Catheter‐Related Mortality among ESRD Patients

Hemodialysis access‐related complications remain one of the most important sources of morbidity and cost among persons with end‐stage renal disease, with total annual costs exceeding $1 billion annually. In this context, the creation and maintenance of an effective hemodialysis vascular access is essential for safe and adequate hemodialysis therapy. Multiple reports have documented the type of vascular access used for dialysis and associated risk of infection and mortality. Undoubtedly, the central venous catheter (CVC) is associated with the greatest risk of infection‐related and all‐cause mortality compared with the autogenous arteriovenous fistula (AVF) or synthetic graft (AVG). The AVF has the lowest risk of infection, longer patency rates, greater quality of life, and lower all‐cause mortality compared with the AVG or CVC. It is for these reasons that the National Kidney Foundation’s Kidney Disease Outcome Quality Initiative Clinical Practice Guidelines for Vascular Access recommend the early placement and use of the AVF among at least 50% of incident hemodialysis patients. This report presents catheter‐related mortality and calls for heightened awareness of catheter‐related complications.     

Risk factors for incident stroke among patients with end-stage renal disease

Although patients with ESRD experience markedly higher rates of stroke, no studies in the US have identified risk factors associated with stroke in this population. It was hypothesized that black race, malnutrition, and elevated BP would be associated with the risk of stroke among patients with ESRD. Data from the United States Renal Data Systems were used. Adult Medicare-insured hemodialysis and peritoneal dialysis patients without a history of stroke or transient ischemic attack (TIA) were considered for analysis. The primary outcome was hospitalized or fatal stroke. Cox proportional hazards models were used to determine the associations between the primary predictor variables and stroke. The rate of incident stroke was 33/1,000 person-years in the study sample. After adjustment for age and other patient characteristics, three markers of malnutrition were associated with the risk of stroke-serum albumin (per 1 g/dl decrease, hazard ratio [HR] = 1.43), height-adjusted body weight (per 25% decrease, HR = 1.09), and a subjective assessment of undernourishment (HR = 1.27)-as was higher mean BP (per 10 mmHg, HR = 1.11). The association between black race varied by cardiac disease status, with blacks estimated to be at lower risk than whites among individuals with cardiac disease (HR = 0.74), but at higher risk among individuals without cardiac disease (HR = 1.24). This study confirms the extraordinarily high rates of stroke in ESRD patients on dialysis and identifies high mean BP and malnutrition as potentially modifiable risk factors. The association between black race and stroke differs by cardiac disease status; the reasons for this differing effect of race deserve further investigation.     

Comparison of urinary amino acids and trace elements (copper, zinc and manganese) of recent neurolathyrism patients and healthy controls from Ethiopia

OBJECTIVE: The irreversibly crippling disease neurolathyrism is caused by prolonged over-consumption of Lathyrus sativus seed. The molecular mechanism of toxicity is unclear and more biochemical information is needed. METHODS: The urinary amino acids from 5 recent patients and 9 healthy subjects in Ethiopia were analysed by HPLC after PITC (phenyl isothiocyanate) derivatisation. The trace elements Cu, Zn and Mn of urine and seeds were determined by atomic absorption spectroscopy. RESULTS: The free amino acids aspartic acid, glycine, beta-aminoisobutyric acid, arginine, alpha-aminoadipic acid and phenylalanine were statistically higher (p<0.05) in urine from patients than in urine from control subjects. The trace element Cu was also statistically higher (p<0.05) in patient urine. CONCLUSION: The amino acid metabolism of the neurolathyrism patients is disturbed by over-consumption of grass pea seeds. The high concentrations of Cu found in the patient urine might indicate the involvement of trace elements in the aetiology of neurolathyrism.     

Pneumocystis jiroveci pneumonia and other pulmonary infections in TB smear-negative HIV-positive patients with atypical chest X-ray in Ethiopia

Pneumocystis pneumonia (PCP) has been considered a rare disease in sub-Saharan Africa. However, a rising prevalence has been noted recently. The objective of this study was to determine the relative prevalence of PCP and other pulmonary opportunistic diseases in patients infected with HIV in Ethiopia. 131 consecutive patients with respiratory symptoms and atypical chest X-ray, who were sputum smear-negative for AFB and seroreactive for HIV, underwent clinical evaluation and investigation for Pneumocystis jiroveci and Mycobacterium tuberculosis from sputum and bronchoalveolar lavage (BAL), and fungal and bacterial pathogens from BAL alone. Bacterial infections, Pneumocystis pneumonia (PCP) and pulmonary tuberculosis (PTB) occurred in 44 (33.6%), 39 (29.7%) and 31 (23.7%) patients, respectively. Pulmonary Kaposi sarcoma and non-specific interstitial pneumonitis occurred in 4 patients each. In a multivariate regression model, predictors of PCP were typical chest X-ray and low CD4 count while purulent sputum predicted bacterial infection. The sensitivity of physicians and chest X-ray diagnosis was particularly low for PTB and bacterial infections. We conclude that chronic bacterial infection and Pneumocystis pneumonia are important differential diagnoses in HIV-infected, smear-negative PTB patients presenting with atypical chest X-ray. We therefore need to escalate the use of preventive and highly active antiretroviral (HAART) treatment in order to prevent a PCP epidemic.     

Low HTLV-1 seroprevalence in endemic tropical spastic paraparesis in Ethiopia

Tropical spastic paraparesis (TSP), a chronic progressive myelopathy, occurs in Ethiopia in epidemic form as neurolathyrism, while the endemic form has remained obscure. We describe the clinical features of 22 patients with TSP and the results of screening for HTLV-1 in these patients, 26 patients with other neurological disorders, 14 patients with leukaemia and 66 blood donors. The major manifestations in the patients with TSP were weakness and spasticity of the lower limbs with upper motor neurone signs and minimal sensory loss and bladder dysfunction. Two patients with TSP (9%), 2 patients with other neurological disorders (7.7%) and one patient with leukaemia and deafness were seropositive for HTLV-1. All the 66 blood donors were seronegative. Our results suggest that HTLV-1 may not play a major role in the pathogenesis of TSP in Ethiopia.