|Year : 2014 | Volume
| Issue : 4 | Page : 221-225
Eight year review of hemodialysis: Treated patients in a tertiary center in Southern Nigeria
Enajite I Okaka, Evelyn I Unuigbe
Department of Medicine, Renal unit, University of Benin Teaching Hospital, Benin City, Edo State, Niger
|Date of Web Publication||7-Oct-2014|
Enajite I Okaka
Department of Medicine, Renal Unit, University of Benin Teaching Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Hemodialysis (HD) is the readily available modality of renal replacement therapy in Nigeria today. The number of centers for HD continues to increase, but the majority is still located in the big cities and towns.
Methods: A retrospective descriptive study in which records of patients on HD from 2004 to 2011 were reviewed. Data in respect of patients' sex, age, occupation and etiology of kidney disease were collected. Data were analyzed using Statistical Package for the Social Sciences statistical software version 16 (SPSS Inc, Chicago IL).
Results: A total of 1278 new patients were admitted for HD over the period of review; 60.9% (778) were males and 39.1% (500) females. Mean age of male patients was significantly higher than that of the females (P < 0.01). Those under the age of 40 years constituted 45.4% (580) of the study population, whereas 43.8% (560) were unskilled workers. Nearly 81.1% had CKD while 18.9% (241) had acute kidney injury (AKI). The most common cause of CKD and AKI were chronic glomerulonephritis (CGN) and sepsis respectively.
Conclusion: This review showed a preponderance of males in the dialyzed population with males significantly older than the female patients. Patients aged ≤ 40 years and unskilled workers formed a large proportion of the population of HD treated patients. CGN and sepsis were the most common causes of CKD and AKI respectively.
| Abstract in French|| |
Contexte: Hιmodialyse (HD) est la modalitι facilement disponible de la thιrapie de remplacement rιnale au Nigιria aujourd'hui. Le nombre de centres pour HD continue d'augmenter, mais la majoritι se trouve toujours dans les grandes villes et agglomιrations.
Mιthodes: Etude de une rιtrospective descriptive dans lequel ont ιtι examinιs les dossiers des patients sur HD de 2004 ΰ 2011. Donnιes ΰ l'ιgard des patients sexe, βge, profession et ιtiologie de la maladie rιnale ont ιtι recueillies. Donnιes ont ιtι analysιes en utilisant le logiciel de statistiques pour la version de logiciel statistique des Sciences sociales 16.
Rιsultats: A de 1278 nouveaux patients ont ιtι admis pour la HD au cours de la pιriode d'examen: 60,9 % (778) ιtaient des hommes et 39,1 % des femmes (500). Moyenne d'βge des patients de sexe masculin ιtait significativement plus ιlevιe que celle des femelles (P < 0,01). Ceux βgιs de moins de 40 ans constituaient 45,4 % (580) de la population ιtudiιe, tandis que 43,8 % (560) ιtaient les travailleurs non qualifiιs. Prθs de 81,1 % comptaient CKD tandis que 18,9 % (241) souffrait d'insuffisance rιnale aiguλ lιsion (AKI). La cause la plus frιquente de CKD et AKI ιtaient respectivement de Glomιrulonιphrite chronique (CGN) et septicιmie.
Conclusion: Cet examen a montrι une prιpondιrance des hommes dans la population dialysιe avec des hommes beaucoup plus vieux que les patientes. Patients βgιs ≤ 40 ans et les travailleurs non qualifiιs a formι une grande partie de la population de patients traitι de HD. CGN et septicιmie respectivement les causes les plus frιquentes de CKD et AKI.
Mots-clιs: 8 annιe d'examen, hιmodialyse, sexe masculin, plus jeune groupe d'βge
Keywords: 8 year review, hemodialysis, male sex, younger age group
|How to cite this article:|
Okaka EI, Unuigbe EI. Eight year review of hemodialysis: Treated patients in a tertiary center in Southern Nigeria. Ann Afr Med 2014;13:221-5
| Introduction|| |
Renal replacement therapy (RRT) either in the form of dialysis or kidney transplantation is the only available treatment for persons in the end stage of chronic kidney disease (CKD) if their survival is desired. Hemodialysis (HD) is the modality of RRT readily available in Nigeria. The unavailability and high cost of peritoneal dialysis (PD) fluids limit the use of PD among adult nephrologists, but some centers offer intermittent PD to patients with acute kidney injury (AKI) whereas mainstay of treatment for pediatric patients with CKD or AKI still remains PD. Kidney transplantation although available in some centers in Nigeria, can only be afforded by a privileged few.
Cost of RRT is enormous even in developed countries. As at 2009, it cost the United States (US) about 40 billion dollars in public and private funds to treat patients with end-stage renal disease (ESRD). Although a good proportion of ESRD patients in America are on PD, HD is still the most commonly used modality of treatment and annual HD cost per patient is $80,000.  In sub-Saharan Africa, patients with ESRD rarely get treatment for the condition due to the high cost of treatment and lack of government support. However, some countries (Mali, Mauritius and South Africa) provide therapy (funded by government) for a small number of ESRD patients. 
The leading causes of CKD in Nigeria are chronic glomerulonephritis (CGN), hypertension and diabetes  while etiological factors for AKI among adult Nigerians include severe sepsis, severe gastroenteritis and acute glomerulonephritis.  Chronic kidney damage can progress to end stage without symptoms until the patient actually decompensates. CKD patients in Nigeria often present late with most of them requiring renal replacement at first presentation to the nephrologist. 
The aim of this study was to review the socio-demographic data; etiology of kidney disease of all HD treated cases of kidney failure (acute and chronic) seen at the University of Benin Teaching Hospital (UBTH) over an 8-year period. The dialysis unit of the UBTH, a tertiary center was established in 1999 and currently has seven functional dialysis machines. The unit offers HD to patients with AKI and CKD. PD is occasionally done for pediatric patients with AKI.
| Methods|| |
This was a retrospective descriptive review of the dialysis records of patients who had HD at UBTH, a tertiary hospital in Southern Nigeria. The review covered the period from 1 st January 2004 to December 31 st 2011. The dialysis unit of the hospital was established in 1999 and provides dialysis facilities for patients with kidney failure. Clientele of the unit include patients from the locality where unit is situated and also patients from neighboring states.
All new adult patients admitted into the unit for dialysis during the period under review were included in the study. Information obtained included age, sex, occupation, type of kidney disease and cause of kidney disease.
Duration of dialysis was 2 h for first HD sessions and 4 h for subsequent sessions. Vascular access for patients with AKI requiring HD was through femoral catheterization while for CKD patients, femoral catheter, internal jugular catheter or arterio-venous fistula was used.
Patients were grouped according to age into three categories: Less than 40 years, 40-65 years and above 65 years of age. Based on occupation, the patients were grouped into six groups: Student, unemployed, unskilled worker, skilled worker, civil servant and professional.
Data obtained were analyzed using Statistical Package for the Social Sciences version 16. Categorical variables were expressed as frequencies and percentages while continuous variables were expressed as means and standard deviation. Independent samples t-test was used to compare the mean age of males and females. Chi-squared (χ2 ) test was used to determine significant difference between proportions. P ≤0.05 were taken as statistically significant.
| Results|| |
A total of 1278 new patients were admitted into the dialysis unit during the period under review. There were 778 males (60.9%) and 500 females (39.1%). Patients aged < 40 years made up 45.4% of the study population. Majority of the patients had CKD (81.1%) while 18.9% had AKI. 560 (43.8%) of patients were unskilled workers while 109 (8.5%) were professionals [Table 1]. The male patients had significantly higher mean age compared with the female patients (P < 0.01).
The number of patients dialyzed for both CKD and AKI increased from 2004 to 2008 thereafter, there was a decline in 2009 and 2010 followed by an increase in 2011 [Figure 1].
CGN was the most common cause of CKD (36.1%) in patients admitted for dialysis followed by hypertension (23.6%) and diabetes (12.8%) while sepsis was responsible for AKI in 76 (31.5%) of patients diagnosed to have AKI. Etiology of AKI was unknown in 34.1% of patients admitted for AKI [Table 2].
Considering the AKI group alone, 126 (52.3%) were males while females made up 47.7% (115). The mean age of males with AKI was 38.9 ± 16.0 years and was significantly higher than the mean age of the female AKI patients of 33.1 ± 13.2 years (P = 0.002, confidence interval: 2.066-9.558).
Two-thirds of patients dialyzed for AKI were <40 years of age. There was a significant association between being female and requiring dialysis for AKI, χ2 = 14.752, P ≤ 0.001 [Table 3].
There was a slight difference in etiology of CKD between the sexes. CGN, hypertensive nephropathy (HNP) and diabetic nephr opathy (DMN) were the most common causes of CKD among male patients in this population of dialyzed patients but among the female patients, CGN, HNP and human immunodeficiency virus (HIV)-related kidney disease were the most common causes with DMN ranking fourth among the female patients [Figure 2]. There was no statistical difference between the number of female and male patients with HIV-related kidney disease (χ2 = 1.53, P = 0.216).
|Figure 2: Causes of chronic kidney disease in male and female patients (N = 1037). CGN = Chronic glomerulonephritis. HNP = Hypertensive nephropathy. DMN = Diabetic nephropathy. Others: Sickle cell nephropathy, toxic nephropathy, obstructive uropathy, polycystic kidney disease|
Click here to view
The association between being aged < 40 years and having CGN was statistically significant (χ2 = 1.35, P < 0.01). HNP was more common among patients above 40 years of age (χ2 = 1.71, P < 0.01). HIV-related kidney disease was least common among the elderly [Figure 3].
|Figure 3: Causes of chronic kidney disease in the age groups. CGN = Chronic glomerulonephritis, HNP = Hypertensive nephropathy, DMN = Diabetic nephropathy. Others: Sickle cell nephropathy, toxic nephropathy, obstructive uropathy, polycystic kidney disease|
Click here to view
| Discussion|| |
More males were admitted for dialysis compared with the females and males were significantly older than the females. This finding agrees with an earlier work that reported that CKD is seen more commonly in males compared with females.  Possible reasons for this preponderance of male patients could be because hypertension is an important cause of CKD among Nigerians and male sex has been reported to be associated with a higher incidence of hypertension compared with age matched pre-menopausal women.  Another factor, which may have contributed to this finding is the financial power of women in Nigeria. Men have more economic power and hence are more likely to be able to pay out of their pocket for costly medical therapies like dialysis.
Male patients dialyzed for AKI in this study also outnumbered the females, but a greater proportions those < 40 years old were females. It is possible that this reflects the cases of women of child bearing age requiring HD following complications of eclampsia and pre-eclampsia.
HIV-related kidney disease (HIV associated nephropathy and non-HIV associated pathologies) ranked third after CGN and HNP among female patients dialyzed over the period as opposed to DMN among the males. This finding is in agreement with reports that showed that women in sub-Saharan Africa have a higher risk for HIV infection. The UNAIDS report of 2004 showed that more women were living with HIV/acquired immunodeficiency syndrome Wrelative to men and this trend continues to increase yearly especially among those aged 15-24 years.  Magadi reported a 60% higher risk of HIV infection in women compared with their male counterparts.  The situation was not different in Europe, for Nicolosi et al. in their study among Italian couples, reported that the efficiency of male to female transmission was 2.3 times greater than that of female to male transmission.  A study by Wira and Fahey also proposed that women are at a higher risk of acquiring HIV infection at certain periods of the normal menstrual cycle due to suppression of innate and cell mediated immunity by estradiol and progesterone. 
Patients aged <40 years and those aged 40-65 years made up 45.4% and 43.1% respectively of dialyzed patients. This is a pointer to the fact that CKD affects the young and active working strata of the Nigerian population. This has a double negative effect on the nation such that there is a reduction in the active workforce of the Nigerian economy while lean family economic resources are expended in treating these young patients. The situation is different in developed countries where a good chunk of patients on dialysis are elderly. 
The most common cause of CKD in patients aged 40-65 years and above 65 years of age in this review was HNP while CGN was the most common cause of CKD in those <40 years old [Figure 3]. Measures taken at a national level to reduce the burden of hypertension among Nigerians will help to reduce the prevalence of CKD. As for CGN, many patients with the condition present in end stage with bilaterally shrunken kidneys such that the etiology of the glomerular disease cannot be ascertained at presentation. Measures need to be put in place so that young people with glomerular disease are identified early and treated to prevent kidney failure.
In general, CGN, HNP and DMN were the commonest causes of CKD among dialyzed patients in this study. This finding agrees with that reported by Ulasi and Ijoma  However, an earlier study done in the late 1980s  showed DMN not to be a prominent cause of kidney disease among Nigerians. Alebiosu reported the increasing importance of diabetes as a cause of kidney failure among Nigerians.  The increasing prevalence of diabetes among Nigerians is in conformity with the trend in developing countries where diabetes mellitus has become more prevalent. Life-style changes, healthy eating amongst others should be encouraged in the Nigerian populace in order to reduce the prevalence of diabetes mellitus and DMN and hence that Nigeria's already impoverished health care system will not further deteriorate.
Sepsis and prerenal AKI were the most common causes of AKI requiring HD and this agrees with the report by Chijoke  although there was a substantial proportion of patients without a known cause of their AKI in their review.
In the review period, patients admitted for dialysis were mainly unskilled workers (43.8%) while professionals accounted for only 8.5% of cases. Nigerian unskilled workers are in the low socio-economic class and hence unlikely to afford dialysis therapy. In most developed countries of the world, dialysis therapy and other treatment for kidney failure is either funded by the government or covered by health insurance. Such measures need to be put in place for patients requiring dialysis in Nigeria.
The number of new cases for dialysis increased from 2004 and peaked in 2008 followed by a decline until 2010 and then an increase in 2011. This increase in new cases cannot be said to represent an increase in incidence of kidney disease among Nigerians because there is no established renal registry in Nigeria and the actual prevalence of CKD is not known. It is however possible that an increasing awareness of kidney disease and its treatment contributed to the surge in number of patients. Our center commenced the dialysis of patients infected with HIV in 2007 and this contributed to the surge in new cases for dialysis in 2007 and 2008. A number of new dialysis centers have emerged in neighboring states such that persons with kidney failure now have more options to choose from. This may be the reason for the decline in number of patients admitted into our dialysis center in 2009 and 2010.
HD is the readily available form of RRT in Nigeria and costs between 100 and 200 US dollars per session depending on the center involved. Although PD is a cheaper form of RRT, it actually costs more money in Nigeria because PD fluids have to be imported. The cost of a standard bag of PD fluid is about 60 US dollars, thus making PD an unaffordable option for many Nigerians with ESRD. Kidney transplantation is under developed in Nigeria with only seven kidney transplant centers and only two of them with regular transplant activities. Lack of sufficient funding for patient care, procurement of equipment and manpower training contribute to low kidney transplant rates in these centers.
In conclusion, this review showed that more males had HD treatment, male patients were older than the female patients, majority of patients were <65 years of age and mainly unskilled workers. The three most common causes of CKD in the patients were CGN, HNP and DMN.
| References|| |
|1.||Collins AJ, Foley RN, Chavers B, Gilbertson D, Herzog C, Johansen K, et al. ′United States Renal Data System 2011 Annual Data Report: Atlas of chronic kidney disease and end-stage renal disease in the United States. Am J Kidney Dis 2012;59:A7, e1-420. |
|2.||Naicker S. End-stage renal disease in sub-Saharan Africa. Ethn Dis 2009;19:S1-13. |
|3.||Ulasi II, Ijoma CK. The enormity of chronic kidney disease in Nigeria: The situation in a teaching hospital in South-East Nigeria. J Trop Med 2010;2010:501957. |
|4.||Chijoke A. The pattern of acute renal failure in Ilorin, Nigeria. Orient J Med 2003;15:18-23. |
|5.||Arije A, Kadiri S, Akinkugbe OO. The viability of hemodialysis as a treatment option for renal failure in a developing economy. Afr J Med Med Sci 2000;29:311-4. |
|6.||Eriksen BO, Ingebretsen OC. The progression of chronic kidney disease: A 10-year population-based study of the effects of gender and age. Kidney Int 2006;69:375-82. |
|7.||Reckelhoff JF. Gender differences in the regulation of blood pressure. Hypertension 2001;37:1199-208. |
|8.||UNAIDS. Women and HIV/AIDS: Confronting the Crisis. Geneva: UNAIDS; 2004. |
|9.||Magadi MA. Understanding the gender disparity in HIV infection across countries in sub-Saharan Africa: Evidence from the Demographic and Health Surveys. Sociol Health Illn 2011;33:522-39. |
|10.||Nicolosi A, Corrêa Leite ML, Musicco M, Arici C, Gavazzeni G, Lazzarin A. The efficiency of male-to-female and female-to-male sexual transmission of the human immunodeficiency virus: A study of 730 stable couples. Italian Study Group on HIV Heterosexual Transmission. Epidemiology 1994;5:570-5. |
|11.||Wira CR, Fahey JV. A new strategy to understand how HIV infects women: Identification of a window of vulnerability during the menstrual cycle. AIDS 2008;22:1909-17. |
|12.||Akinsola W, Odesanmi WO, Ogunniyi JO, Ladipo GO. Diseases causing chronic renal failure in Nigerians - A prospective study of 100 cases. Afr J Med Med Sci 1989;18:131-7. |
|13.||Alebiosu CO. Clinical diabetic nephropathy in a tropical African population. West Afr J Med 2003;22:152-5. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]