourly blood pressure readings were recorded. Readings obtained between 07:00 and 23:00 were taken as daytime blood pressure readings, whereas readings obtained between 23:00 and 07:00 were considered night-time blood pressure. Dippers were considered to be those patients in whom the difference between mean daytime systolic/diastolic blood pressure and mean night-time systolic/diastolic blood pressure was 10/5mm Hg or more. RESULTS: Thirty-six (72%) and 14 (28%) patients with essential hypertension fulfilled the criteria for dippers and non-dippers, respectively. The night-time systolic and diastolic blood pressures were significantly higher in non-dippers than in dippers (P < 0.05). The mean daytime systolic and diastolic blood pressures were not different between these two groups. Twenty-nine out of 36 (80.6%) urinary specimens from dippers were without microalbuminuria, against six out of 14 (42.9%) specimens from non-dippers, p < 0.05. Eighteen out of 20 controls (90%) were without microalbuminuria. CONCLUSION: This study demonstrated that about 28% of the local essential hypertensive population was non-dippers and 57.1% of these had microalbuminuria with the attendant cardiovascular and renal risks.

Clinical diabetic nephropathy in a tropical African population.

Diabetic nephropathy is the single most important disorder leading to renal failure in adults in the Western countries and it is among the first three major causes of end stage renal disease in Nigeria. The aim of this study is to show the features of clinical diabetic nephropathy in the Olabisi Onabanjo University Teaching Hospital, Ogun State, Nigeria. The study group consists of 342 consecutive diabetic patients with persistent proteinuria (positive albustix) and diabetic retinopathy, seen from January 2000 to June 2001 in the Ogun State University Teaching Hospital, Sagamu. Clinical and laboratory parameters were recorded. Students' t-test and Spearman correlation coefficient were used in analysis. The frequency of occurrence of clinical diabetic nephropathy is 28.4% with majority already symptomatic despite normal biochemistry. Mean ages of type 1 and type 2 are 26+/-7.9 years and 53.4+/-6.3 years respectively with a sex ratio of 1.2:1. Mean duration of disease is 6.5+/-3.6 years and 9.4+/-4.1 years respectively. Two hundred and seventy-one (79.2%) patients were hypertensive. Nephrotic syndrome is not a common presentation. Diabetic nephropathy is a significant problem in this environment.

Significant asymptomatic bacteriuria among Nigerian type 2 diabetics.

Significant asymptomatic bacteriuria is a risk factor for symptomatic urinary infection and septicemia among predisposed individuals such as diabetics. We investigated the pattern of asymptomatic bacteriuria among our type 2 diabetics with a view to documenting the prevalence, type of organisms responsible and the antibiotic susceptibility pattern. One hundred and twenty-four type 2 Nigerian diabetics (55 males and 69 females) submitted midstream urine specimens for culture. Thirty-three patients had significant bacteriuria (9 males and 24 females), showing the frequency of occurrence of asymptomatic bacteriuria to be 26.6%. The most common organism isolated was Klebsiella pneumonia at 42.4%. Gram-negative bacilli made up about 23 (69.7%) of the isolates. Isolates were poorly sensitive to the readily available antibiotics (ampicillin, tetracycline and cotrimoxazole), but a large number of the organisms isolated were sensitive to nitrofurantoin, gentamicin, ciprofloxacin and ofloxacin. Sensitivity to erythromycin, nalidixic acid and cefuroxime was moderate. Asymptomatic bacteriuria is, thus, more prevalent among the Nigerian diabetic population than in the non-diabetics. A changing pattern of disease is observed with Klebsiella sp. now accounting for the majority of asymptomatic bacteriuria among diabetics. The organisms are not sensitive to the commonly available antibacterial agents.

An update on 'progression promoters' in renal diseases.

AIM: This paper reviews progression in renal diseases. METHODS: An English language literature search using Medline (1980 January-2001 July) was done to assess research and review articles on progression in renal diseases. RESULTS: Factors that increase the risk of progression in renal diseases are hypertension, dyslipidaemia, underlying nephropathy, high dietary protein intake and proteinuria. Others are smoking, hyperglycemia, low birth weight, obesity, metabolic syndrome X, genetic factors such as angiotensin converting enzyme 'DD' genotype and chromosome 1q21, and exposure to lead. Hypertension induces arteriolar nephrosclerosis. The mechanisms whereby lipids contribute to vascular and renal injury are incompletely understood. Glomerular hyperperfusion and increased proteinuria may explain the adverse effects of increased protein intake on renal disease progression. Proteinuria contains numerous toxic/inflammatory systems that promote progression. Cigarette smoking has vasoconstrictive, thrombotic and direct toxic effects on the vascular epithelium. Hyperglycemia is strongly implicated in the progression of complications in diabetics. Oligonephropathy in low birth weight has been suggested to increase the risk for systemic and glomerular hypertension in adult life. In obesity, the combination of hyperfiltration, glomerular hypertrophy and glomerular hypertension is a primary initiating event for glomerular injury manifesting as glomerulomegally and focal and segmental glomerulosclerosis and proteinuria. Angiotensin I, with enzyme insertion/deletion polymorphism, especially the "DD" genotype, predisposes to a rapid decline in renal function. Finally, long-term exposure to low levels of environmental lead affects renal function. CONCLUSION: The control of hypertension, dyslipidaemia, proteinuria, obesity, avoidance of low birth weight, smoking and heavy metals such as lead are intervention strategies for preventing progression of renal diseases.

A report of clinical trial conducted on Toto ointment and soap products.

OBJECTIVE: The efficacy of Toto ointment and soap on common skin disorders was tested. METHODOLOGY: A cohort of Nigerians with common skin conditions such as fungal and bacterial skin infections, scabies, acne vulgaris, and dandruff were selected and followed for a period of 12 weeks. The study is a randomized, comparative, prospective, blinded observational study. Following a placebo run in/wash out period, patients were given either a Toto ointment or soap, or a combination of these, or sulfur ointment alone. Soap use was preferred in patients with Tinea capitis more than patients with any other superficial skin condition for technical reasons--such as ease of application of the soap lather. Expressed preference for either the soap or the cream was at times taken into consideration. Cure rate, adverse drug effects and acceptability of the products were assessed. RESULTS: Out of the 595 patients with common skin diseases selected for the study, 446 (74.9%) had fungal infections, while 64 (10.8%) had scabies infestation. A total of 47 (7.9%) patients had bacterial skin infections, 36 (6.1%) had acne vulgaris, and two (0.3%) had dandruff. At the end of the treatment period, out of the 129 patients with fungal infections treated with Toto ointment alone, 92 (71.3)% were successfully treated; while 41 (87.2%) out of the 47 patients with scabies were successfully treated with Toto ointment alone. Although few patients were seen with bacterial skin infections during the study period, these patients responded well to the ointment, the soap or a combination of the two. Overall, the combination of Toto ointment and soap had a better clinical success rate on all diseases when compared to sulfur ointment alone. The study has shown the efficacy and tolerability of Toto products (skin ointment and soap) in the management of common skin disorders. CONCLUSION: Toto ointment and soap are particularly efficacious in the management of common skin conditions such as fungal and bacterial skin infections, scabies, acne vulgaris and dandruff.