Indeed, it was taken for granted by healthcare providers that children and teenagers, no matter the symptoms presented, were not likely to suffer any of the ailments
Today More Nigerians are coming down with kidney failure. Even children are not left out. In fact recent hospital-based study found that 8.9 per cent of children on hospital admission have kidney problems.
The Guardian investigations revealed that untreated microbial infections especially urinary tract infections (UTI), diarrhea, malaria, hepatitis, Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), diabetes, hypertension, potassium bromate poisoning, teething powder, abuse of painkillers/analgesics especially paracetamol are responsible for the rising cases of kidney failure in Nigerian children.
The Guardian gathered that other well-recognised risk factors for chronic kidney disease include increasing age, family history of kidney disease, cigarette smoking, exposure to heavy metals such as lead, long term ingestion of herbal concoctions, obesity, sickle cell, prostate problems and cancers, and bleaching lotions, soap and creams.
Indeed, acute kidney injury (AKI), formerly known as acute renal failure is common in children admitted to hospitals. Studies from both developing and developed regions of the world have demonstrated high incidence of AKI in children.
Significantly, AKI is associated with high morbidity and mortality, more so in regions where there is dearth of resources including renal replacement therapy.
Recent studies have shown that hypertension is the leading cause of kidney failure in Nigeria across all ages, closely followed by diabetes and HIV/AIDS, which is fast becoming one of the major causes of kidney failure in Nigeria.
Burden and prevalence
According to the President, Nigeria Association of Nephrology and Chief Medical Director at St. Nicholas Hospital, Lagos, Dr. Ebun Bamgboye, at least 36.8 million Nigerians (23 per cent) are suffering from various stages of kidney disease.
Bamgboye who disclosed this at an awareness programme organised by the Hospital to mark this year’s World Kidney Day in March 2013, regretted that despite the severity of the disease, Nigerian patients are faced with many challenges in terms of treatment.
Bamgboye lamented the burden of the disease, noting that an estimated 15,000 new patients are diagnosed every year in the country.
He said: “Chronic kidney disease prevalence is a problem in our environment. Estimates suggest that one out of every seven Nigerians has one stage of chronic kidney disease. Unfortunately, out of 50,000 patients who should ideally be on dialysis, fewer than 1,000 are currently on dialysis as at today.
“Unfortunately, if you have kidney failure and you do not do dialysis or transplant within two weeks you will die. You can imagine the number of people that are dying every day because of kidney disease.”
Provost of the College of Health Sciences at Osun State University, Prof. Christopher Olutayo Alebiosu, said community studies put kidney disease in adults between 19 and 30 per cent.
Alebiosu while delivering the seventh Inaugural Lecture of the institution titled: ‘Emerging Epidemic of Non-Communicable Diseases – Conspiracy against the kidney’ said that chronic kidney failure was a devastating medical, social and economic problem for patients, their families and the country as a whole.
Paediatricians from the Department of Paediatrics Lagos University Teaching Hospital (LUTH)/College of Medicine, University of Lagos (CMUL), Idi-Araba, Dr. Taiwo Ladapo, and her colleagues led by Prof. Afolabi Lesi in a recent study, which has been accepted for publication by the Saudi Journal of Kidney Disease noted that of all the children admitted over a four-year period (2008 to 20011) in LUTH, kidney disease accounted for 8.9 per cent of paediatric admissions with prevalence of 22.3 admissions per 1000 child-admissions per year; and that yearly incidence doubled over the study period.
The study is titled “Paediatric kidney diseases in an African country: Prevalence, Spectrum and Outcome.”
The researchers noted that nephrotic syndrome, acute kidney injury (AKI) and nephroblastoma accounted for almost 70 per cent of admissions; and that the overall mortality rate was 12.6 per cent with AKI being the leading cause.
They observed that the prevalence of AKI was higher than that reported from other parts of the country; late presentation, inadequate diagnostic and therapeutic facilities and financial constraints negatively impacted outcome; and disease-specific prevalence varied between geographic sections.
Nephrotic syndrome is caused by different disorders that damage the kidneys. This damage leads to the release of too much protein in the urine.
Nephroblastoma or Wilms’ tumor is cancer of the kidneys that typically occurs in children, rarely in adults.
The researchers in an earlier study published in the December 2012 edition of the journal PLOS ONE concluded: “Acute kidney injury is common in children admitted to hospitals. The common causes remain primary kidney diseases, sepsis and malaria but the contribution of sepsis is rising while malaria and gastroenteritis are declining. Acute kidney injury-related mortality remains high.”
The results of the study titled “Paediatric Acute Kidney Injury in a Tertiary Hospital in Nigeria: Prevalence, Causes and Mortality Rate” showed that of the 4 015 children admitted into LUTH between July 2010 and July 2012, 70 episodes of AKI were recorded equalling 17.4 cases per 1000 children.
The researchers found among other things that: the median age of the children with AKI was 4.8 (range 0.1–14.4) years and 68.6 per cent were males. Acute kidney injury was present in 58 (82.9 per sent) children at admission with 70 per cent in ‘failure’ category; primary kidney disease (38.6 per cent), sepsis (25.7 per cent) and malaria (11.4 per cent) were the commonest causes; the primary kidney diseases were acute glomerulonephritis (11) and nephrotic syndrome (eight); nineteen (28.4 per cent) children with AKI died; need for dialysis were associated with death.
Glomerulonephritis may be caused by problems with the body’s immune system. Often, the exact cause of glomerulonephritis is unknown. Damage to the glomeruli causes blood and protein to be lost in the urine. The condition may develop quickly, and kidney function is lost within weeks or months (called rapidly progressive glomerulonephritis).
Glomeruli (glomerulus is singular) are tiny tufts of capillaries, which carry and filter blood within the kidneys. A quarter of people with chronic glomerulonephritis have no history of kidney disease.
Published evidences of causes.
Researchers in a study published in Saudi Journal of Kidney Disease and Transplantation concluded that malaria is associated with acute renal failure, which occurs most commonly in Plasmodium falciparum infected patients. They, however, said early diagnosis and prompt dialysis with supportive management could reduce morality and enhance recovery of renal function.
Results from a recent study published Biokemistri: An International Journal of the Nigerian Society for Experimental Biology showed a possible relationship between hepatitis B infection and insufficient renal function.
Diarrhoea has been shown to be one gastrointestinal tract symptom of kidney failure. Excessive accumulation of creatinine, blood urea nitrogen and other wastes in the patient’s body can cause many sick feeling such as fatigue, nausea, poor appetite. Medical doctors say if left untreated, patients can develop serious vomiting, indigestion, diarrhoea, low blood volume or even rapid decline of kidney functions.
Medical experts are unanimous that diarrhoea can cause or worsen kidney failure. There have been many reports about renal failure after serious diarrhoea; can be caused by food poisons; and can cause many complications if left untreated. Many organs can be involved and renal failure is one relatively severe complication.
Another study published in January 2013 edition of Saudi Journal Kidney Disease Transplantation concluded: “Renal disease was found to be significantly associated with advanced stage of HIV infection. Our study showed that t he prevalence of renal disease in highly active anti-retroviral therapy (HAART)-treated Nigerian children is high and majority of them are asymptomatic of renal disease, but in the advanced stages of HIV infection.”
The study titled “Prevalence of renal disease in Nigerian children infected with the human immunodeficiency virus and on highly active anti-retroviral therapy” was published by researchers from the Department of Child Health, University of Benin, Benin City, Edo State.
The researchers wrote: “It is therefore important that early detection of renal damage, in the asymptomatic stage, is made in order to institute measures early, which may reverse or slow down the progression of kidney disease to End Stage Renal Disease (ESRD). This may be the most significant preventive strategy, especially as facilities for renal replacement care are limited and expensive in resource-poor countries.”
HIV affects virtually every organ system in the body, including the kidneys. Several studies have shown that most of the HIV-related renal diseases reported in children manifest as chronic kidney disease (CKD). Isolated cases of nephro-toxicity have also been reported with almost all HAART agents.
The use of HAART is known to reduce morbidity and mortality in HIV-infected children. With the recent improved access to HAART and expected longer survival among HIV-infected Nigerian children, it is possible that the long-term complications of renal toxicity would increase.
According to a study published in Nigeria Journal of Medicine, “chronic consumption of analgesics/pain killers has been shown to increase the risk of end-stage renal disease. In Nigeria, these drugs are readily available as there is no legislation regulating their consumption. We report the use and abuse of analgesics in a Nigerian population.”
The study titled “Use and abuse of analgesics in Nigeria: a community survey,” was carried out by researchers at the Department of Medicine, Jos University Teaching Hospital, Jos, Plateau State.
Usually, urinary tract infections are harmless and can be cured easily. However, repeated UTI often turn into pyelonephritis, which is an inflammation of the kidney. Inflammation in the kidney worsens renal tissues seriously and thus cause kidney damages. Chronic kidney disease causes no obvious symptoms in early stage. Without a timely diagnosis, chronic kidney problem progresses to end stage kidney failure directly.
However, clinical experiments have shown that drinking large amounts of water will help to remove bacterium out of the urinary tract, which will lower the risk of developing kidney failure. Therefore, drinking much more water is very beneficial in daily life.
Researchers have also reported acute renal failure following accidental potassium bromate poisoning. The study published in Nigerian Journal of Paediatrics noted: “Accidental poisoning is common in children. Potassium bromate is a commonly used additive and raising agent in many edibles particularly bread, a staple food worldwide, yet its accidental poisoning has hitherto, not been documented in Nigeria. We report an unusual case of acute renal failure following accidental ingestion of potassium bromate tablets.”
Alebiosu said the two major enemies of the kidney were diabetes and hypertension. He described hypertension and diabetes as principal “accomplice” in the development of chronic kidney disease.
According to him, ‘There are many identified factors causing chronic kidney disease, however the prevalence of these factors differ to varying extent in different parts of the world. In Nigeria, some socio-cultural practices can lead directly or indirectly to the development of chronic kidney disease. These include long-term ingestion of herbal concoctions/preparations, chronic analgesic abuse (certain pain killers) and the use of certain soaps/creams/lotions used as bleaching agents. Nigerians should refrain from consumption of medications without prescriptions.”
A study published in African Journal of Medicine & Medical Sciences concluded: “Primary chronic glomerulonephritis (CGN) and accelerated hypertension still remain the leading causes of chronic renal failure (CRF), while diseases such as diabetes mellitus and chronic pyelonephritis do not contribute significantly to CRF in Nigerians. Recognition of the early features and the causes of CRF would considerably reduce the prevalence of this condition.”
The study titled “Diseases causing chronic renal failure in Nigerians—a prospective study of 100 cases,” was conducted by researchers at Faculty of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State.
High alert over rising cases in children
Medical experts have alerted on the rise cases of chronic kidney disease in Nigerian children even as they called for screening programmes, manpower training and improvement of diagnostic and therapeutic facilities to address the situation.
Why are more children turning up with chronic kidney disease? Ladapo, told The Guardian: “The reasons are many. Some children are born with abnormality of the kidney tract that are not detected on time and it affects the kidneys. For some it is not known. Some infectious diseases affect kidney functions in children such as hepatitis. Also other conditions like nephrotic syndrome which if not well treated can cause kidney disease.
“You also have acute kidney injury that is acute renal failure, children coming down with malaria, infection, different kinds of infection such as bacteria infection, pneumococcal infection. Then you have diarrhoea, they come in, they have diarrhoea and have been passing stool and the body fluid is not being replaced, the kidney shuts down.
“If the kidney is not getting enough fluid it shuts down. Infections also affect the kidney. We are really trying to raise awareness and raise help for children with kidney disease. We have increased our dialysis services. The Hospital has been very supportive and now we have two nephrologists on ground and we are trying to boost our services.”
How about the adults? Ladapo said: “One of the reasons, which is why we are beginning to cry out is that there have been studies done in the developed world and they have found out that some of these diseases actually start in childhood but they are misdiagnosed. So by the time they are young adults they are already in chronic or end stage meanwhile the problem started long ago.
“What is being done in developed world for example is that they do school screening by simple checking of the urine of school children for protein, can help detect some children with kidney disease. In developed world there are screening programmes that pick up these diseases early.
“We don’t have such in Nigeria; nobody is screening anybody for anything. Nigeria is a country that has infectious disease as a main issue. So you have infections that may affect the kidney then hypertension, diabetes are on the increase. But some have been shown to actually start from childhood.”
What is the statistics? How many children are diagnosed with kidney disease in LUTH? She explained: “The statistics vary widely even in Nigeria because the criteria used in different studies are not the same. It is difficult to do a synopsis of the studies. Some people look at only children that were seen at the emergency room, some look at those on admission, some look at everybody. So it is difficult to say. For example in a study we just published here we found out that 8.9 per cent of children on admissions over a five year period was due to kidney disease.”
Challenges
Ladapo said the first dialysis section for children with chronic kidney disease costs about N40,000 to N50,000 for one and subsequently the child should have it three times a week at the cost of about N20,000 per session.
According to Kidney Consultants International (KCI), the typical renal patient has a three to five hour dialysis treatment; three times per week and dialysis can only replace only about 10 per cent to 15 per cent of the function of healthy kidneys. In Nigeria, each session of dialysis treatment will cost an average of N25,000.00 or N75,000 per week, a cost much more than the average Nigerian worker can bear.
KCI noted: “A kidney transplant provides the patient with a healthy kidney from a donor but it often requires a lot more in terms of finances. When a donor (which so far in Nigeria have been living relatives, spouses or friends) is found, their suitability for surgery is determined and they are tested to determine if their blood type and other issue factors match the patients. Some of these investigations are done abroad and this helps to compound the cost of the surgeries.
“After the surgery, transplant patients must take immunosuppressant drugs, which keep their bodies from fighting and destroying the transplanted organ and these drugs must be taken for life with a combination of other drugs, which are usually not in stock by regular pharmacists due to their high cost. When required, they are often imported specially for the patients’ use.”
Average yearly costs of kidney management
Cost of twice weekly haemodialysis
N2,388,168.00
Cost of thrice weekly haemodialysis
N3,255,368.00
Cost of CAPD (Continuous Ambulatory Peritoneal Dialysis)
N3,699,925.00
Cost of renal transplant plus immunosuppressant for two years
N4,802,680.00
Cost per year
N2,401,340.00
Solutions
Alebiosu said that “chronic kidney disease continues to affect people in their productive years and most patients continue to die due to their inability to sustain dialysis treatment in view of the high cost.”
The professor of medicine stated that considering the damage caused by hypertension on the heart, brain, kidneys and blood vessels, there was the need for physicians to pay more attention to ensure lesser damage to these important body organs in hypertensive patients.
The expert recommended that pre-employment urine screening and health education will go a long way in educating, increasing awareness and preventing the deleterious complications of uncontrolled hypertension, diabetes and glomerulonephitis
Alebiosu also declared the urgent need to implement prevention strategies that include health education policies geared towards adoption of healthy lifestyle measures that prevent or delay the onset of diabetes and hypertension; strengthening of the health care for people with non-communicable diseases; and integration of non-communicable disease prevention in national programmes for sustainable development.
He stated: “much of the burden of non-communicable diseases such as hypertension and diabetes can be averted through primary prevention and the complementary identification of early stage disease, combined with effective treatment of existing conditions.”
Alebiosu warned: “Unless concerted action is taken, the rising financial burden of non-communicable diseases will reach unmanageable levels.”
Ladapo further said: “Unfortunately one of the conditions that are most expensive to treat is kidney disease and there is no where in the world, very few countries in the world do people pay out of pocket. I cannot afford it. You have a lot of government support for children on dialysis, you have a lot of private sector support.
“One of the things we are trying to do is to raise awareness about the increase in kidney disease in children and also raise support for children who need dialysis.”
A study published recently in Saudi Journal of Kidney Disease and Transplantation noted: “We conclude that renal abnormalities, importantly albuminuria, is common in adult Nigerians with Sickle Cell Anaemia (SCA) and the pattern and incidence are similar to those reported from other parts of the world. Regular blood pressure monitoring, early diagnosis and active intervention are advocated to delay progression to end-stage kidney disease in view of poor outcomes of renal replacement therapy in SCA patients with nephropathy.”
The study titled “Renal disease in adult Nigerians with sickle cell anemia: a report of prevalence, clinical features and risk factors,” was conducted by researchers from the Department of Hematology and Blood Transfusion, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State.
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