High malignancy rate in the absence of viral prophylaxis after kidney transplantation in Sudan.

BACKGROUND: Kidney transplantation in Sudan is funded by the government. Cytomegalovirus prophylaxis is provided for patients who receive biological induction or have recipient-negative donor-positive cytomegalovirus serology. Doctor Selma Center for Kidney Diseases joined the national kidney transplant program in May 2019. Since then, we observed the frequent occurrence of cancer in patients who received modest immunosuppression without viral prophylaxis. METHODS: We retrospectively divided kidney transplant recipients between 2019 and 2021 into two groups according to cytomegalovirus prophylaxis and compared tumor occurrence rates. RESULTS: The first group included 77 patients who did not receive biological induction or cytomegalovirus prophylaxis. The second group included 92 patients who received valganciclovir for 3-6 months. There was no other antiviral treatment except entecavir for chronic hepatitis B virus infection in eight patients. Five patients in the first group developed malignancy. The first patient presented eight months post-transplant with Kaposi sarcoma of the stomach and responded to treatment with sirolimus. The second patient presented nine months post-transplant with cutaneous Kaposi sarcoma and also responded to sirolimus. Two patients presented two and four months post-transplant with aggressive non-cutaneous Kaposi sarcoma that involved the gastrointestinal tract and lymphatic system and died soon afterwards. The fifth patient presented three years post-transplant with non-Hodgkin lymphoma of the duodenum and is currently receiving chemotherapy. Malignancy rate (6.5% vs 0.0%, P = 0.02) and Kaposi sarcoma rate (5.2% vs 0.0%, P = 0.04) were significantly higher in the first group. CONCLUSION: In Sudan, omitting valganciclovir prophylaxis after kidney transplantation was associated with a high rate of virus-induced malignancy.

Arabic translation, adaptation, and validation of the kidney disease quality of life short-form 36.

The Kidney Disease Quality of Life Short Form 36 (KDQOL-36) is a self-reported measure of health for patients with chronic kidney disease. Our goal was to develop an Arabic version of KDQOL-36 that is linguistically and conceptually equivalent to the original English version. We translated KDQOL-36 into formal Arabic language using forward and backward translation. To assess conceptual equivalence, we administered the Arabic and English versions simultaneously to a group of 10 bilingual patients. To assess test-re-test reliability, we administered the instrument twice to a group of 10 hemodialysis (HD) patients. To assess internal reliability, convergent validity, and discriminate validity, we administered the instrument to 62 HD patients and 82 kidney transplant patients asking them to simultaneously fill the Depression, Anxiety and Stress Scale (DASS-21). The intraclass correlation coefficient (ICC) between the Arabic and English versions indicated excellent conceptual equivalence. The ICC between test and re-test scores revealed good reliability in the burden of kidney disease subscale and excellent reliability in the remaining four subscales. The translated version of KDQOL-36 had a Cronbach's alpha of 0.81, indicating good internal reliability. We found significant negative correlations between the five subscales of the instrument and DASS-21, indicating good convergent validity. Kidney transplant recipients had significantly better scores than HD patients in the five subscales of the instrument, indicating excellent discriminate validity. The current Arabic version of KDQOL-36 has excellent conceptual equivalence with the original English version. It is a reliable and valid instrument for Arab kidney disease patients.

Gum Arabic Reduces C-Reactive Protein in Chronic Kidney Disease Patients without Affecting Urea or Indoxyl Sulfate Levels.

INTRODUCTION: Gum Arabic (GA) is a complex polysaccharide with proven prebiotic properties and potentially beneficial systemic effects. METHODS: We randomly allocated 36 chronic kidney disease (CKD) patients to receive 10, 20, or 40 grams daily of GA for four weeks and studied the systemic effects of this intervention. RESULTS: Thirty participants completed the study with baseline glomerular filtration rate 29.1 ± 9.9 mL/min/1.7 m2. In contrast to previous observations, we found no effect on serum urea or creatinine levels. GA supplementation was associated with a small but statistically significant drop in serum sodium level (138 ± 2 to 136 ± 3 mmol/L, p = 0.002) without affecting other electrolytes, urine volume, or indoxyl sulfate (IS) levels. GA supplementation was also associated with a significant drop in C-reactive protein (CRP) level (3.5 ± 1.5 to 2.8 ± 1.6 ng/mL, p = 0.02) even in patients who received only 10 g/day (4.4 ± 1.2 to 3.2 ± 1.5 ng/mL, p = 0.03). CONCLUSIONS: Supplementing the diet of CKD patients with 10-40 g/day of GA significantly reduced CRP level which could have a positive impact on these patients' morbidity and mortality. This trial is registered with Saudi Clinical Trial Registry number 15011402.

Re-examination of renal allograft biopsy blocks for C4d positivity: missed cases of antibody mediated rejection.

INTRODUCTION: C4d immunostaining of renal allograft biopsies is recommended for the diagnosis of antibody-mediated rejection (ABMR), but it was not available to us prior to June 2012. In June 2012, we were able to obtain anti-human C4d polyclonal antibody and decided to retrospectively evaluate archived kidney allograft biopsies at our center for C4d deposition. METHODS: Twenty-four paraffin blocks were available for this study. Immunostaining for C4d was performed using anti-human C4d polyclonal antibody by Immunohistochemistry. The score and pattern of C4d positivity were determined according to the Banff 2007 guidelines. RESULTS: All grafts were from living related donors with negative CDC cross-match. The indications for biopsy were primary, acute and chronic graft dysfunction in 29.2%, 33.3% and 37.5% of patients respectively. Two biopsies revealed extensive necrosis rendering it difficult to interpret the result of C4d staining. Among the remaining 22 biopsies, C4d staining was categorized as negative in 40.9%, minimal in 13.6%, focal in 22.7% and diffuse in 22.7%. The prevalence of C4d positivity among biopsies taken due to primary, chronic and acute graft dysfunction was 71.4%, 44.4% and 12.5% respectively. CONCLUSION: C4d positivity was common in biopsies taken from this group of kidney transplant recipients and its prevalence was particularly high among biopsies taken due to primary graft non-function. This indicates that missed ABMR is an important cause for kidney allograft dysfunction in our setting.

Co-administration of ketoconazole and tacrolimus to kidney transplant recipients: cost minimization and potential metabolic benefits.

To evaluate the effects of the co-administration of tacrolimus and ketoconazole to a group of kidney transplant recipients, we studied 30 kidney transplant recipients with stable kidney function who were maintained on tacrolimus-based immunosuppression. They were prescribed ketoconazole (100 mg/day) with a concomitant reduction in daily tacrolimus dose to maintain its level within the therapeutic range. The study included 19 males and 11 females with a mean age of 36 ± 12 years. All patients were at least three months post-transplant and had tacrolimus trough levels within the therapeutic range of 5-7 ng/mL. Desired tacrolimus trough levels could be achieved in 29/30 patients after the addition of ketoconazole. This resulted in a significant reduction of the median tacrolimus dose from 5 mg/day (range 3-20 mg/day) at baseline to 2 mg/day (range 1-4 mg/day) (P = 0.00). The median reduction in the tacrolimus dose was 63% (range 50-83%). The median monthly tacrolimus cost dropped from 375 US$ per patient (range 225-1440 US$) to 150 US$ per patient (range 120-300 US$). There were no reported adverse drug effects during the study period. After one year of follow-up, there was a small but significant improvement in the estimated glomerular filtration rate (72 ± 18 versus 78 ± 20 mL/min, P = 0.01) and a significant reduction in serum uric acid levels (7.7 ± 1.7 versus 5.9 ± 0.8 mg/dL, P = 0.003). The co-administration of ketoconazole and tacrolimus to kidney trans-plant recipients is safe and significantly reduces the cost of immunosuppression. In addition, this combination appears to have a beneficial effect on kidney function.

Prevalence and Risk Factors of Central Venous Stenosis among Prevalent Hemodialysis Patients, a Single Center Experience.

INTRODUCTION: Central vein stenosis (CVS) is a common complication of central venous catheter (CVC) insertion. In this study we evaluated the prevalence and risk factors of CVS among hemodialysis (HD) patients in a single center in Sudan, using Doppler ultrasound as a screening tool. METHODS: The study included 106 prevalent HD patients. For every patient, we performed Duplex Doppler for the right and left jugular, subclavian and femoral veins. A patient was considered to have hemodynamically significant stenosis if the pre-stenosis to the post-stenosis velocities ratio was ≥ 2.5 or they had complete vein occlusion. RESULTS: Overall, 28.3% of patients had Doppler detected CVS, including 25.5% with hemodynamically significant stenosis and 2.8% with compromised flow. The prevalence of CVS was 68.4% among symptomatic patients compared to 19.5% in asymptomatic patients. The prevalence of CVS among patients with history of 0-1, 2-3 and ≥ 4 central venous catheters was 3.4%, 29.4% and 53.8% respectively (p=0.00). CVS was not more common in patients with history of previous/current jugular or femoral vein catheterization compared to no catheter placement in these veins (28.3% vs 28.6% and 35% vs 26.7% respectively; p >0.1). However, CVS was significantly more common in patients with previous/ current subclavian vein catheterization compared to no catheter placement in this vein (47.8% vs 22.9%, p = 0.02). CONCLUSION: CVS is highly prevalent among studied HD patients, particularly in the presence of suggestive clinical signs. The number of HD catheter placements and subclavian vein utilization for dialysis access impose a significantly higher risk of CVS.

Low sensitivity of the exit site scoring system in detecting exit site infections in peritoneal dialysis patients.

INTRODUCTION: To evaluate the utility of the exit site scoring system in diagnosing exit site infections, we compared its scores to the well established exit site categories outlined by Twardowski and Prowant. METHODS: We examined the exit sites of 50 patients on peritoneal dialysis. Each exit site was given a score ranging from "zero" to "≥ 4" according to the exit site scoring system. Exit sites were simultaneously classified into one of the exit site diagnostic categories outlined by Twardowski and Prowant. The sensitivity and specifity of the exit site scoring system in diagnosing exit site infection was then calculated in reference to the exit sites classified as infected according to Twardowski criteria. RESULTS: The proportions of perfect, good, equivocal, and infected exit sites were 24%, 22%, 32%, and 22%, respectively. 21 exit sites had an exit site score of zero. Of those, 12 (57.1%) were perfect, 7 (33.3%) were good, 1 (4.8%) was equivocal, and 1 (4.8%) was actually infected. 21 exit sites had an exit site score ranging from 1 to 3 without purulent discharge. Of those, 4 (18.2%) were good, 15 (68.2%) were equivocal, and 3 (13.6%) were infected. The specifity of the exit site scoring system in diagnosing exit site infection was 100%, but its sensitivity was only 63.6%. CONCLUSION: The exit site scoring system is not a sensitive tool for diagnosing exit site infection mainly because it ignores evaluation of the sinus for granulation tissue. Exuberant granulation tissue in the sinus tract is not always accompanied by purulent drainage.

The potential role of nursing students in the implementation of community-based hypertension screening programs in Sudan.

INTRODUCTION: Hypertension (HTN), diabetes mellitus (DM) and chronic kidney disease (CKD) are important health problems worldwide, and it is possible to reduce their burden through effective HTN screening and treatment programs. It may be feasible to incorporate such programs in the community outreach activities of nursing and medical schools in Sudan. METHODS: Village inhabitants in the Northern state of Sudan were invited to attend a free clinic for screening of hypertension as well as for follow up and treatment of persons with previously diagnosed hypertension. Fourth year nursing students from the National Ribat University were asked to record demographic data and blood pressure measurements for the attendants of the clinic. RESULTS: A total of 389 adults were screened, their mean age was 41±15 years and 83.8% of them were females. Family history of HTN, DM and CKD was reported by 52.7%, 40.4% and 12.9% respectively. Personal history of HTN, DM and CKD was reported by 28.5%, 17% and 6.4% respectively. The overall prevalence of HTN was 39.6%. Among persons previously diagnosed as hypertensive, 80.2% were on antihypertensive medication but only 48.6% had blood pressure > 140/90 mmHg. Among the 278 persons with no personal history of HTN, 19.1% had blood pressure ≥ 140/90 mmHg. Variables significantly and independently associated with the presence of HTN were family history of HTN (OR: 6.4, P: 0.005), less than 10 years of formal education (OR: 3.5, P: 0.000) and age ≥ 40 years (OR: 2.4, P: 0.005). CONCLUSION: With proper coordination, nursing and medical students can effectively contribute to the implementation of hypertension screening programs.

Effect of the patient's knowledge on peritonitis rates in peritoneal dialysis.

INTRODUCTION: After a training period, patients maintained on continuous ambulatory peritoneal dialysis (CAPD) assume responsibility for their own treatment. With the aid of appropriate tools, home visits help with ongoing evaluation and training for these patients. METHODS: We conducted a home visit survey of 50 patients maintained on CAPD in Sudan between April 2009 and June 2010. Housing conditions, home environment, and patient's or caregiver's knowledge about peritoneal dialysis and the exchange procedure were evaluated using structured data collection sheets. Scores were compared with infection rates in the patients before the home visit. RESULTS: Patients were maintained on CAPD for a median duration of 11 months. Their mean age was 42 ± 23 years; 70% were male; and 14% had diabetes. Only 34% of patients had suitable housing conditions, and 56% required assisted PD. Of the autonomous patients and assisting family members, 11.6% were illiterate. The median achieved knowledge score was 11.5 of 35 points. The median achieved exchange score was 15 of 20 points. Knowledge and exchange scores were positively and significantly correlated (R = 0.5, p = 0.00). More patients in the upper quartile than in the middle and lower quartiles of knowledge scores were adherent to daily exit-site care (33.3% vs 5.3%, p = 0.02). Compared with patients in the middle and lower quartiles of knowledge score, patients in the upper quartile had lower rates of peritonitis, exit-site infection, and hospitalization. CONCLUSIONS: The proposed evaluation form is a valid and reliable assessment tool for the follow-up of CAPD patients. Patients in the upper quartile of knowledge score demonstrated better adherence to the recommended treatment protocols and lower infection rates.

Reaching target hemoglobin level and having a functioning arteriovenous fistula significantly improve one year survival in twice weekly hemodialysis.

INTRODUCTION: This is a prospective study of a cohort of 1011 patients maintained on regular hemodialysis (HD) in Khartoum, Sudan, studied in the year 2009 and reevaluated one year later. Their survival rates in November 2010 were related to their baseline characteristics. METHODS: Demographic and clinical data of studied patients was collected by direct patient interviews and dialysis records revision. Survival rates were calculated using the Kaplan Meier method. RESULTS: Patients had a median age of 45 years and a median duration on dialysis of 25 months. Two thirds of patients were males and 4.2% were children. Studied patients had a one-year survival rate of 86%. Most patients (74.8%) received twice weekly HD, and their survival rate was lower than patients receiving thrice weekly HD (85% versus 89%, P = 0.06). The strongest independent predictors of mortality were lack of a documented measure of dialysis adequacy (HR = 2.7, P = 0.00), poor functional capacity (HR = 2.4, P = 0.00), lack of a functioning AV fistula (HR = 2.0, P = 0.00), age ≥ 65 years (HR = 1.6, P = 0.02) and cardiovascular disease (HR = 1.5, P = 0.04). Patients with hemoglobin level < 10 g/dl had significantly lower survival rates (81% versus 92%, P = 0.00) compared to other patients. HD patients' perception of their own general health was also significantly correlated to their survival rates (P = 0.00). CONCLUSION: Patients on thrice weekly HD did marginally better than those on twice weekly HD. In the latter group, however, having an AV fistula and a hemoglobin level of > 10 g/dl appeared to have a positive effect on their survival. Twice weekly HD could be acceptable for many patients provided other aspects of renal care are cared for adequately.

The prevalence of proteinuria among pregnant women as detected by a semi-quantitative method: a single center experience.

INTRODUCTION: We aimed at estimating the prevalence and the natural history of proteinuria among pregnant women attending Bakare and associates OB/GYN center, Harrisburg Pa, USA. METHODS: We chose a simple random sample from patients who attended the center for antenatal care and reviewed their medical and obstetrical records focusing on urine dipstick testing results, blood pressure measurements and pregnancy outcome. RESULTS: The study included 202 pregnant women with no history of proteinuria. Their mean age was 27 ± 7 years (range 15-44 years). Significant proteinuria (≥ 1+ protein) was detected in 3.8%, 10.7% and 10.6% of dipstick tests performed in the first, second and third trimesters respectively. Hypertensive disorders were diagnosed in thirteen patients (6.4%); three patients had chronic hypertension, two patients had preeclampsia, two patients had preeclampsia superimposed on chronic hypertension, and six patients had gestational hypertension. Obese patients were significantly more likely to develop one of the hypertensive disorders of pregnancy (OR 6.1; P = 0.04) than other patients. These disorders tended to be more common among patients who tested positive for proteinuria (≥ 1+) during the first trimester compared to patients with negative urine dipstick testing (OR 3.1; P = 0.3) but the difference was not statistically significant. Proteinuria disappeared in all patients postpartum, and none of the patients had deterioration in her kidney function. CONCLUSION: Despite the fact that proteinuria was common in this study population, both renal and pregnancy outcomes were favorable.

Staff knowledge, adherence to infection control recommendations and seroconversion rates in hemodialysis centers in Khartoum.

INTRODUCTION: We evaluated hemodialysis (HD) staff knowledge, adherence to infection control recommendations and seroconversion rates for hepatitis B virus (HBV) and hepatitis C virus (HCV) in 13 centers that continuously provided HD services in Khartoum State between June 2009 and November 2010. METHODS: The knowledge of 182 HD staff members was evaluated by a self-filled questionnaire. Relevant data were obtained from 1011 HD patients by direct interviews and record review. Adherence to infection control recommendations was evaluated by direct observation. RESULTS: HD staff members achieved a median score of 81% in knowledge evaluation (range 44-100%). Better scores were achieved by more experienced staff. We identified serious gaps in knowledge related to the environmental risk of viral transmission. Regular screening by enzyme-linked immunoassay (ELISA) was performed in 46% of centers. Only half susceptible patients were vaccinated against HBV. Staff dedicated for treatment of HBV positive patients were found in only 57% of centers that served such patients. Hand washing recommendations were strictly observed in 15% of centers, disinfection of HD stations between patients was strictly observed in 23% of centers, medications were prepared in a separate area in 8% of centers and delivered separately to each patient in none of the centers. There were 2.5 HCV seroconversions and 0.6 HBV seroconversions per 100 patient-years. Center characteristics that predicted HCV seroconversion were accommodation of HCV-positive patients in the same center, using ELISA for patient screening, and assigning more than 3 patients for one HD nurse. CONCLUSION: There are serious gaps in HD staff knowledge and adherence to infection control recommendations. A structured training program for HD staff members is urgently required.

Non-infectious complications of peritoneal dialysis among Sudanese patients: five years experience.

INTRODUCTION: The technique of Continuous Ambulatory Peritoneal Dialysis (CAPD) is known to be associated with various infectious and non-infectious complications. The latter term includes anatomical/mechanical complications as well as hemoperitoneum, inflow pain, electrolyte disturbances, metabolic derangements and delayed gastric emptying. METHODS: We retrospectively evaluated all patients who were maintained on CAPD for a minimum of 90 days in Sudan, in the period between May 2005 and Apr 2010. We examined the incidence of various non-infectious complications and their possible associations. RESULTS: The analysis included 296 patients including 71 children (24%). Males constituted 62.2% of the study population and 13.9% were diabetic. The incidence per 100 patient-years of various non-infectious complications was as follows: hypokalemia (30.4), catheter dysfunction (10.8), dialysate leak (5.3), hernia (4.7), hemorrhagic effluent (4.7), inflow pain (2.3), upper gastrointestinal symptoms (2) and cuff extrusion (0.9). Catheter block and hernia were diagnosed with a median duration after catheter insertion of 6 and 7.5 months, respectively. Catheter block was significantly more prevalent among children (22.5% versus 9.3%; P = 0.006). A high body mass index (BMI) was the only identified independent predictor for leak (OR 1.4, P = 0.005). More than half of the 16 hernias were umbilical, and four of the five inguinal hernias were bilateral. Non-infectious complications were responsible for 32% of technique failures. CONCLUSION: Non-infectious complications were fairly common among our CAPD patients and led to catheter removal in a considerable number of patients.

Prevention of hepatitis B virus and hepatitis C virus transmission in hemodialysis centers: review of current international recommendations.

INTRODUCTION: Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in hemodialysis (HD) patients are associated with adverse outcomes, especially after kidney transplantation. REVIEW: In the HD setting, cross-contamination to patients via environmental surfaces, supplies, equipment, multiple-dose medication vials and staff members is mainly responsible for both HBV and HCV transmission. The incidence and prevalence of HBV in HD centers have dropped markedly as a result of isolation strategy for HBsAg positive patients, the implementation of infection control measures and the introduction of HBV vaccine. The incidence and prevalence of HCV infection among HD patients remain higher than the corresponding general population. There is ongoing debate as to whether isolation of HCV infected patients is needed to combat high anti-HCV seroconversion rates. The current guidelines do not recommend isolation or the use of dedicated machines for HCV infected patients, and rely on strict adherence to infection control measures for the prevention of HCV transmission in the HD setting. Investigations of dialysis associated outbreaks of HCV infection indicate that transmission most likely occurs because of inadequate infection control practices. Routine screening of anti-HCV negative patients, with HCV-antibody testing, and monthly monitoring of ALT levels is recommended to monitor transmission within centers. CONCLUSION: Prevention of transmission of HBV and HCV in the HD setting warrants a multi-faceted approach. Not enough stress can be placed on the importance of adequate infection control practices for the prevention of both infections. Prevention of HBV transmission is augmented by correct implementation of isolation strategies and the universal vaccination of susceptible patients.

Peritoneal dialysis in Africa.

BACKGROUND: Africa is the world's second-largest and second most populous continent. It is also the poorest and most underdeveloped continent. Struggling to provide the essential health interventions for its occupants, the majority of African countries cannot regard renal replacement therapy a health priority. REVIEW: In 2007, Africa's dialysis population constituted only 4.5% of the world's dialysis population, with a prevalence of 74 per million population (pmp), compared to a global average of 250 pmp. In almost half the African countries, no dialysis patients are reported. The prevalence of peritoneal dialysis (PD) was 2.2 pmp, compared to a global prevalence of 27 pmp, with the bulk of African PD patients (85%) residing in South Africa. In North African countries, which serve 93% of the African dialysis population, the contribution of PD to dialysis is only 0% - 3%. Cost is a major factor affecting the provision of dialysis treatment and many countries are forced to ration dialysis therapy. Rural setting, difficult transportation, low electrification rates, limited access to improved sanitation and improved water sources, unsuitable living circumstances, and the limited number of nephrologists are obstacles to the provision of PD in many countries. CONCLUSION: The potential for successful regular PD programs in tropical countries has now been well established. Cost is a major prohibitive factor but the role of domestic manufacture in facilitating widespread use of PD is evidenced by the South African example. Education and training are direly needed and these are areas where international societies can be of great help.