lnsigni ficant small can still be mighty: Trend of chronic kidney disease in Nigeria

Oluwaseyi Abiodun AKPOR,Abigael Oluwaseyi ADEOYE, Blessing AWHIN,Olaolorunpo OLORUNFEMI

1Department of Nursing Science, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State,2Department of Maternal and Child Health Nursing, school of midwifery, University of Benin Teaching Hospital, Benin-City,Edo State, 3Department of Medical Surgical Nursing, Faculty of Basic Medical Science, Federal University, Oye-Ekiti, Ekiti State, Nigeria

ABSTRACT

The global burden of chronic kidney diseases (CKDs) kept increasing, and it is a leading cause of mortality and morbidity rate in most African countries.The burden of CKD is felt more in developing countries where there is no adequate social security system or health insurance to meet the huge financial demands the disease places on its sufferers and their families.It is also noted that this disease affects the economically productive age group unlike in developed countries where the elderly are more affected.The prevalence of CKD was found to be highly related to age, gender, hypertension, obesity, history of diabetes mellitus, use of herbal medicines, and prolonged use of nonsteroidal anti-inflammatory drugs in Nigeria.The majority of CKD cases were not clinically recognized promptly, mainly because of the lack of patients’ awareness about CKD and associated risk factors.Therefore, health awareness should be intensified by the nurses on lifestyle modification by individuals at risk of CKD, prompt management, good compliance with prescribed medications, avoidance of self-medication, and indiscriminate use of over-the-counter drugs.In addition to that, nurses also need to advocate for regular population screening, and efforts should be made at all levels of care to reduce the negative impact of the disease and complications on the patients.

Keywords: Chronic kidney disease, management, nurses, prognosis

INTRODUCTION

Chronic kidney disease (CKD), also called chronic kidney failure, involves a gradual loss of kidney function.[1]Presently, kidney disease has become a major public health problem due to its increased prevalence and its impact on global health, first as a direct cause of global morbidity and mortality and second as a significant risk factor for cardiovascular disease (CVD).[2]Globally, about 41 million people die annually which is equivalent to about 71% of all deaths from noncommunicable diseases with CVDs.[3]The diseases of the kidney are the most common and most severe threat to global economic development due to long-term costs of treatment and negative effects on population productivity.[4]Among these deadly diseases,41.5% were due to CKD in 2017 which rised from 31.7% in 2015.[5]The global burden of CKD kept increasing, and it is projected to become the fifth most common cause of death globally by 2040.[6]Furthermore, following the burden of the disease, a study was carried out in 2017 and ranked CKD as the 12thleading global cause of death out of 133 conditions as against the 17thposition in 2015 , and this report places CKD as one of the fastest rising major causes of death with increasing prevalence in low- and middle-income countries where Nigeria is inclusive.[2,7-10]Recent data showed that hypertension and diabetes mellitus are the two major causes of kidney disease worldwide,including both developing and developed countries.[11-13]Some studies established the risk factors associated with the development of CKD as follows: age ＞55 years, rural residence, angiotensin-converting enzyme inhibitor nonusers,poor CKD knowledge, negative attitude, long duration of hypertension, long duration of diabetes mellitus, social drug use, high level of fasting blood sugar, and uncontrolled blood pressure (BP), which were associated significantly with CKD.[14]Other studies conducted in Nigeria identified factors that are responsible for high incidence of CKD in the country as follows: poor knowledge on the causes, prevention and management, late presentation of patients to the hospital,limited unit for renal management, high cost of treatments,life style risk factors and other socio-cultural negative practices.[15-17]

The magnitude of kidney disease is enormous with a dreadful outcome not only for the individual patient but also the family and community as the cost of managing CKD is exorbitant and far beyond the reach of an average patient,particularly in developing countries where out-of-pocket pay for health care is predominant with no social support resulting in reduced quality of life, treatment withdrawal,and ultimately death.Therefore, the aims of this review are to examine the trend, influencing factors, treatment outcome, and the roles of nurses in preventing kidney diseases in Nigeria.

OVERVIEW OF KIDNEY DISEASES

A healthy kidney executes some vital roles in maintenance of body fluid composition, urine formation, secretion of hormones, enzymes and blood pressure (BP) regulation.[18]When kidney is diseased or damaged, a decrease in kidney function that compromises the normal regulation of fluid,electrolyte, and acid-base homeostasis results.[19]Kidney diseases are disorders relating to physiological roles of the kidney as the filtering organ of the body including the other significant functionality to maintain the body’s homeostasis.[18]There are different types of kidney diseases which include nephritic syndrome, nephrotic syndrome,glomerulonephritis, nephrosclerosis, polycystic kidney disease, kidney stones, and renal cancer, which could progress from acute kidney injury to CKD with its attending morbidity and mortality.[20]

Diagrammatic representation of the signs and symptoms of chronic kidney disease

Signs and symptoms of CKD result from the disruption of the normal physiologic functions of the kidney which presents in a systemic way affecting the body homeostasis and fluid and electrolyte balance[21][Figure 1].

Figure 1: The signs and symptoms of chronic kidney disease

Prevalence of chronic kidney disease in Nigeria

In Nigeria, the prevalence of CKD is 7.8%, thus contributing to manpower and economic waste.[15]However, in spite of the large population size of CKD, Nigeria with 180 million people, little is recorded about the epidemiology of CKD in the general population with no national data on prevalence of CKD, and few community-based studies in some regions were found.Studies recorded the prevalence of CKD as 18% in a rural community in South-West Nigeria, a prevalence of 11.4% in rural, and 11.7% in urban region in South-East Nigeria, and a prevalence of 26% in North-West Nigeria,suggesting overall high prevalence of CKD in Nigerian population.[22]

Factors influencing the prevalence of chronic kidney disease in Nigeria

Studies identified age, gender, hypertension, obesity, history of diabetes mellitus, use of herbal medicines, and prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) as risk factors for CKD in Nigeria.[13,15,23]

Age

The healthy kidney loses about 25% of its mass through aging, with the loss involving both cortical glomeruli and tubules which is not usually evident by imaging, probably due to the compensatory hypertrophy of functional nephrons.[24]Older people are predominantly prone to kidney damage from age-related decline in glomerular filtration and chronic disease states, such as diabetes mellitus and hypertension.[25]This is more pronounced in Nigeria where neglect and abuse of the aged population is on the increase.[26]

Gender

The sex hormone was found to be an important determinant of the greater susceptibility of males to progressive kidney injury; although the prevalence of CKD tends to be higher in women, the disease is more severe in men.Akokuwebe et al.[27]from Nigeria opined in 2020 that the disparity in the gender basis for risk of CKD may be attributed to sex differences in dietary habits,age, and lifestyles and concluded that sociocultural and economic factors which are in favor of males in Nigerian communities may also add to their increased risk-inducing lifestyles.

Hypertension

Hypertension can lead to nephrosclerosis which is a major precipitating factor of renal disease.[28]An untreated hypertension leads to sclerosis of the renal arterioles, and the blood supply to glomeruli, the tubules, and interstitium gradually decreases and scar tissue develops in kidney,resulting in loss of renal function and eventually CKD.[29]Nigeria is currently facing insecurity and economic hardship from Boko Haram terrorist, herdsmen-farmer conflict, which may subsequently result in increasing cases of hypertension and CKD.

Obesity

The increasing global prevalence of overweight and obesity reflects the rise in CKD, and each is now recognized to be a CKD risk factor.[30]One long-term follow-up study of over 320,000 members of a large US health-care system discovered that increased body mass index (BMI) was strongly associated with an increased relative risk for end-stage renal disease (ESRD) even after adjustments for BP and diabetes mellitus with similar findings in a US Physicians’ Health Study with a 27% adjusted increased risk of CKD in those who experienced a ＜10% increase in BMI,and additionally, a study among African Americans reported a significant trend between the prevalence of CKD and increasing body weight.[31]

Diabetes mellitus

Diabetic nephropathy refers to the damage to the kidney structure and function that occurs from a long-term complication of diabetes mellitus which could be Type 1 and Type 2 diabetes mellitus characterized by raised blood glucose levels and sustained hyperglycemia.[32]Glycemic control is essential to delay or prevent the onset of diabetic kidney disease.Although there are a number of glucose-lowering medications available, only a fraction of them can be used safely in CKD and many of them need an adjustment in dosing.Patients with diabetes are therefore at increased risk of suffering renal and cardiovascular insufficiency.[33]Overall care of diabetes necessitates attention to multiple aspects, including reducing the risk of CKD, and often, multidisciplinary care is needed, and this is not available in most hospitals,especially in the rural area of Nigeria.

Herbal medicines

Alternative and indigenous systems of medicine are popular among the poorer sections of society in the developing world, and the source and composition of these medicines vary in different parts of the world.Plants have provided remedies for human maladies for centuries, but this can also cause a lot of damages to our body system.Rinaldi et al.[34]in 2017 described nephron-toxin as a noxious agent which could be a drug or chemical that can injure or destroy the kidneys’ cells or tissues and established that this was due to the prevalence of indigenous use of herbal medicine, particularly in developing countries.The use of traditional folk remedies or herbs was associated with significant morbidity and mortality, with an overall mortality rate of 41% in patients with acute renal failure.[35]On the contrary to this, a study carried out in China on association between Chinese herbal medicine (CHM) therapy and the risk of CKD in gout patients found that CHM therapy in gout patients did not increase the risk of developing CKD.[36]The researcher believed that this difference noted was based on technological development in CHM when compared to Nigeria where herbal medicine is not properly developed.

Nonsteroidal anti-in flammatory drugs

The management of pain in patients with CKD is challenging for many reasons, such as altered drug metabolism and excretion, and there are limited safety data for the use of NSAIDs despite a high pain burden.NSAIDs refer to a group of a medicine that relieves pain and fever and reduces inflammation through the inhibition of cyclooxygenase enzymes and prostaglandins.[37]A study conducted by Balamurugan et al.[38]in 2021 established some adverse effects of NSAIDs on the kidney which could precipitate the development of CKD later in life; they include acute tubular injury, metabolic acidosis, hypervolemia, diuretic resistance, exacerbation of hypertension, and a progression of CKD.Another study by Baker and Perazella[39]in 2020 on the safety of NSAIDs in CKD found the use of NSAID to be associated with acute kidney injury, progressive loss of glomerular filtration rate in CKD, electrolyte derangements,and hypervolemia with worsening of heart failure and hypertension, and they concluded that NSAIDs should be avoided and if there is need to use it at all, it must be used with cautious and the risk factors on an individualized basis should be considered.

TREATMENT OUTCOME AND PROGNOSIS OF KIDNEY DISEASE IN NIGERIA

Early detection and treatment of CKD can also prevent or minimize complications associated with CKD, but majority of CKD cases were not clinically recognized promptly,mainly because of the lack of patients’ awareness about CKD and associated risk factors.[14]The burden of CKD is felt more in developing countries like Nigeria where there is no adequate social security system or health insurance to meet the huge financial demands the disease places on its sufferers and their families.The disease affects the economically productive age group unlike in developed countries where the elderly are more affected.A study on the prognosis for CKD patients in Nigeria was found to be poor because there are a misconception and low level of awareness and knowledge of CKD, including those with risk factors, therefore seeking for herbal method for managing themselves.Most Nigerian CKD patients still present very late to nephrologists, implying that the present preventive strategies have not yielded desired results.Early diagnosis and referral of CKD patients could be better achieved through regular education of the public and retraining of health workers, especially those in primary and secondary health institutions.Another major factor is that only a few patients could afford renal replacement therapy or cost of dialysis and concluded that there is a need for preventive measures to reduce the impact of CKD in Nigeria.[40]Aside from the cost of dialysis, patients have other financial burdens of procuring their medications which include the antihypertensive, erythropoiesis-stimulating agents, calcium supplements, among others, regular biochemical profile for monitoring and evaluation costs, and costs of treatment of infection that may arise from dialysis temporal access.The choice of renal transplant comes with lots of factors which include: the patient’s condition, the exorbitant cost,availability of donor, compatibility with donor, the cost of maintenance posttransplant, and the complications which include but not limited to infection, blood clots, and acute rejection.[41]The prognosis of CKD is measured by evaluating the stage of CKD along with the individual’s general health,age, and other comorbidities.[42]Commonly, the diagnosis of CKD is not made until advanced stages due to the silent yet progressive nature of the condition resulting in a negative outcome and poor prognosis.[43]

ROLES OF NURSES IN THE PREVENTION OF KIDNEY DISEASES

The care of patients with CKD is multifaceted and entails continual assessment, planning, intervention, and patient education over a continuum that may last days or years.[44]The key roles for nurses, particularly nephrology nurses, are at the point of ESRD in the hospital, dialysis units, or transplant programs.[45]Recently, due to the increased incidence of CKD, nephrology nurses have assumed more responsibility in the care of patients with CKD.[46]CKD can be prevented from getting to ESRD or can be delayed in progression with appropriate access to basic diagnostics procedures and prompt treatment which include lifestyle modifications and nutritional interventions.[47,48]The Centers for Disease Control and Prevention defined the term “prevention” as actions that are usually categorized by the following three definitions: (1) primary prevention infers intervening before health effects happen in an effort to prevent the onset of illness or disease before the disease process begins, (2)secondary prevention proposes preventive actions that lead to timely diagnosis and prompt treatment of a disease to prevent more severe problems developing which include screening to recognize diseases in the initial stages, and (3)tertiary prevention specifies the treatment of disease after it is well established to regulate disease progression and the development of more severe complications, which include measures such as pharmacotherapy, rehabilitation, and screening for and management of complications.[48]These descriptions have a significant posture in the prevention of CKD by nurses, and precise identification of risk factors that cause CKD or lead to faster progression to renal failure is pertinent in health policy decisions and health education and awareness related to CKD.

Primary prevention of chronic kidney disease

The primary level of prevention entails the awareness of modifiable CKD risk factors and determinations to focus health-care resources on individuals that are at the highest risk of developing new onset of CKD.[49]Nurses’ roles and activities to realize operational primary prevention should focus on the two leading risk factors for CKD including diabetes mellitus and hypertension.[50]Nurses need to encourage lifestyle modification, such as exercise and healthy diet among CKD patients.[51,52]They must let the CKD patients see the need to be grounded on more plant-based foods with less meat, less sodium intake, more complex carbohydrates with higher fiber intake, and less saturated fat.Moreover, for CKD patients with hypertension and diabetes, the nurses must teach them to improve BP and control blood sugar which has been proven to be effective in preventing diabetic and hypertensive nephropathies, how to avoid obesity with weight reduction strategies,[53,54]and how to avoid conditions or exposures that can harm the kidneys or cause a sudden drop in kidney function (called acute kidney injury).

Secondary prevention of chronic kidney disease

Among individuals with preexisting disease, the “secondary prevention” of CKD has the highest priority, and for these earlier stages of CKD, the key roles of nurses here include clinical interventions as modalities to slow disease progression.[55]The nurses’ role in secondary prevention of CKD is directed toward the predialysis CKD care and the ability to help patients prioritize care, monitoring, and clinical management of the patients’ care.Uncontrolled or poorly controlled hypertension is one of the most established risk factors for faster CKD progression.[47]The underlying pathophysiology of faster CKD progression relates to ongoing damage to the kidney structure and loss of nephrons with worsening interstitial fibrosis as it happens with sustained hypertension.[56]

Tertiary prevention of chronic kidney disease

In advanced CKD, management of uremia and related comorbid conditions such as CVD, mineral bone disorders,and anemia is of high priority.Nurses’ role in tertiary prevention aims to restore self-sufficiency to patients and limit the complications and disabilities associated with CKD disease; this includes the promotion of quality of life among CKD patients.[57]This is possible by managing risk factors and treating the disease to slow its progression and reduce the risk of complications.In many ways, tertiary preventive health care boils down to nurses helping CKD patients to help themselves.These roles of nurses in caring for CKD patients are collectively referred to as “tertiary prevention”of morbidity from CKD.

CONCLUSION

There is no cure for CKD and it is irreversible and the only known cure is transplant which is expensive and sometimes not the best option, yet there is a growing prevalence in Nigeria.Hence, in order to reduce the disease burden, it must be addressed through primary, secondary, and tertiary prevention strategies.Furthermore, lifestyle modifications by individuals at risk of CKD and prompt management of individuals with CKD would help to reduce the prevalence as well as mortality rate.There is no free medical care in Nigeria which makes it a burden to the patients and their family.It is out-of-pocket funding although kidney care is generally expensive, the difference in the Western world is that the government takes absolute care of the treatment and takes the burden off the patients through dialysis and transplant funding, hence prevention is the key where nurses have a significant role at all levels.The nursing practice plays a crucial role in advocacy for government involvement and commitment to the care and financial demands of kidney disease through subsidization of medications, funding of significant numbers of dialysis session and transplant, and also treatment of patients.

Recommendations and implications for nursing and/or health policy

Health awareness should be intensified by the nurses to individuals that are at significant risk of CKD, which include diabetes and hypertensive patients which are the leading causes of CKD.Hence, multidimensional methods should be employed to tackle this menace, such as regular monitoring of blood sugar and BP, good compliance with medical regimen and prescriptions, avoidance of self-medication and indiscriminate use of over-the-counter drugs and herbal preparations, and adequately practicing dietary and lifestyle modification, such as smoking cessation, weight control, and abstinence from alcohol.Finally, nurses should also advocate for regular population screening for kidney diseases and presence of CKD, and efforts should be made at all levels of care to reduce the negative impact of the disease and complication on the patients.

Acknowledgment

The authors wish to thank all who granted permission for this study to be conducted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest