THURSDAY, 22 AUGUST 2013 00:00 CHUKWUMA MUANYA FEATURES -NATURAL HEALTH
Healthy diet, moderate alcohol decrease risk in patients with diabetes
Nigerians can reduce their risk of developing end stage kidney disease (ESKD) by reducing the intake of alcohol, quitting smoking, hard drugs and indiscriminate intake of herbal concoctions and analgesics as well as maintaining healthy weight and diet, among others. CHUKWUMA MUANYA writes.
A TEAM of medical experts led by the President Elect of the Nigerian Association of Nephrology (NAN) and Head of the dialysis/transplant unit and clinical director of St Nicholas Hospital, Lagos, Dr. Ebun Bamgboye, has warned that unless certain urgent steps are taken more Nigerians would come down with chronic kidney disease (CKD) and End State Renal Disease (ESRD).
Reasons: Persons of black African heritage are four times more likely to develop CKD than people of other races; the prevalence of three major diseases associated with kidney failure –hypertension, glomerulonephritis and diabetes – is on the rise in the country; growing indiscriminate use of herbal concoctions, bleaching creams and soaps, alcohol, hard drugs and smoking; increasing number of persons living with Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS); low socio economic status that is Gross Domestic Product (GDP) of the country, which is associated with high CKD burden, among others.
Glomerulonephritis is a type of kidney disease in which the part of human kidneys that helps filter waste and fluids from the blood is damaged. The following may increase risk of this condition: blood or lymphatic system disorders; exposure to hydrocarbon solvents; history of cancer; and infections such as strep infections, viruses, heart infections, or abscesses.
To address the situation, the medical experts at the ‘August Event’, a joint programme organised by St. Nicholas Hospital in collaboration with Chief Dr Moses Adekoyejo Majekodunmi Foundation (MAMF), last week in Lagos, recommended among other things government should urgently look at how to improve the socio economic status of Nigerians; ensure good sanitation and literacy; enact a solid Organ Transplant Act; establish a National Renal Registry and Kidney Transplant Programme; extending the National Health Insurance Scheme (NHIS) to support patients with kidney failure; regular public enlightenment sessions; development of data bank for disease donor transplant; subsidy of some sorts for immunosuppressive drugs.
Other members of the team include: Minister of Health, Prof. Onyebuchi Chukwu; Eminent Urologist and Transplant Surgeon at Fortis Hospital, Bangalore, India, Dr. Mohan Keshavamurthy; Consultant Nephrologist and Medical Director Ibadan Hypertension Clinic, Emeritus Professor Oladipo Olujimi Akinkugbe; Professor of Medical Microbiology and Provost, College of Medicine, University of Lagos (CMUL), Prof. Folashade Tolulope Ogunsola; Professor of Forensic Pathology and Vice Chancellor, Lagos State University (LASU), Prof. John Oladapo Obafunwa; Lagos State Commissioner for Health, Dr. Jide Idris; Ogun State Commissioner for Health, Dr. Olaokun Soyinka; and Medical Director St Nicholas Hospital, Dr. Dapo Majekodunmi.
The views of the team of experts put together by St. Nicholas Hospital is supported by a recent study published Monday by JAMA Internal Medicine, a JAMA Network publication. According to the study, eating a healthy diet and drinking a moderate amount of alcohol may be associated with decreased risk or progression of CKD in patients with type 2 diabetes mellitus.
Type 2 diabetes and associated CKD have become major public health problems. However, little is known about the long-term effect of diet on the incidence and progression of early-stage diabetic CKD, according to the study background.
Dr. Daniela Dunkler of McMaster University, Ontario, Canada, and colleagues examined the association of a healthy diet, alcohol, protein and sodium intake with incident or progression of CKD among patients with type 2 diabetes. All 6,213 patients with type 2 diabetes in the ONTARGET trial were included in the observational study.
The study results indicate that 31.7 per cent of patients developed CKD and 8.3 percent of patients died after 5.5 years of follow-up. Compared with patients in the least healthy scoring group on an index that assessed diet quality, patients in the healthiest group had a lower risk of CKD (adjusted odds ratio [OR], 0.74) and lower risk of mortality (OR, 0.61). Patients who ate more than three servings of fruits per week had a lower risk of CKD compared with patients who ate fruit less frequently. Patients in the lowest group of total and animal protein intake had an increased risk of CKD compared with patients in the highest group. Sodium intake was not associated with CKD, while moderate alcohol intake reduced the risk of CKD (OR, 0.75) and mortality (OR, 0.69).
The researchers concluded: “A healthy diet and moderate intake of alcohol may decrease the incidence or progression of CKD among individuals with type 2 diabetes. Sodium intake, within a wide range, and normal protein intake are not associated with CKD.”
Burden of kidney disease
Bamgboye in a paper titled “Renal Transplantation at St. Nicholas Hospital, the Journey so far” said: “With the population of the world growing, currently over the world we have over three million people on treatment for various stages of end stage renal disease. It is estimated that you can expect every year about a 100 new patient per million population. And if you consider that the population of Nigeria is about 160 million you expect at least 16,000 new cases every year. Many of them are on haemodialysis and hitherto that was the only therapy and over half a million people have had transplants. But we recognise that what we are seeing is just a tip of the iceberg, many more people have various other stages of chronic kidney disease that we are seeing in the hospitals.
“What we are saying is that about one fifth of patients are with CKD. The reality is that once you are diagnosed of CKD it is inevitable that it will progress. What we also know that the majority of those in first few stages of CKD will probably die from things like strokes, heart attack, amputation of their limbs well before the end stage renal disease (ESRD) that require dialysis and transplant. In essence what we are seeing is just a tip of the iceberg.
“What we know around the world, the numbers are just spiraling. In the year 1990 we probably had less than half a million people on dialysis, by the year 2000 the number had increased to 1.5 million.
“Currently, we know that close to three million people with different forms of CKD are all around the world. Unfortunately those in developing world particularly sub Saharan Africa are not coping well unlike in North America and Europe where they are able to cope over a thousand patients per million population. The number of patients in Africa that are benefitting from therapy are less than 50 per million and this not because we don’t have patients with chronic kidney disease.
“What we know is that there is a clear association between your Gross Domestic Product (GDP) per capita and the number of patients you are able to provide care for. If you look carefully you will also see that it reflects on your life expectancy, which has gone up to about 52 years in Nigeria.”
The nephrologist said there are non-modifiable and modifiable reasons why CKD is prevalent in our environment. He explained: “Clearly we know that race, ethnicity and genetics have roles to play. You know that CKD tends to be two to three times more common in men than women. You know that the older you get, the greater the likelihood that something will go wrong with your kidneys.
“We also recognize that there is spiral increase in patients with diabetes. It is estimated that very soon we would have doubled the number of diabetics in the world and the number in Nigeria, which incidentally was only about two per cent is now in Lagos it is estimated that about eight per cent of our population are diabetic. Also hypertension, obesity is increasing, we have all become urbanised, no one wants to live in the villages again.
“In developed parts of the world where studies have been done, it has been shown that when you compare people from African origin with people from other ethnicity you find out that the black race for some reasons is more predisposed to CKD than any other.
“In America you find out that the prevalence of CKD in black population is 800 per million people in white people it is 200 per million population. We are four times more likely to develop kidney problems than any other race group, it is the same in the United Kingdom (UK).
“If you follow up someone with straightforward hypertension, you find out that by 15 year about four per cent of them are going to end up requiring dialysis and transplant. This is three to four times more than when you compare them with individuals of Caucasian origin. So you know that hypertension is more common in people of black origin, we know it tends to occur at an earlier age, we know that generally it tends to be much severe.
“Hypertension is twice as likely to cause a stroke in black men, twice as likely to end up with a heart failure and four times more likely to end up with kidney failure. In the United States where blacks are only about 15 per cent of the population they constitute almost 60 per cent of patients on dialysis in that country.”
What are the risk factors?
Bamgboye said: “Even for diabetic nephropathy you find out that part of the reason is you are of African origin. So for some reasons the African kidney is more prone than any other. Some of the reasons have been cast, one of these, which currently under study is the inheritance of several genes. They found out in America that most of the people who inherit these genes generally tend to more likely develop problem with kidney failure, they have hypertension or diabetes or Human Immuno-deficiency Virus (HIV). They found out that this gene tend to be much more common in people of Africa origin. There is also some relationship with growth retardation, which is more common in this part of the world. There are also issues about poor access to healthcare illiteracy and ignorance.
“In this part of the world there is tendency for us to use herbalists who claim to be able to treat all diseases including swollen body, which I assume will be kidney failure. They also claim to deal with fortunes, bad luck, Court cases.
Also the state of some of the hospitals especially the Primary Health Care (PHC) centres, some don’t even have medical doctors.
“Studies have been done in various parts of Nigeria and it shows that CKD actually is actually a very prevalent problem. The study in rural and central urban areas and found the prevalence of almost 11 per cent of patients have CKD. That means of every hundred, 10 people will have kidney problem, that is frightening. Similar study has been done in Maiduguri, which shows a prevalence of almost 20 per cent, that means one in every five persons will have CKD at any stage of their lives.
“Three years ago on the World Kidney Day we went out to screen Nigerians at Silver Bird Galleria, Victoria Island, Lagos, we found out that close to 400 individuals out of 316, which completed the screening. Because of the location almost 80 per cent of them were younger than 40 years. Despite the young age we found out that 10 per cent of them already had hypertension, the majority of them did not know, six per cent of them were diabetic and majority of them did not know. Ten per cent of them already have markers of damaged kidneys by the time we did further analysis we found out that over 20 per cent of the patients had one form of abnormality or the other.”
People from South South and South East more likely to develop kidney damage
Bamgboye said: “Some other interesting thing we have noticed is that for some reason just like CKD seem to be dominant is people of black Africa origin, there seem to be some relation with some areas of the country. One the things we have noticed is that people from South South and South Eastern part of the country for some reasons have greater correlation to develop CKD than others. I don’t know why but certain studies are being done and we are waiting the outcome of that.”
Previous studies have associated the increasing prevalence of cancer and kidney failure in South South Nigeria to oil spills and the use of untreated water from shallow wells.
Modifiable risk factors
Bamgboye said: “So there are certain things we need to be aware of given the situation we find ourselves. Besides there are certain other risk factors besides hypertension and diabetes, those are things you can take care of. Number one is overweight. The bigger you weight the greater the likelihood of developing CKD is you have any of the other conditions. If you smoke it very rapidly progresses kidney damage. If you take a lot of alcohol you find out that the probability increases with the amount of alcohol you take. Of course if you eat too much protein. You just stay back and eat two kilos of stake. Of course if you abuse various forms of hard drugs.
“But in our environment what are the common things that can cause kidney failure? The top three of course is hypertension; what we call chronic glomerulonephritis which usually is an immunological damage to the kidney usually complicating by chronic infection in our environment including malaria, hepatis B or C when not detected and treated; and then diabetes, which is on the increase.
Aside from these it is important to stress one or two others.
“Analgesic nephropathy, abuse of simple Paracetamol. If you take two tablets three times a day and you do that daily for two years, I assure you your kidneys will fail. It is simple and straightforward.
“Most of our elderly people are on Non-steroidal anti-inflammatory drugs (NSAIDs) and many of them are hypertensive and diabetic. NSAIDs are actually not very good to the kidneys, so you have to be extremely careful with the use of these drugs.
“The use of bleaching creams: Prof. Olikoye Ransome-Kuti in his time as the Minister of Health banned it. But it has slipped back to the markets. People are now using it but it is known that they contain mercury, which can cause kidneys to fail.
Toxic nephropathy: many of us have herbs that we take, all these herbal supplements. You better know what they contain. Several studies have shown that in environments where such are consumed there is generally tend to be increase in number of persons that develop kidney disease. These studies have been done not only in Nigeria but also in China and Taiwan that have highest rates of chronic kidney disease than other parts of the world.
“Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) is increasing becoming a huge problem. In fact in males between the ages of 20 and 50 it is the third commonest cause of CKD.
“According to statistics, in Nigeria, hypertension is still the number one cause of CKD but note diabetes is rising. Ten to 20 years ago it constituted only about five per cent, worldwide it is the commonest cause. But gradually we are slowly becoming what happened to the developed world and close to 16 to 17 per cent of our patients now have diabetes. It is important that we detect early. Of course we recognize that early intervention can reduce progression, it can reduce cardiovascular risks, which I said is more likely to kill you than even kidney failure and of course increase the quality of life. The number of diabetics is increasing all over the world and note that for every diabetic there is one that is undiagnosed.
What you need to do
Bamgboye said: “Make sure that not only you check your blood pressure regularly, but when you go to see your doctor get him to do tests to detect the presence of protein in your urine.
“All hypertensive patients should be screened for CKD and all stroke patients, heart attack, HIV, elderly people, pregnant women, particularly those with raised blood pressure. If you have anybody in the family with problem with the kidneys, I advised that you make sure you screen yourself.”
over 25 years and compared them with sex and age match members of our society. They found out that those who donated kidney were much likely over 25 years to survive than those who did not. Maybe we should all go and donate one of our kidneys.
“The usual question is why is that happening? The main reason if that before we have a donor it must be established you do not have diabetes, hypertension and other risk factors. So already the donor is healthier than the average member of the society. You would have lived longer than any member of the society and going ahead to donate your kidney, your life is not in any way shortened. If you compare African with the other parts of the world, in terms of transplant, you find out that Africa practically not represented.
Akinkugbe said: “We must go a step further on the economics of health. Hippocrates has taught us. The complexity of kidney transplantation is a global thing. It is not just incumbent in Nigeria. In more advanced countries you still find the problem. Since we began transplantation, we have done less 200. The implication is that if we look at the etiology of CKD that is the cause. The three major causes chronic glomerulonephritis, hypertension and diabetes. If look at the etiopathogenesis, what are the causes, we will probably be saving thousands of lives.
“Etiopathogenesis is the cause and development of a disease or abnormal condition.
“Glomerulonephritis is a very expensive form of disease to treat and its management, treatment affordability is beyond the generality of the population in the developing world not just in Nigeria. Therefore what should we do? One must begin now seriously to look at etiopathogenesis and I think this is where the Foundations become very relevant because if you combine end stage management of kidney disease and transplant to looking at what actually causes it, why is the incidence so high in this part of the world compared to the black race.
“There must be a reason and to that reason I charge the foundation to perhaps devote sometime on this. Maybe by awarding research grants, you can break new grounds that will lead to the solution to the ethiopathogenesis. Then you would have solved the problem not only for Nigeria but to the rest of the developing world.
“That is the challenge I will like to throw at researchers, which will make the totality of the efforts more effective. I think we should focus more attention on the beginning rather than the end of these conditions.”
Bamgboye said: “We need to start looking at our socio economic status.
We need to ensure good sanitation and literacy. There is an urgent need to enact a solid Organ Transplant Act. There is need for us to have a renal registry, which does not exist in Nigeria. I know government is looking into it but we have to make sure that it should be able to provide for the less privilege members of the society. There is absolutely no reason why the National Health Insurance Scheme (NHIS) should not be extended to support patients with kidney failure.
“We need to cooperate more. We need to have regular public enlightenment sessions. We need to develop data bank because we should be looking at disease donor transplant in the near future.
“More importantly, there is need for subsidy of some sorts for some of the drugs that are used, which is quite expensive. In Sudan once you have a transplant the government provides you with the drugs for free plus other support. There is no reason why we should not be able to do that in Nigeria.”
Keshavamurthy said: “Looking for what to do, we came up with setting up with the possibility of a national matching centre for living donation/paid donation because the need was much more.
“In Africa if Nigeria, South Africa and Egypt do not have a transplant programme that means no other country will have such programme. If Nigeria does not move that means Africa is not going to move forward because you have the largest population of educated people in this part of the world.
“You need legislation on health, that is number one. Number two, consider legislation on organ transplantation Number three, if you want to stop paid donation you have to start national transplantation programme. It is possible because Nigeria and India have so many things in common.
“The national transplant programme will determine what you should do, how much you will get. You need a viable national kidney transplant programme and a legislation to back it up.”
Prof. Holly Kramer of Loyola University Chicago, Maywood, Ill., and Dr. Alex Chang of Johns Hopkins University, Baltimore, United States, write in a related commentary: “Patients with both type 2 diabetes and kidney disease may be frustrated by the numerous dietary restrictions that are recommended by their health care team.
“Patients may even ask ‘what can I eat?’ Perhaps the best dietary advice we can give to patients with type 2 diabetes and kidney disease is the same as the advice for those who want to avoid chronic kidney disease, and the same advice for preventing and treating hypertension, and the same dietary advice for everyone: eat a diet rich in fruits and vegetables, low-fat dairy products, and whole grains while minimising saturated and total fat.”