BACKGROUND: Acute renal failure (ARF) is a clinical syndrome characterised by a rapid deterioration of kidney function over hours to days which may recover/return to normal values following appropriate therapy. Various scoring systems currently exist to predict the severity and outcome in patients with ARF. Recently the Acute Dialysis Quality Initiative (ADQI) Group has established the RIFLE (Risk of injury, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage kidney disease) classification which has become widely used globally. There is however, limited data on its use in Africa. In order to provide data on the use of RIFLE criteria from an African facility, we conducted a retrospective chart review to assess the outcome of ARF in patients admitted in the Intensive Care Unit (ICU) at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). The data reviewed covered the period between January 1st to December 31st 2008. METHODS: This was a retrospective chart review conducted in the adult multi-disciplinary intensive care unit at CMJAH between January 1st to December 31st 2008. Medical records of patients admitted during this period were reviewed and patients with acute renal failure were identified. Demographic data, relevant clinical information such as reason for ICU admission, number of organ(s) involved, presence of co-morbidity, RIFLE criteria on admission and on discharge, modality and duration of treatment of ARF, need for mechanical ventilation and or inotropic support were recorded. For the purpose of this study, serum creatinine based on RIFLE classification was used to define ARF. Statistical analysis was performed using the data collected and STATA version 11. The Primary outcome, which was survival or death, was correlated with the maximum RIFLE classification during patients’ ICU stay. The study was approved by the Human Research Ethics Committee medical (HRECM) of the University of Witwatersrand with Clearance certificate number M090906 RESULTS: One hundred and ninety three (193) patients with acute renal failure were included in the study. The mean APACHE II score was 19 ± 6.4 SD, with the maximum score documented being 38. Patient ages ranged from 21 – 92 years with a mean of 50.5 years ± 18.3SD. Fifty two percent of the patients were male and 48% were female. Majority of patients were black (63%) with 36.8% being other race groups. According to RIFLE criteria on admission, 40.9% had normal renal function, 23.3%, 14.0% and 21.8% were in RIFLE R, I and F classes respectively. The overall mortality in ICU was 59.9%. Of those patients discharged to the ward from ICU, 14.1% subsequently demised. Factors associated with mortality in ICU included race, chronic pulmonary disease, mechanical ventilation, inotropic support, need for ventilation and inotropic support, dialysis and maximum RIFLE criteria reached in ICU. After multivariate analysis using Cox proportion regression model, factors such as race, inotropic support, need for both ventilation and inotropic support and maximum RIFLE criteria were independently associated with mortality in ICU, whereas for patients discharged from ICU to the ward, only cancer was found to be independently associated with mortality. Based on RIFLE criteria, patients in R, I, and F class had 5.41, 3.17 and 5.69 greater risk of dying respectively as compared to patients with normal renal function (Adjusted HR 5.41 95%CI 2.66 - 11.0, p-Value 0.000 for R class, HR 3.17 95%CI 1.65 - 6.07, p-value 0.001for I class, and HR 5.69 95%CI 2.93 - 11.06, p-value 0.001 for F class) CONCLUSION: RIFLE criteria is a useful tool for predicting the outcome of acute renal failure in the intensive care unit.

Outcome of HIV positive patients presenting with renal failure at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) Background The majority of the 33.4 million people infected with HIV worldwide reside in sub-Saharan Africa. The HIV prevalence amongst young South Africans (ages 15- 49) is 16%. HIV is the third leading cause of ESRD in African - Americans aged 20-64 in the United States. There is a paucity of data regarding the prevalence of acute kidney injury (AKI) in HIV patients in sub-Saharan Africa. Methods A retrospective review of 101 HIV positive patients presenting with renal failure at the CMJAH from 1st October 2005 until 31st October 2006 was undertaken. There were 50 HIV positive patients with presumed AKI that were compared to 90 HIV negative patients with AKI. Results A total of 684 patients presented with renal failure, 101(14.8%) of whom were HIV positive. Ninetynine of the HIV positive patients were black and 56 were male. The mean age of HIV positive patients with renal failure was 38 years. Fifty-seven patients presented with AKI (seven patients were excluded due to lack of records), 21 with acute on chronic renal failure and 23 with chronic renal failure. The causes of AKI in the HIV positive group included sepsis (62%), haemodynamic instability (20%), toxins (10%), urological obstruction (8%) and miscellaneous (10%). The common underlying aetiologies of the 90 HIV negative patients studied presenting with AKI were sepsis (43%), haemodynamic instability (17%), toxins (7%), urological obstruction (8%) and miscellaneous (23%). Forty-seven (52%) of these HIV negative patients recovered. Forty-two (47%) patients died, compared with 22 (44%) patients in the HIV positive group. Hyponatraemia, hyperkalaemia, hypochloraemia and acidosis were more common in the HIV positive patients. Dialysis was initiated in 36% of HIV positive patients with AKI. There were more HIV positive patients that recovered with supportive care, including fluid therapy when compared to HIV negative patients. Recovery was noted to be more rapid in the HIV positive group. Using survival and death as the outcome there was no difference between the HIV positive and the HIV negative group presenting with AKI (p<0.7173). Discussion HIV positive patients presented with renal failure at a younger age – a mean age of 38 years in this study. Previous studies have shown mean ages ranging from 35 years to 46.7 years. The majority of the HIV positive patients presenting with renal failure were black (98%). The racial predominance is different to that of other countries which might be due to epidemiological factors. The gender differences were similar when compared to other studies. Sepsis was the more common aetiological factor of AKI (62% of HIV positive patients compared to 43% of HIV negative patients). HIV positive patients with AKI presented at an advanced stage of immunosuppression (more than 50% had CD4<100cells/μl). Electrolyte disturbances were common in HIV positive patients with AKI. Conclusion HIV positive patients with AKI presented with advanced immunosuppression. Sepsis was the most common aetiology of AKI. Supportive management or renal replacement therapy resulted in recovery in a large number of patients.HIV positive patients should be treated acutely just as HIV negative patients and should not be excluded on the basis of their HIV status. Dialysis should be offered when indicated and aggressive fluid resuscitation should be emphasized. Outcomes were similar in HIV positive and HIV negative patients presenting with AKI.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Internal Medicine.Johannesburg, 2013 / Chronic Kidney disease (CKD) is emerging as a global threat to health. In sub-Saharan Africa, most patients do not receive renal replacement therapy due to lack of funds. Measures to retard the progression of CKD are important. METHOD: A retrospective review of 122 patients attending a renal clinic, over a two a year period was performed. Patients with CKD from hypertension, diabetes mellitus, tubulo-interstitial disease were inluded. Patients with CKD due to viruses, malignancies and autoimmune RESULTS: Diabetes mellitus and hypertensiion were the leading causes of CKD. BP control improved, though 765 were on ≥3 anti-hypertensives. Serum creatinine doubled in 8.2% of patients. BP, acidosis and anaemia were independent risk factors for progression of CKD. The two year renal survival rate was 82%. CONCLUSION: Renal function progressed in few patients, which would be related to low levels of proteinuria, good BP control and us of RAS blockers

The present studies investigated the relationship between altered renal carbohydrate intermediary metabolism and kidney functional and structural changes in the adult Spraque-Dawley rat. Both the acute (upto 28 days) and chronic (60-120 days) diabetic states were invstigated. The single intraperitoneal injection of streptozotocin at a dose of 45mg/kg body weight produced a stable, non-ketotic, non-insulin dependent and reproducible diabetic state. Compared to age matched control animals (AMC), diabetic animals (DA) demonstrated a progressive increase in mean UFR, plasma glucose, creatinine, glycosuria values and urea clearance rate over the experimental course while creatinine clearance (CCR) fell from day 21 onwards reaching 50% of AMC values by day 120. Changes in renal and hepatic metabolite concentrations were apparent after 4 days of diabetes and two patterns emerged. Renal and hepatic glucose, glocuse-1-phosphate and β-hydroxybutyric acid concentrations progressively increased over the 120 days experimental period while reduced concentrations of glycolytic and other metabolic intermediates, namely, glucose-60-phosphate, fructose-6-phosphate, fructose-1,6-bisphosphate, glyceraldehyde-3-phosphate, dihydroxyacetone 3- phosphate and malonyl-CoA concentrations were present. Increased concentrations of BHBA in both the liver and kidney was accompanied by the progressive reduction of malonyl-CoA. Since gluconeognesis is favoured at the expense of glycolysis in these diabetic animals, the absence of phosphofructokinase activity may be explained by a decreased concentration of fructose-6-phosphate. Renal gluconeogenic enzymes such as fructose-1,6-phosphatase were mainly located in the kidney cortex, predominantly located in the proximal tubular epithelium and that glycolytic enzymes such as hexokinase occurred mainly in the kidney medulla, restricted essentially in distal segments. Histological examination demonstrated an increasing degree of renal clear cell changes affecting from 5-20% of cells noted from day 10 to day 120, respectively in the cortical renal tubules. In addition acute pyelonephritis was also observed in all diabetic animals on days 90 and 120.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 6 uppsatser.

Diss. (sammanfattning) Stockholm : Katrol. inst. / Härtill 6 uppsatser.

Thesis (doctoral)--University of Uppsala, 1981. / Includes bibliographical references (p. 15-17).

1. Little work has been done on the response of regular haemodialysis patients to dynamic exercise. A systematic study of exercise capacity and the underlying mechanisms is of particular importance because these patients are encouraged to return to as normal a way of life as possible. Accordingly, a select group of healthy young male patients and a group of older males have been studied during submaximal cycling. The young male patients were compared to a closely matched sedentary control group. The 17 subjects discussed represent the fittest of 40 patients tested. 2. In both groups there was decreased work capacity associated with disproportionate tachycardia, which was not obvious at rest. Blood pressure was measured with a sphygmomanometer. During exercise there was a striking rise in the systolic blood pressure in about half the patients from currently acceptable resting levels. This occurred in the absence of any clinical circulatory overload. Mild hyperventilation and disproportionate lactic acidosis was seen towards peak exercise, probably because, in spite of the decreased work capacity, the patients were much closer to their maximum performance. However, the limiting factors were clearly circulatory and not respiratory. 3. A number of the younger male patients were more intensively studied to determine why some remained relatively 'normotensive' during exercise while others developed systolic hypertension. Total blood volume, total body water and plasma renin activity were measured at rest. It was found that the 'normotensive' patients had normal body volumes and normal to high plasma renin activity, while the hypertensive subgroup had increased volumes and normal to low plasma renin activity. Thus, in these patients the blood pressure responses to exercise were largely volume dependent, albeit at a subclinical level. 4. Cardiac output was measured at rest and during exercise. All patients developed a variable hyperkinetic circulation during exercise which was not apparent at rest. The patients were all anaemic and (xi) their cardiac output response was very like that described in patients with anaemia unassociated with renal disease. However, some patients with striking anaemia developed a less hyperkinetic circulation than others who were not so anaemic. When the body volume and the blood pressure response on exercise were considered, those patients who were normovolaemic and 'normotensive' developed a hyperkinetic circulation on exercise appropriate to their degree of anaemia. Those with subclinical volume overload and a hypertensive response to exercise developed a much less striking hyperkinetic circulation, suggesting that the blood pressure and volume excess was depressing the anticipated cardiac output response to their underlying anaemia. 5. One patient with an arteriovenous shunt was studied twice, initially when hypervolaemic with a haemoglobin of 9,1gm/100 ml and again after ultrafiltration when he was normovolaemic but his haemoglobin had risen to 12,5 gm/100 ml. On the first occasion his cardiac output response was moderately hyperkinetic but he developed increasing hypertension with a high calculated total peripheral resistance. On the second occasion his cardiac output response fell within the normal range, his blood pressure was lower but not normal and his calculated total peripheral resistance was even higher than before. Thus, the blood pressure of these volume dependent patients is due to a high total peripheral resistance, but may not simply be on the basis of 'waterlogging' of the peripheral vasculature. Some other factor, such as structural thickening, must be considered. 6. It is suggested that the combination of tachycardia and hypertension which develop on mild exertion and which may not be obvious at rest, is the most potent cause of the increased cardiovascular mortality seen in dialysis patients. Simple exercise testing will reveal those with subclinical volume overload who are most at risk. It was striking that in the two groups tested those who developed striking hypertension on exercise were usually older, between 35 and 50 years. This accelerated aging of their vascular tree would correspond with recent data showing that dialysis mortality increases with age, and is about a decade earlier than in the general population. It is suggested that a more aggressive policy be adopted towards blood pressure fluctuations and that the resting blood pressure should be kept below 140/90 mm Hg at all times, if necessary by complementing ultrafiltration with drug therapy and/or bilateral nephrectomy at an early stage. 7. Thus simple exercise testing with blood pressure recordings not only serves as a yardstick of physical rehabilitation and long-term follow-up, but may also reveal or magnify abnormalities not obvious at rest.

No description available.

Chronic renal failure patients develop a coagulopathy primarily due to reversible platelet dysfunction. This coagulopathy makes certain anaesthetic techniques and procedures such as neuraxial anaesthesia and invasive line placement possibly contra-indicated or risky. There is no evidence to suggest that the degree of platelet dysfunction is proportional to the degree of renal dysfunction. In this research project the platelet function of 39 end stage renal failure patients, who received regular dialysis and who presented to theatre for vascular access, was assessed using the thromboelastogram. A bleeding time was also performed pre-operatively. A linear regression model was used to determine if the bleeding time, plasma urea, plasma creatinine or creatinine clearance could predict maximum amplitude (and therefore clot strength) on the thromboelastogram. No such regression could be found. The clinical implication of this result is that there exists no "safe" plasma urea or creatinine, below which it is safe to perform procedures which are contra-indicated in coagulopathies. The degree of renal dysfunction did not predict the degree of platelet dysfunction. Since dialysis reverses the platelet dysfunction, the question that should be asked before performing such a procedure is not "how severe is the renal dysfunction?" but rather "has the patient been receiving regular dialysis?"