Atlas De Pathologie Renale Pdf Viewer

1. D Margot
2. Histology

Aim. The aim of this study was to assess the referral pattern of patients with kidney impairment in Cameroon. Methods. Medical files of patients received at the out-patients department of nephrology from January 2001 to December 2003 at the Yaounde General Hospital were reviewed. Individual information recorded included age, sex, and referral sources. Data on etiologic and co-morbidity factors, clinical signs of CRF, anthropometric measurements, blood pressure, and biological variables were recorded. Patients were staged for kidney damage in three groups following an adaptation of the Kidney Disease Outcome Quality Initiative (KDOQI) guide recommendations, using the creatinine clearance derived from the Cockroft-Gault equation. Results. Of the 183 patients received during the study period, 140 (77.8%) fulfilled the entry criteria. Men (70%) were more represented, and mean age was 50.19 ± 1.07 years. Hypertension (62.1%) and diabetes mellitus (26.4%) were the most frequent risk factors. There was no major difference between men and women for most clinical and biological variables. Patients were referred mostly by cardiologist (31.4%) and general practitioners (29.3%). Late referral (GFR <30 mL/min) encompassed 82.8% of participants. Regardless of the referral source, the overall trend was toward late referral. Clinical and biological profiles worsen with advanced stage of kidney impairment. In general, management of patients prior to referral was poor. Conclusions. This study has revealed the disconcerting high rate of late referral to nephrologists in this context. Many potential factors can account for this observed pattern, and it is worth investigating to improve referral and outcomes of patients with kidney diseases in Cameroon.

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INTRODUCTION

Chronic kidney diseases (CKD) are a growing health problem with a reported incidence rate more than doubling in many affluent countries over the past two decades, and alarming forecasts for the years to come.[1Thorp ML, Eastman L, Smith DH, Johnson ES. Managing the burden of chronic kidney disease. Dis Manag. 2006; 9: 115–121[Crossref], [PubMed], [Google Scholar]] For example, it has been estimated recently that more than 400,000 people in the United States suffer from end-stage renal failure. With an annual increase in the incidence in the magnitude of 5–8%, this number is expected to double by 2010.[2U.S. Renal Data System. USRDS 2002 annual data report: Atlas of end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md2002[Google Scholar]] The picture in developing countries of sub-Saharan African is less well known. However, given the reported high prevalence of a number of risk factors for CKD, including abnormal levels of blood pressure, diabetes mellitus, and HIV infections in these populations, as well as the relatively poor access preventive measures, CKD is likely to be of major importance in this part of the world.

The growing phenomenon of CKD is paralleled by the increased number of patients in need of renal replacement therapy, such as kidney transplantation and dialysis. Although renal substitution therapies significantly improved the quality of life and outcomes in people with end-stage kidney diseases, strategies to retard the development and progression of chronic diseases are well known and can substantially reduce the need for dialysis. However, most patients are not benefiting from these preventives measures, most often because they are referred late, if referred at all for specialist renal management.[3Lameire N, Wauters JP, Teruel JL, Van Biesen W, Vanholder R. An update on the referral pattern of patients with end-stage renal disease. Kidney Int Suppl. 2002; 27–34[Google Scholar]] Efforts into sensitization of health care professionals have not improved the referral pattern of patients to nephrologists in most countries where almost half of patients with chronic renal failure are referred late to nephrologists.[4Jungers P, Joly D, Nguyen-Khoa T, Mothu N, Bassilios N, Grunfeld JP. [Continued late referral of patients with chronic kidney disease. Causes, consequences, and approaches to improvement]. Presse Med. 2006; 35: 17–22[Google Scholar]] This late referral is associated with significant mortality in dialysis.[5Schmidt RJ, Domico JR, Sorkin MI, Hobbs G. Early referral and its impact on emergent first dialyses, health care costs, and outcome. Am J Kidney Dis. 1998; 32: 278–283[Google Scholar]]

In sub-Saharan Africa, in general, there is scarcity of data on referral pattern of patients with CKD to nephrologists. This study builds on the nephrology out-patients registry of the Yaounde General Hospital in Cameroon to provide a view of the referral pattern of patients with chronic kidney diseases in Sub-Saharan Africa.

MATERIALS AND METHODS

Setting

This was a cross-sectional study of three years' duration from January 2001 to December 2003. The register of the out-patients department of nephrology service of the Yaounde General Hospital (YGH) served as base for patient recruitment. Data were validated by survey of clinical notes. YGH is a 300-bedded hospital, with the main referral nephrology service for the Yaounde city at the time of this study, and one of the two dialysis units available for the whole country (population: 16 million). This study received administrative authorization from the YGH and was approved by the ethic committee of the Faculty of Medicine and Biomedical Sciences (FMSB) of Yaounde 1 University, Cameroon.

Data Collection

Clinical and laboratory data were obtained from the patient records. Files with missing and those of patients referred for acute renal failure were excluded. General individual information recorded included age, sex, and referral sources. Clinical data on etiologic and co-morbidity factors, clinical signs of CRF, anthropometric measurements, and blood pressure were recorded as well as biological parameters (serum urea and creatinine, hemoglobin levels, calcium, albumin, and lipid profile). Secondary variables were derived from primary variables using validated formulas.

Calculations and Definitions

Body mass index (BMI, kg/m²), as defined by weight (kg)/height (m²), was calculated after adjusting the weight by 10% below the recorded value to account for the presence of edema. Predicted GFR (mL/min) was calculated from the Cockroft Gault equation:

Patients were staged for kidney damage at referral in three groups following an adaptation of the Kidney Disease Outcome Quality Initiative (KDOQI) guide recommendations,[6National Kidney Fondation/ Kidney Disease Outcome Quality Initiative. Clinical practices guidelines for chronic kidney disease: Evaluation, stratification and classification. Am J Kidney Dis. 2002; 39(Suppl. 1)S1–S256[Google Scholar]] using the GFR generated from the Cockroft Gault equation:

• early referral: GFR ≥ 30 mL/min;

• late referral: GFR 15–29 mL/min;

• very late referral: GFR < 15 mL/min or dialysis.

The two late referral stages we subsequently pooled together specific analyses. Corrected calcium level (mg/L) was derived as follows:

LDL calculation used the Friedewald formula:

[7Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972; 18: 499–502[PubMed], [Web of Science ®], [Google Scholar]]

D Margot

Emergency dialysis was defined as any dialysis in the course of the first interaction with the nephrologists, and blood pressure (BP) controlled as BP <135/85 mmHg or BP <125/75 mmHg in patients with diabetes and those with proteinuria (i.e., daily urinary protein excretion >1 g).

Statistical Analyses

Statistical analysis were performed using the SPSS® 9 software for Windows. We have reported results as mean, standard error of the mean, and percentages (count). Difference between variables was assessed using the Chi squared test and equivalents, as well as the Kruskal Wallis test. Logistic regressions analyses were used as needed to adjust for the likely influence of extraneous factors on parameter estimates and results expressed as odd ratio (OR) and 95% confidence interval (95% CI). The level of significance was set at p < 0.05.

RESULTS

Data Available

A total of 183 patients were considered for the study period. Medical notes were not available for 23 patients, who were thus excluded. A further 13 patients were excluded because they had acute renal failure, and 7 other for missing data on variables required for estimating the creatinine clearance. Therefore, 140 (77.8%) were eligible for the study, among which there were 98 (70%) males and 42 (30%) females (see Table 1). The age of the patients ranged from 16 to 80 years with a mean of 50.19 ± 1.07 years.

Table 1 Source of referral, aetiological factors, and categories for referral

Rates of Late Referral

The distribution of patients according to the timing of referral was as followed: 24 (early referral), 38 (late referral), and 78 (very late referral). All late referrals encompassed 82.8% of the study population (see Table 1). There was no significant difference with regard to sex (p = 0.5) and age (p = 0.3) distribution.

Sources of Referral

Patients were referred by cardiologist (31.4%), general practitioners (29.3%), internists (7.9%), endocrinologists (5%), and other specialists (10.7%). Whatever the source of transfer, the general trend was toward late referral of patients (see Table 1). After adjustment for age and sex, there was no difference between specialist physicians and other referral sources with regard to the time of referral (early vs. all late referrals); odds ratio (95% confidence interval): 0.89 (0.35–2.22).

Clinical and Biological Profiles

Apart from diabetes mellitus, the distribution of CRF risk factors among groups showed no significant difference. Hypertension was present in 87 (62.1%) patients and diabetes mellitus in 35 (26.4%). No etiological factor was found in 5.7% of patients (see Table 1). After adjustment for age and sex, patients with diabetes [OR (95% CI): 3.19 (1.17–8.67)] were likely to be referred late while those with gout [0.14 (0.03–0.71)] were likely to be referred earlier. Further adjustments for the source of referral (specialist vs. others) and for other co-morbidities had a meaningless impact on the parameters estimates and the precision about. Clinical signs of CRF were regularly found in patients with a high frequency in those referred lately. Asthenia was the most frequent sign, followed by digestive signs like anorexia, nausea, and vomiting (see Table 2). In logistic regression analyses adjusted for age, sex, source of referral, diabetes, and gout, asthenia, anorexia, nausea, vomiting, and cramps were significant positive predictors of late referral (see Figure 1). Blood pressure was high in the study population at large and in subgroups. BMI significantly decreased with the progression of renal failure (p = 0.05). Serum creatinine (p < 0.001), urea (p < 0.001), and phosphorous (p < 0.001) significantly increased with kidney function impairment. There was a reversed trend for serum calcium (p = 0.06) and hemoglobin (p < 0.001). Uric acid levels, albumin, serum electrolytes, and lipid profile showed no significant variation (see Table 3).

Table 2 Signs and symptoms of chronic renal failure by categories for referral

Table 3 Clinical and biological parameters by categories for referral

Figure 1. Odd ratio (with horizontal bars showing 95% confidence interval) estimates, adjusted by age, sex, source of referral, and diabetes status, for various symptoms in all late referral patients compared with the early referral ones. Arrowheads indicate a wide CI that is compressed to fit the scale. Abbreviation: CI = confidence interval.

Figure 1. Odd ratio (with horizontal bars showing 95% confidence interval) estimates, adjusted by age, sex, source of referral, and diabetes status, for various symptoms in all late referral patients compared with the early referral ones. Arrowheads indicate a wide CI that is compressed to fit the scale. Abbreviation: CI = confidence interval.

Treatment at Referral and Early Outcome

At referral, 19 (13.6%) patients were on nephrotoxic treatment, 52 (37.1%) were receiving nephroprotective treatment (ACEI/AIIRB), and no patient was on CRF supplementation treatment. Blood pressure was acceptable in 26 (18.6%) patients. There was no improvement in the quality of treatment in diabetic patients (see Figure 2) nor significant difference by timing of referral after adjustment for confounders (data not shown). Hospitalization rate was high in patients referred late (42.2%). After adjustment for sex, age, source of referral, and status for diabetes, hospitalization was still higher among those referred late [OR (95% CI): 6.90 (1.47–32.33)]. Thirty-nine (33.6%) patients referred late were proposed for emergency dialysis. Among these patients proposed for dialysis, 29 (74.3%) went through the process (all p < 0.001; see Figure 3).

Figure 2. Percentage of patients overall and by referral categories for nephrotoxic, nephroprotective prescriptions and blood pressure control.

Figure 2. Percentage of patients overall and by referral categories for nephrotoxic, nephroprotective prescriptions and blood pressure control.

Figure 3. Immediate outcomes of patients by referral categories.

Figure 3. Immediate outcomes of patients by referral categories.

DISCUSSION

There is a dearth of published literature on chronic kidney diseases in sub-Saharan Africa. The results of this study at large indicate that patients are referred to the nephrologists at the late stage of CRF independently of the referral sources and associated etiological factors. These patients do not regularly received nephroprotective treatment and all related therapeutic adjustments from the referral sources. This study also demonstrates that a large majority of CRF patients are received in nephrology with clinical signs of CRF and related metabolic perturbations, implying the increase need for emergency dialysis.

Patterns of referral of patients with chronic kidney diseases to nephrologists have been explored in most parts of the world, with consistent findings of late referral. The magnitude however varies across countries, with 20% to more than 50% of patients referred at the advanced stage of kidney failure.[4Jungers P, Joly D, Nguyen-Khoa T, Mothu N, Bassilios N, Grunfeld JP. [Continued late referral of patients with chronic kidney disease. Causes, consequences, and approaches to improvement]. Presse Med. 2006; 35: 17–22[Google Scholar],[8]Lhotta K, Zoebl M, Mayer G, Kronenberg F. Late referral defined by renal function: Association with morbidity and mortality. J Nephrol. 2003; 16: 855–861[Google Scholar]] Trends studies also reveal that despite efforts into sensitization of health care professionals and patients, late referral has remained high in many countries.[4Jungers P, Joly D, Nguyen-Khoa T, Mothu N, Bassilios N, Grunfeld JP. [Continued late referral of patients with chronic kidney disease. Causes, consequences, and approaches to improvement]. Presse Med. 2006; 35: 17–22[Google Scholar],[9]Roderick P, Jones C, Drey N, et al. Late referral for end-stage renal disease: A region-wide survey in the south west of England. Nephrol Dial Transplant. 2002; 17: 1252–1259[Crossref], [PubMed], [Web of Science ®], [Google Scholar]] In spite of the overall agreement between our study and previous reports, some findings deserve particular attention. The male dominance among those referred to nephrologists is well known, as male gender is a risk factor for chronic renal failure.[9–11Roderick P, Jones C, Drey N, et al. Late referral for end-stage renal disease: A region-wide survey in the south west of England. Nephrol Dial Transplant. 2002; 17: 1252–1259
Arora P, Obrador GT, Ruthazer R, et al. Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol. 1999; 10: 1281–1286
Iseki K, Tozawa M, Iseki C, Takishita S, Ogawa Y. Demographic trends in the Okinawa Dialysis Study (OKIDS) registry (1971–2000). Kidney Int. 2002; 61: 668–675] However, other factors are likely to account for the 70% proportion of men in our sample. Such factors could include the fact that in the study setting, purchasing power is owned by men, who are therefore more likely to provide for their treatment than women. Compared to other studies, our study population was relatively young.[12Lameire N, Van Biesen W. The pattern of referral of patients with end-stage renal disease to the nephrologists—a European survey. Nephrol Dial Transplant. 1999; 14(Suppl. 6)16–23[Google Scholar]] This young age to is to be attached to the early onset, high prevalence, and severity of risk factors for chronic diseases, including hypertension, diabetes mellitus, glomerulonephritis, and HIV infection. In addition, for many reasons, those risk factors are not regularly detected and appropriately managed in this setting.[13–15Choukem SP, Kengne AP, Dehayem YM, Simo NL, Mbanya JC. Hypertension in people with diabetes in sub-Saharan Africa: Revealing the hidden face of the iceberg. Diabetes Res Clin Pract. 2007; 77: 293–299
Kamadjeu RM, Edwards R, Atanga JS, Unwin N, Kiawi EC, Mbanya JC. Prevalence, awareness and management of hypertension in Cameroon: Findings of the 2003 Cameroon Burden of Diabetes Baseline Survey. J Hum Hypertens. 2006; 20: 91–92
Mbanya JC, Kengne AP, Assah F. Diabetes care in Africa. Lancet. 2006; 368: 1628–1629] The use of herbal medicine and other uncontrolled products in this environment are other major contributors to early onset of chronic renal failure.

The proportion of patients referred late in our study is among the highest reported so far. Many reasons exist to explain this pattern in the study setting and relate to the nature of the disease, patients' factors, health care providers' factors, and the socio-economic circumstances. The silent course of CRF and related risk factors is one of those reasons, and patients most often consult with clinical symptoms of CFR. Only regular monitoring of the kidney function as reported elsewhere can improve early detection of kidney impairment.[3Lameire N, Wauters JP, Teruel JL, Van Biesen W, Vanholder R. An update on the referral pattern of patients with end-stage renal disease. Kidney Int Suppl. 2002; 27–34[Google Scholar]] Other reasons relate to the non-acceptance of CRF by patients, lack of awareness to risk factors, access to specialist care, and financial considerations. As reported elsewhere, poor socioeconomic status is a major contributor to delayed referral of patients with chronic renal failure.[16Obialo CI, Ofili EO, Quarshie A, Martin PC. Ultralate referral and presentation for renal replacement therapy: Socioeconomic implications. Am J Kidney Dis. 2005; 46: 881–886[Google Scholar]] The adverse consequences of late referral have been widely described.[17–20Kessler M, Frimat L, Panescu V, Briancon S. Impact of nephrology referral on early and midterm outcomes in ESRD: Epidemiologie de l'insuffisance renale chronique terminale en Lorraine (EPIREL): Results of a two-year, prospective, community-based study. Am J Kidney Dis. 2003; 42: 474–485
St Peter WL, Schoolwerth AC, McGowan T, McClellan WM. Chronic kidney disease: Issues and establishing programs and clinics for improved patient outcomes. Am J Kidney Dis. 2003; 41: 903–924
Stack AG. Impact of timing of nephrology referral and pre‐ESRD care on mortality risk among new ESRD patients in the United States. Am J Kidney Dis. 2003; 41: 310–318
Levin A. Consequences of late referral on patient outcomes. Nephrol Dial Transplant. 2000; 15(Suppl. 3)8–13] In the absence of a follow-up component, we were unable to pick-up most of them in this study. The overall implication, however, is that patients referred late are less likely to receive interventions that could alter the progression of CRF or reduce its associated co-morbidity, and thus have a worse clinical state at the start of renal replacement therapy. Late referral is associated with frequent and long hospitalization, high demand for emergency dialysis on temporary vascular access, and frequent need for blood transfusion. The financial burden is therefore high and survival on dialysis poor. For example, because of issues relating to accessibility and affordability, 10 patients of our sample proposed for emergency dialysis could not benefit from this treatment.

Some limitations must be accounted for when interpreting the findings from this study. One of these limitations has to do with its retrospective nature and all shortcomings of such a design, including the absence of standardization in the assessment of variables under consideration and issues relating to missing variable/cases. Indeed, 30 patients were excluded from the present analyses because of missing variables. This was most often due to the systematic destruction of files of patients who died in the host institution at certain period. Given that patients who died early were more likely to be those with advanced kidney failure, our finding likely underestimate the true magnitude of the problem of late referral in this setting. However, the major conclusions of the study remain valid. The Cockroft Gault formula was used in this study to assess and rank patients for kidney impairment. It is well known that this approach underestimates the magnitude of kidney damage at the early stage of the condition.[21Nelson AW, Mackinnon B, Traynor J, Geddes CC. The relationship between serum creatinine and estimated glomerular filtration rate: Implications for clinical practice. Scott Med J. 2006; 51: 5–9[Google Scholar]] Again, given the low proportion of those at early stage in this study (25%), the results will be less affected. Cystatin C-based GFR equations are promising alternatives to overcome some of the limitations of Cockroft formula and other serum creatinine-based GRF equations.[22Zahran A, El-Husseini A, Shoker A. Can cystatin C replace creatinine to estimate glomerular filtration rate? A literature review. Am J Nephrol. 2007; 27: 197–205[Crossref], [Google Scholar]] Internationally, there is no consensus as to what should be considered as late referral for patients with kidney diseases to nephrologists. In general, there are two lines of thoughts. Some advocate using the time of follow-up by the nephrologists before starting dialysis as indicator of referral, while others suggest using the degree of kidney function impairment when first received by the nephrologists after referral.[23Van Biesen W, Vanholder R, Veys N, et al. The importance of standardization of creatinine in the implementation of guidelines and recommendations for CKD: Implications for CKD management programmes. Nephrol Dial Transplant. 2006; 21: 77–83[Google Scholar]] We have used this second approach in our study, based on an adaptation of the NK/DOQI guidelines.[6National Kidney Fondation/ Kidney Disease Outcome Quality Initiative. Clinical practices guidelines for chronic kidney disease: Evaluation, stratification and classification. Am J Kidney Dis. 2002; 39(Suppl. 1)S1–S256[Google Scholar]] This approach is more indicated in resource-poor setting hospitals where cohort studies can at times not be feasible because of increased loss to follow-up and the absence of linkage system to trace patients.

Our results are globally in accordance with the literature reports. However, the large proportion of male subjects, the increased number of lately referred patient, and the inappropriate treatment at referral should be closely considered. Socio-cultural and economical considerations, the absence of a national guideline for the management of CRF, the insufficient training of medical doctors and their ignorance of the role of nephrologists, and the unawareness by the public of the CRF risk factors are among many reasons to be explored. We therefore recommend the development and large diffusion of guideline for the management of kidney impairment and the initiation of other research investigations to identify the determinants of late referral in our setting.

AUTHORS' CONTRIBUTIONS

Histology

MPEH took part in the conception of the study, collected the data, and participated in the interpretation and drafting of the manuscript. GA participated in the design of the study, interpretation of the results, and drafting of the manuscript. APK performed the statistical analysis and participated in the interpretations of the results and drafting of the manuscript. All authors read and approved the final manuscript.

DECLARATION OF INTEREST

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

This work was conducted at The Yaounde General Hospital, Yaounde, Cameroon.

Table 1 Source of referral, aetiological factors, and categories for referral

Abbreviations: HIV/AIDS = human immuno-deficiency virus infection/Acquired immuno-deficiency syndrome.

Table 2 Signs and symptoms of chronic renal failure by categories for referral

Table 3 Clinical and biological parameters by categories for referral

Abbreviations: BP = blood pressure, BMI = body mass index, GFR = glomerular filtration rate.

REFERENCES

• Thorp ML, Eastman L, Smith DH, Johnson ES. Managing the burden of chronic kidney disease. Dis Manag. 2006; 9: 115–121
  , [Google Scholar]
• U.S. Renal Data System. USRDS 2002 annual data report: Atlas of end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md2002
• Lameire N, Wauters JP, Teruel JL, Van Biesen W, Vanholder R. An update on the referral pattern of patients with end-stage renal disease. Kidney Int Suppl. 2002; 27–34
• Jungers P, Joly D, Nguyen-Khoa T, Mothu N, Bassilios N, Grunfeld JP. [Continued late referral of patients with chronic kidney disease. Causes, consequences, and approaches to improvement]. Presse Med. 2006; 35: 17–22
• Schmidt RJ, Domico JR, Sorkin MI, Hobbs G. Early referral and its impact on emergent first dialyses, health care costs, and outcome. Am J Kidney Dis. 1998; 32: 278–283
• National Kidney Fondation/ Kidney Disease Outcome Quality Initiative. Clinical practices guidelines for chronic kidney disease: Evaluation, stratification and classification. Am J Kidney Dis. 2002; 39(Suppl. 1)S1–S256
• Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972; 18: 499–502
  , [Google Scholar]
• Lhotta K, Zoebl M, Mayer G, Kronenberg F. Late referral defined by renal function: Association with morbidity and mortality. J Nephrol. 2003; 16: 855–861
• Roderick P, Jones C, Drey N, et al. Late referral for end-stage renal disease: A region-wide survey in the south west of England. Nephrol Dial Transplant. 2002; 17: 1252–1259
  , [Google Scholar]
• Arora P, Obrador GT, Ruthazer R, et al. Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol. 1999; 10: 1281–1286
• Iseki K, Tozawa M, Iseki C, Takishita S, Ogawa Y. Demographic trends in the Okinawa Dialysis Study (OKIDS) registry (1971–2000). Kidney Int. 2002; 61: 668–675
• Lameire N, Van Biesen W. The pattern of referral of patients with end-stage renal disease to the nephrologists—a European survey. Nephrol Dial Transplant. 1999; 14(Suppl. 6)16–23
• Choukem SP, Kengne AP, Dehayem YM, Simo NL, Mbanya JC. Hypertension in people with diabetes in sub-Saharan Africa: Revealing the hidden face of the iceberg. Diabetes Res Clin Pract. 2007; 77: 293–299
  , [Google Scholar]
• Kamadjeu RM, Edwards R, Atanga JS, Unwin N, Kiawi EC, Mbanya JC. Prevalence, awareness and management of hypertension in Cameroon: Findings of the 2003 Cameroon Burden of Diabetes Baseline Survey. J Hum Hypertens. 2006; 20: 91–92
  , [Google Scholar]
• Mbanya JC, Kengne AP, Assah F. Diabetes care in Africa. Lancet. 2006; 368: 1628–1629
• Obialo CI, Ofili EO, Quarshie A, Martin PC. Ultralate referral and presentation for renal replacement therapy: Socioeconomic implications. Am J Kidney Dis. 2005; 46: 881–886
• Kessler M, Frimat L, Panescu V, Briancon S. Impact of nephrology referral on early and midterm outcomes in ESRD: Epidemiologie de l'insuffisance renale chronique terminale en Lorraine (EPIREL): Results of a two-year, prospective, community-based study. Am J Kidney Dis. 2003; 42: 474–485
• St Peter WL, Schoolwerth AC, McGowan T, McClellan WM. Chronic kidney disease: Issues and establishing programs and clinics for improved patient outcomes. Am J Kidney Dis. 2003; 41: 903–924
  , [Google Scholar]
• Stack AG. Impact of timing of nephrology referral and pre‐ESRD care on mortality risk among new ESRD patients in the United States. Am J Kidney Dis. 2003; 41: 310–318
• Levin A. Consequences of late referral on patient outcomes. Nephrol Dial Transplant. 2000; 15(Suppl. 3)8–13
• Nelson AW, Mackinnon B, Traynor J, Geddes CC. The relationship between serum creatinine and estimated glomerular filtration rate: Implications for clinical practice. Scott Med J. 2006; 51: 5–9
• Zahran A, El-Husseini A, Shoker A. Can cystatin C replace creatinine to estimate glomerular filtration rate? A literature review. Am J Nephrol. 2007; 27: 197–205
  , [Google Scholar]
• Van Biesen W, Vanholder R, Veys N, et al. The importance of standardization of creatinine in the implementation of guidelines and recommendations for CKD: Implications for CKD management programmes. Nephrol Dial Transplant. 2006; 21: 77–83