Polycystic kidney disease (PKD) in Nigeria- Get the facts


Kidney cysts are common and can be part of a congenital or inherited disease or simply present as a single or multiple cysts unrelated to any disease with no long-term problems. Decisions on the treatment of cystic disease of the kidney should be made with the help of a qualified and experienced doctor.

There are several genetic and inheritable kidney diseases and polycystic kidney disease (PKD) is the most common of them all. It affects several thousand Nigerians and others around the world as well. Approximately 2 to 3 of every 20 cases of kidney failure requiring dialysis or transplant is due to polycystic kidney disease. In Nigeria, while there is no strong evidence, some studies suggest the likelihood of having PKD is higher among men than women.

To read first hand, some of the literature published on polycystic kidney disease in Nigeria, click on the links at the bottom of this post.

There are 2 forms of polycystic kidney disease

1) Autosomal dominant polycystic kidney disease (ADPKD). 

This is the most common form of the disease seen in patients in Nigeria. In this form of polycystic kidney disease, there is usually a family history although new mutations in the genes can occur leading to the occurrence in a person with no prior family history.  New mutations are the cause of about 10% of cases of PKD and once a mutation occurs in a family, it there is a 50% chance of transmission to each child.

ADPKD results from a mutation in one of two genes. 85% of mutations occur in chromosome 16 (PKD1 gene) and makes a protein called polycystin-1; 15% of mutations occur in chromosome 4 (PKD2 gene) and makes a protein called polycystin-2. Remember that each cell contains pairs of chromosomes (one from either parent) and only one mutated gene of a chromosome pair is required for the disease to occur. The mutated gene can come from either parent. Every child carrying one mutated gene will have ADPKD. Every conception has a 50% chance of the child inheriting the mutated gene and having ADPKD. The disease does not present in childhood but begins to develop in the mid 20-s to 30’s. Half of the people with PKD between the age of 57 and 73 will develop end stage kidney disease. However, some patients may present much earlier or later than the age of 50 years.

2) Autosomal recessive polycystic kidney disease (ARPKD)

Autosomal recessive polycystic kidney disease (ARPKD) is a relatively rare form of PKD, affecting approximately 1 in 20,000 children. ARPKD results from a mutation in chromosome 6 (PKHD gene). This gene pair makes a protein called fibrocystin or polyductin. Both genes of the chromosome pair must carry the mutation for the disease to occur. There is no family history of the disease in affected children because each parent carries only one mutated gene. Each conception carries a 25% chance of the child inheriting both mutated genes and having ARPKD. ARPKD often causes death in the first month of life. For ARPKD children who survive the newborn period (about 70 percent), approximately one-third will need dialysis or transplantation by age 10. Previously thought to be a fatal condition, the prognosis for children with ARPKD has improved dramatically in countries where sufficient medical care and technology exists.

IPLab5PolycysticKidney2

This is a photograph of a polycystic kidney placed next to a normal kidney. This photograph demonstrates how big and abnormal these polycystic kidneys are compared to a normal kidney.

As the name suggests, PKD is a disease where there is an abnormal formation of many fluid filled sacs in the main tissue of the kidney and occasionally in other organs such as the liver. These fluid filled sacs are not cancerous but in regions where these sacs or cysts exists, the normal organ tissue there is destroyed. These fluid filled sacs increase in size and further damage nearby normal tissue causing a worsening of organ function. The enlargement and increase in number of the cysts often leads eventually to kidney failure and only very rarely does the disease lead to liver failure. Enlargement of the cysts often occurs over years but once established, the cysts are not reversible. Research is ongoing to identify treatments to reduce the rate of growth of the cysts but no successes have been made yet.

The signs and symptoms of polycystic kidney disease can range from having no symptoms in the early stages of the disease to having many signs and symptoms such as

  • High blood pressure (hypertension)
  • Frequent urinary tract infections
  • Blood in urine (hematuria)
  • Protein in urine (proteinura)
  • Urinary tract and cyst infection
  • Mitral valve prolapse- abnormal functioning of an important valve in the heart
  • Hernia
  • Back/flank pain due to enlargement or rupture of kidney or liver cysts
  • Kidney stones. There is an increased risk of kidney stones in patients with PKD.
  • Enlarged kidneys with effects on breathing and amount of food a person can eat because of the size of the kidney occupying a lot of the belly space.
  • Depression and anxiety (due to stress and emotional impact)
  • Aneurysms (bulging of the blood vessel walls) in the brain that could burst and cause stroke
  • Diverticulosis (pouches in the intestines) that could burst or get infected and cause a lot of belly pain

How do I know if I have PKD?

Unless a patient has any of the symptoms listed above, ultrasound is the only way to determine if PKD is present. People less than 20 years of age without symptoms do not need to be tested. For those above the age of 20 years with a family history of PKD with or without symptoms there are specific criteria bAsed on age and the number of cysts seen on ultrasound. For instance, a person under the age of 30 with a family history of PKD must have 2 cysts in one or both kidneys while a person over the age of 60 years with a family history of PKD needs to have 4 cysts in each kidney. Genetic testing of family members may also be useful in determining presence of PKD.

Treatment of PKD

  • Back/flank pain: testing needs to be performed to ensure that there is no kidney stone, cancer, bleeding or infection all of which can cause pain. Sometimes in the absence of stone, bleeding cancer or infection, the large size of the cysts can cause pain. Treatment of infection, removal of fluid from very large cysts to help reduce pressure and pain are options for treatment. Less frequently surgical removal of the affected kidney is required.
  • Treatment of urinary tract and cyst infection: These infections are often frequent and can be severe and may involve infection of the kidney cysts or the liver cysts. Treatment with antibiotics after testing for the kind of bacteria causing the infection sometimes for long periods of time or continuously may be necessary.
  • Treatment of kidney stones: treatment of kidney stones in patients with PKD are no different from treatment of kidney stones without PKD.
  • Treatment of hypertension: Very good control of high blood pressure is very important because high blood pressure speeds up the rate of progression to kidney failure.
  • Treatment of kidney failure: Dialysis or kidney transplantation is effective in treating cases of advanced PKD.
  • Treatment of brain aneurysms: stroke is a complication of PKD in some patients who develop aneurysms in the brain. Effective blood pressure control and in some cases surgery to clip the aneurysm is needed.

References

1) Familial polycystic kidney disease in Nigeria: a report of two cases

2)  Prevalence and pattern of cystic kidney diseases in Ilorin, Nigeria.

3) Sonographic analysis of adult polycystic kidney disease: retrospective data from South-East Nigeria.

4) Diseases causing chronic renal failure in Nigerians–a prospective study of 100 cases.

5) Expression of adult polycystic renal disease in a 17-year-old male.

6) Autosomal dominant polycystic kidney disease presenting with liver disease

Living Kidney Donation- What the donor must know.


Are you considering donating a kidney to a family member or friend?

If you are, This post is for you to help empower you to be a smart kidney donor. 

Wanting to donate a kidney to improve or even save the life of another person suffering from kidney failure is a noble and honorable thing. The donation of a live kidney is the best option for the recipient compared to donation from a deceased person as it will last longer and work better if put in properly and taken good care of. It is also certainly offers the recipient of the kidney a better and longer life compared to continued dialysis.

However, the most important thing for you to know about kidney donation as a possible donor is that donation is not safe for everybody.

Your primary responsibility is to ensure that it is safe for you to donate a kidney.

The doctors primary responsibility to you as a potential donor is to help you determine if it is safe for you to donate and nothing else.

If you do not really want to be a donor for whatever reason, you should not be forced to do so. Talk to the doctor evaluating you as a donor in private and tell the doctor your concerns. Your doctor will be able to speak confidentially on your behalf and tell the person hoping to get the kidney from you that you are not medically fit to be a kidney donor. The doctor does not need to tell them of your fears or concerns unless you ask them to do so.

First things first – who can donate a kidney?

The person intending to donate a kidney generally should be healthy, be between the ages of 20 and 65, should have 2 kidneys, should not be obesse (defined as a body mass index of >30) and have none of the following.

1) kidney disease or kidney stones

2) high blood pressure or high blood sugar

3) Large amounts of protein or blood in the urine

4) Have normal liver, heart and blood vessel function.

5) Have no ongoing infections, cancers or bleeding issues

6) Be mentally stable

Many people assume that everybody has 2 kidneys. However, it is important to know that many people live normal healthy lives being born with one kidney as long as it doesn’t get diseased. It is estimated that as many as 1 in 1000 to 1 in 1500 (100,000 to 150,000 Nigerians) were born with one kidney so do  not assume you have 2 kidneys and can donate. 

Most kidney transplants in Nigeria are either from related or unrelated living persons that are ABO blood group compatible. This means that a person with blood group O can donate to a patient with any blood group. A person with blood group AB can only donate to persons with blood group AB, while people with blood group B can only donate to patients with blood group B.  People with blood group A can donate only to patients with blood group A.  In special circumstances of donor blood group type A2, donation to patients with blood group O, B and AB is possible but decisions for such need to be very carefully made. Transplant outside these assignments while possible is associated with a higher risk of rejection of the transplant by the recipient and requires more high risk treatments to the recipient such as removal of the spleen or treatment with strong medications. Rhesus blood group is not considered a barrier to kidney transplantation

Donor Testing

As a donor, you need testing done. This is to ensure the you are of the right blood group, you have 2 kidneys, you are healthy, can stand the stress of surgery and do not have silent kidney disease or conditions that can cause kidney disease as well. Testing is also necessary to ensure that you do not transmit infections or cancers to the recipient. A psychological evaluation may also be necessary to ensure you can withstand the emotional stresses that may come during and after kidney donation.

Special testing also needs to be done to ensure you and the recipient are compatible to avoid rejection 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.

Donor Surgery

As a donor, you should also know who will be performing the surgery and what their track record is. Not all surgeons know how to take out a kidney for the purpose of kidney donation. Taking out the kidney for the purpose of kidney donation is very different from taking the kidney out because of kidney disease. The kidney for donation has to be very carefully handled and it needs to be done quickly with minimal injury to the patient. Therefore ensure your surgeon knows what he or she is doing. Kidney donation surgery can be done in two ways.

The more recent way of taking out the kidney is a more recent and less painful way and is called keyhole or laparoscopic surgery. With this approach, 3 small holes and a 2-3 inch incision are made in your abdomen to remove the kidney. The scars are small, after a while are difficult to see and the recovery time is short. The other way is by open surgery where a long incision 8 or more inches in length is made on your side to take out the kidney. More painful with a longer recovery. Whatever method is used, make sure that the surgeon knows what he is doing. Ask about their complication rates and how many of the procedures they have done to determine their level of experience. A confident doctor should be willing to tell you what you want to know.

The decision to take out the right or the left kidney if prior testing is acceptable really depends on a number of factors that are best determined by the surgeon. However, in general, the right kidney is often selected for removal because it has a longer main artery and vein. Other considerations may make removal of the left kidney a better option.

KidneySolutions-Ikeja-Lagos-Transplant donationKidneySolutions-Ikeja-Lagos-Transplant Donation-2

Risks of kidney donation – short-term and long-term. 

The whole point of testing to ensure that the donor is healthy and finding an experienced surgeon is to ensure that the risk of harm to the donor is as low as possible.

The first living donor kidney transplant was performed over 50 years ago and since then several thousand kidney donations from living persons have been performed. A vast majority of these donors have been doing well several years after donation so the consensus now is that in properly tested and selected donors, the long term outlook is very good. There is also experience from soldiers and other victims of war who were healthy but had to have one kidney removed because of war injuries. These otherwise healthy soldiers or victims of war have also been shown to live well without problems of kidney failure decades afterwards.

However, it is important to know that even if you have 2 kidneys, if you have risk factors for kidney disease or you are not selected properly for donation, you could have problems and possibly end up on dialysis or needing a transplant yourself. 

If after you are evaluated and you are considered a good candidate and eventually donate , you need to follow a few simple rules to ensure all goes well in the long term

1) You must live a healthy life after kidney donation. This means you can not smoke, drink, add weight or engage in any other risky behaviours that could increase your risk for kidney disease.

2) You need to exercise and eat healthy continually.

3) You need to see a doctor at least once a year for the rest of your life. This is not because of a high concern for kidney disease. This is to help identify problems that might lead to kidney disease early so that progressive kidney disease can be treated and hopefully avoided.

Data from the United States shows that the risk of death within 90 days of living kidney donation is approximately 3 per 10,000 donor surgeries. This is better than the risk from laparoscopic gall bladder removal (18 per 10000 cases) or non donor nephrectomy (260 per 10,000). Other risks such as bleeding, infections, problems with wound healing etc occur at a rate of 2 to 5 per 100 cases. The incidence rates in Nigeria or other countries may be significantly different and data is not readily available on such.

The key long term concerns after donation are that of progressive and end stage kidney disease that might also require dialysis or transplant. Similarly, data from the United States and other developed countries show that the long term risk of developing kidney failure in properly selected donors who continue to maintain healthy lifestyle and habits is low.

General acceptability of kidney donation and kidney transplantation. 

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 Jehovah’s Witness church have approved kidney transplantation from either cadaver or living donors. In the case of Jehovah witnesses, the organ is purged/flushed of all blood and transplantation without blood transfusion while risky is possible.

Disclaimer

This post is no substitute for an actual evaluation in a medical center by a qualified and experienced professional. This post is not a recommendation to come to KidneySolutions or any other specific medical center either.

This post is only meant to educate and empower potential donors so that the experience of kidney donation is not as frightening, evaluation is properly done and potential donors have an idea of what is going on.

Questions?

If you have any questions regarding kidney donation, feel free to fill the contact form below. We will endeavour to get back to you with answers as soon as possible.

 

Reproduction and Pregnancy- What men and women with kidney disease, on dialysis or with a kidney transplant should know


Having a child is a joy but conceiving or carrying a baby to term can be a challenge if you have medical problems. A question that likely crosses the mind of many patients of reproductive age, male or female is – “will i be able to have children?”. The good news is that many of the causes of reduced reproductive capability in patients with kidney disease are known and can be treated by carefully following the instructions of knowledgeable specialists in kidney disease and reproduction.

This post will aim to address the background behind reproductive potential of patients with kidney disease and answer questions of relevance to patients with either advanced kidney disease, those undergoing dialysis treatment or those who have a kidney transplant. The information in this post is NOT a substitute for close consultation with a kidney specialist and readers are advised to seek the counsel of such experts to address their care and concerns.

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Getting pregnant can be a challenge even without having kidney disease. Sometimes, it may be safest if a woman does not get pregnant because the pregnancy may worsen the kidney disease or even lead to kidney failure requiring dialysis or transplantation or even death. Patients with a history of kidney disease in a prior pregnancy must be careful before getting pregnant again. With the right advice from doctors, it is possible to conceive and be successful with a pregnancy. Patients must however know that it will require a lot of resources to cover the costs of the more intensive care required.

Advanced kidney disease affects reproductive potential of both males and females and directly can impact the outcome of pregnancy.

In male patients with advanced kidney disease or on dialysis, problems with getting a sufficient erection, decreased sexual desire and decreased sperm count are common problems that make conception difficult. This is often due to low levels of male sex hormone called testosterone- a direct consequence of kidney disease. Getting close follow up with a doctor, getting anemia and hypertension treated properly and getting enough dialysis if necessary at least 3 times a week is key to addressing many of these problems.

Problems with erection and ejaculation however can occur in patients even without kidney disease. Diabetes (high blood sugar) is a common cause. Sometimes the medication used to treat high blood pressure may also cause problems with erection and need to be changed not stopped. Never stop your blood pressure medications because of erection problems or impotence. Talk to your doctor so the right blood pressure medication can be prescribed for you that does not have such side effects.

In female patients with advanced kidney disease there is often an absence of menses or abnormal menses, abnormal uterine bleeding and development of cysts in the ovary that disrupt the processes important for ovulation, fertilization, implantation and carrying the pregnancy to full term. It is estimated that only 1-2% of all patients with advanced kidney disease or on dialysis conceive. These chances improve significantly if you get proper care by a good kidney specialist. Only about half of those who conceive can carry their pregnancies to full term and in many cases the pregnancy is complicated by death of the baby in the womb, hypertension in the mother, premature labor and delivery, malformations in the baby and low birth weight of the baby.  For patients that are pregnant and already on dialysis, an increased dose and frequency of dialysis preferably on a daily basis is the best chance of successful outcome. It is recommended that pregnant dialysis patients undergo at least 20 hours or more of dialysis a week. The kidney specialist also needs to modify the  dialysis prescription to avoid bleeding by reducing the dose of blood thinner given during dialysis. Additional effort to control blood pressure and treat anemia is required. Nutrition is a big issue for pregnant dialysis patients and ensuring the pregnant mother gets enough vitamins including folic acid as well as protein is important. Pregnancy in a dialysis patient is a high risk pregnancy and care should be provided by both a kidney specialist and an obstetrician with experience caring for such patients.

It is important to note that for some women, kidney disease develops for the first time during pregnancy. Infections of the urinary tract need to be treated aggressively because they could lead to generalized infection and kidney failure or death. Some women develop severe  high blood pressure along with kidney and liver problems that can also be deadly.

Sexual problems for either men or women with kidney disease can be either physical or emotional. Emotional causes such as fear, anxiety and depression can seriously affect men and women equally and interfere with sexual intercourse, the ability to conceive or ability to carry a pregnancy to term. Healthy eating, exercise, talking to your partner about sexuality and health in an honest open way and following the doctors instructions are one of many ways to help deal with the emotional stress. For most patients, sexuality improves with the initiation of high quality frequent dialysis and gets even better after kidney transplant. Sometimes there may still be problems with sexual drive that persist even after transplant related to use of medications to prevent rejection or treat high blood pressure.

COMMON QUESTIONS ABOUT REPRODUCTION AND PREGNANCY IN KIDNEY DISEASE, DIALYSIS AND TRANSPLANT PATIENTS

Question: Is sexual intercourse safe for a patient with advanced kidney disease or patients on dialysis?

Answer: This is a common fear among such patients and there should be no such concern. Care should be taken to avoid damaging the dialysis access during sexual intercourse however.

Question: Is sexual intercourse safe for patients with a kidney transplant?

Answer: As long as the scar from the transplant surgery is fully healed, blood pressure is controlled and the doctor says it is safe to resume or start sexual activity, there should be no reason to worry about damage to the transplant kidney.

Question: What are the things that can affect a healthy pregnancy?

Answer: General health, age, presence or absence of high blood pressure, high blood sugar, or heart disease, presence of kidney disease.

Question: Can a woman with “mild” kidney disease have a baby?

Answer: Women with mild kidney disease with little or no protein in the urine can conceive and have a healthy pregnancy. Women with more severe kidney disease have a lower likelihood of getting pregnant and higher chance of serious complications during pregnancy which might lead to loss of the pregnancy, worsening of the kidney disease or both. If you have any degree of kidney disease and want to become pregnant, make sure you talk to a kidney specialist along with the doctor that will care for your pregnancy.

Question: Can a patient on dialysis have a baby?

Answer: It is possible but changes in the bodies of men and women on dialysis make it hard to either impregnate a woman or become impregnanted by a man. The risks to the mother and baby are quite high if a woman becomes pregnant on dialysis. If a woman becomes pregnant on dialysis, she will need close attention and very frequent dialysis to have a successful pregnancy.

Question: Can a kidney transplant patient have a baby?

Answer: Yes a woman with a kidney transplant can have a baby. However, it is usually recommended that such patients wait at least 1-2 years after the transplant with stable kidney transplant function before trying to become pregnant. There should be no protein in the urine and the dose of steroids should be at least 15 mg a day or less. Before you try to become pregnant, tell your doctor because in addition to the tests nneded to confirm it is safe to get pregnant, some of the medications used to prevent rejection of the transplant can affect the baby and need to be changed at least 6 weeks or more before any attempts to get pregnant. If the serum creatinine of a transplant patient is above a certain level, it is often recommended that the patient do not get pregnant in order to avoid the possibility of loosing the kidney transplant. Most pregnant kidney transplant patients will need to deliver by cesarean section although normal delivery has been reported. The obstetrician has to plan carefully on the surgical approach and has to consult with the nephrologist and if possible transplant surgeon to avoid damage to the transplant kidney during cesarean section surgery.

Men who have a transplant can father children. There may be some difficulty and if after trying for at least a year there is no success, you should seek the help of a fertility specialist and advice of your kidney doctor.

Question: What kind of birth control is recommended for patients with kidney disease?

Answer: Sometimes it is important to delay plans to become pregnant and birth control is needed. Women with kidney transplants or with high blood pressure should not use oral tablet or implanted hormonal contraceptives as these may increase the risk of rejection or deadly blood clots. These can also increase blood pressure and risk of events like stroke or heart attacks or heart failure. The safest options for birth control involve the use of condoms, diaphragms, sponges and the newer devices that can be placed in the uterus.

The silent actors in the drama of kidney disease- Smoking and alcohol


Chronic kidney disease (CKD) is a growing worldwide problem that is increasingly shown to be interwoven with cardiovascular disease (CVD), smoking and excessive alcohol consumption. In addition, because of the kidneys’ important and varied role in the body, impairment of their function can result in a range of disorders, from mild differences in fluid balance to acute kidney failure and death. Alcohol, one of the numerous factors that can damage and reduce kidney function, can interfere with kidney function directly, through short term excess or long term consumption, or indirectly, as a consequence of liver disease.

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Alcohol when taken in excess has many negative effects on the body. From impacts on brain function where it leads to confusion and risk for accidents and dementia, to liver disease and cancer. Alcohol can also have negative effects on kidney function.

The benefits of smoking or alcohol consumption are very difficult to identify and are at best minimal and of no real tangible benefit to its users. However, the harmful effects of these common social pleasures are well documented but not commonly known.

This post is aimed at educating readers on the harms of these silent actors to a common and growing problem of kidney disease and kidney failure. In summary, there is no safe amount of cigarette smoke to be exposed to. There are levels of alcohol intake above which health problems occur including kidney disease.

Alcohol and the kidney

Drinking alcohol can affect many parts of your body, including your kidneys. A little alcohol—one or two drinks now and then—usually has no serious effects because the body can easily and quickly get rid of the alcohol from the body. But drinking too much even if you do not have a damaged liver can harm your health and worsen or accelerate kidney disease.

For instance, alcoholics with damaged livers have been shown to have enlarged kidneys  with reduced blood flow to the kidneys. Alcohol can have effects on the kidney even in people without damaged livers by causing loss of water (remember the frequent urination?) as well as nutrients in the body such as magnesium, phosphate, calcium, sodium and potassium all of which have important functions in the body. Alcohol taken in large quantities over months to years can also impair the ability to control blood pressure through mechanisms that are yet to be fully understood and has a negative impact on the ability of the kidney to control acid balance.

How much alcohol is too much?

When experts talk about one drink, they are talking about one 350 ml bottle of beer, one glass of wine (150 ml), or one shot (45 ml) of “hard liquor.” Hard liquor includes vodka, brandy, whisky and other spirits.

Having more than three drinks in a day (or more than seven per week) for women, and more than four drinks in a day (or more than 14 per week) for men, is considered “heavy” drinking. The kidneys of heavy drinkers have to work harder. Heavy drinking on a regular basis has been found to double the risk for kidney disease and kidney failure requiring dialysis and kidney transplantation.

Binge drinking (usually more than four to five drinks within two hours) can raise a person’s blood alcohol to dangerous levels. This can cause a sudden drop in kidney function known as “acute kidney injury.” When this happens, dialysis is needed until a person’s kidney function returns to normal. Acute kidney injury usually goes away in time, but in some cases, it can lead to lasting permanent kidney damage.

Some people should not drink at all. Ask your healthcare provider if it is safe for you to drink, especially if you have a medical condition or take medicines that might be affected by using alcohol. Women, older people, and those with smaller bodies should be especially careful. Of course, pregnant women are advised not to drink alcohol.

For more information on the use of alcohol in Nigeria and the harmful effects including the impact on liver disease and road traffic accidents, read a world health organization report by clicking here.

Smoking and the kidney.

One of the many things that contribute to the poor understanding of the harmful effects of cigarette smoking is a lack of knowledge of what is contained in a cigarette. There are few effective labels or warnings about the dangers or harms of smoking.

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There are no known health benefits of cigarette smoking

Nicotine is the principal substance contained in cigarettes that not only has impact on brain function but has addiction potential. There are approximately 600 ingredients in cigarettes. When burned, they create more than 7,000 chemicals. At least 69 of these chemicals are known to cause cancer, and many are poisonous or can damage the kidney.

Many of these chemicals are also found in consumer products, but these products have warning labels. While the public is warned about the danger of the poisons in these products, there is no such warning for the toxins in tobacco smoke.

Here are a few of the chemicals in tobacco smoke, and other places they are found:

  • Acetone – found in nail polish remover
  • Acetic Acid –  an ingredient in hair dye
  • Ammonia – a common household cleaner
  • Arsenic – used in rat poison
  • Benzene – found in rubber cement
  • Butane – used in lighter fluid
  • Cadmium – active component in battery acid
  • Carbon Monoxide – released in car exhaust fumes
  • Formaldehyde – embalming fluid
  • Hexamine – found in barbecue lighter fluid
  • Lead – used in batteries
  • Naphthalene – an ingredient in moth balls
  • Methanol – a main component in rocket fuel
  • Nicotine – used as insecticide
  • Tar – material for paving roads
  • Toluene – used to manufacture paint

 

Can smoking cigarettes affect my kidneys?

Yes, for the following reasons:

  • Smoking can interfere with medicines used to treat high blood pressure. Uncontrolled or poorly controlled high blood pressure is a leading cause of kidney disease.
  • Substances released from inhaling cigarette smoke can damage blood vessels and eventually slows the blood flow to vital organs like the kidneys and can worsen already existing kidney disease.

E-cigarettes?

E-cigarettes have not been fully studied, so consumers currently don’t know:

  • the potential risks of e-cigarettes when used as intended,
  • how much nicotine or other potentially harmful chemicals are being inhaled during use, or
  • whether there are any benefits associated with using these products.

Additionally, it is not known whether e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death.

 

What health problems are related to smoking?

According to the World Health Organization, smokers have an increased risk of developing:

  • Lung cancer
  • Bladder cancer
  • Lung disease
  • Mouth cancer
  • Heart disease
  • Pancreas cancer
  • High blood pressure
  • Cervical cancer
  • Stroke
  • Pregnancy complications
  • Kidney cancer
  • Early menopause

For more information on the impact of tobacco use on health, read the world health organization fact sheet on tobacco use by clicking here.

 

Food and the patient with Kidney disease or Kidney failure


Kidney function is essential for removing the waste material and some toxins from food that you eat. The kidneys excrete a dietary protein called urea, as well as excess amounts of sodium, potassium, and phosphate. These substances can build up in the body if kidney function is impaired and cause harm.

Following a strict diet can lessen the excessive accumulation of these substances and their bad effects on the body.

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A kidney diet has to be balanced and take into account the stage of the patients disease. Taking too much fluid, salt or potassium may be very harmful. Read below for more details.

 

Controlling your phosphorus (Phosphate)

Excess phosphorus is a mineral that healthy kidneys get rid of in the urine. In kidneys that are failing, phosphorus builds up in the blood and may cause many problems including muscle aches and pains, brittle, easily broken bones, calcification of the heart, skin, joints, and blood vessels. To keep your phosphorus levels in check, consider the following tips:

    1. Intake of foods low in phosphorus

  •      Grape
  •      Vegetables: cabbage, green beans, spinach, lettuce, carrot, cucumber, pear, plum, Pineapple, apple, mango, white bread, pasta, watermelon, potatoes
  1. Moderate intake of high phosphorus foods such as:
  • Meats, poultry, dairy and fish
  • Milk and other dairy products like cheese
  1. Avoid high phosphorus foods such as:
  • Black Beans, Red Beans, Black-eyed Peas, White Beans, and Garbanzo Beans, nuts
  • Dark, whole or unrefined grains, whole wheat, Rice, corn
  • Cheese (low fat cheese), Wara (yoruba)
  • Low fat yoghurt
  • Dried vegetables and fruits, Garlic
  • Chocolate, peanut butter,
  1. Don’t forget to take your phosphate binders with meals and snacks.
  • Your doctor may or may not prescribe a medication called a phosphate binder. You need to take your phosphate binder as prescribed by your doctor. Often you will take a phosphate binder with every meal and snack you take. This reduces the amount of phosphate you absorb from food while allowing you to absorb other important nutrients. Phosphate binders do not prevent absorption of all phosphate.

Controlling your Potassium

Potassium is an element that is necessary for the body to keep a normal electrical activity and water balance between the cells and body fluids. All foods contain some potassium, but some contain larger amounts.

Normal kidney function will remove potassium through urination. Kidneys that are not functioning properly cannot remove the potassium in the urine, so it builds up in the blood. This can be very dangerous to your heart. High potassium can cause irregular heart beats and can even cause the heart to stop if the potassium levels get to high.

Typically, there are no symptoms for someone with a high potassium level. If you are concerned about your potassium level, check with your doctor, and follow the tips below.

  • The following foods are high in potassium and intake of these foods should be limited:

Bananas, Avocado, Oranges, Orange Juice, Prunes, Prune Juice, Tomatoes, Tomato Juice, Tomato Sauce, Tomato Puree, Melon, Nuts, Pawpaw, Chocolate, Red Beans, Milk White Beans, cabbage, onions, groundnut, walnut, mushrooms, corn, potatoes

  • Dark leafy vegetables e.g tete, soko,ugu, green, okro,

Potatoes and vegetables can also contain a lot of potassium but can be specially prepared to reduce the amount of potassium contained in them. For potatoes, 

1. Peel and slice into 1/8 inch pieces.

2. Soak 1 cup potatoes in 5 cups of water for 2 hours.

3. Drain and rinse and drain.

4. Cook in a large amount of water.

5. Drain and mash, fry or serve plain.

For vegetables,

1. Slice and wash in plenty water,

2. Drain the water

3. Cook in plenty water

4. Drain the water

5. Use vegetables to cook food or cook vegetables with other ingredients

Foods Low in Potassium

White bread

White rice

Eggs

Apples ( limited amount)

 

Controlling your sodium (salt)

Sodium, or sodium chloride is an element that is used by all living creatures to regulate the water content in the body. Usually a sodium restriction comes in the form of “No Added Salt.” This is necessary because a greater intake of sodium will result in poorly controlled blood pressure and excessive thirst which can lead to difficulty adhering to the fluid restrictions in your diet. However, your doctor can allow you a limited amount of sodium which can vary between 2-6gms per day

To limit your sodium, you should:

  • Avoid table salt and any seasonings that end with the word “salt”

 

  • Avoid salt substitutes (they contain potassium)
  • Avoid salty meats such as bacon, ham, sausage, hot dogs, lunch meats, canned meats
  • Avoid salty snacks such as cheese curls, salted crackers, nuts, and chips
  • Avoid canned soups, frozen dinners, and instant noodles
  • Avoid bottled sauces, pickles, olives, and MSG

. Salted Butter, milk, carrot, spinach, legumes

 

Foods Low in Sodium

Sugar

Onion, ginger garlic, mushrooms

Pasta, Rice, Macaroni

Tomatoes, plum,

Fresh fruits and vegetables except those listed above

 

Cooking Instructions for low sodium.

1. Cook meat / poultry / fish with recommended allowance of sodium

2. Then use the stock to cook soup / food

 

Controlling your protein

Protein is important to aid in growth and maintenance of body tissue. Protein also plays a

role in fighting infection, healing of wounds, and provides a source of energy to the body.

  • For patients with advanced kidney disease not yet on dialysis, it is important that you take some protein but do not take too much. Remember, you need protein for all of the functions above. The reason for asking patients to reduce their protein intake when they have significant disease but are not yet on dialysis is that an excessive protein load can accelerate the path to kidney failure. However note that many other aspects of care are likely more important than protein intake to reduce the progression of kidney disease such as control of blood sugar, control of blood pressure and relief of any obstruction.                                                                                   
  • For patients with kidney failure, there is absolutely no need to restrict protein as the kidneys have failed and protein restriction will not restore kidney function that has been lost. 
  • You should make sure to eat one tenth of a kilogram of protein every day.
  • Foods that are high in protein include beef, pork, veal, chicken, turkey, fish, seafood, and eggs.
  • 1 average sized egg for example is equal to one-twentieth of a kilogram of protein.

     

    How to be successful on a renal diet

    Moderation

    Dietary Guidelines emphasizes the importance of eating a variety of foods. This applies to dialysis patients, too. You can enjoy all foods in moderation while following a renal diet. One of the guidelines states:

    “Be sensible: Enjoy all foods, just don’t overdo it.”

    We Encourage You To:

    • Slow down while eating. Avoid anxiety and worry at meal times. It takes 20 minutes to send the signal that you’ve had enough to eat.

    . Put down fork between bites

    . Do not put bowls of food on the table

    • Stop eating when full. Patients should walk away from the table feeling that they can eat a little more.

    . Leave the table as soon as eating is done

    • Have one small helping of that chocolate cake once in a while and enjoy every bite.
    • Enjoy that piece of sphagetti twice as much. Eat half in the restaurant and take the rest home to enjoy the next day.

    The Goal

    The goal for our patients should be to achieve optimal nutritional status, a healthy lifestyle, that can be maintained rather than a short-term diet that will most likely be abandoned and produce psychological discomfort and metabolic imbalance.

Upcoming blog post in June 2014- Nigerian foods and the patient with moderate to advanced kidney disease


Food and the Patient with Kidney Disease or Kidney Failure
Kidney function is essential for removing the waste material from food that you eat. The
kidneys excrete the breakdown products of dietary protein called urea, as well as sodium, potassium, and phosphate.

Foods, especially animal protein based meals also generate a acids that must be eliminated by the body. In a healthy state, the kidney is responsible for this.
These substances can build up in the body if kidney function is impaired. Following a strict diet can lessen the excessive accumulation of these substances and their bad effects on the body.

 

what-is-a-renal-diet-will-depend-on-the-foods-we-eat-300x195

There are many myths and misconceptions about what patients with kidney disease should eat. It is important to know what the limitations are and avoid malnutrition which is quite common in kidney disease and dialysis patients. There are also some important differences in the diet recommendations depending on the severity or stage of kidney disease.

In this upcoming blog post, the most important food components and nutrients that need modification in patients with kidney disease will be discussed. The effects of accumulation of these substances and the dietary choices will also be mentioned. Unique issues related to vitamins and nutritional supplements will also be highlighted. The post will not be meant to replace formal discussions with your doctor and nutritionist.

To learn more, visit the KidneySolutions frequently asked questions page at http://www.kidney-solutions.com/faq/or the KidneySolutions YouTube channel, or this free video by the Increasing Kidney Awareness Network (IKAN) here to learn more about diets and food for patients with kidney disease.

Stay tuned and see you next month.

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.

Viral infections in kidney disease and dialysis patients in Nigeria- Truths, myths and what to do


Kidney failure interferes with the ability of the body to fight infections therefore making it easier to acquire infections. In addition, kidney patients may need to undergo important and life saving treatments such as dialysis catheter placement, blood transfusion or dialysis treatment and during such treatments, patients are at risk of acquiring a number of infections.

An important challenge in the care of patients with kidney disease and especially those on dialysis is the prevention and management of infections. The more common infections important to dialysis patients for instance involve infections of the dialysis access such as the dialysis catheter, graft or fistula. However, viral infections involving the HIV, Hepatitis B and Hepatitis C viruses are also quite important as they can cause serious medical problems.

© Copyright 2011 CorbisCorporation

If you are a dialysis patient, make sure you ask your doctor questions about how they reduce the risk of infection that can be acquired during dialysis. Even if you are not a dialysis patient, you need to ask questions about the safety of blood you might be receiving. It is always better to get blood from a known family member.

The first steps to understanding the risk of viral infection in Nigeria and protecting oneself is to know the risk of blood transfusion related and dialysis procedure related infections in Nigeria.

In a study from a major teaching hospital in mid western Nigeria, the risk of blood transfusion related syphilis infection was estimated at about 384 cases per year1. In another study from western Nigeria, the estimated prevalence of Hepatitis B, HIV, Hepatitis C and syphilis was found to be 18.6%, 3.1%, 6% and 1.1% respectively2 meaning that if 5000 transfusions were provided from such a blood pool in a year, approximately 900 cases of blood transfusion related Hepatitis B, 150 cases of HIV, 300 cases of Hepatitis C and 50 cases of syphilis could have been potentially created. In northern, south western and eastern Nigeria, the situation is just as concerning where the prevalence of donors with such infections is just as high3-9. Depending on the age of the donor, the risk of these infections could be even higher as the prevalence of infected donors that look healthy could be as high as 60%9.

It is however important to understand the main reasons for the high prevalence of such infections among persons donating blood.

– Window period for testing: The platform for all currently available blood donor screening testing in Nigeria and most other countries is not based on detection of the actual virus but based on the detection of antibody against the virus in the blood of the possible donor. Antibody is a substance produced by the body to fight infection and sometimes might be able to cure the infection and sometimes it cant. Depending on the infection in question, there is an incubation period during which the person could infect others with live virus without yet producing antibody in their blood to the organism they are infected with. This period during which they are infectious, without symptoms of disease and without antibody in their blood that can be picked up by these antibody based tests is called the “window period”. For HIV, the window period is 3-6 months, for hepatitis B and C it is about 1-3 months

Paid blood donors vs family blood donors: It is estimated that well over 90% of all blood donors in Nigeria are paid or commercial blood donors that receive compensation for their donation as opposed to non-commercial voluntary blood donors such as family members who are not paid. Paid donors are less likely to be truthful about their medical history and risk and still donate blood while knowing they may be infected. However, the medical status of family members is usually know and family or volunteer donors who are unpaid are much less likely to donate when they know they may have a transmissible infection.

Blood-donation--bag--supply---21363159

Haiti Earthquake 2010

Donating blood can save life. However, there is a risk of serious infection if you receive blood from an infected donor. Always try to get blood from a known family member without medical problems, Or ask your doctor where you can get safe blood for transfusion. You can also ask your doctor for alternatives to blood transfusion such as EPO injections. The Nigerian national blood transfusion service helps many hospitals provide safe blood

 

Inadequate blood testing: because of the high demand for blood, many private establishments may not have the appropriately trained staff to screen blood properly. There may also be expired or fake viral testing kits as well as the temptation by hospitals to accept infected blood and proceed to sell the blood as uninfected blood.

The seriousness of the infections in Nigeria is reflected in the high number of people newly infected with these viruses or already living with these infections [See below]

Kaiser Found- HIV prevalence rate

Over 1 million people in Nigeria are living with HIV infection or AIDS. Source: Kaiser Family Foundation

Medscape- Hep B prevalence

Almost 1 out of every 10 Nigerian adults has Hepatitis B infection. Soucre- US Centers for Disease Control-

 

 

Hemodialysis patients are at high risk for infection because the process of hemodialysis requires access to the blood for prolonged periods. In an environment where many patients receive dialysis at the same time, repeated opportunities exist for person-to-person transmission of infectious agents, directly or indirectly via contaminated devices, equipment and supplies, environmental surfaces, shared medications or hands of personnel.

Hep c prevalence

The number of people living with hepatitis C in Nigeria as well as other parts of Africa is not well documented (grey areas) except in Egypt which questionably has among the highest hepatitis C infection rates in the world. Source US Centers for Disease Control. However, based on sparse local data, it is estimated that somewhere between 1-3 in every 100 persons is infected with hepatitis C and the number is increasing.

 

To learn more about the nature of blood donation and transfusion services in Nigeria, click here.

The risk of dialysis related viral infection transmission has not been studied systematically in Nigeria. The only information available on the risk of transmission of such infections by dialysis treatment itself comes from studies performed in other countries. For instance in 1993 before the application of stringent prevention strategies, in Egypt and Columbia, there was an outbreak of HIV due to currently unacceptable dialysis practices10-11. With these observations, a number of safeguards were recommended by a number of professional bodies to reduce the transmission of such infections. In the US where there is very strict monitoring of such infections and application of processes to reduce the risk of infection transmission, the risk of dialysis treatment related infection is as low as 1%.

Listening to Patient's Heartbeat with Stethoscope

Ask your doctor or nurse how infections are controlled in the medical center where you get your care. They should be prepared to tell you and you should be prepared to follow their advice as well.

To learn more about Hepatitis B virus infection, click here.

To learn more about Hepatitis C infection, click here.

To learn more about HIV infection, click here.

Solutions to the problem of viral infections in kidney disease and dialysis patients.

  1. Avoid unnecessary blood transfusion. Ask your doctor how you might be able to avoid transfusion if possible. There are medicines that have been available for up to 30 years that can help avoid blood transfusion. To learn more about treatment of  low blood levels such as anemia in patients with kidney disease, click here.
  2. If you must get a blood transfusion, please ensure the supply is safe.  Get a healthy family member to donate for you.
  3. Medical centers need to sterilize dialysis machines and other durable equipment in between treatments.
  4. There should be single patient use of consumables and medications given during dialysis – all consumables should be used on one patient only. Do not allow a nurse or doctor use any needles, guide wires or equipment that touches blood on you if they have been used on someone else already.
  5. Observation of universal precautions in interactions between staff and patients. Handwashing and changing gloves is important.
  6. Repeat screening and testing for these viruses every couple of months. It might seem like a waste of money but especially if you are a dialysis patient. If you do become infected at some point, finding out early will be of benefit to direct proper and timely treatment.
  7. Vaccination of dialysis patients and staff against hepatitis B. Ask you kidney or dialysis doctor to give you a hepatitis B vaccine if you have never received one. Unfortunately, there is no vaccine for HIV or Hepatitis C yet.
1245

If you are a kidney disease or dialysis patient, ask you doctor about getting the hepatitis vaccine. It will protect you from Hepatitis B infection and might even save your life.

 

References for further reading

  1. AO Adegoke, O Akanni, J Dirisu. Risk of transfusion-transmitted syphilis in a tertiary hospital in Nigeria. N Am J Sci. Feb 2011; 3(2):78-81
  2. FI Buseri, MA Muhibi, ZA Jeremiah. Sero-epidemiology of transfusion-transmissible infectious diseases among blood donors in Osogbo, south-west Nigeria. Blood Transfus. Oct 2009; 7(4):293-299
  3. E Nwankwo, I Momodu, I Umar, B Musa, S Adeleke. Seroprevalence of major blood-borne infections among blood donors in Kano, Nigeria. Turk J Med Sci. 2012;42(2):337-341
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