Received 26 March 2016; accepted 9 June 2016; published 14 June 2016
As well documented in the literature, the nephrologist rarely manages the medical needs of chronic renal failure patients until renal replacement therapy is required. Any unanimous and precise definition of the late reference is found in the nephrology literature neither in French nor in English. Late nephrology case management of patients with chronic renal disease is consistently associated with a more important premature mortality from 20% to 37%, from the end of the first year of dialysis, independently of the age, of the level of the residual renal function and associated co-morbidity. Patients with chronic renal failure are coming too late in nephrology (median creatinin 300 µmol/l), with a poor prognosis (7% death and 29% dialysis in 1 year)  . For hemodialysis, delayed treatment is more frequently associated with dialysis by temporary catheter or central line (75%) than arteriovenous fistula (5% - 20% patients treated early)  . If the detection of kidney disease is early and effective in developed countries, it represents a serious problem in developing countries like the Republic of Guinea where patients are always seen at late stages. The mortality rate of patients with chronic renal failure is affected by a combination of socioeconomic factors, pre-existing medical disorders, comorbidity treatment modalities and renal failure itself  . The objectives of this study were to determine the factors associated with late nephrology case management and to describe the evolution of patients depending on the time of care nephrology.
2. Setting, Material and Methods
This study was conducted at the Nephrology Department of Donka National Hospital with a capacity of 15 inpatient beds and 12 hemodialysis stations. It includes three (3) doctors, four (4) interns and four (4) nurses. It is the only Nephrology Department of the country that is of a populated of 10,628,972 inhabitants. The country has the capital City Conakry (1,667,864 inhabitants) and 4 major natural regions: Maritime Guinea (2,640,630 inhabitants), Middle Guinea (1,727,834 inhabitants), Upper Guinea (2,929,062 inhabitants) and Forested Guinea (1,663,582 inhabitants).
This was a prospective study of observational type during a period of 5 years from January 1st, 2010 to December 31th, 2014. The study included patients admitted to the nephrology department for chronic renal failure. Were included all patients hospitalized with chronic renal failure undergoing or not dialysis and patients hospitalized for acute renal failure were excluded.
The delay in nephrology care was defined by the period between the time of onset of symptoms and the time of consulting the nephrologist.
We looked for the factors related to late nephrology care such as the consultation period, mode of admission (emergency, referred, programed) or the reference patterns and renal risk factors (arterial hypertension, tobacco, diabetes, nephrotoxic drugs, alcohol, urinary infection, obstructive uropathy).
Patients were divided into three categories: those that were able to pay their treatment, those who had support from their families and the needy.
Depending on the mode of admission, we identified patients admitted in emergency, referred by other structures and scheduled for hospitalization. The patients referred from other services were from national, prefectural and communal hospitals and the scheduled patients were those known and followed by nephrologists.
The analysis includes the description of the sample (gender, age, occupation, place of origin), determining the incidence of CKD in the nephrology department, and the description of the factors related to late nephrology care.
The data were entered with Word, Excel and analysed by Epi-info version 3.5.1 software. The results were presented through tables and figures (Tables 1-3 and Figures 1-5).Our results were expressed in percentage and some were subjected to the statistical test of Chi2 and Fisher with a threshold of meaning for any value of p = 0.05.
Table 1. Percent of patients on dialysis according to the region of origin.
Among the dialysed population, 67.6% lived in Conakry where the only dialysis center is located; 14.3% came from the Lower Guinea more than 140 km from the center; 9.9% were from Middle Guinea over 400 km; 5.4% were originate from the Upper Guinea which is more than 650 km and 2.8% from the Forest Guinea more than 1000 km.
Table 2. Initial nephropathy.
The most frequent causes of death are the chronic glomerulonephritis (39/201); followed by renal vascular (37/216); but the vascular renal diseases are the most frequent causes of renal insufficiency (37.5%) followed by glomerulonephritis (35%). Other causes of renal insufficiency were in the order: the diabetic nephropathy (7.3%), the unknow nephropathy (6.4%), the HIVAN (5.6%), the chronic interstitial nephritis (5.5%) and the hereditary nephropathy (2%).
Table 3. Associated diseases and mortality.
The mortality is statistically connected to the arterial high blood pressure, to the cardiac insufficiency, to the diabetes, to the HIV infection, to the pericarditis, to the gastroduodenal ulcer and to the tuberculosis.
Figure 1. Admission pattern. In this population of 575 hospitalized patients, 48 were admitted in emergency, 105 were scheduled by the service of Nephrology and 422 were referred to the other sanitary structures of the country.
Figure 2. Emergency admission pattern. The acute lung edema was the main reason for admission in emergency, followed by anemia, knowledge loss and malignant hypertension.
The limitations of this study were the cost of additional tests and examinations that is not accessible to all patients; the country has only one center of hemodialysis center of 12 posts; there is no peritoneal dialysis, or kidney transplantation.
The study population consisted of 307 men (53.4%) and 268 women (46.6%) with a sex ratio of 1.14. They were all at a terminal stage of chronic renal failure. Patients were aged between 15 and 85 years with a mean of 44.4 ±
Figure 3. Reference pattern of nephrology. The uremic syndrome is the first cause of consultation (54.3%) followed by high blood pressure (42.9%), and then by the oedematous syndrome (40.7%) and oligoanuria (38.6%); the reference to anomalies discovered on ultrasound were rare (0.7%).
Figure 4. Functional signs. On arrival in the service, the functional signs were the vomitings (65.9%) followed by the dyspnoea (50.4%) and the headaches (49.9%).
16.20 years; 6.51% were under 20 years of age; 41.7% were aged in the 40 - 59 age group; 80% were aged under 60. Their social status was as follows: 220 housewives (38.3%), 181 workers (31.5%), 104 civil servants (18.1%), 56 students (9.7%) and 14 unemployed (2.4%). Among them, 121 patients can handle alone, 431 were borne by their families and 23 were indigent. Only 9.2% had access to the hemodialysis. They came from all regions of the country. Among them, 181 patients had consulted before 1 month of the beginning of the signs, 238 between 1 and 2 months and 156 after 2 months.
The first french publications we found on issues due to delay in care, dated back to 1997  . Since then, it was
Figure 5. Risk factors. Factors of renal risk are the arterial high blood pressure (54.3%), followed by to- bacco17.2%), diabetes (13.9%), nephrotoxic drugs (13.6%), alcohol (10.4%), urinary infection (1.7%) and obstructive nephropathy 1.6%).
only in 2001 that two articles for sensitizing internists Doctors and Diabetes Doctors had been published   . No unanimous and precise definition of late referrals was found in the literature. It is most often defined as care within 3 or 4 months before dialysis   . Our study was done in a particular context in a very low resource country with very limited access to healthcare for end-stage chronic renal failure patients; a country of about 11 million inhabitants with only 15 hospital beds and 12 hemodialysis stations; no peritoneal dialysis or kidney transplantation. During the study period, 1162 patients were hospitalized including 575 cases of CKD, a frequency of 49.5% for the population attending our nephrology department. There was a male-predominance (54.4%) with a sex ratio of 1.14. This inequality in CKD could probably be related to its more rapid progression in men compared to women because of the high incidence of cardiovascular risk factors (tobacco and alcohol), observation made in everywhere. The average age of our patients was 44.4 years with extremes of 15 and 80 years. The most affected age group was 40 - 59 years with 41.6%. Our results corroborate those obtained in Africa. For example, in the Democratic Republic of Congo, E. K. Sumaili et al. reported a mean age of 44.5 ± 15 years, with extremes ranging from 12 to 92 years  The predominance of young patients in our study could not be explained because they did not have renal disease or cardiovascular risk factors more than the others populations groups. The most affected category in our series was housewives followed by labors. Our results were similar to those of BAH who reported a predominance of the same social and professional groups respectively 27.92% and 27.68% for housewives and labors  . These results may be related to low economic level of these particular groups, making access to health care quality more difficult resulting in the use of medicinal plants which are responsible for altering renal functions; this has resulted in high rates of delayed consultations in hospitals. Our patients came from all regions of the country: 67.6% resided in Conakry, 14.3% in Lower Guinea, 9.9% in Middle Guinea, 5.4% in Upper Guinea and 2.8% in Forest Guinea. The low incidence of patients from the other regions would be linked to the long distance between Conakry where the only nephrology department of the country is located and the other health care facilities; thus only 9.5% of terminal renal failure in patients has access to hemodialysis. There is no peritoneal dialysis, or kidney transplantation. Considering the nature and delay for consultation, 46.8% of patients who were able to afford health fees consulted within the first month of early signs of kidney failure. For the other cases, where care was supported by family members, only 30.6% had consulted within the same time period against 0% for the poor patients. The findings that emerged is that the lower the socioeconomic status of patients is, the more we will see a delay in adequate nephrology case management. In the US, a study of patients presenting CKD, the majority of those who were starting dialysis had not consulted a nephrologist  . In France, a study on residents in Ile-de-France has shown that 20% - 25% of patients did not benefit from optimal preparation for dialysis. This resulted in an additional cost of 0.25 million francs per patient and a higher mortality rate during the first three months. In particular because of the lack of an arterial-venous fistula previously established for dialysis, a central venous line was required for several weeks, being a significant source for comorbidity  . In Britain, H. Khan et al. had carried out a one year study on all patients with creatinine levels greater than 300 mmol/l in their hospital. They found that only 36% of patients were referred to a nephrologist confirming the assumption of delay in care  . In Guinea, BAH reported that 34.76% of patients were admitted in the terminal phase of the CKD and the mortality rate was 21.58%  . In our series, 422 patients (73.4%) were referred from different health care facilities. Our data differed from those of D. Cordonnier and al. which reported that 50% of patients were referrals  . This high reference rate in our series is the result of symptomatic polymorphism of CKD, extra-renal manifestations being in the front stage, patients consulted nearby facilities or other Hospital services before being referred late to the nephrology services. Among the patients referred, high creatinine level was the first reason of consultation with 54.3%, followed by hypertension (49.9%), edematous syndrome (40.7%) and 38.6% oligo anuria. The high frequency of high creatinine level was related to the fact that the diagnosis was established in the health facilities which referred late the patients to the nephrology department.
Acute pulmonary edema (43.7%) had been the first reason for emergency admissions followed by decompensated anemia (27.1%). In the analysis of symptoms, the main signs shown by order of frequency was uncontrollable vomiting (65.9%); dyspnea (50.4%); headaches 49.9%; oligo-anuria (33.6%) reflecting a very advanced uremic state. Our results are slightly lower than those obtained by A.M. Ahmed in Mali who found for the same signs in the following proportions: uncontrollable vomiting 77.1%; headaches 72.1%; dyspnea 31.4%; epigastralgia 20%  .
In addition to the delay in care, several other reasons could explain these morbidities such as: low socioeconomic level (causing the delay in mobilizing financial resources to pay for exams and the purchase of medicines) and associated co-morbidities.
Vascular nephropathy is the leading cause of kidney failure found in our study (37.5%) followed by other chronic glomerular nephropathies (35%). Hypertension remains the leading cause of CKD in Mali  . This predominance of vascular etiology is explained by the high prevalence of hypertension which was found as a risk factor and predominant medical history in our patients.
Late nephrology case management of chronic kidney disease was frequent in our country. This delay in treatment deprived patients from benefiting nephroprotective treatment exposing them to cardiovascular com- plications. Several phenomena have contributed to the delay in management, which include among others: the insidious nature of the disease, the lower socioeconomic level, the late reference of the patients and the lack of Nephrology unit in the regions. The reasons for the delayed transfer of patients to nephrology consultation should be corrected in each unit and nationwide for attending physicians (general practitioners, internists, cardiologists, diabetes doctors, urologists …). In return, nephrologists provide training and establish close collaboration with them for an optimal management of patients in Guinea.
Conflict of Interest
There is no conflict of interest. The script I am about to present is original and represents my work and that of my co-authors. No part of the manuscript (text, table, figures) has been copied or borrowed from an existing material.