Addressing rising cases, high cost of treating chronic kidney disease

Nigeria, on March 8, joined the rest of the world to celebrate the World Kidney Day (WKD). A day set aside to raise awareness on the plight of people living with Chronic Kidney Disease (CKD) and how to better prevent, treat and manage the “incurable condition.” CHUKWUMA MUANYA (Assistant Editor) and OLUWATOSIN AREO write.

Tina had finished writing her final degree exams. She took ill while waiting for the National Youth Service Corps (NYSC) call up. Tina was diagnosed of Chronic Kidney Disease (CKD). She started seeing doctors (not nephrologists) and also “prayer specialists.” But her condition was not getting better.

By the time the family got direction to send her to India for a kidney transplant, her condition had deteriorated. Tina had developed a lot of complications. The family had to spend more time and money to get her on dialysis and a kidney transplant. But she died six months after the transplant.

However, Mr. Innocent Nnorom has a different story. 39 year- old Innocent, married with two children, is a survivor of CKD. He had a successful kidney transplant with a kidney from his younger brother Chigbo, in 2012. Six years on, Innocent and Chigbo, who hail from Ihiala in Ihiala Local Government Area (LGA) of Anambra State, are alive to tell the story.

Tina and Innocent represent thousands of Nigerians with End Stage Kidney Disease (ESKD) and about 54 million Nigerians that have kidney-related diseases such as hypertension and diabetes.

Innocent told The Guardian yesterday: “CKD is not a terminal disease.”

He enumerated some of the reasons why many victims die: “The common person does not have sufficient information about kidney related ailments. There are very few fully equipped hospitals to treat these types of patients. Many people are not able to gather enough funds to get the treatment done.

“Top of the reason why many die of CKD is lack of information. When you or your relative are diagnosed of kidney disease take the right steps and you will get the right treatment.”

Nephrologists are unanimous that dialysis is the end of the road because it is very expensive. They say, ideally, dialysis costs N90, 000 a week and N360,000 monthly apart from medications that help control the blood pressure. They insist that it is cheaper to prevent than treat because if the person were not placed on dialysis, he or she would die.

Several studies indicate that 17,000 new cases of CKD are diagnosed yearly and only 2000 can afford dialysis treatment in Nigeria.

Consultant Nephrologist and Transplant Physician at the Lagos University Teaching Hospital (LUTH), Dr. Toyin Amira, told The Guardian: “One session for dialysis cost between N20,000 to N30,000 and you can imagine someone with kidney failure that needs to do that three times a week. It is a continuous treatment until the individual gets the transplant and even kidney transplant cost about N6.5 million and above, in some centres N10 million. So the best way out is prevention.

“There is no cure to CKD and it is not reversible, what can be referred as cure is transplant which is expensive, and better not to have it.

“Acute Kidney Disease (AKD) is someone who was well but because of vomiting and diarrhoea leads to injury to the kidney and in most situation, they recover. It is not a respecter of age but for us in Nigeria it happens to people between 20 and 50 (the economically productive age). In the young children, it is due to some abnormality of the urinary tract as they grow older, other things like infection comes in.”

Ahead of the World Kidney Day (WKD), Amira told The Guardian: “There has been an increase in the number of chronic kidney disease and this is due to an increase in prevalence of hypertension and diabetes especially and some other conditions such as Human Immuno-deficiency Virus (HIV), which have increased the burden of kidney disease in Nigeria.”

The theme of this year’s World Kidney Day — kidneys and women’s health — highlights an important but often neglected area of nephrology and, more broadly, of global health.

What are the major causes of chronic kidney disease?

Amira said: “Yes, the common type 2 diabetes is a lifestyle disease. We are adopting the Western lifestyle by eating a lot of food that is high in fat, energy dense food or drink. Most people no longer exercise and many are getting obese. Obesity predisposes one to hypertension and diabetes, so diabetes is really on the high side in driving the increase in kidney disease.

Use of herbal medication that we don’t really know its constituents, the manufacturing process not stringent, some contain toxins that are harmful to the body. Abuse of analgesic also increases it.

So basically not eating right, obesity, use of herbal medications, abuses of analgesic are some of the driving forces.”

She added: “The use of bleaching creams has also been implicated in CKD because it contains mercury, which damages the kidney.”

Why the focus on women? Epidemiological studies suggest that pre-dialysis CKD is more prevalent in women than in men, and women are more likely than men to be kidney donors, but more men than women receive dialysis or undergo kidney transplantation.

According to in a review published ahead of the WKD in the journal Nature, the factors that contribute to these disparities are complex and likely involve biological differences that affect the rate of CKD progression and transplantation criteria (such as the presence of preformed antibodies), as well as sociocultural influences that affect access to care.

A second Review by Kate Wiles and colleagues found that reproductive health and pregnancy are important issues for women with CKD. CKD is associated with reduced fertility and an increased risk of adverse pregnancy outcomes such as pre-eclampsia, preterm delivery and fetal growth restriction. Moreover, low birth weight is a risk factor for hypertension and kidney disease in later life, perpetuating the cycle.

To Amira, the focus on women is because there are some diseases that are peculiar to women and from experience some of the women who ended up with kidney failure started with pregnancy.

The consultant nephrologist said there are some women that are not known to be hypertensive but develop blood pressure doing the end time of pregnancy (pre-eclampsia) and the blood pressure never returns to normal.

She further explained: “Some problems women face have their root in pregnancy, some develop gestational diabetes and after pregnancy transit to be diabetic, maybe not well managed develop some kidney issues. Some diabetes starts in pregnancy, some women have it and are not diagnosed until pregnancy or they have it when they get pregnant, it flares up and destroys the kidney. So this year looks at the diseases that are peculiar to women and what predisposes them to having kidney disease.

“Urinary tract infection (UTI) is more common in women because of the woman anatomy. Aside from UTIs, there are some pelvic tumour or malignancies in women. We have some that have huge fibroid that sit on the pipe that carry urine from the kidney to the bladder, which causes obstruction and when discovered would have caused kidney damage.

“Some with cancer of the cervix and uterus, which sometimes spreads to involve the kidney.”

The nephrologist urged women to be aware of some of these peculiar diseases especially in pregnancy. “Even after delivery there must be regular follow up to ensure that things are okay. Some don’t do it. Like pre-eclampsia can cause acute kidney injury, we see many women referred to LUTH who were not properly managed,” she said.

Amira said women are sensitised that when they are pregnant, they should go for proper antenatal and if any of these disease is discovered, they should be referred to specialist and regular follow up after delivery.

She said pre-eclampsia is a type of hypertension that develops in the later part of pregnancy, the woman develops high blood pressure, leg swelling and spill protein in the urine and the blood pressure can go so high that she convulse. “It is very serious and can harm the mother and the baby and lead to foetal loss or maternal death.”

The nephrologist, however, said with good and early antenatal care, “you would see the trend coming, diagnosed early and nipped in the bud. Gestational diabetes is in women who were not known to be diabetic but blood sugar goes up during pregnancy. So they have high blood glucose and if not well managed can lead to loss of the baby because such women usually have very big babies. So women who have big babies should be screened for gestational diabetes and such women later on develop type 2 diabetes.”

On recommendations on how to survive ESKD/CKD, Innocent said: “Start seeing a kidney disease specialist (nephrologist) immediately – time is of essence. Adjust your diet and life style (your nephrologist will guide you). Take your medicines as at when due. Attend clinics.

Report every change you notice in your body to your doctor for prompt check up. If the family can afford kidney transplantation, start planning for that immediately. It is better to do it when the patient is still very strong. Avoid self medications (orthodox and herbal).”

Amira said kidney care at LUTH is very comprehensive. She explained: “We have all it takes to look after patients with kidney disease. We have dialysis machine, transplant facilities and we have done successfully some in the past. We have well trained specialist who are capable of taking care of this patients, we run two kidney clinics weekly so the patients are sure to get good renal care in LUTH. We are well equipped. We have functional and some new machines and offer dialysis to people.

“There is no free medical care in Nigeria. It is out of pocket money but unfortunately, anywhere in the world, kidney care is expensive, but the difference is that the government take absolute care of the treatment and takes the burden off the patient by paying for dialysis and transplant but unfortunately we don’t have that arrangement here. It makes it expensive.”

The nephrologist said the WKD is to raise awareness because it is far cheaper to avoid kidney dieses than to manage it. “It is expensive and here that we pay out of our pocket, many cannot afford it while the mortality is high. Prevention is key by adopting healthy lifestyle.”

She said most Nigerians do not have a culture of routine medical check up. Amira explained: “The doctor is not there for treating disease but to help individuals maintain good health. Encourage the culture of routine check up.

“It is so cheap with about N3000 you can run urine and blood test, and no one would know whether your kidney are healthy or not. Those with kidney failures must take their drugs and treatment is for life.

Innocent added: “When the patient has got kidney transplantation, he/she can still live for as long as God wills. The major challenge is the cost of the immune suppressants that the persons have to continue taking for the rest of their lives. We therefore implore the government and corporate bodies to come to our aid.

These medicines should be included in the National Health Insurance Scheme (NHIS) scheme so these patients can always access them. Partner with the hospitals treating these patients to subsidize their treatments.”