End-Stage Renal Disease (ESRD) is a state where most of the kidney function is lost, and the individual is incapable of clearing waste products from the body, thereby leading to metabolic derangement and electrolyte imbalances. The progression from CKD to ESRD is often silent and most individuals are not aware that their renal function is deteriorating until they become symptomatic, and are diagnosed with ESRD. For most individuals in Nigeria, a diagnosis of ESRD is a death sentence because of limited availability of therapeutic options, and the exorbitant cost of that which is available. Available therapeutic options for management of ESRD includes kidney transplant, as well as peritoneal and hemodialysis. These three modalities for managing ESRD have been available in Africa and Nigeria for many years, but access to these services remains very limited because of lack of public awareness, cost, and inadequate personnel and providers in this field. Each form of renal replacement therapy (RRT) is addressed below:
- Kidney Transplant: kidney transplant has been available in Nigeria for about 13 years now, but the public is largely unaware of the availability of this service in Nigeria. Many people still have negative attitudes about organ donation, therefore limiting the availability of organs for transplant candidates. Due to the lack of a formal organ donation registry, transplant candidates are dependent on the willingness of family members or friends to donate. In addition, there are very few specialist and centers capable of providing transplant services in Nigeria, so most people travel to foreign countries to obtain transplant service (Bello & Raji, 2016). For patients who are fortunate to obtain a matching organ and receive transplant, their lives are a lot more complex than the obvious, as these patients need maintenance on immunosuppressive medications to prevent organ rejection.
- Peritoneal Dialysis: Peritoneal dialysis is a process whereby a dialysis fluid is infused into the peritoneum through a catheter, and the membrane acts as a filter to cleans the blood of waste products. Peritoneal dialysis is the most feasible and cheapest form of dialysis in the world. It is the cheapest because it can be taught to patients and their family members so that they can carry out dialysis treatment by themselves. The major risk factor with this form of dialysis is infection acquired in the process of infusing or exchanging the dialysis fluid, and poor sanitation in managing the equipment. However, this form of dialysis is very costly in Nigeria because the resources such as peritoneal dialysis catheters and dialysis fluid are in limited supply. The dialysis fluid in particular is imported, increasing the daily cost of management for patients that are dependent on peritoneal dialysis (Arogundade & Barsoum, 2008).
- Hemodialysis: This is the most well-known form of dialysis, and can be used long-term for management of patients with ESRD or until the patient receives a kidney transplant. Hemodialysis involves filtration of the patient’s blood through a dialysis machine to cleans it of toxic waste and correct electrolyte imbalances that are often present in this patient population. Under normal circumstances, hemodialysis should occur approximately 3 times per week for optimum management of ESRD. However, Nigerians with ESRD who seek treatment with hemodialysis face several challenges including limited availability of dialysis facilities and experts, high cost of treatment which is often paid out-of-pocket directly by patients for each treatment obtained, and a high risk of exposure to blood borne infections if dialysis equipment are not properly sterilized. Therefore, most patients who require long-term dialysis do not receive optimum management because of the challenges listed above, and < 5% of patients are able to continue treatment after 3 months (Arogundade & Barsoum, 2008).
Addressing the Challenges of the ESRD Population in Nigeria
The challenges experienced by individuals with ESRD in Nigeria include high cost of treatment, limited availability of dialysis facilities, lack of a Renal Registry and logistics to promote organ donation, and risk of exposure to infections. Contributions by all stakeholders including the government, ministry of health, public health officials, healthcare providers, and non-profit organizations can help alleviate some of these challenges and provide improved care to this very vulnerable population.
- Cost of Treatment: The cost of treatment is directly linked to the limited availability of facilities that are capable of providing dialysis services, and the cost of importing dialysis fluid and other supplies. Most patients in need of hemodialysis get inadequate dialysis, and the survival rate is approximately 20-70%, with most of those who survive experiencing very poor health due to malnutrition and infections (Barsoum, Khalil, & Arogundade, 2015). Therefore, the government and healthcare providers must collaborate to work on solutions by increasing funding for training of nephrologist and other specialist in the field, including dialysis nurses and technicians. The government can also give incentives to manufactures and experts that can promote the production of dialysis supplies particularly dialysis fluid in Nigeria, as this will decrease the long-term cost of management for this patient population, and promote regular dialysis which is necessary for well-being. The government must also provide a form of subsidized insurance coverage to help alleviate the financial burden on affected patients.
- Availability of Dialysis Facilities: the number of facilities capable of providing dialysis and related services are very few, with most of these concentrated in large cities like Lagos. This places a significant burden on patients from rural areas and other states to travel far in order to have access to dialysis. For most of these people, the cost of traveling and lodging in a distant city in order to receive dialysis can influence their willingness to continue with treatment and the frequency in which they follow-up with regular dialysis. Therefore, future plans to improve access to renal replacement therapy should include government supported expansion of dialysis services including building new and fully staffed dialysis centers in each state in order to improve accessibility.
- Renal Registry and Organ Donation: As of today, there is no formal renal registry or organ donation registry in Nigeria and most of Africa. The African Association of Nephrology (AFRAN) and African Pediatric Nephology Association (AFPNA) have an ongoing discussion about establishing a registry for kidney disease in Africa (Davids et al., 2016). A renal registry is fundamental because it would help healthcare providers and government officials ascertain the number of people affected by ESRD, and provide necessary data for research on exposures, comorbid conditions, morbidity, and mortality etc. Such data is essential to developing public health education and promoting awareness on kidney disease, developing interventions for the ESRD population, and preparing budgetary allocation for healthcare management of this group. In addition, a renal registry will increase awareness and improve logistics for kidney transplantation. Kidney transplantation is the only curative way of managing ESRD. A national registry will be beneficial in that individuals can sign up as donors, and patients could be cross-matched for donated organs and do not have to depend solely on the altruism of family members. The logistics associated with maintaining an organ donation registry is significant, but should become one of the goals for developing the healthcare system in order to meet the needs of the Nigerian people.
- Infection Control: Infection control is one of, if not the most important concern for patients with ESRD who undergo dialysis. For patients with peritoneal dialysis, there is a risk of introducing bacteria and other pathogens while infusing or exchanging the dialysis fluid. These patients and their caregivers must be thoroughly educated on self-management, proper sanitation, and infection control when carrying out these procedures. For those on hemodialysis, the risk of exposure to blood borne pathogens like HIV, Hepatitis B and C, and several other infections is a huge concern. Therefore, the onus lies on healthcare providers and administrators of dialysis centers to ensure that appropriate sterilization procedures and standardized infection control measures are carried out and maintained in each dialysis facility to avoid exposing patients to life threatening infections.