Prognostic factors in patients hospitalised with diabetic ketoacidosis at Kenyatta National Hospital, Nairobi.

BACKGROUND: In spite of many advances in the management of diabetes in the last 25 years, the mortality associatedwith diabetic ketoacidosis (DKA) remains high, especially in the developing countries. The mortality appears greatest in the first 24-48 hours of their treatment. Most of the previous studies on DKA focused on children and the precipitating factors thereof but not particularly on clinical predictors of outcomes. OBJECTIVE: To determine the clinico-laboratory predictors of outcomes of patients hospitalised with diabetic ketoacidosis who were undergoing treatment. DESIGN: Cross-sectional descriptive study. SETTING: The accident and emergency department and medical wards of the Kenyatta National Hospital. SUBJECTS: Fifty one patients hospitalised with diabetic ketoacidosis over a nine month period were evaluated clinically and by laboratory tests. They were managed in the standard way with insulin, intravenous fluids and appropriate supportive care. MAIN OUTCOME MEASURES: Serial assays of serum electrolytes, glucose and blood pH, HbA1c and clinical outcome of either discharge home or death. RESULTS: Of the 51 patients enrolled, 47 were included in the final analysis. Fourteen (29.8%) patients died,andthe deaths occurred within less than48 hours of hospitalisation and treatment. Of the patients who died, all (100%) had altered level of consciousness at hospitalisation, 71.4% had abnormal renal functions, 64.3% were newly diagnosed and an equal proportion of 64.3% were females. The alteration in the level of consciousness was significantly associated systolic hypotension and severe metabolic acidosis, (p < 0.001). Patients with altered level of consciousness also had poorer renal function. CONCLUSION: Apparently DKA still carries high mortality during treatment in hospital. Altered level of consciousness, which is an obvious and easily discernible clinical sign, was a major predictor of mortality in our study patients. The majority of patients with altered level of consciousness also had systolic hypotension, severe metabolic acidosis and impaired renal function. Even where and when detailed laboratory evaluation is elusive, clinical signs, especially altered level of consciousness and systolic hypotension are very important markers of severity of DKA that may be associated with unfavourable outcomes. Further studies are necessary to establish why DKA still carries high mortality in the patients who are already receiving treatment in hospitals in developing countries.

Subclinical nephrotoxicity associated with occupational silica exposure among male Kenyan industrial workers.

OBJECTIVE: To determine early signs of renal injury due to occupational silica exposure. DESIGN: Cross-sectional analytical research. SETTINGS: Kenyatta National Hospital for the referent population and Clayworks ceramics, bricks and tiles factory for the assessment of occupational silica exposure. SUBJECTS: Thirty three non-smoking silica-exposed male industrial workers and 38 non-smoking male referents participated in this study. RESULTS: Silica-exposed males excreted significantly increased levels of U.TP, U.Malb, U.ALP, U.y-GT and U.LDH compared to referent males. Among the silica-exposed males, U.Si negatively correlated significantly with age, U.TP correlated significantly to each of U.ALP and U.LDH. However, no correlation was observed between work duration and U.Si. CONCLUSION: The present study shows that there is associated glomerular and proximal tubular damage among silica exposed workers which is not duration related and is seemingly subclinical and nonprogressive and urinary silica levels appears to be similar in all groups and are not affected by exposure and work duration: the reason for which is unclear.

Nephrotoxicity of amphotericin B in the treatment of cryptococcal meningitis in acquired immunodeficiency syndrome patients.

OBJECTIVES: To describe the incidence of renal dysfunction, hypokalaemia and hypomagnesaemia in AIDS patients with cryptococcal meningitis and on amphotericin B treatment. Secondary objective was to determine all-cause mortality in the same group. DESIGN: Prospective, observational study. SETTING: Kenyatta National Hospital (KNH), Nairobi, Kenya. SUBJECTS: Seventy consecutive patients with AIDS and cryptococcal meningitis on amphotericin B. RESULTS: About 58.6% of the patients had at least 100% rise in the creatinine level. Thirty eight point six per cent of patients experienced a rise in serum creatinine of at least 50%. Ninty three per cent of the patients developed hypokalaemia and 80% had hypomagnesaemia at trough magnesium level. Only 54.3% of patients completed the intended 14-day treatment. Thirty point five per cent of patients died within the two week follow-up period. CONCLUSION: The incidences of amphotericin B associated nephrotoxicity, hypokalemia and hypomagnesaemia were high in this studied population.

Diabetic ketoacidosis: clinical presentation and precipitating factors at Kenyatta National Hospital, Nairobi.

OBJECTIVE: To determine the clinico-laboratory features and precipitating factors of diabetic ketoacidosis (DKA) at Kenyatta National Hospital (KNH). DESIGN: Prospective cross-sectional study. SETTING: Inpatient medical and surgical wards of KNH. SUBJECTS: Adult patients aged 12 years and above with known or previously unknown diabetes hospitalised with a diagnosis of diabetic ketoacidosis. RESULTS: Over a nine month period, 48 patients had DKA out of 648 diabetic patients hospitalised within the period, one died before full evaluation. Mean (SD) age was 37 (18.12) years for males, 29.9 (14.3) for females, range of 12 to 77 years. Half of the patients were newly diagnosed. More than 90% had HbA1c > 8%, only three patients had HbA1c of 7-8.0%. More than 90% had altered level of consciousness, with almost quarter in coma, 36% had systolic hypotension, almost 75% had moderate to severe dehydration. Blunted level of consciousness was significantly associated with severe dehydration and metabolic acidosis. Over 65% patients had leucocytosis but most (55%) of them did not have overt infection. Amongst the precipitating factors, 34% had missed insulin, 23.4% had overt infection and only 6.4% had both infection and missed insulin injections. Infection sites included respiratory, genito-urinary and septicaemia. Almost thirty (29.8%) percent of the study subjects died within 48 hours of hospitalisation. CONCLUSION: Diabetic ketoacidosis occurred in about 8% of the hospitalised diabetic patients. It was a major cause of morbidity and mortality. The main precipitant factors of DKA were infections and missed insulin injections. These factors are preventable in order to improve outcomes in the diabetic patients who complicate to DKA.

Risk factors and prevalence of diabetic foot ulcers at Kenyatta National Hospital, Nairobi.

BACKGROUND: Diabetic foot ulcers contribute significantly to the morbidity and mortality of patients with diabetes mellitus. The diabetic patients with foot ulcers require long hospitalisation and carry risk of limb amputation. The risk factors for developing diabetic foot ulcers are manageable. In Kenya there is paucity of data on such risk factors. OBJECTIVE: To determine the prevalence of diabetic foot ulcers and the risk factors in a clinic-based setting. DESIGN: Cross-sectional study. SETTING: Kenyatta National Hospital, Kenya. SUBJECTS: Patients with both type 1 and 2 diabetes mellitus who had active foot ulcers in both outpatient and inpatient units. MAIN OUTCOME MEASURES: Diabetic foot ulcers glycated haemoglobin, neuropathy, peripheral vascular disease and fasting lipid profile. RESULTS: One thousand seven hundred and eighty eight patients with diabetes mellitus were screened and 82 (4.6%) were found to have foot ulcers. The males and females with diabetic foot ulcers were compared in age, duration of foot ulcers, blood pressure, glycaemic control, neurological disability score and their proportion. Diabetic foot ulcers occurred mostly in patients who had had diabetes for a long duration. The types of (occurence) ulcers were neuropathic (47.5%), neuroischaemic (30.5%) and ischaemic (18%). The neuropathic ulcers had significantly poorer glycaemic control compared to other types and the longest duration (23.3 weeks). Ischaemic ulcers had significantly higher total cholesterol and diastolic blood pressure compared to other ulcer types. Wagner stage 2 ulcers were the commonest (49.4%) but stage 4 ulcers had their highest neuropathic score (7.8/10) and longest duration (23.6 weeks). Aerobic infective pathogens were isolated from 73.2% of the ulcers. CONCLUSION: The prevalence of diabetic foot ulcers was 4.6% in this tertiary clinic. The risk factors of diabetic foot ulcers in the study were poor glycaemic control, diastolic hypertension, dyslipidaemia, infection and poor self-care. These findings are similar to studies done in other environments and they are modifiable to achieve prevention, delay in formation or improved healing of foot ulcers in patients with diabetes. Therefore, specific attention should be paid to the management of these risk factors in patients with or without diabetes foot ulcers in this clinic.

Polycystic kidney disease in a patient with achondroplasia: case report.

Autosomal dominant polycystic kidney disease is a multisystem disease involving many organs. An association with other diseases such as tuberous sclerosis, von Hippel-Lindau disease and Marfan syndrome have been previously described. We describe a 35 year old female with achondroplasia who developed polycystic kidney disease involving both kidneys and progressing to end-stage renal disease. To the best of our knowledge this is the first such case described in the literature. We also delve, briefly, into the possibility of the genes and chromosomes involved in Marfan syndrome, polycystic kidney disease, tuberous sclerosis and achondroplasia playing a role in the co-occurrence of these entities.

Neurofibromatosis type 1: report of two contrasting cases.

We present two cases of neurofibromatosis type 1 (NF-1), one a 35 year old male who first recognised his problem at the age of fifteen years and at the time of assessment, satisfied the National Institute of Health (NIH) diagnostic criteria for NF-1 and had a nodular plexiform neurofibroma involving the left fifth dorsal nerve root and a diffuse plexiform neurofibroma involving the left lower limb. The second patient, a 45 year old female recognised her problem at the age of 39 years, did not quite satisfy the NIH diagnostic criteria for NF 1 and had diffuse plexiform neurofibroma involving both lower limbs and buttocks almost symmetrically, a finding which has not previously been described to the best of our knowledge. The scarcity of management options are briefly outlined.

Endoscopic findings and the prevalence of Helicobacter pylori in chronic renal failure patients with dyspepsia.

BACKGROUND: Peptic ulcer disease (PUD) occurs in up to one fourth of patients with chronic renal failure (CRF). Some of the factors implicated in its causation include hypergastrinaemia, secondary hyperparathyroidism, drugs and, recently, Helicobacter pylori infection. Studies on the latter have been few, with none having been carried out in Kenya. OBJECTIVE: To evaluate the upper gastrointestinal tract endoscopic findings and to determine the prevalence of H. pylori in CRF patients with dyspepsia. STUDY DESIGN AND POPULATION: A prospective study of seventy seven consecutive patients with CRF and dyspepsia compared with consecutive age, sex and socio-economically matched seventy seven controls (no CRF) with dyspepsia. SETTING: Kenyatta National Hospital (KNH), the major referral and teaching hospital, Nairobi, Kenya. METHODS: In both the study population and the controls, upper gastrointestinal endoscopy was carried out. H. pylori was tested for using the biopsy urease test and histology. Patients were considered to have H. pylori if they tested positive on both tests. OUTCOME MEASURES: Findings at endoscopy and presence of H. pylori. RESULTS: Inflammatory lesions (gastritis, duodenitis) (42%) and duodenal ulcers (18.4%) were the commonest findings in the two groups combined. The prevalence of H. pylori in the 154 subjects studied was 54.5%. There was no statistically significant difference between the prevalence of H. pylori in CRF patients (53.2%) and the controls (55.8%) (p = 0.746). Patients with endoscopically proven PUD had a very high prevalence of H. pylori (87.3%) regardless of their renal function status. CONCLUSION: Dyspepsia in patients with or without CRF was due to multiple causes and over 50% were attributable to H. pylori. The prevalence of H. pylon in dyspeptic CRF patients was similar to that in dyspeptic patients with normal renal function.

Haemolytic uraemic syndrome: a review.

OBJECTIVES: To provide an overview of the current understanding of the classification of haemolytic uraemic syndrome (HUS) and to describe the epidemiology, pathogenesis, clinical picture, renal histopathological findings, treatment and prevention of shiga toxin (Stx)-associated HUS, the most common type of HUS and; to compare and contrast features of idiopathic (atypical) HUS and inherited HUS with those of Stx-associated HUS. DATA SOURCE: A literature review was performed of major published series between 1989 and 1998 inclusive, using the Index Medicus and MEDLINE search. Some earlier published series were also reviewed in instances where they indirectly led to the current studies or reported on rarer organ involvements in HUS. STUDY SELECTION: Data and opinions from twelve general reviews of HUS, twelve on aetiology and classification, twelve on clinical features, eight on pathogenesis and nine on treatment and prognosis are summarised. CONCLUSION: HUS is a thrombotic microangiopathy with several aetiologies currently thought to play a role. Vascular endothelial cell injury appears to be central to the pathogenesis of all forms of HUS, although the triggering factors may be different and not well understood in some cases. In HUS, supportive therapy is of paramount importance. Reported specific therapies do not have sufficient evidence to support them. Prevention of HUS is possible in Stx-associated form, but not in the others. In patients who go on to develop end-stage renal failure, transplantation is possible, but recurrence rates are high in forms other than those which are Stx-associated. Persisting sequelae in other organs in HUS are infrequent.

T-cell subset counts and serum immunoglobulin concentrations in patients with chronic renal failure at the Kenyatta National Hospital.

This study was designed to determine whether there was any difference in the T-cell subset counts and serum immunoglobulin concentrations in patients with chronic renal failure as compared to normal controls. Ninety individuals participated in the study. These were divided into three groups as follows; (i) 30 subjects with normal renal function; (ii) 30 subjects with chronic renal failure (CRF)(creatinine clearance 10-50 mls/min), not requiring haemodialysis and; (iii) 30 subjects with end stage renal disease (creatinine clearance < 10 mls/min) on haemodialysis. The subjects in the three groups were matched for age and sex. In addition, it was ascertained that none of the subjects was on any medication or suffered from any ailment known to interfere with the immune system. The T-cell subset counts were carried out using flow cytometry while the serum concentration of immunoglobulins was measured using the radio-immunodiffusion method. Patients with CRF, whether on haemodialysis or not, had significantly lower lymphocyte counts as a proportion of total white cell count (19% and 19.2% respectively versus 39%) and low absolute CD4 cell counts per mm3 (337 +/- 94 and 449 +/- 116 respectively versus 891 +/- 360) and CD8 cell counts per mm3 (437 +/- 234 and 490 +/- 176 respectively versus 644 +/- 228) as compared to normals, with no statistically significant difference between the two groups with CRF. The CD4: CD8 ratios in the three groups studied were 1.487 +/- 0.233, 0.961 +/- 0.326 and 0.751 +/- 0.167 respectively, being significantly higher in normal controls than in any of the groups with CRF (p < 0.05) and in the group with CRF not requiring dialysis than in those requiring it (p < 0.05). The serum concentration of immunoglobulins in the two groups with CRF were similar to those in the group with normal renal function. It is concluded that CRF represents a state of immunodeficiency not significantly corrected by haemodialysis.

Smoking--an emerging risk factor for renal diseases.

The health, economic and social costs of smoking are enormous and well known to physicians. Smoking results in a lot of morbidity and mortality mainly related to cardiovascular disease, cancer and pulmonary disease. The effect of smoking on the kidneys is little appreciated. It is the purpose of this review article to give evidence from available literature that smoking is indeed deleterious to the kidneys and may result in progression of chronic renal failure to end stage renal disease. It is concluded that nephrologists, and indeed all physicians, should make a concerted effort to save their patients from this vice.

Autosomal dominant polycystic kidney disease - a systemic disorder.

Autosomal dominant polycystic kidney disease [ADPKB] is one of the commonest genetic diseases. Apart from the involvement of the kidneys, several other organs, viz. the liver, the central nervous system, the pancreas, the spleen, the ovaries and the gut, amongst others, are also sometimes involved. This makes ADFKD more of a systemic rather than an isolated renal disorder. This becomes more so considering that the involvement of the other organs contribute significantly to the morbidity and mortality of ADPKD. This review looks at the pattern and prevalence of involvement of other organs, apart from the kidney in ADPKD.

Pathogenesis of lupus nephritis: a review.

Systemic lupus erythematosus (SLE) is a non-organ specific autoimmune disease in which the primary autoantigen has been a subject of debate despite detection of antibodies to several nuclear antigens. Contrary to previously held belief that SLE and, by extension, lupus nephritis is an immune complex disease mediated by DNA-AntiDNA complexes, it is becoming increasingly clear that nucleosomes and possibly complement factor Clq are the major players in the pathogenesis of these entities. This review article looks at the structure, source and possible pathogenetic role of nucleosomes and anti-nucleosome specific antibodies in lupus nephritis. Additionally, the possible role of Clq and anti-Clq antibodies in the pathogenesis of lupus nephritis is considered.