Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 19  |  Issue : 2  |  Page : 98-103

Obstructive Nephropathy in a Kidney Care Hospital in Southwest Nigeria: The need for early screening and prevention


1 Department of Internal Medicine, Kidney Care Centre, University of Medical Sciences Ondo, Ondo, Nigeria
2 Department of Internal Medicine, University of Benin, Benin City, Edo State, Nigeria

Date of Web Publication15-Nov-2017

Correspondence Address:
Oluseyi A Adejumo
Kidney Care Centre, University of Medical Sciences, Ondo, Ondo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_15_17

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  Abstract 


Background: Most of the preventive efforts in Nephrology are focused on hypertension and diabetes mellitus. Obstructive Nephropathy (ON) which is a relatively common cause of CKD in Nigeria has not received adequate attention. This study reviewed the clinical profile of patients with ON at a Kidney hospital with the aim of identifying areas where preventive strategy should be targeted.
Materials and Methods: This was a 3 year retrospective study that reviewed records of patients managed for ON in a Kidney hospital in Southwest Nigeria.
Results: Thirty patients managed during the review period had ON with a prevalence of 7.0%. The mean age of the patients was 63.4 ± 12.08 years. Twenty-three (76.7%) were males and 7(23.3%) were females. The mean packed cell volume, creatinine and estimated glomerular filtration rate at presentation were 25.17 ± 7.84%, 920.41 ± 642.79 micromol/l and 14.27 ± 15.45mls/min/1.72 m2 respectively. Common aetiologies of ON were prostate cancer 13(43.3%), urolithiasis 6(20.0%), and cervical cancer 5(16.7%). Identified renal co-morbidities were hypertension 21(70.0%), diabetes mellitus 4(13.3%) and urinary tract infection in 11(36.7%). Anemia was present in 27(90.0%), hyperkalemia in 16(53.3%) and metabolic acidosis in 23(76.7%). Twenty-one (70.0%) had stage 5 CKD. A higher proportion of patients with malignancies had stage 4 and 5 CKD. Twenty-one (70.0%) had haemodialysis.
Conclusion: Majority of patients with ON presented late and required hemodialysis. The common causes of ON were prostate cancer, stones, and cervical cancers which are largely preventable or treatable. Screening for prostate and cervical cancer and human papilloma virus vaccination of at risk population is highly recommended.

Keywords: Chronic kidney disease, obstructive nephropathy, prevention, screening


How to cite this article:
Adejumo OA, Akinbodewa AA, Okaka EI, Alli OE, Abolarin OS. Obstructive Nephropathy in a Kidney Care Hospital in Southwest Nigeria: The need for early screening and prevention. J Med Trop 2017;19:98-103

How to cite this URL:
Adejumo OA, Akinbodewa AA, Okaka EI, Alli OE, Abolarin OS. Obstructive Nephropathy in a Kidney Care Hospital in Southwest Nigeria: The need for early screening and prevention. J Med Trop [serial online] 2017 [cited 2017 Dec 15];19:98-103. Available from: http://www.jmedtropics.org/text.asp?2017/19/2/98/218398




  Introduction Top


Chronic kidney disease (CKD) has become a major public health challenge because of its increasing incidence and prevalence globally, as well as associated morbidity and mortality. According to the 2010 Global Burden of Disease study, CKD ranked among the top 20 causes of death.[1] The global prevalence of CKD is estimated to be between 11 and 13%.[2] In Nigeria, the reported prevalence of CKD according to both hospital and community-based studies varied between 6 and 12%.[3],[4],[5],[6]

The burden of CKD is enormous especially in the developed countries because of late presentation, inaccessibility to continuous renal replacement therapy (RRT), insufficient funds and/or inadequate social security to meet these financial needs and high mortality.[7],[8] The financial impact of CKD especially relating to RRT and cardiovascular complications is quite high even in countries such as the United Kingdom.[9] Likewise, in other developed countries, 2–3% of their total health annual budget is expended on the care of patients with ESRD who account for only 0.02–0.03% of the total population.[10] There is fear even among the developed countries of being unable to meet the financial requirements to cater for patients on RRT in the near future if this evolving epidemic is not curbed.

Preventive nephrology is the key to reduce the burden of CKD especially in developing countries, where the budget allocated for the health sector is lean, and the cost of renal care is out of the reach of most patients. Most preventive efforts have been targeted at hypertension, diabetes mellitus and chronic glomerulonephritis, which are the leading causes of CKD. However, obstructive nephropathy, which ranks as the 4th or 5th leading cause of CKD in Nigeria, has not received adequate attention.

Previous studies showed that obstructive nephropathy is the cause of CKD in 4.4–11.0% of adult patients.[11],[12],[13],[14],[15],[16],[17] The most common cause of CKD among the paediatric Egyptian population is obstructive nephropathy with a prevalence of 21.7%.[18] Roth et al.[19] also reported that obstructive nephropathy accounts for 16.5% of all paediatric patients requiring renal transplantation. The burden of obstructive nephropathy has significantly reduced in North Africa, particularly in Egypt, because of the effective eradication and treatment of bladder schistosomiasis, which was identified to be largely responsible for its high prevalence.[20]

The common causes of obstructive nephropathy are benign prostatic hyperplasia (BPH), urolithiasis, prostatic cancer and cervical cancer. Obstructive uropathy as a cause of renal failure is preventable and potentially reversible if diagnosed early and followed by the timely institution of appropriate therapeutic intervention.

This study determined the profile of patients presenting with obstructive nephropathy at a kidney care hospital in Southwest Nigeria with the aim of identifying areas where preventive strategy should be targeted.


  Material and methods Top


This study was a descriptive retrospective study conducted at Kidney Care Centre, a tertiary health institution located in Ondo State, Southwest Nigeria that receives referrals from within and outside the state.

Adult patients with CKD because of obstructive nephropathy who presented to the centre over a 3-year period between May 2014 and April 2017 were recruited for the study. Out of 426 adult patients managed for CKD, 30 had obstructive nephropathy. Patients below the age of 18 years and those managed for acute kidney injury were excluded. The case records of the adult patients with obstructive nephropathy were retrieved, and the following information extracted: socio-demographic data, clinical characteristics at presentation, co-morbidities such as hypertension, diabetes mellitus and urinary tract infection, the mode of referral to the nephrologist, the cause of obstructive nephropathy, investigation results and treatment given. The cause of obstructive nephropathy was determined by the clinical features, as well as investigations including biopsy and histology reports.

Operational definitions

Obstructive nephropathy was defined on the basis of unilateral or bilateral uretero-pelvic dilatation confirmed on ultrasound by a radiologist and by the presence of impaired renal function.

The Modification of Diet in Renal Disease equation was used to estimate glomerular filtration rate (GFR). CKD staging was undertaken using estimated GFR as follows: stage 1 (GFR of ≥90 ml/min with evidence of kidney damage), stage 2 (GFR of 60–89 ml/min with evidence of kidney damage), stage 3 (GFR of 30–59 ml/min with or without evidence of kidney damage), stage 4 (GFR of 15–29 ml/min with or without evidence of kidney damage) and stage 5 (GFR <15 ml/min with or without evidence of kidney damage).[21] Anaemia was defined as haematocrit <36% in females and <39% in males.[22] Hyperkalemia was defined as serum potassium level greater than 5.0 mmol/L, and metabolic acidosis was defined as serum bicarbonate level <18.0 mmol/L.

Ethical Approval was obtained from the hospital’s ethical committee on research.

Data analysis

Data generated were analyzed using the Statistical Package for the Social Sciences version 17.0 software (IBM SPSS Inc., Chicago, IL, United States). Results were presented in tabular form. Discrete variables were presented as frequency and percentages. Continuous variables were presented as means and standard deviation. Chi-square was used to determine the association between categorical variables. P < 0.05 was considered as significant.


  Results Top


Thirty patients among the 426 patients managed for CKD during the review period had obstructive nephropathy and constituted the study population. Thus, the hospital prevalence of obstructive nephropathy was 7%. Among the 30 patients with obstructive nephropathy, 23 (76.7%) were males and 7 (23.3%) were females. The mean age of the study population was 63.40 ± 12.08 years. Fifteen (46.9%) patients were middle aged, and 16 (50.0%) were elderly [Table 1].
Table 1: Characteristics of the study population

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Renal co-morbidities identified in the study population were hypertension in 21 (70.0%) patients, diabetes mellitus in 4 (13.3%) patients and urinary tract infection in 11 (36.71%) patients. Twenty (66.7%) patients had blood transfusion, whereas 21 (70.0%) patients had haemodialysis [Table 1].

Anaemia was present in 27 (90.0%) patients, hyperkalemia in 16 (53.3%) patients and metabolic acidosis in 23 (76.7%) patients. Three (10.0%), 6 (20.0%) and 21 (70.0%) patients presented in CKD stages 3, 4 and 5, respectively [Table 1].

The mean number of haemodialysis (HD) sessions among those dialyzed was 7.2 (6.4), while the mean duration of hospital stay among those admitted was 15.9 ± 6.71 days. Only 8 (26.7%) of the patients presented because of self-referral, and others were referred from other health facilities [Table 1].

The cause of obstructive nephropathy was prostate cancer in 13 (43.3%) patients, urolithiasis in 6 (20.0%) patients, cervical cancer in 5 (16.7%) patients, BPH in 2 (6.7%) patients and pelvi-ureteral junction obstruction in 1 (3.3%) patient. The cause of obstructive nephropathy was unknown in 3 (10.0%) patients [Figure 1].
Figure 1: The aetiologies of obstructive nephropathy

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The mean systolic blood pressure and diastolic blood pressure of the patients were 146.33 ± 38.88 mmHg and 83.53 ± 22.82 mmHg, respectively. Their mean packed cell volume, serum urea, creatinine, sodium, potassium, bicarbonate and chloride levels were 25.17 ± 7.84%, 26.01 ± 15.51 mg/dl, 920.41 ± 642.79 μmol/L, 128.65 ± 10.57 mmol/L, 5.37 ± 1.45 mmol/L, 17.00 ± 7.29 mmol/L and 104.33 ± 10.32 mmol/L, respectively [Table 2].
Table 2: Laboratory parameters of the study population

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A higher proportion of patients with malignancies had stage 4 and 5 CKD [Table 3].
Table 3: Association between the cause of obstructive nephropathy and the stage of presentation

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  Discussion Top


The hospital prevalence of obstructive nephropathy among patients with CKD in this study was 7.0%. This was similar to a report by Arogundade et al., who reported a prevalence of 6.7% in a study conducted in Ile-Ife, southwest Nigeria.[13] The hospital prevalence was higher than the 4.4 and 5.6% reported by Amoaka et al. and Okaka and Unuigbe from studies conducted in Ghana and southern Nigeria, respectively.[11],[12] Safouh et al. and Roth et al. reported a higher prevalence of obstructive nephropathy: 16.5 and 21.7% among their respective CKD study population.[18],[19] However, only paediatric patients were included in their study unlike our study that involved only adults.

Majority of the affected patients were middle aged and elderly with a mean age of 63.4 ± 12.1 years. The mean age in this study was higher than the 50 ± 18 years reported by Halle et al.[23] The occurrence of obstructive nephropathy in Nigeria may increase as the life expectancy increases due to improvement in healthcare services and delivery, if preventive measures are not put in place. Males were predominantly affected, which agreed with previous studies.[23],[24],[25]

Common aetiologies of obstructive nephropathy in this study were prostate cancer, urolithiasis and cervical cancer, which agreed with the findings of Soyebi et al. and Banaga et al., who reported similar aetiologies for obstructive uropathy in their studies.[24],[25] These conditions are largely preventable or treatable if diagnosis is promptly made. Surprisingly, some of these patients were first diagnosed with cancer during the course of evaluation for renal disease, indicating a lack of awareness regarding the common symptoms of prostate and cervical cancers among our population. Ajape et al. reported poor awareness regarding prostate cancer among men in a study conducted among the Nigerian urban population.[26] Various studies have also shown poor awareness regarding cervical cancer screening methods and its low utilization among Nigerian women.[27],[28],[29] This underscores the need to continuously educate our at-risk population on early symptoms and screen them for BPH, as well as prostate and cervical cancers.

Vaccination of young females against human papilloma virus is an effective way of reducing the incidence of cervical cancer and attendant complications such as obstructive nephropathy; however, the high cost of the vaccine has severely limited its utilization among Nigerians despite its high acceptance.[27],[28] The government could improve the utilization of this vaccine by incorporating it into the national immunization scheme or subsidizing its cost to make it affordable and accessible.

This study showed that patients with malignancies were more likely to present in the late stage of CKD compared to other aetiologies such as urolithiasis. This may be because of the fact that severe pain is a common feature of renal stones; hence, patients with urolithiasis are likely to present earlier compared to those with malignancies.

Majority of our patients had anaemia at presentation, with about 67% requiring blood transfusion during the course of treatment. This may be because of the fact that most of them presented very late with advanced stage CKD and malignancies. About two-third of our patients were managed as in-patients with an average hospital stay of about 2 weeks. Hyperkalemia and metabolic acidosis were present in about 53 and 77% of the patients, respectively, which may be partly due to defective bicarbonate absorption in the proximal tubules and/or defect in hydrogen ATPase activity of the alpha intercalated cells that commonly occur during obstructive nephropathy.

Hypertension, diabetes mellitus and urinary tract infection were common co-morbidities present in these patients. These conditions could contribute to the loss of renal function in these patients; hence, blood pressure and glycaemic control must be carefully achieved in patients with hypertension and/or diabetes with obstructive uropathy to reduce their risk of developing CKD. Recurrent urinary tract infection, which is common in patients with obstructive nephropathy due to urine stasis, may also contribute to the deterioration in renal function. Therefore, patients with obstructive nephropathy should be regularly screened for urinary tract infection and adequately treated when indicated with appropriate antibiotics with consideration of renal safety. Majority of the patients presented late, with about 70% presenting at end-stage renal disease and requiring dialysis on immediate referral to a nephrologist. This is higher than the 41 and 23% reported by Halle et al. and Imam et al., respectively.[23],[30] The higher proportion of our patients requiring urgent dialysis compared to these latter studies may be related to the fact that we studied only patients with obstructive nephropathy unlike the other studies that also involved patients with obstructive uropathy without renal impairment.

The limitation of this study is that it was a single-centre study with a relatively small sample size; hence, the findings cannot be generalized.


  Conclusion Top


This study showed that the common causes of obstructive nephropathy in our patients were prostate cancer, stones and cervical cancers, which are largely preventable or treatable. In addition, majority of the patients with obstructive nephropathy presented late and required haemodialysis.


  Recommendation Top


At-risk groups should be provided health education regarding the early symptoms of prostate and cervical cancers and the importance of periodic screening. In addition, the renal function of patients with obstructive uropathy should be regularly assessed in urology clinics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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