Abstract Background and Aims Community acquired Acute kidney injury (AKI) and leads to poor outcomes in low and middle-income countries due to delayed diagnosis however its epidemiology is poorly studied due to lack of biochemical diagnosis. Supported by the International Society of Nephrology, we evaluated the accuracy of point of care creatinine (POC Cr) technology using capillary samples [1] and its use implementing a clinical algorithm to select patients at risk of AKI for POC Cr testing in the Hospital Emergency Department in Port Harcourt in Nigeria. In this phase of the project POC Cr was used in a large primary care health centre for early detection and management of community acquired AKI. Method The study is conducted in Ozuoba Model Comprehensive Primary Health Care Centre. The centre has 4148 patient attendances per month (20.3% medical, 18.8% obstetrics and 60.8% paediatrics) with 11.1% considered acute requiring short admission at the centre usually for intravenous fluids. Historically, decision making is based largely on clinical judgement and renal function tests when requested from external laboratories are reported in > 48 hours. During this project POC Cr was offered on high-risk patients based on the clinical algorithm from the previous stage (Fig. 1) and patients with detected AKI were offered short admission for intravenous fluids and antibiotics. Results To date 54 patients have been screened with POC Cr. Median age is 25.5 years, minimum 2 months, maximum 85 years, interquartile range (48-10), 62% are females, 57% presented with malaria diagnosis and 9% with gastroenteritis. Mean (standard deviation) of POC Cr was 105 (54) µmol/L. There were 5 cases (9%) of AKI (Cr >150 µmol) detected in patients aged 5 months, 13 months, 7 years, 19 years and 31 years. All were treated with short admission and intravenous fluids and were discharged after clinical improvement. Knowledge of the presence of AKI altered management in all patients prompting short admission. Conclusion Community acquired AKI is common in young patients with malaria and early biochemical diagnosis can improve outcomes. The study continues to recruit and aims to investigate the characteristics of community acquired AKI in Africa and to contribute to the design of optimal and sustainable pathway for early detection and management of AKI.

The prevalence of chronic kidney disease (CKD) in Nigeria is estimated at 13.9% per total Nigerian population and the vast majority with end stage CKD die because of lack of renal replacement therapy (RRT). Very few patients are able to afford occasional sessions with haemodialysis costing an average monthly salary per session. In addition, RRT is rarely provided as life-saving treatment to individuals with severe acute kidney injury because of extremely high cost and occasional compromised infrastructure due to high maintenance costs and reliance on electricity.

Early detection and management of community acquired Acute Kidney Injury (AKI) can reduce associated morbidity and mortality particularly in low and low middle-income countries where infrastructure for laboratory tests is limited and renal replacement therapy is largely unavailable. We have established a collaborative project between the Renal Unit of the University of Port Harcourt Teaching Hospital and the Renal Department of Salford Royal NHS Foundation Trust, supported by the International Society of Nephrology aiming at investigating the use of point of care (POC) Creatinine (Cr) for early identification and management of community acquired AKI.

The ISN Sisters Renal Centre collaboration between University of Port Harcourt Teaching Hospital, Nigeria and Salford Royal NHS FT aims to establish PD in Port Harcourt CKD is a significant health issue in Nigeria. Treatment of ESRD is beyond the financial means of most people, exacerbating health inequalities. Intermittent HD with temporary central vascular access is the norm. Problems are exacerbated by technical issues with dialysis machines and water treatment PD offers more affordable life sustaining treatment, less dependence on technical infrastructure and multiple venous punctures for access Previous collaboration has included videoconferencing, visits to the UK by a Nigerian physician and clinical and academic links Visiting clinicians from the UK 2019 participated in a project of point of care testing of creatinine in acute kidney injury with a multidisciplinary workshop, designing the algorithm for the subsequent testing. Didactic and practical skills training for HD and PD access. Long term tunnelled HD access was established for the first time locally The major objective of establishing PD was not possible–no fluid available in the country and international commercial suppliers without reliable supply chain Coinciding with the Covid pandemic a commercial suppler began producing PD fluid in Nigeria Despite enthusiasm for hands on collaboration further visits to establish physician inserted PD catheter access were cancelled An alternative programme of collaboration at distance was established Regular monthly planning Zoom meetings maintained contact between clinicians Recognising that PD is nurse delivered and will not be successful without MDT working, alliances were formed by the respective nursing teams Zoom teaching helped established working relationships with the anticipation of offering real time support and troubleshooting once PD is established The nursing team in Salford produced video teaching of PD exchanges to produce a teaching aid available on the group YouTube channel Relatively low-tech use of available equipment, including a head mount for mobile phones to allow operator eye view of procedures via the phone camera have helped with real time teaching of dialysis access and point of care ultrasound for junior and senior clinicians The proposed commencement of PD recognises local issues: housing, water supply and sanitation pose major difficulties in the standard model of patient delivered home PD The new commercially available PD fluid is potentially more affordable than intermittent HD, but not if utilised in traditional standard pattern of 4 CAPD exchanges daily. Local practice in the UK unit has changed in keeping with recent ISPD guidelines towards incremental, patient specific dialysis prescription. The new PD project in Port Harcourt is being designed around patient reported outcomes and technique tolerability in keeping with modern best practice The huge challenge of the covid pandemic for practising clinicians maintaining collaboration needs to be recognised.

Early detection and management of community-acquired acute kidney injury (CA-AKI) can reduce associated morbidity and mortality in low- and middle-income countries where infrastructure for laboratory tests is limited.1Cerdá J. Mohan S. Garcia-Garcia G. et al.Acute kidney injury recognition in low- and middle-income countries.Kidney Int Rep. 2017; 2: 530-543https://doi.org/10.1016/j.ekir.2017.04.009Abstract Full Text Full Text PDF PubMed Scopus (24) Google ScholarWe established a collaborative project between a UK and Nigerian renal center to investigate the use of point-of-care creatinine (POC Cr) for early identification of CA-AKI in Nigeria. Initial evaluation of the POC Cr technology had been conducted at Salford Royal Hospital.2Simpson S. Storrar J. Ritchie J. et al.Point-of-care creatinine to assist clinical decision making in suspected sepsis in the community.Point Care J Near Patient Test Technol. 2019; 18: 41-45https://doi.org/10.1097/POC.0000000000000184Crossref Scopus (1) Google Scholar Methods are presented in the Supplementary Methods. During the first stage of the study, the accuracy of POC Cr technology compared with standard laboratory assay (Jaffe) was evaluated in 96 concurrent capillary (POC Cr) and venous samples provided by adult patients attending for regular phlebotomy. Pearson correlation was r = 0.956 (Supplementary Figure S1), and Bland-Altman plot mean bias was 27.2 μmol/l (Figure 1a). The results of the evaluation phase were reviewed in an AKI workshop including 85 primary and secondary care physicians, and an algorithm was developed for the use of POC Cr, using an adjusted cutoff value for AKI diagnosis in clinically suspected CA-AKI (Figure 1b). The second stage of the study investigated the use of POC Cr in the emergency department in adult patients with clinically suspected CA-AKI based on this algorithm before expanding its use to community centers. Of 53 patients screened with POC Cr, 18 (36%) were diagnosed with having CA-AKI, 6 (11%) afforded blood tests, and 14 (26.4%) were self-discharged owing to lack of affordability. Patient characteristics are presented in Supplementary Table S1. With the emergence of the COVID-19 pandemic, the project was modified to include POC Cr for CA-AKI screening in the regional isolation centers irrespective of symptoms. Of 69 COVID-19–positive patients screened with POC Cr, 8 (11.6%) had AKI, and presence of AKI was associated with low oxygen saturation and history of hypertension. Patient characteristics are presented in Supplementary Table S2.POC Cr can be used with adjustment as a screening tool for early detection of CA-AKI. However, its cost-effectiveness and clinical impact on outcomes as a triage screening tool in low-resource settings should be explored in prospective studies incorporating a minimum affordable bundle of AKI care.3Mehta R.L. Cerdá J. Burdmann E.A. et al.International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology.Lancet. 2015; 385: 2616-2643https://doi.org/10.1016/S0140-6736(15)60126-XAbstract Full Text Full Text PDF PubMed Scopus (577) Google Scholar,4Drain P.K. Hyle E.P. Noubary F. et al.Diagnostic point-of-care tests in resource-limited settings.Lancet Infect Dis. 2014; 14: 239-249https://doi.org/10.1016/S1473-3099(13)70250-0Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar Early detection and management of community-acquired acute kidney injury (CA-AKI) can reduce associated morbidity and mortality in low- and middle-income countries where infrastructure for laboratory tests is limited.1Cerdá J. Mohan S. Garcia-Garcia G. et al.Acute kidney injury recognition in low- and middle-income countries.Kidney Int Rep. 2017; 2: 530-543https://doi.org/10.1016/j.ekir.2017.04.009Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar We established a collaborative project between a UK and Nigerian renal center to investigate the use of point-of-care creatinine (POC Cr) for early identification of CA-AKI in Nigeria. Initial evaluation of the POC Cr technology had been conducted at Salford Royal Hospital.2Simpson S. Storrar J. Ritchie J. et al.Point-of-care creatinine to assist clinical decision making in suspected sepsis in the community.Point Care J Near Patient Test Technol. 2019; 18: 41-45https://doi.org/10.1097/POC.0000000000000184Crossref Scopus (1) Google Scholar Methods are presented in the Supplementary Methods. During the first stage of the study, the accuracy of POC Cr technology compared with standard laboratory assay (Jaffe) was evaluated in 96 concurrent capillary (POC Cr) and venous samples provided by adult patients attending for regular phlebotomy. Pearson correlation was r = 0.956 (Supplementary Figure S1), and Bland-Altman plot mean bias was 27.2 μmol/l (Figure 1a). The results of the evaluation phase were reviewed in an AKI workshop including 85 primary and secondary care physicians, and an algorithm was developed for the use of POC Cr, using an adjusted cutoff value for AKI diagnosis in clinically suspected CA-AKI (Figure 1b). The second stage of the study investigated the use of POC Cr in the emergency department in adult patients with clinically suspected CA-AKI based on this algorithm before expanding its use to community centers. Of 53 patients screened with POC Cr, 18 (36%) were diagnosed with having CA-AKI, 6 (11%) afforded blood tests, and 14 (26.4%) were self-discharged owing to lack of affordability. Patient characteristics are presented in Supplementary Table S1. With the emergence of the COVID-19 pandemic, the project was modified to include POC Cr for CA-AKI screening in the regional isolation centers irrespective of symptoms. Of 69 COVID-19–positive patients screened with POC Cr, 8 (11.6%) had AKI, and presence of AKI was associated with low oxygen saturation and history of hypertension. Patient characteristics are presented in Supplementary Table S2. POC Cr can be used with adjustment as a screening tool for early detection of CA-AKI. However, its cost-effectiveness and clinical impact on outcomes as a triage screening tool in low-resource settings should be explored in prospective studies incorporating a minimum affordable bundle of AKI care.3Mehta R.L. Cerdá J. Burdmann E.A. et al.International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology.Lancet. 2015; 385: 2616-2643https://doi.org/10.1016/S0140-6736(15)60126-XAbstract Full Text Full Text PDF PubMed Scopus (577) Google Scholar,4Drain P.K. Hyle E.P. Noubary F. et al.Diagnostic point-of-care tests in resource-limited settings.Lancet Infect Dis. 2014; 14: 239-249https://doi.org/10.1016/S1473-3099(13)70250-0Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar The project was part of the Sister Center Programme supported by the ISN. Point-of-care creatinine devices were provided by the Salford Renal Department and consumables were provided free of charge by NOVA Biomedical. The Greater Manchester Strategic Clinical Network supported the evaluation of point-of-care creatinine technology at Salford Hospital. Supplementary Material Download .docx (.16 MB) Help with docx files Supplementary File (WORD)Supplementary Methods.Figure S1. Scatter diagram showing the relationship between point-of-care creatinine and laboratory creatinine (a) for all samples and (b) for samples restricted to laboratory creatinine values < 200 μmol/l.Table S1. Characteristics of patients presented to the emergency department with clinically suspected community-acquired acute kidney injury by point-of-care creatinine values above and below 150 μmol/l.Table S2. Characteristics of patients screened in the COVID-19 isolation centers by point-of-care creatinine values above and below 150 μmol/l. Download .docx (.16 MB) Help with docx files Supplementary File (WORD) Supplementary Methods. Figure S1. Scatter diagram showing the relationship between point-of-care creatinine and laboratory creatinine (a) for all samples and (b) for samples restricted to laboratory creatinine values < 200 μmol/l. Table S1. Characteristics of patients presented to the emergency department with clinically suspected community-acquired acute kidney injury by point-of-care creatinine values above and below 150 μmol/l. Table S2. Characteristics of patients screened in the COVID-19 isolation centers by point-of-care creatinine values above and below 150 μmol/l.

Abstract Background Secondary hyperparathyroidism may lead to increased cardiovascular risk. The use of cinacalcet may improve bone and cardiovascular health with improved parathormone (PTH) and phosphate control. Methods This is an open-label prospective randomised controlled trial to compare progression of cardiovascular and chronic kidney disease mineral and bone disorder (CKD-MBD) parameters. Patients were randomised to receive cinacalcet alongside standard therapy or standard therapy alone. Thirty-six haemodialysis patients who had > 90 days on dialysis, iPTH > 300 pg/mL, calcium > 2.1 mmol/L and age 18–75 years were included. Following randomization, all 36 patients underwent an intensive 12-week period of bone disease management aiming for iPTH 150-300 pg/mL. The primary outcome was change in vascular calcification using CT agatston score. Secondary outcomes included pulse wave velocity (PWV), left ventricular mass index (LVMI), carotid intima-media thickness (CIMT), augmentation index (Aix) and bone measurements. The above measurements were obtained at baseline and 12 months. Results There was no evidence of a group difference in the progression of calcification (median change (IQR) cinacalcet: 488 (0 to1539); standard therapy: 563 (50 to 1214)). In a post hoc analysis combining groups there was a mean (SD) phosphate reduction of 0.3 mmol/L (0.7) and median (IQR) iPTH reduction of 380 pg/mL (− 754, 120). Regression of LVMI and CIMT was seen (P = 0.03 and P = 0.001) and was significantly associated with change of phosphate on multi-factorial analyses. Conclusions With a policy of intense CKD-MBD parameter control, no significant benefit in bone and cardiovascular markers was seen with the addition of cinacalcet to standard therapy over one year. Tight control of hyperphosphataemia and secondary hyperparathyroidism may lead to a reduction in LVMI and CIMT but this needs further investigation. Although the sample size was small, meticulous trial supervision resulted in very few protocol deviations with therapy.

Under the auspices of the International Society of Nephrology Sisters Renal Centres programme, Renal centres from Port Harcourt, Nigeria and Salford UK have maintained collaboration in various aspects of kidney care. A key issue in sustaining dialysis care in a lower middle income economy is access for haemodialysis (HD). Before this project all HD access was via temporary femoral vein lines inserted for a single dialysis session.

Background: Patients undergoing haemodialysis (HD) are at higher risk of developing worse outcomes if they contract COVID-19. In our renal service we reduced HD frequency from thrice to twice-weekly in selected patients with the primary aim of reducing COVID 19 exposure and transmission between HD patients.Methods: Dialysis unit nephrologists identified 166 suitable patients (38.4% of our HD population) to temporarily convert to twice-weekly haemodialysis immediately prior to the peak of the COVID-19 pandemic in our area. Changes in pre-dialysis weight, systolic blood pressure (SBP) and biochemistry were recorded weekly throughout the 4-week project. Hyperkalaemic patients (serum potassium > 6.0mmol/L) were treated with a potassium binder, sodium bicarbonate and received responsive dietary advice.Results: There were 12 deaths (5 due to COVID-19) in the HD population, 6 of which were in the twice weekly HD group; no deaths were associated with change of dialysis protocol. A further 19 patients were either hospitalised and/or developed COVID-19 and thus transferred back to thrice weekly dialysis as per protocol. Of 141 eligible patients 113 (80.1%) were still receiving twice-weekly HD by the end of the 4-week project. Indications for transfer back to thrice weekly were; fluid overload (19), persistent hyperkalaemia (4), patient request (4) and compliance (1). There were statistically significant increases in SBP and pre-dialysis potassium during the project. Conclusions: Short term conversion of a large but selected HD population to twice-weekly dialysis sessions was possible and safe. This approach could help mitigate COVID-19 transmission amongst dialysis patients in centres with similar organisational pressures.

Acute Kidney Injury (AKI) in low- and middle-income countries is mostly community-acquired, affects young people, typically has a single cause such as infection or dehydration and is mostly a preventable disorder if it is diagnosed and treated at early stages. A collaborative project has been established between the Renal Unit of the University of Port Harcourt Teaching Hospital and the Renal Department of Salford Royal NHS Foundation Trust, supported by the International Society of Nephrology aiming at the evaluation of the use of point of care (POC) Creatinine (Cr) for early identification and management of community acquired AKI.

Abstract Background and Aims Acute Kidney Injury (AKI) in low- and middle-income countries is mostly a community-acquired potentially reversible syndrome and has high morbidity and mortality. Due to limited laboratory infrastructure diagnosis of AKI is often delayed until life threatening complications have developed and dialysis treatment is largely unavailable. Decisions for hospital referral from primary health care centers and triage decisions for hospital admission are not based on laboratory results in Port Harcourt Nigeria. To address the need for early diagnosis and treatment of AKI we established a collaboration between the Renal Unit of the University of Port Harcourt Teaching Hospital, Primary Health Care Board Rivers State and the Renal Department of Salford Royal NHS Foundation Trust, aiming at the evaluation of the use of point of care (POC) Creatinine (Cr) for early detection and management of community acquired AKI. Method The first stage of the project evaluated the accuracy of POC Cr technology. Following informed consent patients underwent concurrent measurement of Cr using the central laboratory (Lab) assay (Jaffe) from a venous sample and a point of care Cr measurement using a capillary sample (fingerstick) with the NOVA Stasensor Xpress Cr analyser. Pearson Correlation and Bland-Altman plots were used to assess correlation and agreement between the two methods. During the second stage, the results were discussed at a focused AKI workshop and guidance for the use of POC Cr was developed. Results During the first phase 96 concurrent POC Cr capillary and venous Lab Cr samples were analysed. Mean age was 49±14 years and 66 subjects were females. POC Cr values were 127±122 umol/l and Lab Cr values were 100 ±85 umol/L, mean positive bias of 27.2±47.94 umol/L. Overall, correlation between POC Cr and Lab Cr was very good, with Pearson correlation r=0.956) Figure 1A. All 4 out of 96 values that were outside the limits of agreement (set at mean ±2 standard deviations) were for Lab Cr values >200 umol/L. A Bland-Altman Plot is presented for paired samples with Lab Cr values <200 umol/L (Figure 1B).

Deaths due to Acute Kidney Injury (AKI) can be prevented if the disorder can be diagnosed and treated at early stages. The majority of AKI cases arise in the community. In University of Port Harcourt Teaching Hospital in Nigeria triage decisions for hospital admission are not based on laboratory results. In addition most of the regional primary care health centres, that are the first point of medical assessment, do not have the infrastructure to perform blood tests and diagnose AKI. We have established a collaborative project between the Renal Unit of the University of Port Harcourt Teaching Hospital, Primary Health Care Board Rivers State and the Renal Department of Salford Royal NHS Foundation Trust, supported by the International Society of Nephrology aiming at the evaluation of the use of point of care (POC) Creatinine (Cr) for early identification and management of community acquired AKI.

The impact of renal registries that promote service planning, disease management, quality improvement, and research is dependent on the quality of baseline data. Inadequate baseline data collection tools and the low utilization of electronic Health Information Management Systems (eHIMs) are key challenges to the development of renal registries in Africa as stated by the African Regional Association of Nephrology (AFRAN). This state of affairs prompted the baseline assessment of renal data quality and the development of a structured data collection tool as a prerequisite for the commencement of a community-level primary care renal service and the establishment of the local renal registry at an ISN/SRC center, at the University Port Harcourt Teaching Hospital, Nigeria,

Myosin heavy chain-9-related disorders (MYH9-RDs) are a group of autosomal-dominant disorders caused by mutations in the MYH9 gene. The features include congenital macrothrombocytopaenia, inclusion bodies in neutrophils and a variable risk of developing sensorineural deafness, progressive renal impairment and presenile cataracts. A 44-year-old Caucasian man was initially thought to have Alport's syndrome and thrombocytopaenia secondary to idiopathic thrombocytopaenic purpura (ITP). A detailed family history and genetic analysis revealed a diagnosis of MYH9-RD. This case highlights the implications of a delayed diagnosis and the ongoing challenges encountered during management of individuals with this condition.

Background A female with autosomal dominant polycystic kidney disease was followed up over the course of four pregnancies. Her first three pregnancies were unsuccessful. Her fourth pregnancy resulted in a live birth, but at what expense?Investigations The diagnosis of autosomal dominant polycystic kidney disease was confirmed by ultrasound imaging. Physical examination, blood pressure measurement, and urine and blood analyses were performed at each follow-up visit.Diagnosis Deterioration of renal function following multiple complicated pregnancies.Management Attention to blood pressure and proteinuria delayed initiation of dialysis, but effects of the number of pregnancies took their toll. The patient was started on hemodialysis and underwent renal transplantation.