PROF. MCLIGEYO SETH O

BACKGROUND: Diabetic foot ulcers contribute significantly to the morbidity and mortality of patients with diabetes mellitus. The diabetic patients with foot ulcers require long hospitalisation and carry risk of limb amputation. The risk factors for developing diabetic foot ulcers are manageable. In Kenya there is paucity of data on such risk factors. OBJECTIVE: To determine the prevalence of diabetic foot ulcers and the risk factors in a clinic-based setting. DESIGN: Cross-sectional study. SETTING: Kenyatta National Hospital, Kenya. SUBJECTS: Patients with both type 1 and 2 diabetes mellitus who had active foot ulcers in both outpatient and inpatient units. MAIN OUTCOME MEASURES: Diabetic foot ulcers glycated haemoglobin, neuropathy, peripheral vascular disease and fasting lipid profile. RESULTS: One thousand seven hundred and eighty eight patients with diabetes mellitus were screened and 82 (4.6%) were found to have foot ulcers. The males and females with diabetic foot ulcers were compared in age, duration of foot ulcers, blood pressure, glycaemic control, neurological disability score and their proportion. Diabetic foot ulcers occurred mostly in patients who had had diabetes for a long duration. The types of (occurence) ulcers were neuropathic (47.5%), neuroischaemic (30.5%) and ischaemic (18%). The neuropathic ulcers had significantly poorer glycaemic control compared to other types and the longest duration (23.3 weeks). Ischaemic ulcers had significantly higher total cholesterol and diastolic blood pressure compared to other ulcer types. Wagner stage 2 ulcers were the commonest (49.4%) but stage 4 ulcers had their highest neuropathic score (7.8/10) and longest duration (23.6 weeks). Aerobic infective pathogens were isolated from 73.2% of the ulcers. CONCLUSION: The prevalence of diabetic foot ulcers was 4.6% in this tertiary clinic. The risk factors of diabetic foot ulcers in the study were poor glycaemic control, diastolic hypertension, dyslipidaemia, infection and poor self-care. These findings are similar to studies done in other environments and they are modifiable to achieve prevention, delay in formation or improved healing of foot ulcers in patients with diabetes. Therefore, specific attention should be paid to the management of these risk factors in patients with or without diabetes foot ulcers in this clinic.

We present two cases of neurofibromatosis type 1 (NF-1), one a 35 year old male who first recognised his problem at the age of fifteen years and at the time of assessment, satisfied the National Institute of Health (NIH) diagnostic criteria for NF-1 and had a nodular plexiform neurofibroma involving the left fifth dorsal nerve root and a diffuse plexiform neurofibroma involving the left lower limb. The second patient, a 45 year old female recognised her problem at the age of 39 years, did not quite satisfy the NIH diagnostic criteria for NF 1 and had diffuse plexiform neurofibroma involving both lower limbs and buttocks almost symmetrically, a finding which has not previously been described to the best of our knowledge. The scarcity of management options are briefly outlined.

We present two cases of neurofibromatosis type 1 (NF-1), one a 35 year old male who first recognised his problem at the age of fifteen years and at the time of assessment, satisfied the National Institute of Health (NIH) diagnostic criteria for NF-1 and had a nodular plexiform neurofibroma involving the left fifth dorsal nerve root and a diffuse plexiform neurofibroma involving the left lower limb. The second patient, a 45 year old female recognised her problem at the age of 39 years, did not quite satisfy the NIH diagnostic criteria for NF 1 and had diffuse plexiform neurofibroma involving both lower limbs and buttocks almost symmetrically, a finding which has not previously been described to the best of our knowledge. The scarcity of management options are briefly outlined.

OBJECTIVES: To provide an overview of the current understanding of the classification of haemolytic uraemic syndrome (HUS) and to describe the epidemiology, pathogenesis, clinical picture, renal histopathological findings, treatment and prevention of shiga toxin (Stx)-associated HUS, the most common type of HUS and; to compare and contrast features of idiopathic (atypical) HUS and inherited HUS with those of Stx-associated HUS. DATA SOURCE: A literature review was performed of major published series between 1989 and 1998 inclusive, using the Index Medicus and MEDLINE search. Some earlier published series were also reviewed in instances where they indirectly led to the current studies or reported on rarer organ involvements in HUS. STUDY SELECTION: Data and opinions from twelve general reviews of HUS, twelve on aetiology and classification, twelve on clinical features, eight on pathogenesis and nine on treatment and prognosis are summarised. CONCLUSION: HUS is a thrombotic microangiopathy with several aetiologies currently thought to play a role. Vascular endothelial cell injury appears to be central to the pathogenesis of all forms of HUS, although the triggering factors may be different and not well understood in some cases. In HUS, supportive therapy is of paramount importance. Reported specific therapies do not have sufficient evidence to support them. Prevention of HUS is possible in Stx-associated form, but not in the others. In patients who go on to develop end-stage renal failure, transplantation is possible, but recurrence rates are high in forms other than those which are Stx-associated. Persisting sequelae in other organs in HUS are infrequent.

Like systemic lupus erythematosus (SLE) itself, manifestations of lupus nephritis are highly varied in their clinical presentation, ranging from mild proteinuria to rapidly progressive glomerulonephritis causing renal insufficiency within weeks. The clinical variability is in keeping with the broad spectrum of histological abnormalities present in renal biopsy specimens from these patients. The therapeutic modalities currently being used in lupus nephritis include oral steroids, pulse methylprednisolone and cytotoxic drugs such as cyclophosphamide and azathioprine either singly or in combinations, depending on the World Health Organisation morphologic classification of the disease. The use of plasmapheresis for proliferative lupus nephritis (WHO class III and IV) and cyclosporin for membranous lupus nephritis (WHO class V) is based on open trials, but not supported by randomised controlled trials. This review assesses the therapeutic modalities available for the treatment of lupus nephritis, giving the available evidence from the literature and acknowledging that none of them might be perfect.

The health, economic and social costs of smoking are enormous and well known to physicians. Smoking results in a lot of morbidity and mortality mainly related to cardiovascular disease, cancer and pulmonary disease. The effect of smoking on the kidneys is little appreciated. It is the purpose of this review article to give evidence from available literature that smoking is indeed deleterious to the kidneys and may result in progression of chronic renal failure to end stage renal disease. It is concluded that nephrologists, and indeed all physicians, should make a concerted effort to save their patients from this vice.

Autosomal dominant polycystic kidney disease [ADPKB] is one of the commonest genetic diseases. Apart from the involvement of the kidneys, several other organs, viz. the liver, the central nervous system, the pancreas, the spleen, the ovaries and the gut, amongst others, are also sometimes involved. This makes ADFKD more of a systemic rather than an isolated renal disorder. This becomes more so considering that the involvement of the other organs contribute significantly to the morbidity and mortality of ADPKD. This review looks at the pattern and prevalence of involvement of other organs, apart from the kidney in ADPKD.