Upsala J Med Sci 92: 65-73, 1987 Chronic Renal Failure in Khartoum, Sudan E. M. Osman,' 0. I. Abboud' and B . G. Danielson2 'University of Khartoum, Khartoum, Sudan and 2Department of Internal Medicine, University Hospital, Uppsala, Sweden ABSTRACT A study o f t h e c l i n i c a l p r e s e n t a t i o n and c o n c i e v a b l e causes o f c h r o n i c r e n a l f a i l u r e ( C R F ) i n 6 1 Sudanese p a t i e n t s i n Khartoum i s presented. The c l i n i c a l f e a t u r e s i n v o l v e d almost a l l t h e systems, however, g a s t r o i n t e s t i n a l and c a r d i o v a s c u l a r s i g n s and symptoms predominated. The causes o f c h r o n i c r e n a l f a i 1 u r e i n Sudan and Sweden a r e a l s o s t u d i e d f o r comparison. The causes o f C R F i n Sudan a r e c h r o n i c g l o m e r u l o n e p h r i t i s , o b s t r u c t i v e nephropathy ( s t o n e disease), h y p e r t e n s i o n and d i a b e t e s m e l l i t u s i n t h a t o r d e r (1). The main causes o f CRF i n Sweden a r e c h r o n i c g l o m e r u l o n e p h r i t i s , diabe- t e s m e l l i t u s and c h r o n i c p y e l o n e p h r i t i s . O f t h e 6 1 Sudanese p a t i e n t s 16 have kidney t r a n s p l a n t s , o n l y one i n Sudan, t h r e e p a t i e n t s a r e on r e g u l a r h e m o d i a l y s i s , n i n e p a t i e n t s a r e on i n t e r m i t t e n t p e r i t o n e a l d i a l y s i s , 1 6 a r e on c o n s e r v a t i v e t r e a t m e n t and 17 d i e d d u r i n g t h e course o f t r e a t m e n t . INTRODUCTION Renal f a i l u r e i n i t s m i l d and c h r o n i c forms has v a r y i n g f a c e t s i n i t s c l i - n i c a l p r e s e n t a t i o n . W i t h a b l o o d urea o f 100 mg% one may be i n reasonably good h e a l t h and can u s u a l l y l e a d a normal l i f e (8). B u t as a r e s u l t o f a supervening i l l n e s s , r e n a l f u n c t i o n can r a p i d l y d e t e r i o r a t e ; and t h i s has t o be recognised e a r l y on. P a t i e n t s w i t h r e n a l f a i l u r e can be asymptomatic o r may have symptoms from any organ o r organ system. The p r e s e n t paper i s a r e v i e w o f t h e c l i n i c a l p r e s e n t a t i o n o f 6 1 Sudanese p a t i e n t s who were t r e a t e d i n t h e Medical Department o f Soba U n i v e r s i t y Hos- p i t a l Khartoum. 5 -878571 65 A comparison o f t h e causes o f CRF i n Sudan and Sweden i s a l s o presented. MATERIALS AND METHODS Over a p e r i o d o f two y e a r s , Jan 1984 - Feb 1986, 6 1 Sudanese p a t i e n t s o f Afro-Arab o r i g i n , aged between 15 and 75 y e a r s (mean 4 0 . 1 y e a r s ) were s t u - died. There were 38 men and 23 women. The m a j o r i t y o f t h e p a t i e n t s were i n - p a t i e n t s . Most o f these p a t i e n t s were r e f e r r e d from o t h e r h o s p i t a l s i n t h e c o u n t r y as o u r h o s p i t a l i s one o f t h e main r e f e r r e n c e c e n t r e s i n t h e c o u n t r y , which has one m i l l i o n square m i l e s s u r f a c e area and a p o p u l a t i o n o f 22 m i l l i o n people. The h o s p i t a l has no c a s u a l t y ward so most p a t i e n t s came t o t h e o u t - p a t i e n t c l i n i c s o r r e c e i v e d i n t h e main c a s u a l t y ward i n Khartoum H o s p i t a l i n t h e c i t y c e n t r e . The c r i t e r i a f o r i n c l u s i o n i n t h i s study was t h e f i n d i n g o f a p e r s i s t e n t l y r a i s e d b l o o d u r e a and c r e a t i n i n e , supported by t h e f i n d i n g o f small kidneys on X-rays o r ultrasonography. The c r e a t i n i n e c l e a r a n c e was i n f e r r e d from t h e serum c r e a t i n i n e concen- t r a t i o n (4). H y p e r t e n s i o n i s d e f i n e d as a b l o o d p r e s s u r e (BP) o f >160/90 mm Hg. M a l i g - n a n t h y p e r t e n s i o n i s diagnosed when t h e d i a s t o l i c BP i s >130 mm Hg o r t h e p a t i e n t had papilloedema. The d a t a concerning causes o f CRF i n Sweden was o b t a i n e d from y e a r l y s t a - t i s t i c s , from t h e Swedish N e p h r o l o g i c a l S o c i e t y , 1984. RESULTS F i g u r e 1 shows t h e sex d i s t r i b u t i o n and age i n c i d e n c e . Males outnumbered females and t h e peak o f i n c i d e n c e o f age o c c u r r e d between 30 and 40 years. Tables 1 and 2 g i v e a summary o f t h e o b s e r v a t i o n s . The commonest modes o f p r e s e n t a t i o n (see Table 1) were: f a t i g u e , a n o r e x i a , nausea and v o m i t t i n g ; a n k l e s w e l l i n g , b r e a t h l e s s n e s s , p u f f i n e s s o f t h e face, cough and insomnia i n t h a t o r d e r . 66 I n t h i s s e r i e s 17 d i e d o u t o f t h e 61 p a t i e n t s d u r i n g t h e course o f t r e a t - ment. No p o s t mortem was done f o r reasons o u t o f hand. The m o r t a l i t y was 28%, f a r l e s s t h a n i n s e r i e s s t u d i e d b e f o r e (3). . D u r i n g f o l l o w - u p (some p a t i e n t s were n o t o f f e r e d immediate d i a l y s i s be- cause o f l a c k o f vacancies) g a s t r o i n t e s t i n a l symptoms predominate (Table 2). Number of patients M F a17 AGE (YEARS) F i g . 1. Table 1. Sex d i s t r i b u t i o n and age i n c i d e n c e i n 6 1 p a t i e n t s w i t h CRF. Main c o m p l a i n t s a t t h e t i m e o f p r e s e n t a t i o n i n o r d e r o f frequency. Camp1 a i n t s ~ ~~ No o f p a t i e n t s Percentage 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 F a t i g u e Anorexia, nausea, v o m i t t i n g Ankle s w e l l i n g Breath1 essness P u f f i n e s s o f t h e f a c e Cough Insomnia I t c h i n g Chest p a i n D i a r r h o e a P a r a s t h e s i a , h o t sensations i n f e e t and hands E p i s t a x i s Bad v i s i o n P a i n i n t h e j o i n t s Headache 51 46 33 30 23 20 19 18 13 9 9 5 5 3 3 82 75 52 49 36 32 31 29 21 15 15 8 8 5 5 67 E p i s t a x i s was t h e p r e s e n t i n g f e a t u r e i n 1 4 p a t i e n t s , and some o f t h e s e pa- t i e n t s were r e f e r r e d from e a r , nose and t h r o a t (ENT) departments: one p a t i e n t d i s c o v e r e d l a t e r t o be s u f f e r i n g from A l p o r t ' s syndrome, a f t e r s t u d y i n g h i s r e n a l b i o p s y and audiometry, was under t h e c a r e o f an ENT s p e c i a l i s t f o r deafness. P e r i c a r d i t i s o c c u r r e d i n 11 p a t i e n t s , and a l l were d i a l y z e d . Table 2. Observed c l i n i c a l f e a t u r e s d u r i n g t h e course o f i l l n e s s C l i n i c a l f e a t u r e s i n v o l v i n g No o f p a t i e n t s Percentage I G a s t r o i n t e s t i n a l t r a c t 1 Anorexia, nausea, v o m i t t i n g 55 2 D i a r r h o e a 10 3 Hiccough 5 4 Haematamesi s 1 t e r m i n a l 1 F a t i g u e 55 2 Insomnia 25 3 Convulsions 2 4 Myoclonus 2 5 Tremors - F l a p p i n g 6 6 P e r i p h e r a l neuropathy 11 1 Hypertension m a l i g n a n t 7 non-malignant 29 2 P e r i c a r d i t i s 11 3 E p i s t a x i s 1 4 I 1 Neuromuscular system I11 C a r d i o r e s p i r a t o r y system I1 I V I n v o l v i n g s k i n 1 Purpura 2 3 I t c h i n g 22 4 Pigmentation 9 2 Uraemic f r o s t 25 V Miscellaneous c l i n i c a l f e a t u r e s Anaemia; normochronic normocytic 42 90 16 8 1 90 4 1 3 3 10 19 19 8 1 19 22 3 4 1 36 15 69 P e r i p h e r a l neuropathy o c c u r r e d i n 11 p a t i e n t s and was so troublesome t h a t a l l o u r p a t i e n t s a p p l i e d HENA (a l o c a l dye from p l a n t s w i t h a soothening e f f e c t ) t o t h e i r hands and f e e t . It g i v e s a r e d - b l a c k c o l o u r and i s v e r y c h a r a c t e r i s t i c o b s e r v a t i o n i n t h e p a t i e n t s . One p a t i e n t had severe neuropathy w i t h p a r a l y s i s o f t h e l o w e r l i m b s , ame- l i o r a t e d by p e r i t o n e a l d i a l y s i s . I t c h i n g was observed i n 22 p a t i e n t s and i t d i d n o t disappear a f t e r d i a - l y s i s . However, 3 p a t i e n t s were symptom f r e e a f t e r t r a n s p l a n t a t i o n . Nine o f o u r p a t i e n t s became more d a r k , t h i s i s n o t a w e l l recognized f e a t u r e i n 68 b l a c k s ; o u r p a t i e n t s a r e o f Afro-Arab o r i g i n and some have v e r y f a i r c o l o u r . Normochromic n o r m o l y t i c anaemia o c c u r r e d i n 42 p a t i e n t s (Table 2). Other causes had been excluded. F i g u r e 2 d e p i c i t s t h e b l o o d p r e s s u r e l e v e l a t admission, most o f t h e hy- p e r t e n s i v e p a t i e n t s responded t o drugs and d i a l y s i s . 0 'y - I ....* n o o c ll..... F i g . 2. Blood p r e s s u r e i n 6 1 p a t i e n t s a t p r e s e n t a t i o n . F i g u r e s 3 and 4 show t h e b l o o d u r e a and c r e a t i n i n e a t t h e t i m e o f s e e i n g t h e p a t i e n t s . Four p a t i e n t s showed v e r y h i g h l e v e l s and one male 28-years-old w i t h a b l o o d u r e a o f 600 mg% and c r e a t i n i n e o f 40 mg% d i e d d u r i n g d i a l y s i s due t o h y p e r t e n s i v e encephal opathy. F i f t y - n i n e p e r c e n t o f t h e p a t i e n t s had h y p e r t e n s i o n and o f these 19% had ma1 i g n a n t hypertension. The i n c i d e n c e o f h y p e r t e n s i o n i n o u r p a t i e n t s i s l o w e r t h a n o t h e r s ( 3 ) . Three o f o u r p a t i e n t s had a d u l t p o l y c y t i c disease as t h e p r i m a r y cause o f CRF and two p a t i e n t s had s a l t l o o s i n g nephropathy; 69 250 200 150 4 0 . 35. 30- 25 ~ ........ 4 : . ...... . . 0 . . 50 0 1 F i g . 3. B l o o d urea l e v e l i n 6 1 p a t i e n t s a t p r e s e n t a t i o n . Serum Creatinine (mg%) i:: ..... 1 0 1 ':fff ..................... ..... 5 t : : : . 0 1 F i g . 4. Serum c r e a t i n i n e l e v e l i n 6 1 p a t i e n t s a t p r e s e n t a t i o n . Table 3 compares t h e causes o f CRF i n Sudan and Sweden. Chronic glomerulo- n e p h r i t i s i s t h e commonest cause o f C R F b o t h i n Sudan and Sweden, however, o b s t r u c t i v e nephropathy i s t h e second common cause i n Sudan which i s n o t t h e case i n Sweden. Diabetes m e l l i t u s i s t h e second common cause o f C R F i n Sweden. 70 Table 3. Causes o f c h r o n i c r e n a l f a i l u r e (CRF) i n Sudan and Sweden i n percentage (%) Cause Sudan ( n = 61) Sweden* ( n = 524) (%I (%I Chronic g l o m e r u l o n e p h r i t i s O b s t r u c t i v e nephropathy H y p e r t e n s i v e n e p h r o s c l e r o s i s Diabetes m e l l i t u s Chronic p y e l o n e p h r i t i s P o l y c y s t i c disease o f t h e kidney Systemic diseases Other causes and unknown 33 18 13 12 3 5 16 - 27 - 11 22 13 7 9 11 *According t o s t a t i s t i c s from t h e Swedish N e p h r o l o g i c a l S o c i e t y , 1984. D I S C U S S I O N F a t i g u e was t h e p r e s e n t i n g symptom i n 82% o f o u r p a t i e n t s w i t h end stage r e n a l f a i l u r e . T h i s was v o l u n t e e r e d by t h e p a t i e n t s and many o f them had been under medical c a r e and were s u p p l i e d w i t h v i t a m i n e s u n t i l t h e b l o o d u r e a was done and t h e y were r e f e r r e d t o us. Although many people complain o f f a t i g u e i n t h e h o t weather o f Sudan due t o excessive sweating e t c , c l i n i c i a n s s h o u l d be a l e r t and l o o k f o r o t h e r f e a t u r e s o f CRF, e s p e c i a l l y now where t e s t s l i k e b l o o d u r e a a r e a v a i l a b l e i n b i g c i t i e s . F a t i g u e i n CRF i s a t t r i b u t e d t o anaemia, d e h y d r a t i o n , p r o t e i n - c a l o r i e mal- n u t r i t i o n and accumulation o f uraemic t o x i n s (2). G a s t r o i n t e s t i n a l symptoms o c c u r r e d i n 75% as t h e p r e s e n t i n g f e a t u r e , how- e v e r , t h e y predominate d u r i n g f o l l o w - u p . These g a s t r o i n t e s t i n a l f e a t u r e s have d e l e t e r i o u s e f f e c t on r e n a l f u n c t i o n and s h o u l d be l o o k e d f o r and t r e a t e d p r o m p t l y because i n a p l a c e l i k e ours i t i s always cheaper t o r e v e r s e t r e a t - a b l e causes and keep p a t i e n t s w i t h ESRD s t a b l e on c o n s e r v a t i v e t r e a t m e n t (7). Nine p a t i e n t s had p e r i p h e r a l neuropathy, s i x w i t h o b j e c t i v e s i g n s m a i n l y i n t h e l o w e r limbs, one p a t i e n t was c r i p p l e d , however, he improved a f t e r p e r i t o n e a l d i a l y s i s and i s now w a l k i n g w i t h a s t i c k . The p e r i p h e r a l neuro- p a t h y seems t o be r e l a t e d t o t h e GFR and d u r a t i o n o f CRF (9, 10). 71 A l l t h e 6 1 p a t i e n t s w e r e anaemic, however, 69% had t h e t y p i c a l normo- chromic normocytic anaemia o f CRF ( 6 ) . G a s t r o i n t e s t i n a l b l e e d i n g was seen i n o n l y one p a t i e n t who was v e r y ill and d i e d b e f o r e i n s t i t u t i n g therapy. The i n c i d e n c e o f h y p e r t e n s i o n i n o u r p a t i e n t s i s lower t h a n o t h e r obser- v e r s ' (3). I n a s t u d y done by Makene i n Oar-es-Salaam where a l l h i s 42 p a t i e n t s were p u r e A f r i c a n s 91% had h y p e r t e n s i o n and 24% o f those p a t i e n t s g o t m a l i g n a n t h y p e r t e n s i o n . I n o u r s e r i e s as mentioned e a r l i e r t h e p a t i e n t s a r e o f Afro-Arab o r i g i n and t h r e e had p o l y c y s t i c kidneys and t w o had s a l t l o o s i n g nephropathy. The l a s t two decades had seen improvement i n d i a l y s i s and t r a n s p l a n t (2, 5). However, i n a p l a c e l i k e Sudan, where p r i o r i t y goes t o m a l n u t r i t i o n and endemic diseases l i k e m a l a r i a , t u b e r c u l o s i s and s c h i s t o m a t o s i s , o u r d u t y as n e p h r o l o g i s t s i s t o p r e v e n t and f i n d remediable causes b e f o r e o u r p a t i e n t s succumb t o ESRO. The comparison o f t h e causes o f C R F i n Sudan and Sweden shows t h a t c h r o n i c g l o m e r u l o n e p h r i t i s i s t h e commonest cause o f CRF i n b o t h c o u n t r i e s . Obstruc- t i v e nephropathy ( s t o n e disease) i s a common cause o f CRF i n Sudan. T h i s i s a t t r i b u t e d t o : 1. l a c k o f f a c i l i t i e s , e.g. X-rays and u l t r a s o u n d , 2. l a t e p r e s e n t a t i o n o f p a t i e n t s . Three o f o u r p a t i e n t s p r e s e n t e d w i t h C R F w i t h o u t been seen b e f o r e and had no X-rays examination i n t h e i r l i f e . A v a i l a b i l i t y o f such f a c i l i t i e s and e a r l y r e f e r r a l o f p a t i e n t s w i l l d e t e c t p a t i e n t s b e f o r e t h e y develop CRF. T h i s p r e v e n t s C R F , postpones d i a l y s i s and i t s c o s t s (7) and makes l i f e e a s i e r f o r t h e p a t i e n t and t h e people i n charge o f h e a l t h care. Diabetes m e l l i t u s i s n o t a common cause o f C R F i n Sudan as i n Sweden. Probably o u r d i a b e t i c p a t i e n t s i n Sudan succumb t o o t h e r c o m p l i c a t i o n s and do n o t l i v e l o n g enough t o develop CRF. ACKNOWLEDGMENT I would l i k e t o t h a n k O r B j o r n Wikstrom f o r r e v i s i n g t h e m a n u s c r i p t and p r o v i d i n g d a t a from Sweden. My g r a t i t u d e a l s o t o M r s I v a Kulhanek who typed t h e manuscript. 72 REFERENCES Abboud, 0.1.: Chronic r e n a l f a i l u r e i n t h e Sudan. MD t h e s i s , U n i v e r s i t y o f Khartoum, Sudan. 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