Month: April 2014

Environmental causes of kidney disease and failure in Nigeria, a big public health problem


Many people think of kidney disease and think of more commonly publicized medical causes such as high blood pressure, diabetes or inherited disorders such as polycystic kidney disease.

However, it is important to know that there are a group of causes of kidney disease and kidney failure that are likely under recognized by the public, under diagnosed by doctors and most likely, a bigger public health problem than currently appreciated.

These under recognized causes are toxins and other exposures in the natural and occupational environment. These exposures may occur through what we eat, drink, breath or put on our skin knowingly or unknowingly.

An appreciation of these causes of kidney disease along with the more commonly known causes is important to enable early identification and management before kidney impairment becomes advanced and irreversible.

The causes of kidney disease and kidney failure in Nigeria that are related to occupational and environmental exposures have not been fully established but of those identified, there are a broad range that include,

Expired drugs:

A commonly overlooked and easily preventable cause of kidney disease is kidney disease due to exposure to expired drugs. One of the most commonly implicated medications that cause kidney disease when expired are the tetracycline family of drugs. When expired, tetracyclines breakdown and produce chemicals that are toxic to the kidney and make it malfunction.

In general, if the color, taste or smell of a drug has changed, if a medication has been in an open, warm and damp place for a long time or if the label shows the medication has expired, THROW the medication away and get a new prescription.

Expired drugs

Expired drugs are harmful. A commonly used antibiotic, tetracycline can be harmful when expired as some of the breakdown products can damage the kidney.

 

 

Heavy metal poisoning: 

This is an under recognized occupational and environmental hazard that has certainly been associated with kidney disease.  Lead that is contained in petrol, paints and batteries over even a few years can accumulate to high levels in the body and cause several problems ranging from nerve damage to kidney damage. Lead exposure is also common among people that work in precious metal mines such as gold mines. Artisanal miners extract the gold from lead-rich ores, many grinding them in flour mills, which creates lead dust. The gold and lead laden dust then mixes with the soil and increased levels of lead have then been identified local foods grown in the area of such activity. Adding to the concern, miners also use mercury, another contaminant harmful to the kidney, to bind with the gold and increase mining yields.  For a report on the documented risk of exposure to lead and other heavy metal poisonings due to pollution that are capable of causing kidney failure in Nigeria, read the an excellent article by Galadima and Garba from the Ahmadu Bello University in Nigeria here.

Lead poisoning

Lead poisoning can be caused by exposure to lead based paint, petrol, battery recycling, old damaged electronics and working in precious metal mines

Excessive amounts of copper and chromium have also been clearly implicated as causes of kidney disease. The leather tanning and processing business in the norther parts of Nigeria has been identified as a source of such heavy metal exposure. The waste water used in processing the leather skins is known to contain levels of copper, chromium and other metals well in excess of toxic levels and the sludge or waste water is commonly drained and spread on soils including farmlands. The heavy metals then can also leach into sources of water used for farming, drinking, washing and bathing. Indeed elevated levels of copper and other toxic substances have been found in rice and other cereals in leather tanning areas as documented in this report by Tudunwada, Essiet and Mohammed here.

When acidic foods are cooked in unlined copper cookware, or in lined cookware where the lining has worn through, toxic amounts of copper can leach into the foods being cooked. This effect is exacerbated if the copper in the pots and pans has corroded, creating reactive copper salts. Actual cooking may not be required for copper to leach into acidic liquids if they are stored in copper for a period of time. Many countries prohibit or restrict the sale of unlined copper cookware. Copper oxide glaze on cups used for hot liquid might also be a concern, as well as copper pipes for conveying water to the home.

Copper poisoning

Copper poisoning is not uncommon among people working with tanning solutions in the leather industry. However, the more common cause of copper toxicity might be with the use of unlined, poor quality copper pots and pans used as cookware. Copper is a good conductor of heat and has been used for many years for making pots and pans.

Mercury exposure may also go unrecognized in people who use mercury containing skin lightening/bleaching products. In the United States and Europe, mercury containing cosmetics are no longer permitted for sale but a number of such products are still widely available and sold in Nigeria. In one survey, up to 77% of Nigerian women reported use of a skin lightening product regularly. The recommendation is to always carefully look at the ingredients for cosmetics and avoid purchase of mercury containing products. For more information on the magnitude of the problem of mercury in cosmetics, read a World Health Organization report that covers the issues in Nigeria as well here.

Mercury poisoning

Mercury can cause kidney problems and is a common component of cosmetics and flourescent bulbs. The more common source of mercury poisoning is with use of mercury based cosmetics.

 

Snake and insect bites:

While venomous snake and insect bites are easily recognized, they may not be as readily identified as causes of kidney disease usually presenting in the form of acute kidney failure. The poisons (venom) from snakes and insects that cause kidney failure usually do not have a direct effect on the kidney but an indirect one though toxic effect on the muscle and red blood cells where heme pigment in the form of myoglobin or hemoglobin can be released in massive amounts and cause toxic damage to the kidneys. The treatment for kidney failure due to snake and insect bites is usually supportive in nature and focused on maintaining blood pressure, flushing the kidneys and making as soluble as possible any other substances such as hemoglobin or myoglobin so that they are not as toxic to the kidneys. Anti-venom medications are not widely available in Nigeria and even where available often are specific to a specific kind of snake or insect bite. An interesting paper on the epidemiology and management of snake related bites in Nigeria is published by A. Habib from the Bayero University in Kano and can be accessed here.

 

Traditional herbal medications.

Not all herbal medications are harmful and a number are clearly beneficial in some circumstances. However, a number of herbal remedies including mushrooms contain certain poisonous chemicals and in the wrong clinical circumstance can cause or worsen kidney diseaseeven irreversibly. Kadiri and colleages in a paper published in the African Journal of medical sciences over 20 years ago estimated that traditional herbal remedies were responsible for about 1 in every 3 cases of sudden kidney failure presenting to the University College hospital Ibadan (access link to abstract of paper here). A paper by A. Mustapha from Nassarawa state university (access here) showed how commonly used one of many traditional herbs are and likely reasons for such even though the hazards were not discussed.

The kidneys are especially vulnerable to the side effects of such toxins from traditional herbal medicines because of the large blood supply to the kidneys. For example a number of traditional herbal medicines in African contain Securidaca longepedunculata (containing saponin and methylsalicylate), Euphoria matabelensis (containing latex), Crotalaria laburnifolia (contains hepatonephrotoxic alkaloids), Callilepsis lauereola or Cape aloesSecuridaca longepedunculata (violet tree) for instance is commonly found in Nigerian herbal mixtures and has been used for the treatment of numerous ailments ranging from abortion, cough and pneumonia to protection from withcraft, “sexual boosting” and tooth aches. A mushroom called Amanita smithiana contains an acid that can cause kidney damage within hours. This mushroom has on occasion been mistaken as an edible mushroom and caused trouble for the unsuspecting recipient. What is under appreciated with herbs like this and the others mentioned is that in many circumstances they cause sudden kidney cell death or raise blood pressure.

Mushroom poisoning

Traditional herbal medications. Mushrooms are a common component of many traditional medicinal remedies. While many mushrooms may be useful and are edible, a number of mushrooms and other herbs are known to be harmful and can cause kidney problems.

Paraquat: 

Is a common component of pesticides used in farms in Nigeria and other developing countries. It is a known environmental cause of sudden kidney failure and know to even cause death. For access to a full length paper describing paraquat toxicity and its mode of action in some commonly consumed vegetables in Abeokuta, Nigeria, click here. A paper reporting a 5 years experience of of a local hospital in India (access here) reported kidney failure as the most common feature of paraquat poisoning as well.

Paraquat insecticide poisoning

Paraquat is a chemical used in pesticides commonly used on farms and is known to cause kidney disease and even kidney failure.

 

Conclusions

This is by no means meant to be an exhaustive discussion of these environmental hazards with an impact on the kidney. The post is meant to raise awareness of the rather common environmental exposures we all may be unaware of that can lead to significant problems for individuals, their families and the community.  Nothing substitutes for attention to what we eat, drink,  breath or put on our skin and advocacy for strict regulation where possible is important.

 

 

SICKLE CELL ANEMIA AND KIDNEY DISEASE IN NIGERIA- A BRIEF REVIEW


The red blood cell is an important cell component of the blood and functions to deliver oxygen to all the tissues. Each red blood cell contains what is called hemoglobin, the vehicle for carrying oxygen within the red blood cell. Abnormalities of the hemoglobin in the red blood cell can make the red blood cell function abnormally and cause serious problems in tissues of the body including the bone, brain, intestines, lung and even the kidney.

Sickle cell disease is also called sickle cell anemia or drepanocytosis. It is a hereditary disorder of red blood cells most common in Africa and in persons of African descent where under stressful conditions such as infection, dehydration or low oxygen tissue supply, the red blood cells assume an abnormal rigid sickle shape- a process called sickling. Sickling decreases the flexibility of the red blood cell makes the red blood cell unable to pass through the blood vessels easily and for this reason reduces oxygen supply to tissues including the kidneys. If this sickling happens sufficiently, it can cause damage in these tissues and even death.

sickle cell1

A high powered electron micrograph of a sickled red blood cell. See how different it looks from the smooth round normal red blood cells nearby. These sickle cells are rigid and when a sufficient number of sickle cells accumulate in the blood, they block the blood vessels and cause crises in body tissues such as the brain, lung, bone, intestines and even the kidney.

 

function due to sickling

The blood vessel on the left shows how normal red blood cells permit normal overall blood flow. In the blood vessel on the right, the sickled red blood cells are rigid, inflexible and obstruct normal flow of blood and therefore oxygen to involved blood vessels.

 

There is also a less severe form of the sickling condition called the sickle cell trait or “AS” condition, where in simple language only half of the hemoglobin expressed is at sickling risk. Because the other half of their available hemoglobin is normal, they can provide oxygen better to tissues and are at much lower risk for clinical problems although if stressors are very severe, they may develop crises.

 

The number of people living with sickle cell disease is highest in Nigeria where over a million people live with the full sickle cell disease (SS) and over 30 million live with the sickle cell trait (AS). There are also high numbers of people born with the disease in east Africa (specifically, the Democratic Republic of Congo) and India. It has been estimated that about 90,000 babies were born with sickle cell disease in 2010 and this number is expected to grow to about 150,000 in 20501. This therefore means that a larger number of people will be alive with the disease and attention has to be paid by doctors in caring for the people as the number of cases of kidney disease due to sickle cell anemia will also increase.

15799_Sickle_cell_anaemia_MAP

Heat map showing the distribution of persons living with sickle cell disease across the world. The highest prevalence of sickle cell disease (number of people living with a disease) is in west and east Africa. A large number of sickle cell anemia patients also live in India. Up to 25% of the Nigerian population have the sickle cell trait (AS), up to 6% of the population have the full blown sickle cell disease (SS).

 

Sickle cell disease and the kidney

About 1 or 2 out of every 20 patients with sickle cell disease will develop problems with decreased kidney function2,3. The number of patients with sickle cell disease and kidney problems increases with age and among sicklers alive and over the age of 45, 6 out of 10 of them will have kidney problems requiring medical attention. However, only 1-5 out of 20 sickle cell patients with kidney disease will go on to develop kidney failure requiring dialysis or kidney transplantation2,3.

Problems with the kidney due to sickle cell disease is usually due to sickling in the small blood vessels of the kidney. The beginning of kidney problems in patients with sickle cell disease is usually quiet starting between the ages of 10 and 20 without symptoms. This symptom free stage is however progressive and requires close attention by doctors to detect early.

The most common signs of kidney disease in sickle cell patients is-

–        Frequent urination and increased volume of urine. Noticed even in the first 10 years of life and is just another reason for sicklers to always remain well hydrated and drink sufficient amounts of water

–        The presence of protein in the urine,

–        The presence of blood even in microscopic amounts in the urine

–        The development of high blood pressure and

–        Worsening anemia.

The presence of any of these problems in a sickler should push the patient and doctor to pay close attention to kidney function in order to prevent progression to kidney failure. Majority of patients with sickle cell disease and kidney failure present between the ages of 20 and 40 years and these patients often are dead within 4 years of diagnosis of kidney failure2,4.

It may appear that the number of people with sickle cell disease and kidney disease is low. However kidney failure is clearly an identified risk for death among sicklers so it is important to prevent kidney disease due to sickle cell anemia and control of kidney disease in those who already have poor kidney function is important.

It is equally important to note that not all kidney disease in patients with sickle cell anemia is due to sickle cell disease. Other causes of kidney disease in these patients might include lupus, or infection with hepatitis B, Hepatitis C or HIV. These infections are common infections among Nigerian sickle cell patients because of all the blood transfusions they often need over time that puts them at increased risk for acquiring the infections.

For more information on the concerns about blood transfusion and how they may be of importance to sickle cell patients, read our recent blog post about these infections by clicking here.

Sickle cell disease patients also appear to be at increased risk for medullary cancer of the kidney. This often presents with abdominal pain, a swelling in the abdomen, blood in the urine and weight loss. Any sickle cell patient with these symptoms must discuss immediately with their doctor.

What to do to prevent or control kidney disease and symptoms in sickle cell patients.

  • (Please note that these recommendations are only good practices to help empower patients with sickle cell disease. They do not replace the need to see a trained medical professional for detailed proposals for treatment and follow up.)

 

  1. Be vigilant for signs and symptoms of kidney disease such as increasing blood pressure and blood in the urine.
  2. Visit your doctor regularly and ask for a kidney check up with blood and urine tests.
  3. Drink plenty of water
  4. Pay attention to controlling blood pressure.
  5. Make sure as a sickler you get vaccinated against common infections. Fevers and infections are dealt with as quickly as possible by seeing a doctor.
  6. If you already have some kidney disease as a sickler make sure you are seen from time to time by a kidney specialist
  7. Talk to your doctor about medications like EPO, iron and vitamins you can take to increase blood production and decrease the need or frequency of blood transfusions.

 

References

  1. Piel FB, Hay SI, Gupta S, Weatherall DJ, Williams TN. Global burden of sickle cell anaemia in children under five, 2010-2050: modelling based on demographics, excess mortality, and interventions. PLoS Med. 2013;10(7):e1001484. doi: 10.1371/journal.pmed.1001484. Epub 2013 Jul 16.
  2. Saborio P1, Scheinman JI. Sickle cell nephropathy. J Am Soc Nephrol. 1999 Jan;10(1):187-92.
  3. Sharpe CC, Thein SL. Sickle cell nephropathy – a practical approach. Br J Haematol. 2011 Nov;155(3):287-97. doi: 10.1111/j.1365-2141.2011.08853.x. Epub 2011 Sep 9. Review.
  4. Wong WY, Elliott-Mills D, Powars D. Renal failure in sickle cell anemia. Hematol Oncol Clin North Am. 1996 Dec;10(6):1321-31.

Important web links for patients

  1. The sickle cell foundation of Nigeria. http://www.sicklecellfoundation.com/
  2. World Health Organization Fact sheet on sickle cell disease. http://www.who.int/mediacentre/factsheets/fs308/en/

 

UPCOMING BLOG POST- SICKLE CELL DISEASE AND THE KIDNEY IN NIGERIA


The red blood cell is an important cell component of the blood and functions to deliver oxygen to all the tissues. Each red blood cell contains what is called hemoglobin, the vehicle for carrying oxygen within the red blood cell. Abnormalities of the hemoglobin in the red blood cell can make the red blood cell function abnormally and cause serious problems in tissues of the body including the bone, brain, intestines, lung and even the kidney.

Sickle cell disease is also called sickle cell anemia or drepanocytosis. It is a hereditary disorder of red blood cells most common in Africa and in persons of African descent where under stressful conditions such as infection, dehydration or low oxygen tissue supply, the red blood cells assume an abnormal rigid sickle shape- a process called sickling. Sickling decreases the flexibility of the red blood cell makes the red blood cell unable to pass through the blood vessels easily and for this reason reduces oxygen supply to tissues including the kidneys. If this sickling happens sufficiently, it can cause damage in these tissues and even death.

sickle cell1

A high powered electron micrograph of a sickled red blood cell. See how different it looks from the smooth round normal red blood cells nearby. These sickle cells are rigid and when a sufficient number of sickle cells accumulate in the blood, they block the blood vessels and cause crises in body tissues such as the brain, lung, bone, intestines and even the kidney.

function due to sickling

The way sickle cells can block red blood cell flow and delivery of oxygen to tissues.

The prevalence of sickle cell disease is highest in Nigeria where over a million people live with the full sickle cell disease and over 30 million with the sickle cell trait.

15799_Sickle_cell_anaemia_MAP

The highest prevalence of sickle cell disease (number of people living with a disease) is in west and east Africa. Up to 25% of the Nigerian population have the sickle cell trait (AS), up to 6% of the population have the full blown disease (SS).

 

Stay tuned for an update to this post for a full description of how this common, dangerous and important disease can affect the kidney. We will discuss what can be done to reduce the impact of the disease on the kidney as well.