The looming epidemic of Kidney Failure in Nigeria. The magnitude of the problem Dr Ebun L Bamgboye F.W.A.C.P Consultant Transplant Nephrologist Clinical Director, St Nicholas Hospital Lagos. President, Transplant Association of Nigeria President, Nigerian Association of Nephrology Director-MetroHealth HMO

Kidney Failure • Basically two types Acute and Chronic Kidney failure. • Both are quite common particularly in persons of African origin. • The black kidney is particularly prone to suffer the kidney complications of many conditions. • Conditions that frequently lead to kidney failure are common in our environment. • The condition may be only mildly symptomatic in its early stages.

Introduction • Chronic kidney disease (CKD) is emerging as a major worldwide public health problem.

• In the developed countries, the cause of the rise of CKD appears not to be due to intrinsic renal disease but to the dramatic rise in systemic diseases that damage the kidney, such as hypertension and type 2 diabetes. • Chronic kidney disease is associated with increased mortality and morbidity especially that due to cardiovascular diseases and it also imposes a huge economic burden on the family and health care delivery system.

Chronic Kidney Disease • Progressive and irreversible. • Usually involves both kidneys. • Categorised into 5 stages.

• Earlier stages can be managed conservatively. • Stage 5 invariably requires some form of renal replacement therapy or the other.

ESRD Worldwide • • • • • • • •

Incidence increasing – 5-6 % every year. Population growth rate - 1.1%. Prevalence worldwide end 2014; 3,346,000. Estimate incidence; 100/million population yearly. Global average prevalence 465 p.m.p. 89% on haemodialysis (2,358,000). 11% on CAPD. (304,000) >684,000 post transplants surviving on their grafts.

ESRD in Nigeria • Incidence; Number of new cases yearly at 100 p.m.p. will be 17,000 new cases yearly!! • Prevalence; Total number expected too be on management (new + old) at 465 p.m.p. 79,050. • Total patients with ESRD currently on management in all the dialysis units in Nigeria is less than 2,000. • Estimated expected expenditure on dialysis yearly; 316,000,000,000. (316 billion naira).

The epidemiology of chronic kidney disease in Saharan Africa: a systematic review and meta-analysis

sub-

John W Stanifer, Bocheng Jing, Scott Tolan, Nicole Helmke, Romita Mukerjee, Saraladevi Naicker, Uptal Patel. (Lancet Glob Health 2014; 2: e174–181).

• CKD is a prevalent and potentially escalating disease across sub-Saharan Africa with risk factors that include both communicable and noncommunicable diseases. • The overall prevalence of CKD from the 21 medium-quality and high-quality studies was 13·9%.

Health Care in SSA • •

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Government expenditure on health in the WHO’s Africa region averaged 6.2% compared with a global average of 9.1%. African countries are disproportionately dependent on external resources for health care financing (12% compared to global average of 0.4%). Most of this is however focused on specific diseases such as malaria, HIV and TB (and more recently EBOLA). CKD and other NCD not on the radar. Communicable diseases remain the primary cause of death in Africa but behavioral diseases like heart diseases are becoming more prominent. Arguably, more patients die from ESRD than are currently dying from many of these diseases. Life expectancy averages 46 years with wars, crime and violence additional drains on the economy.

Nigeria loses N81bn annually to medical tourism. • • • • •

The Indian High Commission in Lagos issues about 40 medical visas per day. The Nigerian High Commissioner to India, stated that 20,000 out of 25,000 Nigerians given visas in 2011 went there for medical care. In 2012 when 38,000 visas were issued to Nigerians, 18,000 travelled for medical treatment, spending $260m, or average of $15,000 each. Open-heart surgery, renal transplants, brain surgery, cancer and eye treatment were the main treatments sought. According to the Nigerian Medical Association President, “We lose at least $500 million every year to patients travelling abroad for treatment. India makes $260 million from Nigerian patients annually.”

Chronic Renal Failure; Causes • Hypertension. • Diabetes. • Chronic glomerulonephritis. • Chronic pyelonephritis. • Analgesic nephropathy. • Bleaching creams and soaps containing heavy metals (mercury).

• Polycystic kidney disease. • Sickle cell disease. • Obstructive uropathy e.g. stones, prostate, fibroids, strictures and cancers. • Connective tissue disorders e.g. SLE . • Toxic nephropathy. • HIVAN.

Global Challenges Risk factors for causes and progression of Chronic Kidney Disease Non modifiable causes •Race •Ethnicity •Genetics •Gender •Age Modifiable causes •Diabetes

•Word wide increase 171 million in 2000 to 366 million in 2030

•Hypertension •Estimated to increase from 972 million in 2009 to 1.56 billion in 2025

•HIV •Obesity •Hyperlipidemia •Smoking •Poverty •Social Deprivation

Reasons for the African Proneness to CKD

• • • • • •

Inheritance of the APOL1 gene. Inheritance of the MYH9 gene. IUGR. Poor access to health care. illiteracy. Ignorance.

Hypertension and the African • • • • • • •

Commoner in persons of black African origin. Earlier onset in Africans. Greater severity. 1.8 X greater risk of stroke. 1.7 X greater risk of CHF. 4.2 X greater risk of ESRD. In data from the S.A. renal registry of ESRD; Blacks 34.6%, whites 4.3%, Indians 13.8%, mixed 20.9% had hypertension as cause of ESRD. • In the U.S. blacks 15% of population, 50% ESRD.

Hypertension in Nigeria • Commonest non-communicable disease. • Affects 25% of adult Nigerians (>20 million).

• 70% (14 million) do not know they have hypertension. • Only 65% of those that know are on treatment. • Only 30% of those on treatment are well controlled. • Providentially, majority have mild hypertension.

Prevalence of Hypertension Increases with Age Prevalence of hypertension (%)

80 70 60 50 40 30 20 10 0

65.2

29.1

6.7

2039

4059

60

Age (years) Estimated non-institutionalized US adults, 19992002 Adapted from Centers for Disease Control and Prevention

Brown. BMJ 2006;332:8336

Diabetes Mellitus; Worldwide

• Commonest endocrine disease in man. • Prevalence worldwide in 2000 2.8%. Currently 250,000,000. • Expected to rise to 4.4% by 2030!! 366,000,000. • Incidence increasing with urbanization, obesity and age. • Two times more common in Africans and 3-5 times more common in Asians than in white Europeans.

Dialysis in the 3rd World • CAPD usually generally unavailable. • Many personnel migrate for financial reasons. 20% of trained nephrologists in India, more Nigerian and Ghanaian nephrologists practicing outside their countries than within. • Most patients present late. 87% of patients at SNH, 58% of patients at Sao Paulo with 6 months survival 18% lower than those diagnosed earlier.

Dialysis Activity in Nigeria • PD commenced though intermittently since 1966, mainly paediatrics and IPD. • HD started in LUTH in 1981.

• Currently 76 dialysis units all over Nigeria (42 public, 34 private). • Currently over 160 trained and actively practicing nephrologists all over Nigeria. Many more all around the world. • 10 renal transplant units. (8 public, 2 private).

Distribution of Renal Units • Lagos; 20 dialysis units (5 public, 15 private). 2 transplant units (1 private, 1 public). • South west (5 states); 10 dialysis units (7 public, 3 private). 2 transplant units both public. • South east (5 states); 12 dialysis units (5 public, 7 private). No transplant unit. • South south (6 states); 12 dialysis units (7 public, 5 private). One transplant unit. • Abuja; 8 dialysis units (4 public, 4 private). 3 transplant units. • North (11 states); 14 transplant units. All public. 3 transplant units all public.

Draw Backs of Dialysis • Most efficient dialysis achieves only 10% of small solute clearance, higher even less. • Remain unwell, fatigue and malaise persist despite EPO. • Progressive CVD, peripheral and autonomic neuropathy, osteodystrophy and sexual dysfunction are all not uncommon. • Dependent on family for physical, emotional and financial support. • Rehabilitation is poor.

Economics of Transplantation in the Developing World • Average cost of dialysis; 25,000 per session. • Average cost of a transplant; 5,000,000. • Average cost of immunosuppression per year; 1,500,000. • With GDP generally less than $3125, majority can not afford maintenance dialysis and less so transplantation. 80% of patients at UCH could not afford more than 3 sessions of dialysis. • Absence of functional health insurance schemes. • Close relationship between GDP and RRT activity.

The Burden of Renal Therapies • Dialysis – N75, 000 (Seventy Five Thousand Naira) weekly per person consisting of 3 sessions. – N4 million annually • Kidney transplant – Between Five and seven million Naira • Post Transplant Care – Medications = N150, 000 monthly for life (N1.8 million annually) – Follow up and tests

Transplantation in Africa • SA the clear leader in the continent. Averages over 300 transplants per year. Both Public and private. • Sudan also a leader. 186 transplants yearly in 6 units (4 public and 2 private). • Nigeria since 2000. Pioneers in West African subregion. 10 units (8 public and 2 private). 20-30/year. • Kenya leaders in the East African sub-region. 130 in public and 130 in private in the last 5 years.

• Costs average $3,000-$20,000 in the various units.

Transplants done in Nigeria till date • • • • • • • • • •

SNH BUK OAU Zenith Abuja UCH Garki Abuja DELSUTH UMTH LUTH UITH

Numbers

150 33 14 6 4 2 2 1 4 1

SNH BUK OAUTHC UCH

71% 14% 7% 3% 2% 1% 1% 0.5% 2% 0.5%

Solutions • Improve socio-economic status of the developing world. (Debt forgiveness etc). • Ensure more stable and democratic governments. • Improve sanitation. • Improve literacy. • Collaboration with more established programmes.

Solutions • Enactment of a solid organ transplant act of parliament as a matter of urgency.

• Establishment of a renal registry supported by government to compile data. • Commencement of the National Health insurance scheme with extension to ensure support for ESRD care.

Solutions • Greater cooperation within and amongst the various units involved in renal care. • Regular Public enlightenment on the causes, methods of prevention and management of ESRD. Focus on the relative safety of kidney donation.

• Establishment of a computerized data bank of potential cadaver donors and recipients. (Vital for any cadaver transplant programme).

Solutions • Establishment of a transparent, independent and functional national kidney foundation. • Availability of immuno-suppressives at affordable costs. (No duty charged on these drugs + subsidy if possible). • Encouragement of research in tertiary institutions on peculiarities of the African in transplantation. • Further training and improved motivation. • Prevention, prevention, prevention.

Implement Programs for the Prevention, Screening & Treatment of Kidney Diseases • The number of patients with ESRD will continue to increase unless the delivery of optimal preventive medical care to prevent the progression of chronic kidney disease is addressed. • The leading contributors to this burden are diabetes and hypertension. Fortunately, kidney disease can be prevented and progression can be slowed with early identification and treatment of patients with chronic kidney disease. • There are sound and cost-effective models of screening and treatment of kidney diseases that could be integrated within the health care systems for effective outreach and improved patient outcomes.

Screening for Diabetic Nephropathy Test

When

Normal range

Blood pressure1

Each office visit

< 130/80 mmHg Ideal