Unaffordability of renal replacement therapy in Nigeria

AbstractWith the increase in epidemic proportions of diabetes worldwide, the number of patients who will require renal replacement therapy (RRT) will be a great challenge to the health infrastructures of developing countries such as Nigeria. Because those mostly affected are in the economically productive age group, a vicious circle is established whereby those who keep the economy going are the same people affected. Secondary and tertiary care of chronic kidney disease involving RRT would exact disproportionate toll on the income of patients in the developing world where patients pay out of pocket for their own care. Whilst there is an increase in the number of facilities offering RRT, there is no commensurate sustainability of care either by the patients themselves or even by the government. The level of unemployment is increasing. Kidney transplantation is out of reach in addition to the cost of post-transplant care, which includes hospitalization and immunosuppressive medications. Most of the end-stage kidney disease patients who enlisted in our dialysis program were unable to get or sustain adequate hemodialysis. The data also showed that more men were dialyzed at our facilities over the period under review and the age distribution has not changed much over the decade. From this dismal picture in the last decade emerges a series of questions as to why this is so and what must be done to increase access to RRT. Prudent fund management and cost containment, local manufacture of dialysis materials and nongovernmental sources of funding are means of driving down the cost of dialysis. In countries where drugs and equipment for health services are locally manufactured, such as India and other countries, the cost of health care is more affordable than in countries such as Nigeria where these are imported.在全世界，糖尿病的盛行率與日俱增，然而對於發展中國家如尼日利亞，基礎醫療架構並不足以應付患者對腎置換療法 (RRT) 的需求。本地民眾必須自費支付自身的醫療費用，但其收入水平遠不足以負擔慢性腎病二級與三級照護所需的 RRT。即使目前 RRT 設施已有所增加，但無論是患者或政府均難以維持治療的長期實施。此外，腎臟移植所需的資源在本地更是相當之有限。在被我們納入透析計劃的末期腎病 (ESKD) 患者間，大多數並未能接受足夠或持續的透析治療。過去十年間，在我們設施內接受透析的病人中，年齡分佈大致穩定，且男性佔較多數。目前，我們正研究如何能促進 RRT 普及實施的方案。透過謹慎的理財與成本控制、透析物料的本土生產、及非政府資金的運用，透析的相關費用可望得以降低。目前，發展中國家如尼日利亞的藥物與醫療器材大多仰賴進口，因此相關物資的本土生產是降低醫療成本的可行方案

Correlation between Albuminuria and Ankle Brachial Index among Nigerians with Chronic Kidney Disease

Background: Peripheral arterial disease (PAD), the most common manifestation of atherosclerosis and chronic kidney disease (CKD), has been described as an independent risk factor for its development. The combination of CKD and PAD multiplies the risk of cardiovascular disease. Ankle-brachial pressure index (ABPI) is a good marker of atherosclerosis and is useful for the diagnosis of PAD. The study aimed to determine the prevalence, pattern and predictors of PAD in patients with CKD. Materials and Methods: This was a cross-sectional study of patients with CKD with age and gender-matched controls. Medical history relating to CKD and PAD was obtained using a pre-tested questionnaire. The ABPI was measured using handheld Doppler ultrasound equipment. Blood samples were drawn for serum creatinine and spot urine for Urinary Albumin Creatinine Ratio (UACR). Results: One hundred and thirty-two subjects participated in the study, 66 cases and 66 controls. The mean ages were 47.5±15.9 years in cases and 41.6±11.6 years in controls. The mean ABPI (0.9±0.2 vs 1.0±0.1, p-0.01), eGFR (62.8±28.2 vs 98±23.1ml/min/1.73m2 , p-0.01) were lower in the cases compared to the controls while UACR was higher in the cases (3.1±1.1 vs 1.2±0.1, p-0.01. The prevalence of PAD was 36 (54.5%) and 15 (22.7%) among cases and controls, respectively (p < 0.01) while low eGFR OR, 3.9 (1.86-10.41), elevated Systolic blood pressure (SBP) OR, 1.83 (1.40-5.78) and UACR (t-3.663, p-0.023) were associated with PAD in CKD. Conclusion: This study demonstrated that high prevalence of PAD among individuals with CKD while low eGFR, elevated SBP and microalbuminuria were clinical correlates of PAD in CKD

Effects of gender on patient's satisfaction with physician care and communication skills in a tertiary hospital in Nigeria

Patient satisfaction is an important indicator of quality of care. Satisfied patients tend to be more adherent to medical recommendations and are less likely to disenroll from healthcare plans. The study set out to empirically investigate the influence of patient and physician gender on patient’s satisfaction with the clinical care and physician’s communication skills. The study is a cross sectional survey of 300 patient-physician pairs at 5 adult outpatient clinics of a tertiary hospital in Nigeria. Satisfaction to the clinical care received and communication skills of the physician were assessed by the patients using the adapted Patients Satisfaction Questionnaire Form 18 (PSF-18). Three hundred patient-physician pairs were examined, and they made up of 300 patients and 150 physicians. Two hundred and eleven (70.3%) and 249 (83%) respondents were satisfied with the clinical care and physician’s communication skills respectively. Respondents attended to by female physicians were more likely to be satisfied with the clinical care [female 72.8% vs male 62.8%, p < 0.01] and communication skills [female 88.8% vs male 77%, p < 0.01] than those attended to by male physicians. Respondent’s gender had no influence on both the clinical care [male 49.7% vs female 50.3%, p - 0.90] and physician’s communication skills [male 49.0% vs female 51.0%, p - 0.44]. Physician’s gender [Odd Ratio (OR), 2.4] and cadre (OR, 3.8) independently predict patient’s satisfaction to the clinical care received, while only physician’s gender (OR, 1.7) predicts patient’s satisfaction to communication skills. This study showed that physician’s gender influenced patient’s satisfaction to both the clinical care and physician’s communication skills during medical consultation.Keywords: Communication, Clinical care, Gender, Physician, Satisfaction

Salivary electrolytes, total protein and immunoglobulin a in patients with chronic kidney disease: A case control study

Summary: The objectives of this study were to compare levels salivary electrolytes, total protein and immunoglobulin A (IgA) in patients with chronic kidney disease (CKD) and healthy individuals; and to determine the relationship between the salivary and blood levels of these factors between the two groups. Ninety-eight participants consisting of 48 patients with CKD and 50 healthy individuals (age and gender matched) were included. Whole saliva and blood samples were collected and analyzed for concentrations of electrolytes (K+, Na+, Ca2+, Cl-, and HCO32-), total protein and IgA. Data were analyzed using Independent-Samples t-test and Pearson correlation test. Concentrations of salivary K+, Ca2+, Cl-, and total protein were higher; while concentrations of salivary Na+, HCO32- were lower in patients with CKD compared with healthy individuals. There was no difference in the salivary IgA levels in patients with CKD compared with healthy individuals. Salivary calcium level showed linear correlation with the plasma calcium level while salivary chloride level showed negative correlation with plasma chloride level among patients with CKD. These findings indicate that saliva and plasma from patients with CKD are characterized by higher potassium, chloride, and lower sodium concentrations than their levels in healthy individuals; thus, suggesting a possible increased adrenal-cortical activity in patients with CKD.Keywords: Saliva, electrolytes, total protein, correlation, chronic kidney diseaseNiger. J. Physiol. Sci. 33(December 2018) 177-18

Health care-seeking behavior among patients with chronic kidney disease: A cross-sectional study of patients presenting at a single teaching hospital in Lagos

Introduction: Health care-seeking behavior of individuals determines how early they present for appropriate care. In patients with chronic kidney disease (CKD), late presentation to the nephrologist is associated with poor outcomes. This study aims to describe the health care-seeking behavior of patients with CKD attending the nephrology outpatient clinic of a teaching hospital located in Lagos, Nigeria. Materials and Methods: This was a cross-sectional survey conducted on 104 consecutive adult patients with CKD, presenting for the first time at the nephrology outpatient clinic of a teaching hospital located in Lagos, South West Nigeria. Information was retrieved from the study participants using a structured interviewer-administered questionnaire, entered into an Excel spreadsheet, and analyzed using Epi Info® statistical software version 7.0. Results: Overall, 74 (71.2%) patients sought help, first from a trained health care provider, and their health care-seeking behavior was adjudged to be appropriate. Compared to patients with appropriate health care-seeking behavior, those with inappropriate health care-seeking behavior had a lower mean age (40.4 ± 13.7 years vs 47.3 ± 15.6 years;P = 0.03), were less likely to see their illness as a medical problem (46.7% vs 67.6%;P = 0.04), more likely to have a monthly income less than N25,000 ($150) (80.0% vs 59.5%;P = 0.04), and have received below tertiary level education (20.0% vs 48.6%; P < 0.01). They were also more likely to have consulted more than one health care provider before being referred to our clinic. The factors predicting inappropriate health care-seeking behavior were education below the tertiary level and age less than 45 years. Conclusion: Though health care-seeking behavior was appropriate in majority of our patients with CKD, there remains a need for improved public health awareness

Outcomes of tunneled internal jugular venous catheters for chronic haemodialysis at the University College Hospital, Ibadan, Nigeria

Introduction:&nbsp;vascular access is an important aspect of haemodialysis treatments and determinant of patient outcomes. Arteriovenous (AV) fistula has been described as the preferred haemodialysis vascular access for patients on chronic dialysis. There continues to be a challenge with the creation of AV fistula, due to shortage of vascular surgeons skilled in the AV fistula creation particularly in source limited setting. We described the outcomes of the tunneled internal jugular venous catheters amongst our patients at the University College Hospital (UCH) Ibadan. Methods:&nbsp;a retrospective study of patients on maintenance haemodialysis at the UCH, Ibadan, we reviewed the records of all patients on chronic dialysis over a period of 5 years. Information obtained include demographics, types and aetiology of renal failure, types of vascular access, observed complications and outcomes. Results:&nbsp;a total number of 147 catheters were inserted during the period under review, 94 were in males while 53 were females. The age range was 18-85 years while the mean age was 46.3 ± 17.2 years. The range and mean duration for Tunneled Dialysis Catheter (TDC) carriage were (30 - 1,440) and 220±185 days respectively. The observed immediate complications of TDCs were failed first attempt 7(4.7%), reactionary haemorrhage 5(3.4%), arrhythmia 3(2.0%), haemothorax 2(1.4%) while death during catheter placement was recorded in 2(1.4%) cases. Catheter related infection was the commonest long-term complications and occurred in 15 cases (10.1%), while being diabetic increased the risk of developing catheter related complications. One tenth of our patients with End Stage Renal Disease on TDC had kidney transplantation while catheter related mortality was 16.3%. Conclusion:&nbsp;internal jugular tunneled dialysis catheters despite its shortcomings, has been a safe procedure with good outcomes among our patients on maintenance haemodialysis

Predictors and outcome of acute kidney injury after non-cardiac paediatric surgery

Abstract Background It is necessary to define the problem of acute kidney injury (AKI) after non-cardiac surgery in order to design interventions to prevent AKI. The study aimed to evaluate the occurrence, determinants and outcome of AKI among children undergoing general (non-cardiac) surgery. Methods This was a prospective cohort study of patients aged ≤ 15 years who had general surgery over 18 months period at a tertiary hospital in Nigeria. AKI was evaluated at 6 and 24 h and within 7 days of surgery. Data were analysed using SPSS version 21. Results A total of 93 patients were studied with age ranging from 3 days to 15 years (median = 4 years). AKI occurred within 24 h of surgery in 32 (34.4%) and cumulatively over 7 days in 33 (35.5%). Patients who had sepsis were nearly four times as likely as others to develop perioperative AKI (OR = 3.52, 95% CI 1.21, 10.20, p = 0.021). Crude mortality rate was 12.1% (4/33); no mortality was recorded among those without AKI, p = 0.014. Conclusion Perioperative AKI occurred in 35.5% of children who underwent general (non-cardiac) surgery. Patients who had sepsis were four times more likely than others to develop AKI. Mortality was documented only in patients who had AKI

Rationale and Design of the Diet, CKD, and Apolipoprotein L1 Study in Low-Income and Middle-Income Countries

IntroductionDiet, chronic kidney disease (CKD), and Apolipoprotein L1 (APOL1) (DCA) Study is examining the role of dietary factors in CKD progression and APOL1 nephropathy. We describe enrollment and retention efforts and highlight facilitators and barriers to enrollment and operational challenges, as well as accommodations made in the study protocol.MethodsThe DCA study is enrolling participants in 7 centers in West Africa. Participants who consented were invited to complete dietary recalls and 24-hour urine collections in year 1. We conducted focus groups and semistructured interviews among study personnel to identify facilitators and barriers to enrollment as well as retention and operational challenges in the execution of the study protocol. We analyzed emerging themes using content analyses.ResultsA total of 712 participants were enrolled in 18 months with 1256 24-hour urine and 1260 dietary recalls. Barriers to enrollment were the following: (i) a lack of understanding of research, (ii) the burden of research visits, and (iii) incorporating cultural and traditional nuances when designing research protocols. Factors facilitating enrollment were the following: (i) designing convenient research visits, (ii) building rapport and increased communication between the research team and participants, and (iii) cultural sensitivity - adapting research protocols for the populations involved. Offering home visits, providing free dietary counseling, reducing the volume of study blood collection, and reducing the frequency of visits were some changes made in the study protocol that increased participant satisfaction.ConclusionAdopting a participant-centered approach with accommodations in the protocol for cultural adaptability and incorporating participant feedback is vital for carrying out research in low-income and middle-income regions