Chronic kidney disease

What to Know About the Kidneys As We Get Older


Portrait of senior African American couple

Growing old is a compulsory process in life. As we age certain things weaken. The brain, our muscles, our joints age. Our kidneys get old too and their function reduces sometimes to a level that causes important problems requiring the attention of a doctor or kidney specialist.

As we get older, there are a number of changes that happen to our bodies that we can not avoid. Our memory weakens, our strength in our muscles and joints fall over time. Our energy levels reduce. The same thing happens to our kidneys too. The kidneys loose function as we age even though we might be healthy. This makes added problems such as high blood pressure, high blood sugar, heart problems, urine infections, taking medications at the wrong dose or wrong frequency problems we should avoid because they damage the kidneys even further and put our older people at high risk for kidney failure and premature death.

This post is meant to empower the older among us as well as to make family members of our older population more aware of the changes that happen in the kidney as we get older and the things that can be done to reduce additional damage to the kidney.

What happens to the kidneys as we get older?

As we age, the filtering units of the kidney called the glomeruli get scarred over and we loose some of the filtering units every year from the age of 40 or so. There is also a thickening of the blood vessels supplying the kidney leading to a reduction of blood flow to the kidney. Reducing filtering units and reduced blood flow to the kidney together lead to reductions in overall function of the kidney. In fact, approximately 2-3 our of every 10 elders over the age of 70 years old are believed to have only 60% or less of their kidney function left. In some clinical studies, it has been observed that about 1% of kidney function is lost every year we get older after the age of 40 years although it is not entirely clear if the loss of kidney function is due to age or diseases like high blood pressure, high blood sugar or other problems.

Why is it important to be aware of changes in kidney function as we age?

  • Kidney disease can progress faster if a new problem such as diabetes develops.
  • There are no proven treatments to stop or reverse age-related decreases in kidney function. Any treatment aimed at improving kidney function by causing the remaining functional kidney to work more may actually be harmful rather than beneficial to the kidney.
  • Increased risk for sudden kidney injury from even mild events such as dehydration or exposure to usual amounts of pain medication such as aspirin, naproxen, indocin, ibuprofen and other similar drugs.
  • Toxic accumulation of some medications that are cleared by the kidney may occur. Patients with disease or age-related decreases in kidney function may require medication dose adjustments. For example the dose of the drug may need to be reduced significantly or the frequency of the dosing reduced as well.
  • With the increase in number of living kidney donor transplants, we need to be aware that even healthy older people may not be appropriate candidates for kidney donation.

How are Nigerians aging, what are the most important causes of death and what has this information got to do with kidney disease?

Life expectancy refers to the average length of time people can expect to live. It provides summary information of the death rates and health of a nation, an area, or a group of people. In the last 100 years, the global average life expectancy has more than doubled but there remains marked difference between countries with the highest and lowest life expectancy (Japan 82.1 years versus Angola 38.2 years)

Overall, Nigerians rank 183rd in life expectancy among 194 countries based on 2013 WHO statistics. The life expectancy at birth for a Nigerian in 1960 was about 37 years. By 2013, this had risen appreciably to 52.5 years. Other analyses show that a 60 year old Nigerian person is expected to live till about the age of 75. This means that an increasing number of elders will have to contend with problems related to kidney disease simply by aging even if they do not have any known medical problems. The problems older people have with kidney disease may be accelerated however if they develop other medical conditions such as high blood pressure, high blood sugar or heart disease.

Pneumonia, HIV infection, stroke and heart disease are the leading causes of death in Nigeria. While kidney disease is not a top cause of death, about 20,000 people were estimated to have died from kidney disease in 2013- greater than all the people that died from Asthma and appendicitis combined.

Therefore, as Nigerians get older, more people will have kidney problems to pay attention to and these kidney problems can become a real and large cause of expense, suffering and death. In support of these statements, In many parts of the world, the fastest growing population of patients on dialysis or getting a transplant due to kidney failure are patients over the age of 65 years.

 

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The death rate per 100,000 deaths in Nigeria due to kidney disease is estimated at about 17.4. Nigeria ranks 58th in the world in death rates due to kidney disease. Worse than Ukraine with the lowest death rates due to kidney disease in the world by 2013 WHO data. South Africa ranks 11th in the world with a higher death rate per 100,000 due to kidney disease of 26.6

Thanks for reading this short post. Share the information you learn with others and if you have any questions feel free to ask them in the form below

 

Diabetes and Kidney disease in Nigeria


The body has a complex and amazing way of controlling energy and chemical needs. One of the substances produced by the body to deal with the starch and sugars in food is insulin. Insulin is produced by an organ in the body called the pancreas whenever a starch or sugar containing food is eaten. The pancreas is located deep in the belly under the stomach and contains cells called islet cells that specifically produce insulin. The pancreas also produces other chemicals important in digesting the fat and proteins in food but the islet cells of the pancreas are responsible for insulin that in turn lowers blood sugar levels after a meal.

The pancreas is an important organ needed to digest food. It is found deep in the abdomen under the stomach.

The pancreas is an important organ needed to digest food. It is found deep in the abdomen under the stomach.

Diabetes is also called Diabetes Mellitus and is a disease that occurs when the body either does not produce enough insulin or cannot effectively use the insulin it already produces. This leads to an increase in blood sugar levels which over time leads to damage of many organs such as the heart, blood vessels, nerves, eyes and the kidney.

According to a 2014 International Diabetes Federation (IDF) report, approximately 46 out of every 1,000 adults in Nigeria between the age of 20 and 79 years have diabetes with an estimated 4 million cases many of which are undiagnosed. Several thousands are estimated to die from diabetes related conditions every year. Some women may develop diabetes during pregnancy resulting in large babies, or other problems in pregnancy. After the pregnancy, the diabetes may disappear but for some patients, it is the beginning of what will later present as full blown diabetes.

For the Nigerian score card from the International Diabetes Federation click here

For contact information of the nearest Diabetes Association of Nigeria representative near you, click here

For a clinical overview of diabetes mellitus in Nigeria, click here

Symptoms of uncontrolled diabetes   

Common symptoms of type 1 diabetes include:

Excessive thirst, frequent urination, sudden weight loss, severe tiredness and blurred vision.

People with type 2 diabetes may have the same symptoms but they may be less noticeable. Many patients have no symptoms and are only diagnosed after several years with the condition. In Nigeria over 50% of people with type 2 diabetes are are estimated to not be aware they have the condition at the time of the diagnosis.

There are two main types of diabetes:

  • Type 1 diabetes is an autoimmune disease that prevents the body from producing enough insulin. Type 1 diabetes occurs most often in children and young adults. Approximately 5 to 10 per cent of people with diabetes have type 1 diabetes.
  • Type 2 diabetes is a disease that results from the body’s inability to make effective use of the insulin produced. Genetics, obesity and lack of appropriate diet and physical activity are factors that appear to play a role in the development of type 2 diabetes. Type 2 diabetes occurs most often in adults over the age of 40 and accounts for up to 95 percent of all diabetes cases. However, as a consequence of increased obesity and inactivity among young people, type 2 diabetes is now affecting children and young adults.

Complications of diabetes. Without proper insulin production and action, sugar remains in the blood, leading to long term raised blood glucose levels. This can result in short and long-term complications, many of which, if not prevented and left untreated, can kill. All these complications have the potential to reduce the quality of life of people with diabetes and their families.

Diabetes can be a horrible disease but by paying attention you can overcome and avoid problems related to diabetes including stroke, heart attack, kidney failure, blindness, sexual problems wounds on the feed as well as amputation of the legs.

Diabetes can be a horrible disease but by paying attention to the disease, you can overcome and avoid problems related to diabetes. These problems including stroke and paralysis, heart attack, kidney failure, blindness, sexual problems, wounds on the feet that may require amputation of the foot or legsdiabetic-foot-ulcerdiabetic_gangrene

What does diabetes do to the kidneys?

With diabetes, the small and large blood vessels as well as the heart are injured. Small blood vessel damage over long periods of time eventually leads to poor function and eventually failure of the kidneys as well as other important organs such as the eyes. Because of the kidney damage from diabetes, waste products begin to accumulate in the blood and damage other body organs, the body will loose protein in the urine when there should be little to no protein in the urine and the body will retain more water and salt than it should, which can result in weight gain and ankle and eye swelling. Diabetes also may cause damage to nerves in your body. This can cause difficulty in emptying your bladder. The pressure resulting from your full bladder can back up and injure the kidneys. Also, if urine remains in your bladder for a long time, you can develop an infection from the rapid growth of bacteria in urine that has a high sugar level.

How many diabetic patients will develop kidney disease?

Three out of every 10 patients with Type 1 diabetes and 1 to 4 out of every 10 patients with Type 2 diabetes eventually will suffer from kidney failure. It usually takes 10 or more years of uncontrolled diabetes to cause kidney disease but it could occur earlier

What are the early signs of kidney disease in patients with diabetes?

The earliest sign of diabetic kidney disease is an increased excretion of protein in the urine. This is present long before the usual tests done in your doctor’s office show evidence of kidney disease, so it is important for you to have this test on a yearly basis. Weight gain and ankle swelling may occur. You will use the bathroom more at night. Your blood pressure may get too high. As a person with diabetes, you should have your blood, urine and blood pressure checked at least once a year. This will lead to better control of your disease and early treatment of high blood pressure and kidney disease. Maintaining control of your diabetes can lower your risk of developing severe kidney disease.

What are the late signs of kidney disease in patients with diabetes?

As your kidneys fail, your blood urea nitrogen (BUN) levels will rise as well as the level of creatinine in your blood. You may also experience nausea, vomiting, a loss of appetite, weakness, increasing fatigue, itching, muscle cramps (especially in your legs) and anemia (a low blood count). You may find you need less insulin. This is because diseased kidneys cause less breakdown of insulin. This does not mean your diabetes is getting better and you should not stop trying to treat your diabetes. If you develop any of these signs, call your doctor.

Prevention of diabetic kidney disease

The prevention of diabetic kidney disease starts with

  • Control your diabetes- daily checking blood sugar and hemoglobin A1c every couple of months  to see how well your blood sugar is controlled is important
  • Checking your blood sugar levels regularly will help you know how well you are doing in controlling diabetes.

    Checking your blood sugar levels regularly will help you know how well you are doing in controlling diabetes.

  • Control high blood pressure- target systolic blood pressure should be 130/80 or less
  • Get treatment for urinary tract infections
  • Correct any problems in your urinary system such as obstruction by kidney stones
  • Avoid any medicines that may damage the kidneys (especially over-the-counter pain medications)
  • Get check ups and blood tests of your blood and urine to assess your kidney function at least once a year
  • Get enough exercise and control your weight.

Treatment of diabetes

  • Treatment of type 1 diabetes typically includes a carefully calculated diet, physical activity, blood glucose testing and daily insulin injections. Some patients may be candidates for islet cell or pancreas transplant
  • Treatment of type 2 diabetes typically includes appropriate diet, exercise, home glucose testing, oral medication/tablets and/or insulin. More recently medications that are not insulin but are injectable have become available and are useful in controlling blood glucose. Pancreas or islet cell transplant is not usually given to patients with type 2 diabetes.

Currently the only known cure for diabetes is a pancreas/islet cell transplant. For patients not receiving a transplant, taking medications along with diet and exercise is very effective in controlling blood sugar and avoiding complications.

Remember That Good Care Makes a Difference

People with diabetes should

  • have their doctor measure their A1C level at least twice a year. They should aim to keep it at less than 7 percent.
  • work with their doctor regarding insulin injections, medicines, meal planning, physical activity, and blood glucose monitoring.
  • have their blood pressure checked several times a year. If blood pressure is high, they should follow their doctor’s plan for keeping it near normal levels. They should aim to keep it at less than 130/80.
  • ask their doctor whether they might benefit from taking an ACE inhibitor or ARB.
  • ask their doctor to measure their kidney function at least once a year to learn how well their kidneys are working.
  • ask their doctor to measure the amount of protein in their urine at least once a year to check for kidney damage.
  • ask their doctor whether they should reduce the amount of protein in their diet and ask for a referral to see a registered dietitian to help with meal planning.

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

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.

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.

 

Quality And Clinical Performance Measures in Kidney Disease And Dialysis Care In Nigeria


Healthcare quality has several dimensions that are all inter-related

Healthcare quality has several dimensions that are all inter-related

“The wish for healing has always been half of health”

– Lucius Annaeus Seneca (4 BC- AD 65)

The quote above by Lucius Annaeus Seneca has made many think about what the other half of health or healing is. The other half could be represented by any number of actions including getting an actual diagnosis and treatment but an important part is the conscious effort on the part of the person desiring health to inform him or herself of their disease and not only to seek help but find “high quality ” help.

To support the quest of those in need for the other half of a health, this discussion on quality and clinical performance measures in kidney disease and dialysis care in Nigeria will start with a brief explanation of the functions of the kidney and kidney disease.

The kidneys are important organs with the important function of removing waste products and toxins from the body. These wastes and toxins are filtered out into the urine. The kidney also is important for the regulation of blood pressure and for creating the signals to the bone to create blood.

Kidney disease is a condition where the functions of the kidneys are lost. Sometimes the loss of function of the kidney is temporary. On other occasions it is permanent or progressive leading eventually to kidney failure requiring dialysis or kidney transplantation to sustain life. It is estimated that some 15-20 million Nigerians to have some form of kidney disease and about 100-500 of every million Nigerians have advanced end stage kidney failure requiring dialysis or kidney transplantation. In some studies, 1 in every 10 hospital admissions have been associated with kidney failure requiring dialysis in Nigeria.(Ref 1-4).

The most common causes of kidney disease in Nigeria are diabetes mellitus, hypertension, infections , glomerulonephritis and toxin exposure from herbal medications or poorly manufactured or expired drugs. (Ref 3). Therefore, if you are over the age of 40, or have a personal history of diabetes or hypertension or a family history of kidney disease, you should ask your doctor to perform simple tests to detect kidney disease early. There are means available to hopefully prevent or delay kidney failure. Your doctor can also help you treat the cause of your kidney disease.

Treatment of kidney disease can be expensive if it is not detected early or managed by competent professionals (Ref 5). Not all healthcare providers or medical centers are equipped to deal with this disease so persons with kidney disease must know what is important in identifying centers that can provide high quality care.

It is therefore the intent of this brief post is to shine light on the issues that are necessary for the delivery of high quality kidney disease and dialysis care in Nigeria. To keep the reader engaged, the post will identify the quality measures, as they should be even in the Nigerian healthcare circumstance so that the information is of most benefit to readers. For the purpose of introduction, a performance measure or quality indicator is a standard of care that implies that healthcare providers are in error if they do not care for patients to the standards of the performance or clinical measure. This post does not intend to cover the more common healthcare service delivery issues such as location, access, respectful and timely service delivery or pricing, as it is probably safe to presume the public, government, payors and healthcare providers have sufficient knowledge and expectations on these front end issues. The strategies to measure quality and clinical performance in this field of healthcare are beyond the scope of this post.

For the purpose of this discussion, kidney disease refers to all severities of the disease before a diagnosis of kidney failure or end stage kidney disease requiring dialysis or transplantation is made. Dialysis care refers to all types of dialysis provided to patients with kidney failure or end stage kidney disease.

An important question for any reader is “how should I look at the information presented in this post?” Well the answer lies in the reason for reading the post in the first place, which in turn defines the position of the reader as a stakeholder. The questions from a patient, their family and friends would and should come from a different stake holder viewpoint than a health policy maker, a payor responsible for paying for kidney disease and dialysis care or the providers that include both the kidney specialists and general practitioners directly or indirectly involved in the provision of the care.

For example

  • A patient and their family might focus on quality and clinical performance measures that support a medical centers claim that they will deliver on the promise of preventing death and improving quality of life.
  • A policy maker or regulator while also interested in outcomes of death and quality of life would also focus on quality and performance measures that require governmental oversight or incentives.
  • A payor may ask questions focusing on a centers process of care that decreases the incidence of poor outcomes and minimizes costs of clinical outcomes of kidney disease such as catheter infections or hospitalizations due to stroke, heart failure and heart attacks. Payors are likely also interested in clear metrics of performance and quality that can be applied across the industry.
  • A provider may be interested in knowing the core quality and clinical performance measures necessary to improve patient and payor satisfaction and gain an edge over competitors.

With this in mind, let’s identify what quality and clinical performance measures are important in the delivery of effective kidney disease and dialysis care. These measures are best broken down into three categories based on the structure, process and outcome framework proposed by Donabedian (Ref 6)

The Structure of care refers to the components of the healthcare system

  • Adequacy of equipment and resources both for routine and emergency diagnosis and treatment
  • Administrative and organizational features of a clinic to efficiently mobilize resources for patient care. For example
  1. Pre-treatment triage for dialysis patients to determine the best environment for care
  2. Dialysis machine/water treatment system operation and disinfection protocols to ensure safe and timely delivery of treatment
  3. Systems to ensure patient education.
  • The resources and plans in place to ensure adequate physician, nurse and technician training and oversight
  • The resources, plans and administrative plans in place to ensure regulatory compliance.

The Process of care refers to the use of appropriate diagnostic and therapeutic modalities for the individual patient

  • Order entry and prescriptions

This includes plans and resources in place to ensure that the assessment of proteinuria, estimating the level of kidney function, prescribing kidney protective medications, correctly identifying threshold and timing of referral to a kidney specialist, evaluating abnormalities of mineral metabolism or evaluation by a surgeon for vascular access for dialysis is done in a timely manner.

  • Documentation and health care privacy compliance o Informed consent, patient record safety and privacy
  • Patient care including the procedures and protocols in place for routine and emergency care
  • Patient education on their disease, treatment options, dialysis access , dialysis adequacy and diet
  • Transplantation education and care

The Outcomes of care for kidney disease refer to the consequences of treatment and can represent markers of disease progression, health status or cost.

Examples of key outcomes of care for kidney disease include

  • Proportion of patients in a program with adequate blood pressure and anemia control
  • Proportion of dialysis patients who started long-term dialysis in an emergency situation

Examples of key outcomes of dialysis care include

  • Catheter infection rates
  • Rates at which patients get dialysis with a groin catheter.
  • The proportion of dialysis patients at a center with a fistula or graft instead of a dialysis catheter,
  • Admission/Hospitalization rates for complications of kidney failure such as heart failure
  • Death rates
  • Dialysis dose goal achievement.

In the Nigerian context, many patients do not come as regularly as 3 times a week for reasons primarily related to out-of-pocket costs of care. Nevertheless, programs should be able to provide patients whenever they come in for treatment with a dialysis dose Kt/V of approximately 1.2 at each treatment. Modern dialysis machines have online monitoring systems that permit the doctor and nurse make adjustments in real-time to achieve this goal.

  • Proportion of patients with moderate and severe anemia
  • Proportion of patients with adequate blood pressure control

To conclude this discussion, It is important for all stakeholders, especially healthcare providers to realize that clinical practice guidelines while important in improving the quality of care are not quality and clinical performance measures. Guidelines for care are written to suggest diagnostic and treatment approaches for most patients most of the time. They do not however set the standards to which the quality of care and patient outcomes should be measured.

The issue of quality in Nigerian healthcare is a growing topic of interest and discussion. All stakeholders are demanding for more but it is important that they know what to ask for. For additional reading on the greater issue of healthcare quality especially from a patient perspective, the reader is referred to a recent blog post by Dr Uche Ofoma on the Nigeria Health Blog at http://www.healthblogng.com/rating-nigerian-hospitals/#more-671

References

1. Ulasi I and Ijoma C.K. The enormity of chronic kidney disease in Nigeria: the situation in a teaching hospital in South-East Nigeria

2. Akinsola W, Odesanmi W.O, Ogunniyi J.O, Ladipo G.O. Diseases causing chronic renal failure in Nigerians- a prospective study of 100 cases. African Journal of Medicine and Medical Sciences, 1989. vol 18, no 2, pp 131-137

3. Adetuyibi A, Akinsanya J.B, Onadeko B.O. Analysis of the causes of death on the medical wards of the university college Hospital Ibadan over a 14 year period (1960-1973). Transactions of the Royal Society of tropical Medicine and Hygiene. 1976. Vol 70, no 5-6, pp466-473.

4. Alebiosu C, Ayodele O, Abbas A and Olutoyin A. Chronic renal failure at the Olabisi Onabanjo University teaching hospital, Sagamu Nigeria. Afr Health Sci. 2006 September; 6(3):132-138

5. Ijoma C.K, Ulasi I.I. Cost implications of treatment of end stage renal disease in Nigeria. Journal of the College of medicine. 1998, vol 3, no 2, pp 95-96

6. Donabedian A. Evaluating the Quality of Medical Care. Millbank Memorial Fund Quarterly 1966; 44(suppl):166-206

Upcoming blog post- Quality and clinical performance measures in kidney disease and dialysis care.


The inaugural post for the KidneySolutions blog will be on the important topic of “Quality and clinical performance measures in kidney disease and dialysis care”. In an era where patients and regulatory authorities demand the highest possible care from healthcare providers, it is important that the issues that are critically most important in delivery of such care are made clear to all parties involved.

Stay tuned for a focused post on the topic by the 15th of December, 2013. In the mean time, visit our website at http://www.kidney-solutions.com/discussion-forum.html to participate in a forum discussion on a related topic.