|Year : 2020 | Volume
| Issue : 6 | Page : 340-344
Clinical characteristics and outcomes of hemodialysis in a new center in Northern Nigeria
Alhaji Abdu, Ibrahim Maigari Mahmood, Kabeer Yakubu Audi, Mustapha Sabo Umar
Department of Internal Medicine, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
|Date of Submission||04-Sep-2019|
|Date of Decision||06-Oct-2019|
|Date of Acceptance||15-Aug-2020|
|Date of Web Publication||19-Dec-2020|
Dr. Alhaji Abdu
Department of Internal Medicine, Abubakar Tafawa Balewa University Teaching Hospital, P.M.B. 0117, Bauchi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Hemodialysis is the most common renal replacement therapy (RRT) modality in Africa and few countries enjoy reimbursement from the government to fund it. Africa contributes <10% of the total RRT patients worldwide this is mainly due to high cost. Aims and Objectives: We aimed to review the clinical characteristics and outcomes of patients requiring hemodialysis in our center over a 7 years period, to highlight the enormous challenges encountered. Materials and Methods: This is a retrospective study of patients aged 15 years and above that was seen between April 2010 and March 2017 at the Hemodialysis unit of Abubakar Tafawa Balewa University Teaching Hospital. Information was extracted from the patient's case folders and dialysis charts. Results: In total, 226 patients had hemodialysis over the period, 124 (54.9%) were male and 102 (49.1%) were female. Sixty-one (27%) patients had acute kidney injury (AKI), 143 (63.3%) had chronic kidney disease (CKD), whereas 22 (9.7%) had acute-on-CKD. A total of 2215 sessions of hemodialysis were done in the period, of which 782 (35.3%) were for AKI and 469 (21.2%) for acute on CKD. A total of 138 (60.6%) patients were discharged and 58 deaths were recorded. Conclusion: Although there is rapid proliferation of hemodialysis facilities in the country, many patients could not afford adequate hemodialysis. Inadequate dialysis due to finances was the main cause of death in these category of patients.
Keywords: Bauchi, clinical characteristics, hemodialysis, Northern Nigeria, outcomes
|How to cite this article:|
Abdu A, Mahmood IM, Audi KY, Umar MS. Clinical characteristics and outcomes of hemodialysis in a new center in Northern Nigeria. Niger Med J 2020;61:340-4
|How to cite this URL:|
Abdu A, Mahmood IM, Audi KY, Umar MS. Clinical characteristics and outcomes of hemodialysis in a new center in Northern Nigeria. Niger Med J [serial online] 2020 [cited 2021 Apr 17];61:340-4. Available from: https://www.nigeriamedj.com/text.asp?2020/61/6/340/304009
| Introduction|| |
The prevalence of all stages of chronic kidney disease (CKD) worldwide was 13.4%, whereas stages 3–5 CKD was 10.6% in the period 2000–2014. With the continuing rise in prevalence and incidence, CKD has now become a significant public health problem.
This increase in prevalence is mainly due to the rising incidence of hypertension and diabetes. Overall, CKD mortality has increased by 31.7% over the past 10 years, making it one of the fastest rising major causes of death, alongside diabetes and dementia. The global burden of disease study estimated that there were about 1.2 million deaths attributable to CKD in 2016, with 82% of years of life lost.
The prevalence of CKD stages 1–5 range from 10.1% to 15.8% in the entire African continent; however, the prevalence was higher in sub-Saharan Africa and among certain high-risk groups such as hypertension (34.5%) and diabetes (24.7%)., Hemodialysis is the most common renal replacement therapy (RRT) modality in Africa and few countries enjoy reimbursement from government to fund RRT services. There has been an upsurge of hemodialysis centers in countries like Nigeria, both in private and public hospitals, which are mostly concentrated in urban areas. Despite this seeming proliferation of hemodialysis centers, many end-stage renal disease (ESRD) patients could not afford the optimum dose of hemodialysis in the country.
This is 7 years review of the clinical characteristics and outcomes of patients requiring Hemodialysis at Abubakar Tafawa Balewa University Teaching Hospital.
| Methods|| |
This is a retrospective study of all patients aged 15 years and above that were seen at the Hemodialysis unit of Abubakar Tafawa Balewa University Teaching Hospital between April 2010 and March 2017. Ethical approval was granted by the research and ethics committee of the hospital. Information on patient's demography, clinical, and laboratory parameters were extracted from the patient's case folders with additional information on vascular access, duration, and frequency of dialysis extracted from dialysis charts.
The diagnosis of chronic glomerulonephritis was based on a history of progressive edema, hypertension, anemia, proteinuria, red cell casts, and bilaterally shrunken kidneys on ultrasound in young persons. Hypertensive nephrosclerosis was diagnosed based on history and clinical features of long-standing hypertension, and features of kidney disease. 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 clinical features of obstruction, ultrasound features of hydronephrosis, and clinical and biochemical features of kidney disease. The diagnosis of acute kidney injury (AKI) was based on the Kidney Disease Improving Global Outcome (KDIGO) clinical practice guidelines for the diagnosis of AKI. ESRD was diagnosed based on KDIGO 2012 clinical practice guidelines on the evaluation and management of CKD.
Data were analyzed using the Statistical package for social sciences version 21 (SPSS V. 21 IBM corporations 2013). Continuous variables were presented as means ± standard deviation, whereas categorical variables were presented as percentages. Chi-square test was used to assess the association between categorical variables, while the Wilcoxon rank-sum test was used to assess the association of continuous nonnormally distributed variables. Value of P = 0.05 was considered significant.
| Results|| |
In total, 226 patients had hemodialysis over the 7 years, 124 (54.9%) were male and 102 (49.1%) were female with a male: female ratio of 1.2:1. Their mean age was 41.5 ± 16.25 years, 142 (62.8%) and 22 (10%) were aged <45 and >65 years, respectively. About half (59.3%) of the patients were of Hausa/Fulani ethnicity, and 23.5% were from Bauchi Local Government Area. Thirty-five (15.5%) were from neighboring states of Gombe, Plateau, Jigawa, Adamawa, and Taraba. Farming and trading constituted 14.2% and 6.6% of patient's occupation, respectively, whereas 8% were students. [Table 1] summarizes the main clinical presentation of the patients.
Sixty-one (27%) patients comprising 31 males and 30 females had AKI, 143 (63.3%) comprising 77 males and 66 females had CKD, 22 (9.7%) had acute-on-CKD (AoCKD). In terms of presentation, patients with CKD presented with edema compared to AKI or AoCKD patients. Patients with CKD also presented with other symptoms such as nausea, vomiting, pruritus, and severe lethargy more often than either AKI or AoCKD patients. One hundred and thirty-four (73.2%) of the CKD patients had systolic BP >140 mmHg, whereas 131 (71.6%) had diastolic BP >90 mmHg, only 9 (36%) of AKI patients had systolic or diastolic BP >140 mmHg or 90 mmHg, respectively. This observation suggests that patients with CKD present late in the course of their illness with prominent and severe uremic symptoms and poor blood pressure control. This could have a major affect on survival.
Patients with CKD had more blood transfusion than AKI or AoCKD patients (P = 0.003). Only 2 of the CKD patients were on regular erythropoiesis stimulating agents. [Table 2] compares some clinical and laboratory parameters between patients with CKD and AKI. Patients with CKD were significantly younger than AKI patients; likewise, serum urea was significantly higher in CKD patients. [Figure 1] shows the causes of AKI among the study patients. Chronic glomerulonephritis was the cause of CKD in 78 (54.5%), while hypertension, diabetes, obstructive uropathy, and sickle cell nephropathy were the cause of CKD in 42 (29.3%), 10 (7%), 5 (3.5%), 5 (3.5%), and 3 (2.2%), respectively.
About 15% of the CKD patients had other comorbidities, which included hepatitis B and hepatitis C infection, deep venous thrombosis, and cerebrovascular disease seen in 6%, 4.9%, 2.7%, and 1.6%, respectively. Less than 5% of the patients with CKD had functional arteriovenous fistula (AVF); all others had hemodialysis via a subclavian or internal jugular catheter. All the AKI patients had dialysis through subclavian catheter (69.4%) and femoral catheter (30.6%). All patients with acute on CKD had dialysis through subclavian catheters except three who had femoral catheters.
During the period 2215 sessions of hemodialysis were done, of which 964 (43.5%) were for CKD, 782 (35.3%) were for AKI, and 469 (21%) were for acute on CKD. Most patients with AKI had 2–8 sessions of hemodialysis before recovery with a range of 2–14 sessions. Among the patients with CKD, 28 (19.1%) were on twice-weekly hemodialysis and 5 (3.4%) were on three times weekly dialysis. Twenty (13.7%) of the CKD patients were on dialysis for more than 12 weeks, while 35 (24%) were on dialysis for 9–12 weeks. Hyperkalemia was seen in 57 (40%) and 19 (30.6%) of CKD and AKI patients, respectively. Acidosis (defined as serum bicarbonate <18 mmol/L) was seen in about 46% of both AKI and CKD patients.
Complications during dialysis were recorded in 43 (19%) of the patients, of which intra-dialysis hypotension was seen in 11 (4.9%) of the patients. A total of 138 (60.6%) patients were discharged of which 82 (57.3%), 46 (75%), and 10 (45%) had CKD, AKI, and AoCKD, respectively. Two of the CKD patients went for transplant out of the country. Thirteen (8.9%) and 9 (14.5%) of the patients with CKD and AKI, respectively, were lost to follow-up. There were a total of 58 deaths, of which 46 (31.5%) had CKD, 8 (12.9%) had AKI, and 4 (22.2%) had AoCKD. Among the 46 AKI patients discharged 8 (17.4%) progressed to CKD, whereas 3 of the 10 patients with AoCKD also progressed to CKD.
| Discussion|| |
The mean age of 41.5 ± 16.25 years was similar to many studies in Nigeria. Arogundade et al. reported the age range of hemodialysis patients in southwest Nigeria between 15 and 90 years, similarly in 7 years' experience of hemodialysis in a south-south Nigeria, Alasia et al. reported the mean age of their patients as 46.2 ± 17.6 years. In another study from the northwest Nigeria, the author reported a younger age of hemodialysis patients of 39.19 ± 16.9 years. This is in contrast to the developed countries where hemodialysis patients were older, with a mean age of 61.1 ± 15.5 years. This relatively younger age of patients from the developing nations has been attributed to higher infectious causes of CKD compared to developed nations where noncommunicable diseases are the major causes.
This has significant economic implications to the country, where the most productive age group is affected. This places heavy financial burden and major psychological trauma to the family that are left impoverished by a lack of basic social amenities, education, and insecurity.
It is therefore not surprising that CKD patients' presentation to a health facility is rather late when less can be done to salvage the failing kidney. From this study, it is apparent that about a quarter of the patients presents in encephalopathy, in addition to mild uremic symptoms such as nausea/vomiting and lethargy. This is the typical presentation of patients in most hospitals in the developing world. For instance, Arogundade et al. while reviewing hemodialysis outcome in Ife observed that >60% of their patients presented with body swelling, and uremic symptoms. Similarly, Alasia et al. in Port Harcourt found out that 85% of their patients presented in an unstable clinical state.
The situation is not different from other developing countries. In Asia, many patients receive dialysis only when uremia became overwhelming and/or life-threatening complications such as fluid overload, metabolic acidosis, and encephalopathy necessitate presentation. This attitude of presentation has been partly responsible for the poor outcome of these patients. Although multifactorial, one important factor in our environment is ignorance. Many of our patients have tried other means such as traditional or spiritual medications, only presenting in hospital rather late with the small amount of money remaining, making it difficult to afford continues treatment such as RRT and other care.
One of the main aims of adequate hemodialysis is volume and blood pressure control. Sadly, many of our patients have fluid overload and severe hypertension. Several observational studies in the hemodialysis population have demonstrated that hypertension is associated with adverse consequences.,, These adverse consequences include fatal arrhythmias and sudden death. It is, therefore, not surprising the high mortality seen in these patients.
Anemia is another major complication of ESRD and is a significant cause of reduced health-related quality of life, morbidity, and mortality in addition to adverse cardiovascular outcomes. In this study, the average hemoglobin of 7.3 ± 1.9 g/dl is far below the recommended target of 11.5–12.5 g/dl. Several studies in Nigeria have reported a high prevalence of anemia at presentation.,, That is why many patients had blood transfusions at a certain period of time with its associated complications. Only four (about 2%) patients could afford regular erythropoietin, the remaining patients were on oral hematinics and occasionally parenteral Iron.
Hyperkalemia was seen in 30.6% and 40.3% of patients with AKI and CKD, respectively. In peritoneal dialysis patients, Torlén et al. have shown that abnormalities in serum potassium contribute disproportionately to the high death risk. In a large observational study Kovesdy et al. also reported that after adjustment for potential confounding variables hyperkalemia (defined as serum potassium ≥ 5.6 mmol/L) was associated with higher all-cause and cardiovascular mortality in patients on maintenance HD. Apart from inadequate dialysis, dietary indiscretion, blood transfusion, and metabolic acidosis are also important causes of hyperkalemia. Some of which are common features of our patients.
Perhaps, all the above factors could be responsible for the higher mortality of 25% seen in this study. However, of much significance is the adequacy of dialysis, which is a function of frequency and duration of the procedure. Whereas all international guidelines recommended at least three hemodialysis sessions per week,,, only 3.4% of our patients could afford three sessions of hemodialysis per week, while >75% could only afford once-weekly session. Therefore, the majority of the CKD patients had inadequate hemodialysis with all its adverse consequences.
However, this is the norm rather than the exception in many centers in low- to middle-income countries. Several studies from across Nigeria have consistently reported a discontinuation rate between 70% and 90% among chronic hemodialysis patients within the first 12 weeks after commencing dialysis., Alasia et al. from Port Harcourt south-south Nigeria, reported that within 12 weeks of commencing maintenance dialysis, 97% of the patients had dropped out of the program through deaths and abandonment. Similarly, Oluyombo et al. in Ekiti, South-west Nigeria, reported that 73% of patients had discontinued hemodialysis by the end of 12 weeks, over a 3 years. In many African countries, chronic dialysis is not sustainable, with patients unable to afford dialysis beyond the first 2–3 months.
| Conclusion|| |
Although RRT services are available in Nigeria, high cost precludes its maximum utilization with attendant's high mortality and morbidity from the condition.
Due to the retrospective nature of the study, causal relationship cannot be ascertained. More robust interventional studies are needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nathan RH, Samuel TF, Jason LO, Jennifer AH, Christopher AO, Daniel SL, et al
. Global prevalence of chronic kidney disease – A systematic review and meta-analysis. PloS One 2016;11:e0158765.
GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1459-544.
World Health Organization. Global Burden of Diseases: 2016 Update. Geneva: World Health Organization; 2008. Available from: https://who.int.org/gbd
. [Last accessed on 2019 Apr 04].
Samar A, Davide B, Graziella D, Evangelia D, Giovanni T, Carmine Z. Prevalence and burden of chronic kidney disease among the general population and high risk group in Africa: A systematic review. BMJ Open 2018;8:e015069. Available from: https://bmjopen.bmj.com/doi: 10.11361.bmjopen-2018-e015069
. [Last accessed on 2018 Dec 12].
Kaze AD, Ilori T, Jaar BG, Echouffo-Tcheugui JB. Burden of chronic kidney disease on the African continent: A systematic review and meta-analysis. BMC Nephrol 2018;19:125.
Oluyombo R, Okunola OO, Olanrewaju TO, Soje MO, Obajolowo OO, Ayorinde MA. Challenges of hemodialysis in a new renal care center: Call for sustainability and improved outcome. Int J Nephrol Renovasc Dis 2014;7:347-52.
Samuel A, Yemi R, Temitope B, Lanre J, Babatunde S. Unaffordability of renal replacement therapy in Nigeria. Hong Kong J Nephrol 2016;18:15-9.
Salako BL, Ayodele OE, Kadiri S, Arije A. Prevalence of hepatitis B and C in pre-dialysis patients with CRF. Afr J Med Sci 2002;31:311-4.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guidelines for Acute Kidney Injury (AKI). Kidney Intl 2012;2 (Suppl):1-138.
Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for the Evaluation and Management of Chronic Kidney Disease (CKD). Kidney Intl 2013;3:s1-163.
Arogundade FA, Sanusi AA, Hassan MO, Akinsola A. The pattern, clinical characteristics and outcome of ESRD in Ile-Ife, Nigeria: Is there a change in trend? Afr Health Sci 2011;11:594-601.
Alasia DD, Emem-Chioma P, Wokoma FS. A single-center 7-year experience with end-stage renal disease care in Nigeria – A surrogate for the poor state of ESRD care in Nigeria and other sub-Saharan African countries: Advocacy for a global fund for ESRD care program in sub-Saharan African countries. Int J Nephrol 2012;2012:639653.
Alhaji A, Ademola LB, Awwal TS, Sani T. Hemodialysis outcome at Rasheed Shekoni Hospital. Niger J Basics Clin Sci 2019;16:42-5.
Hymes JL, Mooney A, Zandt CV, Lynch L, Ziebol R, Killion D. Dialysis catheter-related bloodstream infections: A cluster-randomized trial of the clearguard HD antimicrobial barrier cap. Am J Kidney Dis 2017;69:220-7.
Stanifer JW, Jing B, Tolan S, Helmke N, Mukerjee R, Naicker S, et al
. The epidemiology of chronic kidney disease in sub-Saharan Africa: A systematic review and meta-analysis. Lancet Glob Health 2014;2:e174-81.
Parameswaran S, Geda SB, Rathi M, Kohli HS, Gupta KL, Sakhuja V, et al
. Referral pattern of patients with end-stage renal disease at a public sector hospital and its impact on outcome. Natl Med J India 2011;24:208-18.
Hörl MP, Hörl WH. Hemodialysis-associated hypertension: Pathophysiology and therapy. Am J Kidney Dis 2002;39:227-44.
Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 1996;49:1379-85.
Dinanda J, Diana CG, Kitty J. Cardiovascular and non-cardiovascular mortality in patients starting hemodialysis. J Am Med Assoc 2009;302:1782-9.
Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for Anemia in Chronic Kidney Disease. Kid Intl 2012;2:123-286.
Wokoma FS, Okafor HU. Characteristics of hemodialysis patients at UPTH during the first year of operation. Trop J Nephrol 2008;3:95-101.
Erikpo UE, Udo AI, Ikpeme EI, Effa EE. Hemodialysis in an emerging centre in a developing country: A two-year review and predictors of mortality. BMC Nephrol 2011;12:50-3.
Torlén K, Kalantar-Zadeh K, Molnar MZ, Vashistha T, Mehrotra R. Serum potassium and cause-specific mortality in a large peritoneal dialysis cohort. Clin J Am Soc Nephrol 2012;7:1272-84.
Kovesdy CP, Regidor DL, Mehrotra R, Jing J, McAllister CJ, Greenland S, et al
. Serum and dialysate potassium concentrations and survival in hemodialysis patients. Clin J Am Soc Nephrol 2007;2:999-1007.
Daugirdas JT, Depner TA, Inrig J, Mehrotra R, Rocco MV, Surl RS, et al
. KDOQI clinical practice guidelines for hemodialysis adequacy: 2015 update. Am J Kidney Dis 2015;66:884-90.
European Best Practice guidelines Expert Group on Hemodialysis, European Renal Association. Nephrol Dial Transpl 2002;17:16-31.
Yuzo W, Kunihiro Y, Shinichi N, Hideki H, Norio H, Chie S, et al
. Japanese society for dialysis therapy clinical guideline for 'Hemodialysis initiation for maintenance Hemodialysis'. Therapeu Aph Dial 2015;19:93-107.
[Table 1], [Table 2]