Implementation of Kidney Biopsy in One of the Poorest Countries in the World: Experience from Zinder Hospital (Niger).

Kidney biopsy (KB) has become essential in the nephrologist's approach to kidney diseases, both for diagnosis, treatment, and prognosis. Our objective is to describe the preliminary results of KBs in Niger, one of the poorest countries in the world. This is a descriptive cross-sectional study that took place over 36 months in the nephrology/dialysis department of the Zinder National Hospital. Biopsy results were obtained in less than 5 working days. Patients were responsible for covering the cost of the kidney biopsy. The data collected were analyzed using Epi Info V7 software. We performed 120 kidney biopsies during the study period. The average age of the patients was 35 years ± 15.4 [5-68]. The male/female sex ratio was 2:1. Patients' medical history included herbal medicine use in 33% of cases and high blood pressure in 27.5% of cases. Proteinuria was present at a rate of ≥3 g/24 h in 46.6% of them. The primary indication for kidney biopsy was glomerular syndrome in 62.5% of cases, including 50% with nephrotic syndrome. All kidney biopsies were performed with real-time ultrasound guidance, using an automatic gun fitted with a 16G needle. Regarding complications, macroscopic hematuria was present in 12.5% of cases. Inadequate kidney biopsy was infrequent (5.8% of cases). The most common findings were (i) glomerular diseases (58.4%), such as membranoproliferative glomerulonephritis (13.3%), focal-segmental glomerulosclerosis (10.6%), lupus nephritis (8.8%), minimal change disease (8%), and membranous nephropathy (2.7%), and (ii) tubulointerstitial changes (31.8%). Diabetic nephropathy was rare (2.6%), as was IgA nephropathy (0.9%). We have demonstrated that implementing a sustainable kidney biopsy program in a very poor country is feasible, thanks to the dedication of a specialized renal pathologist. Having a clear diagnosis can assist in properly treating these renal patients according to international guidelines, thereby delaying the progression to end-stage kidney disease.

Histopathological Pattern of Kidney Diseases Among HIV-Infected Treatment-Naïve Patients in Kano, Nigeria.

INTRODUCTION: Kidney biopsy in patients with HIV-associated kidney diseases allows for histopathologic diagnosis and institution of appropriate treatment as well as proper prognostication. There is a paucity of data on the histopathological pattern of HIV-associated kidney diseases in most sub-Saharan African countries. This study was aimed at evaluating the histopathologic patterns of kidney diseases seen among HIV-infected treatment-naive patients in our center as this will allow for proper diagnosis and institution of appropriate treatment. METHODS: In this cross-sectional study, consecutive patients who satisfied inclusion criteria and consented to participate were recruited. Percutaneous kidney biopsies were carried out as day procedures under real-time ultrasound guidance using an automatic spring-loaded biopsy gun as per our unit protocols. Baseline investigations including urea, creatinine, electrolytes, CD4 count, complete blood count, and glomerular filtration rate (eGFR) calculations, urinalysis and urine protein creatinine ratios were done on all the participants. RESULTS: Fifty-five patients who satisfied the inclusion criteria were studied. The mean age of the study population was 38.34± 9.26 years, with 32% females. Mean serum creatinine was 249.6±164.6 µmol/L, and mean CD4 count was 238 ±210 cells/mL. The commonest histological type was FSGS seen in 20 patients (37.7%), followed by HIVAN seen in 17 (32.1%) patients; chronic interstitial nephritis in 7 patients (13.2%) and 6 (11%) had no significant pathological finding. Compared to non-HIVAN, HIVAN patients tended to have higher systolic BP (p= 0.05); higher serum creatinine levels (p= 0.05); lower eGFR (0.03) and higher urine protein to creatinine ratio [uPCR; p= 0.02]. CONCLUSION: Kidney involvement is still a form of presentation among HIV-infected treatment-naïve patients and though a wide range of glomerular and tubulointerstitial lesions may be seen, FSGS and HIVAN are still the most common. We recommend assessment of kidney function, including urinalysis, as part of the routine evaluation of newly diagnosed HIV patients and biopsy where indicated to prognosticate and institute appropriate early treatment.

Clinical, morphologic and histological features of chronic pyelonephritis: An 8-year review.

BACKGROUND: Urinary tract infection (UTI), especially pyelonephritis when inadequately treated may culminate in end-stage renal disease. The study aims to evaluate the risk factors for and clinico-pathologic features of chronic pyelonephritis (CPN) among patients in Aminu Kano Teaching Hospital, Kano, in North-Western Nigeria. MATERIALS AND METHODS: Data on cases diagnosed as CPN between 2010 and 2017 in the study centre were retrieved from archives and analysed for risk factors and clinic-pathologic features. RESULTS: Forty-three cases of CPN were diagnosed in the study period and comprised 24 males and 19 females, with a male: female ratio of 1.3:1. The ages ranged from 3 to 80 years with a mean age of 37.0 ± 19.6 years. Urinary tract obstruction, poorly treated UTI, HIV infection and polycystic kidney disease were the risk factors in 21 (49%), 15 (35%), 6 (14%) and 1 (2%) cases, respectively. Proteinuria was seen in 10 (23.3%) of the patients, hypertension in 7 (16.3%) and haematuria in 3 (7.0%) of cases. Nephrectomy was done in 17 (39.5%) of the 43 CPN cases, indications for surgery were pus-filled, non-functioning kidneys. The diameters of the removed kidneys ranged from 10 to 28 cm and they weighed between 140 g and 2500 g. Scarring, reported in 79.0% of patients, was the most common pathological finding, followed by pus casts in 48.8% and focal segmental glomerulosclerosis in 27.9%. No statistically significant difference was found between age or gender and aetiology or risk factors of the disease (P > 0.05). CONCLUSION: CPN with pus-filled and non-functioning kidneys is a common indication for nephrectomy. Urinary tract obstruction, poorly treated UTI, and HIV infection were major risk factors seen in this environment. To prevent this complication there is a need for better training of clinicians in the diagnosis and adequate treatment of UTI.

Optimal management of HIV- positive adults at risk for kidney disease in Nigeria (Renal Risk Reduction "R3" Trial): protocol and study design.

BACKGROUND: Individuals with two copies of the apolipoprotein-1 (APOL1) gene risk variants are at high risk (HR) for non-diabetic kidney disease. The presence of these risk variants is highest in West Africa, specifically in Nigeria. However, there is limited availability of dialysis and kidney transplantation in Nigeria, and most individuals will die soon after developing end-stage renal disease. Blocking the renin angiotensin aldosterone system with angiotensin-converting enzyme inhibitors (ACEi) is a well-recognized strategy to slow renal disease progression in patients with diabetes mellitus with chronic kidney disease (CKD) and in patients with HIV-associated nephropathy. We propose to determine whether presence of the APOL1 HR genotype alters or predicts responsiveness to conventional therapy to treat or prevent CKD and if addition of an ACEi to standard combination antiretroviral therapy (ART) reduces the risk of kidney complications among non-diabetic Nigerian adults. METHODS/DESIGN: We will screen 2600 HIV-positive adults who have received ART to (1) determine the prevalence of APOL1 risk variants and assess whether APOL1 HR status correlates with prevalent albuminuria, estimated glomerular filtration rate (eGFR), and/or prevalent CKD; (2) assess, via a randomized, placebo-controlled trial (RCT) in a subset of these participants with microalbuminura (n = 280) whether addition of the ACEi, lisinopril, compared to standard of care, significantly reduces the incidence or progression of albuminuria; and (3) determine whether the APOL1 HR genotype is associated with worse kidney outcomes (i.e. eGFR slope or regression of albuminuria) among participants in the RCT. CONCLUSIONS: This study will examine the increasing prevalence of kidney diseases in HIV-positive adults in a West African population, and the relationship between these diseases and the APOL1 high-risk genotype. By evaluating the addition of an ACEi to the care of individuals with HIV infection who have albuminuria, our trial will provide definitive evidence to guide strategies for management and clinical care in this population, with the goal of reducing HIV-related kidney complications. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03201939 . Registered on 26 August 2016.

Perceived and Real Histopathology Turnaround Time: A Teaching Hospital Experience.

BACKGROUND: This study aims to audit analytic turnaround time (TAT) in a histopathology laboratory with a view to assessing the timeliness of its reports, identify causes of delay in its TAT, and compare this with client perception of its performance. MATERIALS AND METHODS: Records of 1440 batches of specimens processed over a 5-year period in the histopathology laboratory of a teaching hospital were retrieved from archives. From these, median and mean TATs were calculated and causes of delay identified. Questionnaires were also deployed to assess physicians' perception of the laboratory's performance. RESULTS: Analytic TAT was 3.6 ± 2 days, with 86.7% of reports being ready within 5 working days. The delays in timeliness of report generation were due mainly to residency training-related factors; tissue processing-related factors, and inadequate clinical information among others. Client perception of TAT rated the laboratory below average by 18.4%; average by 57.5%; good by 20.7%, and excellent in its performance by 3.4% of respondents. CONCLUSION: Even though physicians perceived the laboratory's TAT to be just average, its analytic TAT for reports is within acceptable international standards but with room for improvement in its performance.

Perceived and real histopathology turnaround time: A teaching hospital experience

Background: This study aims to audit analytic turnaround time (TAT) in a histopathology laboratory with a view to assessing the timeliness of its reports, identify causes of delay in its TAT, and compare this with client perception of its performance. Materials and Methods: Records of 1440 batches of specimens processed over a 5-year period in the histopathology laboratory of a teaching hospital were retrieved from archives. From these, median and mean TATs were calculated and causes of delay identified. Questionnaires were also deployed to assess physicians' perception of the laboratory's performance. Results: Analytic TAT was 3.6 ± 2 days, with 86.7% of reports being ready within 5 working days. The delays in timeliness of report generation were due mainly to residency training-related factors; tissue processing-related factors, and inadequate clinical information among others. Client perception of TAT rated the laboratory below average by 18.4%; average by 57.5%; good by 20.7%, and excellent in its performance by 3.4% of respondents. Conclusion: Even though physicians perceived the laboratory's TAT to be just average, its analytic TAT for reports is within acceptable international standards but with room for improvement in its performance

Wilms' tumour: Determinants of prognosis in an African setting.

BACKGROUND: The few studies available in the literature on Wilms' tumour (WT) from sub-Saharan Africa have reported a dismal outcome for children with the tumour. This study evaluated the risk factors that have been correlated with outcome in the literature and compare these with outcome among our patients. MATERIALS AND METHODS: Cases of histologically confirmed WT between 2009 and 2013 in a tertiary hospital in Northwestern Nigeria were evaluated for gender, age, laterality, symptoms, duration before presentation, stage at presentation, histologic subtype and p53 mutation. These were then correlated with outcome. RESULTS: Totally, 30 cases of WT were diagnosed with mean age of 4.8 ± 1.9 years; and male:female ratio of 2:1. No statistically significant relationship with outcome was found for gender (P = 0.138) or histologic subtype (P = 0.671). The most significant variables which positively influenced the outcome were presentation at earlier stages (P = 0.007) and completion of therapy (P = 0.0007). p53 mutation was seen in 3 (16.7%) of 18 cases and was not associated with a poor outcome (P = 0.089). However, 2 of the 3 cases presented in Stage IV and none of them survived the 1 st year. CONCLUSION: This study shows that even though p53 mutation was associated with a more aggressive phenotype, the most significant determinants of a good outcome among patients in a developing country like ours is non-blastemal dominant histologic subtype, early stage at presentation and completion of therapy.

Wilms' tumour in African children: Can an institutional approach improve outcome?

BACKGROUND: The poor outcome for patients with Wilms' tumour (WT) in developing countries has been predicated on late presentation, poverty and low rate of chemotherapeutic access. This study aims to evaluate the effects of an institutionalised approach to improving outcome for patients managed in a tertiary hospital in Nigeria. MATERIALS AND METHODS: Oncology records of children diagnosed with WT between 2009 and 2013 were analysed for therapy completion and other prognostic parameters. Ensuing data were then compared with those from other centres in Africa. RESULTS: Compared with results from some local and African studies, the therapy completion rate was higher (60%) with a survival rate among this group being between 1 and 4 years. No patient was lost to follow-up because of unavailability or unaffordability of cytotoxic agents. CONCLUSION: This study shows that an institutionalised approach can help to improve access to anti-cancer drugs, reduce the rate of loss to follow-up and thus improve outcome. There is however need to improve on patient-doctor communication, form support groups and establish a WT registry.

Out-patient percutaneous renal biopsy among children in Northern Nigeria: a single center experience.

BACKGROUND: The safety of percutaneous renal biopsy (PRB) has been debated. The primary aim of this study was to review the procedure and secondary aim is to evaluate the safety of PRB in children in a developing nephrology unit in Northern Nigeria. METHODS: Renal biopsies carried out in the renal unit of a teaching hospital in northern Nigeria between November 2011 and April 2013 were retrospectively reviewed. All biopsies were carried out electively and under real-time ultrasound guidance using an automatic spring-loaded biopsy gun. Risk factors for complications were analyzed using logistic regression. RESULTS: A total of 24 biopsies were carried out in 20 children with nephrotic syndrome during the period under review. Mean age was 8.3 ΁ 3.0 years. Steroid resistant nephrotic syndrome was the most common indication for biopsy in 11 (55%) cases. Adequate tissue was obtained in 91.7%. Complications occurred in 2 (8.3%) cases. One required hospitalization with blood transfusion. Pre-biopsy hemoglobin concentration of <10 g/dL was found to be a significant predictor for the development of complications (P < 0.05). There was no significant difference in the rate of complications between the in-patient biopsies and day case biopsies. CONCLUSIONS: PRB can be safely carried out as an out-patient procedure in children. Low hemologlobin concentration was the major risk factor for complication.

Utility of Aspiration Cytology in the Evaluation of Oral and Maxillofacial Lesions

Background: Fineneedle aspiration cytology (FNAC) as a cheap diagnostic technique has helped reduce diagnostic turnaround time of pathological entities from different body sites. It is thus also important to evaluate its utility in the diagnosis of maxillofacial lesions in view of heterogeneity of morphological patterns noted for this site. Methodology: Cytology and corresponding histology reports for lesions from patients where both were available were compared for concordance between specific cytological diagnosis and final histological diagnosis. From these; sensitivity; specificity; positive predictive value and accuracy of FNAC were calculated. Result: Cytological diagnosis of maxillofacial lesions demonstrated a sensitivity; specificity; positive predictive value and accuracy of 100; 95.7; 97 and 98.2; respectively. The concordance of specific cytological diagnosis with final histological diagnosis was 85.5. Conclusion: This study concludes that FNAC is a cheap and diagnostically reliable technique for evaluation of maxillofacial lesions in a resource poor setting

Role of surgeons in determining outcome of histopathology specimens.

BACKGROUND: In the changing world of clinicopathologic practice where surgeons and pathologists are faced with increasing therapeutic demands, precise demands of each group from the other have often been reduced to blames and counter-blames. This study is thus aimed at auditing the current practice of specimen handling as a means of highlighting areas where mutual best practice is required. MATERIALS AND METHODS: A total of 200 specimens and 100 separate request cards received over the 3 months were audited for: Use of fixative, adequacy of fixative used, types of specimen containers and appropriate labeling of containers. The request cards were audited for: Documentation of patients' hospital numbers, ages, histories of disease, sites of biopsy, examination findings, investigations done, provisional diagnosis and concordance of clinical diagnosis with histopathological diagnosis. RESULTS: About 20% of specimens were unfixed, 23.5% had inadequate fixative, 16.5% were in inappropriate containers and 32.5% were incompletely labeled respectively. In 25%, 50% and 53% of forms the age, clinical history and examination findings respectively were not documented. Provisional diagnosis was in concordance with eventual histological diagnosis in 69% of cases. CONCLUSION: To ensure the quality of histopathological diagnosis with minimal turnaround time, the surgeon plays a vital role by ensuring adequate and prompt fixation of tissue biopsies, put in the right container and accompanied by well labeled request cards.

Sensitivity of cytology in the diagnosis of paediatric malignancies in Nigeria.

BACKGROUND: Prompt and accurate diagnosis of solid malignant childhood neoplasms requires ancillary diagnostic techniques to supplement clinical acumen. This study aims to assess the role and sensitivity of Fine Needle Aspiration Cytology (FNAC) as a tool to meet these needs in a developing country like Nigeria. MATERIALS AND METHODS: Primary working diagnosis and cytological reports for all solid malignant neoplasms in children over a 4-year period were extracted from archives. These were then compared with histological diagnosis and/or response to therapy and clinical versus cytological sensitivity calculated. RESULTS: Clinical sensitivity for head/neck vs. abdominal cavity malignancies was (83% vs. 46%) compared with cytological sensitivity (100% vs. 90%). Cytological positive predictive value for malignancy at all sites was 100%. CONCLUSION: This study concludes that FNAC should be included in the routine investigation of these tumours in view of its high sensitivity and positive predictive value for malignancy.

A histopathologic study of salivary gland tumors in Kano, northern Nigeria.

Significant differences in the global distribution of salivary gland tumors have been reported, but no formal study has been carried out here in Kano, the largest city in northern Nigeria. We therefore undertook this eight-year retrospective study of all histologically diagnosed salivary neoplasms at the histopathology laboratory of our referral teaching hospital in Kano. Seventy-eight salivary gland tumors were diagnosed during the eight-year study period accounting for 0.4% of all neoplasms. Benign tumors were more prevalent, comprising 56.4%, while malignancies were 43.6%. Pleomorphic adenoma and mucoepidermoid carcinoma were the commonest histological types constituting 48.7% and 23.1% respectively, while the most frequent sites were parotid, submandibular and minor salivary glands accounting for 49%, 26% and 24% respectively. As in most studies of black populations there were no adenolymphomas. Age distribution was bimodal with a benign peak in the third decade and a malignant peak in the sixth. Our findings were broadly similar to most other African reports but somewhat at variance with Western literature. Improved hospital attendance with more comprehensive reporting would yield more representative data.