Practice of Pediatric Spinal Anesthesia in a Country with Limited Means: Example of Togo

Introduction: The practice of spinal anesthesia in pediatric surgery is declining, especially in countries with limited means. What about in our context? Objective: To evaluate the practice of spinal anesthesia in pediatric surgery in Togo. Framework and method of study: This was a prospective study from November 2017 to May 2018 in pediatric surgery at CHU SO de Lomé, in the operating room and hospital ward of CHU Kara. The surgical, anesthesiological and evolutionary aspects of the patients were analyzed. Results: Sixty children were selected for the study who had an indication for sub-umbilical surgery. The male sex was predominant (73.3%). 47 (78.30%) patients were operated on for scheduled surgery. Hernia repair was the most performed surgical intervention (43.30%). The mean duration of the surgery was 78 ± 35.9 minutes. Most of the patients were ASA 1 (98.30%). The local anesthetic used was 0.5% isobaric Bupivacaine. Fentanyl was the predominant adjuvant (55%). The most widely used lumbar puncture needle was 25 Gauge with 75 millimeters in length (63.30%). Diazepam was the most widely used sedative (50%). The predominant spinal anesthesia protocol was spinal anesthesia alone (60%). Only one patient had hypotension (1.70%). Conclusion: The fairly satisfactory pediatric spinal anesthesia in Togo remains poorly performed. Its promotion involves the training of anesthesia practitioners and the strengthening of the technical platform.

Pathophysiological 角色和在糖尿病的 nephropathy 的发炎的治疗学的含意

Diabetes mellitus and its complications are becoming one of the most important health problems in the world. Diabetic nephropathy is now the main cause of end-stage renal disease. The mechanisms leading tothe development and progression of renal injury are not well known. Therefore, it is very important to f ind new pathogenic pathways to provide opportunities for early diagnosis and targets for novel treatments. At the present time, we know that activation of innate immunity with development of a chronic low grade inflammatory response is a recognized factor in the pathogenesis of diabetic nephropathy. Numerous experimental and clinical studies have shown the participation of different inflammatory molecules and pathways in the pathophysiology of this complication.

WJD 5^(th) Anniversary Special Issues(2): Type 2 diabetes Inflammation in diabetic kidney disease

Diabetes mellitus entails significant health problems worldwide.The pathogenesis of diabetes is multifactorial,resulting from interactions of both genetic and environmental factors that trigger a complex network of pathophysiological events,with metabolic and hemodynamic alterations.In this context,inflammation has emerged as a key pathophysiology mechanism.New pathogenic pathways will provide targets for prevention or future treatments.This review will focus on the implications of inflammation in diabetes mellitus,with special attention to inflammatory cytokines.

Implications of Klotho in vascular health and disease

Cardiovascular disease(CVD) is a prevalent condition in general population and the first cause of death overall. Klotho, a pleiotropic protein related to longevity that acts as a co-receptor of the fibroblast growth factor 23, has been proposed as a key regulator of the development of CVD. In the few clinical studies made, it has been observed a relationship between low levels of soluble Klotho and the occurrence and severity of CVD, as well as a reduction of cardiovascular risk when they are high. Also, different polymorphisms of human Klotho gene have been related to the incidence of cardiovascular events. Moreover, several experimental studies indicate that this protein acts in the maintenance of vascular homeostasis. Klotho improves endothelial dysfunction through promotion of NO production and mediates antiinflammatory and anti-aging effects such as suppression of adhesion molecules expression, attenuation of nuclear factor-kappa B or inhibition of Wnt signaling. Furthermore,this protein is related to the attenuation of vascular calcification as well as prevention of cardiac hypertrophy. The expression of this protein in the vascular wall implies a new scenario for the treatment of vascular disorders. The purpose of this review is to provide an overview of the relationship between the Klotho protein and CVD, in addition to its role in the maintenance of functional vascular integrity.

The Global Role of Kidney Transplantation

World Kidney Day on March 8th 2012 provides a chance to reflect on the success of kidney transplantation as a therapy for end stage kidney disease that surpasses dialysis treatments both for the quality and quantity of life that it provides and for its cost effectiveness.Anything that is both cheaper and better,but is not actually the dominant therapy,must have other drawbacks that prevent replacement of all dialysis treatment by transplantation.The barriers to universal transplantation as the therapy for end stage kidney disease include the economic limitations which,in some countries place transplantation,appropriately,at a lower priority than public health fundamentals such as clean water,sanitation and vaccination.Even in high income countries the technical challenges of surgery and the consequences of immunosuppression restrict the number of suitable recipients,but the major finite restrictions on kidney transplantation rates are the shortage of donated organs and the limited medical,surgical and nursing workforces with the required expertise.These problems have solutions which involve the full range of societal,professional,governmental and political environments.World Kidney Day is a call to deliver transplantation therapy to the one million people a year who have a right to benefit.

让肾脏健康人人可享,处处可及——从预防到诊治

Around 850 million people currently are affected by different types of kidney disorders.Up to 1 in 10 adults worldwide has chronic kidney disease(CKD),which is invariably irreversible and mostly progressive.The global burden of CKD is increasing,and CKD is projected to become the fifth most common cause of years of life lost globally by 2040.If CKD remains uncontrolled and if the affected person survives the ravages of cardiovascular and other complications of the disease,CKD progresses to endstage kidney disease,where life cannot be sustained without dialysis therapy or kidney transplantation.Hence,CKD is a major cause of catastrophic health expenditure.

Podocyturia: Potential applications and current limitations

Chronic kidney disease is a prevalent condition that affects millions of people worldwide and is a major risk factor of cardiovascular morbidity and mortality. The main diseases that lead to chronic kidney disease are frequent entities as diabetes mellitus, hypertension and glomerulopathies. One of the clinical markers of kidney disease progression is proteinuria. Moreover, the histological hallmark of kidney disease is sclerosis, located both in the glomerular and in the interstitial compartments. Glomerulosclerosis underscores an irreversible lesion that is clinically accompanied by proteinuria. In this regard, proteinuria and glomerular sclerosis are linked by the cell that has been conserved phylogenetically not only to prevent the loss of proteins in the urine, but also to maintain the health of the glomerular filtration barrier: The podocyte. It can then be concluded that the link between proteinuria, kidney disease progression and chronic kidney disease is mainly related to the podocyte. What is this situation due to? The podocyte is unable to proliferate under normal conditions, and a complex molecular machinery exists to avoid its detachment and eventual loss. When the loss of podocytes in the urine, or podocyturia, is taking place and its glomerular absolute number decreased, glomerulosclerosis is the predominant histological feature in a kidney biopsy. Therefore, tissular podocyte shortage is the cause of proteinuria and chronic kidney disease. In this regard, podocyturia has been demonstrated to precede proteinuria, showing that the clinical management of proteinuria cannot be considered an early intervention. The identification of urinary podocytes could be an additional tool to be considered by nephrologists to assess the activity of glomerulopathies, for followup purposes and also to unravel the pathophysiology of podocyte detachment in order to tailor the therapy of glomerular diseases more appropriately.

Klotho in cardiovascular disease:Current and future perspectives

Protein Klotho,beyond its role as a regulator of the phosphatemia,is also involved in the maintaining of the cardiovascular health,being associated its alterations with the development of cardiovascular damage and increased morbi-mortality. For all this,nowadays Klotho is the subject of a thorough research which is focused on uncover its intimate mechanisms of action,and in analyzing the utility of its modulation as a potential strategy with clinical applicability. Molecular mechanisms of Klotho are not well understood but an emerging research area links Klotho deficiency with vascular pathology. Changes in this protein have been associated with cardiovascular-related complications like inflammation,vascular calcification,and endothelial dysfunction. All this is particularly relevant if considering the recent discovery of Klotho expression in vascular tissue.

Hyperuricemia in Patients with Chronic Renal Failure in the General Hospital of National Reference of N’Djamena (Chad)

Introduction: Hyperuricemia is defined as a level of serum uric acid greater than or equal to 70 mg/l (420 μmol/l) in men and 60 mg/l (360 μmol/l) in women. Several studies have shown that it is a risk factor or a factor of progression of chronic kidney disease. Recent experimental and epidemiological data correlate the association of hyperuricemia with chronic kidney disease (CKD), arterial hypertension and cardiovascular diseases, thus raising the question of the usefulness of therapeutics in the prevention of renal diseases. The objective of this study is to seek a link between chronic kidney disease and hyperuricemia. Materials and Methods: This is a descriptive and analytical study conducted at hemodialysis unit and cardiology service of General Hospital of National reference of N’Djamena (Chad) from 1th January to 1th October 2013 (10 months). We included all chronic kidney disease patients hospitalized in hemodialysis unit and cardiology service who presented associated hyperuricemia. Results: There were 712 CKD patients who were hospitalized. Among them, there were 108 patients who were included in the study and who had hyperuricemia as a prevalence of 15.20%. The average age of patients was 35.5 years and the sex ratio was 3/1. The age group between 40 to 60 years represented 54.6%. There were 41.7% of traders. Hypertensive patients accounted for 49.1%;association of diabetes and hypertension was noted in 12.90%. Renal insufficiency was moderate in 43.5% of patients. Hyperuricemia was present in more than 90% of patients. Profession, age, hematuria, proteinuria and hypertension were statistically positively related to hyperuricemia. Treatment consisted of prescribing allopurinol in 84% of patients. In more than 11% of patients the progression was unfavorable. Conclusion: The implication of hyperuricemia in chronic kidney disease has been proved in several recent studies. However, randomized studies at very long scales have to be carried out to conclude from its real impact on the prevention and treatment of chronic kidney disease.

Epidemiology of Renal Failure in Children at the Pediatric University Hospital Charles De-Gaulle of Ouagadougou (Burkina Faso)

Objective: Renal failure (RF) is a serious condition that is still insufficiently evaluated in our context. We wanted to know its epidemiology at the Pediatrics University Hospital Center Charles De-Gaulle (PUHC-CDG) of Ouagadougou. Patients and Methods: We retrospectively studied all children aged from three to fifteen years old who were diagnosed with renal failure (RF) in the Department of Medical Pediatrics, from January 1, 2011 to December 31, 2013. RF was defined by a glomerular filtration rate (GFR) less than 80 mL/min/1.73m2, estimated by the formula of Pottel et al., which ignored the size that was rarely found in the medical records. The department constantly lacked pediatric blood pressure monitors or urinary strips. Results: In total, 119 cases of RF (3.3% of all admissions) were collected. They were about acute RFs (ARFs), chronic RFs (CRFs), and Unclassified RFs (URFs), respectively in 28.6%, 2.5% and 68.9% of cases. The overall average age of patients was 6.7 ± 3.4 years old. The average GFR was 35.2 ± 22.2 mL/min/1.73m2. The mechanism of ARF was presumed to be organic in 26 cases (76.5%). The most common presumed etiology was malaria (47.9%). Twelve patients (10.1%) died. Conclusion: RF was common at the PUHC-CDG but it was unclassified in over half of the cases. The diagnosis was based on the estimation of the GFR by Pottel et al.’s formula which was a good alternative to the Schwartz’s formula. The improvement of human and material resources would certainly help for a screening and characterization of RF at the PUHC-CDG.

Profile of Patients with Acute Renal Injury in N’Djamena: About 36 Cases

Introduction: The incidence of acute renal injury (AKI) has increased in recent decades. Acute renal failure is defined by the abrupt arrest (within hours or days) of the kidney excretory function. Oliguria (urine output 24h) is presented in about half of the cases. The circumstances of the occurrence of AKI are multiple: surgical, traumatic, obstetric, medical, often obvious. Its prognosis depends on the speed of management and the associated organ failure. The objective of this study is to describe the profile of patients in emergency hemodialysis at the Nephrology Unit of the National Reference General Hospital (HGRN) in N’Djamena, Chad. Methods: This was a multicenter, descriptive study in patients with acute renal failure place over a period of 12 months in the emergency departments of the 2 hospitals in N’Djamena. Defined as carriers of an AKI (RIFLE criteria), patients with: 1) Oliguria: urinary output 400 ml/24h (<0.5 ml/kg/h in children) or anuria: urinary output 300 ml/24h;2) Associated with an increase in serum creatinine: serum creatinine × 3 or serum creatinine> 350 μmol/l or decrease of GFR by 75%. Results: Of the 311 patients admitted, 36 cases met the inclusion criteria, a frequency of 11.57%. The mean age was 34.46 years with extremes ranging from 7 to 80 years. The female sex predominated with 52.80% as sex ratio of 0.91. Isolated hypertension was noted with 38.88%. Dyspnea accounted for 41.66% of patients admitted to emergency departments. In our series, 50% of our patients had hyperthermia at admission. Oliguria was observed in 41.70% of the cases. Edema accounted for 33.33% of cases. The AKI with the “failure” criterion was 58.34% (21/36), with the criterion “injury” 25% (9 cases) and the criterion “risk” 16.66 (6 cases). AKI were organic in 83.34% (30/36). It was noted that 14 patients, 38.8% had an infectious syndrome. There were 6 patients who had (16.66%) an obstructive AKI, 5 patients (13.88%) had eclampsia, 4 patients (11.12%) had hepatocellular insufficiency, 3 patients (8.34% Cardiac, 2 patients (5.56%) extracellular dehydration and 2 patients (5.56%) whose cause is indeterminate. It was noted that 10 patients, as 27.7%, had fully recovered their renal function after vascular filling and etiological treatment. Four (4) patients with obstructive obstruction were referred to the urology department. There were 22 patients who had benefited from the hemodialysis. 6 patients recovered completely their renal function. We had recorded a number of deaths in our study which was 44.44% (16/36). Septic shock was the most frequent cause of death in 50% of cases. Conclusion: The incidence of AKI in our study was 11.57%. It affects a young population and despite the therapeutic progress, the mortality remains high. The causes are multiple, entangled, dominated by infectious syndrome and hypovolemia. Prevention seems to be the best therapeutic option to avoid the installation or worsening of an AKI.

Latin American Dialysis and Transplant Registry:Experience and contributions to end-stage renal disease epidemiology

In 2015, 634387 million people(9% of the world's population) resided in Latin America(LA), with half of those populating Brazil and Mexico. The LA Dialysis and Transplant Registry was initiated in 1991, with the aim of collecting data on renal replacement therapy(RRT) from the 20 LA-affiliated countries. Since then, the Registry has revealed a trend of increasing prevalence and incidence of end-stage kidney disease on RRT, which is ongoing and is correlated with gross national income, life expectancy at birth, and percentage of population that is older than 65 years. In addition, the rate of kidney transplantation has increased yearly, with > 70% being performed from deceased donors. According to the numbers reported for 2013, the rates of prevalence, incidence and transplantation were(in patients per million population) 669, 149 and 19.4, respectively. Hemodialysis was the treatment of choice(90%), and 43% of the patients undergoing this treatment was located in Brazil; in contrast, peritoneal dialysis prevailed in Costa Rica, El Salvador and Guatemala. To date, the Registry remains the only source of RRT data available to healthcare authorities in many LA countries. It not only serves to promote knowledge regarding epidemiology of end-stage renal disease and the related RRT but also for training of nephrologists and renal researchers, to improve understanding and clinical application of dialysis and transplantation services. In LA, accessibility to RRT is still limited and it remains necessary to develop effective programs that will reduce risk factors, promote early diagnosis and treatment of chronic kidney disease, and strengthen transplantation programs.

Daptomycin,Methicillin Resistant Staphylococcus hominis Catheter-Related Bacteraemia in a Hemodialysis Patient

We report a case of a haemodialysis patient that presented a catheter-related bacteraemia caused by a Coagulase negative Staphylococcus. With the utilization of molecular biology techniques the bacterial isolate recovered from catheter was surprisingly identified as S. hominis by sequencing of the 16S ribosomal gene. The S. hominis isolate, which is not often associated with infections in dialysis patients, was resistant to methicillin, being mecA positive, and to daptomycin. The patient was successfully treated with vancomycin together with the catheter retirement.

Diabetic Renal-Retinal Syndrome and Inflammatory Markers of Acute Phase

Objective: To determine the association between the acute inflammatory markers and Diabetic Renal-Retinal Syndrome in our patients. Methods: A total of 44 patients were included in this transverse (cross sectional), observational, analytical, and comparative study. Two groups of patients were created. Results: In patients with chronic renal failure, stages 3, 4, or 5 (scale 1 to 5) were identified and divided into two groups: Group I (Patients with concomitant diabetic retinopathy stabilized with photocoagulation) 22 patients. Group II (Patients with progression of retinopathy, after photocoagulation, in the form of intraocular bleeding) 22 patients. The number of patients with chronic renal failure in stage 3 was: Group I;16. In Group II;12 patients (OR: 1.0). Stage 4: Group I;4 patients. Group II: 3 patients (OR: 1.0, CI 95%;0.3843 - 2.021). Stage 5: Group I;2 patients. Group II;7 patients (OR: 1.8148, CI 95%;1.0448 - 3.1523;Chi-squared (x2) 2.7450, p = 0.097). t-Test found statistical significance in Erythrocyte Sedimentation Rate (ESR): p < 0.0001 (CI 95%;7.8959 - 23.2515);R = 0.56 p = 0.001;and OR = 1.959 (CI 95%;1.193 - 3.217). By non-parametric tests, C-reactive protein with binomial test showed p < 0.001. ESR showed p < 0.001 with U of Mann Whitney. Conclusions: With this study revealed a possible association of inflammatory markers with Diabetic Renal-Retinal Syndrome.

Relevance of Protein Content within the Renal Scaffold for Kidney Bioengineering and Regeneration

Chronic kidney disease is currently a major public health problem around the world. Although hemodialysis increases survival of patients with end-stage renal disease, kidney transplantation remains the only potentially curative treatment. However, transplantation as a therapeutic option is limited by availability of suitable donor organs. This situation highlights the urgent need to find new and potentially inexhaustible sources of transplantable organs. Perfusion decellularizarion of whole organs is a novel approach to organ engineering and regeneration. In the present research, we used a continuous perfusion decellularization protocol to eliminate cellular componet of kidney and evaluated residual scaffold components after decellularizarion process by proteomics analysis. Our proteomic data show that this protocol results in incomplete removal of cellular proteins. However, unlike other authors, we assume that proteins retained within decellularized kidney scaffold could be the basis for specific homing and celular differentation in the recellularization process.

Obstructive uropathy and severe acute kidney injury from renal calculi due to adenine phosphoribosyltransferase deficiency

APRT) deficiency is an uncommon genetic cause ofchronic kidney disease due to crystalline nephropathy.Methods: A case of a Chinese boy with APRT defi ciencypresenting with severe acute kidney injury secondaryto obstructive uropathy from multiple renal calculi wasreviewed.Results: The patient underwent staged removal of thecalculi. Infrared spectrometry of the renal calculi showed2,8-dihydroxyadenine. APRT deficiency was confirmedwith abolished APRT enzyme activity in red blood cells.He was started on allopurinol and low purine diet withcomplete resolution of the residual calculi.Conclusion: APRT defi ciency should be considered inpatients with multiple radiolucent renal calculi.

Local administration of porcine immunomodulatory,chemotactic and angiogenic extracellular vesicles using engineered cardiac scaffolds for myocardial infarction

The administration of extracellular vesicles(EV)from mesenchymal stromal cells(MSC)is a promising cell-free nanotherapy for tissue repair after myocardial infarction(MI).However,the optimal EV delivery strategy remains undetermined.Here,we designed a novel MSC-EV delivery,using 3D scaffolds engineered from decellularised cardiac tissue as a cell-free product for cardiac repair.EV from porcine cardiac adipose tissue-derived MSC(cATMSC)were purified by size exclusion chromatography(SEC),functionally analysed and loaded to scaffolds.cATMSC-EV markedly reduced polyclonal proliferation and pro-inflammatory cytokines production(IFNγ,TNFα,IL12p40)of allogeneic PBMC.Moreover,cATMSC-EV recruited outgrowth endothelial cells(OEC)and allogeneic MSC,and promoted angiogenesis.Fluorescently labelled cATMSC-EV were mixed with peptide hydrogel,and were successfully retained in decellularised scaffolds.Then,cATMSC-EV-embedded pericardial scaffolds were administered in vivo over the ischemic myocardium in a pig model of MI.Six days from implantation,the engineered scaffold efficiently integrated into the post-infarcted myocardium.cATMSC-EV were detected within the construct and MI core,and promoted an increase in vascular density and reduction in macrophage and T cell infiltration within the damaged myocardium.The confined administration of multifunctional MSC-EV within an engineered pericardial scaffold ensures local EV dosage and release,and generates a vascularised bioactive niche for cell recruitment,engraftment and modulation of short-term post-ischemic inflammation.