Raising awareness of kidney disease
Ten percent of the world’s population is affected by chronic kidney disease (CKD) and millions die each year due to lack of access to affordable treatment, according to the International Society of Nephrology. Optimal condition, financing, and regulation of care of people with CKD from diagnosis, along with care and access to renal replacement treatments in low and middle income countries are challenges to be addressed.
Coming off World Kidney Day, recognized on March 14, under the theme “Kidney Health for Everyone Everywhere”, a day designed to raise awareness of the high and increasing burden of kidney diseases worldwide during March which is designated kidney month, an advocate for national strategies to improve care, Dr. Adrian Sawyer, director and chief nephrologist at the Dialysis Centre Bahamas said the objective is to raise awareness of the importance of kidneys to overall health, and reduce the frequency and impact of kidney disease and its associated health problems.
Sawyer said this year’s theme calls for universal health coverage for prevention and early treatment of kidney disease.
“The objective is to raise awareness of the importance of our kidneys to overall health and reduce the frequency and impact of kidney disease and its associated health problems worldwide. Improve awareness of the importance of kidney function; highlighting the overwhelming impact of diabetes and hypertension (high blood pressure) contributing to CKD. Encouraging the systematic screening of all patients with diabetes and hypertension for CKD; encouraging preventive behaviors; educating medical professionals about their important role in detecting and reducing the risk of CKD in high risk populations; stressing the role of local and national health authorities in managing and controlling the emerging CKD epidemic; and educating health authorities of the high disproportionate costs associated with treating people with CKD and encourage these entities to take action and invest in further kidney screening he said is their mission.”
CKD is separated into five stages as reflected by a surrogate measure of the function of the filtering capacity of the kidneys combined with the extent of protein in the urine. Stage one reflects almost normal kidney function; stage three CKD reflects loss of more than 40 to 50 percent of kidney function and stage five indicates the need for dialysis or transplantation.
The doctor said generally advancing kidney disease produces no symptoms until late stage five and they are non-specific – consisting of fatigue, decreasing appetite, weight loss reduced functional capacity, fluid accumulation in the lower extremities and ultimately heart failure.
“Back pain/loin discomfort occurs in less than seven percent of patients and is usually associated with kidney stone disease or kidney inflammatory disease. As a result, most patients are unaware of the presence of kidney disease. The USRDS report 2018 shows a prevalence of CKD in the population of 15 percent; with 10 percent awareness of CKD and 57 percent awareness among patients with stage four CKD.
“Within the last decade there has emerged the realization that patients who recover from acute kidney injury/failure who have been hospitalized, develop CKD over the ensuing years, even though biochemical indices at the time of discharge were in the normal range. This is a novel risk factor,” said Sawyer. “Patients at risk, diabetes, high blood pressure, family history of kidney disease, past acute kidney injury, need to undergo screening testing annually at the very least to detect kidney disease.”
Testing he said involves a blood test called a renal profile from which a measurement of a product of metabolism called creatinine is utilized into an equation to stage kidney damage and the measurement of the amount of protein and creatinine in a sample of urine will assess the quantity of protein. Once identified he said patients require closer medical follow-up and referral to a kidney specialist for optimal management aimed at slowing down the progression of kidney damage by optimized control of diabetes, blood pressure, mineral/bone metabolism, lipid management and cardiovascular risks. Once dialysis commences Sawyer said patients require monthly or bi-monthly clinical and laboratory studies to deal with dialysis-related issues such as blood pressure control, the dialysis prescription, dialysis bone disease management, anemia (low red blood cell count) and access issues.
Patients who are informed and referred earlier he said adapt to dialysis better and in general enjoy a better quality of life. But he said patients also need to be informed of kidney replacement treatment options such as haemodialysis, peritoneal dialysis, or kidney transplantation.
Statistics on the incidence (number of new cases per year), prevalence (total number of current cases); population demographics among ethnic and racial groups age distributions, causative disease entities, modalities of treatments (dialysis /kidney transplantation), complications/morbidity and mortality, and all total economic costs for treatment and management of CKD and End Stage Renal Disease (ESRD) are kept by the United States Renal Data System (USRDS) annually. Canada has a similar data system for reporting; in Europe the European Renal Association/European Renal Dialysis & Transplant Association (ERA/EDTA) keep data related to the above parameters of CKD and ESRD.
According to Sawyer, the data-driven information from the data banks indicate that diabetes is far and away the single largest cause of CKD and ESRD; accounting for approximately 45 percent of ESRD in the United States; with the figure closer to the mid- 30s in Europe. Hypertension he said follows in second place as the single largest cause of CKD/ESRD; inflammatory diseases such as systemic lupus erythematosus (SLE) kidney disease, other inflammatory glomerulonephritis such as IgA disease; membranous nephropathy and other immune-related diseases.
For the regional and local population, Sawyer said SLE is of importance due to the disproportionately high incidence of lupus kidney disease in child-bearing age black females of African ancestry along with a pattern of more severe disease burden overall in this population. And he said hereditary cystic kidney diseases, such as autosomal dominant polycystic kidney disease (ADPKD) accounts for somewhat less than 10 percent of causes of ESRD.
“In The Bahamas there are families from the south eastern islands with this disease entity burden,” he said.
The doctor said black populations have a uniquely disproportionately high incidence of CKD/ESRD related to HIV infections (AIDS).
“In the United States Renal Data System (USRDS), African Americans have a 3.5 to 4.5 fold higher incidence of diabetic and non-diabetic kidney diseases contributing to end stage kidney disease. They account for some 12 to 14 percent of the population, but account for 20 to 25 percent of the ESRD population. The demographics of The Bahamas with a population of approximately 400,000 persons of which 85 percent are of African ancestry and the remainder classified as Caucasian/mixed, the USRDS data bank is the most relevant for analysis and projection of expected kidney disease burden and cost nationally,” he said.
According to Sawyer the ISN published results relate to the kidney disease burden in The Bahamas and considerations for the way forward in management and funding for what has now emerged as one of the leading causes of mortality and morbidity, with very low patient awareness; medical provider unawareness, but disproportionate healthcare costs for patients and health care systems.
He said important considerations that need to be addressed include the projected estimates of the number of new cases of ESRD requiring dialysis annually which is approximately 120 to 150. And that the estimated cost of dialysis treatments alone per patient is approximately $80,000 to $90,000 per year.
“The rising incidence of obesity, diabetes and hypertension in the local population will lead to ever increasing numbers of new cases of CKD and ESRD over the intermediate future. The 2018 USRDS report indicates that the overall incidence [new cases] for 2016 was 373.4 per million population; the ratio of African-Americans to Caucasians was 2.9. The prevalence [total number of cases currently undergoing treatment] at the end of 2016 was 726,331 patients; the prevalence for African-Americans was 5,816 per million; among Caucasians the corresponding figure was 1,573 per million. Extrapolating to The Bahamas, a figure of approximately almost 2,000 patients will comprise the total prevalent population of ESRD requiring kidney replacement treatments. Dialysis only will amount to a cost of $160,000,000 per year.”
The doctor said the cost of a kidney transplant ranges from $125,000 to $200,000 for the first year and falls to around $25,000 to 30,000 per year after the first year. And that there is universal agreement among nephrologists that successful kidney transplantation is the optimal modality of kidney replacement treatment in terms of quality of life and survival.
“Other associated costs for patient care such as the costs of monthly or quarterly laboratory test monitoring, costs of medications, the cost of other investigations, such as imaging studies (radiology, CT scanning and ultrasound studies), along with the costs of an average of one hospitalization per year for access, cardiovascular, or infectious complications, need to be considered in the costing of comprehensive medical care of the ESD patient. The indirect cost is almost $50,000 per year added to the direct cost of dialysis treatment only.”
The doctor said there is a need for the medical professional community to embrace the task of recognizing the risks for CKD and ESRD and undertaking efforts at early recognition, identification and appropriate and timely referral for specialist care. He said more than 90 percent of ESRD patients present at advanced stages of kidney failure without documented evidence of informed physician involvement.
He said there is need of the establishment of a national data bank on CKD and end ESRD in The Bahamas so that realistic comprehensive planning for the burden of expanding patient population and the costs associated can be prepared. He said that includes preventative measures to include education of the population and medical care providers of measures that can be undertaken to address prevention issues, such as the adoption of healthy lifestyles to include exercise, weight loss training, reduction in salt and high calorie intake, regular health maintenance check-ups and appropriate informed consultations with healthcare providers, along with addressing compliance issues for patients at risk with diabetes and hypertension. Advocacy he said is also essential and that the profession needs to inform the government and health agencies of the extent of the problem and measures along with resources required to deal with CKD/ESRD in the population.