CHALLENGES OF RENAL REPLACEMENT THERAPY IN NIGERIA: SOLUTIONS FROM MEDICAL STUDENTS’ PERSPECTIVES

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A.S. Adetunji¹ and T.S. Fatokun¹

1. Alexander Brown Hall, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria..

Abstract

Introduction: During our posting at the Renal Unit, Department of Medicine, University College Hospital, Ibadan, we observed numerous difficulties encountered by patients requiring renal replacement therapy and the family members/caregivers of these patients. These are broadly categorized into patents’ related challenges, institutional inadequacies, infrastructural challenges, policy, and funding issues.

Perspective: Patients’ challenges are poor health-seeking habits culminating in late diagnosis in advanced uremic state and poor economic status resulting in catastrophic out-of-pocket spending. Institutional and infrastructural challenges include epileptic power supply in the dialysis unit, a lack of necessary materials needed for dialysis, among others. Policy issues included the absence of an organ donor system and regulations guiding them. More importantly, there is insufficient support from the government concerning patients with end-stage kidney disease.

Conclusion: Tackling the management of end-stage kidney disease would require paying attention to and addressing these challenges.

Keywords: Stroke, Renal replacement therapy, Challenges, Solutions, Nigeria.

Introduction

Chronic Kidney Disease (CKD) is defined as a glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for >3 months. It is a global public health problem that causes significant cardiovascular morbidity and could lead to premature death.¹ CKD prevalence is increasing and it is estimated that it accounts for 10% of mortality worldwide, affecting over 800 million people.²

Non-communicable diseases, such as hypertension and diabetes, are the major causes of CKD worldwide.² In recent times, diabetes, obesity, and hypertension have assumed epidemic proportions, not only in developed countries but also in developing countries,³ and they also pose a great risk of complications in those who are already affected by CKD.⁴Furthermore, in developing countries, infections are also important causes of CKD.⁵ Therefore, the incidence and prevalence of CKD are expected to escalate in the next few years, although it is doubtful if the low income and middle-income countries will be able to cope with it. CKD is receiving a lot of attention now because of the enormous cost of treatment and the economics of sustainable policy to stem the tide of this disabling disease.

THE BURDEN OF END STAGE RENAL DISEASE (ESRD) IN NIGERIA
Studies in Nigeria have shown that CKD prevalence ranges between 1.6% and 12.4%.⁶ The wide disparity in the reported prevalence is due to differences in the definition of CKD and the inconsistent data gathering and the near absence of a renal registry where data could be interrogated. The prevalence of CKD using various equations are as follows: Cockcroft–Gault, 4.4% and 26%, Modification of Diet in Renal Disease (MDRD) 12.3%-14.2%, and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), 11.4%.⁷ Some studies, especially community studies, use only the presence of proteinuria or increased serumcreatinine at a defined value for epidemiologic study of CKD.

The observed risk factors in these studies whose prevalence was mentioned above include advanced age, family history of renal disease, low-income occupation, traditional medication use, low haemoglobin, obesity, diabetes mellitus, hypertension.⁷ The increased prevalence of End-Stage Renal Disease (ESRD) among blacks, irrespective of location, suggests that ESRD may be more prevalent in Africa than in other countries. Again, hypertension takes a more aggressive course in blacks than in Caucasians⁸ , making hypertension to be the most important cause of not only cardiovascular disease but also kidney disease in the adult populations.⁹ Sadly, access to renal replacement therapy (RRT) in Nigeria, one of the largest countries in Africa, is limited, hence the high mortality rates ranging from about 40 to 50%.⁶

Agaba et al in their study on the management of chronic kidney disease and end stage renal disease in Nigeria noted that patients with CKD not treated either by dialysis or kidney transplantation, have a high mortality rate and only 20 percent of the patients had the expected number of thrice weekly dialysis and many others are infrequently dialysed contributing to increased mortality.⁵ Even so, many patients who are dialysis dependent in Nigeria may not be adequately dialysed because of either a suboptimal dialysis dose to meet the patients’ dialysis needs or other logistics reasons, as it was also stated that none of these patients in the study by Agaba et al met the Kidney Disease Outcomes Quality Initiative (KDOQI) standards for Kt/V urea .^{5, 101112} This inadequate dialysis session would invariably result in a poor quality of life. Despite the reduced cost of dialysis in Nigeria, the overwhelming majority of patients cannot afford to have a three times weekly dialysis session.⁵