…Says disease devourer that  has wrecked families

30 million Nigerians suffer from it

 

 

Prof Ume Okafor is a consultant nephrologist, specialising in kidney care. 

The Professor of Medicine is the Consultant in Charge of Nephrology at the Enugu State University of Science and Technology (ESUT) Teaching Hospital, Enugu. 

He also teaches medicine and is the current Dean of the Faculty of Medicine, ESUT. 

He equally consults for Hilton Clinics Enugu, a clinic that has interest in managing patients with kidney diseases. 

In this interview, the medical expert warned that the economic stronghold of Nigeria is being decimated by kidney diseases.

According to him, 30 million Nigerians are suffering from the killer disease, while 20 per cent of the people in Enugu city have a kidney disease, one way or the other.

 

I have heard people, including medical experts say that kidney diseases are among the major killers in the country today. How factual is this?

It is an understatement to say that it is a major killer. Let us even start looking at it globally. It is one of the major killers globally because it is taking so much toll on most developed countries, even with so much concern from the government and non-governmental sector. You find people dying of kidney diseases, even in the developed countries. You will also notice that the number of people developing kidney disease annually is increasing. The number of people living with it is also increasing. When you juxtapose it with our own environment in Nigeria, including Enugu where I reside, using the word “major” is an understatement because it is actually ravaging and destroying the population. It is not just killing them, but debilitating them and their families. The problem with kidney disease in our own case is that it doesn’t only affect the patient, it affects everybody around the patient, both the family, the friends, church members, among others. So, it is more than a major disease. It is a killer. It kills patients physically. It kills them emotionally before they finally die and also kills those that are around them mentally. That will tell you the extent of it. And when you talk about those that are developing kidney disease, it is very scary. There is a work we did in this Enugu metropolis and we found out that more than 20 per cent of the people living in Enugu metropolis have kidney disease one way or the other.

 Beyond Enugu State, what is the incidence nationally?

Nationally, we are talking about 13 to 15 per cent of the population of Nigeria, which is over 30 million Nigerians living with kidney disease. Kidney disease is such a terrible thing that it is very silent. The way the kidney was programmed by the maker, it has the endurance to tolerate a lot of insults and assaults, that even at the point that the kidney function had gone down, it is still going ahead and carrying the person. So, what am I saying? You may find out that among these 30 million Nigerians that have kidney disease, less than five per cent of them are aware that they have kidney disease. Majority of the time that we hear of people having dialysis and this and that, they constitute the microcosm of the quantum of problems we have with kidney diseases. It is a killer.

What are the symptoms?             

Kidney disease has some specific symptoms, but the unfortunate thing with the disease, the reason I said it is a silent killer, is that the early stage of it doesn’t have any symptom that you can say is particularly specific to kidneys. For instance, most people who their kidneys have gone down by 50 per cent do not show any symptoms. As at the time the kidney functions have dropped by 50 per cent, the majority don’t show any symptoms. By the time it gets to 30 per cent, some will come with vague symptoms like feeling unwell, weakness, not eating well, and occasionally, depending on what is causing the disease, the urine is foaming at that particular time. Some, you may notice a little bit of swelling around the eyes, that usually appears in the morning and disappears as well, later in the day. So, you find out that as at the time the kidney function has dropped to 30 per cent, some may be just vaguely treating malaria, typhoid, one disease or the other. So, what I am saying is that those symptoms that we are going to mention, the majority of them come in when the disease has got to the severe stage of it. We are talking about swelling. The swelling can increase and get worse. You may have the swelling affecting the legs and the abdomen. More so, it can also cause swelling, affecting the internal organs. They come with cough, coughing out blood, coughing out things that look like saliva. Some of them also come with urinary symptoms. The symptoms occurring with the urine in kidney disease varies. Most times, there is a decrease in your volume of urine. Occasionally, it may not at that stage. You may have urine now appearing as coca cola or you may find blood in the urine. You also notice that you urinate more frequently at night. Probably, you used to wake up three or four times in the night, but now you are urinating five or six times in the night before it is morning. The urine may have an odour that you are perceiving, which is not the normal odour of urine. And like I said, the frequency of passing urine may decrease. Occasionally, it may increase. Although, that is not a very common thing that we find out. You may have other symptoms that are occurring because of the effects of kidney disease in other organs. Like, it causes hypertension. The blood pressure may start going up for somebody who is not hypertensive. They may come with other complications, such as heart failure. The patient may start vomiting, especially in the morning. Some develop itching all over the body that you cannot even specifically say the cause of the itching. Some come with hiccoughing.  So many can make the sick person not to sleep well. Some cannot sleep in the night, but during the day they sleep. You think it is a normal thing, but it is not. It is a reversal because it is kidney disease. If the thing happens, be able to ensure that it is normal; that it is not kidney disease that is causing it. Some may come with strokes, seizures, convulsion and even loss of consciousness. So may come with vague things, such as the person’s legs cannot stay in one place. The person will be having body twitching and the rest. These are some of the things that will come in. But remember what I said, if everybody keeps waiting to die, it may be too late. That is why we preach that you don’t wait for it to get to that stage before you start taking care of yourself, to be able to check whether you can pick it early and there may be intervention.

Can we know the causes and how it can be diagnosed?     

I will start by mentioning that kidney disease or kidney failure are not the same. But for the benefit of this interview, let us assume that they are the same. Kidney disease leads to kidney failure. But it is not all kidney failure that is disease. There is one called an acute kidney disease and acute kidney failure. We have the chronic kidney disease or chronic kidney failure. The difference is that acute can be reversed and the kidney goes back to normal. In chronic, the kidney cannot get back to normal. The best you can do is for it to keep on functioning. By the way, if somebody has kidney disease, it doesn’t signify that the function has failed. That is the difference between disease and failure. If you have someone with chronic one, you may not be able to reverse it. I want to say here that acute kidney disease, which is reversible, is one of the commonness causes of chronic kidney disease. Why? Because one of the things that are supposed to be done to reverse them are not in place. They are not done. People are ignorant about them. That one is potentially reversible, ended up being chronic kidney disease. And it constitutes the quantum of the chronic kidney diseases that we have. What it means is that the majority of the patients had set out with something that is potentially reversible, but because they are ignorant, they don’t know what to do and they have gone to the wrong places, they didn’t seek intervention until that acute kidney disease turns into chronic disease. Chronic disease is what most people hear about.

So, what causes chronic kidney disease?

Most of the things you know; vomiting, stooling, a woman had put to bed and she is bleeding. Somebody is taking medication that is attacking the kidney that also may be reversed. There may be some toxins and venoms. There may be some drugs that can affect the kidney. There are some infections associated with it. There are problems with other organs that can cause this chronic kidney disease. There may be some obstruction. You may have heard about kidney stones. Prostrate of men can cause acute kidney diseases that if intervention is taken, it may be reversible. There are other things causing the disease, which are actually those things that are troubling the world. Acute is either you get to chronic or the person recovers or dies. So, the main thing is those chronic ones. Apart from those moving from acute, there are things established that cause chronic kidney diseases. One is hypertension. The other one is the inflammation of glomerulus, which is end of the part of the kidney that can occur because of past infection. That can occur because of auto immunity. This is when the body begins to react to the kidney. The third one is diabetes mellitus. In fact, globally, diabetes is the commonest cause of chronic kidney disease. In Nigeria, it is coming up. About 20 years ago when we were coming up in this field, if you mention diabetes, they would say that it constitutes five per cent of the cause, but now it constitutes 10 to 20 per cent in series of studies. So, diabetes mellitus is another one. Then, things like prostrate and some medications, such as ordinary pain killers that we take, have been associated with it. Some antibiotics have been associated with it. Another one that is very important in this country is herbal concoctions. I forgot to mention that herbal concoction can cause acute kidney disease. It also causes chronic kidney diseases, especially for habitual consumers of these herbal concoctions. So many of them are toxic to the kidney. They can cause kidney stone. There are some cancers that have been associated with chronic kidney diseases. If I will attach to these causes, which I have not exhausted, there are those at the risk of developing that. Number one is cigarette smokers. If you are taking cigarette, you will likely develop that. If you are obese or overweight, you are very likely. People who don’t take enough water are at the risk of developing chronic kidney disease. Then, there are people that their chronic kidney disease resulted from what happened when their mother was pregnant. Their kidney didn’t develop because of what happened to their mother when she was pregnant. You have patients who inherited it from their parents. They got it vertically and developed chronic kidney disease. Like I said, the causes are almost not exhaustive. Venoms, like snake venoms and scorpion venoms have been associated with chronic kidney disease. Some of the herbicides we use have been associated with chronic kidney disease.

How often can one subject himself to kidney tests?

Usually, you ask yourself questions. Are you at risk? Do you have diabetes? Do you have hypertension? Do you have a family history of chronic kidney disease? Do you have prostrate? If you are at risk, it is expected that you will be able to run the test at least, once every year, to be able to access your kidney function. To access evidence of kidney injury. Are you a smoker? Are you overweight? Do you have sickle cell disease? If you have these, you are expected to check yourself at least, once every year if the kidney function is normal. If it is not normal, you are expected to see a nephrologist who is a specialist in kidney care, like us here, so that they will be able to monitor you. There are cases that you may start running that test every month. Everybody, whether at risk or not, as you are 50 years old, you should run that test at least, once every year. Why is the test necessary? One, for it to be picked early. Even chronic kidney diseases, if you pick it early, there are things that you can do that can slow down the progression. The test basically is testing your blood, to check the kidney function, urine to see if there is evidence of injury to kidney. Then, you can also do abdominal ultra sound to see the structure of the kidney, to see whether it is normal or not?

But you know that things are very difficult in the country, in terms of the unprecedented economic hardship, how much does it cost to run these tests?

Well, I don’t deal so much will cost. But I am sure with about N10,000 to N15,000 at most, you can do all these investigations at least, once a year.

Another very important issue is the issue of transplant. It does appear that doctors in Nigeria cannot do transplant. Most of the time, you hear about people, especially the well-to-do Nigerians going to UK or United States or even Asian and Middle East countries to do kidney transplant. A particular senator and his wife got into trouble with the law in the United Kingdom, trying to secure a transplant for their daughter. Why can’t it be done here in Nigeria?

One, saying that it is not done in Nigeria is a false information. As at last year, more than 1,000 kidney transplants have been done in Nigeria. Monthly, more than 20 to 30 kidney transplants are being done in Nigeria. They are being done efficiently well. There are several centres, more than 15 centres in Nigeria that had done kidney transplants. Currently, three of them are doing transplants efficiently, effectively and regularly. So, nobody can say it is not done in Nigeria. People go outside because of choice. People go outside because most of the time, they don’t have confidence and trust in where they belong. Prior to now, even before the current inflation, you find out that transplant used to be cheaper outside than within the country. That was one of the attractions of people going outside the country for transplant. But, even as it is said, transplant is still not our option in the management of kidney disease. Do you know why? We are talking about potentially 30 million patients with chronic kidney disease and we have just about three efficient transplant centres, doing about 30 in a month. That can never equate assuming that a system is put in place and those that develop kidney disease got to the stage of doing transplant. But I can tell you that less than 0.005 percent of the people that develop the disease are able to do transplant. One, either they don’t live to get to transplant or they don’t have the capacity financially and otherwise to do transplant. So, is transplant available in Nigeria? Yes, it is available. Is it the answer to the horrendous negative impact of kidney disease on our system? Obviously, it is not. It cannot and it will not and it can never be. It has never been, even in the developed countries. It is the last resort. There are so many countries where things work. They try to make the society, their citizens not to get to that point of kidney transplant. Kidney transplant is very demanding. It is very costly. Kidney transplant in Nigeria in the private practice costs over N20 million. The only public centre here is about N10 million, but you know things that go with public centres. And you have to be on post-transplant medication, obviously carrying another person’s kidney. Always look at the possibility of getting to a point that you don’t need a transplant. It is very possible because the majority of kidney diseases, well over 70-80 per cent of them are preventable. You can say treatable, but you can prevent them from developing and getting to that stage where you don’t need a transplant, only if the right thing is put in place to be able to achieve that.

The statistics that you have reeled out are quite alarming. It shows that this matter should be treated with a sense of urgency. What exactly do you think that the government should do to support experts like you to see that this ravaging issue of kidney disease is reduced to the barest minimum in Nigeria?

Globally, most areas where you see kidneys being managed that has some microcosm of results, you see government intervention. Even in this West African sub-region, we have seen government intervention, which has been of tremendous help in reducing the number of people that develop kidney disease and the number of people that have the disease that progress to the point of talking about kidney transplant. So, government has so much to do. In the United States, you find out that the medicare who takes care of the medical care of the citizens, devote so much money to kidney care because they know that the percentage of people requiring kidney transplant in the American population is about one per cent. You discover that the one per cent is taking almost seven per cent of the total budget of medicare. So, they try everything to stop patients from getting to that point that they start needing kidney transplant. It is the same thing with NHS in UK. They take care of this? In Germany, it is even an offence if they pick you early and you miss your appointment. They will trace you because they know that you are trying to place so much burden on the government. But unfortunately, here nobody cares. It does not concern anybody. Even as I am granting you this interview, people will read it and it will not make any meaning to them. But I think there is need for government to start paying true attention to the health needs of then citizens. And part of this is to do real assessment and quantify the various types of ailments. They vote so much money to HIV. They vote so much money to malaria. They vote so much money to tuberculosis. And I can tell you that what these diseases combined, kill in this country, may not be up to 40 per cent of persons who are dying of kidney disease. And like I told you, more than 80 per cent of them never got to be attended to or to be heard of. So, when the government starts looking at that, it is going to save them a lot of cost. The other thing I didn’t mention is that the kidney disease is even decimating the population constituting the economic stronghold of Nigeria. The majority of the patients that die, die under 50 years old. That is at the prime of their lives. They die with their intellect. They die with their strength, with their power and the value they would have added to the society. But like I said, government is not paying attention.

Can the government really do anything?

Yes, they can. What stops the government from opening a channel through which we can educate the populace? Let the populace know that this is available. Let the populace know that these diseases are preventable. Let the populace know those things that they got to do that will stop them from developing the disease. Let them know those things that they will do, so that even if they develop the disease, it will be detected early, to stop it from progressing to the level that the patient needs a kidney transplant. Health education is the key. I have approached so many media houses, they are not interested. In fact, I approached one television station and they said that I should pay N300, 000 per slot. Where will a poor teacher like me get that kind of money? I was there with the knowledge of what to do and I didn’t ask anybody to pay me. Let us educate our populace. If you go to radio stations, they are not interested if you are not ready to pay money. The interest is not to educate and make money because those people who are going to educate and pay money, will find a way of getting it back from the patient who will come for treatment. But it will not help. If we will be able to get health education, to educate the people seeking primary health care and even doctors, because so many of the doctors are ignorant about kidney diseases. There is need to make provision for us to go to primary health centres and educate primary healthcare workers. They will be able to know about the disease and pass the information down to the root. In my village, I do annual medical health outreach.

Does it make any impact?

It does. I noticed consistently that each time I come in and give them that health talk, hypertension reduced. It became clear. We have not been able to publish it, but we noticed that it has a positive impact. Many of those women look forward to that health outreach. They come in and listen to what you say and do that. So, health education is key. People should also re-learn what they have learnt. People think it is just to take herbs, but some of these herbs contain aristolochic acid, which is very toxic to the kidneys. So, people should be told. Government should assist and make those provisions. What I do is that I go to the churches and communities but it does not make so much impact. So, it should be integrated into probably what the government should be able to offer to their people. That is one. Then, government can also help in the screening. You can say those that have so, so and so symptoms, you screen them and be able to pick those with the disease early enough. That is going to help a lot. Primary health care is also going to help in preventing all these acute kidney diseases. Remember that I said that acute kidney disease is potentially reversible, if only the right thing is done. The primary health care workers can also be taught what you can do when you have diarrhea. They can be taught what you can do when you are vomiting. If you notice high blood pressure, refer this patient as fast as possible. If a patient is bleeding, this is what you do. Those things will have great tremendous impact in reducing those that develop those chronic kidney diseases. So, government can help with the screening. Government can offer a little bit of subsidy to those patients that are at risk of developing kidney diseases. We have Nigeria Health Insurance Agency, but it is not working. Definitely, it is not working. Most people cannot access it. The job they give is even something else. So, government should be able to bring out a policy. They are going to impress it on people. If you have hypertension, you can access hypertensive care at will. If you have diabetes, you can access it at will.  If you control the blood pressure, hypertension can never cause kidney disease. If you control blood sugar, diabetes can never cause kidney disease. It is that simple, if it is done and it is followed. So, if government can do that, it can impact significantly. The other thing that government can do is to take care of those that have kidney disease. If you have it in South Africa, they take it as a burden. The late Governor Umaru Musa Yar’Adua took it over in Katsina State.  As you are diagnosed, government took it up because he knows that if you are going to allow it to get where it would head to, there would be problem. So, government should try and subside the treatment. Like you have dialysis. Dialysis in this our facility here is about N50, 000, which may be one of the cheapest around here. How many people can afford dialysis? And it is done two to three times a week. The patient is expected to take another medication, which may cost about N30,000 to N40,000 a week. How many people can afford that? So, this is where the government can intervene. I have a friend who is in Spain, doing dialysis free and the government is paying him. And that is why you go there and see people who have done or lived on dialysis for 30 years. The reasoning is that this person has contributed to the society and if I take care of this person, the person is going to be very useful. So, let government bring subvention to reduce the cost of all these things. It is going to help a lot. Also, it does not take much to build kidney centres. It doesn’t take much for you to have knowledge. I went to India to train myself. Not everybody can afford that. But government can. You can sponsor the experts.

Don’t you think the issue of doctors migrating overseas, popularly called the Japa syndrome, is discouraging the government from investing in them?

I was discussing with somebody this afternoon, I said if you are serious about Japa, invest in your specialists. Their conscience will not even allow them to go. But when they keep on struggling and struggling and we keep on going round and round and round, they leave. The governments are basically not doing anything. From local government to the Federal Government, they are not doing anything. What you hear is that they have given money to somebody to go and do transfer. That doesn’t make any impact on the society. So, they should be able to look into how to establish kidney centres. In 2012, in this state (Enugu), a proposal was packaged and by the time it got to the governor, it was killed. In this present government, we have also said, invest in kidney care. Nobody is showing interest.

You said the proposal was made in 2012. Was it not under Governor Sullivan Chime?

Yes, under Governor Sullivan Chime. It was packaged. Somebody got interested, we made provisions and wonderful proposal on how we are going to manage from prevention of kidney disease to kidney transplant and it would have helped this state a lot, but it was killed. It didn’t see the light of the day. Nobody mentioned about it. So, that is the unfortunate situation we have found ourselves in our country.

What is the way forward?

If government and non-governmental organisations can help and even private individuals, it could go a long way. It could be in form of Corporate Social Responsibility (CSR) by corporate bodies. One thing is that this thing is decimating the economic stronghold of our population. So, it is something that we expect that the government should look into. All the other concerned individuals should look into it because it is an area to invest in. I must also give kudos to Aliko Dangote. Aliko Dangote established a dialysis centre there is Lagos and there is a number of dialysis done in that centre free of charge. Kano also understands this very much. However, my worry is that Kano is focusing on the people who have got to the end. But we should start thinking how to prevent them from getting to that level. How do you tell them? How do you pass the information? Like I said, we can sponsor radio programmes. We can sponsor TV programmes. We can sponsor online programmes and it is going to reach a population. We can go to communities. We can reach town criers if we have funds. Like I said, the target audience could be the primary health centres. Educate those people and they will be able to pass it to the community.

You have talked about dialysis, which is very expensive. I also know that there is the problem of high cost of drugs. How is it affecting the treatment of kidney diseases?

Just as you have said, most patients that have kidney disease, you hear them say that they take 10 tablets or 15 tablets daily. I am sure you know that they are all money. You know that a person with kidney disease may have heart issue or hypertension or diabetes. So, there are so much things bordering on one person. So, there is the problem of cost of drugs. Like I said, there are things you have to do in the kidney, apart from dialysis. There is the blood level. There is injection, which is about N15, 000 for a vial of that injection. Dialysis varies apart from N50, 000 that we take here. Some people are taking N75, 000. And like I said earlier, dialysis is something that you do two to three times a week, if you have got to the point of transplant. So, the cost of medication is exorbitant. And even the so-called high and mighty will not be able to manage kidney disease because of the cost. Like I told you, it has wrecked families. It is a devourer. It devours cash of families. It devours assets of families. It devours maintenance of family members. It wreaks psychological, mental and social havoc on families. So, the cost is unquantifiable. Again, I will bring government in here. You know we have heard on radio that there is zero cost in the importation of drugs, it is not true. I can tell you that most people that are bringing drugs into this country are still passing through hell. That is why the cost of drugs is very expensive. So, the drugs are still an issue. They are still coming from outside the country. When those restrictions are placed, they make drugs expensive. Also, many of the pharmaceutical companies are leaving because of taxation in the country as a result of inflation. So, the drugs are very expensive. Management of kidney diseases when it gets to the end stage, which is the stage that requires transplant or regular dialysis is very costly.

•Chekwube Emmanuel Nzomiwu, Ph.D, contributed this interview 



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