Healthcare in Nigeria

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.

 

KidneySolutions-kidney-disease

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

 

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