Wasiu A. Olowu

Outcomes of acute kidney injury in children and adults in sub-Saharan Africa: a systematic review

BACKGROUND Access to diagnosis and dialysis for acute kidney injury can be life-saving, but can be prohibitively expensive in low-income settings. The burden of acute kidney injury in sub-Saharan Africa is presumably high but remains unknown. We did a systematic review to assess outcomes of acute kidney injury in sub-Saharan Africa and identify barriers to care. METHODS We searched PubMed, African Journals Online, WHO Global Health Library, and Web of Science for articles published between Jan 1, 1990, and Nov 30, 2014. We scored studies, and all were of medium-to-low quality. We made a pragmatic decision to include all studies to best reflect reality, and did a descriptive analysis of extracted data. This study is registered with PROSPERO, number CRD42015015690. FINDINGS We identified 3881 records, of which 41 met inclusion criteria, including 1403 adult patients and 1937 paediatric patients. Acute kidney injury in sub-Saharan Africa is severe, with 1042 (66%) of 1572 children and 178 (70%) 253 of adults needing dialysis in studies reporting dialysis need. Only 666 (64%) of 1042 children (across 11 studies) and 58 (33%) of 178 adults (across four studies) received dialysis when needed. Overall mortality was 34% in children and 32% in adults, but rose to 73% in children and 86% in adults when dialysis was needed but not received. Major barriers to access to care were out-of-pocket costs, erratic hospital resources, late presentation, and female sex. INTERPRETATION Patients in these studies are those with resources to access care. In view of overall study quality, data interpretation should be cautious, but high mortality and poor access to dialysis are concerning. The global scarcity of resources among patients and health centres highlights the need for a health-system-wide approach to prevention and management of acute kidney injury in sub-Saharan Africa. FUNDING None.

Quartan malaria-associated childhood nephrotic syndrome: now a rare clinical entity in malaria endemic Nigeria

BACKGROUND The study determined (i) whether or not quartan malaria nephropathy (QMN) is still a major cause of childhood nephrotic syndrome (CNS) in Nigeria, (ii) secondary causes other than QMN and their associated glomerular pathology and (iii) renal and patient outcome. METHODS The study was a prospective non-randomized study of consecutive cases of secondary CNS. Patients with idiopathic CNS were excluded. RESULTS Twenty-four of 78 (30.8%) CNS cases were of secondary aetiology. Overall mean ages at onset of secondary CNS aetiology and CNS onset were 8.97 +/- 3.59 (1-15.3) and 9.95 +/- 3.15 (5-15.3) years, respectively. Male (14)/female (10) ratio was 1.4. Secondary causes comprised systemic lupus erythematosus (SLE, 37.5%), sickle cell anaemia (SCA, 16.7%), hepatitis B virus (HBV, 16.7%) infection, Churg-Strauss syndrome (12.6%), SLE/human immunodeficiency virus infection (4.2%), rhabdomyosarcoma (4.2%), bee stings (4.2%) and Addisons disease (4.2%). The overall cumulative complete remission (CR) rate was 88.0%. Remission was sustained in 11 of 16 (68.8%) CR patients, while one patient (6.25%) relapsed; the remaining four patients (24.95%) were yet to attain sustained remission. Median relapse-free period was 10.5 (0.75-25) months. Cumulative renal survival was 75.2% at 3 years. Three patients were lost to follow-up, while two died. Overall cumulative patient survival probability at 36 months was 90.8%. All patients were followed for a median period of 12.5 (0.11-36.0) months. CONCLUSION Overall outcome of CNS has improved significantly compared to the 1960s and 1970s when the poor outcome of QMN was the predominant glomerular lesion in Nigeria. While quartan malaria-associated nephrotic syndrome has become a rare clinical entity, SLE, SCA and HBV infection have become the major secondary aetiologies of CNS in Nigeria.

Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review

BACKGROUND The burden of end-stage kidney disease (ESKD) in sub-Saharan Africa is unknown but is probably high. Access to dialysis for ESKD is limited by insufficient infrastructure and catastrophic out-of-pocket costs. Most patients remain undiagnosed, untreated, and die. We did a systematic literature review to assess outcomes of patients who reach dialysis and the quality of dialysis received. METHODS We searched PubMed, African Journals Online, WHO Global Health Library, and Web of Science for articles in English or French from sub-Saharan Africa reporting dialysis outcomes in patients with ESKD published between Jan 1, 1990, and Dec 22, 2015. No studies were excluded to best represent the current situation in sub-Saharan Africa. Outcomes of interest included access to dialysis, mortality, duration of dialysis, and markers of dialysis quality in patients with ESKD. Data were analysed descriptively and reported using narrative synthesis. FINDINGS Studies were all of medium to low quality. We identified 4339 studies, 68 of which met inclusion criteria, comprising 24 456 adults and 809 children. In the pooled analysis, 390 (96%) of 406 adults and 133 (95%) of 140 children who could not access dialysis died or were presumed to have died. Among those dialysed, 2747 (88%) of 3122 adults in incident ESKD cohorts, 496 (16%) of 3197 adults in prevalent ESKD cohorts, and 107 (36%) of 294 children with ESKD died or were presumed to have died. 2508 (84%) of 2990 adults in incident ESKD cohorts discontinued dialysis compared with 64 (5%) of 1364 adults in prevalent ESKD cohorts. 41 (1%) of 4483 adults in incident ESKD cohorts, 2280 (19%) of 12 125 adults in prevalent ESKD cohorts, and 71 (19%) of 381 children with ESKD received transplants. 16 studies reported on management of anaemia, 17 on dialysis frequency, eight on dialysis accuracy, and 22 on vascular access for dialysis INTERPRETATION: Most patients with ESKD starting dialysis in sub-Saharan Africa discontinue treatment and die. Further work is needed to develop equitable and sustainable strategies to manage individuals with ESKD in sub-Saharan Africa. FUNDING None.

AUTOPSY DIAGNOSIS OF ENDEMIC BURKITT LYMPHOMA AS THE PRIMARY ETIOLOGY OF ACUTE RENAL FAILURE IN CHILDREN

Two cases of Burkitt lymphoma are reported who presented atypically with acute renal failure and significant proteinuria as initial features of the lymphoma. The cases underscore the need for high index of suspicion for Burkitt lymphoma in any child with rapidly enlarging kidneys and acute renal failure of obscured origin in parts of the world where Burkitt lymphoma is endemic.

Acute renal failure in African children with Burkitt's lymphoma: A comparison of two treatment regimens

The outcome for patients presenting with acute renal failure and Burkitt lymphoma (BLARF) without dialysis is poor. This was a retrospective non‐randomized comparative study designed to determine the outcome of two different treatment protocols.

Hypertension, erythrocyturia and proteinuria in childhood non-Hodgkin's lymphoma.

Aim:  The objectives were to determine the prevalence and outcome of hypertension, significant microerythrocyturia and proteinuria among children with acute renal failure (ARF) due to Burkitt‐type non‐Hodgkin’s lymphoma (BNHL).

Clinicopathology of childhood-onset renal systemic lupus erythematosus

Aims:  To determine the clinicolaboratory renal manifestations; glomerular, extra‐glomerular histopathologic lesions; renal tubular dysfunction (RTD) frequency and outcome of a short‐term renal follow up in Nigerian children with systemic lupus erythematosus (SLE).

Nephropathy, polyneuropathy, and gastroenteritis in a child with Churg-Strauss syndrome.

Churg–Strauss syndrome (CSS) is a serious but rare pauci-immune vasculitis of small- and medium-sized blood vessels. It is commonly seen in association with bronchial asthma and/or allergic disorders. The syndrome is characterized by the presence of asthma, hypereosinophilia, and vasculitis in any part of the body. Vasculitis is often associated with significant distortion of normal functions. A rather severe case of CSS in an 8-year-old Nigerian girl with asthma and allergic rhinoconjunctivitis is reported. She presented with multiple morbidities, namely, vasculitic polyneuropathy and also nephritic–nephrotic syndrome that eventuated in acute renal failure after an onset of vasculitic gastroenteritis. Routine screening of all asthmatic patients for CSS is advocated.

Burden of Hypertension and Abnormal Glomerular Permeability in Hypertensive School Children

Background Childhood hypertension has been associated with target-organ damage in young adults. It is often asymptomatic in both children and adolescents; when persistent, and long-standing, it could be a significant risk factor for kidney damage and increased glomerular permeability. Objectives Burden of hypertension and its impact on glomerular permeability were prospectively determined in randomly recruited primary school children. Patients and Methods Blood pressure (BP) measurement was performed by the auscultation method, and abnormal glomerular permeability was assessed by dipstick testing of urine for persistent proteinuria and/or hematuria for ≥ three months in hypertensive children. Results Of 1,335 pupils aged 10.0 ± 2.4 (6.0 - 14.0) years, 33 (2.5%) were hypertensive. Overall mean systolic/diastolic BP was 125.6 ± 6.5/81.7 ± 3.3 (range: 114.0 - 140.0/80.0 - 90.0) mmHg. Nine (27.3%) had combined systolic and diastolic hypertension, 126.7 ± 5.7/80.0 - 80.0 ± 0.0 (120.0 - 130.0/80.0 - 80.0) mmHg. Isolated systolic hypertension, 125.4 ± 6.7 (114.0 - 140.0) mmHg, was present in 14 (42.4%), whereas 10 (30.3%) had isolated diastolic hypertension, 82.0 ± 3.5 (80.0 - 90.0) mmHg. Mean systolic and diastolic BP were 131.0 ± 3.3 (130.0 - 140.0) mmHg and 86.5 ± 4.43 (80.0 - 90.0) mmHg, respectively. According to the dipstick test, none of the hypertensive pupils showed urinalysis evidence of proteinuria and/or hematuria after three months of testing. Conclusions Although the burden of hypertension was 2.5%, the dipstick method did not detect any hypertension-related abnormal glomerular permeability in the school children.

Stage 2 hypertension in a child with a rapidly enlarging kidney: answer

1. Burkitt’s lymphoma (BL) is the most likely aetiology, especially in an endemic region. BL is a nonmetastatic, highly proliferative, multicentric tumour. It is the fastest growing tumour in humans, with a doubling rate of 24 h [2]. 2. These will include nephroblastoma, acute unilateral obstructive uropathy and renal vein thrombosis. 3. Confirmation is either by fine-needle aspirate of the tumour for cytology or renal biopsy for histopathology. Both procedures confirmed BL on admission day 4 (Fig. 1a). There was also glomerular evidence of proliferative glomerulonephritis with Bowman’s capsule ruptures and tuft adhesions (Fig. 1b). Renal biopsy findings at 4 weeks are shown in Fig. 1c. 4. It is possible that the extensive renal infiltration by Burkitt’s tumour with glomerulotubular compression and destruction (Figs. 1a–c), glomerulonephritis and enhanced renin-angiotensin-aldosterone-system (RAAS) activity played dominant roles in the causation of hypertension (HTN) in this patient. The proteinuria could have been due to the combination of glomerulonephritis and systemic and intraglomerular HTN brought about by increased RAAS activity. HTN may cause high glomerular filtration pressure in both kidneys with resultant proteinuria. Hypernatraemia, hypokalaemia, avid tubular sodium reabsorption and kaliuresis suggest enhanced RAAS activity in the patient. 5. BL is highly responsive to cytotoxic drugs. Tumour remission was induced with low-dose cyclophosphamide infusion, 125 mg/m/48 h for four doses [3]. He also received antitumour lysis syndrome regimen, including allopurinol [3]. Significant reduction in the renal mass occurred within 72 h of cyclophosphamide infusion. Tumour remission was subsequently maintained with cycles of combination chemotherapy that comprised cyclophosphamide 1,000 mg/m/dose, methotrexate 75 mg/m/dose and vincristine 1.5 mg/m/dose as stat intravenous doses. Intrathecal (IT) methotrexate 12.5 mg/m on chemotherapy days 1 and 8, and IT cytosine arabinoside 50 mg/m on day 4 were also given. The cycle was repeated fortnightly after ensuring normal blood counts. Overall, he received only three of six prescribed cycles because he was immediately lost to follow-up after hospital discharge. His hypertension was appropriately treated with parenteral hydralazine, frusemide, oral spironolactone and lacidipine. BP normalised (100/60 mmHg) by day 10 of induction chemotherapy. The antihypertensives were subsequently discontinued without adverse events. 6. Given the severity of the glomerular lesion that included Bowman’s capsule ruptures with interstitial communications (Fig. 1b) and tuft synechiae as shown in the histopathology of the second renal biopsy (Fig. 1c), progression to chronic renal failure is a potential complication. Pediatr Nephrol (2008) 23:729–731 DOI 10.1007/s00467-007-0646-4