CKD 
Topics

Chronic Kidney Disease occurs when there is a gradual decline in kidney function. In other words, your kidneys lose their ability to filter waste from your body, resulting in dangerous complications such as hypertension, nerve damage, nutritional declines, and more. There are five stages of CKD, with Stage 5 being end stage kidney disease, where death can result.

Africa has the lowest dialysis rates in the world, despite CKD being three to four times more common (Bello, 2014). Geographical inequalities have also been identified in long term renal replacement therapy with “rates of 1228 per million population in developed countries such as the United States (US) and western Europe while in sub-Saharan Africa, RRT uptake rates have been estimated to be about 20 per million population” (Bello, 2014). While many Nigerians suffer from CKD the accessibility to treatment falls short of the need. Dialysis treatment in Africa is dependent on and influenced by: per capita gross domestic product, national expenditures on health, availability and adequate training of healthcare providers, health literacy, and financial constraints (Barsoum et al., 2017). The average survival rate undergoing dialysis treatment in Africa is 20-70% with a relatively poor quality of life (Barsoum et al., 2017). 

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Lack of data and resources

• In recent years, Nigeria has focused its efforts on communicable diseases (malaria and human immunodeficiency virus infection) with an emphasis on maternal and child health, as CKD which is classified as a noncommunicable disease is getting overlooked (Bello, 2014). It is difficult to prove the impact CKD is having on the population due to the lack of data being recorded. In Nigeria there is no national collation of data, but rather single studies from clinics. Without a national renal registry, policy makers are unable to justify the epidemic of CKD and ESRD. Therefore no awareness of the disease is presented to the general population and patients often contact doctors during the irreversible stage where the only option is transplant or prolonged dialysis (Bello, 2014).  

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Inadequacy of dialysis infrastructure 

• The limited hemodialysis units are located in urban areas, despite 65% of Africans living in rural areas. The long travel distances to facilities is another barrier to dialysis people encounter. Treatment centers are also unequally distributed. Nigeria made steps to increase the number of dialysis units, but they are only located in the southwestern part of the country, leaving the population in the north out of options. Where machines are present, they are subjected to frequent breakdowns, malfunctions, and power outages. The overall reliability is not adequate.   

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Financial

• Financial constraints make it difficult for the average person to afford dialysis treatment contributing to the 59% of people in need of dialysis stopping treatment while it is still needed (Crosby et al., 2020).

• This is due in part to a lack of funding for dialysis that leaves many patients unable to afford treatment as there are no government subsidies or insurance programs. According to (Bello, 2014), “up to 80% the population live on less than 2.5 dollars per day and a session of hemodialysis costs as much as USD 100 – 200 most patients with ESRD have to rely on financial support from their extended families, religious organizations and philanthropists to be able to pay for dialysis.” Adding on to the unaffordability is the factor of whether or not a person qualifies for maintenance dialysis. Due to rationing policies, treatment is limited to people with the least co-mobilities. The rationing of dialysis leads to a small population with end-stage renal disease actually receiving dialysis. This is due in part to socioeconomic rather than medical reasons (Crosby et al., 2020). The large volume of people requiring dialysis in Nigeria is not matched by the country's resources or financial standing. In 2010, 75 000 Nigerians were in need of dialysis, this would equate to $3.5 billion consuming 15–55% of the total domestic governmental health expenditure (Crosby et al., 2020). Expansion of the dialysis health program is far too expensive for the country consuming a disproportionate amount of health-care resources.

• The Nigerian government has done a poor job managing the national budget. In 2013 4% went to healthcare and almost 80% to salaries of staff (Bello, 2014). 

• It was reported that only 3.3% of southwestern Nigerians afforded their thrice weekly dialysis, and 13% of Nigerians in the town of Uyo achieved 70% of their sessions (Bello, 2014), due to the bankruptcy that dialysis treatment puts families in.   

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Human Resources

• Many African countries experience a shortage of nephrologists, dialysis nurses, and technicians. There are approximately 11 nurses per 10,000 people, well below the levels seen in the Americas and Europe. Reasons for this deficit of health care workers include the lack of medical schools and migration of personnel elsewhere in pursuit of better opportunities. Bello (2014) estimates Nigeria has 0.6 nephrologists per million population.  

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Illiteracy

• Lack of education on CKD results in nonadherence to treatment, skipping dialysis sessions, disregarding dietary restrictions, failing to take medications, all of which lead to poor dialysis outcomes. 

The early symptoms of CKD signify the most treatable state, but are often overlooked. Symptoms are usually represented through the side effects of related medical conditions. Diabetes is the most common signifier of CKD. It has been shown that 40-60 percent of those who reach end-stage kidney disease have diabetes. 15-30 percent have hypertension, nearly 1- percent have glomerulonephritis and 2 to 3 percent have cystic kidney (James et al., 2010; Król et al., 2009; Noble & Taal, 2019; Snyder & Pendergraph, 2005). Proteinuria and albuminuria are correlated to a faster progression of chronic kidney disease leading to end-stages. 

The genetic disease of adult polycystic kidney disease (APKD) is also a causal factor of CKD, as well as Alport’s syndrome which is associated with hereditary nephritis. Furthermore, drugs such as non-steroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors, diuretics, and lithium can provoke the development of intersitital nephritis which can lead to CKD. Urological conditions such as reflux nephropathy and urinary obstructions is known causal aspect. Additionally, infections and acute kidney injury are also associated with initiating CKD (Evans & Taal, 2015). 

Within developing regions such as Africa, infections such as streptococcal infection, HIV, hepatitis B and C and common causes of kidney failure.  Within Southern Nigeria, the top related conditions that were detected in screening processes included hypertension, obesity, metabolic syndrome, hyperglycaemia, proteinuria, and glycosuria (Odetunde et al., 2014; Ulasi & Ijoma, 2010; Ulasi et al., 2013; Wachukwu et al., 2015). Nigeria also has the highest rates of Type 2 diabetes in the African continent (Wachukwu et al., 2015).

There are a multitude of genetic, environmental, and socioeconomic factors that place individuals in Nigeria at risk for CKD. 

Beginning with the role of genes, APOL1 is an encoded protein gene in humans that originally developed to protect species from parasitic viruses. Overtime, APOL1 developed two disease genetic variants which quickly spread to the African population (Friedman & Pollak, 2020, pp.1) and these two variants of APOL1 are causes of many different types of kidney diseases that lead to CKD and ERSD. Family histories of CKD, hypertension, diabetes, and cardiovascular disease are also significant risk factors. Specifially, hypertension is starting to become a public health issue in Nigeria and self-reported hypertension cases are very low due to the low awareness on the disease (Olanrewaju et al., 2020). In addition, Nigeria has the highest rates of diabetes comapared to all the other countries in africa (Olanrewaju et al., 2020). 

Other somatic issues are also important to consider. For instance, damages to the kidney such as albuminuria, which is a condition when the kidney abnormally leaks albumin (a protein found in the blood) into the urine can place the individual at a higher risk for developing CKD. Obesity is another issue to consider as it leads to an increase in hypertension.

Moving on to the issue of CKDU(Suilemann et al., 2019). CKDU is chronic kidney disease caused by unkown factors or unkown orgins and relevant to the main risk factors (Sulaiman, 2019). People who are exposed to mercury and cadmium specifically those living around mining sites or work in mining sites. Also, researchers concluded that farmers in Nigeria and other developing countries are exposed to variety of chemicals in products they use such as glyphosate, phosphate fertilizer which have nephrotoxic metals such as lead, cadmium, cobalt and vanadium, contaminated water, dehydration, and pesticides which all increase the risk of develop CKD. In fact, a study showed that the majority of patients in Komadugu-Yobe of North eastern Nigeria have a diagnosis of CKDu or CGN. Socioeconomic status is another important factor to consider as those who have income less than $16k a year are 2.5 times more likely to end up with CKD compared to those with higher income due to poor diet, alcohol intake, nephrotoxins, etc (Kidney Int Suppl, 2011). Lastly, unhealthy habits such as smoking also lead to anincrease in high blood pressure, oxidative stress, glomercurolsis, heart rate, and reduced blood flow to the kidneys.

Other causal factors include the urological conditions such as eflux nephropahty, urinary obstructions, urinary tract infections, as well as adulthood diseases such as Adult Polycystic Kidney Disease (APKD). Moreover, CKD has shown to have a higher prevalence in women than men. In North-central Nigeria, a cross-sectional study in eight urban communities in Kwara state and focused on the host community, showed that (n=1353) had 12% CKD is more prevalent in women (14.1%) than men (9.5%), p = 0.001 (Olanrewaju et al., 2020). Moreover, stage 3 CKD accounted for the highest prevalence (9.5%) and was significantly higher in women (11.6%) than men (6.9%), p = 0.001 (Olanrewaju et al., 2020). Furthermore, the second highest independent risk factor of CKD is age. The prevalence of CKD was observed to increase from the age of to 40-49 years. Lastly, NSAIDs, or nonsteroidal anti-inflammatory drugs have been associated with the worsening of CKD and individuals with CKD are advised to avoid the use of NSAIDs, with the exception of aspirin. This is because, NSAIDs play a significant role in acute kidney injury and may also decrease the effectiveness of certain prescription medications that are meant to be used for thedisease, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and more. 

CKD is usually asymptomatic, and can only be detected based on community-based screening processes which identify risk factors including genetic factors such as hereditary renal disease, and a 

Patients that should be screened include patients with a family history of chronic kidney disease or cardiovascular disease, and those with diabetes, hypertension, cardiovascular disease, reoccurring urinary tract infections, cognitive dysfunction, impaired physical functioning, and those with a urinary obstruction, or any other system illness related to the kidneys. As well, patients over the age of 60 should be screened. Those with a high body-mass index, and smoking habits are at risk for this disease. Those with risk factors such as family history of polycystic kidney disease, and urinary tract complications should be screened using renal ultrasonography (James et al., 2010; Noble & Taal, 2019; Snyder & Pendergraph, 2005).

Screening can be done with inexpensive laboratory tests that detect abnormalities in the function of the kidneys. It has been recommended by the current Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) that a serum creatinine measurement can be used in assessing GFR rates and analyze urine samples for albuminuria. 

Early recognition and intervention can reduce the risk of cardiovascular events and progression to end-stage renal disease, and kidney failure.  Screening for reduced rates of glomerular filtration is most useful for those with hypertension, diabetes and those older than 60 years of age. It has been indicated that screening for albuminuria is the most effective for identifying CKD in young adults, while the analysis of glomerular filtration rate is best for the elderly. Additionally, screening using urinalysis for the detection of glomerulonephritis is common for adults and school children aged 6-18 years. 

Health-screening questionnaires can be used to detect early symptoms and encourage lifestyle changes that can prevent progression and medical assistance to chronic kidney disease (James et al., 2010; Wachulwu et al., 2015; Noble & Taal, 2019). Population-based screening programs for CKD increase detection of early symptoms and providing awareness to those who may be at risk of developing kidney disease (Jaar et al., 2008; James et al., 2010; McClellan et al., 2003; Noble & Taal, 2019; Wachukwu et al., 2005)

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1. What is your gender? Male or Female (circle one)

2.  Are you of African descent?

3. Do you consume NSAIDS?

4. What is your primary occupation?

   1. If you are a farmer, do you use phosphate fertilizers?

5. Are you of low socioeconomic status?

6. What is your age?

7. Do you have a family history of chronic kidney disease?

8. Do you have a family history of hypertension?

9. Do you have a family history of diabetes?

10. Do you have diabetes?

11. Do you have hypertension?

12. Are you considered obese?

13.  Do you have a urinary tract infection, or any type of urinary-tract obstruction?

14. Do you have a bacterial or viral infection?

15. Do you have an autoimmune disease?

• Monitoring for Diabetes: very important as it is the leading factor of CKD patients are more at risk. Therefore, 

• As a diabetic patient, it is important to monitor the which is a blood test that shows the glucose level in the hemoglobin. 

• Those with T1D and T2D tend to have an HbA1c over 6.5% which could lead to nephropathy and other macrovascular complications. HbA1c and  glycemic monitoring is very important and should be monitored according to your physician’s requirements, this can vary from from T1D to T2D patients  from 2 times per year for those who achieve their glucose level goals and monitor their diet and 4 times per year for those who are somewhat careless. 

 - Measuring HbA1c is convenient where it could be done at home using a blood sugar meter and people can save money from doing lab testing and traveling far distances to do the testing 

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TESTING FOR YOUR BLLOD SUGAR LEVEL AT HOME ;

Blood sugar testing requires the use of a blood sugar meter. The meter measures the amount of sugar in a small sample of blood, usually from your fingertip, that you place on a disposable test strip. Even if you use a CGM, you'll still need a blood sugar meter to calibrate your CGM device daily.

Your health care provider or certified diabetes care and education specialist can recommend an appropriate device for you. He or she can also help you learn how to use your meter.

Follow the instructions that come with your blood sugar meter. In general, here's how the process works:

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1. Wash and dry your hands well. (Food and other substances can give you an inaccurate reading.)

2. Insert a test strip into your meter.

3. Prick the side of your fingertip with the needle (lancet) provided with your test kit.

4. Touch and hold the edge of the test strip to the drop of blood.

5. The meter will display your blood sugar level on a screen after a few seconds.

Research has shown the dangers that high sodium diets have in developing and worsening kidney disease as they promote increased blood pressure levels. In addition, studies have shown that the best diet for kidney disease prevention is one which includes plant-based rather than animal-based sources of protein. 

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Many sources of animal-based protein are sold as processed products and therefore often have increased sodium levels, furthering hypertension and kidney damage. Having too much protein intake above the required nutritional amount has also been linked to renal hyperfiltration and kidney injury. (Marckmann et al., 2015; Obesity & Diabetes Week, 2021)

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In addition to plant-based protein intake, high intake of legumes, nuts, and low-fat dairy foods have been associated with CKD prevention. Through a plant-based diet, higher levels of magnesium and calcium can be achieved which have been indicative of improving kidney function. (Rebholz et al., 2016)

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There are numerous benefits of switching to plant-based diets for CKD prevention. Firstly, plant-based diets encourage weight loss which subsequently leads to the reduction of blood pressure, sodium intake, and oxidative stress. One concern with plant-based diets is their phosphate content which has shown to be a risk factor in the worsening of CKD, but research has shown that only a small amount of the phosphate is absorbed into the body. In fact, due to a lack of the phytase enzyme necessary for releasing phosphates in the body, only approximately 10 to 30 percent of plant-based phosphate is absorbed. Moreover, when compared to plant-based foods, animal-based foods including dairy, fish, meat and eggs show a low of 40 and a high of 80 percent phosphate absorption due to processed food additives for taste and preservation. Industrial processing can also increase phosphate content in plant-based products, therefore home cooked and locally purchased produce are the best options for a preventative diet. Another concern regarding plant-based foods is their potential for hyperkalemia. Fortunately, a plant-based diet excluding juices, dried fruit, sauces, and abnormally high-potassium foods (e.g. raw legumes and molasses) and supplements can help mitigate this potential. Lastly, plant-based diets also allow for a recommended daily intake of 0.7 to 0.9kg of protein in order to reduce risks for hyperfiltration that come from high-protein diets. Maintaining lower protein content has also shown to decrease the potential for kidney failure. (Joshi et al., 2021)

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• (Cases et al., 2019), (Davita, 2022), (Kindey.org, 2022)

• Sugar should be a bit lower than average and sodium (less than 1.5g) since Africans are more susceptible to hypertension, diabetes, and CKD.  

• For a weight loss of 1–1 ½ pounds per week, daily intake should be reduced by 500 to 750 calories

• DASH Diet was related with 45% of decreased risk of renal failure (Cases et al., 2019)

  • High

    • Fruits, vegetables, low-fat dairy products, whole grains, nuts, legumes, seeds, fish, poultry (lean meats) 

  • Low

    • Red meat, sweets and added sugars, total fat, saturated fat, cholesterol

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Malnutrition is the number one risk factor of development of chronic kidney disease in Nigeria and obesity increase by 20% from 2002 to 2010 where people in the urban citys are more likely to experience obesity and those in rural areas are more likely to experience undernutrition (Morgan & Fanzo, 2020). More than half of the nigerian population live on 2$ or less especially in the rural areas, spend around 65% of their income on food expenditure, and the farmers use the food they produce to feed their families (Morgan & Fanzo, 2020).  

Plant-based diet:

• A meta-analysis conducted on around 21000 participants and it showed that plant-based diets were related to reduction of systolic and diastolic blood pressure compared to animal-based protein. 

• Dietary fibers are known to remove any uremic toxins 

• Bioavailability of phosphates in plant based foods is between 10-30% which is the amount of phosphorus that will be absorbed while animal-based diets is around 40-80% 

Taking care of your wellbeing is as important as receiving treatment. Caring for a loved one or yourself when diagnosed with CKD can be a challenge. Chronic Kidney Disease (CKD) has an effect on both physical and psychological health, including experiences of depression, embarrassment about appearance, feelings of worthlessness, anxiety, and despair, all of which contribute to a poorer quality of life. Dealing with your emotions, fears and concerns, adjusting your life and living with CKD is very important! Taking care of your wellbeing both Individual and family wellness involves actively putting effort into your physical, mental and spiritual wellness.  

1. Physical WellBeing 

Regular physical activity is important for everyone - even patients diagnosed with Chronic Kidney Disease. When on dialysis, any kind of exercise can be strenuous, however; incorporating it into your lifestyle is exactly what you need. Regular exercise has several benefits ranging from improved heart function, regulating blood sugar in those with diabetes to helping with anxiety and depression.  Before starting an exercise routine, please talk to your nephrologist and dietician. They will help define what exercises are best for you. Appropriate exercise also  improves physical capacities and alleviates symptoms such as weariness. Aerobic energy generation is also more efficient, which results in lower muscular tiredness and better tolerance for daily tasks. Additionally, exercise may enhance quality of life through enhancing sleep quality, which contributes to favorable improvements in quality of life 

1. Mental WellBeing

You can make a list of your concerns and discuss all of your concerns with them as they’ll have more information and be in a position to provide you sound advice. Surround yourself with a good support system, join a local support group and associations that can provide you with the support you need. Also, speaking and sharing your emotions with your friends or certified therapist is important in ensuring that your mental state is as healthy and stable as possible.

To improve one's quality of life, a psychological intervention known as Mindfulness-Based Cognitive Therapy can be used which teaches patients how to discern between ideas and real occurrences by teaching them to be aware of explicit thoughts, emotions, and experiences without analyzing them. The successful outcome may be seen in the emergence of a greater sense of enjoyment in life

Wagner Chronic Care Model

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There is some evidence to indicate that the current standard of treatment for chronic kidney disease should be divided into three stages (Wouters et al., 2015).

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1. Vascular risk management in primary care throughout the early stages of disease: exercise, dietary modifications, smoking cessation, blood pressure, glycemic, and cholesterol control, and periodic kidney health monitoring

2. Organised intervention aimed at addressing comorbidities that occur in progressive cases, with a particular emphasis on anaemia, bone disease, and secondary hyperparathyroidism.

3. Extensive multidisciplinary care for patients undergoing renal replacement therapy: All patients with chronic renal disease should have their primary care practitioners examine for medication interactions that might result in acute kidney damage (Wouters et al., 2015).

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Involvement of specialists:

Studies of the clinical and cost-effectiveness data regarding early versus late (or no) nephrologist referral discovered that early referral is related with improved health outcomes and may be cost-effective (Wouters et al., 2015).

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Exercise:

Exercise has been linked to an enhanced quality of life for individuals diagnosed with CKD in terms of its influence on the burden of renal disease, cognitive function, sleep, physical role, pain perception, and energy/fatigue. Appropriate exercise improved physical capacities and alleviated symptoms such as weariness. Aerobic energy generation is also more efficient, which results in lower muscular tiredness and better tolerance for daily tasks. Additionally, exercise may enhance quality of life through enhancing sleep quality, which contributes to favourable improvements in quality of life (Ma et al., 2020).

Mindfulness-Based Cognitive Therapy (MBCT):

Chronic Kidney Disease (CKD) has an effect on both physical and psychological health, including experiences of depression, embarrassment about appearance, feelings of worthlessness, anxiety, and despair, all of which contribute to a poorer quality of life. To improve one's quality of life, a psychological intervention known as Mindfulness-Based Cognitive Therapy is required (MBCT). The purpose of this research is to determine the impact of MBCT treatments on the quality of life of patients on hemodialysis who have Chronic Kidney Disease (CKD) (Hasanudin et al., 2019). MBCT treatments teach patients how to discern between ideas and real occurrences by teaching them to be aware of explicit thoughts, emotions, and experiences without analysing them. The successful outcome may be seen in the emergence of a greater sense of enjoyment in life (Hasanudin et al., 2019).

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