Treatment

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.

Upcoming Blog Post in March 2014- Viral Infections in Kidney Disease & Dialysis Patients- Truths, Myths and What Can And Needs to be Done


Hepatitis B, Hepatitis C and HIV

An increasing number of apparently healthy people as well as people with kidney disease on dialysis are getting infected with one or more of the Hepatitis B, Hepatitis C or HIV viruses in Nigeria. These are growing problems that need better public knowledge especially among dialysis patients and their family and friends.
Stay tuned and revisit our blog in March 2014 to read on the truths, myths and important issues in dealing with these infections in Nigeria especially as a dialysis patient.

 

Kidney stones- A beginers guide for patients


What are kidney stones?

Kidney Stones are solid materials that develop from substances dissolved in high concentration in urine. Kidney stones may remain in the kidney or break loose and move down the urinary tract to be passed in the urine. Sometimes kidney stones may form in the bladder. Depending on the size of the stone, the stone may pass freely into the urine with or without symptoms. On other occasions, the stone gets trapped along the urinary tract causing pain, blockage to the free flow of urine or other problems.

5338_kidney_stones (1)

Figure 1: Kidney stones may develop anywhere along the urinary tract. They may form in the kidneys, the ureters or the bladder.

Kidney stone- img_2 kidneystones size-201_calcium_oxalate_0-sizes

Figure 2: Kidney stones vary in size from being invisible to the eye to being as large as a finger nail. Small stones or large stones are still capable of causing symptoms. Larger stones are most painful and problematic.

How common are kidney stones?

Even though kidney stones are less common in Africans compared to white people, kidney stones occur fairly frequently among Nigerians and it is estimated that about 65,000-130,000 new cases occur every year in Nigeria. Several hundred thousand Nigerians with longer histories of kidney stones live with kidney stones occurring predominantly in men and in those between the ages of 20 and 45 years of age.  Once a person develops the first kidney stone, he or she is more likely to develop additional stones.

The number of people suffering from kidney stones every year is increasing. The reasons for this are not entirely clear but changing food intake and better diagnostic capability are considered likely causes.

Who gets or develops kidney stones?

Increasing body weight, diabetes, hot temperatures, excessive salt and protein intake and insufficient water intake are considered risk factors for developing kidney stones as well.

The typical person with a kidney stone is a heavy Nigerian male between the ages of 20 and 45 years with a family history of kidney stones who lives in the northern part of the country and works outside most of the time.

It is interesting to note that obese people and diabetic patients have a lower urine pH and a higher urinary uric acid excretion putting them at increased risk  of developing uric acid kidney stones

What are the kinds of kidney stones?

It is important to know that there are different kinds of kidney stones because the treatments for a particular kind of kidney stone may be different from treatments for other kinds of kidney stones. Some patients may have mixed types of kidney stones.

The most common kind of kidney stone is a calcium stone. For patients with calcium stones, the calcium in the urine combines with substances like oxalate or phosphate to form a salt crystal in the urine that can grow and form a large stone. Calcium is an important substance needed for giving strength to bones and teeth, and important in muscle and heart contraction, blood clotting, food digestion, nerve function and many other functions. Free calcium in the blood is filtered by the kidneys into the urine and if calcium accumulates in excess in the blood or urine, it can increase the risk of kidney stone formation. Concentrated urine, excessive amounts of oxalate and uric acid in the urine or low amounts of citrate in the urine are risk factors for developing calcium stones.

Struvite stones form in patients who have infections in the urinary tract with ammonia producing microorganisms. Usually involves gram negative bacteria that are urea splitting . Highly alkaline urine and a high urinary magnesium load can predispose to struvite stones in the presence of the right bacteria. These stones can grow to be very large, may need surgical removal and often need treatment with long term antibiotics along with other measures to control or prevent them.

Cystine stones result from a genetic disorder called cystinuria that causes cystine to leak through the kidneys and into the urine, forming crystals that tend to accumulate into stones. These stones can be hard to find even on x-ray. Cures do not exist but they can be managed effectively by a good doctor.

Uric acid stones develop in people who over produce uric acid or with normal uric acid concentrations but with high urinary uric acid excretion. Some genetic disorders of metabolism as well as gout can be associated uric acid stones. Some blood cancers and defects in kidney handling of uric acid can also predispose to uric acid stones. Low urine pH increases the likelihood of developing a uric acid stone.

Excessive excretion of oxalate in the urine may also be a cause of kidney stones. This excessive excretion may be genetically inherited with treatment ranging from vitamin B6 administration for mild disease to simultaneous liver-kidney transplant for patients with severe disease often leading to kidney failure. On other occasions, the excretion of oxalate in high quantities into the urine may be due to other disorders such as poor intestinal absorption of fatty and bile acids.

Other uncommon causes of kidney stones occur in patients with cystic fibrosis, in those taking the HIV drug called indinavir or in those taking excessive amounts of Vitamin C

21_brushite_apatite_017_struvite_apatite_0_001_calcium_oxalate_0-sizescystine stones06_uric_acid_010_stone_shower_0_0

Figure 3: Types of kidney stones. Kidney stones can come in different colors, sizes and shapes. Sometimes they can be mixed. Different types of stones require different types of treatment.

Top left- Brushite/Apatite stones, Top right- Struvite stones, Middle left- Calcium oxalate stones, Middle right- Cystine stones, Bottom left- Uric acid stones, Bottom right- Mixed type stones.

What are the symptoms, signs and complications of kidney stones?

Symptoms of kidney stones might include some or all of the following

  • Pain in the abdomen or groin,
  • Bloody urine,
  • Nausea, vomiting and frequent urination,
  • Cloudy  or smelly urine
  • Fevers and body shaking if associated with infection of the urinary tract.
Locations for kidney stone pain

Figure 4: Locations for kidney stone pain. The pain often is only on one side but may be on both sides.

Signs of kidney stones that may be detected by a medical professional include

  • Tenderness in the lower back, abdomen or bladder regions
  • Decrease intestinal activity
  • Painful groin or testicles
  • High heart beat or blood pressure
  • Fevers and chills

Complications of kidney stones include

  • Urinary tract obstruction
  • Urinary tract infection including abscess formation
  • Perforation along the urinary tract and leakage of urine
  • Urinary fistula formation
  • Increased risk for kidney disease and kidney failure due to obstruction or infection
  • Increased risk of hypertension which in turn can damage the kidneys.

How do I know if my symptoms are from a kidney stone? Could it be from something else?

Do not assume that all abdominal pain is due to a kidney stone. It is important that you go to see a doctor so that a proper diagnosis can be made because if the wrong diagnosis is made, it may be life threatening. Important other diagnoses to be considered include

  • Abdominal aortic aneurysm
  • Appendicitis
  • Gall bladder infection or gall stone disease
  • Diverticulitis- inflammation of the colon
  • Gastric or duodenal ulcers
  • Liver abscess
  • Pancreatitis
  • Testicular torsion or epididymitis

What tests can be performed to determine if I have kidney stones?

A number of tests need to be performed to determine

1)      if your symptoms are due to kidney stones,

2)      if there are complications due to the kidney stones

3)      what kind of kidney stone you have

4)      the best sort of treatment to offer you.

Tests should be performed on your urine and blood. Special x-rays, CT scans or ultrasound tests may need to be performed to determine the size and location of the stone or if there are any complications of the stone such as abscess for fistula formation. A good doctor will ask you to bring in a sample stone if possible for detailed analysis of the stone type or ask you to perform a collection of all urine passed in a 24 hour period to determine the type of urine abnormality leading to stone formation.

How are kidney stones treated?

Treatment of kidney stones involves medical treatment and at times surgical management. Depending on the situation, this may need to be provided on an emergency basis.  Some cases will need hospital admission while sometimes the situation can be managed on an outpatient basis.

  • Fluid hydration. You need to take at least 3 liters of water every day to help prevent formation of more stones and help dissolution of existing stones
  • Treating possible infection with antibiotics
  • Pain control- with medication or with emergency stenting or drainage.
  • Attempts at medical management to enable passing the stone without surgery can be planned by your kidney specialist or urologist. It is not always successful.
    • The medical management often involves fluid hydration, drugs to help relax the urinary tract and enable passing of the stone in the urine, reducing calcium, oxalate or uric acid excretion into the urine, increasing substances in urine to help prevent and dissolve stones. Those with struvite stones in addition to antibiotics may need to be treated with drugs that inhibit some of the activity of urea splitting bacteria while those with cystine stones may need additional treatment with a binding agent that increases the dissolution of  excess cystine in the urine.
    • There often is a need to modify your diet to reduce the amount of stone forming substances in your urine. For example, kidney stone patients need to significantly reduce their salt and animal protein intake. For patients with oxalate stones, reducing the amount of oxalate intake in food such as is seen in chocolate and spinach and other green leafy vegetables is recommended. patients with uric acid stones need to reduce their intake of organ meats.  There is often no need to reduce the amount of calcium in the diet as long as 
    • Weight loss and better control of diabetes may also be important in some patients especially those with uric acid stones.

Your doctor will determine which drugs, diet and lifestyle changes are necessary for you to undertake  depending on the type of stone you have.

  • When a stone is too big or medical non-surgical attempts at passing the stone have failed, or there are significant complications, surgical treatment is required and can range from
    • Stenting or urinary diversion
    • Open surgery
    • Ultrasound blasting/dissolution of the stone(s)
    • Video assisted removal of the stone often by passing a scope into the bladder and upwards into the urinary system

Make sure you see a well trained doctor to advise you on whether you have kidney stones, what type of kidney stone you have and what the proper treatment is. Not all kidney stones are treated the same way. Always ask about your options and what you can do to prevent kidney stones.

Transplant 101- What you need to know as a transplant patient in Nigeria.


The intention of this post is to empower patients, their family and friends in Nigeria with information that will help them make the best decisions and have the best outcomes with kidney transplantation.

At the present time, if patient’s original kidneys fail, there is no known way to regenerate them and artificial kidneys are not yet available, so the only treatment options are dialysis and kidney transplantation. Kidney transplantation is currently the optimal treatment for kidney failure for patients that qualify. Most patients can live long and productive lives with a kidney transplant similar to that of people without kidney failure if they are careful, take their medications as prescribed, have experienced kidney specialists and perform the required routine testing. To have the best chances of success, take your time to find kidney doctors with experience taking care of transplant patients. Not all kidney doctors know how to take care of transplant patients.

Your kidney doctor will have to perform a number of tests to make sure it is safe to perform the transplant surgery and ensure the cause of your original kidney disease does not destroy the transplant kidney. The testing is also needed to determine the best treatment plan to reduce the risk of transplant kidney rejection or complications such as infections, poor wound healing and cancers. If you have pets such as cats, you must let your kidney transplant specialist know so that you can be appropriately advised. Cats can transmit serious infections to transplant patients and you need to take precautions against getting such infections

Doctor-Patient interaction Make sure your kidney specialist has experience with kidney transplant patients. Not all kidney doctors know how to take care of transplant patients

The steps leading to a successful kidney transplant are

1. Understand the particular cause of kidney failure in your case from a kidney doctor/specialist and find a blood group compatible donor

It is important to know the cause of kidney failure as some of the causes of kidney failure can affect the transplant kidney and destroy it. Your doctor may want to treat the cause of kidney failure and stabilise it before recommending proceeding with transplant.

While these evaluations are going on, you need to look for a donor. In Nigeria, there is no option for a donor kidney from someone who has died as such are not yet legally allowed. So the only option is to get one from a living person who agrees to donate the kidney. Speak to family and friends about your condition. Let them know your increased risk of death and how difficult life is especially if you are on dialysis. These discussions can be difficult because you may be worried about being turned down. If this is the case and you have family or friends interested in learning more but not sure if they want to proceed, ask them to talk to your kidney doctor to discuss the risk and benefits involved in kidney donation. The best donor is from a healthy living person between the ages of 25 and 50 of the same blood group as you with no medical problems.

2. Work up for recipient and donor – reduce risk of bad outcome for recipient and donor.

Transplantation and the surgery involved can be stressful to the body and carry a risk of severe injury or even death. To avoid these complications, your doctor will have to perform tests on your heart, lungs, blood and blood vessels to make sure you can handle the stress of transplantation. You will also need to be tested for certain infections or cancers because transplant medications that prevent rejection of the transplanted kidney weaken the immune system that protects against infection and cancer. Part of preparation for transplant may involve getting vaccines against infections such as hepatitis B.

Your donor also needs testing done. This is to ensure the donor is healthy, can stand the stress of surgery and does not have silent kidney disease or conditions that can cause kidney disease as well. Testing is also necessary to ensure that the donor does not transmit infections or cancers to the recipient. Special testing also needs to be done to ensure the donor and recipient are compatible and help the surgeons know which kidney to take out of the donor and how best to take it out. Some transplant centers require that a donor be related to the recipient while other transplant centers do not insist on such a relationship.

3. Find expert center for transplant and discuss risks and complications

While cost is an important consideration in selecting a transplant center, it is most important to find a center with specialist doctors and experts that know what they are doing. Ask questions of the doctors of their experience taking care of transplant patients, speak to transplant patients and learn about their experiences. Take your time and don’t rush the process. It is an important decision and could be a matter of life and death or a short bad experience only leading you back to dialysis.

At the present time, there are a few centers in Nigeria that perform the surgery. There are also experienced centers outside Nigeria in India, the United States and United Kingdom where kidney transplantation can be performed. Wherever you decide to have your transplant, you must ask questions and get a good understanding of their experience and capabilities to provide excellent care to you and your donor.

 4. Undergo transplant surgery

For the donor, this more recently is done by keyhole (laparoscopic) surgery lasting 3-4 hours. On rare occasion is an open surgery required. Keyhole surgery is the better option and recovery time for the donor is shorter. After successful keyhole surgery, the donor can be discharged from the hospital after 48 to 96 hours. 

Kidney transplant surgery Your transplant surgeon has to be experienced too. Ask around for good centers. Ask about their patient and kidney transplant survival rates at 1 and 5 years after surgery. Also ask about their rejection rates and surgical and transplant medication protocols.

For the recipient, an open procedure is performed that lasts 1-3 hours. The kidney will be put in the lower left or lower right part of your belly close to your bladder. Your original kidneys will not be removed unless there is a good reason to do so such as difficult to control infection, cancer or large cysts. A stent may be put in by your surgeon during the surgery. A lot of medication will be given to you to prevent infection and rejection. You likely will remain in the hospital for 7 to 10 days before you are discharged for out patient follow up. If your surgeon puts in a stent, the stent is taken out 2-3 weeks later after the incisions have healed. This is a simple procedure that takes only a few minutes.

Kidney transplant anatomy Your newly transplanted kidney will be placed at the lower left or lower right portion of your belly. Your original kidneys will not be taken out unless they are infected, have cancer or are too big due to some kidney diseases like polycystic kidney disease.

5 Life after transplant- doctors visits, medications, testing, etc

Immediately after discharge from the hospital after a transplant, you would have to see your doctors at least once or twice a week for the first 4-6 weeks. If there are complications, you may need to be seen more frequently. Each visit will almost alway be accompanied by tests which may be even be requested shortly in advance of the visit so the doctor has real time information on the function of the kidney. Then onwards, the frequency of the visits become less frequent. By the time you hit the 6 month time point, you probably are seeing your doctor only once a month even though you may be doing lab tests twice a month. Your schedule of clinic visits and blood testing after the 6 month time point will depend on your doctor. It is important that you keep these appointments and do the required testing as they are the only opportunities to identify problems early before they become big issues.

You will be on several medications after your transplant. ALL these medications are important. Some are for preventing rejection, some are for preventing dangerous infections due to the rejection medicine. Some patients may continue to need medication for high blood pressure. Initially you may also continue to need EPO for low blood levels (anemia) for some weeks to months till your transplant kidney is working well enough. If you were diabetic before the transplant and on insulin, you may notice that your insulin requirements even go up as the new transplant kidney starts “eating up” some of the insulin. Some of the rejection medicine may also have side effects such a headaches, nausea, vomiting, shaking of the hands, diarrhoea, bone pain, pins and needle sensations in the hands and feet, gout, or even cause high cholesterol or high blood sugar. Some patients that were not diabetic before transplant might become diabetic because of the transplant medication. You transplant doctor will help you control the new onset diabetes.

If you have any of side effects from your medications, you must tell your kidney doctor as soon as possible so that careful changes can be made. NEVER change or stop your medication on your own as this can affect you or your transplant kidney. NEVER start new medicine without your kidney doctor knowing either. Certainly do not take any herbal medicines.

Transplant Medication You MUST take your medicine regularly. Do not start or stop any medication without the knowledge of your kidney doctor.

Many patients are able to return to a high level of functioning after kidney transplantation. Returning to work is possible but depends on a lot of things. It depends on how sick you were before the transplant, if there were serious complications during or after the transplant and how well the kidney transplant is working. Those with simple jobs like working behind a desk can probably return to work before a person that has a physically demanding job. Talk to your kidney specialist about going back to work and the best time to do so. 

6. Do’s and Dont’s

You must take your medications every day as prescribed. You can not forget to take any medications

Do not believe anyone who tells you that you do not need to follow up regularly with your doctor after a kidney transplant. You may get away with no problems for a while but you eventually will pay a heavy and unnecessary price with the kidney failing before it should or having a serious problem that could have been prevented with close follow up. Without proper follow up, you could die, get a serious complication and end up back on dialysis.

Do your routine testing. Sometimes it is the only way to identify a problem when it can be managed easily and cheaply. Routine testing is necessary and important to prolong the life of your kidney. A number of patients have had their transplant kidney function well for up to 30-40 years. This was only because they took really good care of the kidney and kept all their appointments and checkups.

Don’t treat malaria without letting your transplant doctor know. Some malaria medications may reduce the level of your transplant medication in the blood and put you at risk of rejecting the transplant kidney.

Do not take grapefruit or grapefruit juice as a transplant patient. It can affect the levels of transplant medications and increase the risk of rejection.

If you have a fever, do not ignore it or self treat. Talk to your transplant doctor immediately. It could be a sign of a serious problem that threatens your life or your transplant.

It is important to know that transplantation in Nigeria presents a unique and challenging circumstance that patients need to be aware .

First of all, not all patients with kidney failure are candidates for kidney transplantation. It may therefore mean that certain patients will never be suitable candidates for transplant while some with the right medical advice and treatment may eventually become candidates for transplantation.

Patients above 60-70 years of age, with active infections such as tuberculosis, HIV, Hepatitis B or C, patients with certain parasite infestations, patients with active heart or vascular disease or patients with certain cancers are considered poor candidates transplant. Patients without adequate family or social support are not candidates either for transplant as there are a lot of demands before, during and after transplant that most if not all patients can not deal with on their own. Other reasons for not being a transplant candidate may be that the surgery might be too stressful for patients with bad heart or blood vessel disease and lead to death during or shortly after surgery. In addition medications for preventing rejection could worsen existing infections or cancers.

So before rushing for a transplant, speak to a kidney specialist or transplant doctor. The kidney specialist will help you decide if transplant is a safe option for you. For many patients, it may be safer to proceed with dialysis.

Secondly, transplantation worth it but is not cheap and despite the success in many patients it is never 100% certain it will work out easily without costly complications. Also, remember that the kidney transplant may fail and you may need to return to dialysis. The good news is that the cost of transplant is cheaper than dialysis after a few years. The current cost of performing an uncomplicated transplant ranges from 6-10 million Naira in Nigeria to 10-15 million Naira in the US or UK. If there are complications, the costs are higher. The medications to be taken after transplant to prevent rejection or infections can cost as much as 50,000 to 100,000 Naira per month. In addition, monthly testing to check on the level of transplant drugs may cost another 20,000 to 50,000 per month. As far as lab testing is concerned, some of the tests such as transplant drug levels or immune testing need to be performed outside Nigeria such as in South Africa or the UK and drive the cost of testing up. Hopefully, these tests become available locally soon at cheaper rates.

Patients need to have these costs in mind and compare them to the costs of a years worth of sufficient dialysis (3 times a week) that comes to about 5 million Naira per year. This compares to the initial cost of surgery (4-10 million Naira) and then the yearly cost of drugs and testing of about 2 million Naira. Therefore by the beginning of the 3rd to 4th year after transplantation it is cheaper to have a transplant that to remain on dialysis. The reasonable concern with transplant is the huge initial costs.

Thirdly, many patients have trouble finding a donor kidney. There is currently no option of getting a kidney from a dead person as there are not yet any laws in Nigeria to govern or control the use of organs from deceased people. Therefore, the most viable and legal option for obtaining a donor kidney is from a living donor. This person can be related or non related to the potential recipient although it should be noted that many transplant centers do not perform transplant from unrelated donors.

Getting a kidney from a living donor is also the best option for the recipient as it will last longer and work better if put in properly and taken good care of. Some patients and their families may have concerns that it is religiously unacceptable to get a kidney transplant. The Catholic and Anglican Church, the major Islamic bodies and Jehovas Witness church have approved kidney transplantation from either cadaver or living donors. In the case of Jehovas witnesses, the organ is purged/flushed of all blood and transplantation without blood transfusion while risky is possible.

To summarize, getting a kidney transplant is the best option for kidney failure. It is a complicated process and demands sufficient finances, an experienced set of doctors, a supportive family and an informed patient that follows all recommended follow up instructions for the best results.

If you have any questions about kidney transplantation in Nigeria feel free to fill out the contact form below.

 

Upcoming post in January 2014: Transplantation 101- All you need to know as a patient about kidney transplantation


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The next blog post is in January 2014 and will be about kidney transplantation as an alternative to dialysis to treat kidney failure in Nigeria.

It will cover all that patients, their families and friends need to know to understand the process. The post will cover the benefits, the risks, the options for a donor kidney currently available in Nigeria, the preparation for the surgery, the surgery itself, life after the surgery and all that is needed to be a successful kidney transplant patient.

Stay tuned