Kidney failure

Living Kidney Donation- What the donor must know.


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

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

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

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

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

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

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

First things first – who can donate a kidney?

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

1) kidney disease or kidney stones

2) high blood pressure or high blood sugar

3) Large amounts of protein or blood in the urine

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

5) Have no ongoing infections, cancers or bleeding issues

6) Be mentally stable

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

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

Donor Testing

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

Special testing also needs to be done to ensure you and the recipient are compatible to avoid rejection and help the surgeons know which kidney to take out of the donor and how best to take it out. Some transplant centers require that a donor be related to the recipient while other transplant centers do not insist on such a relationship.

Donor Surgery

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

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

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

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

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

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

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

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

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

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

2) You need to exercise and eat healthy continually.

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

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

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

General acceptability of kidney donation and kidney transplantation. 

Some patients and their families may have concerns that it is religiously unacceptable to get a kidney transplant. The Catholic and Anglican Church, the major Islamic bodies and Jehovah’s Witness church have approved kidney transplantation from either cadaver or living donors. In the case of Jehovah witnesses, the organ is purged/flushed of all blood and transplantation without blood transfusion while risky is possible.

Disclaimer

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

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

Questions?

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

 

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


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

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

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

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

Alcohol and the kidney

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

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

How much alcohol is too much?

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

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

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

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

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

Smoking and the kidney.

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

cigarette

There are no known health benefits of cigarette smoking

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

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

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

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

 

Can smoking cigarettes affect my kidneys?

Yes, for the following reasons:

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

E-cigarettes?

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

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

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

 

What health problems are related to smoking?

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

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

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

 

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


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

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

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

Doctor-Patient interaction

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

The steps leading to a successful kidney transplant are

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

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

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

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

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

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

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

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

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

 4. Undergo transplant surgery

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

Kidney transplant surgery

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

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

Kidney transplant anatomy

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

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

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

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

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

Transplant Medication

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

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

6. Do’s and Dont’s

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

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

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

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

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

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

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

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

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

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

Secondly, transplantation worth it but is not cheap and despite the success in many patients it is never 100% certain it will work out easily without costly complications. Also, remember that the kidney transplant may fail and you may need to return to dialysis. The good news is that the cost of transplant is cheaper than dialysis after a few years. The current cost of performing an uncomplicated transplant ranges from 3-6 million Naira in Nigeria to 4-7 million in India, to 10-15 million Naira in the US or UK. If there are complications, the costs are higher. The medications to be taken after transplant to prevent rejection or infections can cost as much as 50,000 to 100,000 Naira per month. In addition, monthly testing to check on the level of transplant drugs may cost another 20,000 to 50,000 per month. As far as lab testing is concerned, some of the tests such as transplant drug levels or immune testing need to be performed outside Nigeria such as in South Africa or the UK and drive the cost of testing up. Hopefully, these tests become available locally soon at cheaper rates.

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

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

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

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

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

 

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


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

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

Stay tuned

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