The cost of treating kidney failure in Uganda

*Kathy* had had recurrent vaginal yeast infections and did not get proper treatment. A year ago, her feet started swelling and she experienced breathing difficulties. At the hospital and after examining her urine and blood, it was determined that her kidneys were failing, a condition the doctors attributed to the poorly managed urinary tract infection.

“Although one kidney was removed, the remaining one is also failing. I go to the hospital for dialysis three times a week at a cost of Shs350,000 per session. I need a kidney donor but the process of a transplant is also expensive and we cannot afford it,’’ she says.

What is kidney failure?

Kidney failure is when your kidneys do not have the ability to remove waste from your blood after digestion, filter extra water out of your blood and help control your blood pressure. It can also affect red blood cell production and vitamin D metabolism needed for bone health.

According to Dr Dennis Kiguli, a renal specialist at Case Hospital in Kampala, acute kidney failure is when your kidneys suddenly stop working, when you do not have enough blood flow to the kidneys, are dehydrated and have direct damage to the kidneys or urine backed up in the kidneys.

This can last between a week and 90 days beyond which it becomes chronic and although the damage is slow and gradual, it can be detrimental.

Causes

The causes of kidney failure are characterised into pre, intra and post renal causes. Age is a common cause of kidney failure among the elderly because as we grow older, our nephrons (filtering units) keep wearing out and kidney function reduces over time.

Poorly managed malaria, especially in children can cause anaemia and damage to their kidneys in the long run. This is common and about 20 percent of the cases in children are due to malaria.

“When you eat too much red meat, you put a lot of strain on your kidneys, wearing them out. Dehydration also affects the kidneys and it can be aggravated by destructive medication,” Dr Kiguli says.

Other causes include uncontrolled blood pressure and diabetes, heart diseases which interferes with the perfusion rate (rate of blood circulation through organs and tissues), genetics, alcohol and smoking.

Intra renal causes include kidney stones, polycystic kidney disease, auto immune problems and sepsis. Post renal causes can include urinary tract infections that are not well managed and spread to the kidneys.

Holding urine can cause a backflow of urine and over time, this can damage the kidneys. Tumours, prostate enlargement, urethral strictures and other blockages can increase the risk of kidney failure.

Dr Kiguli says, “Your medical history is important in the diagnosis of kidney failure. Thereafter, urine and blood tests are helpful in determining how much waste your urine or blood has. Also, imaging tests, such as an ultrasound, would let the doctor see your kidneys clearly.”

Measurement

Kidney failure is a dysfunction of the kidney when it functions less than normal.  This dysfunction has types and stages. To determine how much your kidneys function, a renal function test is done from a urine or blood sample.

According to Dr Kiguli, the estimated glomerular filtration rate (eGFR) of 60 or higher (up to 120 per cent) is in the normal range but one below 60 may mean kidney disease. A GFR of 15 or lower means kidney failure. He says, “Majority of the patients in Uganda come to hospital when their kidney function is at 40 per cent and are not able to excrete toxins from the body.”

Signs and symptoms

In the early stages of kidney failure, there are no signs but as the condition advances, one may experience fatigue, trouble thinking, nausea and vomiting, loss of appetite, a metallic taste in the mouth, urine in blood, sleep issues and swelling in the feet and ankles, among others.

Treatment options

Upon diagnosis, Dr Kiguli says a patient is put on clinical observation, monitored and given medication. They are also put on a restricted diet and observed for any improvements.

National Kidney Foundation guidelines recommend you start dialysis when your kidney function drops to 15 percent or less or if you have severe symptoms such as shortness of breath, fatigue, muscle cramps, nausea or vomiting.

“If you suffer from acute kidney failure, it may be a temporary problem and dialysis can be stopped when your kidneys recover. However, people with chronic kidney failure have to be on dialysis for the rest of their lives and often need a kidney transplant,” Dr Kiguli says.

Dialysis, also known as renal replacement therapy, is the process of removing excess water, solutes, and toxins from the blood in patients whose kidneys can no longer perform these functions naturally. There are two types:

Haemodialysis

This is the most common type of dialysis and during the procedure, a tube is attached to a needle in your arm. Blood passes through the tube and into an external machine that filters it, before it is passed back into the arm through another tube.

Haemodialysis is more effective and requires you to have three treatment sessions per week but you may need to visit hospital each time. It can also cause itchy skin and muscle cramps.

Peritoneal dialysis

Peritoneal dialysis uses the inside lining of your abdomen (the peritoneum) as the filter, rather than a machine. The peritoneum is a useful filtering membrane which contains thousands of tiny blood vessels.

To initiate the process, an incision is made near the belly button of a patient and a thin catheter is inserted through the incision to the space inside your abdomen (the peritoneal cavity) and left there permanently.

Dialysis fluid is then pumped into the peritoneal cavity through the catheter. As blood passes through the blood vessels lining the peritoneal cavity, waste products and excess fluid are drawn out of the blood and into the fluid.

The used fluid is thereafter drained into a bag about five hours later and replaced with fresh fluid and the process needs to be repeated around four times a day.

“Peritoneal dialysis can be done quite easily at home and can sometimes be done while you sleep. However, it needs to be done every day and also puts one at risk of developing peritonitis, an infection of the thin membrane that surrounds your abdomen,” he says.

Kidney disease in Uganda is increasing and is among the top 10 causes of death, with a case fatality rate of 21 percent among admitted patients. Many patients with kidney failure in Uganda present late for care (51 percent present for the first time with ESKD) and with advanced symptoms.

This is because kidney failure does not show any symptoms until it is too late. This is why Dr Kiguli recommends that people go for frequent kidney function tests.

Access to dialysis services

According to research by Dr Robert Kalyesubula, a kidney specialist, Uganda follows the international eligibility criteria for initiating dialysis but the greatest determinant of who gets dialysis and who does not is financial status. Whereas government or public centres fill to capacity at times, private centres often have empty dialysis chairs or beds because of their relatively high costs. A session costs Shs400,000 in a private hospital and most of the costs for the care are out of the patient’s pocket.

 Those that are not able to afford haemodialysis are offered palliative care at hospitals and dialysis units, whereas others are referred to be monitored by peripheral hospitals. Most patients with Acute Kidney Infections (often children or pregnant women) recover, but the few that progress to acute kidney disease (lasting seven to 90 days) or CKD (less than 90 days) resort to palliative care.

Dr Kalyesubula remarks that the nephrology workforce in Uganda is too small for the need. The nephrologist to population ratio is 0.3 nephrologists per million people (pmp), compared with the global median of 9.1 nephrologists pmp.

The nurse to dialysis-patient ratio in the centres is estimated to be 1:13 in public hospitals and 1:4 in private centres. All dialysis patients are reviewed once every month by a nephrologist as standard practice.

To access dialysis, many patients have to relocate to cities such as Kampala, which further incurs higher costs of rent, changing livelihoods, loss of jobs, or a lack of support. Even then, only an estimated 15 percent of people who need dialysis in Uganda can afford it.

The future?

By the end of 2022, Uganda had 94 dialysis chairs and 14 nephrologists, which is a great improvement compared to 2012 when the country had only two dialysis chairs and two nephrologists.

Despite these improvements, access to dialysis and kidney transplants remain out of reach for most of the population, due to high costs and a lack of health insurance schemes to support patients with Chronic Kidney Disease.

Without universal health insurance, the limited numbers of dialysis nurses, nephrologists, and centres for dialysis mean the future of kidney care in Uganda is uncertain.