Blog entry by Meguid El Nahas
Africa and Nephrology: The Forgotten Continent
(I.J. Katz, T. Gerntholtz, S. Naicker, South Africa; Nephron Clin Pract 2011;117:c320-c327 ) The authors highlight the plight of healthcare and nephrology in Africa. Africa is in the grip of a double-hit by communicable (HIV/AIDS, Malaria and Tuberculosis) and non-communicable diseases impacting on healthcare and its provisions. Whilst infectious diseases remain uncontrolled, the rising tide of non-communicable diseases, such as obesity/diabetes and hypertension, is likely to increase the burden of CKD and the associated CVD. Whilst CKD in the West may predominantly mirror the underlying severity of CVD affecting an aging population, CKD in emerging economies is likely to result from a triple hit of poverty, infections and globalisation/westernisation.
The Opposite View is presented in Hemodialysis of Patients with HCV Infection: Isolation Has a Definite Role
(S.K. Agarwal, India; Nephron Clin Pract 2011;117:c328-c332 ) The author argues that whilst the Center for Disease Control (USA) has suggested that 'patients who are anti-HCV positive (or HCV-RNA positive) do not have to be isolated from other patients or dialyzed separately on dedicated machines'. This assumes that universal precautions (UP) are strictly adhered to. UP implementation involves additional costs, knowledge about UP and commitment to adhere to them. Dr. Agarwal argues that all three factors may be with variable degree responsible for not having strict UP in place in many dialysis units in developing countries. Comments are welcomed by those who share his Opposite View.
The Best Way to Detect Elevated Albuminuria
(Abbas Deeb and colleagues, France; Nephron Clin Pract 2011;117:c333-c340) Deeb and colleagues argue for the value of correcting urinary albumin excretion rate for creatininuria. Whilst this has become established practice over the last decade, attention has recently shifted to the potential of a confounding effect of the fall in urinary creatinine excretion in wasted, malnourished or ill individuals. Interestingly, a fall in urinary creatinine excretion has similar poor prognostic values in terms of morbidity and mortality than a raised ACR! So caution is called for in the interpretation of raised ACR in the general population as it could result from either an elevation of urinary albumin excretion, but also from a fall in urinary creatinine excretion; both have poor prognostic implications.
Single Estimated Glomerular Filtration Rate and Albuminuria Measurement Substantially Overestimates Prevalence of Chronic Kidney Disease
(M.J. Bottomley and colleagues, UK and Belarus; Nephron Clin Pract 2011;117:c348-c352) The authors draw attention to a point all too often neglected, i.e. the importance of multiple confirmatory testing before CKD can be diagnosed in the community. Most so-called CKD detection programs test once and assume that those found positive suffer from CKD. In the study by Bottomley et al., repeated sampling/testing revealed that 21% of those tested changed CKD stage. Proteinuria was reproducible in only 48% at 3 months. This had a major impact on estimated CKD prevalence; a point prevalence of 8.2% halved with repeat testing. This study emphasises the importance of confirming abnormal eGFR and proteinuria on at least one further sample 3 months apart before categorising the individual as having CKD. This has wide implications for screening in general populations in the West as well as in emerging countries. This may give more accurate estimates of CKD prevalence and deflate the so-called "CKD epidemic".