M.M. Cissé

Mineral and bone disease in black african hemodialysis patients: a report from senegal.

Background Chronic kidney disease related mineral and bone disease (CKD-MBD) is a worldwide challenge in hemodialysis patients. In Senegal, number of dialysis patients is growing but few data are available about their bone disorders. Objectives To describe patterns of CKD-MBD in Senegalese dialysis patients. Patients and Methods We performed a cross-sectional study including patients from three dialysis centres in Senegal. Diagnosis of different types of CKD-MBD relied on clinical, biological and radiological data collected from medical records in dialysis. Results We included 118 patients and 79 of them presented CKD-BMD (prevalence of was 66.9 %). Mean age of CKD-MBD patients was 47.8 ± 15.7 years (16-81 years) and sex-ratio (Male/Female) was 1.15. Secondary hyperparathyroidism was the most frequent disorder (57 patients) followed by adynamic bone disease (21 patients) and osteomalacia (1 patients). The main clinical manifestations were bone pain (17.5% of cases), pruritus (36.8% of cases) and pathological fractures (2.5% of cases). Bone biopsy was not available. Valvular and peripheral vascular calcification were present in 24.5% and 21.2% of patients respectively. Management of CKD-MBD included optimization of dialysis, calcium bicarbonate, sevelamer, vitamin D analogues and calcimimetics. The NKF/DOQI recommended levels of serum calcium, phosphate and parathormone PTH were not achieved in one third of patients. Six patients presented major cardiovascular events during their dialysis period. Conclusions CKD-MBD are frequent in Senegalese hemodialysis patients and they are dominated by high turn-over disease. Clinical and biological manifestations are unspecific and accurate diagnoses are often difficult in absence of histomorphometry. Treatment is suboptimal for many patients in a context of limited resources.

PILOT EXPERIENCE IN SENEGAL WITH PERITONEAL DIALYSIS FOR END-STAGE RENAL DISEASE

♦ Introduction: Peritoneal dialysis (PD) is occasionally used in western sub-Saharan Africa to treat patients with end-stage renal disease (ESRD). The present study is a retrospective review of the initial six years’ experience with PD for ESRD therapy in Senegal, a West African country with a population of over 12 million. ♦ Material and Methods: Single-center retrospective cohort study of patients treated with PD between March 2004 and December 2010. Basic demographic data were collected on all patients. Peritonitis rates, causes of death and reasons for transfer to hemodialysis (HD) were determined in all patients. ♦ Results: Sixty-two patients were included in the study. The median age was 47 ± 13 years with a male/female ratio of 1.21. Nephrosclerosis and diabetic nephropathy were the main causes of ESRD. The mean Charlson score was 3 ± 1 with a range of 2 to 7. Forty five peritonitis episodes were diagnosed in 36 patients (58%) for a peritonitis rate of 1 episode/20 patient-months (0.60 episodes per year). Staphylococcus aureus and Pseudomonas aeruginosa were the most commonly identified organisms. Touch contamination has been implicated in 26 cases (57.7%). In 23 episodes (51%), bacterial cultures were negative. Catheter removal was necessary in 12 cases (26.6%) due to mechanical dysfunction, fungal or refractory infection. Sixteen patients died during the study. ♦ Conclusion: Peritoneal dialysis is a suitable therapy which may be widely used for ESRD treatment in western sub-Saharan Africa. A good peritonitis rate can be achieved despite the difficult living conditions of patients. Challenges to the development of PD programs include training health care providers, developing an infrastructure to support the program, and developing a cost structure which permits expansion of the PD program.

Hypertension in Black Africans with Autosomal Polycystic Kidney Disease

Introduction: High blood pressure (HBP) that is a leading cause of end-stage renal disease (ESRD) in black African populations and is frequently associated to autosomal polycystic kidney disease (ADPKD). This study aimed to describe prevalence and severity of HBP in black Africans with ADPKD and to identify associated risk factors. Patients and methods: We performed a retrospective study of 65 ADPKD patients regularly followed in outpatient nephrology clinic between 1995 and 2009. ADPKD was diagnosed according to recent unified criteria (2009). Statistical analyses were done with SPSS 16.0. Results: We included 65 patients (36 males and 29 females) with a mean age of 47 ± 5 years. Hypertension was found in 73.8 % of patients and it preceded diagnosis of ADPKD in 23 patients (median delay of 28 months). Mean systolic/diastolic blood pressure was 168 ± 30 /96 ± 16 mm Hg respectively. All hypertensive patients presented retinopathy and left ventricular hypertrophy. Two patients presented stroke. Fifty one percent of patients were treated with angiotensin converting enzyme inhibitors alone and 29% received combinations of anti-hypertensive drugs. One third of them had their blood pressure normalized. Patients with HBP at diagnosis showed a similar proportion of ESRD in comparison with normotensive patients (p=0.12). At univariate analysis, HBP was correlated with age, gender, BMI, GFR and proteinuria. Multiple regression analysis identified age (OR=1.95, p=0.05) and glomerular filtration rate (OR=2.33, p=0.001) as independently associated to HBP. Conclusion: Hypertension with organ damage is frequent in Senegalese patients with ADPKD. Age and glomerular filtration rate at diagnosis were the main risk factors of HBP identified in our patients.

Obstetric Cortical Renal Necrosis, Even Reality in the Tropics

Obstetric cortical renal necrosis is a serious complication that can lead to chronic renal failure and the need for dialysis for life in some cases. In Africa, despite progress, much remains to provide in order to prevent this complication. Difficulties in health care access and lack of monitoring of pregnancies are contributing factors. We propose through 5 cases report the characteristics of obstetric renal cortical necrosis in the tropics.

Encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a rare but potentially lethal complication of peritoneal dialysis (PD). Peritoneal tuberculosis is considered an etiologic factor. We report a case of EPS in a 40-year-old man who was switched to hemodialysis because of peritoneal tuberculosis after 2 years of PD. Because of the persistence of gastrointestinal symptoms and cachexia, laparoscopic exploration was performed, which revealed an important thickening of the peritoneal membrane sheathing the intestinal loops. Accordingly, a diagnosis of EPS was made. Anti-tuberculosis treatment associated with a low dose of corticosteroids stabilized the disease.

Problematic of Vascular Access for Hemodialysis in Sub-Saherienne Africa: Experience of Dakar

Aim: Vascular access is important for a good survive in hemodialysis. It can be temporary or permanent, and needs particular attention because of possible complications, especially infectious. We conducted a study to determine the type and the outcome of vascular access in two hemodialysis units in Dakar. Materials and Methods: A multicenter retrospective study was conducted from the 1st January 2005 to 10 September 2010 in two hemodialysis centers: Hospital Aristide Le Dantec and the MDTC (Multifunctional Diagnosis and Treatment Center) of Dakar. All the patients- regularly dialyzed since at least three months in these centers were included. Results: Sixty five patients were included. The mean age was 50.2 years with a sex ratio of 1.7. The mean duration in hemodialysis was 23.2 month. Only five patients (7.80%) had an AVF before starting in hemodialysis. Sixty patients (92.2%) started dialysis with a central venous catheter. Among them, 49 (81.6%) had a double lumen femoral catheter and 11 had a jugular one with 4 tunneled. Complications of vascular access were noted for 23 patients (39.7%) with 12 infections. Blood culture was positive for Staphylococcus Aureus in seven cases. Seven patients presented lower limb thrombophlebitis. Thrombosis of the catheter was noted in four patients. Radial arterio-venous fistula (AVF) was the first intention permanent access in 41 cases (64.1%) followed by cephalic AVF in 14 cases (21.9%) and basilic AVF in 9 (14%). AVF complications were presented in 56.9% of case (40 patients). Most of them was early defect in 18 cases (27.7%), thrombosis in 9 (13.8%) and stenosis in 5 (7.7%). Radial AVF infection to Staphylococcus Aureus was noted in 3 cases, and one pseudo aneurysm was noted. Conclusion: Vascular access for hemodialysis is a great problem in Senegal. More than two third of our patients start dialysis on venous catheters, this is far from the clinical practice guidelines.

Light Chain Deposition Disease in Black African, Report of Three Cases from Senegal

Background: Although there are numerous publications on multiple myeloma in black people, it seems sub-Saharan literature particularly Senegalese’ one is silent about Light chain deposition disease (LCDD) which is linked to immunoglobulin light chain deposition in glomerulus. The authors report the first three observations of LCDD collected in Nephrology department of Aristide Le Dantec hospital in Dakar, Senegal. Cases: we report three cases a man and two women of 61, 69 and 47 years old respectively, admitted to the Nephrology department of Aristide Le Dantec hospital for rapidly progressive renal failure in one case and a nephrotic syndrome in 2 other cases. The renal biopsy showed a nodular glomerulosclerosis and immunofluorescence microscopy, revealed deposition of IgG light chains suggesting LCDD. On the other hand, the diagnosis of multiple myeloma of IgG kappa type in 2 cases and IgG lambda type in the other one was done. A combination of chemotherapy (Mephalan Prednisone) and hemodialysis was instituted for all 3 cases. The evolution was marked by the appearance of an end stage renal disease in 2 cases and the third one was expired due to an infected bed sore secondary to a pathological fracture of the neck of the femur. Conclusion: Although the LCDD is rare, the prognosis of this syndrome seems to be poor as more than half of the patients die or progress to ESRD within 2 years.

Prevalence and risk factors of chronic kidney disease in an african semi-urban area: Results from a cross-sectional survey in Gueoul, Senegal

Chronic kidney disease (CKD) is a public health priority worldwide; however, its prevalence and incidence are difficult to assess. In Africa, few studies have been conducted on the prevalence of CKD. This study sought to describe the epidemiological characteristics and profile of CKD, as well as the related risk factors in Guéoul, a semi-urban zone in Senegal. An observational, cross-sectional, and descriptive study was conducted in Guéoul city in Senegal from November 1, 2012, to December 10, 2012, according to the WHO STEPS approach. People older than 35 years living in Guéoul city were included in the study. Cardiovascular and renal disease risk factor screening was conducted for this population. Data were analyzed using the 3.5.1 version of Epi Info software. The significance level was a P <0.05. One thousand four hundred and eleven participants with a mean age of 48 ± 12.68 years and a sex ratio of 0.34 were included in the study (359 men/1052 women). The prevalence of renal disease was 36.5%. Sixty-eight people showed proteinuria greater than two cross with urinary dipsticks. Two hundred and six people had a glomerular filtration rate <60 mL/min, and among them, 201 were in stage III, two in stage IV, and three in stage V according to the modification of diet in renal disease formula. Ninety-eight participants had morphological abnormalities. Cardiovascular risk factors found among participants with renal disease were obesity (25.2%), hypertension (55.5%), diabetes (2.3%), and renal and metabolic syndrome (32.43%). Those that statistically significantly correlated with renal disease were obesity (P = 0.0001), hypertension (P = 0.0001), and diabetes (P = 0.021). This study assessed the extent of renal disease in the population of Guéoul city. Being aware of the prevalence of CKD in the general population of Senegal is mandatory for defining appropriate strategies for the management of these risk factors and progression of renal diseases.

Scleroderma renal crisis in tropical region: two senegalese cases

Scleroderma renal crisis (SRC) is defined as the new onset of accelerated arterial hypertension and /or rapidly progressive oliguric renal failure during the course of systemic sclerosis. It is a rare but life-threatening complication. This formerly serious complication has got a considerable brighter outlook since the introduction of angiotensin converting enzyme inhibitors (ACE) however the mortality is still remaining high. We report two cases of SRC which to our knowledge are the firsts described in Dakar. They were two women aged 45 and 32 years, one of them was previously following for systemic sclerosis. Both of them had malignant hypertension associated with rapidly progressive renal failure, the other was put under corticosteroid therapy four months before SRC occurrence. The histological and laboratory finding showed thrombotic microangiopathy. The height blood pressure returned to normal value after treatment with ACE inhibitors. The final outcome was undesirable with the death of one after two months due to the hemodialysis discontinuation and persistence of renal failure in the other.

Hemophagocytic Syndrome, an Uncommon Complication of Microscopic Polyangitis: A Case Report From Senegal

Introduction: We reported a case of hemophagocytic syndrome complicating microscopic polyangitis presented by crescentic glomerulonephritis. Case Presentation: A 22-year-old female patient originated from Dakar, Senegal presented with nephrotic syndrome and rapidly progressive glomerulonephritis. On physical examination, we noticed hyperchromic diffuse punctilious purpura skin lesions predominant on the trunk, the neck and the upper thigh. Immunology investigations revealed strongly positive anti SSA/Ro and anti-SSB. Anti-neutrophil cytoplasmic antibodies had positive results with a peri-nuclear type fluorescence, specific to myeloperoxidase. In optic microscopy, renal biopsy showed a crescentic glomerulonephritis with circumferential cellular and fibrous proliferation affecting 85% of glomeruli. The diagnosis of microscopic polyangitis with renal and skin involvement was retained. The patient received methylprednisolone and cyclophosphamide 700 mg/m2 every 15 days for the first 3 pulses and every 21 days thereafter. After the 5th month, she developed obnubilation, fever and central pancytopenia. Bone marrow aspiration was performed, which showed medullary invasion by macrophages with signs of hemophagocytosis. Diagnosis of hemophagocytic syndrome complicating a microscopic polyangitis was retained and methylprednisolone pulses started. The patient was under hemodialysis after follow-up of about 9 months with stable clinical state. Conclusions: The occurrence of SAM in pauci-autoimmune vasculitis is rarely described, particularly in Africa. Our case is an illustration of the reality of this association.