Francois Folefack Kaze

Day-to-Day Variation of Insulin Requirements of Patients With Type 2 Diabetes and End-Stage Renal Disease Undergoing Maintenance Hemodialysis

OBJECTIVE To evaluate day-to-day variations of insulin needs in type 2 diabetic patients with end-stage renal disease (ESRD) on maintenance hemodialysis. RESEARCH DESIGN AND METHODS We developed a 24-h euglycemic clamp in patients who received an average of 2,200 calories in a standardized three-meal and two-snack regimen per day, adjusted to body size and sex. Intravenous insulin was adjusted every 30 min to achieve 5.5 ± 1.1 mmol/l glycemia over 24 h prehemodialysis, during hemodialysis session, and 24 h posthemodialysis in 10 type 2 diabetic patients, aged 55.7 ± 8.7 years with 11.9 ± 4.5 years diabetes duration, undergoing maintenance hemodialysis for 2.3 ± 2.3 years. Insulin requirements were derived from the dose of insulin administered to maintain euglycemia per period of time and day-to-day comparisons performed. RESULTS Mean capillary glycemia was 5.5 ± 0.3 mmol/l prehemodialysis and 5.3 ± 0.2 mmol/l posthemodialysis (P = 0.39). Pre- and posthemodialysis areas under the glucose curve were comparable. This was achieved by infusing 23.6 ± 7.7 IU/24 h prehemodialysis vs. 19.9 ± 4.9 IU/24 h posthemodialysis, indicating a 15.3% decrease posthemodialysis (P = 0.09). Basal insulin needs decreased from 0.4 ± 0.1/h prehemodialysis to 0.3 ± 0.1/h posthemodialysis (P = 0.01). Total boluses were decreased by 2.2 ± 3.1 IU (P = 0.15). Changes in blood urea did not correlate with changes in insulin needs (r = 0.1, P = 0.79). CONCLUSIONS The present study has demonstrated a significant 25% reduction in basal insulin requirements the day after dialysis compared with the day before. No significant change in boluses was observed, and overall the reduction of total insulin requirements was −15% equivalent to −4 IU/day posthemodialysis of marginal statistical significance.

Complications of Arteriovenous Fistula for Hemodialysis: An 8-Year Study

BACKGROUND To assess the frequency and characteristics of complications of arteriovenous fistula (AVF) and their effect on fistula outcome. METHODS We retrospectively reviewed 628 AVFs constructed from November 2002 to October 2010 to record the complications and their management options. The association between age, sex, comorbidities (HIV, hypertension, and diabetes), fistula type, and complications was sought. RESULTS Most patients were males (73.7%). The mean age was 45.3 years. Comorbidities seen included diabetes mellitus (22.12%), hypertension (83.12%), and HIV infection (9.87%). AVFs constructed were mainly radiocephalic (68%) and brachiocephalic (24.9%). The median follow-up period was 275 days. The cumulative patency rate was 76% and 51% at 1 year and 2 years, respectively. Altogether, 211 complications occurred in 16% of the AVFs. Among them, 36.96% were severe, 25.11% moderate, and 43.91% minor. With respect to the time of occurrence, 63.98% were late complications, 12.79% immediate, and 23.22% early. Aneurysms, failure to mature, and thrombosis were the most frequent complications occurring in 26.54%, 14.69%, and 12.79% of cases, respectively. The management options for the complications included the creation of a new access in 36.96%, a temporary catheter before a new AVF in 10.52%, and nonoperative management in 43.12%. We found no adverse effect of comorbid factors such as diabetes mellitus (χ(2) = 3.58, P > 0.05) or HIV-positive status (χ(2) = 0.64, P > 0.05) on the complication rate. CONCLUSION This study shows an overall frequency of complications of 16%. These results show the potential for low complication rate of AVF in selected population.

Acute hemodialysis complications in end-stage renal disease patients: the burden and implications for the under-resourced Sub-Saharan African health systems.

Little is known about the challenges of routine renal replacement therapy in Sub‐Saharan Africa. We investigated the fatal and nonfatal acute hemodialysis (HD) complications in patients with end‐stage renal disease (ESRD) in two main dialysis centers in Cameroon. 1000 consecutive HD sessions incurred over a 4‐month period by 129 patients (96 men, 74%) with ESRD, receiving two weekly HD sessions of 4 hours each, were considered. Personal and clinical profiles before, during, and within 24 hours after HD sessions were used to diagnose complications. Participants were aged 7 to 80 years (mean 46 years). In all, 452 acute complications were recorded in 411 (41%) of the 1000 HD sessions. Of the 11 types of complications, hypotension (25%), muscular cramps (22%), hypertensive crisis (14%), pruritus (10%), and fever (7%) were the most frequent. Three hundred and six complications (67.7%) occurred during understaffed nighttime. The vascular access was the main bleeding site with 64%. Being diabetic and ultrafiltration rate >1000 mL/h were associated with hypotension and muscle cramps. The shorter duration in dialysis was associated with the risk of bleeding and the disequilibrium syndrome while longer duration was associated with muscle cramps. Four deaths (three from bleeding and one from disequilibrium syndrome) occurred, all during nighttime. Nearly half of dialysis sessions in these settings are associated with acute complications, some of which are fatal. Those complications occurred mostly during understaffed periods. Urgent strategies are needed to quickly solve the human capital crisis in the health care sector.

Efficiency of an intervention package for arterial hypertension comprising telemanagement in a Cameroonian rural setting: The TELEMED-CAM study.

Introduction Sub-Saharan Africa has a disproportionate burden of disease and an extreme shortage of health workforce. Therefore, adequate care for emerging chronic diseases can be very challenging. We implemented and evaluated the effectiveness of an intervention package comprising telecare as a mean for improving the outcomes of care for hypertension in Rural Sub-Saharan Africa. Methods The study involved a telemedicine center based at the Yaounde General Hospital (5 cardiologists) in the Capital city of Cameroon, and 30 remote rural health centers within the vicinity of Yaoundé (20 centers (103 patients) in the usual care group, and 10 centers (165 patients) in the intervention groups). The total duration of the intervention was 24 weeks. Results Participants in the intervention group had higher baseline systolic (SBP) and diastolic (DBP) blood pressure, and included fewer individuals with diabetes than those in the usual care group (all p < 0.01). Otherwise, the baseline profile was mostly similar between the two groups. During follow-up, more participants in the intervention groups achieved optimal BP control, driven primarily by greater improvement of BP control among High risk participants (hypertension stage III) in the intervention group. Conclusion An intervention package comprising tele-support to general practitioners and nurses is effective in improving the management and outcome of care for hypertension in rural underserved populations. This can potentially help in addressing the shortage of trained health workforce for chronic disease management in some settings. However context-specific approaches and cost-effectiveness data are needed to improve the application of telemedicine for chronic disease management in resource-limited settings.

Influence of migration on characteristics of type 2 diabetes in sub-Saharan Africans

AIM This study compared the clinical and biochemical characteristics and microvascular complications found in three groups of type 2 diabetes (T2D) patients: Africans living in Africa; African immigrants living in France; and Caucasians living in France. METHODS Diagnosed T2D Africans living in Cameroon (n=100) were compared with 98 African migrants diagnosed with T2D after having moved to France, and a group of 199 T2D Caucasian patients living in France. All underwent clinical and biochemical evaluations, and all were assessed for microvascular complications. RESULTS The median duration of stay of the migrants in France was 15years before being diagnosed with diabetes. Despite similar durations of diagnosis, they were 8.9years younger at the time of diagnosis than Africans living in Cameroon (P<0.001). Caucasians and African immigrants in France had lower HbA1c values than Africans in Cameroon (P<0.001); they were also more aggressively treated for hypertension and dyslipidaemia and, therefore, had significantly lower blood pressure levels and better lipid profiles. Diabetic nephropathy and retinopathy rates were higher in Cameroon than in the two other groups. After adjusting for age, diabetes duration, HbA1c, hypertension and other covariates, only the prevalence of diabetic nephropathy (OR: 5.61, 95% CI: 2.32-13.53; P<0.0001) was higher in Cameroon compared with those living in France. CONCLUSION Our results suggest that Africans who emigrate to France may develop diabetes earlier than those staying in their home country. However, the latter may be a reflection of late diagnosis of diabetes. Also, the less adequate diabetes and hypertension control in the latter would explain their higher rates of nephropathy. Large-scale cohorts are now warranted to substantiate these observations.

HIV/AIDS Occurrence in the Main University Teaching Hospital in Cameroon Audit of the 2001 Activities of the Service of Internal Medicine

Aim: This study describes the impact of HIV/AIDS on the inpatient service of the main teaching hospital in Cameroon in 2001. Methods: The authors analyzed routinely collected hospital data and data validated by survey of clinical notes. Results: Admission and bed utilization rates for HIV/AIDS over the period accounted for 20.1% and 17%, respectively, primarily due to the management of opportunistic infections in young people (mean age, 39.9 years). Housewives (21.9%) and students (10.3%) were the most identified groups. Tuberculosis (23.3%), the most frequent infection, was associated with a good prognosis. Hospital stay ranged from 1 to 99 days. HIV/AIDS accounted for 49.3% of deaths registered. Conclusion: HIV/AIDS is the major cause of hospital admissions and death in this service. This situation is likely to remain constant for some time given the national prevalence of HIV. Consideration needs to be given to the options for prevention and provision of care.

Prevalence and Determinants of Chronic Kidney Disease Among Hypertensive Cameroonians According to Three Common Estimators of the Glomerular Filtration Rate

Hypertension is a risk factor for renal diseases, which, in turn, are precursors of hypertension. The authors assessed the prevalence and determinants of chronic kidney disease (CKD) among 336 hypertensive adult Cameroonians (mean age, 60.9±11.3 years; 63.4% women) at Yaoundé. Any participant with an estimated glomerular filtration rate <60 mL/min/1.73 m2 regardless of the equation used (Cockcroft‐Gault [CG], Modification of Diet in Renal Disease [MDRD], and Chronic Kidney Disease Epidemiology Collaboration [CKD‐EPI]) and/or dipstick proteinuria was reviewed 3 months later. Participants presented a high prevalence of diabetes (18.5%), dyslipidemia (17.6%), gout/hyperuricemia (10.7%), overweight/obesity (68.8%), self‐medication (37.5%), and alcohol consumption (33.3%). Hypertension was uncontrolled in 265 patients (78.9%). The prevalence of CKD was 49.7%, 50.0%, and 52.1% according to MDRD, CKD‐EPI, and CG equations, respectively. Advanced age, adiposity, and severity of hypertension were determinants of CKD. Nearly half of the hypertensive patients had CKD regardless of the estimators used, predicted by well‐known risk factors.

Performance of three glomerular filtration rate estimation equations in a population of sub-Saharan Africans with Type 2 diabetes.

We evaluated the performance of the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) and Cockcroft–Gault (CG) equations against creatinine clearance (CrCl) to estimate glomerular filtration rate (GFR) in 51 patients with Type 2 diabetes.

Outcomes of Non‐Tunneled Non‐Cuffed Hemodialysis Catheters in Patients on Chronic Hemodialysis in a Resource Limited Sub‐Saharan Africa Setting

The aim of the present study was to investigate the adverse outcomes of non‐tunneled hemodialysis catheters and determinants in chronic hemodialysis patients receiving care at the Yaoundé General Hospital hemodialysis center, Cameroon. This was a prospective study of 11 months duration (February–December 2008) involving 81 non‐tunneled non‐cuffed catheters (63 femoral, 18 internal jugular) placed in 72 adults (47 men, 65.3%) on chronic hemodialysis. Baseline clinical and laboratory parameters associated with catheter‐related complications during follow‐up were investigated. The difference between variables was assessed using the χ2 test and equivalents. Sixty‐five (80.2%) catheters were inserted for emergency dialysis, 11 (13.6%) for a failed native arteriovenous fistula and five (6.2%) for a failed prior catheter. The mean time‐to‐catheter removal was 35 ± 28 days. Catheter‐related complications accounted for a third of catheter removals. The main catheter‐related complications were infections (17/27, 62.9%) and bleeding (6/27, 22.2%), which were associated with unemployment (P = 0.0002) and longer duration of catheter (P = 0.004). The catheter‐related infections were sepsis (11.8%), exit‐site (29.4%) and both (58.8%); leading to death in 11/17 (64.7%) cases. Fever (94.1%), pain (88.2%) and pus (70.6%) were the main infectious signs with Staphylococcus aureus involved in 70.6%. Unemployment was significantly frequent in patients with infectious complications (76.5% vs. 26.6%, P = 0.0004). Non‐tunneled hemodialysis catheters are mainly used for emergency dialysis through the femoral vein in this setting. Catheter‐related infections due to Staphylococci are the leading complications associated with unemployment and longer utilization. Efforts are needed to improve early transfer of patients to nephrologists for better preparation for renal replacement therapy.

The Epidemiology of Acute Kidney Injury in a Tertiary Hospital in Cameroon: A 13 Months Review

Background: The etiologies and outcome of Acute Kidney injury (AKI) in resource-limited countries are largely related to poverty. Outcome is marred by limited access to renal replacement therapy. Recently, partial government funding for hemodialysis in Cameroon and the SYL program have increased access to RRT for AKI in Cameroon. Data on AKI is sparse in Cameroon. We sought to describe the epidemiology of diagnosed AKI amongst patients in a tertiary hospital. Method: We retrospectively reviewed records of patients seen by the nephrology department for AKI over a 13 months period in a tertiary Hospital in Cameroon. Diagnostic of AKI was done using usual criteria. We evaluated access to dialysis, renal recovery at hospital discharge and at 3 months and patient survival at hospital discharge. Results: A total of 108 (61 males, 12 children) patients with AKI were identified among 303 nephrology in-patient consults or admissions during the study period. The mean age was 45.65± 21.23 years. Community acquired AKI was most common (70.4%). Pre-renal, renal and obstructive causes accounted for 26.9%, 62% and 11.1% patients respectively. Infections (n=36, 33.34 %) and toxins (n=21, 19.4 %) were most frequent causes. AKI was pregnancy related in 12 (11%), and malaria-related in 10 (10 %) cases. AKI was multifactorial in 21.3% of patient. Dialysis was indicated in 55 (50.9%) patients but only 30 (27.8%) patients effectively underwent the therapy. Reasons for no access to dialysis were lack of appropriate material and lack of funds. At 3 months, 34 (31.5%) were known dead, 41 (38%) complete renal recovery, 25 (23%) partial recovery and 8 (7.5%) loss to follow-up. No patient was dialysisdependent. Conclusion: Infection and nephrotoxins are the main etiologic factor of AKI. Its prognostic is severe: half of patients need dialysis and third die.