The Management of chronic kidney diseases can be done at 3 levels o f care: (i) Prin1:iry healthcare level -mainly targeted at the prevention of the development of relial disease in those at risk anti could be a community approach or at s r l e c l ~ ~ d clinic populations: iind the proniotion cf renal health through apr~ro[~ri;~chealth education on the right attitudes, behavior and practices that rnay pmrnote renal healthi'. These include healthy livins i.e. avoidance of smoking and excessive alcohol, regular exercise, vptimal body weigh^, halnnccd diet -(with moderate salt, low saturated fats. rich in h i t s md vegetables): avoidance of self medicarions, and indiscriminate use of analgesics ant1 herbal medications and skin lightenin, u cam\.
-
..restricted e x p o s ~ ~ r e to environmental pollutants like heavy r n e ~ . ~ l s ant1 hydrocarbons; and improved health seeking attitude. [ndividuals with specific conditions such as Hypertension, Diabetes Mellitus, fandy hisloiy of renal disease, recurrent urinary tract infection and obstruction and other risk factors should be screened regularly. Treatment should include use 01' renoprotective d l u ~ s particularly in pat ierlts with hypertension. DM and glomerulonephirit ides.
Secondary Prevention and Control of CKD:
The goals are ( i ) early detection of renal disease. (ii) halti11~ of it\
progression. (iii) mitigation of the effects a~id ~orn1.1lii:diiunx.
Tratmnent of the ~~rxlerlying causeofthe re11:d diqease il'k~iown is pxtic~dirrl!
rewarding, as it \\.ill re1;1rd the progression of t l(!,,, ~ .:..I. pal~i~iilarl!~ i f cases of hypertension ant1 Diabetes. Tru-get Illood !)ic.\.\i.i[.l: levels in p;uienis with CKD shoirld bc less than 130180 turn)-lg in thr: absence of tliithctck or proteilli 1 1 i : ~ and < 125175 mmHg in patients with DM and those u.ith proteinuria in excess o f I g124h.
'Targel blood su_e;a. levelx chould be 6.5 -7%. glycosylated haemoglobin.
Control of albiunInur-iadproteinuria is also a proven strategy for delaying die progression of xnal disease. thus antihypertensive drugs- ACE inbibiton and Angiotensin receptor blockers that reduce proteinuria, are widel!' advocated". They may also have additional renoprotective effect C~rough
:lney tlisea\e?; can be done at 3 levels inhibition of Rnal inflammation and fibrosis. Lipid lowering has been
1
mai~llv txgeted at the prevention of %%ested to m-neliorate CKD thus favouring the use of statins in addition in th0.c at risk and could he a commu1liQ to antiproteilluric dnigs. In addition, diet and life style modifications-
,,,,pnla,i~,llc: ;md the pronwlion cf renal such a weight reduction, regular exercise and dietary regiment of
,,
cdul,-a,io~~ (111 h e right attitudes, bt:havior restriction and diets rich in fruit and vegetables and ]ow in saturated fat should be adopted.r,t.Ilaj health". n e s e include healthy livirlg
~~,:c\i\;r alcohol, sezular exercise, optimal i.irh "1cttjer;ltt salt, low satura~ed fats, rich ilcs of \c\f 1nsdica[ic-,ns, and inciiscriminatc ,~edicarion.; and skin lightening creamy.
irnental pollutants like heavy rnet.3'1.. ;]nil
Control
In the glomemlonephritides, modulation of the immunopathogenic process can be effected with the use of anti-inflammatory and immunosuppressive drugs.
Dietary Management:
' ,\ \ i , i t k ~
health \cekil~g att i t d e . [ndividu?':' D i e t q manipulation is very effective ul early and moderately severe aqes enensioll, Diabetes Mcllitus, fiu'ngy hisl('l>' ( s e ~ u m matinine levels < 500ym01/1). It stahili7es renal f ~ l n c l i ~ ~ . In a
trac[ infection and c)bstruction alld otller collabo~tive study with nutritionists we constn~cted a dietary repime%
&L,larly, ~re:ltmellt should urlnde use of h s e d on the available local staples (Table 14) - providing prolein (20 -
rjv in palielus with hypertensioo. DM 30 E per day), of hizh biological value made up of fish, epg protein and or tray fish; and high calorie intake (3000 kcallday) derived from locally of CKI): available food items - cassava, yarn. corn e.1.c: and low sodium (60 mmo])
and potassium (40 - 60 mmol).
renal disease. (ii) halting of it.
:I< ; L I ) ~ c.i)m~?lii'diiOih.
i\t. u l r re11;tl dice2i.e ifknown i h piu~ic~d;u-l!
c p~oy-~\rii,r\ of tlilx ' ! - v ,:...; p n s \ i c ~ ~ l ; i ~ - l ~ il y t ~ s . T . x g ~ ~ I>Io(rJ !>ii.+tir.2 IL'VCI~ i11 ~ ; I I ~ c I : ~ . \
n 13018i) m n l 1 1 ~ in rllc abi;sncc of t l i i t h ~ t ~ .
nmHp in patients ivitll DM and tho\r u ill?
ih.
:111111 la ,,,nlso a proven strategy for delaying r. thus antihypertensive drugs -ACE inhibiton ockers rhar reduce proteinuria, are widel), iditional renoprotective effect through
14: Sample day's menu providing 25-30g protein, 3000kcal mEq (1380mg) Na+, 40-6OmEq (1560-2340 mg) K *
1
One (20k worth) salt free
akara ball (approx. 502)
1
4 3 6Lunch
Eba ( 2 % K~tchen spoon
scoop = approx. 4UOg 1.73 Okro ( 5 large. approx. 50g)
! s t e w (small onion/tomato/
I
Itwokitchen spoon scoop oil)l Neg
Seven patients ( 5 males, 2 females) with mild to moderately se\.ere CRF were followed up on this regimen for a pericd ranging from? to 28 months.
Protein intake was assessed by 2-day dietary recall. The rate of progressio!i of renal failure was significantly lower in the shid\;' ~ 1 s t . ~ than
40
One 50k worth piece o f meat or fish ( 3 0 g
Supper
Three heaped kitchen, spoons plain hc~iled rice (approx. 3 0 0 g )
Stew (small onion/tomato/
two kitchen loon N q . . .
One L O I ~ \\:(.r.rh pierc of
" ' I
I
I I I C ~ I I o r fist] t .;Og) 7.6
I
: 7.6
5 . 2
16.8 111.0 ,Y6S
a..i,o
I
15.0
--
1 > 5 . 0nEq ( 1560-2340 mg) li '
nalei) n:ith mild to moderately sewre CRF uing fro~n 9 to 28 111011th.
nen for a period ran>
:d by 2-day dietary recall. Tllr rate of
a.; s,ignificantly lower in the s t ~ ~ d y elsex than 40
the controls. T!iel-e was i ~ ~ ~ p r o v e m c ~ ~ t of'clinical symptoms c )f uraemia.
and stability and imp~.o.i,crnentj~frc.t~al j.kiction [7';lllle 1.5: Figure .I 81 CVe hrt-her intl.od~lceif n-E;c.to-aria?c~~!rcs ufhmina acid5 availaMe, in fonn of - Ketostcl-il tahlets - to supplement the low protein intake in a few
!~;ltients [ h a ( cot~ld afhrd 11-IC therapy. We observed a si:<nificanr improvement in qii;~li~y of
life
and rcxpite from uraernic symprorns. In Nigeria high quality protein is very expensive and ketoanalogue~ are o~~rngeously so. Co~npliance to the dietary therapy is f ~ ~ r t h e r wor$ened by the fnonotonoics md unpalatable nature of the regimen. Cuihue, atstc?ln.i;and tradi~ion XI: also strong hall-iers to dietary therapy. There is a need to examine all these constraints while packaging an acceptable food [able from our local staples, for the treatment of CRF.
Figure 18: Relationship of the reciprocal of serum creatinine concentration plotted against time in the study group (a) and control group (b). (a) n=7, slope =-0.00092; duration of observation = 18- 28 months. (b) n=S, slope =-0.0056: duration of observation = 9-18 months.
Tertiary Management:
' Vlc goals are to mitigate the effects and complications of renal failiue ant replace renal function by dialysis or renal transplantation:
Haemodialysis
Dialysis intervention as a maintenance therapy in ESRF(creatinine .
.
.5m min) has been successful and its practice continues to improve wit development of biocompatible. high flux dialysis membranes, high precision, high-tech, computerized dialysis machines and effective control of anaemia with erythropoietin and effective control of renal osteodystrophy and improved patient education. The costs of these manazement strategiesthe reciprocal of serum creatinine lime in the study group (a) and control
D0092: duration of observation = 18- ,0056; duration of observation = 9-18
11 complica~iotls of renal failure and
1 4 5 or renal transplantation:
Ilenance therapy in ESRF (creaiinine
. .
.5mV l d it\ practice continue\ to improve with .high flux dialysis membranes. high precision\I, machines and effective control of anaemia :ctivr control of renal osteodystrophy and
, 'ihe costs of these manaeement strategies
rue enormous and even in thc ifcvelopeil economy with good irlfrastn~ch~re.
are a cause for concern. hfainte~ittnce hilernodialysis is largely not feasible, in Nigeria due to
lIigh cost of machine maintenance services.
Lack of trained per~onnel and
The high prevalence of heapatitis B and indeed The cmerging scourge of IIIV,
11-~ccssant work disruption occasioned by industrial disputes ,ind Poorly cle\?eloped infi-astmchue,
- iinsteady supply of treated water and electricity;
- poor road and communication network.
We have observed that high cost of dialysis and distance of patients' homes to centre are major constraints to effective dialysis as the dialysis facilities are available only in ma-jor city centres. At a cost of between US$70 -
I00 per HD session and USS I500 3000 per month (against per capital income of US$400) for the dialysis service and laboratory investigations and dn~gs, only a tiny fraction of our patients can afford this treatment. In our survey of renal centres. we found that majority of the paii~nts - proportions varying from 38 - 90%: could afford only one HD scssion, n:tiile between 30-40% ccoirld al'lhrd 2 sessions and percentages vaiying born O - 90% could not afford even one HD s e s ~ i o n ' . ~ ' .
To promote maintenance dialysis as a management option, there will be need for government subsidy 3116 local sourcing of dialysis hardwase and consumables. This needs a bold initiative from our government. Majority of Nigelias live in the n~ral .area with poorly developed infrastruchlre and n:here they have access to oniy p~imary and seconday health care facilities.
Maintenance dialysis therapy in the form of continuous ambulatory peritoneal dialysis (CAPE) should overcome most of the constraints associated with maintenance HD. It is practicable in the rural communities.
Continuous Ambulatory Peritoneal Dialysis
-
Practicability and ProspecL3:Experience with CAPD is very limited in Nigeria inspite of its practicability, prospects and suitability particularly in a resource poor and low technology environment as ours. Our published experience stands out as providing the guiding lights into this modality of renal replacement in this country. We studied 8 patients who were offered CAPD for periods ranging from 2 weeks to 9 months with a total of 39 patient-months showed the feasibility and practicability and the benefits of this treatmenP2. There was a good blood pressure control, while the requirement for blood transfusion was minimized. 4 of the patients returned to work as quality of life and good rehabilitation were achieved. Complications encountered included, peritonitis occ~~n-ing in 87.5% with 14 episodes during a total of 39 months of treatment. Staphylococci epidennidis, Pser~domonas and unspecified c.nlifontt organisms were isolated from culture. Other complications were sepsis syndrome in 2, hypoalbuminaemia in 3, pain on running in fluid 2, rupture of line I , bloody effluent 2, hyperlipidaemia in 2, pleural effilsion 1, hyperglycaemia and pancreatitis in1 .CAPD seems an attractive option of management in the rural communities. Availability of fluids and software and consumahles could be inproved with local sourcing of these.
Peritonitis - a major constraint should be tackled with improved technique, patient selection. adequate patient tfaining and adequate /optimal dose of dialysis (through assessment using relevant methods - kinetic modeling protein catabolic rate e.t.c. Only physician!; with training and experience in this technique should supervise CAPD programmes. Institution of a national CAPD programme provides an opportunity for the rural communities to benefit from one form of renal replacement therapy which is not available to that large proportion of Nigerians. Sadly our efforts through informaVinforma1 interactions with successive govenunents and indeed those whose slogan was "Better Life For Rural Women" have been unrewarding. There is a need for legislation on minimum health
standards for every Nigerian. nual or urban in the spirit of equity.
ANAEMIA and EPO treatment:
b a ~ D;atysis
-
Practicability and in Nigeria inspite of its practicability, a resource poor and low technology II
experience stands out as providing /renal replacemenl in this m~nby. We fl CAFD for periods ranging from 2 batient-months showed the feasibility~f this treatment6'. There was a good quirement for blood transfusion was fd to work as quality of life and good mplications encountered included, 4 episodes during a total of 39 months
?~itli.v. Pse~tdornonnv and unspecified I from culture. Other complications huminnemia in 3, pain on n~nning in luent 2. hyperlipidaemia in 2, pleural :reatitis in I .CAPD seems an attractive ommunities. Availability of fluids and
: inproved with local sourcing of these.
Id be tackled with improved technique, raining and adequate I optimal dose of relevant methods - kinetic modeling nysidank; \vith-training and experience : CAPD programmes. Institution of a
~vides an opportunity for the rural 11n1 of re11a1 replacement therapy which ortion of Niserians. Sadly our efforts tions with successive governments and
"Better L.ife For Rural Women" have ed for le~islarion on minimum health
11 or urban in the spirit of equity.
Anaemia is common in patients with chronic renal future and isassociated with significant ~norbidity and mortality. Severe anaemia (below 18%) was found in about 25% of the patients in our study6! Many factors have been incriminated in i:s etiology, namely bone marrow hypoplasia, inmtsed red cell desti-uction, increased tendency to bleed, while reduced erythropoietin production and uraemic.toxins have been considered fundamentally responsible. A significant inverse relationship was observed in many studies (including om6') [Figure 171 indicating that the severity of renal failure is an important factor in the level of the anaemia.
Figure 17: Relationship between serum creatinine concentration (umoVL) and haematocrit ( %).
We have noted in another study a prominent role of Iron in a significanl proportion of patients, who demonsuated reduced stainable bone manou Iron and low Transferin saturation and who responded dramatically to parenteral Ironh4. That finding is n:'practical importance in a resource constrauled environment a< oirs as ir would significantly reduce the use of Erythropoietin which is nor 'affordable by most of our patients. Our experience wilh Erythropoietin has been reported and it is in agreement with the observed beneficial effects of this therapy in pntients who are well dialysed and have good iron stants (Figure 1 9yS. Treatment with iron and recombinant erythropoietin (EPO) is generally very expensive everywhere and it is available at subsidized rates to make affordable. Generic EPO
ients.
should be made available at affordable cost to our p2t'
,ri,mincnl role of Iron in a significar-11
;rated reduced stainable bone marroL\
1 3 r d who responded dramatically to ,
?.'p-uctical importance in a resource
il would sigificmly rcduce the use 01-
~rdahle hv most of our patients. Our
1, hrc.n reported and it is in agreement , ot.t}lis therapy in patients who are well
; ( Firuse 1 9 r 5 . Treatment with iron and i\ gcl~u:lily very expcnsi\~e everywhere
lteq to rnake affordable. Generic EPO d:lble cost to our patients.
. .., C r= ."
CARDIOVASCULAR MORBIDITY
AND
MORTALITY:In recent times, excess cardiovascular morbidiijr/mortallty has been associated with CKD even in the early stages before patients develop end stage renal f2 ilure. CKD is regarded as a most potent cardiovascular risk factor by itself.
A number of cardiovascular events including congestive cardiac failure, cardiac arrythmias, cardiac ischaemiafinfarction, strokes and peripheral vascular diseases are seen in renal failure. The associated risk factors include Hypertension, LVH, Anaemia, dyslipidaemia, obesity, cigarette smoking, insulin resistance, CalciumNit. DParathromune disturbances, C-reactive protein and a number of others. The burden of the cardiovascular disease events in patients with CKD ICRF is ill-defined, thus efforts at preventing or controlling them will remain conjechlral.
At present, control of hypertension is with an antihypertensive regimen which includes ACE inhibitors and this is not effective in many cases;
control of lipidaemia is wually by dietary manipulation as statins are largely unaffordable by our patients. Dietary manipulation for the control of hyperphosphatelnia and the use of Calcium supplements are the mainstay of Ca & PO, disturbance, while Vit. D is generally not given due to its inaffordabilil y and lack of laboratory monitoring facilities. The treatment of anaemia with EPO & Iron supplements improves cardiovasc~~lar status in a small proportion of patients that can afford it. The control of calinvrtcc~11:u- hurdcn in C'KD should be by multidisciplinary, collaborative and coordinated efforts.
An ongoins e\,aluarion study of cardiovascular risk factors in our patients has identified Hypertension, LVH, Anaemia and Diabetes Nephropathy as the predominant risk factors. while those that are commonly found among cauca.;ians are not prominent(". Strategies at preventing proge.9sion of CKD must incorporate these risk factors in their design.
Itenal 'Ikansplantation:
rest Afric
ith ours 1
Renal transplantation (RTx) is globally adjudged the best modality of renal replacement therapy in view of its cost-effectiveness and eficiency and a near return to normal life by the patient and it should be preferred even in a resource - constrained economy as ours. It is however complex and elaborate in organization. This fonn of therapy was unavailable in Nigeria or M a subregion, imtil oiu hospit~~l and a private hospital pioneercti it, w being distinctly wholly indigenous. Surgical and medical management was entirely by our local staff. That fear justified the status of our hospital as a designated centre of excellence in renal medicine. Even though that development marked a nri-ior 'triumph' in rend care medicine in Nigeria, it nevertheless opened up new challenges and trials. The daunting challenges have been highlighted in oul-initial report of the first 3 cases6'. Maintenance /life-long irmniu~osuppressive therapy is the mainstay of transplantation, but no sooner we transplantecl t 1 1 3 1 1 0 1 ~ patients ran out of dnlgs, as fmancid support &om the enthusiaqtic philanthropists petered nut.. This leads to repeated episodes of acute rejection and suhsequenr loss of graft. In~rnimosuppresci\ ~o;lito~ing ;-~~cilj~iv.< vailablc and this continually tasked our( ~dse~l?c!:t. I)i.l;ar !ifit'> for
\cpsis - particularly viral are ~naaequate a% :Ire ;~c!tci~~ spccrnc a_ntivir:~l tlnr?,. centralized tissue typing facility and wel! :r:iine~l and co~nmirlt:cl serial ~nedical and surgical staff are requisctl. Adcq~rate inves~isati\:~:
1'acilitit.s (laboratory and radiology) and t~utritin~~:!i :HI(! coimseling unit art:.
;I priority. Perhaps the greatest rate limiting fact(-11- i. . ! \ rii!;lhiIit!~ofdon:~~
. <'rg:Ln.
ie dlug m clinical j~
.
.
Osgan procurement is a major constraint and is irilluenced by the attin~clt:.
beliaviour and practice of the people all which are intricately tied to thc a r l ! ~ ~ s e . customs and tradition of the peopli. We have in o ~ i c .
epidemiological study evalaated the attitude, behaviour and practice (-)I-
Nigerians to organ donation. We compared theso between hospital workers, relatives of potential transplant patients (patients with ESRF') and healthy rural dwellers. We were impressed by the positive attitude t o organ donation inspite of the widely held belief in reincamation. 'Ihi9 attih~tlc
- - - - - - - -
48
ily adjudged the hest modality of renal [,a-effectiveness and efficiency and a lent und it should be preferred even in
1
as ours It is however complex and of therapy was unavailable in NigeriaI .
i , q l i ; ~ l and a private. hospital pioneered
iy
indigenous. Surgical and medical1 ; ~
qtaff. That featjustified the status of id'mcellence io renal medicine. Even111,jor 'triumph' in renal care medicine , i up new chnllenpcs and trials. The i\li~lited in urir initial repott of the first 3
~t~~~osi~ppressive therapy is the mainstay
I
c. transplanted rhrtt~ our patients ran out the enthusiastic' philanthropists petered deS of acute rt3tlction and suhscquen~bug mo:li~uring $cilitio..; are not available lica] judnelT:cl:i. I)i:?.~palic f,~vililic\ fry-
Idequate 2.: ;ire ~wtcia specific u ~ l i v i r n l facility a~al we1 i :r:jinal and ctxnmil lcil
are sequirc~i. .Liequatc inveslipt i l k .
b) m J m,tritio~!:!i ;ax! counseling unit art:
11, limiliog i.ictt ,r i- .I niiahilil~r of don;,^
lottraint and 1, ir~ll~~enced by the attinid(.
:opls all u hich a ~ c ~lvncately tied to t 1 1 ~ o n of the psnplc We have In OJIL'
*d the artrtude, b c h ~ i lour and practice 01 We compared thew between hospital tran~plant patient. (patients with ESRF i
were impressed by the positive attitude to
e\y held belief in reincarnation ?hi$ attitu(-Ic
\\,as expressly llvt motiv~tred by any t-cward or monetary hi.nefitsh". This kind of stody is very cruci;il to the establishment oFRTx program in this count~y. RTx is also acceptable to a l a s e majority 1hol1gl.1 wme wc~uld not agree to transplant, rathel- prefening to die. That study also revealed that knowledge of renal disease and renal failure is generally inidequate among Nigerixls.
Conclusion
Our effort to tackle the problem of CRF should cornrnence with improving oirl;no~.i l c d p of renal health. Renal care should therefore be incorporated . into primary health care programme and it should include awareness
education, screening for hypertension, Diabetes mellitus and proteinuria.
Ed~lcation on risk factors such as unrestricted consumption of analgesic and herbal concoctions as well as exposure to environmental toxins; early detection of chronic renal disease and renal failure by paying attention to features such as nocturia, changes in the frequency of micturition, frothy urine, haematuria, dysuria and loin pains. Efforts at early detection of renal disease will be more rewarding when carried out in childhood.
CKD has assumed a priority public health issue. and it is devastating.
There is a need for a national policy to provide a coordinated renal care and set obligatory minimal standard of renal care to every Nigerian citilen, and to facilitate access to life saving/ life preserving procedure such as dialysis or transplantation for the rich or the poor, the city or n~ral dwellers, the Fanner. student, academic. senior government ~fficials, or politician, male or fernale and yoi[n,o or old. This is the task for all of us!
I 1. Akinsola W, Odesanrni WO, Ogunniyi JO, Ladipo GO: Diseases causing chronic renal failure in Nigerians- a prospective study of
100 cases..Afri. J. Med. & med Sc. 1989,18: 13 1-137.
2. Anonymous (2002). WDOQI Clinical Practice Guidelines for Chronic Kidney Disease, Evaluation, Classification and stratification. Kidney Disease Outcome Quality Initiative. Am J
~ i d n e y Dis. 39:s 1-246.
3. Akinsola '4, Adelekun T.A. Arogundade FA, Sanusi AA (2004) Magnitude of the problem of CRF in Nigerians -African Journal of Nephrology 8: 24-26.
4. Kadiri S, Arije A (1 999). Temporal variations and meteorological factors in fiospital admissions of chronic renal failure in south west Nigeria. West Afr J Med. 18: 49-5 1. Erratum in: West Afr J Med
1999; 1 8: 264.
5. Coresh J, Astor BC, GreeneT, et a1 (2003). Prevalence of Chronic Kidney Disease and decreased kidney function in adult US population. Third National Health and Nutrition Examination Survey. Am J Kidney Dis. 4 1 : 1 - 12.
. 6. Schena FP (2000). Epidemiology of end stage renal disease:
International comparisons. Kidney Int. 74: S39-S44.
7. Chadban SJ, Briganti EM, Ken PG, et a1 (2003), Prevalence of kidney damage in Australian adults: The AusDiab Kidney Study. J AmSocNehrol. 14: S131 -S138
8. Ramirez SPB, Hsu SI-H, McClellan W. (2003)Taking a public health approach to the prevention of end-stage renal disease.
Kidney Int. Suppl83: S61-65.
9. Bello AK, Nwankwo E, El Nahas AM (2005). Prevention of chronic kidney disease: a~&balcballenge_Kidney h&@. -
-pp-p---p -
98:Sll-7.
WO, 05pnniyi JO, Ladipo GO: Diseases ailure in Nigerians- a prospective study of d. & med Sc. 1989,18: 131-137.
D O Q I Clinical Practice Guidelines for , sease, Evaluation, Classification and Disease Outcome Quality Initiative. Am J :6.
I 1 .A. ~rogundade FA, Sanusi AA (2004) 4em of CRF in Nigerians -African Joumal
!6.
I ) . Temporal variationsand meteorological issions of chronic renal failure in south west
-
- 19-5 1. Erratum in: West Afr J Med
ICLUG I , et a1 (2003). Prevalence of Chronic decreased kidney function in adult US zional Health and Nutrition Examination
Dic.41:l-12.
,pidemiology of end stage renal disease:
,sons. Kidney Int. 74: S39-S44.
EM. Kerr P G et a1 (2003), Prevalence of ualian adults: Tne AusDiab Kidney Study. J 5131 -S138
I-H, McClellan W. (2003) Taking a public , , le prevention of end-stage renal disease.
: S61-65.
10. USKDS .4~11~1al data licyorl: Incidence and prevalenceof ESRD (2003) Am J kidney L)is. 42 (Suppl5) S37- 1?3.
I 1. Cornhi< li. Stzistny P. Shorey J, Bai~t:ni A. el al ( 1971 ). Antisen antihotl!. complexes in glomerular basement membrane. The Lance11 ii : 234.
12. Brzosko J, Krawozynski K, Kazarewicz T et a]. (1974).
Glomerulonephritis associated with hepatitis B surface antigen immune complexes in children. Lancet; ii : 477.
13. Lai KN. Lai FM. Tam JS, Valiance-Owen J (1988). Strong assoc.ia~io11 l ~ t w e e n IgA nephropathy and Hepatitis B surface antigenaemia in endemic areas. Clinical Nephrology. 29:229,234.
14. Akinsola A, Olusanya 0, Iyun AO, Mbanefo CO. The role of Hepctitis Bs inchronic glomerulonephritis in Nigerians. AfiJ.Med.
med Sci. 1984;13: 33-39.
15. Pillay V K G Kirch E. Kunzman NA. ( 1 973). Glomerulopathy associated with Filarial Loaisis. JAMA 225-239.
16. Ngu JL, Chatelanat F, Leke R, et al. (1985) Nephropathy in Cameroon: Evidence for Filarial derived immune complex pathogenesis in some cases. Clinical Nephrol. 24: 128- 134. ' 17. Thomas MA, Frampton G, Isenberg DA; Shoenfeld Y, Akinsola
A, Ranlzy M, Lilleywhite J, Wllliarns DG ( 1989):Acommon anti- DNA antibody idiotype 'and anti-phospholipid antibodies in sera from patients with schistoso~niasis and filariasis with and without nephritis. JAutoimml1n.2:803-1 I .
18. AkinsolaA et a1 (1988). Loiasis and elomerulonephritis. Repon of two cases and review of literature. West Afr. J. Me@. 62-68 19. Adebajo AO. Akinsola A, Maizel.: RM. Cawston TE. , Hazleman BL ( 1
.
992). Rheumatoid factor and rheumatoid factor isotypes in:, E. El Nahas AM (2005). Prevention of se: a global challenge. Kidney Int Suppl.
5 1