Kidney

World Kidney Day 2016- Childhood Kidney Diseases.


March 10th 2016 was world kidney day with a specific focus on childhood kidney disease. 

Kidney disease affects millions of people worldwide, including many children who may be at risk at an early age. It is therefore crucial that we encourage and facilitate education, early detection and a healthy life style in children, to fight the increase of preventable kidney diseases and to treat children with inborn and acquired disorders of the kidneys worldwide.

Kidney disease can affect children in various ways, ranging from treatable disorders without long-term effects to life-threatening conditions. Acute kidney disease develops suddenly, lasts a short time, and can be serious with long-lasting effects or may go away completely once the underlying cause has been treated. Chronic kidney disease (CKD) does not go away with treatment and tends to get worse over time. CKD eventually leads to kidney failure, described as end-stage kidney disease or ESRD when treated with a kidney transplant or blood-filtering treatments called dialysis.
Children with CKD or kidney failure face many challenges, which can include

  • a negative self-image
  • relationship problems
  • behavior problems
  • learning problems
  • trouble concentrating
  • delayed language skills development
  • delayed motor skills development

Children with CKD may grow at a slower rate than their mates, and urinary incontinence—the loss of bladder control, which results in the accidental loss of urine—is common.

  
Urinary tract inside the outline of the upper half of a human body. Every day, the two kidneys filter about 120 to 150 liters of blood to produce about 1 to 2 liters of urine, composed of wastes and extra fluid.

The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the back. Every day, the two kidneys filter about 120 to 150 liters of blood to produce about 1 to 2liters of urine, composed of wastes and extra fluid. Children produce less urine than adults and the amount produced depends on their age. The kidneys work around the clock; a person does not control what the kidneys do. Ureters are the thin tubes of muscle—one on each side of the bladder—that carry urine from each of the kidneys to the bladder. The bladder stores urine until the person finds a time and place to urinate.

The kidney is not one large filter. Each kidney is made up of about a million filter units called nephrons. Each nephron filters a small amount of blood. The nephron includes a filter, called a glomerulus, and a tubule. The nephrons work through a two-step process. The glomerulus lets fluid and waste products pass through it; however, it prevents blood cells and large molecules, mostly proteins, from passing. The filtered fluid then passes through the tubule, which changes the fluid by sending needed minerals back to the blood and removing wastes. The final product becomes urine.

The kidneys also control the level of minerals such as sodium, phosphorus, and potassium in the body, and produce an important hormone to signal to the bone to create blood. A low level of red blood cells is called anemia and can be a result of kidney disease. 

  
Picture above of a kidney with an inset of a nephron. Each kidney is made up of about a million filtering units called nephrons. Each nephron filters a small amount of blood. The nephron includes a filter, called a glomerulus, and a tubule.

What are the causes of kidney disease in children?

Kidney disease in children can be caused by

  • birth defects
  • hereditary diseases
  • infection
  • nephrotic syndrome
  • systemic diseases
  • trauma
  • urine blockage or reflux

From birth to age 4, birth defects and hereditary diseases are the leading causes of kidney failure. Between ages 5 and 14, kidney failure is most commonly caused by hereditary diseases, nephrotic syndrome, and systemic diseases. Between ages 15 and 19, diseases that affect the glomeruli are the leading cause of kidney failure, and hereditary diseases become less common.

Birth Defects

A birth defect is a problem that happens while a baby is developing in the mother’s womb. Birth defects that affect the kidneys include renal agenesis, renal dysplasia, and ectopic kidney, to name a few. These defects are abnormalities of size, structure, or position of the kidneys:

  • renal agenesis—children born with only one kidney
  • renal dysplasia—children born with both kidneys, yet one does not function
  • ectopic kidney—children born with a kidney that is located below, above, or on the opposite side of its usual position
  • Some children are born without kidneys. They usually are born dead or die soon after birth

In general, children with these conditions  except being born without kidneys lead full, healthy lives. However, some children with renal agenesis or renal dysplasia are at increased risk for developing kidney disease.

Hereditary Diseases:  Hereditary kidney diseases are illnesses passed from parent to child through the genes. One example is polycystic kidney disease (PKD), characterized by many grapelike clusters of fluid-filled cysts—abnormal sacs—that make both kidneys larger over time. These cysts take over and destroy working kidney tissue. 

 

a picture of a normal kidney to the left and a diseased polycystic kidney on the right

 
Another hereditary disease is Alport syndrome, which is caused by a mutation in a gene for a type of protein called collagen that makes up the glomeruli. The condition leads to scarring of the kidneys. Alport syndrome generally develops in early childhood and is more serious in boys than in girls. The condition can lead to hearing and vision problems in addition to kidney disease.

Infection

Hemolytic uremic syndrome and acute post-streptococcal glomerulonephritis are kidney diseases that can develop in a child after an infection.
Hemolytic uremic syndrome is a rare disease that is often caused by the Escherichia coli (E. coli) bacterium found in contaminated foods, such as meat, milk products, and juice. Hemolytic uremic syndrome develops when E. coli bacteria lodged in the digestive tract make toxins that enter the bloodstream. The toxins start to destroy red blood cells and damage the lining of the blood vessels, including the glomeruli. Most children who get an E. coli infection have vomiting, stomach cramps, and bloody diarrhea for 2 to 3 days. Children who develop hemolytic uremic syndrome become pale, tired, and irritable. Hemolytic uremic syndrome can lead to kidney failure in some children.

Post-streptococcal glomerulonephritis can occur after an episode of strep throat or a skin infection. The Streptococcus bacterium does not attack the kidneys directly; instead, the infection may stimulate the immune system to overproduce antibodies. Antibodies are proteins made by the immune system. The immune system protects people from infection by identifying and destroying bacteria, viruses, and other potentially harmful foreign substances. When the extra antibodies circulate in the blood and finally deposit in the glomeruli, the kidneys can be damaged. Most cases of post-streptococcal glomerulonephritis develop 1 to 3 weeks after an untreated infection, though it may be as long as 6 weeks. Post-streptococcal glomerulonephritis lasts only a brief time and the kidneys usually recover. In a few cases, kidney damage may be permanent.

Nephrotic Syndrome

Nephrotic syndrome is a collection of symptoms that indicate kidney damage. Nephrotic syndrome includes all of the following conditions:
albuminuria—when a person’s urine contains an elevated level of albumin, a protein typically found in the blood

  • hyperlipidemia—higher-than-normal fat and cholesterol levels in the blood
  • edema—swelling, usually in the legs, feet, or ankles and less often in the hands or face
  • hypoalbuminemia—low levels of albumin in the blood

child with swollen eyes and face from nephrotic syndrome affecting the kidneys

Nephrotic syndrome in children can be caused by the following conditions:
Minimal change disease is a condition characterized by damage to the glomeruli that can be seen only with an electron microscope, which shows tiny details better than any other type of microscope. The cause of minimal change disease is unknown; some health care providers think it may occur after allergic reactions, vaccinations, and viral infections.

Focal segmental glomerulosclerosis is scarring in scattered regions of the kidney, typically limited to a small number of glomeruli.

Membranoproliferative glomerulonephritis is a group of autoimmune diseases that cause antibodies to build up on a membrane in the kidney. Autoimmune diseases cause the body’s immune system to attack the body’s own cells and organs.

Systemic Diseases

Systemic diseases, such as systemic lupus erythematosus (SLE or lupus) and diabetes, involve many organs or the whole body, including the kidneys:
Lupus nephritis is kidney inflammation caused by SLE, which is an autoimmune disease.

Diabetes leads to elevated levels of blood glucose, also called blood sugar, which scar the kidneys and increase the speed at which blood flows into the kidneys. Faster blood flow strains the glomeruli, decreasing their ability to filter blood, and raises blood pressure. Kidney disease caused by diabetes is called diabetic kidney disease. While diabetes is the number one cause of kidney failure in adults, it is an uncommon cause during childhood.

Trauma: Traumas such as burns, dehydration, bleeding, injury, or surgery can cause very low blood pressure, which decreases blood flow to the kidneys. Low blood flow can result in acute kidney failure.

Urine Blockage or Reflux: When a blockage develops between the kidneys and the urethra, urine can back up into the kidneys and cause damage. Reflux—urine flowing from the bladder up to the kidney—happens when the valve between the bladder and the ureter does not close all the way.

How is kidney disease in children diagnosed?

A health care provider diagnoses kidney disease in children by completing a physical exam, asking for a medical history, and reviewing signs and symptoms. To confirm diagnosis, the health care provider may order one or more of the following tests:

Urine Tests
Dipstick test for albumin. The presence of albumin in urine is a sign that the kidneys may be damaged. Albumin in urine can be detected with a dipstick test performed on a urine sample. The urine sample is collected in a special container in a health care provider’s office or a commercial facility and can be tested in the same location or sent to a lab for analysis. With a dipstick test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the person’s urine sample. Patches on the dipstick change color when albumin is present in urine.

Urine albumin-to-creatinine ratio. A more precise measurement, such as a urine albumin-to-creatinine ratio, may be necessary to confirm kidney disease. Unlike a dipstick test for albumin, a urine albumin-to-creatinine ratio—the ratio between the amount of albumin and the amount of creatinine in urine—is not affected by variation in urine concentration.

Blood test: Blood drawn in a health care provider’s office and sent to a lab for analysis can be tested to estimate how much blood the kidneys filter each minute, called the estimated glomerular filtration rate or eGFR. This is a simple test not expensive and results can be available in a few hours

Imaging studies: Imaging studies provide pictures of the kidneys. The pictures help the health care provider see the size and shape of the kidneys and identify any abnormalities. This may be an ultrasound or CT scan or special type of x-ray 

Kidney biopsy: Kidney biopsy is a procedure that involves taking a small piece of kidney tissue for examination with a microscope. Biopsy results show the cause of the kidney disease and extent of damage to the kidneys.

How is kidney disease in children treated?

Treatment for kidney disease in children depends on the cause of the illness. A child may be referred to a pediatric nephrologist—a doctor who specializes in treating kidney diseases and kidney failure in children—for treatment.

Children with a kidney disease that is causing high blood pressure may need to take medications to lower their blood pressure. Improving blood pressure can significantly slow the progression of kidney disease. The health care provider may prescribe

angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) which help relax blood vessels, reduce blood pressure and make it easier for the heart to pump blood

diuretics, medications that increase urine output and reduce body swelling

Many children require two or more medications to control their blood pressure; other types of blood pressure medications may also be needed.

As kidney function declines, children may need treatment for anemia and growth failure. Anemia is treated with a hormone called erythropoietin, which stimulates the bone marrow to produce red blood cells. Children with growth failure may need to make dietary changes and take food supplements or growth hormone injections.

Children with kidney disease that leads to kidney failure must receive treatment to replace the work the kidneys do. The two types of treatment are dialysis and transplantation. 

Birth Defects: Children with renal agenesis or renal dysplasia should be monitored for signs of kidney damage. Treatment is not needed unless damage to the kidney occurs. 
Ectopic kidney does not need to be treated unless it causes a blockage in the urinary tract or damage to the kidney. When a blockage is present, surgery may be needed to correct the position of the kidney for better drainage of urine. If extensive kidney damage has occurred, surgery may be needed to remove the kidney. 

Hereditary Diseases: Children with PKD tend to have frequent urinary tract infections, which are treated with bacteria-fighting medications called antibiotics. PKD cannot be cured, so children with the condition receive treatment to slow the progression of kidney disease and treat the complications of PKD. 
Alport syndrome also has no cure. Children with the condition receive treatment to slow disease progression and treat complications until the kidneys fail. 

Infection: Treatment for hemolytic uremic syndrome includes maintaining normal salt and fluid levels in the body to ease symptoms and prevent further problems. A child may need a transfusion of red blood cells delivered through an intravenous (IV) tube. Some children may need dialysis for a short time to take over the work the kidneys usually do. Most children recover completely with no long-term consequences. 
Children with post-streptococcal glomerulonephritis may be treated with antibiotics to destroy any bacteria that remain in the body and with medications to control swelling and high blood pressure. They may also need dialysis for a short period of time. 

Nephrotic Syndrome: Nephrotic syndrome due to minimal change disease can often be successfully treated with corticosteroids. Corticosteroids decrease swelling and reduce the activity of the immune system. The dosage of the medication is decreased over time. Relapses are common; however, they usually respond to treatment. Corticosteroids are less effective in treating nephrotic syndrome due to focal segmental glomerulosclerosis or membranoproliferative glomerulonephritis. Children with these conditions may be given other immunosuppressive medications in addition to corticosteroids. Immunosuppressive medications prevent the body from making antibodies. 

Systemic Diseases.                              

Lupus nephritis is treated with corticosteroids and other immunosuppressive medications. A child with lupus nephritis may also be treated with blood pressure-lowering medications. In many cases, treatment is effective in completely or partially controlling lupus nephritis. 

Diabetic kidney disease usually takes many years to develop. Children with diabetes can prevent or slow the progression of diabetic kidney disease by taking medications to control high blood pressure and maintaining normal blood glucose levels. 

Trauma: The types of trauma described above can be medically treated, though dialysis may be needed for a short time until blood flow and blood pressure return to normal.

Urine Blockage and Reflux: Treatment for urine blockage depends on the cause and severity of the blockage. In some cases, the blockage goes away without treatment. For children who continue to have urine blockage, surgery may be needed to remove the obstruction and restore urine flow. After surgery, a small tube, called a stent, may be placed in the ureter or urethra to keep it open temporarily while healing occurs. 
Treatment for reflux may include prompt treatment of urinary tract infections and long-term use of antibiotics to prevent infections until reflux goes away on its own. Surgery has also been used in certain cases. 

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Eating, Diet, and Nutrition
For children with CKD, learning about nutrition is vital because their diet can affect how well their kidneys work. Parents or guardians should always consult with their child’s health care team before making any dietary changes. Staying healthy with CKD requires paying close attention to the following elements of a diet:

Protein. Children with CKD should eat enough protein for growth while limiting high protein intake. Too much protein can put an extra burden on the kidneys and cause kidney function to decline faster. Protein needs increase when a child is on dialysis because the dialysis process removes protein from the child’s blood. The health care team recommends the amount of protein needed for the child. Foods with protein include

  • eggs
  • milk
  • cheese
  • chicken
  • fish
  • red meats
  • beans
  • yogurt
  • cottage cheese

Sodium. The amount of sodium children need depends on the stage of their kidney disease, their age, and sometimes other factors. The health care team may recommend limiting or adding sodium and salt to the diet. Foods high in sodium include

  • canned foods
  • some frozen foods
  • most processed foods
  • some snack foods, such as chips and crackers

Potassium. Potassium levels need to stay in the normal range for children with CKD, because too little or too much potassium can cause heart and muscle problems. Children may need to stay away from some fruits and vegetables or reduce the number of servings and portion sizes to make sure they do not take in too much potassium. The health care team recommends the amount of potassium a child needs. Low-potassium fruits and vegetables include

  • apples
  • cranberries
  • strawberries
  • blueberries
  • raspberries
  • pineapple
  • cabbage
  • boiled cauliflower
  • mustard greens
  • uncooked broccoli

High-potassium fruits and vegetables include

  • oranges
  • melons
  • apricots
  • bananas
  • potatoes
  • tomatoes
  • sweet potatoes
  • cooked spinach
  • cooked broccoli

Phosphorus. Children with CKD need to control the level of phosphorus in their blood because too much phosphorus pulls calcium from the bones, making them weaker and more likely to break. Too much phosphorus also can cause itchy skin and red eyes. As CKD progresses, a child may need to take a phosphate binder with meals to lower the concentration of phosphorus in the blood. Phosphorus is found in high-protein foods. Foods with low levels of phosphorus include

  • liquid non milk creamer
  • green beans
  • popcorn
  • unprocessed meats from a butcher
  • lemon-lime soda
  • root beer
  • powdered iced tea and lemonade mixes
  • rice and corn cereals
  • egg white
  • sorbet

Fluids. Early in CKD, a child’s damaged kidneys may produce either too much or too little urine, which can lead to swelling or dehydration. As CKD progresses, children may need to limit fluid intake. The health care provider will tell the child and parents or guardians the goal for fluid intake.

  

Kidney disease, children and the responsibility we have to protect them. The two purple colored images on the back of the little baby boy below with yellow lines represent the kidneys. To learn more about kidney disease, visit us at www.kidney-solutions.com/faq 

#kidney #kidneydisease #kidneyfailure #hemodialysis #kids #children #childhoodkidneydisease #transplant #peritonealdialysis

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

 

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


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

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

© Copyright 2011 CorbisCorporation

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

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

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

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

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

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

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

Haiti Earthquake 2010

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

 

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

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

Kaiser Found- HIV prevalence rate

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

Medscape- Hep B prevalence

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

 

 

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

Hep c prevalence

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

 

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

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

Listening to Patient's Heartbeat with Stethoscope

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

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

To learn more about Hepatitis C infection, click here.

To learn more about HIV infection, click here.

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

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

 

References for further reading

  1. AO Adegoke, O Akanni, J Dirisu. Risk of transfusion-transmitted syphilis in a tertiary hospital in Nigeria. N Am J Sci. Feb 2011; 3(2):78-81
  2. FI Buseri, MA Muhibi, ZA Jeremiah. Sero-epidemiology of transfusion-transmissible infectious diseases among blood donors in Osogbo, south-west Nigeria. Blood Transfus. Oct 2009; 7(4):293-299
  3. E Nwankwo, I Momodu, I Umar, B Musa, S Adeleke. Seroprevalence of major blood-borne infections among blood donors in Kano, Nigeria. Turk J Med Sci. 2012;42(2):337-341
  4. 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.
  5. 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.
  6. 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.
  7. 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
  8. 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.
  9. 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.
  10. 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.
  11. 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.

 

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


Healthcare quality has several dimensions that are all inter-related

Healthcare quality has several dimensions that are all inter-related

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

– Lucius Annaeus Seneca (4 BC- AD 65)

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

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

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

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

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

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

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

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

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

For example

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

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

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

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

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

  • Order entry and prescriptions

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

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

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

Examples of key outcomes of care for kidney disease include

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

Examples of key outcomes of dialysis care include

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

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

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

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

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

References

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

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

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

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

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

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

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


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

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