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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 185-190
Risk factors for chronic renal failure in Ivory coast: A prospective study of 280 patients

Service of Nephrology, Dialysis and Hypertension, Yopougon Teaching Hospital, Abidjan, Ivory Coast

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Date of Web Publication30-Dec-2010


Chronic renal failure (CRF) represents the major cause of mortality in the nephro­logy unit in Ivory Coast because the means for appropriate management are lacking. The present study was performed to investigate the risk factors for CRF so that strategies for prevention could be elaborated. A case-control study was performed prospectively at the Yopougon Teaching Hos­pital in Abidjan from January 2006 to December 2006. Factors known to cause CRF were investigated in patients and controls. Their prevalence rates were compared with the general population. A total of 280 patients and 113 controls were recruited. The mean age of the patients was 37.88 ± 13.33 years and that of the controls was 41.5 ± 9.72 years. Both genders were equally represented. The main causes of CRF were chronic glomerulonephritis (47.48%), with HIV infec­tion accounting for 15% of them, and essential hypertension (HTA) (25%). Essential HTA repre­sented the only factor which, if untreated, inevitably leads to CRF. Thus, our study indicates that HTA is a major public health concern. All efforts should be implemented to reduce the high prevalence of HTA and the deleterious effect of this disorder in Ivory Coast.

How to cite this article:
Ackoundou-N'Guessan K C, Lagou D A, Tia M W, Gnionsahe D A, Guei M C. Risk factors for chronic renal failure in Ivory coast: A prospective study of 280 patients. Saudi J Kidney Dis Transpl 2011;22:185-90

How to cite this URL:
Ackoundou-N'Guessan K C, Lagou D A, Tia M W, Gnionsahe D A, Guei M C. Risk factors for chronic renal failure in Ivory coast: A prospective study of 280 patients. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2021 May 17];22:185-90. Available from: https://www.sjkdt.org/text.asp?2011/22/1/185/74347

   Introduction Top

Chronic renal failure (CRF) is defined as a permanent reduction in the glomerular filtration rate (GFR) sufficient to produce detectable alterations in well-being and organ function. The prevalence and the incidence of CRF vary from one country to another. In the USA, [1] the incidence has increased from 293 to 334 per million population (pmp) over the period from 1996 to 2001. In Europe, this value is around 462 patients pmp per year. The Third National Health and Examination Survey (NHANES III) estimated that the prevalence of chronic kid­ney disease in adults in the United States was 11% (19.2 million). Furthermore, the preva­lence of chronic kidney disease increased from 10% in 1988-1994 to 13.1% in 1999-2004. [2] Although survival has steadily increased over the past decade, the management of patients with CRF remains very expensive. In the United States, the expenditure on CRF is esti­mated to double in the next year to more than US$ 28 billion by 2010. [3] Diabetes and glome­rulonephritis represent the main causes of CRF in western countries. Similar figures are lac­king in Africa and, indeed, the Ivory Coast. However, the United States Renal Data System Registry (USRDS) [4] and the European Dialysis and Transplantation-European Renal Association (EDTA-ERA) reports are invaluable sources of data on the trends in prevalence and incidence of end-stage renal disease (ESRD) worldwide. [5] The exact prevalence rate of chronic renal disease (CRD) in Ivory Coast is not known. Non-published, hospital-based data in Ivory Coast have reported the prevalence rate to average 69% of 610 hospitalized pa­tients in the nephrology department. The mean age of these patients was 37 years. About 74% of the patients died because of the lack of means for appropriate caring. The main aim of this study was to identify the causative factors of CRF in order to elaborate the strategies for its prevention and treatment.

   Patients and Methods Top

This prospective, case-control study was per­formed at the University Hospital of Yopougon, Abidjan, Ivory Coast, from January 2006 to December 2006. Patients were consecutively recruited over the study period. The inclusion/ exclusion criteria were as follows:

Inclusion criteria

Controls: both gender, aged >5-years-old, re­cruited in the internal medicine and pediatrics departments.

Patients with CRF: both gender, aged >5­years-old, serum creatinine >120 μmol/L after more than two months of evolution.

Exclusion criteria: patients hospitalized in the following services: cardiology, diabetology, infectious diseases and hematology to avoid bias in the recruitment strategy.

The risk factors known to potentially induce CRF were collected. They were divided into six groups: Group-1: past history of bacterial diseases (ENT, cutaneous, urinary, tooth decay); Group-2: past history of parasitic diseases (malaria, schistosomiasis); Group-3: past his­tory of viral disease (HIV 1/2); Group-4: past history of hypertension (HTA), diabetes, kid­ney disease during pregnancy; Group-5: past history of hereditary disease (sickle cell di­sease, polycystic kidney disease); and Group­6: past history of renal disease (edema, hema­turia, albuminuria). Kidney biopsy was not per­formed to formally establish a link between the risk factors and CRF. All risk factors were collected in patients with CRF, in controls and in the general population. A risk factor for CRF was considered when its prevalence was significantly higher in this population than in the controls and in the general population. Fi­gures from the general population were re­trieved from studies performed in different ser­vices dealing with such diseases on a daily basis and published in local scientific journals. Moreover, when such a factor was highlighted, as suggested earlier, its likelihood to be res­ponsible for CRF was further strengthened by the fact that it led to clinical renal symptoms in the absence of any other disease susceptible to induce CRF. Furthermore, when HIV 1/2 was considered, there should be advanced CRF with persisting massive proteinuria and lack of HTA. When it came to HTA, there should have been a familial history of HTA, presence of proteinuria <1 g/day and absence of hematuria. The presence of left ventricular hypertrophy and kidneys with small size bilaterally have added much to the diagnosis, as were the ab­sence of clinical renal symptoms suggestive of glomerulopathy prior to the discovery of HTA and that of secondary HTA.

The diagnosis of CRF was based on the level of serum creatinine. The serum creatinine was measured using the colorimetric reaction of Jaffe, which has been described elsewhere. [6] The serum creatinine was performed three times at an interval of 3 weeks. CRF was defined as serum creatinine >120 μmol/L at each mea­surement and persisting after two months of evolution of the kidney disease.

   Statistical Analysis Top

Parameters are expressed in percentage or mean ± SD. A comparison between the qualitative parameters was made using the X2 test or the Fischer exact test. A comparison between the quantitative parameters was made using the Student "t"-test or the Mann-Whitney test. A P-value <0.05 was considered as significant. The relative risk (RR) for a factor to induce CRF was calculated using the following for­mula: a/(a + b)/c/(c + d) (a = number of pa­tients exposed to the factor; b = number of patients unexposed to the factor; c = number of controls exposed to the factor; d = number of controls unexposed to the factor). A given fac­tor was considered to be a risk factor when the RR was >1.

   Results Top

Two hundred and eighty CRF patients and 113 controls were recruited during the study period. The mean age of the patients and the controls were, respectively, 37.88 ± 13.23 and 41.5 ± 9.72 years. The difference was not sig­nificant. About 2/3 of the patients and the con­trols were males. The mean creatinine levels in the patients and in the controls were, respec­tively, 707.27 ± 121.7 and 110.7 ± 21.4 μmol/L [Table 1]. The main causes of CRF in Ivory Coast were essential HTA and chronic glome­rulonephritis [Figure 1]. The prevalence rates of bacterial infections (ENT, Skin, and tooth decay) in the different populations were 35%, 28.75% and 24.7%, respectively, in patients with CRF, 66.37%, 65.50% and 56.60%, res­pectively, in the controls and 12.60% and 60- 90% in the general population. We did not find any study that has dealt with skin infections in the general population [Figure 2]. As the pre­valence of bacterial infections in patients with CRF was lower than that in the controls and the general population, bacterial infections as a risk factor for CRF appeared unlikely. Similar findings were noted in patients with diabetes (0.35% in CRF, 1% in controls and 7-12% in the general population); sickle cell disease (2.5% in CRF, 7.9% in the controls and 4.7% in the general population), malaria (42.85% in CRF, 82.3% in the controls and 20.77% in the general population), urinary in-fections (16.4% in CRF, 41.5% in the controls and 44% in the general population) and kidney disease during pregnancy (32.73% in CRF, 32.78% in the controls and 4.7% in the general population). Conversely, HTA appeared to be a risk factor for CRF as its prevalence (24.6%) was signi­ficantly higher than that in the controls (7%) and that in the general population (8.14%) (P <0.05) [Figure 3] with a RR = 1.30. Likewise, HIV infection showed a trend towards being a risk factor since the prevalence of HIV infec­tion was 15% in CRF, 11.5% in the controls and 13.18% in the general population (P < 0.09).
Figure 1: Main etiologies of chronic renal failure in Ivory Coast.

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Figure 2: Prevalence of bacterial infections in the different subjects.

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Figure 3: Prevalence of hypertension in the different subjects.

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Table 1: Characteristics of the study population.

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   Discussion Top

The occurrence of kidney disease related to HTA is universally appreciated. In western countries, HTA was reported to lead to kidney disease in 2-15% of the cases after five years of evolution. Risk factors for HTA to induce kidney failure are systolic blood pressure >160 mmHg, proteinuria >1 g/day and advanced age. [7] Moreover, HTA in black patients has been known to be severe and frequently results in kidney failure. In 1996, renal failure related to HTA was found to be 20-times more frequent in blacks residing in the South East of the USA and seven-times more frequent nation­wide. Furthermore, HTA in blacks occurred ten years earlier, with no nocturnal decrease in values. [8] In a study by Chicaya et al, [9] it has been reported that more than 80% of black African patients with HTA display diastolic blood pressure >110 mmHg, and that the pre­valence of CRF related to HTA was estimated to be about 11%. This value was reported to average 26.1% in Nigeria, [10] as in the present study. Because of the low economic status widely spread in black Africa, most of the patients cannot afford the treatment of HTA, leading to persisting high blood pressure with a high possibility of kidney injury. The preva­lence of HTA was significantly higher in pa­tients with CRF than in the controls, which may suggest that there is a susceptibility to the deleterious effect of HTA and a genetic pre­disposition of black subjects to CRF. [11]

Most of the bacterial infections (ENT, skin, tooth decay) leading to kidney lesions are due to β-hemolytic streptococcus of the A group, among which the A-12 serotype was reported to be the most nephritogenic. In a study by D'Almeida et al, [12] the prevalence of β-hemo­lytic streptococcus of the A group was found to average 0.86% versus 18.10% for the C group, 6.90% for the B group and 0.86% for the G group. As the prevalence of the A group is very low, their likelihood to lead to CRF appears weak. Moreover, in a recent study by Niang et al (personal communication), the analysis of 362 kidney biopsies performed over ten years in adult patients with glomerulo­pathy in Senegal showed that around 50% of the cases were related to primary glomerulo­nephritis (focal and segmental glomeruloscle­rosis, membranous nephropathy), 15% to HIV nephropathy, 15% to lupus nephritis and the remaining to unclassified lesions. As mesan­giocapillary glomerulonephritis was not found on biopsies, CRF attributable to bacterial infec­tions appears unlikely.

HIV nephropathy represents a severe disease, leading to renal failure within four months of starting the first clinical renal symptoms. De­fined in the present study as the presence of severe renal failure in young black African patients with massive proteinuria in the ab­sence of HTA, we have reported the same pre­valence of HIV nephropathy as in Senegal (personal communication). In the present study, the prevalence of HIV infections was higher among patients with CRF than in the controls, but almost similar to the general population. Further studies are needed to substantiate these findings. The mechanisms leading to renal le­sions in HIV patients are not clearly eluci­dated. However, it is widely admitted that HIV nephropathy is more prevalent in black than in white patients and that some virus strains are more nephritogenic than others. [13]

The prevalence of diabetes in Ivory Coast has been reported to average 5-9% in the general population, among whom 70% are non-insulin dependant diabetes mellitus (NIDDM) and 30% are insulin-dependant diabetes mellitus (IDDM). Moreover, around 80% of our pa­tients have a diabetes duration of <10 years. [14] As CRF generally occurs after 15-20 years of the evolution of diabetes, one can understand why the prevalence of CRF in our diabetes patients appears to be very low. The short evo­lution time of our patients with diabetes could be attributed to the high mortality frequently encountered in this population and also to their younger age.

Ivory Coast represents an endemic zone for malaria, which is the leading cause of morta­lity in children aged between 0-4 years. [15] Plas­modium falciparum is the parasite that is most frequently encountered in Ivory Coast, which is reported to be responsible for acute nephro­pathy. Conversely, Plasmodium malariae, which is responsible for chronic nephropathy, is re­ported to be rare in the West African area, [16] explaining the low prevalence of CRF related to malaria in our patients.

In approximately 12% of the cases, we were not able to attribute CRF to any specific risk factor, particularly chronic pyelonephritis. In­deed, our study population is very young and the long-term evolution of such diseases to CRF, as is currently known, could explain their low prevalence.

In conclusion, the present study suggests that HTA is the main risk factor for CRF in Ivory Coast. HIV could also be considered as a po­tential risk factor, although further studies are needed to substantiate this observation. As HIV in Ivory Coast, HTA should be declared a public health concern and dealt with appro­priately. The Government should implement policies aimed at systematic screening of HTA in the general population and raising the a­wareness of factors that could lead to HTA (i.e., smoking, obesity, kidney dysfunction, al­cohol, drugs, sedentary life style, high con­sumption of salt) and the main complications related to untreated HTA that could be either invalidating or even lethal.

   References Top

1.US Renal Data system. USRDS 2003 Annual Data report 2003 Bethesda, MD, the National Institutes of Health, National Institute of Dia­betes and Digestive and Kidney Disease. Ref type: report  Back to cited text no. 1
2.Coresh J, Selvin E, Stevens L, et al. Prevalence of chronic kidney disease in the United States. JAMA 2007;298(17):2038-47.  Back to cited text no. 2
3.Collins A, Xue JL, Ma JZ, et al. Estimating the number of patients and Medicare cost for ESRD in the United States to the year 2010. J Am Soc Nephrol 2000;11:133A.  Back to cited text no. 3
4.The USRDS and its products. Unites States Renal Data System. Am J Kidney Dis 1998; 32(suppl):S20-194.  Back to cited text no. 4
5.Valderrabano F, Berthoux F, Jones EH, et al. Report on management of renal failure in Europe, XXV, 1994 ESRD and dialysis report. The ETDA-ERA registry. Nephrol Dial Transplant 1996;11(suppl):2-21.  Back to cited text no. 5
6.Vassault A, Cherruau B, Labbe D. Measure­ment of serum creatine: results from 16 ana­lytic systems A multicentric study. Ann Biol Clin 1992;50:81-95.  Back to cited text no. 6
7.Vikse BE, Aasaro D, Bostad L. Clinical prognostics factors in biopsy proven benign nephrosclerosis. Nephrol Dial Transplant 2002;18:517-23.  Back to cited text no. 7
8.Freedman BI, Iskandars S, Appel RG. The link between hypertension and nephrosclerosis. Am J Kidney Dis 1995;25:207-21.  Back to cited text no. 8
9.The renal risk in essential hypertension in black African adult. A study of 133 hospitalized patients. Med thesis 1995: n΀ 1572 (French, Ivory Coast)  Back to cited text no. 9
10.Olutaye C, Olugbenga OA, Adigun A. Chronic renal failure at the Olabisi Onabanjo university teaching hospital, Sagamu, Nigeria. Afr Health Sci 2006;6(3):132-8.  Back to cited text no. 10
11.Price DA, Crook ED. Kidney diseases in Africans Americans: genetic considerations. J Natl Med Assoc 2002;94(8):16S-27S.  Back to cited text no. 11
12.D'almeida DA. Streptococcal infection in Ivory Coast. A survey on the nasal carrying in urban regions in children aged between 0-6 years. Med Thesis 1989: n΀1006 (French, Ivory Coast)  Back to cited text no. 12
13.Kajiyama W, Kopp JB, Marinos NJ. Glome­rulosclerosis and viral gene expression in HIV­transgenic mice: role of nef. Kidney Int 2000; 58(3):1148-59.  Back to cited text no. 13
14.Kouame P. Intertropical diabetes mellitus: A prospective study of 207 diabetic patients in Ivory Coast. Med Thesis 1992:n΀1272 (French, Ivory Coast).  Back to cited text no. 14
15.Kone B. Malaria in the Tai region (GUIGLO) in Ivory Coast: management policies. Med Thesis 1995: n΀1196.  Back to cited text no. 15
16.The nephrotic syndrome. Malarial infection. In Heptinstall's pathology of the kidney. 5th edition. J Jennette J Colson MM Schwartz 1998:240-2.  Back to cited text no. 16

Correspondence Address:
K C Ackoundou-N'Guessan
Service of Nephrology, Dialysis and Hypertension, Yopougon Teaching Hospital, P.O. Box 632, Abidjan 21
Ivory Coast
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PMID: 21196643

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