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Doctoral Degrees (Clinical Medicine)

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Browsing Doctoral Degrees (Clinical Medicine) by Author "Assounga, Alain Guy Honore."

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    The effect of HIV infection on the management of end-stage renal failure among patients undergoing continuous ambulatory peritoneal dialysis.
    (2017) Ndlovu, Kwazi Celani Zwakele.; Assounga, Alain Guy Honore.
    Continuous ambulatory peritoneal dialysis (CAPD) is cost effective, easy to learn, and requires no complex equipment, thus, is well-suited as a home dialysis modality in areas with distant or limited dialysis facilities. We aimed to evaluate the effects of HIV infection on CAPD outcomes in dialysis-requiring end-stage renal disease (ESRD) patients. The first report (Chapter 2) evaluated the effects of HIV-infection on primary end points of mortality and catheter failure, and primary morbidity outcomes of first peritonitis and hospital admissions at one year. HIV infection was not shown to adversely influence catheter failure rates or patency; however, uncontrolled HIV infection was associated with increased relative risk of mortality, first peritonitis, and hospital admissions. The second report (Chapter 3) evaluated the effects of HIV infection on all peritonitis episodes, including relapses and subsequent episodes at 18 months. HIV infection was associated with increased risk for overall peritonitis and peritonitis relapse. Although peritonitis was also associated with adverse catheter failure outcomes, HIV infection was not shown to result in significantly increased catheter failure rates at 18 months. The third report (Chapter 4) evaluated the effects of HIV infection on nasal carriage of Staphylococcus aureus, staphylococcal peritonitis, and catheter infection rates. HIV infection was shown to be a risk factor for methicillin-resistant S. aureus nasal colonisation, and that it can increase the risks of coagulase-negative staphylococcal peritonitis and S. aureus catheter infections in association with S. aureus nasal carriage. The fourth report (Chapter 5) evaluated shedding of HIV-1 particles into CAPD effluents. HIV particles were shown to be shed in detectable amounts into CAPD effluents even in patients with suppressed plasma viral load, raising concerns of a localised sanctuary site and potential infectivity of HIV-positive CAPD patients on a full complement of antiretroviral therapy. The thesis contributes to our understanding of the morbidity and mortality associated with uncontrolled HIV infection in ESRD patients on CAPD, the shedding of HIV-1 particles into CAPD effluents, and the resistance profiles of S. aureus colonisers and the organism patterns that are likely to cause infection, which may assist in guiding appropriate antibiotic therapy and prophylaxis.
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    Epidemiology of chronic kidney disease in KwaZulu-Natal: evaluation of risk factors, complications and diagnostic methods.
    (2017) Madala, Nomandla Daphne.; Assounga, Alain Guy Honore.
    Chronic kidney disease (CKD) is associated with increased morbidity and mortality as well as costly renal replacement therapy. The aim was to determine risk factors and complications that contribute to morbidity as well as a suitable diagnostic detection method for CKD. Methods Observational studies were done at 2 hospitals. To assess risk factors, 283 patients were included at the Durban site, and sub-studies undertaken within this sample for CKD complications, while 302 patients were studied at the Empangeni outreach site. To evaluate predictive performance of estimated glomerular filtration rate (eGFR), data from 148 patients were analysed. A further 76 patients were recruited, to develop an African equation. Cockcroft Gault, Modified Diet in Renal Disease and CKD Epidemiology Collaboration eGFR equations were compared with technicium-99-mdiethylenetriaminepentaacetic acid (99mTc-DTPA)-GFR as the gold standard. Body composition was assessed by anthropometry and dual energy X-ray absorptiometry. Data were analysed with STATA. Results The commonest CKD risk factors were hypertension (75%), diabetes (29%) and human immunodeficiency virus (HIV) infection (24%), with HIV commoner at the outreach site (28.5% vs 19.8%). Over 80% of females and ∼60% males were overweight/obese overall; however, clinical cardiovascular disease was commoner in Durban (28% vs 5%). Complications were observed in early CKD; prevalence increased as eGFR declined from ≥90 ml/min/1.73m2 to <30 ml/min/1.73m2: hyperuricaemia increased from 17% to 74%, metabolic acidosis (11.6% to 72.7%), anaemia (2.9% to 69.7%), hyperphosphataemia (10.1% to 48.5%), all p<0.001, respectively, and hypocalcaemia from 1.5% to 18.2% (p=0.003). Lower GFR levels were also associated with lower serum albumin levels, and lower whole body as well as regional lean mass and fat mass in males. A further observation at GFR <30 ml/min/1.73m2 was that eGFR underestimated 99mTc-DTPA-GFR in African patients. Prediction of 99mTc DTPA-GFR was also poor at GFR levels ≥60 ml/min/1.73m2, with eGFR overestimating 99mTc-DTPA-GFR. An eGFR equation developed in African patients resulted in significantly better GFR prediction and showed the lowest bias, highest precision as well as accuracy. Conclusion Efforts are needed to enable non-nephrologists to manage CKD risk factors and complications. Prediction of GFR may be substantially improved by using an equation developed in Africans.