Urinary tract infections in chronic kidney disease in Nephrology unit, University Hospital Center of Befelatanana, Antananarivo.

INTRODUCTION: Urinary tract infection is the leading cause of nosocomial infection worldwide. It is a factor in the progression of chronic kidney disease. AIM: To determine the epidemiological, clinical, microbiological, therapeutic and evolving profile of patients with chronic kidney disease and urinary tract infection. METHODS: This was a retrospective, descriptive study lasting 5 years, from January 2014 to december 2018 in chronic kidney disease with urinary tract infection. RESULTS: Fifty-one patients (7.15%) were retained with a mean age of 53.03 years and a sex ratio of 0.55. Chronic kidney disease was in end-stage in 45.1% (n=23). Cystitis was found in 49.02% (n=25) and gram-negative bacilli were found in 74.50% (n=38), predominantly Escherichia coli (54.90%). Third generation of cephalosporins and fluoroquinolones were frequently prescribed as probabilistic antibiotics. Resistance to beta-lactam antibiotics was 50% for Escherichia coli. Factors influencing severe infection were: advanced age, male gender, urinary lithiasis, multiple antibiotic resistance and non-enterobacterial germs. CONCLUSION: Urinary tract infection in chronic kidney disease were frequent and particularly severe.

Emergency hemodialysis in the Joseph Raseta Befelatanana hospital, Antananarivo, Madagascar / Hémodialyse en urgence à l'hôpital Joseph Raseta Befelatanana, Antananarivo, Madagascar

Introduction: Initiation of emergency dialysis is a critical situation responsible for high morbidity and mortality. This study describes the characteristics of emergency hemodialysis patients in a hospital in Madagascar. Patients and methods: It is a descriptive study over a period of 7 months, from September 1, 2018 to March 31, 2019, on emergency hemodialysis patients in the hemodialysis department of the University Hospital of Joseph Raseta Befelatanana, Antananarivo. Emergency hemodialysis was defined as dialysis performed immediately or within the first 48 hours of hospitalisation in a life-threatening situation. Results: Among 124 haemodialysis patients, 52 patients (41.93%) had started dialysis as an emergency. The mean age of patients was 50.5 years and the sex ratio (male/female) was 1.08. Hypertension (51.92%) and diabetes (34.61%) were the main comorbidities. Chronic kidney disease was found in 82.7%. The majority of patients were unprepared and had initiated dialysis with a central venous catheter. The most frequent indication was Kussmaul's breathing (32.6%) followed by anuria (28.84%). The mortality rate was 23.08% and the prognosis was influenced by their condition on arrival. Conclusion: The predominance of chronic kidney disease and the absence of a permanent vascular approach can be explained by the late referral to nephrologists of patients with chronic kidney disease. Efforts need to be made to increase the proportion of scheduled dialysis patients with a permanent approach.

Introduction: L'initiation de la dialyse en urgence est une situation critique responsable d'une morbi-mortalité élevée. Cette étude décrit les caractéristiques des patients hémodialysés en urgence dans un centre hospitalier de Madagascar. Patients et méthodes: Il s'agit d'une étude descriptive sur une période de sept mois, du 1er septembre 2018 au 31 mars 2019, portant sur les patients hémodialysés en urgence dans le service d'hémodialyse du centre hospitalier Joseph Raseta Befelatanana, Antananarivo. L'hémodialyse en urgence était définie par une dialyse réalisée dans l'immédiat ou dans les 48 premières heures d'hospitalisation devant une situation mettant en jeu le pronostic vital. Résultats: Parmi les 124 patients hémodialysés, 52 patients (41,93 %) avaient démarré la dialyse en urgence. L'âge moyen des patients était de 50,5 ans et le sex-ratio (hommes/femmes) était de 1,08. L'hypertension artérielle (51,92 %) et le diabète (34,61 %) étaient les principales comorbidités. L'insuffisance rénale chronique a été trouvée dans 82,7 %. La majorité des patients n'étaient pas préparés et avaient initié la dialyse avec un cathéter veineux central. L'indication la plus fréquente était la dyspnée de Kussmaul (32,6 %) suivie de l'anurie (28,84 %). Le taux de mortalité était de 23,08 % et le pronostic était influencé par l'état à l'arrivée. Conclusion: La prédominance de l'insuffisance rénale chronique et l'absence d'abord vasculaire permanent peuvent s'expliquer par la référence tardive aux néphrologues des patients ayant une insuffisance rénale chronique. Des efforts doivent être faits pour augmenter la proportion de patients dialysés programmés avec une approche permanente.

Use of Perindopril Arginine/Indapamide/Amlodipine in the Management of Hypertension in Two Sub-Saharan African Island Countries of Madagascar and Mauritius.

INTRODUCTION: Most patients with hypertension in sub-Saharan Africa require two or more drugs to control their blood pressure. Triple fixed-dose combination therapy of perindopril arginine/indapamide/amlodipine is more effective in lowering blood pressure, offers better target organ protection and has increased adherence compared to monotherapy and free combination therapy, and is safe to use. This observational study evaluates the effectiveness of perindopril arginine/indapamide/amlodipine in controlling blood pressure at least 1 month after treatment initiation and assesses patient- and physician- reported drug tolerance over a 3-month period in Madagascar and Mauritius. METHODS: A total of 198 patients with hypertension in ambulatory care who had been on fixed-dose combination of perindopril arginine, indapamide, and amlodipine for at least 4 weeks were included. The main outcome measures were changes in systolic and diastolic blood pressure, attainment of blood pressure control under 140/90 mmHg and 130/80 mmHg, self-reported drug tolerance by the patient, and perceived drug tolerance by the treating physician. Data was collected at 1 month and 3 months. RESULTS: Mean systolic blood pressure was significantly lower at the 1-month (- 3.4 mmHg, p = 0.002) and 3-month (- 8.5 mmHg, p < 0.0001) visits. Diastolic blood pressure also decreased significantly (- 2.4 mmHg at 1-month, p = 0.017 and - 5.4 mmHg at the 3-month visits, p < 0.0001). At 3 months, 80.4% of the patients attained blood pressure targets less than 140/90 mmHg and 42.7% attained targets less than 130/80 mmHg on the basis of their baseline blood pressure. Excellent drug tolerance was reported by more than 90% of patients and physicians at the 1-month visit and by more than 95% at the 3-month visit. CONCLUSION: Triple fixed-dose therapy of perindopril arginine/indapamide/amlodipine continues to show additional blood pressure-lowering capacity even months after initiating the treatment in patients with hypertension in Madagascar and Mauritius. It is also well tolerated by patients with hypertension and assessed as safe to use by physicians.

[Prevalence of chronic kidney disease in Antananarivo, Madagascar]. / Prévalence de la maladie rénale chronique à Antananarivo, Madagascar.

INTRODUCTION: Chronic kidney disease is defined as an inability of the kidney to perform its normal functions and which persists beyond three months. Nowadays, the estimated glomerular filtration rate based on plasmatic creatinine level remains the gold standard to assess renal function. In Madagascar, we miss national data concerning the epidemiology of chronic kidney disease probably due to the complexity of carrying out the serum creatinine assays. The recent availability of creatinometer using a creatinine strip test with capillary creatinine facilitated the determination of the creatinine level in epidemiological study. PATIENTS AND METHODS: This simple technique allowed us to plan a pilot study in Antananarivo, the capital of Madagascar. The main objective was to assess the prevalence of chronic kidney disease determined from capillary creatinine level. The secondary objective was to determine the factors associated with chronic kidney disease in Madagascar. It is an analytical cross-sectional study over a period of three months. Chronic kidney disease is defined as a decrease of the glomerular filtration rate of capillary creatinine less than 60mL/min/1.73m2 and calculated with Chronic Kidney Disease Epidemiology formula (CKD-EPI). The minimum number of studied population has been assessed and settled at 210 people. Cluster sampling was performed for randomization of participants. RESULTS: At the end of the study, 210 people were randomized for screening. The average age was 40 years old with 14.9 as standard deviation. The sex ratio (male/female) was 1.76. The prevalence of chronic kidney disease was 13.8% with extreme values of 9,1 and 18.5. With chronic kidney disease, high blood pressure (hypertension) and diabetes were found respectively in 41.3 and 17.2%. Chronic kidney disease affected mainly in 72.4% of population aged 25 to 54 years old. CONCLUSION: This is the first study in Africa to screen chronic kidney disease using a creatinine strip test. This prevalence is relatively different compared to other African countries. The limits of the study are the absence of a subsequent control and/or double control of the creatinine, which definitively confirms the chronicity of kidney disease, the absence evaluation of the urinary sediments to determine proteinuria. Nevertheless, the results of our study can be used as data awaiting the results of a multicenter studies. To determine the national prevalence of chronic kidney disease, screening in the six provinces is currently in progress.

[Acute kidney injury and severe malaria in adults: A monocentric descriptive study in Madagascar using KDIGO criteria]. / Insuffisance rénale aiguë et paludisme grave chez l'adulte : étude descriptive monocentrique à Madagascar en utilisant les critères KDIGO.

INTRODUCTION: Acute Kidney Injury (AKI) is one of the criteria for severe malaria with a varied incidence. Our objectives are to determine the prevalence of malaria-associated AKI and to report the characteristics of patients with the evolution of cases. PATIENTS AND METHOD: This is a 5-year retrospective descriptive study from January 1, 2015 to December 31, 2019 in the Infectious Diseases department of the University Hospital Center of Befelatanana Antananarivo. Among 379 patients diagnosed, 103 patients (27,18%) with associated AKI were included. We used the criteria of Kidney Disease Improving Global Outcomes group to define AKI. RESULTS: The prevalence of AKI was 27.18%. The mean age of patients was 34.92 years and the sex-ratio was 3.68. Plasmodium falciparum was the causative agent in 98.06% of cases followed by Plasmodium vivax. Diuresis was preserved in 69.86% of cases. Jaundice was the main sign of severity associated (49.51%). The mean creatinine level was 466.93µmol/L. The evolution was favorable under antimalarial drug and rehydration. Dialysis was required in 25.24% of cases. Thirteen patients had died, a rate of 12.62%, of which 8 patients (61.54%) had dialysis criteria but had not been purged for economic reasons. CONCLUSION: AKI is a frequent complication of malaria. It is responsible for significant mortality despite improved care in the fight against malaria.

[A retrospective study on the incidence of chronic renal failure in the Department of Internal Medicine and Nephrology at University Hospital of Antananarivo (the capital city of Madagascar)]. / Une étude rétrospective sur l'incidence de l'insuffisance rénale chronique dans le service de Médecine Interne et Néphrologie du Centre Hospitalier Universitaire d'Antananarivo.

Chronic renal failure is a global public health problem. In developed countries, this disease occurs mainly in the elderly, but in Africa it rather affects active young subjects. This disease need for expensive treatments in a low income country, because of its costs. Our aim is to describe the epidemiology of new cases of chronic renal failure in Madagascar. This is a retrospective, descriptive study of 239 patients with chronic renal failure over a 3 year period, starting from 1 January 2007 to 31 December 2009, in the Department of Internal Medicine and Nephrology at University Hospital of Antananarivo. The incidence was 8.51% among patients hospitalized in the Department. The average age of patients was 45.4 years with extremes of 16 and 82 years and a sex ratio 1,46. The main antecedent was arterial hypertension (59.8%). Chronic renal failure was terminal in 75.31% of the cases (n=180). The causes of chronic renal failure were dominated by chronic glomerulonephritis (40.1%), nephroangiosclerosis (35.5%). Hemodialysis was performed in 3 patients (1.26%), no patient was scheduled for a renal transplantation. Mortality rate in the Department was 28.87%. Chronic renal failure is a debilitating disease with a dreadful prognosis which affects young patients in Madagascar. Its treatment remains inaccessible to the majority of patients. The focus must be mainly on prevention, especially on early effective management of infections, arterial hypertension and diabetes to reduce its negative impacts on the community and public health. The project on renal transplantation: living donor, effective and less expensive treatment compared to hemodialysis could also be a good solution for these Malagasy young subjects.

[Renal dimensions in the Nephrology Department of Befelatanana Hospital, Antananarivo]. / Dimensions rénales en Service de Néphrologie Clinique, Befelatanana, Antananarivo.

The knowledge of normale renal sizes specific for each individual and for any ethnicity, allows diagnostic and therapeutic medical decision. For a low-income country such as Madagascar, ultrasound is an ideal tool for this purpose. This study aims to collect data on renal dimensions and to seek the correlation between these data and the demographic and anthropometric parameters in Malagasies. This is a retrospective study of 200 non-diabetic patients without chronic kidney disease, spanning 3 years, conducted in the Nephrology Department of Befelatanana Hospital, Antananarivo. The average age of our patients was 45 ±16 years, with a sex-ratio of 0,9. On average, the dimensions (length x width x thickness) were 98 mm × 42 mm × 30 mm for right kidney, 99 mm × 45 mm × 31 mm for the left kidney. We found a significant difference between the right and left kidney in length (p<0.00001) and width (p = 0.03). A significant relationship was also found between renal length and age (p = 0.0016 and p = 0.04 respectively for the right kidney and the left kidney). No significant relationship was found between renal dimensions and size and patients weight. Despite its limitations, our study would provide important supports for clinical practice as well as for further studies.