Many challenges of Nigerians living with chronic kidney disease

Innocent undergoing dialysis

Yesterday was World Kidney Day.  World Kidney Day (WKD) is an annual global awareness and education event held on the second Thursday in March. The 2016 campaign has a specific focus on kidney disease and children. The Guardian in this exclusive report, including an interview with a survivor, draws public attention to the importance of kidney health – what can be done to protect kidneys before the disease strikes and how to assist patients who already have chronic kidney disease. CHUKWUMA MUANYA, Assistant Editor (Head Insight Team, Science and Technology) writes.

37 YEARS old Innocent Nnorom is married with two children and  has been having high blood pressure that refused to go down despite taking several recommended medications.

Innocent who hails from Ihiala in Ihiala Local Government Area (LGA) of Anambra State is a printer. In addition to hypertension, his legs started swelling and would get worse after wearing shoes for hours.  “When I pressed my finger into my feet it would form a hole that would take a time to disappear. I was also having constipation. I found it difficult to go to the toilet. I was always very weak. When I do any little thing I will be gasping for breath. I also had persistent hiccups,” he told The Guardian.

Innocent was diagnosed of End-Stage Kidney Disease (ESKD) in 2011 and needed regular dialysis and organ transplant to live. “Only God knows why He allows bad things happen to good people and good things to bad people at times. Going by human speculations I should not have been a victim of Chronic Kidney Disease (CKD). I was privileged to give my life to Christ at the age of 16. So I never tasted the smoking and boozing side of life,” he said.

    In 2012 when 38,000 visas were issued to Nigerians, 18,000 travelled for medical treatment, spending $260m or an average of $15,000 each. Open-heart surgery, renal transplants, brain surgery, cancer and eye treatment were the main treatments sought.

Innocent, who is an evangelist at St Paul’s Anglican Church, Oke-Afa, Isolo, Lagos, said he knew almost nothing about the kidney and its functions in the human body before he was diagnosed. “I ate whatever appealed to my eyes whenever I wanted. I lived life as though it is all mine. Though I visited the sick sometimes I’m not sure I really appreciated their pains.”

That was how Innocent captured his living style before he was down with kidney disease. With a monthly income of not more than N100, 000, it was not easy for Innocent and indeed anybody diagnosed with CKD.

He said raising money for dialysis became another challenge. “God showed Himself. There was no day I missed my dialysis or any of my medications because of money,” he said.

The doctors advised that Innocent can no longer depend on dialysis but should have a kidney transplant.“My brother, Chigbo, willingly offered to donate his,” he said.
Chigbo told The Guardian: “I just had to do it. I did not just think about any other thing. I was 24 years old.”

Innocent, like so many other Nigerians with CKD, was advised to travel to India. He too does not have faith in Nigerian hospitals because according to him “there are few who can effectively conduct kidney transplant, and those ones rather charge exorbitant fees.”

Innocent was connected to one of the best nephrologists and surgeon in India, Prof. D. K. Agarwal who successfully carried out the transplant.

Five years on, Innocent and Chigbo are alive to tell the story. Chigbo got married last year.Innocent represents thousands of Nigerians with ESKD or CKD.

“Life after kidney transplant is a whole new experience but there are some good lessons to learn from the experience,” he told The Guardian.

He said the first is discipline.  “The first slogan every transplant patient is given is ‘whatever you are asked to do, do it’. You must ‘eat’ your medicines every twelve hours; you must drink a certain minimum quantity of water every day, and so on; in order to maintain your borrowed kidney. It has really helped me in various areas of my life.”

Looming epidemic of kidney failure in Nigeria
A consultant transplant nephrologist, and Clinical Director, St Nicholas Hospital Lagos, Dr. Ebun Bamgboye, said CKD is emerging as a major worldwide public health problem. He said in the developed countries, the cause of the rise of CKD appears not as a result of intrinsic renal disease, but due to the dramatic rise in systemic diseases that damage the kidney, such as hypertension and type-2 diabetes.

Bamgboye who is also the President, Transplant Association of Nigeria (TAN) and Nigerian Association of Nephrology (NAN) said CKD is associated with increased mortality and morbidity especially caused by cardiovascular diseases and it also imposes a huge economic burden on the family and health care delivery system.

The nephrologist who is a Director at MetroHealth, Health Maintenance Organisation (HMO) said CKD is progressive and irreversible and usually involves both kidneys. “It is categorised into five stages. Earlier stages can be managed conservatively. Stage five invariably requires some form of renal replacement therapy or the other,” he said.
Bamgboye said total patients with ESRD currently on management in all the dialysis units in Nigeria are less than 2,000 and estimated expected expenditure on dialysis yearly is N316 billion.
Nigeria loses N81 billion annually to medical tourismAccording to Bamgboye, the Indian High Commission in Lagos issues about 40 medical visas per day. He explained: “The Nigerian High Commissioner to India, stated that 20,000 out of 25,000

Nigerians given visas in 2011 went there for medical care.
According to Bamgboye, the Indian High Commission in Lagos issues about 40 medical visas per day. He explained: “The Nigerian High Commissioner to India, stated that 20,000 out of 25,000 Nigerians given visas in 2011 went there for medical care.

“In 2012 when 38,000 visas were issued to Nigerians, 18,000 travelled for medical treatment, spending $260m or an average of $15,000 each. Open-heart surgery, renal transplants, brain surgery, cancer and eye treatment were the main treatments sought.

According to the Nigerian Medical Association President, Nigeria loses, at least, $500 million every year because of patients travelling abroad for treatment. And India makes $260 million from Nigerian patients annually.
Symptoms

Innocent with family after the kidney transplant

According to a study published in The New England Journal of Medicine, chronic kidney disease often causes severe organ damage before symptoms — such as blood in the urine, swollen hands and feet, and excessive thirst — develop.

In the advanced phases, patients develop serious complications, including high blood pressure, and eventually the kidneys may fail. However, because the heart works very intimately with the kidneys, most people with kidney disease die of heart problems before their kidneys give out.

Causes
Bamgboye said the causes of CKD include: hypertension, diabetes; chronic glomerulonephritis; chronic pyelonephritis; analgesic nephropathy; bleaching creams and soaps containing heavy metals (mercury).

Other causes of CKD, according to Bamgboye are: polycystic kidney disease; sickle cell disease; obstructive uropathy example stones, prostate, fibroids, strictures and cancers; connective tissue disorders example Lupus nephritis, which is inflammation of the kidney that is caused by systemic lupus erythematous (SLE); toxic nephropathy; and Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS).

Risk factors for causes and progression of CKD
Bamgboye said the non-modifiable causes are: race; ethnicity; genetics; gender; and age while the modifiable causes include: diabetes; hypertension; HIV; obesity; hyperlipidemia (high cholesterol); smoking; poverty; and social deprivation.

Why are Africans more prone to CKD?He said: “This is due to some inheritable genes, poor access to health care, illiteracy, and ignorance.”

Bamgboye said hypertension is common in persons of black African origin. He said several studies have shown that Africans are at greater risk with 1.8 times greater risk of stroke; 1.7 times greater risk of Chronic Heart Failure (CHF); and 4.2 times greater risk of ESRD.

He said data from the South African renal registry of ESRD shows that blacks 34.6 percent, whites 4.3 percent, Indians 13.8 per cent, mixed 20.9 percent had hypertension as a cause of ESRD.

In the United States (U.S.), 15 percent of the black population had hypertension and 50 percent ESRD, he said, adding that hypertension is the commonest non-communicable disease in Nigeria and affects 25 percent of adult Nigerians. He said 70 percent of Nigerians do not know they have hypertension, only 65 percent of those that know are on treatment, and only 30 percent of those on treatment are well controlled.

Bamgboye said diabetes is the commonest endocrine disease in man. He said the incidence increasing with urbanization, obesity and age, and that the disease is two times more common in Africans and three to five times more common in Asians than in white Europeans.

Drawbacks of dialysis
Bamgboye said Continuous Ambulatory Peritoneal Dialysis (CAPD)is usually generally unavailable. CAPD means it happens throughout the day, at home or at work, while the person goes about his or her daily life.

He said many personnel migrate for financial reasons. “20 per cent of trained nephrologists in India practice outside their countries, but there are many more Nigerian and Ghanaian nephrologists practicing abroad,” Bamgboye said.

The nephrologist said there are currently over 76 dialysis units all over Nigeria (42 public, 34 private); 10 renal transplant units (eight public and two private) and over 160 trained nephrologists are actively practicing all over Nigeria.
Bamgboye said dialysis has limitations. “Most efficient dialysis achieves only 10 percent of small solute clearance. The patient remains unwell, fatigue and malaise persist despite erythropoietin (EPO), which is a hormone produced by healthy kidneys. Progressive CVD, peripheral and autonomic neuropathy, osteodystrophy and sexual dysfunction are all not uncommon. The patient is dependent on family for physical, emotional and financial support, and rehabilitation is poor.

High cost of treatment
Bamgboye said an average cost of dialysis is not less than N25, 000 per session while the average cost of a transplant is N5 million. He said the average cost of immunosuppression drugs per year is N1.5 million.
He said: “With Gross Domestic Product (GDP) generally less than $3125, a majority can not afford maintenance dialysis and less so transplantation. 80 percent of patients at University College Hospital (UCH) Ibadan, Oyo State, could not afford more than three sessions of dialysis.

Solution
The nephrologist recommends: Improve socio-economic status of the developing world; ensure more stable and democratic governments; improve sanitation; improve literacy; collaboration with more established programmes; enactment of a solid organ transplant act of parliament as a matter of urgency; establishment of a renal registry supported by government to compile data; commencement of the National Health Insurance Scheme with extension to ensure support for ESRD care.

Bamgboye also wants greater cooperation within and amongst the various units involved in renal care; regular public enlightenment on the causes, methods of prevention and management of ESRD with focus on the relative safety of kidney donation; establishment of a computerized data bank of potential cadaver donors and recipients, which is vital for any cadaver transplant programme; establishment of a transparent, independent and functional national kidney foundation; availability of immuno-suppressives at affordable costs with no duty charged on these drugs plus subsidy if possible; encouragement of research in tertiary institutions on peculiarities of the African in transplantation; further training and improved motivation; and prevention, prevention, prevention.

He said the number of patients with ESRD will continue to increase unless the delivery of optimal preventive medical care to prevent the progression of chronic kidney disease is addressed.
Bamgboye explained: “The leading contributors to this burden are diabetes and hypertension. Fortunately, kidney disease can be prevented and progression can be slowed with early identification and treatment of patients with chronic kidney disease.

“There are sound and cost-effective models of screening and treatment of kidney diseases that could be integrated in the healthcare systems for effective outreach and improved patient outcomes.”

Innocent said the government should please have a programme to be supporting kidney disease patients and transplant patients.
This, he said, they could do by: including them in National Health Insurance Scheme (NHIS) programme. “Right now they are not there. The programme does not cover CKD management and kidney transplant drugs,” he said.

Innocent also recommended upgrading more of our hospitals so they can be taking adequate care of patients locally.
“There are only very few of them that can do that right now,” he said.