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.
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
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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.
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.
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]
Over 1 million people in Nigeria are living with HIV infection or AIDS. Source: Kaiser Family Foundation
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.
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%.
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.
Solutions to the problem of viral infections in kidney disease and dialysis patients.
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.
If you must get a blood transfusion, please ensure the supply is safe. Get a healthy family member to donate for you.
Medical centers need to sterilize dialysis machines and other durable equipment in between treatments.
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.
Observation of universal precautions in interactions between staff and patients. Handwashing and changing gloves is important.
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.
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.
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
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
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
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
Uneke CJ, Ogbu O, Inyama PU, Anyanwu GI, Njoku MO, Idoko JH. Prevalence of hepatitis-B surface antigen among blood donors and human immunodefi ciency virus-infected patients in Jos, Nigeria. Mem Inst Oswaldo Cruz 2005; 100: 13-6.
Egah DZ, Mandong BM, Iya D, Gomwalk NE, Audu ES, Banwat EB et al. Hepatitis C virus antibodies among blood donors in Jos, Nigeria. Annals of African Medicine 2004; 3: 35-7.
Muktar HM, Suleiman AM, Jones M. Safety of blood transfusion: prevalence of Hepatitis B surface antigen in blood donors in Zaria, Northern Nigeria. Nigerian Journal of Surgical Research 2005; 7: 290-2.
Ayolabi CL, Taiwo MA, Omilabu SA, Abebisi AO, Fatoba OM. Sero-prevalence of hepatitis C virus among donors in Lagos, Nigeria. African Journal of Biotechnology 2006; 5: 1944-6
Chikwem JO, Mohammed I, Okwara GC, Ukwandu NC, Ola TO. Prevalence of transmissible blood infections among blood donors at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. East African Medical Journal 1997; 74: 213-6.
Ejele O, Erhabor O, Nwauche C. Trends in the prevalence of some transfusion-transmissible infections among blood donors in Port Harcourt, Nigeria. Haema 2005; 8: 273-7.
El Sayed NM, Gomatos PJ, Beck-Sagué CM, Dietrich U, von Briesen H, Osmanov S, Esparza J, Arthur RR, Wahdan MH, Jarvis WR. Epidemic transmission of human immunodeficiency virus in renal dialysis centers in Egypt. J Infect Dis. 2000 Jan;181(1):91-7.
Velandia M, Fridkin SK, Cárdenas V, Boshell J, Ramirez G, Bland L, Iglesias A, Jarvis W. Transmission of HIV in dialysis centre. Lancet. 1995 Jun 3;345(8962):1417-22.
The intention of this post is to empower patients, their family and friends in Nigeria with information that will help them make the best decisions and have the best outcomes with kidney transplantation.
At the present time, if patient’s original kidneys fail, there is no known way to regenerate them and artificial kidneys are not yet available, so the only treatment options are dialysis and kidney transplantation. Kidney transplantation is currently the optimal treatment for kidney failure for patients that qualify. Most patients can live long and productive lives with a kidney transplant similar to that of people without kidney failure if they are careful, take their medications as prescribed, have experienced kidney specialists and perform the required routine testing. To have the best chances of success, take your time to find kidney doctors with experience taking care of transplant patients. Not all kidney doctors know how to take care of transplant patients.
Your kidney doctor will have to perform a number of tests to make sure it is safe to perform the transplant surgery and ensure the cause of your original kidney disease does not destroy the transplant kidney. The testing is also needed to determine the best treatment plan to reduce the risk of transplant kidney rejection or complications such as infections, poor wound healing and cancers. If you have pets such as cats, you must let your kidney transplant specialist know so that you can be appropriately advised. Cats can transmit serious infections to transplant patients and you need to take precautions against getting such infections
The steps leading to a successful kidney transplant are
1. Understand the particular cause of kidney failure in your case from a kidney doctor/specialist and find a blood group compatible donor
It is important to know the cause of kidney failure as some of the causes of kidney failure can affect the transplant kidney and destroy it. Your doctor may want to treat the cause of kidney failure and stabilise it before recommending proceeding with transplant.
While these evaluations are going on, you need to look for a donor. In Nigeria, there is no option for a donor kidney from someone who has died as such are not yet legally allowed. So the only option is to get one from a living person who agrees to donate the kidney. Speak to family and friends about your condition. Let them know your increased risk of death and how difficult life is especially if you are on dialysis. These discussions can be difficult because you may be worried about being turned down. If this is the case and you have family or friends interested in learning more but not sure if they want to proceed, ask them to talk to your kidney doctor to discuss the risk and benefits involved in kidney donation. The best donor is from a healthy living person between the ages of 25 and 50 of the same blood group as you with no medical problems.
2. Work up for recipient and donor – reduce risk of bad outcome for recipient and donor.
Transplantation and the surgery involved can be stressful to the body and carry a risk of severe injury or even death. To avoid these complications, your doctor will have to perform tests on your heart, lungs, blood and blood vessels to make sure you can handle the stress of transplantation. You will also need to be tested for certain infections or cancers because transplant medications that prevent rejection of the transplanted kidney weaken the immune system that protects against infection and cancer. Part of preparation for transplant may involve getting vaccines against infections such as hepatitis B.
Your donor also needs testing done. This is to ensure the donor is healthy, can stand the stress of surgery and does not have silent kidney disease or conditions that can cause kidney disease as well. Testing is also necessary to ensure that the donor does not transmit infections or cancers to the recipient. Special testing also needs to be done to ensure the donor and recipient are compatible and help the surgeons know which kidney to take out of the donor and how best to take it out. Some transplant centers require that a donor be related to the recipient while other transplant centers do not insist on such a relationship.
3. Find expert center for transplant and discuss risks and complications
While cost is an important consideration in selecting a transplant center, it is most important to find a center with specialist doctors and experts that know what they are doing. Ask questions of the doctors of their experience taking care of transplant patients, speak to transplant patients and learn about their experiences. Take your time and don’t rush the process. It is an important decision and could be a matter of life and death or a short bad experience only leading you back to dialysis.
At the present time, there are a few centers in Nigeria that perform the surgery. There are also experienced centers outside Nigeria in India, the United States and United Kingdom where kidney transplantation can be performed. Wherever you decide to have your transplant, you must ask questions and get a good understanding of their experience and capabilities to provide excellent care to you and your donor.
4. Undergo transplant surgery
For the donor, this more recently is done by keyhole (laparoscopic) surgery lasting 3-4 hours. On rare occasion is an open surgery required. Keyhole surgery is the better option and recovery time for the donor is shorter. After successful keyhole surgery, the donor can be discharged from the hospital after 48 to 96 hours.
For the recipient, an open procedure is performed that lasts 1-3 hours. The kidney will be put in the lower left or lower right part of your belly close to your bladder. Your original kidneys will not be removed unless there is a good reason to do so such as difficult to control infection, cancer or large cysts. A stent may be put in by your surgeon during the surgery. A lot of medication will be given to you to prevent infection and rejection. You likely will remain in the hospital for 7 to 10 days before you are discharged for out patient follow up. If your surgeon puts in a stent, the stent is taken out 2-3 weeks later after the incisions have healed. This is a simple procedure that takes only a few minutes.
5 Life after transplant- doctors visits, medications, testing, etc
Immediately after discharge from the hospital after a transplant, you would have to see your doctors at least once or twice a week for the first 4-6 weeks. If there are complications, you may need to be seen more frequently. Each visit will almost alway be accompanied by tests which may be even be requested shortly in advance of the visit so the doctor has real time information on the function of the kidney. Then onwards, the frequency of the visits become less frequent. By the time you hit the 6 month time point, you probably are seeing your doctor only once a month even though you may be doing lab tests twice a month. Your schedule of clinic visits and blood testing after the 6 month time point will depend on your doctor. It is important that you keep these appointments and do the required testing as they are the only opportunities to identify problems early before they become big issues.
You will be on several medications after your transplant. ALL these medications are important. Some are for preventing rejection, some are for preventing dangerous infections due to the rejection medicine. Some patients may continue to need medication for high blood pressure. Initially you may also continue to need EPO for low blood levels (anemia) for some weeks to months till your transplant kidney is working well enough. If you were diabetic before the transplant and on insulin, you may notice that your insulin requirements even go up as the new transplant kidney starts “eating up” some of the insulin. Some of the rejection medicine may also have side effects such a headaches, nausea, vomiting, shaking of the hands, diarrhoea, bone pain, pins and needle sensations in the hands and feet, gout, or even cause high cholesterol or high blood sugar. Some patients that were not diabetic before transplant might become diabetic because of the transplant medication. You transplant doctor will help you control the new onset diabetes.
If you have any of side effects from your medications, you must tell your kidney doctor as soon as possible so that careful changes can be made. NEVER change or stop your medication on your own as this can affect you or your transplant kidney. NEVER start new medicine without your kidney doctor knowing either. Certainly do not take any herbal medicines.
Many patients are able to return to a high level of functioning after kidney transplantation. Returning to work is possible but depends on a lot of things. It depends on how sick you were before the transplant, if there were serious complications during or after the transplant and how well the kidney transplant is working. Those with simple jobs like working behind a desk can probably return to work before a person that has a physically demanding job. Talk to your kidney specialist about going back to work and the best time to do so.
6. Do’s and Dont’s
– You must take your medications every day as prescribed. You can not forget to take any medications
– Do not believe anyone who tells you that you do not need to follow up regularly with your doctor after a kidney transplant. You may get away with no problems for a while but you eventually will pay a heavy and unnecessary price with the kidney failing before it should or having a serious problem that could have been prevented with close follow up. Without proper follow up, you could die, get a serious complication and end up back on dialysis.
– Do your routine testing. Sometimes it is the only way to identify a problem when it can be managed easily and cheaply. Routine testing is necessary and important to prolong the life of your kidney. A number of patients have had their transplant kidney function well for up to 30-40 years. This was only because they took really good care of the kidney and kept all their appointments and checkups.
– Don’t treat malaria without letting your transplant doctor know. Some malaria medications may reduce the level of your transplant medication in the blood and put you at risk of rejecting the transplant kidney.
– Do not take grapefruit or grapefruit juice as a transplant patient. It can affect the levels of transplant medications and increase the risk of rejection.
– If you have a fever, do not ignore it or self treat. Talk to your transplant doctor immediately. It could be a sign of a serious problem that threatens your life or your transplant.
It is important to know that transplantation in Nigeria presents a unique and challenging circumstance that patients need to be aware .
First of all, not all patients with kidney failure are candidates for kidney transplantation. It may therefore mean that certain patients will never be suitable candidates for transplant while some with the right medical advice and treatment may eventually become candidates for transplantation.
Patients above 60-70 years of age, with active infections such as tuberculosis, HIV, Hepatitis B or C, patients with certain parasite infestations, patients with active heart or vascular disease or patients with certain cancers are considered poor candidates transplant. Patients without adequate family or social support are not candidates either for transplant as there are a lot of demands before, during and after transplant that most if not all patients can not deal with on their own. Other reasons for not being a transplant candidate may be that the surgery might be too stressful for patients with bad heart or blood vessel disease and lead to death during or shortly after surgery. In addition medications for preventing rejection could worsen existing infections or cancers.
So before rushing for a transplant, speak to a kidney specialist or transplant doctor. The kidney specialist will help you decide if transplant is a safe option for you. For many patients, it may be safer to proceed with dialysis.
Secondly, transplantation worth it but is not cheap and despite the success in many patients it is never 100% certain it will work out easily without costly complications. Also, remember that the kidney transplant may fail and you may need to return to dialysis. The good news is that the cost of transplant is cheaper than dialysis after a few years. The current cost of performing an uncomplicated transplant ranges from 6-10 million Naira in Nigeria to 10-15 million Naira in the US or UK. If there are complications, the costs are higher. The medications to be taken after transplant to prevent rejection or infections can cost as much as 50,000 to 100,000 Naira per month. In addition, monthly testing to check on the level of transplant drugs may cost another 20,000 to 50,000 per month. As far as lab testing is concerned, some of the tests such as transplant drug levels or immune testing need to be performed outside Nigeria such as in South Africa or the UK and drive the cost of testing up. Hopefully, these tests become available locally soon at cheaper rates.
Patients need to have these costs in mind and compare them to the costs of a years worth of sufficient dialysis (3 times a week) that comes to about 5 million Naira per year. This compares to the initial cost of surgery (4-10 million Naira) and then the yearly cost of drugs and testing of about 2 million Naira. Therefore by the beginning of the 3rd to 4th year after transplantation it is cheaper to have a transplant that to remain on dialysis. The reasonable concern with transplant is the huge initial costs.
Thirdly, many patients have trouble finding a donor kidney. There is currently no option of getting a kidney from a dead person as there are not yet any laws in Nigeria to govern or control the use of organs from deceased people. Therefore, the most viable and legal option for obtaining a donor kidney is from a living donor. This person can be related or non related to the potential recipient although it should be noted that many transplant centers do not perform transplant from unrelated donors.
Getting a kidney from a living donor is also the best option for the recipient as it will last longer and work better if put in properly and taken good care of. Some patients and their families may have concerns that it is religiously unacceptable to get a kidney transplant. The Catholic and Anglican Church, the major Islamic bodies and Jehovas Witness church have approved kidney transplantation from either cadaver or living donors. In the case of Jehovas witnesses, the organ is purged/flushed of all blood and transplantation without blood transfusion while risky is possible.
To summarize, getting a kidney transplant is the best option for kidney failure. It is a complicated process and demands sufficient finances, an experienced set of doctors, a supportive family and an informed patient that follows all recommended follow up instructions for the best results.
If you have any questions about kidney transplantation in Nigeria feel free to fill out the contact form below.
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.