KidneySolutions

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.

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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.

 

Kidney stones- A beginers guide for patients


What are kidney stones?

Kidney Stones are solid materials that develop from substances dissolved in high concentration in urine. Kidney stones may remain in the kidney or break loose and move down the urinary tract to be passed in the urine. Sometimes kidney stones may form in the bladder. Depending on the size of the stone, the stone may pass freely into the urine with or without symptoms. On other occasions, the stone gets trapped along the urinary tract causing pain, blockage to the free flow of urine or other problems.

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Figure 1: Kidney stones may develop anywhere along the urinary tract. They may form in the kidneys, the ureters or the bladder.

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Figure 2: Kidney stones vary in size from being invisible to the eye to being as large as a finger nail. Small stones or large stones are still capable of causing symptoms. Larger stones are most painful and problematic.

How common are kidney stones?

Even though kidney stones are less common in Africans compared to white people, kidney stones occur fairly frequently among Nigerians and it is estimated that about 65,000-130,000 new cases occur every year in Nigeria. Several hundred thousand Nigerians with longer histories of kidney stones live with kidney stones occurring predominantly in men and in those between the ages of 20 and 45 years of age.  Once a person develops the first kidney stone, he or she is more likely to develop additional stones.

The number of people suffering from kidney stones every year is increasing. The reasons for this are not entirely clear but changing food intake and better diagnostic capability are considered likely causes.

Who gets or develops kidney stones?

Increasing body weight, diabetes, hot temperatures, excessive salt and protein intake and insufficient water intake are considered risk factors for developing kidney stones as well.

The typical person with a kidney stone is a heavy Nigerian male between the ages of 20 and 45 years with a family history of kidney stones who lives in the northern part of the country and works outside most of the time.

It is interesting to note that obese people and diabetic patients have a lower urine pH and a higher urinary uric acid excretion putting them at increased risk  of developing uric acid kidney stones

What are the kinds of kidney stones?

It is important to know that there are different kinds of kidney stones because the treatments for a particular kind of kidney stone may be different from treatments for other kinds of kidney stones. Some patients may have mixed types of kidney stones.

The most common kind of kidney stone is a calcium stone. For patients with calcium stones, the calcium in the urine combines with substances like oxalate or phosphate to form a salt crystal in the urine that can grow and form a large stone. Calcium is an important substance needed for giving strength to bones and teeth, and important in muscle and heart contraction, blood clotting, food digestion, nerve function and many other functions. Free calcium in the blood is filtered by the kidneys into the urine and if calcium accumulates in excess in the blood or urine, it can increase the risk of kidney stone formation. Concentrated urine, excessive amounts of oxalate and uric acid in the urine or low amounts of citrate in the urine are risk factors for developing calcium stones.

Struvite stones form in patients who have infections in the urinary tract with ammonia producing microorganisms. Usually involves gram negative bacteria that are urea splitting . Highly alkaline urine and a high urinary magnesium load can predispose to struvite stones in the presence of the right bacteria. These stones can grow to be very large, may need surgical removal and often need treatment with long term antibiotics along with other measures to control or prevent them.

Cystine stones result from a genetic disorder called cystinuria that causes cystine to leak through the kidneys and into the urine, forming crystals that tend to accumulate into stones. These stones can be hard to find even on x-ray. Cures do not exist but they can be managed effectively by a good doctor.

Uric acid stones develop in people who over produce uric acid or with normal uric acid concentrations but with high urinary uric acid excretion. Some genetic disorders of metabolism as well as gout can be associated uric acid stones. Some blood cancers and defects in kidney handling of uric acid can also predispose to uric acid stones. Low urine pH increases the likelihood of developing a uric acid stone.

Excessive excretion of oxalate in the urine may also be a cause of kidney stones. This excessive excretion may be genetically inherited with treatment ranging from vitamin B6 administration for mild disease to simultaneous liver-kidney transplant for patients with severe disease often leading to kidney failure. On other occasions, the excretion of oxalate in high quantities into the urine may be due to other disorders such as poor intestinal absorption of fatty and bile acids.

Other uncommon causes of kidney stones occur in patients with cystic fibrosis, in those taking the HIV drug called indinavir or in those taking excessive amounts of Vitamin C

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Figure 3: Types of kidney stones. Kidney stones can come in different colors, sizes and shapes. Sometimes they can be mixed. Different types of stones require different types of treatment.

Top left- Brushite/Apatite stones, Top right- Struvite stones, Middle left- Calcium oxalate stones, Middle right- Cystine stones, Bottom left- Uric acid stones, Bottom right- Mixed type stones.

What are the symptoms, signs and complications of kidney stones?

Symptoms of kidney stones might include some or all of the following

  • Pain in the abdomen or groin,
  • Bloody urine,
  • Nausea, vomiting and frequent urination,
  • Cloudy  or smelly urine
  • Fevers and body shaking if associated with infection of the urinary tract.
Locations for kidney stone pain

Figure 4: Locations for kidney stone pain. The pain often is only on one side but may be on both sides.

Signs of kidney stones that may be detected by a medical professional include

  • Tenderness in the lower back, abdomen or bladder regions
  • Decrease intestinal activity
  • Painful groin or testicles
  • High heart beat or blood pressure
  • Fevers and chills

Complications of kidney stones include

  • Urinary tract obstruction
  • Urinary tract infection including abscess formation
  • Perforation along the urinary tract and leakage of urine
  • Urinary fistula formation
  • Increased risk for kidney disease and kidney failure due to obstruction or infection
  • Increased risk of hypertension which in turn can damage the kidneys.

How do I know if my symptoms are from a kidney stone? Could it be from something else?

Do not assume that all abdominal pain is due to a kidney stone. It is important that you go to see a doctor so that a proper diagnosis can be made because if the wrong diagnosis is made, it may be life threatening. Important other diagnoses to be considered include

  • Abdominal aortic aneurysm
  • Appendicitis
  • Gall bladder infection or gall stone disease
  • Diverticulitis- inflammation of the colon
  • Gastric or duodenal ulcers
  • Liver abscess
  • Pancreatitis
  • Testicular torsion or epididymitis

What tests can be performed to determine if I have kidney stones?

A number of tests need to be performed to determine

1)      if your symptoms are due to kidney stones,

2)      if there are complications due to the kidney stones

3)      what kind of kidney stone you have

4)      the best sort of treatment to offer you.

Tests should be performed on your urine and blood. Special x-rays, CT scans or ultrasound tests may need to be performed to determine the size and location of the stone or if there are any complications of the stone such as abscess for fistula formation. A good doctor will ask you to bring in a sample stone if possible for detailed analysis of the stone type or ask you to perform a collection of all urine passed in a 24 hour period to determine the type of urine abnormality leading to stone formation.

How are kidney stones treated?

Treatment of kidney stones involves medical treatment and at times surgical management. Depending on the situation, this may need to be provided on an emergency basis.  Some cases will need hospital admission while sometimes the situation can be managed on an outpatient basis.

  • Fluid hydration. You need to take at least 3 liters of water every day to help prevent formation of more stones and help dissolution of existing stones
  • Treating possible infection with antibiotics
  • Pain control- with medication or with emergency stenting or drainage.
  • Attempts at medical management to enable passing the stone without surgery can be planned by your kidney specialist or urologist. It is not always successful.
    • The medical management often involves fluid hydration, drugs to help relax the urinary tract and enable passing of the stone in the urine, reducing calcium, oxalate or uric acid excretion into the urine, increasing substances in urine to help prevent and dissolve stones. Those with struvite stones in addition to antibiotics may need to be treated with drugs that inhibit some of the activity of urea splitting bacteria while those with cystine stones may need additional treatment with a binding agent that increases the dissolution of  excess cystine in the urine.
    • There often is a need to modify your diet to reduce the amount of stone forming substances in your urine. For example, kidney stone patients need to significantly reduce their salt and animal protein intake. For patients with oxalate stones, reducing the amount of oxalate intake in food such as is seen in chocolate and spinach and other green leafy vegetables is recommended. patients with uric acid stones need to reduce their intake of organ meats.  There is often no need to reduce the amount of calcium in the diet as long as 
    • Weight loss and better control of diabetes may also be important in some patients especially those with uric acid stones.

Your doctor will determine which drugs, diet and lifestyle changes are necessary for you to undertake  depending on the type of stone you have.

  • When a stone is too big or medical non-surgical attempts at passing the stone have failed, or there are significant complications, surgical treatment is required and can range from
    • Stenting or urinary diversion
    • Open surgery
    • Ultrasound blasting/dissolution of the stone(s)
    • Video assisted removal of the stone often by passing a scope into the bladder and upwards into the urinary system

Make sure you see a well trained doctor to advise you on whether you have kidney stones, what type of kidney stone you have and what the proper treatment is. Not all kidney stones are treated the same way. Always ask about your options and what you can do to prevent kidney stones.

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