Clinical and demographic characteristics of chronic kidney disease patients in a tertiary facility in Ghana

Introduction Chronic kidney disease (CKD) has emerged as a public health challenge in countries around the world. The cost of management of CKD is enormous and unaffordable to most patients in the developing world. There is a dearth of data on characteristics of Ghanaian CKD patients at presentation. Methods This was a prospective cross sectional study of CKD patients during their first visit to the renal clinic of a tertiary hospital adult renal service. Following informed consent, a questionnaire was used to gather demographic, anthropometric and clinical details of patients. Laboratory data of patients were also collected and analysed. Results The majority (64.5%) of 203 participants were male. Most were less than 60 years old and about one third were unemployed. Across all age groups stage 5 disease was the commonest presentation; however only 4.3% could afford to initiate haemodialysis. The mean number of dialysis sessions was 12.4 (range 6-18). Chronic glomerulonephritis (33%), hypertension (21.2%) and diabetes mellitus (22.2%) were found to be the leading causes of CKD. Common complications of CKD at presentation included anaemia (86.7%), pulmonary oedema (31%), high blood pressure (55%), and infection. Conclusion Early detection of CKD and institution of measures to slow disease progression are to be encouraged. There is the need to make renal replacement therapy increasingly accessible and affordable to patients.


Introduction
The kidneys play a central role in fluid, electrolyte and acid base homeostasis in humans. In chronic kidney disease (CKD), irreversible damage results in an inability of the kidneys to perform its vital homeostatic, excretory and synthetic functions. CKD is the presence of kidney damage, manifested by abnormal albumin excretion or decreased kidney function that lasts longer than three months as quantified by measured or estimated glomerular filtration rate (eGFR) [1]. Progressive renal disease usually leads to the common end point -end stage kidney disease (ESKD) -of a shrunken, fibrotic kidney. The cost for renal replacement services for ESKD is enormous. In the UK and Italy, the 0.02% -0.06% ESKD population account for an estimated 0.7%-1.8% of the health service budget [1]. In the United States, the expenditure on ESKD was estimated as US $28 billion in 2010 [2]. CKD affects between 5-15% of the adult population in the developed world [3][4][5]. In Africa, CKD is estimated to affect about 10.4% of some populations [6,7] making it a significant public health issue. It has been found to account for 8-10% and 5% of medical admissions in Nigeria [8,9] and Ghana [10] respectively. The risk factors for CKD abound in the sub -Saharan African population. Osafo [11] and colleagues found a prevalence of 46.9% among hypertensives in a Ghanaian outpatient setting, similar to the findings from an earlier review of autopsy data [12]. In Burkina Faso [13], 44% of hospitalised hypertensives had chronic renal failure. Chronic glomerulonephritis remains an important cause of CKD in tropical Africa [9,[14][15][16]. Diabetes mellitus and HIV infection are other important contributors to CKD burden [9,15]. The National Institutes of Health [17] have recommended that patients with chronic progressive renal insufficiency be referred to a multidisciplinary pre-dialysis team in order to minimize patient morbidity and ensure a smooth transition to dialysis therapy. The pre-dialysis clinic is staffed by a multidisciplinary team, including nephrologists, pre-dialysis nurses, dieticians, and social workers. Components of the pre-dialysis programme include: efforts to delay CKD progression through control of hypertension and hyperglycaemia; patient education regarding CKD, dialysis modalities, and dietary interventions; correction of metabolic abnormalities; insertion of permanent dialysis access; and timely outpatient dialysis initiation [17]. Timely referral to a pre-dialysis programme has been associated with a decreased risk of adverse patient outcomes at the time of initiation of dialysis [18,19]. Patients referred to a multidisciplinary predialysis teams are better nourished, demonstrate better metabolic profiles, are less likely to require central venous catheter insertion, and require fewer urgent dialysis starts and hospital admission days at the time of dialysis initiation compared to patients who receive standard care [17,19]. Patients presenting at the later stages of CKD are more likely to have complications requiring emergency interventions and admission. CKD patients in developing countries tend to present with severe disease and with complications. This puts enormous burden on the health system and the few skilled staff working in it. Although CKD remains an important cause of morbidity and mortality in our hospital, there is limited data on patient characteristics and associated factors at initial assessment by the nephrology team. We set out to determine the pattern and clinical presentation of CKD at the Komfo Anokye Teaching Hospital (KATH) over a one-year period.

Methods
This prospective cross sectional study was carried out over Definition of terms: CKD was defined as the presence of kidney damage, manifested by abnormal albumin excretion or decreased kidney function, quantified by measured or estimated glomerular filtration rate (GFR) that persists for more than three months. In the absence of previous data on eGFR or markers of kidney damage, chronicity was inferred from clinical presumption of kidney disease for >3 months. Proteinuria was defined as normal (urine dipstick negative), mild (urine dipstick reading trace or 1+), or heavy (urine dipstick reading greater than or equal to 2+). Hypertension was defined as the presence of a persistently elevated systolic blood pressure ≥ 140mmHg and/or diastolic blood pressure ≥ 90mmHg in patients aged 15 years and above, and/or the use of antihypertensive drugs and/or past medical history of hypertension.
Diabetes mellitus (DM) was defined as a random blood glucose level of 11.1mmol/L or greater, and/or fasting blood glucose level of 7.0mmol/L or greater, and/or use of insulin or an oral hypoglycaemic agent. Anaemia was defined as haemoglobin (Hb) level < 11 g/dL. Primary cause of renal disease: The determination of the primary cause of renal disease was based on history, physical examination, and laboratory investigations such as ultrasonography,

Results
A total of 203 participants were recruited for the study. The basic demographic characteristics of the participants are represented in Table 1. Males were in the majority (64.5%) and most patients

Discussion
There was a preponderance of males in this cohort (64.5% vs 35.5%) and this is comparable to similar studies done in Spain [20] and United States of America [21], which also reported a male predominance might be a reflection of the fact that CKD and its risk factors such as hypertension and smoking are commoner in males than females. Differences in the health seeking behaviours of males and females might also play a role in the observed differences in CKD prevalence in the two sexes. The mean age of patients was 43.9 ± 17.8 years, with a peak age between 40 -49 years. 82.3% were age less than 60 years, the economically active age group.
This is similar to the findings from Nigeria [9,22] and other developing countries [15,23] but contrasts with that seen in developed countries [24,25] as depicted in Table 4.  [27]. Diabetic nephropathy occurs at a younger age and is more aggressive in blacks than Caucasian populations [28]. The prevalence of HIV associated nephropathy is also high in the developing world [29]. The primary renal diagnosis could not be ascertained in 12.3% of cases. For those whom the primary kidney disease was known, chronic glomerulonephritis was the most probable cause (33.0%) followed by diabetes mellitus (22.2%) and hypertension (21.2%). Several studies in Ghana [11,12,15] and Nigeria [9] have identified chronic glomerulonephritis and hypertension as the commonest causes of CKD. The same is true in other developing countries [23]. In the developed world, diabetes mellitus is the most common cause of CKD [25].
As pertains in other developing countries [22], the majority (85.8%) of the patients in this study presented with advanced CKD (stages 4 and 5) unlike the situation in the developed countries. This late presentation might be partly due to the low detection and treatment/control rates of CKD risk factors like hypertension and diabetes mellitus [12,30]. (range 6-18). In a previous report from our centre [15], 50% of 40 patients initiated on HD were able to afford 20 sessions before stopping. In Ibadan, Nigeria, 70% of patients were not able to afford more than 3 sessions of maintenance haemodialysis [31].
The fact that renal replacement therapy is not affordable to most patients requiring such service makes it expedient to institute interventions to prevent the development of ESKD in at risk populations. There is an urgent need to make renal replacement therapy increasing available and affordable to CKD patients to reduce the impact of the disease on society. Public and private Page number not for citation purposes 5 sector partnerships may be needed to address the challenge, as the cost involved is enormous for individual patients and their families.
Complications of chronic kidney disease were common in this study.
Anaemia was present in 86.7% of patients. The majority (58.6%) had microcytic hypochromic anaemia. The high prevalence of anaemia is consistent with findings from other African studies [32,33]