Report from the Caribbean renal registry, 2006

AIM: To develop a renal registry that will monitor renal epidemiology in the Caribbean and help determine the burden of disease. METHODS: Questionnaires were sent out to different Caribbean countries for distribution to the dialysis units. Data were obtained for patients with End Stage Renal Disease (ESRD) who were on long term renal replacement therapy in 2006. The demographic data, type of renal replacement therapy, laboratory data and causes of ESRD were obtained from the questionnaire. Data were analyzed using SPSS 11.0 RESULTS: Data were reported from six English-speaking Caribbean countries: Bahamas (n = 211), Barbados (n = 185), British Virgin Islands (n = 27), Cayman Islands (n = 41), Jamaica (n = 366) and Trinidad and Tobago (n = 436). Haemodialysis was reported in all the countries; transplantation was not reported from the Cayman Islands. Only Bahamas, Jamaica and Trinidad and Tobago reported peritoneal dialysis. In Jamaica, male to female ratio was 1.5:1. The three commonest causes of end stage renal failure were hypertension (65.5%), diabetes mellitus (27.6%) and primary chronic glomerulonephritis (12.5%). The age range was 11-94 years (mean 47.7 years). Barbados had a male to female ratio of 1.8:1, age range of 19-81 years (mean age: 52.3 years). Hypertension (55.7%) and diabetes mellitus (27.0%) were the commonest causes. Trinidad and Tobago had a male to female ratio 1.3:1. The age range was 8-84 years (mean age 52.5 years). The four commonest causes of ESRD were diabetes nAellitus (28.9%), hypertension (25.3%) and autosomal dominant polycystic kidney disease (3.9%) and chronic glomerulonephritis (3.9%). The British Virgin Islands, Tortola, had a male to female ratio 1.7:1.0. Age range was 26-86 years (mean, 57 years). Hypertension (67.9%) and diabetes mellitus (46.4%) were also the commonest causes. The Bahamas had a male to female ratio of 1:1.1 unlike the other countries. Hypertension (25.6%), diabetes mellitus (28.0%) and chronic...

Acute renal failure post coronary artery bypass grafting at the University Hospital of the West Indies / Fallo renal agudo tras injerto bypass de la arteria coronaria en el hospital universitario de west indies

OBJECTIVES: The purpose of the study was to determine the period prevalence of acute renal failure (ARF) after coronary bypass surgery (CABG) at the University Hospital of the West Indies and to identify risk factors. METHOD: A retrospective analysis of patients who underwent CABG during the period 1994-2004 was done. Data collected included; age, gender, weight, the presence of hypertension (HTN), diabetes mellitus (DM), hypercholesterolaemia, previous myocardial infarction (MI), blood pressure on admission, urea and creatinine one year prior to surgery, on admission for surgery and post-surgery, duration of intra-operative hypotension, duration of cardiopulmonary bypass, perfusion pressure and the perioperative medications. RESULTS: The case notes of 62 patients (68.9%) were obtained for analysis. There were 47 (75.8%) males and 15 females (24.2%)--a 3:1 ratio. The prevalence of HTN and DM in the study sample was 78% and 72% respectively, hypercholesterolaemia was 31% and a previous MI was 29%. There were no differences based on gender. Post CABG complications were: persistent postoperative hypotension (6.8%), congestive cardiac failure (CCF) (6.8%), arrhythmia (6.8%), sepsis (6.8%), lower respiratory tract infection (LRTI) and pleural effusion (5.1%), heart block (3.4%), pulmonary embolism (1.7%), cellulitis and haematoma formation were 1.7%. Three patients had increases in postoperative creatinine values > 89 micromol/L over the postoperative value resulting in a prevalence of ARF of 5%. One of the three patients died and none received dialysis. There were no statistical difference in pre-operative clinical and biochemical characteristics based on the presence or absence of ARE. The presence of diabetes and increased length of stay were significant predictors of increasing postoperative creatinine values adjusting for pre-operative creatinine values. In addition, the presence of diabetes mellitus and...

Cardiac disease in dialysis patients in a Jamaican hospital: echocardiographic findings that predict mortality / La enfermedad cardíaca en los pacientes de diálisis en un hospital de Jamaica: hallazgos ecocardiográficos que predicen la mortalidad

The aim of the study was to assess, by echocardiography, the cardiac abnormalities in a group of patients with chronic renal failure and to determine the cardiovascular predictors of mortality. The study comprised forty-five patients from the Renal Unit, University Hospital of the West Indies, Kingston, Jamaica, and was undertaken between October 1, 1998 and July 31, 2000. All echocardiography was done by a single operator. The parameters assessed were systolic dysfunction, diastolic dysfunction, ejection fraction, regional wall motion abnormalities and valvular disease. Left ventricular cavity size, septal and posterior wall thickness were measured and left ventricular mass calculated. Demographic data were obtained directly from each patient by interview. The patients were mainly of African/mixed-African origin. Their mean age was 43.2 +/- 16.0 years. The average body mass index was 23.7 +/- 6.9. Twenty-eight (60.9%) patients were male and seventeen (39.1%) female. Hypertension, chronic glomerulonephritis and diabetes mellitus were the leading causes of chronic renal failure. Blood pressure was controlled at a mean value of 145/90 mm Hg pre-dialysis and 140/90 mm Hg postdialysis. The mean duration of renal failure was 2.8 years. Echocardiographic M-mode and two dimensional apical, four chamber view measurements indicated that mean left ventricular internal diameter (LVID) diastole was 55.7 +/- 7.9 mm (normal 38-56 mm) and LVID systole was 38.9 +/- 9.8 mm (normal 24-45 mm); the mean thickness of the chamber walls was 10.3 +/- 2.8 mm and 10.6 +/- 2.4 mm for the interventricular septum (normal 6-11 mm) and left ventricular posterior wall (normal 6-11 mm) respectively. Diastolic dysfunction was seen in 15 (34%) patients and systolic dysfunction in 12 (23%) patients who had ejection fractions less than 50%. The mean left ventricular ejection fraction was 56.3% +/- 16% (normal 65-85%), mean stroke volume was 82.9 +/- 27.2 mls (normal 51-96 ml). After 21 months enrolment in the study, Kaplan Meier analysis revealed a two-year mortality of 28.3%. Cox regression analysis indicated that a history of smoking current or past, low haemoglobin level, high aorta flow velocities, severity of mitral regurgitation and a negative association with serum creatinine were independent predictors of mortality. The correction of anaemia and control of other factors that impact negatively on cardiac function in dialysis patients is vital to enhance survival.

Antinuclear antibodies and HLA class II alleles in Jamaican patients with systemic lupus erythematosus / Anticuerpos antinucleares y aleles HLA de clase II en pacientes Jamaicanos con lupus eritematoso sistémico

OBJECTIVE: The relationship between human leukocyte antigens class II (HLA) and antinuclear antibodies was investigated in Jamaican patients with Systemic Lupus Erythematosus (SLE). METHODS: Samples of blood of 82 patients with SLE and 75 healthy controls were tested for antinuclear antibodies using the fluorescent antinuclear antibody (FANA) test, counterimmunoelectrophoresis (CIEP) and the Crithidia luciliae immunofluorescence test (CL-IFT). A DNA-based HLA typing method was used to determine the frequencies of alleles of HLA-DRB1, DRB3, DRB4 and DRB5 in patients and healthy controls. RESULTS: The FANA test was positive in all of the sera from patients with SLE. Anti-dsDNA antibodies were present in 49% (40/82), anti-Sm/RNP 44% (36/82) and anti-Ro/La 43% (35/82) of the sera from SLE patients. The frequency of HLA-DR4 was significantly lower in SLE patients than in healthy controls (2/82, 2% vs 15/75, 20%; RR = 0.12; p = 0.0004; CP = 0.005) but no other HLA-DRB1 SLE associations were found. A positive HLA-DR3 anti-Ro/La antibody association was found in the patients with SLE (9/21, 43% vs 5/55, 9%; odds ratio (OR) = 7.5; CP = 0.01). In contrast, possession of HLA-DR6 was negatively associated with the absence of anti-dsDNA antibodies (9/32, 28% vs 27/44, 61%; OR = 0.2; CP = 0.05). CONCLUSION: The HLA-DR6 allele is associated with the absence of antinuclear antibodies and HLA-DR3 with the presence of anti-Ro/La antibodies in Jamaican patients with SLE. However, these results and those of previous studies of Jamaican patients suggest that the HLA-DR3 association with the development of SLE reported in other populations might in fact reflect the association of HLA-DR3 with anti-Ro/La antibodies. Further investigations are needed to determine whether HLA-DRB antinuclear antibody associations define clinical subsets of SLE in Jamaican patients.

OBJETIVO Se investigó la relación entre los antígenos de leucocito humano (human leukocyte antigens o HLAs). Clase II y los anticuerpos antinucleares en pacientes jamaicanos con lupus eritematoso sistémico (LES). MÉTODOS: Se examinaron muestras de sangre de 82 pacientes con LES y 75 controles saludables para determinar la presencia de anticuerpos antinucleares, usando la prueba del anticuerpo antinuclear fluorescente (FANA), la contrainmunoelectroforesis (CIEP) y el test de inmunofluorescencia con Crithidia luciliae (CL-IFT). Un método de tipificación HLA basado en el ADN fue usado para determinar las frecuencias de aleles de HLA-DRB1, DRB3, DRB4 y DRB5 tanto en los pacientes como en los controles saludables. RESULTADOS: La prueba FANA fue positiva en todos los sueros de pacientes con LES. Anticuerpos anti-dsADN se hallaban presentes en 49% (40/82), anti-Sm/RNP en 44% (36/82) y anti-Ro/La en 43% (35/82) de los sueros de los pacientes de LES. La frecuencia de HLA-DR4 fue significativamente más baja en los pacientes con LES que en los controles saludables (2/82, 2% vs 15/75, 20%; RR = 0.12; p = 0.0004; CP = 0.005) pero no se hallaron otras asociaciones de LES con HLA-DRB1. Se halló una asociación positiva de anticuerpos HLA-DR3 anti-Ro/La en los pacientes con LES (9/21, 43% vs 5/55, 9%; odds ratio (OR) = 7.5; CP = 0.01). En contraste con ello, la posesión de HLA-DR6m estuvo asociada negativamente con la ausencia de anticuerpos anti-dsADN (9/32, 28% vs 27/44, 61%; OR = 0.2; CP = 0.05). CONCLUSIÓN: El alele HLA-DR6 está asociado con la ausencia de anticuerpos antinucleares y el de HLA-DR3 con la presencia de anticuerpos anti-Ro/La en pacientes jamaicanos con LES. Sin embargo, estos resultados al igual que los de los previos estudios de pacientes jamaicanos, sugieren que la asociación HLA-DR3 con el desarrollo de LES reportado en otras poblaciones podría de hecho reflejar la asociación de HLA-DR3 con anticuerpos anti-Ro/La. Se requieren investigaciones ulteriores a fin de determinar si las asociaciones de anticuerpo antinuclear HLA-DRB definen subconjuntos de LES en pacientes jamaicanos.

Prevalence of chronic renal failure in the diabetic population at the University Hospital of the West Indies

The prevalence of chronic renal failure (CRF) in 460 patients with diabetes mellitus attending the diabetic outpatient clinic at the University Hospital of the West Indies in Jamaica was determined from a review of medical records. The prevalence of CRF was 10 (39/386) in the diabetic clinic population. Significant positive associations with CRF were found with male gender (20/98, 20 vs 19/287, 7; odds ratio (OR), 3.24; p = 0.001); age 60 years and older (22/162; 14 vs 17/221, 8; OR, 2.01; p = 0.04); fasting blood glucose concentrations exceeding 8.0 mmol/L (22/162, 13 vs 12/182, 7; OR, 2.08; p = 0.05); the presence of significant proteinuria as a marker for outcome (13/39, 33 vs 48/346, 14; OR, 3.60; p = 0.02) and peripheral vascular disease (6/20, 30 vs 139/386, 10; OR, 4.75; p = 0.005). The prevalence of CRF did not differ significantly between patients with Type 1 and Type 2 diabetes mellitus. Also, the presence of CRF was not significantly associated with duration of diabetes mellitus, type of hypoglycaemic agents used, or history of hypertension. However, the presence of persistent proteinuria was significantly associated with duration of diabetes mellitus exceeding five years (46/255, 17 vs 11/149, 7; OR, 2.52; p = 0.005) and a history of hypertension (41/235, 17 vs 20/198, 10; OR, 1.88; p = 0.03) but not with age or gender. This study emphasizes the need to evaluate patients with diabetes mellitus for renal impairment so that intervention strategies may be adopted early to delay progression to endstage renal disease

A survey of chronic renal failure in Jamaica

The prevalence of chronic renal failure (CRF)/end stage renal disease and the accessibility of long term renal replacement therapy in Jamaica were evaluated. The study was conducted at six Jamaican healthcare facilities between July 1998 and December 1999 and included 605 patients with CRF. Men with CRF (57 of patients, mean age of 56.7 years) were significantly older than women (mean age 53.2 years). Hypertension was the most commonly associated medical condition (60.8 of patients) followed by diabetes mellitus (31.4 of patients). The estimated crude point prevalence of CRF in persons 20 years and over at the end of 1999 was 327 per million population. More than one-third of patients with CRF (39) were receiving renal replacement therapy, the most common modality being haemodialysis, and only 1.8 of patients had received kidney transplantation. The prevalence of chronic renal failure was not increased in areas known to have high soil cadmium levels. Chronic renal failure is a significant public health problem in Jamaica and is placing an increasing financial burden on the healthcare sector

The mid-forearm arteriovenous fistula as vascular access for haemodialysis

Successful chronic haemodialysis requires permanent vascular access. The Scribner procedure which utilizes an external arteriovenous shunt, the internal synthetic arteriovenous shunt and the direct arteriovenous fistula as described by Cimino and Brescia have all been used for haemodialysis. Of the three methods, the arteriovenous fistula is the most trouble-free and durable. However, as originally described and constructed in the distal forearm, the morbidity associated with this method is significant. The cubital fossa fistula has even more problems. The mid-forearm fistula was designed by the authors and has been used for chronic haemodialysis over the past eighteen years. This article compares the various methods of access used in the haemodialysis units of the University Hospital of the West Indies and the Kingston Regional Hospital. The mid-forearm fistula was found to have the lowest initial failure rate and was associated with fewer complications than any of the other methods used for access.

Antibiotic susceptibility of Clostridium difficile isolates from adult patients at two Jamaican hospitals. Clinical and epidemiological implications

The susceptibility of 39 toxin producing Clostridium difficile isolates from stools of hospitalized patients was determined, by disc diffusion, to six antibiotics. All but one isolate (toxin A negative) produced toxin A and toxin B. A wide variation in susceptibility to clindamycin, tetracycline and chloramphenicol was noted. Erythromycin and cotrimoxazole showed a clear-cut discrimination in resistance and susceptibility, while all isolates were sensitive to vancomycin. Erythromycin sensitive isolates demonstrated a significant association with diarrhoea (60.9, 14/23, p < 0.001). These strains were predominantly found at the University Hospital of the West Indies (UHWI, 94.1, 16/17). Strains resistant to erythromycin and clindamycin together were commonly found at the National Chest Hospital (NCH, 68.2, 15/22). All erythromycin sensitive strains found at the NCH were from patients transferred to that hospital. These findings suggest that there is a common strain of C difficile (erythromycin resistant) at the NCH different from that found at the UHWI; the resistant pattern seen with isolates from the NCH was typical of toxigenic serogroup C strain and could be typed by the the disc diffusion method. Patients at the NCH who were colonized with either of the two strains of C difficile were likely to get diarrhoea, once there was suppression of the normal microflora by antibiotics and colonic overgrowth with C difficile.