The Tribune

By Dr. Adrian Sawyer

MBBS, DM

Director and Chief Nephrologist
The Dialysis Centre Bahamas

Tuesday July 17th, 2012 marked the first Anniversary of The Dialysis Centre Bahamas on Collins Ave, Nassau, Bahamas. The ever increasing Bahamas and world burden of people with kidney failure requiring kidney replacement treatments such as Dialysis (Haemodialysis/Peritoneal/CAPD/APD dialysis) or kidney transplantation has brought the gravity and significance of this increasing scourge to the attention of the medical community, health authorities, governments in developed and less developed nations, in The Bahamas and all over the world.

The primary reasons for this are related to cost of treatments, high morbidity and mortality of such patients, the increasing contribution of diabetes, related to the current and continuing epidemic of obesity worldwide, and the economic burden of increasing numbers of persons rendered incapable of maintaining gainful employment when the diagnosis of kidney failure (End-Stage Kidney Disease/ESRD) is made and then have to undergo treatment. Unfortunately, in the less- developed nations, with limited resources and other competing health-related priorities, this diagnosis is more often a death sentence.

It is estimated that the number of persons with ESRD/Kidney failure will increase by some 60 % to 80 % above current levels in all countries by the year 2020, again driven primarily by the pandemic of obesity and diabetes.
Diabetes is by far the single largest contributor to causes of kidney failure, accounting for some 47% of diagnoses in the United States as reflected in the USRDS statistics for 2011, which reflects figures for 2009. Hypertension (high blood pressure) is second, accounting for some 25-30%.

Unfortunately, in the United States, people of the African Diaspora account for a disproportionately afflicted group, by making up, some 24-30% of the ESRD population, but contributing to only 12% of the U.S. population. African Americans have almost four times the level of kidney failure as that of Caucasians There are other potential contributing genetic factors that have been advanced for accounting for the increased risk of kidney failure in this susceptible population related to a form of kidney inflammation called focal segmental glomerulosclerosis, and HIV (AIDS-related) Kidney disease.

The latter occurs almost exclusively in African-Americans in the United States. It is clear that there are implications for the burden of kidney disease locally in the Bahamas and there is a clear need for enhancing awareness of this devastating problem in the minds of citizens, health policy makers, the Government, and health-care providers.
Measures that can be undertaken to address recognition and awareness:

1. Public Education:

Professional and non-professional organizations such as the Medical Association of the Bahamas, The Association of Medical Technologists, The Kidney Foundation, and other such groupings should find ways to embark on a programme to make the public aware of the major health-related diseases that predispose to high risks for kidney disease/ and failure, such as hypertension (High blood pressure), and Diabetes; the former has a prevalence that reflects an estimation of one in three adults being affected.

There has been some evidence indicating that the prevalence of Diabetes in the local population is approximately around some 12-15%; current estimates for the prevalence of Diabetes in the United States is of the order of some 11-12%. Most authorities indicate that these are conservative estimates, and the increasing public health burden of Obesity-related diabetes and hypertension pose a potential for higher numbers of people being affected within the next 5-10 years.

The spread of the relevant information can be facilitated by forming alliances with civic organizations and clubs such as the Kiwanis, Rotary and other such groupings to provide for a for spreading the relevant message. The engagement of the informational arms of the Ministry of Health, and the institutional private health entities such as Doctors Hospital and The Medical Pavilion Bahamas will contribute significantly to this effort.
The public information campaign needs to be planned on a continuing basis and not a one-time project.

2. Medical Provider Education

and focus on screening and

early detection:

Physicians, Nursing and other allied Health professionals have an important role in participating in programmes related to screening and detection of persons with kidney disease or those deemed to be at significantly increased risks of developing kidney disease and failure. The routine of regular testing of urine for the presence of protein and/or blood, along with sugar, should be a part of every regular medical clinical evaluation of patients seeing their respective medical providers. Annual blood tests for kidney function along with those for cholesterol/lipid profiles should be routinely required and mandated along with the implementation of professional recommendations for early, appropriate and timely referral to specialists (Kidney Specialists/Nephrologists), for implementation of strategies to treat and slow-down the progression of disease to the stage of end-stage kidney failure (ESRD).
There are limited options for treatment-related- reversal of kidney failure, save for a handful of specific causes; most forms of treatment are directed at slowing down the progression to the stage of kidney replacement treatment.

The early and appropriate
referral by physicians to the Nephrologists will allow the utilization of maximally effective treatments to slow disease progression such as the use of specific types of medications that can reduce urine protein levels, control blood pressure at optimally-recommended levels of 130-135/ 75-80 mm. hg; utilization of medications to control levels of cholesterol and its components, and optimal regulation of the levels of blood glucose in those with diabetes.
The final advantage of such a programme will be the provision of opportunity for informed patient education of the options for kidney replacement treatments such as the forms of dialysis (Haemodialysis or peritoneal dialysis), and/or kidney transplantation.

The earlier that patients and their relatives are involved in this process related to renal replacement options, including the time for thoughtful and informed consideration by relatives or other persons who may wish to become living organ (Kidney) donors, the better the long term outcomes. It is well established that late referral to a Nephrologist, late initiation of kidney-replacement (dialysis) treatment when disease is at an advanced stage is associated with significantly higher rates of mortality (death), and morbidity (complications).

The costs associated with kidney replacement treatments, haemodialysis, peritoneal
Dialysis and kidney transplantation are significant; one year of haemodialysis treatments thrice per week, without hospitalisations or other complications, is of the order of $ 75,000.00 -$ 85,000.00; peritoneal dialysis, approximately $ 40,000.0-$ 45,000.00. Kidney transplantation has an initial cost of $135,000 - $ 185,000.00, with subsequent annual costs after a successful procedure, of around $ 20,000.00- $25,000.00. Kidney transplantation affords the best option for renal replacement therapy, by having the highest potential for quality of life and rehabilitation.

Current one year figures for organ (kidney) survival and patient survival are approximately 85-95% and 95-98%, respectively. Kidneys from deceased donors have a lower success rate than those from living donors. It has been established over the last 30-40 years that live- donation from a well- screened kidney donor is a safe procedure with multiple studies showing that the long-term medical consequences for such donors are no less than those for age-matched healthy controls.

Among African-Americans, living donor kidneys have the best survival compared to figures for Caucasians who have excellent results with deceased-donor and living donor kidneys. Unfortunately living and deceased organ donation is very low among peoples of African-based ethnicity, as compared to other ethnic groups.

Among the major challenges of kidney transplantation, is the ever-increasing gap between the increasing numbers of patients with end-stage renal disease (ESRD) on dialysis who access kidney transplant wait-listing and the lack of donor Kidneys for transplantation, has been one of the most driving. It has created an ever expanding
shortage of available organs for transplantation.

This has led to the utilization of kidneys from sources that were previously considered less than acceptable, such as kidneys from older donors, and a category that has now been classified as Expanded Criteria Donors. Advances in immunology and better medications that help to reduce the risks of rejection have paved the way for the acceptance of living donors who are not closely immunologically related as the outcomes are now as good as those of living-related donors who are closely immunologically matched.

Over the last decade, live donation of kidneys have risen from less than 10-15% of high-volume transplant centres, to well over 40-46% of donor kidneys currently. Many first-world nations have legislation in place allowing individual citizens to indicate their wish for organ donation should circumstances befall them that would make them eligible, by the acceptance of organ donation cards; some countries such as the United Kingdom and Canada have provision for organ donation with the issuance of drivers licenses.

3. Government and Health

Authorities Active and Positive

Involvement in Provision of

Renal Replacement Treatment

The information noted above, makes it clear that kidney failure is a catastrophic illness, justified by the costs and the morbidity and mortality figures. The projected numbers of new patients developing end stage kidney disease (ESRD), annually in the Bahamas, given the latest population data, are of the order of some 200-250 per year. Considering that approximately 60-70% of these patients will be considered eligible for chronic renal replacement treatments, based on considerations of co-morbid, associated medical disease, and other considerations, the projected real costs would be of the order of $15,000,000.00 per year, just for dialysis treatments alone.

Currently, the Public Health Authority collects less than $50,000.00 per year in total for treatments rendered to some 320 plus patients in the Princess Margaret Hospital, Grand-Bahama, and more recently, Abaco, and the private sector providers, for which it has responsibility for care.
Some innovative source of funding for this level of care requires consideration by the government, given the increased expectations of the population related to health care.

The engagement of the private sector in partnership with the public sector related to the establishment of facilities for the provision of dialysis and transplantation is the most promising way forward. Health planners need to undertake advice from the relevant medical professionals, by way of the Medical Association of the Bahamas, or other experts, both locally and abroad with a view to establishing projected population
figures for which considerations will have to be made for the building of adequate facilities for the care of these patients, training of Nursing and other support personnel for undertaking care in this specialized field, and the provision of associated technical resources for efficient provision of dialysis facilities such as water-treatment, among other resources needed.

Finally, strategies and plans need to be undertaken for the expansion of kidney transplantation services in the Bahamas with a view to encouraging the population to engage in healthy life-styles and become more health- conscious; the education of citizens to reduce the risks of kidney disease and failure, and encourage living organ donation as the preferred method of providing kidney replacement treatment. Kidney transplantation has been undertaken locally in the past, both in the private and public sector, but now requires more committed institutional, health authority, and government support with a view to providing a level of care that the population have come to expect in the 21st century.

By Dr. Adrian Sawyer, MBBS, DM
Director and Chief Nephrologist
The Dialysis Centre Bahamas