Strategies for Prevention of Kidney Failure in Nigeria – We all Have a Role to Play

Dr. Onyekachi Ifudu
Email – dodokinase@gmail.com

To put it bluntly, the overwhelming majority of Nigerians who develop end-stage kidney failure cannot afford dialysis or kidney transplantation and are typically dead within a few months. Thus, prevention – by any means necessary – should be the mantra. Ensuring that citizens remain in good health and productive is enlightened self-interest.

No country has a limitless amount of resources. How any society deploys their healthcare funds is consequential. Stressing disease prevention is not just our only hope of alleviating our intractable primary healthcare problems, but is extremely cost-effective.

Public health is best distinguished from clinical medicine by its emphasis on preventing disease rather than curing it, and its focus on populations and communities rather than the individual patient. Prevention of kidney failure is a crucial public health goal.

The multi-pronged plan humbly detailed herein to prevent kidney failure in Nigeria entails efforts by; a) Clinical Laboratories and Laboratory scientists, b) State Governments, c) The Gatekeepers – Nurses, Pharmacists and General Physicians d) Hospitals and Healthcare facilities and e) The Individual.

Implementation of these initiatives must be jump started and vigorously championed by those in leadership. The appeal of the prescribed initiatives is that they entail the expense of no or little money – rather they necessitate a high level of vigilance, diligence and moral commitment to do the right thing.

Clinical Laboratories and Laboratory Scientists
One of the most important steps in the quest to prevent kidney failure is for all Clinical Laboratories in Nigeria to report an estimated glomerular filtration rate (eGFR) with each serum creatinine result. The serum creatinine level is a routinely requested blood test that is used to evaluate kidney function.

However, the serum creatinine level alone is an imperfect measure of kidney function because a rise in serum creatinine is observed only after significant loss of kidney function. Therefore, the fact that you have a “normal” serum creatinine level does not necessarily mean you have “normal kidney function”.

After studies validated eGFR as superior to serum creatinine level alone to measure kidney function about 20 years ago, many countries urged Clinical Laboratories or mandated them by legislation to calculate eGFR every time doctors order a serum creatinine level. To calculate eGFR, all that is required is for the Clinical Laboratories to install an inexpensive software in their machines. Since no additional laboratory test is required, calculating and reporting the eGFR won’t increase the cost of the laboratory test. Using the eGFR leads to early detection of kidney failure, avoidance of drugs toxic to the kidneys and proper adjustment of the dose of medications in persons with kidney failure.
State Governments
Each State of the Federation should formulate a strategic plan for prevention, early detection and control of kidney failure in their State. Each State may accomplish this by formation of a “Task Force” to provide advice, guidance, grassroots education and recommendations to improve chronic kidney disease care in their State.

Members of the Task force should at the minimum include, a nurse, a clinical pharmacist, a dietician, a laboratory scientist, an individual with CKD, a kidney transplant recipient, a general physician, a nephrologist and a physician with public health training.

A major focus of the Task Force is to raise awareness about kidney health and kidney disease among the populace, educate healthcare workers in the State, including primary healthcare workers about the utility of eGFR and highlight simple measures they can implement to prevent kidney failure.

The Gatekeepers ─ Critical role of Nurses, Pharmacists and General physicians
Collaboration between all the professionals in healthcare is crucial in the prevention and early detection of kidney failure. Hypertension and diabetes mellitus are the first and second leading causes of CKD. Both disorders are detected and managed by non-nephrologists for years before any kidney damage emerges. By serving as “gate keepers,” generalist physicians can facilitate recognition and detection of CKD.

Nurses are an underutilized asset in disease prevention efforts, which is unfortunate and a missed opportunity. Nurses constitute the largest single group of healthcare workers, spend the most time with patients, administer prescribed medications to patients and possess the requisite knowledge base to disseminate kidney disease prevention information.

An additional impetus to galvanize Nurses to champion this endeavor is that they are more likely to reside within the community, and will not only apply kidney disease prevention skills in their own practices, but will through their interactions within the community be able to disseminate this information in both formal and informal settings.

With use of eGFR to measure kidney function, hospital Clinical Pharmacists can now verify that the dose of the drug prescribed is adjusted to the level of kidney function before dispensing. Even in situations where a doctor prescribes the wrong dose for the level of kidney function, or prescribes a drug that is toxic to failing kidneys, the Clinical Pharmacist detects it and informs the doctor – disaster averted. In addition, the Pharmacist has the requisite knowledge base to advice other healthcare professionals about discontinuation or avoidance of drugs that are toxic to the kidneys.

Hospitals and Healthcare Facilities
Acute kidney injury (AKI) is common in hospitalized patients especially among those in the intensive care unit (ICU) or following a surgical procedure. The one area that hospitals and healthcare facilities can make an immediate impact is to devise and implement measures to prevent AKI or to promptly recognize it and treat it quickly.

One approach to achieve this goal is for Hospitals and Healthcare facilities to convene a Kidney Protection Committee whose members will include, a nurse, a clinical pharmacist, a dietician, a laboratory scientist, a general physician and a nephrologist. The committee will;
a) Liaise with the Clinical Laboratory to ensure that they begin reporting eGFR each time a serum creatinine blood test is ordered if they are not already doing so.

b) Educate the hospital staff on the utility of eGFR.

c) Implement a “red flagging” system to highlight the medical record of any hospitalized patient with reduced kidney function.

d) Devise a system to ensure prompt discontinuation or avoidance of drugs that are toxic to the kidneys.

e) Ensure that the Pharmacists always verify that the dose of any drug prescribed is adjusted to the level of kidney function before dispensing the drug.

The individual ─ What You Must Do to Protect Your Kidneys
It is all about prevention and it is up to you. Remember you are responsible for everything you put in your mouth. While alternative medicine products and herbal concoctions are very popular, they are unregulated, stated label ingredients may be inaccurate, thus patients may not be taking what they think they are. Since the kidney is the major organ that excretes drugs and toxins, it is susceptible to injury from untested and unregulated products. This thesis is particularly relevant among those who already have impaired kidney function from other causes such as diabetes or hypertension.
Therefore, you must;

● Avoid drugs or products that will damage your kidneys like NSAIDs – painkillers used to treat arthritis (Ibuprofen, Naproxen, Diclofenac, etc); Certain Antibiotics (Aminoglycosides like Gentamicin), or herbal concoctions.

● Check your blood pressure (BP) often and get annual blood and urine tests.
● Make sure ─ if you have high BP or diabetes mellitus, that it is well controlled. Your BP should be less than 130/80, or down to 120/75 if there is protein in your urine or if you have diabetes mellitus. In addition to taking medications as prescribed by your doctor for your high blood pressure, the under listed nonpharmacologic interventions will greatly help to improve your blood pressure and often results in your requiring less medication;
i) Reduce salt intake.
ii) Exercise.
iii) Maintain ideal weight.
iv) Smoking cessation.
v) Reduce alcohol intake.
vi) Good sleep hygiene.
vii) Reduce stress.

Finally, the Kidney Protection Project will enthusiastically provide technical support free-of-charge to any State government or Hospital that wants our input as they formulate a plan for kidney failure prevention.

The Kidney Protection Project
The Kidney Protection Project is focused on sharing scientific information with the Nigerian populace in a user-friendly format to promote kidney health, improve awareness and enhance understanding of kidney failure and debunk myths about kidney failure.

Awareness and knowledge about a disease will generally correlate with health seeking behavior and enhance the chances for early detection. When kidney failure is undiagnosed or undetected, the healthcare system loses the opportunity to improve outcomes. The expectation is that this public health endeavor will ultimately lead to early detection of kidney failure and a reduction in the incidence of kidney failure in Nigerians and save lives.

Project Coordinator: Dr. Onyekachi Ifudu
Dr. Ifudu is board-certified in Internal medicine & Nephrology/Hypertension and is an Adjunct Professor of Medicine at SUNY Downstate, Brooklyn, New York. He graduated from University of Nigeria and Harvard University – did residency training at Columbia University College of Physicians & Surgeons, New York, and fellowship at SUNY Downstate, Brooklyn, New York.

He has done volunteer work for the National Kidney Foundation in New York, and the National Hospital, Abuja. He authored a state-of-the-art article in The New England Journal of Medicine on the “Care of Patients Undergoing Hemodialysis”. Email: dodokinase@gmail.com