Lipid profile of ambulatory patients with type 2 diabetes mellitus at Kenyatta National Hospital, Nairobi.

BACKGROUND: Patients with type 2 diabetes are at high of cardiovascular events because they have abnormal lipid status compared to their non-diabetic counterparts. OBJECTIVE: To determine the quantitative lipid profile of ambulatory patients with type 2 diabetes mellitus. DESIGN: Prospective, cross-sectional descriptive study. SETTING: Out-patient diabetic clinic of the Kenyatta National Hospital. SUBJECTS: Ambulatory patients with type 2 diabetes but without obvious cardiovascular, renal or foot complications. RESULTS: A total of 213 patients with type 2 diabetes were studied, 56.8% were females. The age range of the study population was 34 to 86 years, mean(sd) age of females was 54.45 (9.4) years and that of males was 55.83 (9.3) years. The mean body mass index (BMI) of females was 27.85 (6.2) kg/m2 and 25.98 (5.8) kg/m2 for males. The female subjects were more obese than the males in this study. Over 70% of the study participants had total cholesterol > 4.2 mmol/l, 43.8% and 57.6% of the females and males respectively had LDL-C > 2.6 mmol/l , 25.6% of the females and 30% of the males had HDL-C < 1.00 mmol/l. Only a modest proportion of males (28.3%) and females (32.2%) had triglycerides > 1.7 mmol/l. The LDL-C showed a significant positive correlation with age, duration of diabetes, fasting blood glucose, and total cholesterol but no correlation with glycated haemoglobin, body mass index, gender and the mode of glucose-lowering treatment. CONCLUSION: There was significant proportion of quantitative dyslipidaemia in the study population especially with the Total--and LDL- cholesterols. Although treatment goals and lipid thresholds for cardiovascular risk in diabetes are not yet well-defined, even by the large randomized trials, high-risk patients with significant quantitative dyslipidaemia would require deliberate effort to correct the abnormal values to reduce the risk status. These high-risk patients without complications but already had significant dyslipidaemia, which enhances the risk of cardiovascular events, certainly required therapeutic intervention.

Patterns of homocysteine in Kenyans with type 2 diabetes without overt cardiovascular disease at Kenyatta National Hospital, Nairobi.

BACKGROUND: Increased total homocysteine (tHcy) is an independent risk factor for cardiovascular disease. The measurement of tHcy in blood is therefore of potential great importance especially in patients with type 2 diabetes. OBJECTIVE: To determine the total homocysteine levels in ambulatory patients with type 2 diabetes. DESIGN: Cross-sectional, prospective study. SETTING: Outpatient diabetic clinic of the Kenyatta National Hospital. SUBJECTS: Ambulatory patients with Type 2 diabetes without overt cardiovascular, renal, liver or other chronic disease. MAIN OUTCOME MEASURES: Serum levels of tHcy, HbA1c, lipids and socio-demographic characteristics. RESULTS: A total of 115 patients, 48% males, with type 2 diabetes were included in the study. The mean (sd) age of the males was 56.85 (8.96) years and of the females was 55.68 (8.93) years. The mean (sd) total serum homocysteine for males of 12.97 (6.06) micromol/l was significantly higher than that of the females of 10.64 (4.41) micromol/l. The cholesterol, glycated haemoglobin, the body mass index and blood pressure of the study subjects did not show any statistically significant influence on their homocysteine levels. However, increasing age and duration of diabetes showed a significant linear relationship with rising level of total serum homocysteine. Some study participants reported smoking habit but unreliably. CONCLUSION: There was a significant proportion of the study patients with high levels of serum homocysteine, although most of them were of low to intermediate risk category. It may be prudent to assay homocysteine levels in patients with type 2 diabetes who are either older or have had diabetes for long duration for potential intervention.

Cardiovascular risk factors in patients with type 2 diabetes mellitus in Kenya: levels of control attained at the Outpatient Diabetic Clinic of Kenyatta National Hospital, Nairobi.

OBJECTIVES: To determine the proportion of specific cardiovascular risk factors in ambulatory patients with type 2 diabetes and the levels of control achieved in them. DESIGN: Prospective, cross-sectional study over a six month period. SETTING: Out-patient diabetic clinic of the Kenyatta National Hospital. SUBJECTS: Two hundred and eleven patients with type 2 diabetes. MAIN OUTCOME MEASURES: Sociodemographic attributes, duration of diabetes, levels of glycaemia, body weight, blood pressure, fasting lipids and modes of treatment. RESULTS: A total of 211 patients were enrolled, 57.3% were females. The mean (SD) age for women was 54.45 (9.44) and that of men was 55.8 (9.02) years. About 77% of the study population were on oral glucose-lowering agents with or without insulin but less than 30% achieved HbA1c < 7%; 15% were active cigarette smokers; about 50% were hypertensive with female predominance but 65% of them did not achieve desired blood pressure level inspite of treatment. Just over 50% had raised LDL-cholesterol and over 75% had raised total cholesterol but only three men were on statins without achieving desired targets. Body mass index above 30 kg/m2 as a measure obesity was found in 32% of females and 16% males. Most of the study patients admitted use of Aspirin at certain times in the course of their diabetes. CONCLUSION: The study showed that specific cardiovascular risk factors of hyperglycaemia, dyslipidaemia, hypertension and obesity were prevalent although not adequately controlled to targets. Statin use was extremely low in people who already needed them. Regular Aspirin use was infrequent because many patients did not quite understand its role in their diabetes treatment. It is recommended that a more pro-active approach in multifactorial address of cardiovascular risk factors be used in high-risk patients with type 2 diabetes to forestall future cardiovascular events.

Nephropathy in patients with recently diagnosed type 2 diabetes mellitus in black Africans.

BACKGROUND: Albuminuria is long recognised as a sign of renal disease in diabetes. In type 1 diabetes, renal disease occurs after a longer duration of diabetic state. In type 2 diabetes, it is more variable. OBJECTIVE: To determine the prevalence and any risk factors of albuminuria in short-term (< or = 2 yrs) type 2 diabetes. DESIGN: Cross sectional, descriptive study. Microalbuminuria was assessed using micro II strips. SETTING: Outpatient diabetic clinic at Kenyatta National Hospital, Nairobi. SUBJECTS: Patients who were newly diagnosed or had had type 2 diabetes for two years or less. MAIN OUTCOME MEASURES: Microalbuminuria, lipids, glycated haemoglobin, fasting blood glucose and blood pressure. RESULTS: One hundred and thirty nine patients who had type 2 diabetes mellitus for < or = 2 yrs were seen, but only 100 patients were included in the study over a six month period. Their mean (SD) age was 53.7 (9.3) years. Mean (SD) duration of diabetes was 10.3 (7.5) months. Fifty per cent of the study patients were hypertensive. Only 48% had HbA1c < 8% while 36% had HbA1c > 9%. The lipid profile of total, LDL-HDL-cholesterol and triglycerides were predominantly within normal limits. Twenty six per cent were established to have albuminuria of which one patient had macroalbuminuria. Blood pressure, glycated haemoglobin and lipid parameters were not significantly different from patients without albuminuria CONCLUSION: Albuminuria occurred in a significant proportion of patients with short term type 2 diabetes. Comparable to studies done elsewhere on short-term type 2 diabetes, albuminuria is both a sign of nephropathy and a cardiovascular risk factor. It should be looked for in all patients with type 2 diabetes attending this clinic, even at diagnosis.

The urinary levels of catecholamines, aldosterone and cortisol in hypertensive East Africans: a pilot study.

This pilot project studies the prevalence of hypertension among unique social groups in Kenya, as well as the hormonal profiles accompanying the hypertensive and normotensive states in these populations. The purpose of this report is to enlarge and improve upon the statistical data currently available concerning the prevalence, etiology and prognosis of hypertensive disease in this region. In this study, the urinary concentrations of three vasoactive metabolites were measured in hypertensive and normotensive outpatients. The excretion values for the metabolites were ultimately tabulated as the quantity excreted per milligram of creatinine. The results demonstrate that the subjects with elevated blood pressures (>140/90 mm Hg) excreted double the concentrations (ng/mg creatinine) of cortisol and aldosterone excreted by normotensives. There were no apparent differences in urinary catecholamines between hypertensives and normotensives.

Clinical and socio demographic aspects of congestive heart failure patients at Kenyatta National Hospital, Nairobi.

OBJECTIVE: To analyse the underlying aetiology, precipitating factors and certain socio-demographic determinants in patients admitted to Kenyatta National Hospital, Nairobi in congestive heart failure. DESIGN: Cross sectional descriptive study. SUBJECT: All patients aged thirteen years and above of either sex consecutively admitted with clinical diagnosis of congestive heart failure. SETTING: Kenyatta National Hospital (KNH), a national referral hospital. PATIENT EVALUATION: Detailed history including socio-demographic characteristics and physical examination was done. Patients underwent haematological and biochemistry tests followed by a chest x-ray, ECG and 2D Echo-doppler examination. Blood culture sensitivity was done when clinically indicated. RESULTS: Ninety one patients were studied, 44 males and 47 females. Almost 32% had rheumatic heart disease, 25.2% had cardiomyopathy, 17.6% hypertensive heart disease, 13.2% had pericardial disease while 2.2% had ischaemic heart disease. Three quarters of patients with hypertensive heart disease were above the age of 50 years, while 79% of patients with rheumatic heart disease were below the age of 30 years. Factors associated with patient deterioration leading to admission with congestive heart failure (CHF) included inadequate therapy (27.4%), arrhythmia (20.9%), respiratory infections (17.6%), anaemia (13.2%) and infective endocardiatis. Sixty two per cent of patients investigated were in New York Heart Association (NYHA) functional classification class IV, 31.9% in class III and 5.5% in class II. CONCLUSION: Congestive heart failure constitutes 3.3% of all medical admissions at KNH. Rheumatic heart disease is the commonest cause of congestive heart failure in our set-up while inadequate therapy, arrhythmias and respiratory infections are the three major causes of decompensation in our patients with cardiac disease.

Cardiovascular disease in elderly in-patients at the Kenyatta National Hospital, Nairobi-Kenya.

A prospective study to determine the prevalence and profile of cardiovascular disease in elderly patients admitted into the medical wards, Kenyatta National Hospital, was carried out between July 1991 and January 1992. Two hundred and two patients over 60 years of age were admitted into the medical wards over this period. This formed seven per cent of the total medical admissions. Two of these refused to take part in the study. Of the 200 elderly patients evaluated for cardiovascular disease, 146 (73%) were between 60 and 75 years of age with only 26 (13%) being over 85 years. Fifty seven per cent were males. Clinical evidence of cardiovascular disease was present in 79 (39.5%) of the patients evaluated. There was no sex difference in the prevalence of cardiovascular disease as judged from clinical evaluation (37.7% males versus 41.9% females, p > 0.05). Cardiovascular diseases in our medical in-patients at Kenyatta National Hospital are common and especially so with hypertension which plays an important role in the aetiology of congestive heart failure and cerebravascular accidents. Cardiac arrhythmias are also common though not necessarily symptomatic. Rheumatic heart disease and cardiomyopathies were uncommon in our study population. A community-based survey is needed to determine the true prevalence of cardiovascular diseases in the elderly and their contribution to morbidity in this sector of the population.

Hints : Management of hypertension in Africa

Guidelines for management of hypertension continually change as research findings shed more insight into the disease process and as new classes of anti-hypertensive agents are developed. In 1993; three bodies issued revised guidelines. However; since management of hypertension depends on a number of factors including demographic and socio-economic realities; what is prescribed in developed countries may not be applicable in Africa. The need for African experts treating patients with hypertension to establish a consensus committee on hypertension to develop appropriate guidelines is urgent. The hints in this paper are an attempt to interpret the available facts on the management of hypertension in a manner that reflects the realities in Africa

Cardiovascular risk factor profiles in mild to moderate hypertensives seen at Kenyatta National Hospital.

Sixty newly diagnosed adult patients with mild to moderate essential hypertension were assessed to determine their cardiovascular risk factor profiles. Detailed history and physical examinations were done. Resting 12-lead ECG was done and serum levels of uric acid, fasting cholesterol, and fasting glucose were determined. Twenty nine patients had hypertension and two or more cardiovascular risk factors. The most prevalent cardiovascular risk factors other than hypertension were electro-cardiovascular left ventricular hypertrophy (31.7%), obesity (28.3%) and hypercholesterolaemia (28.3%). About a half of these patients (48.3%) can be classified as high risk hypertensives. This calls for aggressive management of cardiovascular risk factors as a whole and not just hypertension alone if we are to reduce incidence of hypertensive complications.

Metabolic effects of propranolol and hydroflumethiazide treatment in Kenyans with mild to moderate essential hypertension.

In a prospective single-blind comparative trial, sixty newly diagnosed mild to moderate hypertensives were randomly assigned to either propranolol or hydroflumethiazide monotherapy. Baseline fasting serum glucose lipid profiles, serum uric acid and potassium levels, were determined at the beginning of the trial. Repeat levels were determined at completion of twelve weeks of treatment. Propranolol treatment significantly reduced HDL-cholesterol (p < 0.02) and increased both VLDL and total serum triglycerides (p < 0.01). Hydroflumethiazide significantly increased total and LDL-chole-sterol, fasting serum glucose and uric acid levels (p < 0.01); potassium levels were significantly lowered (p < 0.01). Treatment with either propranolol or hydroflumethiazide is associated with significant metabolic side-effects which require regular monitoring and intervention as appropriate.

Comparative study of the efficacy and tolerability of hydroflumethiazide versus propranolol in Africans with mild to moderate hypertension.

Sixty patients with Diastolic Blood Pressure (DBP) of 100-110mmHg matched for age, sex and Bp levels were randomly assigned to propranolol 80mg daily or Hydroflumethiazide (HFM) 50mg daily. HFM causes a significant reduction in systolic blood pressure (SBP) and DBP within 4 weeks compared both with baseline and propranolol (SBP 143.7 +/- 12.3 vs 158.1 +/- 10.9mmHg, P < 0.05; DBP 92.0 +/- 4.5 vs 102.4 +/- 5.1mmHg, P < 0.05), (SBP 143.7 +/- 12.2 vs 152 +/- 11.0mmHg P < 0.05; DBP 92.0 +/- 4.5 vs 101.1 +/- 6.1mmHg, P < 0.05), respectively. Propranolol produced no significant difference from the baseline at 4 weeks (SBP 152.0 +/- H.0 vs 154.1 +/- 11.5mmHg NS; DBP 101.1 +/- 6.1 vs 102.2 +/- 5.6mmHg, NS). Reduction in BP by HFM was maintained after 8 and 12 weeks with further reduction but which did not achieve statistical significance. Increased dose of propranolol (160mg daily) after 4 weeks caused significant reduction in BP by 8 week (SBP 146.8 +/- 11.8 vs 152.0 +/- 11.0mmHg, P < 0.05; DBP 95.9 +/- 4.4 vs 101.1 +/- 6.1mmHg P < 0.05), which was maintained upto 12 weeks. The values however remained higher than in the HFM group. More patients in the HFM group achieved target BP (< 140/90), SBP 53.8% vs 29.6% P < 0.05, DBP 69.2% vs 14.8% P < 0.01. Incidence of side effects was similar and will be discussed. Thiazides are superior to B'blockers as initial monotherapy in black hypertensives.