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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 42-45

Hemodialysis outcome at Rasheed Shekoni Hospital


1 Department of Medicine, Rasheed Shekoni Specialists Hospital, Dutse, Jigawa State, Nigeria
2 Department of Internal Medicine, Aminu Kano Teaching Hospital, P.M.B. 3452, Kano, Nigeria

Date of Web Publication5-Mar-2019

Correspondence Address:
Dr. Alhaji Abdu
Department of Internal Medicine, Abubakar Tafawa Balewa University Teaching Hospital, P.M.B. 0117 Bauchi
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_30_18

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  Abstract 


Introduction: The growing number of patients with Chronic Kidney Disease (CKD) is alarming. This is particularly so in developing countries where glomerulonephritis and unknown causes are common in addition to the rising incidence of hypertension and diabetes. Hemodialysis is the common Renal Replacement Therapy (RRT) modality worldwide; however, many ESRD patients in developing countries cannot sustain hemodialysis beyond few months. We review the experience of a new hemodialysis center in a developing country to highlight the indications and outcome of hemodialysis. Materials and Methods: We retrospectively reviewed the case files and dialysis charts of all patients that had hemodialysis at Rasheed Shekoni Specialist Hospital over the first two years. Result: A total of 96 patients were dialyzed in the center during the two years. Fifty-seven were males and 22 were businessmen. The mean age was 39.19 ± 16.9 years, females were slightly younger. Seventy one of the patients had CKD while 25 had Acute Kidney Injury (AKI). Males had significantly higher serum urea and calcium, while the females had significantly higher serum albumin. More than half of the patients with CKD could not afford hemodialysis beyond the first 6 weeks. At the end of two years only one patient was still on dialysis, 3 patients were referred for kidney transplantation while the remaining patients had discontinued dialysis after an average of 8 weeks. Conclusion: The discontinuation rate of hemodialysis due to ESRD is high in developing countries. This is mostly due to the high cost of hemodialysis and relatively few centers that are concentrated in urban areas. The government has to develop policy to subsidize hemodialysis as well as develop other RRT modalities such as peritoneal dialysis and transplantation.

Keywords: Hemodialysis, indications, northwest, outcome


How to cite this article:
Abdu A, Lawrence AB, Shuaibu AT, Sani T. Hemodialysis outcome at Rasheed Shekoni Hospital. Niger J Basic Clin Sci 2019;16:42-5

How to cite this URL:
Abdu A, Lawrence AB, Shuaibu AT, Sani T. Hemodialysis outcome at Rasheed Shekoni Hospital. Niger J Basic Clin Sci [serial online] 2019 [cited 2019 May 26];16:42-5. Available from: http://www.njbcs.net/text.asp?2019/16/1/42/253408




  Introduction Top


The growing number of patients with chronic kidney disease (CKD) is alarming; this is particularly so in developing countries where glomerulonephritis and unknown causes are more common in addition to the rising incidence of diabetes and hypertension.[1] The disproportionately high cardiovascular mortality among patients with CKD means that only a small fraction progress to end-stage renal disease (ESRD). For patients with ESRD, the role of renal replacement therapy (RRT) has been well established.[2] Hemodialysis is the most common RRT modality worldwide and in Nigeria.[3],[4] Hemodialysis was started in Nigeria in 1981, and since then, many centers have sprung all over the country both in public hospitals and private hospitals.[5] In Nigeria, there are no formal national dialysis program, as such individual centers set up their dialysis criteria without recourse to national guidelines.

Currently, there are over 40 hemodialysis centers in the country mostly concentrated in urban centers. Provision of effective renal care services is a big challenge in sub-Saharan Africa (SSA), particularly Nigeria which has a gross domestic product per capita income of $2,037 or less. The associated lower purchasing power and lack of government commitment put ESRD patients at a great disadvantage. The huge financial burden of hemodialysis is mostly borne by patient's family, in addition to drugs such as erythropoiesis stimulating agents (ESAs), anti-hypertensives, and other logistics. These have made maintenance hemodialysis extremely difficult to sustain beyond first few weeks by most patients. This underscores the need to develop a policy on use of other RRT modalities such as peritoneal dialysis (PD) and kidney transplantation.

Various guidelines recommend thrice weekly hemodialysis of 3–5 hours duration per se ssion.[6],[7] However, achieving this level is very difficult for most patients in Nigeria. This is largely due to the high cost of the procedure, as well as the concentration of the centers in urban areas. These have been responsible for a large number of ESRD patients having inadequate hemodialysis. Observational studies have shown that the amount of dialysis a patient receives affects mortality. Alasia et al. in Port Harcourt reported a 90-day mortality of 40% over a 7-year period among 320 ESRD patients on maintenance hemodialysis.[8] Also, Erikpo et al. reported a 90-day mortality of 40% among 98 ESRD patients in Uyo.[9] This has brought to the forefront the need for government to develop policies that will ensure affordable and accessible hemodialysis services in the country, particularly in rural areas.

Hemodialysis was started at Rasheed Shekoni Specialist Hospital in 2012 with four hemodialysis machines. The cost of a session was about $30, and patients have to pay for the service out of their pocket because there were no reimbursement or health insurance programs in place. We present the epidemiology of ESRD patients on hemodialysis over a 2-year period, with the aim of determining possible areas of intervention by government and soliciting for global funding of ESRD care services in Nigeria.


  Materials and Methods Top


This is a retrospective study of all patients aged 15 years and above who were seen in the hemodialysis unit of Rasheed Shekoni Specialist Hospital between November 2012 and October 2014. Information on patient's demography and clinical and laboratory parameters were extracted from the patient's case folders while information on vascular access, duration, and frequency of dialysis were extracted from patient's dialysis charts. The unit has four functional hemodialysis machines. But, there are no machines dedicated for retroviral, hepatitis B, or hepatitis C patients; so, these patients were referred to nearby Aminu Kano Teaching Hospital.

Diagnosis of chronic glomerulonephritis (CGN) was based on history of progressive edema, hypertension, anemia, proteinuria, red cell casts, and bilaterally shrunken kidneys on ultrasound of younger persons. Hypertensive nephrosclerosis was diagnosed based on history of long-standing hypertension and clinical features of long-standing hypertension such as hypertensive heart disease, thickened arterial wall, and locomotor brachialis. Diagnosis of diabetic nephropathy was entertained in a known diabetic (≥5 years), with microalbuminuria or proteinuria, hypertension, azotemia, and normal or enlarged kidneys on ultrasound. Obstructive uropathy was diagnosed on the basis of ultrasound features of hydronephrosis, clinical and biochemical features of kidney disease in a patient with history, and clinical evidence of urinary tract obstruction.[10]

Diagnosis of acute kidney injury (AKI) was based on the Kidney Disease Improving Outcome (KDIGO) clinical practice guidelines for the diagnosis of AKI.[11] ESRD was diagnosed based on KDIGO 2012 clinical practice guideline on staging and classification of CKD.[12] Three end points were used in this study. These are the proportion of patients who were alive at 12 weeks, 6 months, 12 months, and 24 months from the date of first dialysis session; proportion of patients who died at anytime within the period; and the number of patients who were referred for kidney transplantation during the study period.

Data were analyzed using Statistical Package for Social Sciences version 21 (SPSS v. 21). Continuous variables were presented as means ± standard deviations, while categorical variables were presented as percentages. Chi-square test was used to assess association between categorical variables while Wilcoxon rank sum test was used to assess association of continuous non-normally distributed variables. P value of 0.05 was considered significant.


  Results Top


During the 2-year study period, a total of 96 patients were dialyzed in the unit. There were 57 males (59.3%) and 39 females (40.6%) with a ratio of 1.4:1. The mean age of the patients was 39.19 ± 16.9 years, with a range between 16 and 75 years. More than half of the patients were in the age range 25–54 years, females were slightly older (mean age = 40.05 ± 14.7 vs. 38.6 ± 18.4, P = 0.68). The main occupations of the patients were trading (22, 23%), farming (11, 11.5%), and students (19, 20%), while civil servants and unskilled artisans constituted 6% and 2.1%, respectively.

Seventy-one patients had CKD while the remainder had AKI. Of the CKD patients, 32 (33%) had CGN, 21 (21.9%) had hypertensive nephrosclerosis, and 11 (11.5%) had obstructive uropathy [Figure 1]. There was no significant association between cause of CKD and gender. Among the patients with AKI, eight (32%) had acute glomerulonephritis (AGN), five (20%) presented with acute gastroenteritis (AGE), and four (16%) had features of septicemic illness. Hypovolemia from other causes (except diarrhea) constituted 32%. More males had dialysis for AKI than females (χ2 = 3.87, df = 1, P = 0.049).
Figure 1: Showing causes of chronic kidney disease. ADPKD: Autosomal dominant polycystic kidney disease, CGN: Chronic glomerulonephritis, CPN: Chronic pyelonephritis, DM: Diabetes mellitus, HTN: Hypertensive Nephrosclerosis, OU: Obstructive uropathy, SCN: Sickle cell nephropathy

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The mean systolic and diastolic blood pressure was 151.19 ± 33.5 and 90.04 ± 19.2 mmHg, respectively; 42 patients (43.8%) had severe uncontrolled hypertension. Patients with CKD had significantly higher mean blood pressure than patients with AKI (χ2 = 14.59, df = 1, P = 0.0001). [Table 1] summarizes the clinical features of the patients based on gender. Males had significantly higher serum urea and corrected serum calcium, while the females had significantly higher serum albumin. There is no difference in serum total cholesterol, high-density lipoprotein (HDL) cholesterol, and low-density lipoprotein (LDL) cholesterol between the sexes.
Table 1: Showing the clinical and biochemical parameters

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There was significant difference in age between the patients who developed AKI and CKD, with CKD patients tending to be older. The serum urea was higher in patients with AKI while the systolic and diastolic blood pressures were significantly higher in patients with CKD. CKD patients have significantly lower packed cell volume (PCV) than patients with AKI (χ2 = 65.579, df = 2, P = 0.0001) with 60.6% of CKD patients having PCV <24%.

[Table 2] is a comparison of some clinical and biochemical parameters between the study subjects. Patients with AKI were significantly younger than CKD patients. There was no significant difference in serum total cholesterol, HDL cholesterol, LDL cholesterol, calcium, phosphorus, and albumin. The kidneys were normal or enlarged in all the AKI patients, while it was shrunken and enlarged in 79% and 16% of CKD patients, respectively.
Table 2: Comparing clinical and biochemical parameters between patients with CKD and AKI

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During the period, a total of 1,009 hemodialysis sessions were done with a median of 4 sessions per week. All the patients with AKI had hemodialysis for 1–6 weeks; 36 (50.7%) of the CKD patients could only do dialysis for the first 1–6 weeks while only 3 (3.9%) patients could sustain dialysis beyond 6 months. Sixty-eight (70.8%) of all the patients dialyzed once weekly of which 22 (32.4%) had AKI. Only one male patient could afford three sessions of hemodialysis per week. At the end of 2 years, only one patient was continuing hemodialysis, three patients had living-related kidney transplantation, while the remaining had discontinued the procedure.


  Discussion Top


We presented 2 years of hemodialysis experience of a new renal center in Northwest Nigeria. The mean age of our patients was lower than reported from Uyo,[9] Port Harcourt,[13] and Ekiti[14]; this could be due to the young age of the patients with AKI in this study. However, the age range was closely similar to previous studies in developing countries.[9],[11] The major cause of CKD among the patients were CGN and hypertension similar to what Udeme et al. and Wokoma et al. reported from the southern part of the country.[9],[13] The contribution of diabetes to the CKD population was lower than reported from other parts of Nigeria. Alasia et al. reported diabetes mellitus to constitute 17.9% among 320 ESRD patients who had hemodialysis over a 7-year period in Port Harcourt.[8]

Anemia is a major factor contributing to high morbidity and decreased quality of life of ESRD patients. In our study, 43 (60.6%) of all CKD patients had PCV <24%. This is far below the recommended target hemoglobin of 11.0–12.0 g/dL.[15],[16] This predisposed the patients to repeated blood transfusions with its attendant risks. None of the patients was on ESAs due to cost. In observational studies, anemia was associated with faster progression of left ventricular hypertrophy, inflammation, and increased myocardial and peripheral oxygen demands.[17],[18]

Our study shows overall inability to sustain hemodialysis beyond the first 9 weeks after initiation. This high attrition rate is mainly due to cost and other logistics as many of the patients were peasant farmers from rural areas. More than 70% of our patients could only be dialyzed once weekly. This is far below the international recommendation of three dialysis sessions in a week.[6],[7],[12] In Japan and the United Kingdom, up to 98% and 95% of prevalent hemodialysis patients receive three dialysis sessions in a week.[19],[20] By the end of 1 year, less than 5% of our patients were on hemodialysis.

The seemingly high discontinuation rate among ESRD patients in this study is due to inadequate finances to fund dialysis. Majority could not afford hemodialysis beyond 6 weeks. This also applies to other low to medium income countries (LMIC) like India where less than 10% of ESRD patients receive RRT, while up to 70% of those starting dialysis die or stop treatment due to cost.[21] However, this is in contrast to the developed countries where 1-year crude mortality ranged between 7% and 22%.[22] In the United Kingdom, the 90-day and 1-year age adjusted survival among incident and prevalent hemodialysis patients was 96.8% and 88.3%, respectively.[23]

Lack of funding for maintenance hemodialysis is arguably the single most important barrier to the provision of hemodialysis in SSA. In most parts of the region, there are no reimbursements or government subsidies for dialysis, and health insurance does not exist.[24] These countries face the difficult task of allocating adequate resources for the care of this condition from the large economic strain likely to be imposed by provision of maintenance dialysis.[25] There is an urgent need to explore ways of providing high quality, lower cost RRT services. In LMIC, the high cost of imported consumables contributes to the expense of dialysis. Domestic manufacturing might significantly reduce costs. Government might provide incentives to foreign companies to facilitate licensing and registration of dialysis items.[26] There is therefore the need for a national dialysis guideline that will provide policy direction of funding RRT services.

Apart from provision of RRT services, there is also the need for affordable and accessible support services. As shown by several studies, anemia, mineral bone disorder, and vascular access affect mortality. The provision of cheap ESAs, calcimimetics, and arteriovenous fistula (AVF) services will certainly help to reduce this unacceptable trend. Hence, the government at various levels needs to make concerted efforts to reduce the plight of ESRD patients in the country. There is the need for universal coverage for health insurance policy for both urban and rural dwellers. Finally, kidney transplantation services should also be supported in all government health facilities that have the personnel.

Acknowledgements

Management of Rasheed Shekoni Specialist Hospital

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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