2. QUOTATIONS Brethren, let’s tee off with these germane quotable quotes:- The death of every man diminishes me, for I’m involved in Mankind. The death of every man diminishes me, for I’m involved in Mankind. - John Dohne. My people perish for lack of knowledge. My people perish for lack of knowledge. - Hosea 4 6 Beloved, I pray that all may go well with you and that you may be in health; I know that it is well with your soul. Beloved, I pray that all may go well with you and that you may be in health; I know that it is well with your soul. - 3 John 2.

3. Prevention of Chronic Kidney Diseases: A Clarion Call For Sociocultural Changes In Nigeria. By Dr J. K. L. Osinfade. B.Sc, M.B.Ch.B,MMCP,F.W.A.C.P.,PGD. Theo, MJF. Consultant Special Grd 1/Nephrologist Head of Clinical Services. F.M.C. Abeokuta.

4. Outline Introduction Introduction Classification Classification Epidemiology Epidemiology Common causes of Chronic Kidney Diseases Common causes of Chronic Kidney Diseases Harmful socio- cultural practices Harmful socio- cultural practices Clinical Presentations Clinical Presentations Management Management Burden of CKD Burden of CKD Prevention of Chronic Kidney Diseases Prevention of Chronic Kidney Diseases Recommendations Recommendations

5. Introduction Chronic kidney disease is a progressive and irreversible loss of kidney function that has lasted more than 3 months. Chronic kidney disease is a progressive and irreversible loss of kidney function that has lasted more than 3 months. It is also defined as evidence of kidney damage of greater than 3 months with or without decrease in GFR. It is also defined as evidence of kidney damage of greater than 3 months with or without decrease in GFR. Evidence of kidney damage include: Evidence of kidney damage include: a. pathological abnormalties a. pathological abnormalties b.abnormalties in the composition of blood or urine,or abnormalties in imaging tests. b.abnormalties in the composition of blood or urine,or abnormalties in imaging tests.

6. Introduction[Cont’d] CKD can also be defined as GFR of <60mls/min/ 1.73m2 of greater than 3 months. CKD can also be defined as GFR of <60mls/min/ 1.73m2 of greater than 3 months. Some of the functions of the kidneys that are lost include: Some of the functions of the kidneys that are lost include: a. regulation of salt and water a. regulation of salt and water b.electrolyte balance b.electrolyte balance c. prostanglandin secretion c. prostanglandin secretion d. erythropoietin production d. erythropoietin production e. vitamin D metabolism e. vitamin D metabolism f. blood pressure regulation f. blood pressure regulation

7. Classiffication STAGEGFRDESCRIPTION 1 >90 Kidney damage with 1 >90 Kidney damage with normal GFR 260-89Kidney damage with 260-89Kidney damage with mild decrease in GFR 330-59moderate decrease in 330-59moderate decrease inGFR 415-29Severe decrease in 415-29Severe decrease in GFR GFR 5<15Kidney failure 5<15Kidney failure Normal GRF (Glumerular Filtration Rate = Creatinine Clearance) = 120 ml/min.

8. Epidemiology The burden of CKD is enormous and in fact the incidence and prevalence of CKD worldwide is increasing at an alarming rate. The burden of CKD is enormous and in fact the incidence and prevalence of CKD worldwide is increasing at an alarming rate. Country Incidence Prevalence Country Incidence Prevalence U.S. 336 1,403 U.S. 336 1,403 U.K. 101 626 U.K. 101 626 Europe 135- 173 600- 800 Europe 135- 173 600- 800 Nigeria Unknown 2.5 Nigeria Unknown 2.5 N.B. Incidence and prevalence are expressed in per million population 8per year. Endstage Renal Failure however 3 – 4 times more common in blacks than in caucasians. It is estimated that by 2030 more than 2 million people in the USA will need dialysis or transplantation for kidney failure.

9. Impact of CKD In Nigeria Population figures not available but based on hospital figures Population figures not available but based on hospital figures ESRF accounts for 1.6-8% of hospital admission rates. ESRF accounts for 1.6-8% of hospital admission rates. Mortality is over 90% within 3 months[about 11.4% of all admissions in the medical wards of a tertiary health institution in Nigeria]. Mortality is over 90% within 3 months[about 11.4% of all admissions in the medical wards of a tertiary health institution in Nigeria]. Less than 1% are able to afford renal transplant. Less than 1% are able to afford renal transplant.

10. Common Causes of CKD - There are many aetiological factors that have been identified as causes of CKD. - However the prevalence of these factors differ to varying extents in different parts of the world. - Some of the causes include: - Chronic glomerulonephritis - Hypertension - Diabetes - Ingestion of herbal concoction. - Analgesic nephropathy - Exposure to heavy metals. - HIV –associated nephropathy. - Infections - Sickle cell nephropathy.

11. Harmful Socio cultural practices] Some sociocultural practices that can lead directly or indirectly to CKD. Some sociocultural practices that can lead directly or indirectly to CKD. Chronic ingestion of herbal concoctions Chronic ingestion of herbal concoctions Chronic analgesic abuse. Chronic analgesic abuse. Use of mercury containing soap- soap use as bleaching agents. Use of mercury containing soap- soap use as bleaching agents. Exposure to heavy metals- lead found in paints and mercury as above. Exposure to heavy metals- lead found in paints and mercury as above. Obesity – which is regarded as a sign of good living in Africa, obesity associated glomerulonephropathy as now being described. Obesity – which is regarded as a sign of good living in Africa, obesity associated glomerulonephropathy as now being described.

12. Harmful Sociocultural Practices[Cont’d] High salt diet- adding salt to food after cooking. High salt diet- adding salt to food after cooking. High protein diet- bukateria people eating all kinds of meat –liver, and assorted meat all at once.Proliferation of fast food joints not helpful. High protein diet- bukateria people eating all kinds of meat –liver, and assorted meat all at once.Proliferation of fast food joints not helpful. Scarification marks made with unsterile sharp instruments leading to transmission of hepatitis and HIV with ultimate effect on the kidneys. Scarification marks made with unsterile sharp instruments leading to transmission of hepatitis and HIV with ultimate effect on the kidneys. Smoking – adolescents smoke cigarettes to feel belong. Smoking – adolescents smoke cigarettes to feel belong. Alcohol – Heavy alcohol consumption. Alcohol – Heavy alcohol consumption.

13. Clinical Presentations CKD is silent & asymptomatic in the early stage.Most cases therefore present in the advanced stage. CKD is silent & asymptomatic in the early stage.Most cases therefore present in the advanced stage. Presentation in early stage: Presentation in early stage: -Incidental finding of abnormalty in renal marker during health screening exercises i preadmission/preemployment medical tests ii during investigation for other disease conditions. - Pain in the loins/renal angles. - Passage of stones or ‘gravel’in urine. - Unexplained growth retardation in the young. - Haematuria. - Polyuria/Nocturia/Enuresis in children.

14. Clinical Presentations[Cont’d] Presentations in advanced stage Presentations in advanced stage Clinical: Clinical: GIT- Nausea, vomiting,hiccups. GIT- Nausea, vomiting,hiccups. CNS-Twitching, flapping tremor, drowsiness,convulsions,coma. CNS-Twitching, flapping tremor, drowsiness,convulsions,coma. CVS- Severely elevated BP,cardiac damage e.g. LVF, CCF. CVS- Severely elevated BP,cardiac damage e.g. LVF, CCF. Laboratory: Laboratory: Deranged E/U/Cr such as excessively high urea & creatinine Deranged E/U/Cr such as excessively high urea & creatinine Hypocalcaemia Hypocalcaemia Hyperphosphataemia Hyperphosphataemia Anaemia Anaemia Abnormal urinalysis Abnormal urinalysis

15. Management Conservative Conservative Control of risk factor Control of risk factor - Modifiable - Non- modifiable..Renal Replacement Therapy..Renal Replacement Therapy. - Haemodialysis - Peritonial dialysis - Transplant.

16. Burden of CKD Chronic kidney disease is now a worldwide public health concern. Chronic kidney disease is now a worldwide public health concern. There is evidence of an increasing incidence and prevalence of kidney failure,with both high costs and poor outcomes of treatment. There is evidence of an increasing incidence and prevalence of kidney failure,with both high costs and poor outcomes of treatment. It should be noted that CKD is grossly underdiagnosed both in our environment and even in the developed world. It should be noted that CKD is grossly underdiagnosed both in our environment and even in the developed world. This is due, to a large extent, to its silent and asymptomatic nature in the early stages, as a result of which most patients only present in the advanced stages of disease. This is due, to a large extent, to its silent and asymptomatic nature in the early stages, as a result of which most patients only present in the advanced stages of disease.

17. Burden of CKD[Cont’d] The cost of treatment of ESRD is enormous and cannot be easily accommodated within the government health budgetary allocations in developing countries. The cost of treatment of ESRD is enormous and cannot be easily accommodated within the government health budgetary allocations in developing countries. It should be noted that renal diseases is not accommodated in NHIS. It should be noted that renal diseases is not accommodated in NHIS. Hence emphasis should be laid on prevention of CKD rather than treatment which is not only expensive but also has poor outcome. Hence emphasis should be laid on prevention of CKD rather than treatment which is not only expensive but also has poor outcome.

18. Prevention of CKD ‘Prevention, they say is better than cure’ this is very relevant in the case of CKD. ‘Prevention, they say is better than cure’ this is very relevant in the case of CKD. Successful prevention depends on the knowledge of causation, dynamic of transmission and identified risk factors. Successful prevention depends on the knowledge of causation, dynamic of transmission and identified risk factors. There are 4 levels of prevention viz: There are 4 levels of prevention viz: Primordial Primordial Primary Primary Secondary Secondary Tertiary Tertiary

19. Primary Prevention This aim at preventing kidney disease from occuring at all and calls for knowledge of: This aim at preventing kidney disease from occuring at all and calls for knowledge of: - risk factors predisposing to renal disease - risk factors predisposing to renal disease - risk factors that initiate renal damage - modification,removal or avoidance of risk factors. - Development of a positive health seeking attitude & behaviour.

20. Secondary Prevention This aim at identifying factors that aid or hasten progression of kidney disease and/or accelerate loss of kidney function and preventing or removing such factors. This aim at identifying factors that aid or hasten progression of kidney disease and/or accelerate loss of kidney function and preventing or removing such factors. While a few of those factors are not modifiable,majority of them could be modified,controlled or completely avoided. While a few of those factors are not modifiable,majority of them could be modified,controlled or completely avoided. Some of the factors include: Some of the factors include: - Increasing proteinuria - Elevated or uncontrolled blood pressure - Poor glycaemic control in diabetics - Smoking - NSAID’S - Herbal preparations - Dehydration - Infections

21. Tertiary Prevention A.This aim at preventing the development of complications of CKD such as: - Cardiovascular events- CCF, MI. - Dyslipidaemia. - Metabolic bone disease. - Anaemia. - Neuropathies. B.Adaptation to incurable diseases. C.Prosthesis provision D.Rehabilitation.

22. Recommendations Targeted screening of at risk population. Targeted screening of at risk population. At risk population are people with one or more risk factors. At risk population are people with one or more risk factors. Lifestyle modification/ behavioural changes. Lifestyle modification/ behavioural changes. Avoidance of physical inactivity- discourage excessive use of remote control, lift. Avoidance of physical inactivity- discourage excessive use of remote control, lift. Avoidance of stress- economic, financial,emotional and executive. Avoidance of stress- economic, financial,emotional and executive. Dietary pattern. Dietary pattern.

23. Recommendations[Cont’d] Avoidance of infections- STI[viral],HBV, and UTI. Avoidance of infections- STI[viral],HBV, and UTI. Non- communicable disease tend to have multifactorial causation usually classified as: Non- communicable disease tend to have multifactorial causation usually classified as: - Modifiable- factors that we have control over e.g. hypertension, diabetes, smoking, alcohol, obesity. - Non- modifiable- factors that we have no control over e.g. age, gender, family history. - Need to cultivate positive attitude to routine check up.

24. Teasers One million naira question is.How healthy are your kidneys? One million naira question is.How healthy are your kidneys? Wishing you all Amazing Kidneys for the rest of your life. Wishing you all Amazing Kidneys for the rest of your life. Stay healthy and blessed. Stay healthy and blessed.

25. THANKS AND GOD BLESS.