CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Chronic Kidney Disease (CKD) is an abnormality in kidney structure or function assessed using a matrix of variables including glomerular filtration rate (GFR), thresholds of albuminuria and duration of injury [Abdoli et al., 2021]. The global prevalence of CKD in 2015 was estimated at 13.4%, with a prevalence as high as 36.1% amongst high-risk populations [Ahmadi et al., 2016]. Chronic kidney disease poses a serious threat to global health due to its high morbidity and mortality rate [Alhomayani et al., 2021].

According to the 2015 Global Burden of Disease Study, CKD was the 12th common cause of mortality, accounting for about 1.1 million deaths worldwide [Allahmoradi et al., 2022]. Mortality due to CKD increased by 31.7% over the past decade to represent one of the rapidly rising causes of death worldwide [Allahmoradi et al., 2022]. Chronic kidney disease is the 17th leading cause of global disability-adjusted life years (DALYs) lost to disease [Allahmoradi et al., 2022].

Chronic kidney disease disproportionately affects low-income and middle-income countries (LMICs) with a prevalence that is 15% (oiled diabetes mellitus and hypertension, infection, and herbal and environmental toxins play an essential role in the epidemiology of CKD in these settings [Anees et al., 2018]. Chronic kidney disease is both a cause and consequence of non-communicable diseases (NCDs) [Asadizake et al., 2022, Brockman et al., 2017]. The burden of CKD in LMICs is worsened by limited accessibility to and affordability of renal replacement therapy (RRT) [Davis et al., 2012]. The number of people requiring RRT worldwide is projected to increase from 3.3 million to 5.4 million people by 2030 with most of this increase in developing countries (Delshad et al., 2019)

High-risk groups for CKD include persons living with hypertension, diabetes mellitus, overweight, obesity [Remor et al., 2013, Gratz et al., 2011] and human immune deficiency virus (HIV) [Shields et al., 2016] as well as the elderly. A meta-analysis conducted in 2018 estimated the pooled prevalence of CKD stages 1–5 and 3–5 in the general African population at 15.8 and 4.6%, respectively [Shields 2018]. Among high-risk populations, the prevalence of CKD stage 1–5 and 3–5 were 32.3 and 13.3%, respectively [Shields et al., 2018].

Moreover, the prevalence of CKD was about four times higher in Sub-Sahara Africa compared to North Africa. A large-scale population-based study of about 8000 participants aged 40–60 years from six communities in sub-Saharan Africa revealed an age-standardized prevalence of CKD of 2.4% [Mooppil et al., 2013]. By 2030, it is estimated that over 70% of people with end-stage kidney disease will be living in developing countries like countries in sub-Saharan Africa [Hadian et al 2016] due to the rising prevalence of diabetes mellitus, hypertension, obesity, and HIV in these sub-Saharan countries (Haghigats et al., 2020).

Adherence was defined as “the extent to which a person’s attitude matches with the agreed recommendations of a healthcare giver in terms of taking medications, following a recommended diet regimen and/or carrying out lifestyle changes” [Abdoli et al., 2021]. Adherence to medications is a major challenge in patients with chronic diseases since non-adherence to was usually associated with disease deterioration and increased hospital admissions [Ahmadi et al., 2020). End-Stage Renal Disease (ESRD) is a major public health problem that has been associated with a growing burden on healthcare systems and the economy worldwide [Ahmadzade et al., 2012].

Non-adherence to treatment is a common behavior among patients with ESRD, which has been associated with unfavorable consequences, such as hypertension (31%) [Golipoor et al 2016], diabetes mellitus (6%) [Eslami 2011], and obesity (15%) [Chari et al., 2021] are high with a prevalence of HIV of 4% [Kims et al., 2010], bone demineralization, pulmonary edema, metabolic disorders, and increased mortality [Alhomayani et al., 2021]. In Dialysis Outcomes and Practice Patterns Study (DOPPS), a large prospective observational study for the outcomes of hemodialysis practice, non-adherence to hemodialysis (HD), dietary and fluid restrictions, and medical treatment were significantly associated with increased hospital admissions and mortality [Allahmoradi et al., 2022].

Over 485,000 people in the United States have chronic kidney disease, a progressive kidney disease that may lead to hemodialysis. Hemodialysis involves a complex regimen of treatment, medication, fluid, and diet management. In 2005, over 312,000 patients were undergoing hemodialysis in the United States. Dialysis nonadherence rates range from 8.5% to 86%. Dialysis therapy treatment nonadherence, including treatment, medication, fluid, and diet nonadherence, significantly increases the risk of morbidity and mortality.

Chronic kidney disease (CKD) is a public health problem worldwide with approximately 13% of adults affected [Abdoli et al., 2021]. CKD progress in five stages and at end stage renal replacement therapy (RRT) through either dialysis or renal transplantation is necessary for survival [Ahmadi et al., 2022]. RRT is a high-costly treatment and hemodialysis (HD) is the most commonly used modality in the world [Ahmadzade et al., 2012].

Adequate HD improves the quality of life of patients and the success of the therapy needs the patient’s cooperation and depends on their adherence to medication, to diet, to dialysis sessions, and to fluid restrictions [Alhomayani et al., 2021, Allahmoradi et al., 2022]. Non-adherence (NA) to these regimens is a frequent phenomenon and reported prevalence varies depending on the continent and the parameter studied, and it is an important cause of morbidity, and mortality amongst patients on maintenance HD [Haghigats et al., 2020].

Excessive fluid intake leads to hypervolemia which can result in high blood pressure and pulmonary edema, increasing cardiovascular damage, and death [Brockman et al., 2017, Wilson et al., 2005, Golipoor et al., 2016]. Several socio demographics, psychological, and clinical factors are associated with NA to HD regimens [Eslami et al., 2011, Kims et al 2010]. The reported prevalence rates of NA to fluid restriction varied from 7.4% to 75.3% worldwide depending on the definition used [Anees et al., 2018, Davis et al., 2012, Remor et al., 2013, Wessel et al., 2022].

End Stage Renal Disease (ESRD) is a known increasing public health concern globally [Abdoli et al., 2021]. The irreversible advanced CKD leads to End Stage Renal Disease (ESRD) where there is permanent loss of kidney function causing extreme mortality rates among this population [Abdoli et al., 2021]. The increasing prevalence of ESRD is similar to the increasing prevalence of type 2 diabetes mellitus which further complicates into ESRD as the total number of people with diabetes is expected to grow from 336 million in 2012 to 522 million in 2030 [Tayebi et al., 2019].

The increase of ESRD patients necessitates management on dialysis for better outcomes, thus making adherence to prescribed treatment essential [Alhomayani et al., 2021]. Although kidney transplantation is the best choice of treatment of renal failure, resource constraints and shortage of kidney donations remain an issue [Allahmoradi et al., 2022]. Nevertheless, hemodialysis is also expensive but the preferred modality of treatment of ESRD patients in Rwanda [Anees et al., 2018].

In 2015, Rwanda Demographic Health Survey data showed a projected total population of 11,274,221 people with approximately 84 percent of them living in rural area. It is also evident that there is little or nothing known about the proportion of people living with ESRD or requiring RRT in Rwanda. From the national statistics, the majority of the people live in rural areas and yet the majority hemodialysis services for them are available in urban setting of Rwanda.

There are four (4) dialysis units in Rwanda for which three are in the city center of Kigali and one in the rural setting in the southern province. There are approximately twenty working machines in the three dialysis units in the city center of Kigali and six (6) in the southern province [Asadizake et al., 2022]. This makes it difficult for far away rural populations in other provinces to access hemodialysis services, forcing the majority of the patients with ESRD to go to urban dialysis centers.

The prevalence of CKD in adult Cameroonians varied between 11 and 14.2% [Remor et al., 2013, Wilson et al., 2019]. The prevalence of hypertension (31%) [Golipoor et al., 2016], diabetes mellitus (6%) [Eslami et al., 2011], and obesity (15%) [Chari et al., 2012] are high with a prevalence of HIV of 4% [Kim et al., 2010]. Dialysis was introduced in Cameroon in the early 1980s, and included both peritoneal and hemodialysis [Magnard et al., 2013]. However, hemodialysis has been the only available modality of RRT for over two decades now [Magnard et al., 2013]. When WORTH’s initiative began, 1 private and 2 public dialysis units (1 in Yaoundé) were operational.

The public centers have been highly subsidized by the government since 2002, with a cost per session less than $12 USD [Allahmoradi et al., 2022]. Between 2006 and 2007, Cameroon had 6 nephrologists, 3 of them in Yaoundé [ Sheikh et al., 2022] The center in Yaoundé had 6 dialysis machines in 2006 and 12 recently, and offered twice-weekly 4-hour dialysis sessions to approximately 54 patients per month. The death rate was 4/100 patient-months, a value that includes new patients referred late for dialysis. The WORTH sample of 8 patients is too small for inferences about effectiveness.

The drop in the urea reduction ratio, if accurate, in May 2007 likely reflects poor dialysis quality resulting from inadequate water supply. Unlike the authors’ claims that they recruited patients on a first-come, first-served basis, their 8 patients were selected from among those followed in the Yaoundé General Hospital dialysis center, a selection restricted to patients with a permanent arteriovenous fistula and stable on dialysis. These patients continue to receive care provided by the nephrologists at the Yaoundé General Hospital because the WORTH center has no physician available for ongoing care. There is also no reference to the outcome of other patients who received emergency care at the worth center

HD is the only modality of RRT available in Cameroon, Cameroonian health authorities say the country has about 2,500 patients with acute kidney infections, up from 400 in 2012. There where about seven towns in Cameroon with dialysis centers, with five dialysis machines at each. Yaoundé has two such centers — the largest with 20 dialysis machines. But health authorities acknowledge they are often not working as a result of overuse and poor power supply. 12 centers in 2015 and is partly subsidized since 2002 [Regan et al., 2013]. Despite the state subsidies, management of end-stage kidney disease (ESKD) in Cameroon is challenging.

Patients have no medical insurance and the out of pocket payment for medications, routine laboratory test, and hospitalizations are very high and not affordable for the majority [Milbagher et al., 2016]. Consequently, morbidity of these patients is high Kaze found that hypertensive crisis (14%), muscle cramps (22%) were frequent acute HD complications [Kaze et al., 2015]]. Heart failure was associated with high interdialytic weight gain (IDWG) [26] and hyperkalemia was frequent in HD patients before the second HD session [Nazart et al., 2014].

Also, mortality of patients on maintenance HD in Cameroon is high ranging from 26.6% to 57.58% with some of the principal causes being uremia and catheter-related sepsis [Omranifard et al., 2017, Ross et al., 2017]. Despite the importance of adherence to dialysis regimen, data are inexistent in our setting. Therefore, this study is aimed at finding out the hemodialysis therapy adherence and factors influencing supportive needs amongst end stage renal disease patients at the Buea Regional Hospital

 1.2: Problem statement

Nonadherence to hemodialysis remains a major obstacle in the management of End Stage Renal Disease (ESRD) population. Documented literature reveals that approximately 50% of individuals with ESRD undergoing hemodialysis (HD) were not adhering to their prescribed treatment regimen [Varghese et al., 2021]. This is also confirmed by Ibrahim and colleagues, who showed that nonadherence through skipping hemodialysis sessions ranged from 7 to 32% among ESRD patients [Garcia et al., 2015].

Similarly, a study conducted on Zimbabweans showed that more than 50% of patients were not adhering to the scheduled hemodialysis plan. In fact, 93% of the respondents had missed at least one session of HD with 61% missing most of the scheduled sessions. Only seven percent had attended to all the hemodialysis sessions as scheduled. Sixty-seven percent had rescheduled the prescribed hemodialysis sessions more than once [Tonelli et al., 2010].

According to Duong, nonadherence to treatment plan among patients with ESRD was problematic with approximately half of patients missing their sessions. Eleven percent (11 %) of the patients required extra treatment and 12 % had shortened their sessions[Duong et al., 2014].  Negative patient outcomes and increased health care expenses as well as workload of the hemodialysis unit are consequences of nonadherence behaviors in ESRD population [Yap et al., 2015].

Numerous studies have also revealed that nonadherence is the cause of mortality, frequent hospitals visits, and hospital admissions [Yap et al., 2015, Komenda et al., 2019]. According to [Abo et al., 2010] missed and shortened dialysis treatment time resulted in physical problems such as hypotension, cramps, fatigue, and clots in access site. Therefore, this study is aimed at finding out the hemodialysis therapy adherence and factors influencing supportive needs amongst end stage renal disease patients at the Buea Regional Hospital

1.3: Research questions

1. What is the level of adherence towards hemodialysis therapy among patients with end stage renal disease at the Buea Regional Hospital?
2. What are the supportive needs for patients with end-stage renal disease at the Buea Regional Hospital?
3. What are the factors influencing the supportive needs amongst end-stage renal disease patients at the Buea Regional Hospital?

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