International Conference on Nephrology November 19-21, 2018 Cape Town, South Africa

Marguerite Barnard is a Medical Doctor at Stellenbosch University with a dedicated interest in Urology and Nephrology. Her research was recently published in the African Journal of Urology.

Introduction: The knowledge urethral stricture patients in a developing country Specialist Clinic have regarding their own

the disease remains uncertain.

Objectives: To measure patient’s knowledge of own disease attending Tygerberg Urethral Stricture clinic.

Patients & Methods: A total of 81 patients were assessed from May to August 2015, presented with a questionnaire containing

questions on demographics, ten knowledge questions and qualitative comments. Subgroups were created for patient less and

more than 50 years of age, and education level up to Grade 10 and more than Grade 10. Means were compared using the

Student t-test, correlations were assessed using Pearson’s correlation coefficient and the significance was assumed at an alpha

level of 0.05.

Results: Average age of patients attending the clinic was 55, the average level of education Grade 7 (completed Primary School).

The average level of knowledge for all patients was 46%, with the highest score for question 2 (80%) relating to the definition of

a urethral stricture. The lowest score was achieved for question 8 (28%) relating to self-catheterization frequency. There was no

linear correlation between knowledge and age and a very weak correlation between patient knowledge and level of education.

Conclusion: This study demonstrates that the level of knowledge of owns disease is unacceptably poor across the whole patient

profile. Interventions to improve patient knowledge regarding urethral stricture disease are indicated.

Sameh Mohamed Abouzeid is the Assistant Professor of Internal Medicine and Nephrology, Theodor Bilharz Research Institute (TBRI). He is the Director of

Nephrology unit Al shorouk hospital, Consultant Nephrologist and Head of Nephrology Departments at Mahmoud Hospitals Group.

There is an increasing awareness about the risks of arterial and venous thromboembolism (TE) in hospital patients and the general public which has led to consideration of thrombosis prevention measures in earnest. Early recognition of the symptoms of TE disease has led to timely administration of antiplatelet and anticoagulant drugs, translating to the better outcome in many of these patients. In this respect, patients with chronic kidney disease (CKD) represent a special group. They indeed represent a high-risk group for thrombosis both in the cardiovascular territory and also in the venous circulation. At the same time, abnormalities in the platelet membranes put them at risk of bleeding which is significantly more than other patients with chronic diseases. Anticoagulation may be ideal to prevent the former, but the co-existing bleeding risk and also that the commonly used drugs for inhibiting coagulation are eliminated by renal pathways pose additional problems. In this review, we try to explain the complex thrombotic-hemorrhagic state of chronic kidney disease patients, and practical considerations for the management of anticoagulation in them with a focus on novel anticoagulant drugs.

The prediction of renal allo-graft dysfunction is one of the major concerns in a

patient’s early follow-up, regarding any surgical or non-surgical complications; thus raising the demand for a non-invasive, affordable, non-toxic and an accurate method of screening. Also graft color doppler and ultrasound examination during follow up with any deterioration in kidney functions, urine output, episodes of uncontrolled hypertension or urinary symptoms. It's better to be held by bedside nephrologist for better correlation of image findings and clinical condition. In addition to treatment modifications according to ultrasound findings or need of surgical or non-surgical interventions the examination protocol includes the following: Preparation of the patients, Transplant drugs that interfere with proper examination, Grey scale ultrasound examination of the graft, graft ureter, if there is a stent, perinephric space, Color Doppler ultrasound to evaluate arterial anastomosis, ilio-renal ratio and venous anastomosis, as well as acceleration and resistivity indices, Power Doppler and B-flow to estimate perfusion defects. Also candidates will be able to know methods of examination, timing and interpretation of results simple calculations.

Mahmoud Montasser is a Lecturer of Internal Medicine and Nephrology at Ain Shams University in Cairo/Egypt. Currently, works as a specialty trainee registrar in Renal Medicine in the UK. He also worked as an Honorary Lecturer of Medicine and Nephrology at St. Georges University London and has completed his Post-Graduation in Healthcare and Biomedical Science. His primary interest is hemodialysis and dialysis in the elderly population.

An increasingly older End-Stage Renal Disease (ESRD) population requires nephrologists to focus on issues relating to palliative care. The Renal Physicians Association (RPA), for example, sponsored an evidence-based guideline relating to withholding and withdrawing from dialysis, and the United Kingdom Expert Consensus Group published guidelines for symptom management in adults dying with Chronic Kidney Disease (CKD). Kidney Disease: Improving Global Outcomes (KDIGO) sponsored a workgroup on the topic of palliative or supportive care in CKD outlining the need for additional study and the initiation of palliative treatments. Since nearly 20% of dialysis patients stop dialysis before death and increasingly, older patients are choosing not to begin dialysis in part due to poor outcomes and decreasing functional status with dialysis, it is likely that all nephrologists will be involved in end-of-life care of ESRD and CKD patients. As a group, however, physicians are poorly trained in palliative care and often feel uncomfortable with the responsibility of dying patients. In one survey of American and Canadian physicians, for example, only approximately 40% of 360 nephrologists stated that they were very well prepared to make end-of-life decisions. Despite the identification of the importance of palliative care in ESRD care, nephrology fellows remain uncomfortable and poorly trained in these aspects of clinical care. The primary aim of this talk is to highlight the importance of this critical point and make nephrologists more aware and more familiar with dealing with such a problematic and essential topic.

Gina Granger is a lifelong learner, who completed a Master’s Degree in Nursing, a Bachelor Degree in General nursing, a Bachelor Degree in Education and Community Health, a Diploma in Midwifery, a Diploma in Psychiatric Nursing, Certification in NICU Nursing, Certification as International Board Certified Lactation Consultant  and she is a certified AHA BLS Instructor. During a nursing career of over 40 years (in General Nursing, Midwifery, Psychiatric Nursing, Community Health, NICU and Nursing Education); she was a preceptor, mentor, and educator for nurses in South Africa, as well as in the United Arab Emirates. This included the commissioning of education departments, planning training for dialysis nurses to up-skill them, preparing staff for international accreditation; training basic & advanced life support; and developing of and training staff on nursing policies, procedures and competency assessment tools in various healthcare facilities.

Patients with Chronic Kidney Disease commonly develop End-Stage Renal Disease (ESRD); which requires renal replacement therapy at some stage. The disease combined with the treatment, have a major impact on patients’ personal, family and social lives. Patients have to get used to changes in their lifestyles, diet & fluid intake; due to the condition, routine medical procedures, doctor’s visits, and medical expenses. Studies have found that elderly and younger patients experience the disease and treatment differently, and have different needs. In one study, younger patients have expressed certain gaps in healthcare; that can help improve younger patients’ experiences. Many of them volunteered to act as mentors for other “new” patients; to improve patient education. Families are usually the main social support system for patients, and can greatly contribute to the patient’s disease management. In patients with ESRD consultation is large with the families. One large study showed a close relationship between family education levels and PD patient outcomes. This may be due to higher education levels being associated with better access to healthcare, as well as better understanding of information. Apart from the effects on the patient, the disease also impacts on the patient’s family; who may have to help care for him/ her. The whole family is affected by the fact that dialysis and kidney transplant is needed, and this can be overwhelming for both patient and family members. Financial pressures due to medical costs and sick leave, place a further strain on the wellbeing of the whole family. The speaker will present the experience of a peritoneal dialysis patient whose father also suffered from CKD, and had a kidney transplant.

Moataz Fatthy Abdelnaeem is a lecturer and consultant nephrology and internal medicine at Cairo university medical college and hospitals, interested in

interventional nephrology and bedside diagnostic ultrasound ,received training on interventional sonography skills at Egypt and Preston England my hope is to let

all clinicians be a sonographers also so as to better interpret diseases and save time and this will be the future of examination

Introduction of this modality for nephrologists will help them examine patients in better reliable way as ultrasound machines are available and new technologies of mobile ultrasound will be installed in near future and will be available for every physician and it may a part of the clinical examination, not such an investigation ordered by the clinician. The scope of lung ultrasound (LUS) in emergency and critical care settings has been studied extensively. LUS is easily available at a bedside, free of radiation hazard and real time. All these features make it useful in reducing the need of bedside X-rays and CT scan of the chest. LUS has been proven to be superior to the bedside chest X-ray and equal to chest CT in diagnosing many pleural and lung pathologies. The first International Consensus Conference on Lung Ultrasound (ICC-LUS) has given recommendations for a unified approach and language in major six areas of LUS. The LUS diagnosis is to be given after integration of findings of both lungs.

Colleen Davis started her professional journey as a registered nurse and is registered with the South African Nursing Council with quite a few qualifications including psychiatry, primary healthcare and education. Colleen has worked in different capacities within the healthcare industry, in South Africa, for the past 27 years, with extensive experience in learning and development in a private hospital setting. Colleen moved into executive coaching in 2016, her passion is the development of women in leadership, in Africa, not restricted to the healthcare industry, supporting leaders to become the powerful influencers they have the potential to become. Colleen holds a black belt in karate (JKA), is a cancer survivor, wife and mother to two teenagers. She is a dynamic speaker, influencer and motivator, encouraging hope in an uncertain world

Physician burnout is a well-documented phenomenon; it has been referred to as a “burnout epidemic” which cannot be ignored. The effect is on the professional and personal capability of the physician, the statistics of physician suicide are showing an upward trend. When looking at the breakdown of burnout in medical specialties’, Nephrology gets placed centrally in its percentages and severity. Burnout in Nephrologists and Nephrology nurses affects the quality of care, lower productivity, absenteeism, high turnover and ultimately burdening an already over-burdened healthcare system. The medical profession is traditionally a harsh environment in which superhuman effort is expected on the part of its practitioners and any perceived weakness is hidden, ignored or exploited. Studies in neuroscience show how the human brain responds to being threatened and how trust and hope can build resilience. The purpose of this talk is to create awareness of the impact of burnout on the individual as well as the healthcare system and encourage engagement that can bring about a significant change in the way we view the cause, the victims of, as well as the possible solutions to burnout in the discipline of Nephrology. Findings: Burnout is caused by a mixture of complex interactions resulting in exhaustion, cynicism, and inefficiency directly affecting the Nephrologist, the nephrology interdisciplinary team, the patient and the community. Conclusion and Significance: The American Society of Nephrology has recognized the importance of taking action and in 2018 called for experts to find a workable solution to address physician burnout, for measures to be taken that will improve the professional lives of Nephrologists. Solutions are available; we should be open to a new approach that will ensure that the next generations of physicians are not placed under the same pressures.

Helena (Maria Guerreiro) José completed her PhD in Nursing by the University of Lisbon in 2009. She is the coordinator of the Multiperfil Polytechnic University, Luanda. She is a Professor at the same Institution. She has published 59 articles in scientific journals and 25 papers in events proceedings, has 3 book chapters and 5 books published. She has directed 25 master's and Doctoral thesis in Social Sciences and Health Sciences. She is researcher in Health Sciences with emphasis on Communication Sciences. In her professional activities she interacted with 156 collaborators in co-authorship of scientific works and the most frequent terms in her contextualization of scientific, technological and artistic-cultural production are: humor, nursing, health, nurses, patients, active aging, adherence, child, children, community health nursing, community nursing, content validation and elderly people.

Statement of the Problem: Non-communicable chronic diseases are responsible for about 60% of the causes of death worldwide and Chronic Kidney Disease (CKD) affects an estimated 14% of adults in sub-Saharan Africa, with lowers levels of therapeutic adherence. At present, non-adherence is the main cause for increased morbidity and mortality, reducing the quality of life, increasing health costs, and for overutilization of health services. Regardless of disease, treatment, and prognosis, many patients do not continue with their treatment when they return home or do not fully comply with it. The purpose of this study is to describe the relevance of communication in the therapeutic adherence of CKD patients. Methodology & Theoretical Orientation: A literature review was conducted, the therapeutic adherence models were considered and the model of Levy's cognitive hypothesis of adhesion was a reference. Findings: Therapeutic adherence can be predicted through a combination of client satisfaction with the appointment, understanding of the disease’s cause, extension and treatment, and the ability to remember information provided by health professionals. It is possible to improve adherence if the communication between patients and health professionals is also improved with a clear, simple and true message. In order to increase therapeutic adherence, health professionals should establish a relationship with the patient and the family caregiver through active listening, respect and empathic relationship. Thus, effective communication between health professionals and CKD patients is fundamental to encourage them to therapeutic adherence.

Shailesh Kumar Samal has his expertise in the field of Clinical Immunology. His research interests mostly focused on "Targeting extracellular vesicles for diagnosis

and treatment of vascular calcification".

Background: Malondialdehyde (MDA) is by-product of lipid peroxidation as in oxidized low- density lipoprotein. Antibodies against phosphorylcholine have been previously evaluated in prevalent hemodialysis dialysis patients. We here studied the association between IgM antibodies against MDA (anti- MDA) and risk of death in patients undergoing hemodialysis.

Aim: To see the association of natural IgM antibodies against MDA with all-cause mortality in prevalent hemodialysis patients.

Methods: Low levels of IgM anti-MDA conjugated with human serum albumin concentrations were measured by direct Enzyme Linked Immune-Sorbent Assay (ELISA). The association between IgM anti-MDA and five-year all-cause mortality was investigated. We performed post hoc data analyses in 210 prevalent hemodialysis patients (median age 66 years; 44% female). The patients with an anti-MDA value below cut-off value are compared with a crude hazard ratio. Cox regression analysis, after adjusted by age, gender, diabetes, cardiovascular disease, dialysis vintage and level of interleukin 6, the association between lower IgM anti-MDA level and all-cause mortality was performed.

Results: Among 210 hemodialysis patients, 137 patients (65%) had a IgM anti- MDA level >71.3 U/mL (cut-off value derived from receiver operating characteristic analysis). The patients with an anti-MDA value below cut- off value had a higher mortality rate with a crude Hazard Ratio (HR) of 1.95 (95% CI 1.33-2.88). In Cox regression analysis, after adjusted by age, gender, diabetes, cardiovascular disease, dialysis vintage and level of interleukin 6, the association between lower IgM anti- MDA level and all-cause mortality remained significant (HR 1.79; 95% CI 1.19 - 2.70).

Conclusion: Low levels of natural IgM antibodies against MDA are independently associated with all-cause mortality in prevalent hemodialysis patients.

Roy Aghwana obtained his bachelor's degree in medicine and surgery from the University of Benin teaching hospital in 2004. In 2017 he also obtained membership with the west African college of physicians, Dr. Aghwana is currently undergoing subspecialty training in nephrology in Delta State University Teaching Hospital. He is also in the process of attaining the ISN clinical nephropathology certificate.

Urine microscopy remains a very relevant investigation, as it is affordable and non-invasive, this study aims to determine the pattern of urinary abnormalities, the frequency of urinary tract infections, the pattern of microorganisms causing UTI, and the antibiotic sensitivities.

Methodology and Theoretical Orientation: A retrospective study carried out in DELSUTH, using the urine microscopy results of all patients tested over a 3month period from January 1st, 2017 to March 31st 2017. Available demographic data and urine exam reports were collected using Microsoft Excel. Data analysis was performed using SPSS version 22. Findings: Majority of patients were females (54.9%). The mean age was 49 ± 17year, while age range was between 10-99yr. The highest proportions of patients were between 60-69 (25.5%) and patients between ages 90-99 made up only 0.7%. The prevalence of hematuria and pyuria were 19% and 52.3% respectively; casts were seen in only 2.7% and crystals in 6.5% of the sample. The commonest crystals found were ca oxalate (3.9%). Of the 152 patients, 72 patients (47.1%) had significant cultures and the most common organisms grown were E. coli (40%), Klebsiella (19.4%), and candida (9.7%). UTI was more prevalent in males compared to females (53.6% vs. 41.7%, p=0.188). Overall, antibiotic sensitivity to Amoxicillin/clavulanic acid was 24.1%, Ofloxacin 12.5%, and Gentamicin 9.7%. Conclusion and Significance: Urine abnormalities are common in the sample studied; the frequency of haematuria and pyuria were higher compared to casts and crystalluria. Hematuria was significantly commoner in males and more males had UTI. E.coli was the commonest organism implicated. Although urine microscopic examination is an indispensable tool in nephrology care, to benefit from its wealth of information, it has to be properly executed by trained personnel, with the right protocols and equipment.

Tetsuhiro Tanaka is a currently working at the Division of Nephrology and Endocrinology, the University of Tokyo, School of Medicine. His major research interest is the role of chronic hypoxia and hypoxia-inducible gene transcription in the pathogenesis of CKD. He has completed Graduation from the University of Tokyo, School of Medicine in 1997 and has obtained his PhD degree at the University of Tokyo, Graduate School of Medicine in 2005. He has received the Young Investigator Award of the Japanese Society of Nephrology in 2014. He is currently serving as an Editorial Board Member of Kidney International and Clinical and Experimental Nephrology.

Tubulointerstitial hypoxia plays an essential role as the final common pathway to end-stage renal disease. Hypoxia-Inducible Factor (HIF) is a master transcriptional factor responsible for tissues to adapt to the environment of reduced oxygen concentration. Such mechanisms include regulation of downstream target genes involved in angiogenesis, erythropoiesis and anaerobic metabolism. In some pathophysiological contexts, hypoxia may be recorded as epigenetic changes (“hypoxic memory”) and be responsible for the progression of the kidney disease in the long term. In this regard, we performed genome-wide analysis of HIF-1 binding sites using high-throughput sequencers and found novel downstream targets relevant to epithelial cell behavior. By simultaneously checking histone modification marks, we identified novel roles of HIF-1 in histone modification which enhances its target gene expression. Furthermore, microarray analysis and RNA-seq in cultured tubular cells exposed to hypoxia demonstrated the expression of several novel long non-coding RNA (lncRNA), including aspartyltRNA synthase anti-sense 1 (DARS-AS1), which was most strongly induced by hypoxia and suggested to play anti-apoptotic roles. In an AKI to CKD transition model of ischemia-reperfusion injury in vivo, we observed that pharmacological targeting of histone modifications was effective in ameliorating fibrosis. In summary, HIF is responsible for a variety of epigenetic changes and may ultimately determine the consequences of the disease phenotypes.

It’s common practice in Africa for patients including those diagnosed or undiagnosed with Kidney diseases to first contact Primal Health Care prior to using the western health care systems such as primary health care and nephrology department. It is also believed by most Western-trained practitioners that Primal Health care is harmful to patients with Kidney diseases, however, it’s not the case and therefore, the researcher attempts to correct this misconception by exploring two attributes

(Ubuntu and Holism) of African primal health care (APHC) to facilitate healing on patients suffering from Kidney disease.

‘Primal’ was coined during a colloquium by Dr Mbulawa and Seboka team members; however, no formal conceptualization took place, only operational definition.

Aim: Exploring two attributes (Ubuntu and Holism) of African primal health care to facilitate healing on patients suffering from Kidney disease.

Objectives: Explore philosophical grounding of APHC in Patients with kidney diseases; Describe epistemology of APHC with kidney diseases;

Method: Narrative synthesis, concept analysis (qualitative design). Lekgotla was used as a method of data collection

Results: APHC uses a holistic approach and the family & community are involved in the healing process of patients diagnosed with kidney disease. The praxis involved during the healing process including medicinal plants are anchored in the concept of holism and Ubuntu and therefore does not only focus on the patient diagnosed with kidney disease but also the cosmos. The practices come from the community, for the community and be authenticated by the community.

Michael T Fawzy has completed his Graduation from Minia University Medical School (Egypt). He is dually trained in Internal Medicine and Nephrology. He has fulfilled his training program in 3 countries i.e.; the UK, Egypt and Saudi Arabia. He has been practicing since 2001, the last 3 years in London, UK, at Guy’s hospital (selected as one of the top 5 hospitals in the UK). His practice specializes in the care of renal failure in critically ill patients, chronic kidney disease, hypertension and Vasculitis. His special interests also include end-of-life issues, advanced directives and furthering organ procurement. He is also a Clinical Associate Lecturer of Medicine at University Medical School in Egypt and is a Member of Royal College of Physicians in London. He used to be lecturer and examiner at King’s college medical school in London.

Until the law in the United Kingdom (UK) changed in May 2016 so-called "legal highs" or "new psychoactive substances" were freely available in high street shops across the UK. Following prohibition, these drugs are still easily purchased illegally via the internet. We report a case of a patient who self-administered 3-fluorophenmetrazine intravenously with catastrophic consequences. Adverse effects were almost immediate with symptoms of malaise and tachycardia. Two days post administration he was transferred to the intensive therapy unit with acute kidney injury and irreversible four limb ischemia. He required a period of renal replacement therapy and bilateral lower limb amputation. This case highlights the fact that new psychoactive substances have many unintended adverse effects which has not been previously described. Multiple routes of administration are used by people taking these agents including intravenously. Medical practitioners should always consider ingestion of new psychoactive substances in the differential diagnosis of acutely ill patients.

Pércia Bezerra has completed his Graduation in Medicine at Federal University of Pernambuco (2002), Internal Medicine Residency and Nephrology Residency

at São Paulo University.

Acute Kidney Injury is a life-threatening disease that occurs in about 9-16% of hospitalized patients, however, it can be higher in different settings, like in Intensive Care Units, where AKI can be seen in about 22-57% of the patients, depending on the population studied. AKI increase the morbidity and mortality of the patients, even in episodes of subclinical AKI, as demonstrated by Husain-Sayed F et al and many others authors. Besides that, the costs after an episode of AKI can increase dramatically the cost of hospitalization, the length of stay and can also lead to late no complete recovery of kidney function, leading to a real public health problem. In a recent past and also in the majority of Countries, the diagnosis of AKI is still based on an increase in creatinine levels and low urinary output. However, there are promises advances in techniques trying to detect the presence of AKI in subclinical stages, what could be a great step in prevention and also in precise interventions that could try to stop that damage caused by an episode of acute kidney failure. A promising in earlier diagnosis of AKI is the use of cell-cycle arrest biomarkers of acute kidney damage, like the use of Urinary tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7). The combination of these both biomarkers can detect AKI in a subclinical stage when there were still no changes in creatinine level or urinary output. In a recent paper published by Husain-Syed F and co-workers, in a specifical population of patients undergoing to elective cardiac surgery, the use of the biomarkers [TIMP-2]. [IGFBP7] in the immediate postoperative could predict the development of AKI with an AUC of 0.87. But we cannot talk about the advances in the treatment of AKI when the patients had to go to hemodialysis. The machines are becoming each day more precise, with control of the amount of volume that should be removed from the patient, different kind of alarms that prevent eventual complications during the therapy and also the possibility to combine hemodialysis with others treatments like ECMO, machines to support patients for liver transplantation and many others. In conclusion, there are still a lot of to do, but all community of nephrologists, critical care intensivists and physicians are focus on studying ways to make an early diagnosis, interventions that could prevent the development of AKI and new strategies of treatment.