|Year : 2017 | Volume
| Issue : 4 | Page : 184-193
Challenges facing the growth of kidney transplantation programs in Nigeria: Perceptions and knowledge of the nephrologists and other health-care providers
Yemi Raheem Raji1, Samuel Oluwole Ajayi1, Babajide A Gbadegesin2, Temitope Oluwatobi Bello3, Babatunde L Salako1
1 Department of Medicine, College of Medicine, University of Ibadan; Department of Medicine, University College Hospital, Ibadan, Nigeria
2 Department of Medicine, Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, Nigeria
3 Department of Medicine, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||28-Dec-2017|
Yemi Raheem Raji
Department of Medicine, College of Medicine, University of Ibadan, Ibadan
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study was to determine the perception and knowledge of health-care providers to the challenges of sustaining the growth of kidney transplantation programs in Nigeria. Materials and Methods: We conducted a survey of 166 health-care providers. A pretested questionnaire was administered on all participants. Information obtained were demographics, characteristics of end-stage renal disease (ESRD) patients, and prospective kidney donors encountered and perception of the barriers to the growth of kidney transplantation program. Results: The respondents returned 134 questionnaires out of 166 (response rate: 80.7%) and only 121 with complete responses were included in the analysis. The mean age was 42.5 ± 0.8 years and 47.9% were females. A quarter of the health-care providers encountered ESRD patients who were more likely to refuse kidney transplantation and 34.1% reported that most of the prospective kidney donors were unwilling to donate. Most of the health-care professionals (71.1%) preferred centers outside Nigeria for their patient's kidney transplantation, while three leading barriers to the growth of kidney transplantation program reported were lack of patients' trust (58.8%), failure of interprogram collaborations (55.0%), and absent of governmental supports (48.1%). Conclusions: The health-care professionals reported that more than a third of ESRD patients were not likely to accept kidney transplantation and an equal proportion of prospective donors will not agree to kidney donation. Majority of the health-care professionals preferred centers outside Nigeria for patients' kidney transplantation.
Keywords: Challenges, health-care providers, kidney transplantation, nephrologists, Nigeria
|How to cite this article:|
Raji YR, Ajayi SO, Gbadegesin BA, Bello TO, Salako BL. Challenges facing the growth of kidney transplantation programs in Nigeria: Perceptions and knowledge of the nephrologists and other health-care providers. Indian J Transplant 2017;11:184-93
|How to cite this URL:|
Raji YR, Ajayi SO, Gbadegesin BA, Bello TO, Salako BL. Challenges facing the growth of kidney transplantation programs in Nigeria: Perceptions and knowledge of the nephrologists and other health-care providers. Indian J Transplant [serial online] 2017 [cited 2018 Dec 10];11:184-93. Available from: http://www.ijtonline.in/text.asp?2017/11/4/184/221851
| Introduction|| |
Kidney transplantation is the best standard treatment for individuals with end-stage renal disease (ESRD) worldwide, because it offers the recipients normal or near-normal life when compared to dialysis., In most developed countries, the kidney transplantation programs include both the deceased and living donor kidney transplantations. However, kidney transplantation as a form of treatment is not available in most of the sub-Saharan African (SSA) countries., Only few of the SSA countries have established kidney transplantation program and these were mainly restricted to living donor kidney transplantation, with the exception of South Africa and Egypt that have deceased donor kidney transplantation programs in addition.,
Nigeria has the largest human population in Africa with over 180 million people  and has a substantial burden of chronic kidney disease (CKD)., CKD is estimated to affect 20%–30% of the population while ESRD accounted for 8%–10% of all medical admissions, in most of the tertiary hospitals.,,, Dialysis was previously the only modality of treatment available until 2000 when a privately owned hospital in Lagos (Saint Nicholas Hospital) started a kidney transplantation program. Two government-owned facilities (Ile-Ife and Kano) established their kidney transplantation programs 2 years after. These three centers were only able to carry out living donor kidney transplantations, as the technical know-how, infrastructural facilities, societal acceptability, and the enabling laws required for successful deceased donor transplantation were not yet available in the country.
These pioneering efforts were subsequently followed by attempts by other health-care facilities in the country to start kidney transplantation program and at present, there are two privately owned health-care facilities and eight government-owned tertiary hospitals that have successfully established kidney transplantation programs, and at least carried out one kidney transplantation each. Surprisingly, most of these centers have not been able to sustain the programs, and more than 80% of these centers were unable to carry out more than five living donor kidney transplantations in a year.
Most of the patients with ESRD in the country shy away from patronizing these centers and preferred to have their kidney transplantation surgery carried out outside the country, with India and South Africa being the most favored destinations. The preference of foreign destinations for kidney transplantation by patients apart from being a significant source of economic drain also serves as the main source of the underdevelopment of the kidney transplantation program in the country. The medical tourism has not been a major source of concern for the nephrologists and other health-care professionals only, but also to other stakeholders which include the patients, their relatives, insurance companies, and the government. As part of the initiatives to reduce kidney transplantation tourism, Zenith hospital, a privately owned facility, formed a partnership with some foreign hospitals. This arrangement allowed a group of foreign transplantation surgeons to schedule back-to-back kidney transplantation for pooled patients.
In order to change the tide of the current underdevelopment of the kidney transplantation program in the country, a critical appraisal of the programs in its existing form is necessary. And important to this appraisal is the assessment of the attitudes, knowledge, views, perceptions, and opinions of the stakeholders, concerning the underdevelopment of kidney transplantation program in the country. This has the potential of providing useful insight into the magnitude of the problem, more so that the kidney care providers are critical to the sustainability of the programs; their opinions and perceptions of the challenges and solutions to the stunted growth of the program in the country will be key to finding solutions to the challenges. This study aimed to evaluate the perceptions, opinions, and knowledge of the nephrologists and other health-care professionals involved in the care of patients with kidney disease, on the challenges facing growth of kidney transplantation programs in Nigeria.
| Materials and Methods|| |
This is a cross-sectional survey of kidney disease health-care providers, who were members of the Nigerian Association of Nephrology (NAN) attending the association's annual conference in Calabar (January 2015). The health-care providers included nephrologists, nephrology residents, and nephrology nurses.
These were practicing nephrologists who have had fellowship training in nephrology and were involved in the day-to-day care of patients with kidney disease.
This category included the nephrology trainees who were taking part in the management of patients with kidney disease under the supervision of nephrology fellows.
These were nurses who have had training in nephrology nursing or had at least 2 years of experience working as a caregiver in the management of patients with kidney disease.
There were 35 items in the questionnaire which was pretested in a cohort of 10 randomly selected health-care providers. During the pretesting survey, eight items were misunderstood by the participants and were subsequently dropped from the list [Table 1]. The health-care providers who participated in the pilot survey were excluded from the study. The 27 items were included in the final questionnaire and they were grouped into 7 subsections, among which 5 items addressed demographics, 6 items on kidney care programs being offered by the respondents' centers, 4 items for patients' factors, 5 items for kidney donor factors, 3 items for available laboratory backup, 1 item for challenges facing kidney transplantation programs, and 3 items for suggested solutions to the challenges. Item 1 was dichotomized into male or female while items 6 and 23 were dichotomized into yes or no responses. Item 2 which is age was asked as a continuous variable while items 3–5, 8, and 11 were with four to six options, with only one option to be selected [Table 1]. Item 12 assessed the providers' perception of their patients' willingness to be enrolled in the kidney transplantation program and responses ranged from strongly agree to strongly disagree. Item 18 evaluated the perception of the health-care provider to willingness of relatives offering to donate a kidney to the affected patient and the responses ranged from highly motivated to extremely rare. Items 7, 9, 10, 13–17, 19, 20, and 21–24 were with multiple options and responses could be more than one option [Table 1]. Items 25–27 were open-ended questions that sought ways to overcome the challenges to kidney transplantation program growth in the country, vis-à -vis capacity building, boosting kidney donation, and increasing patronage of the kidney transplantation program in the country.
|Table 1: Pro forma for the study on the knowledge and perception of renal caregivers to the barriers to the growth and development of kidney transplantation programs in Nigeria|
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Ethical approval was obtained from the Joint University of Ibadan and University College Hospital, Ibadan, for the survey, and informed consent was obtained from all participants. The questionnaires were administered to the health-care providers during the 5 days NAN Conference that took place in Calabar, Cross River State, Nigeria, between January 25 and 29, 2015. The questionnaires were administered to all the health-care providers attending the conference and who gave written informed consent. The self-administered questionnaires were distributed to the participants during the conference break sessions. Excluded were dialysis technicians and nonhealth-care providers who were part of the conference. One hundred and sixty health-care professionals gave their consent to participate in the survey out of the 166 approached during the conference. Only 134 participants returned the questionnaires with responses, given an overall response rate of 80.7%.
Data were analyzed using the Statistical Package for the Social Sciences (SPSS) IBM Corporation. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, New York, United States of America. Cronbach's α coefficient was used to determine the internal consistency reliability of items within group and values >0.7 were considered to be reliable. Continuous variables were expressed as mean ± standard deviation while categorical variables were expressed as proportions and percentages. Association between continuous and categorical variables was determined using Student's t-test and Chi-square test, respectively. All statistical values were considered significant with P < 0.05.
| Results|| |
Demographics of participants
A total of 160 questionnaires were administered to the participants and 134 were returned while 13 of the returned questionnaires were with inadequate responses or were filled by individuals excluded from the survey and were excluded from the analysis. Only 121 respondents with complete responses were included in the analysis. The mean age of participants was 42.5 ± 0.8 years, while females were 58 (47.9%). Other sociodemographic details are shown in [Table 2].
|Table 2: Sociodemographic characteristics of the health.care providers (n=121)|
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Characteristics of kidney disease patients and kidney care services offered by the respondent centers
One hundred and fifteen respondents (95.1%) had a functioning renal unit in their hospital while six respondents (4.9%) had none. When asked about the leading causes of ESRD in their centers, 92 (82.5%), 79 (67.5%), and 74 (63.3%) of the respondents reported hypertension, chronic glomerulonephritis (CGN), and diabetes mellitus as the leading etiologies of ESRD, respectively. One hundred and thirteen respondents (93.4%) practiced in centers that offered hemodialysis only while 23 (19.0%) worked in centers that offered both hemodialysis and kidney transplantation as treatments for ESRD.
Patient's willingness to accept kidney transplantation
When asked how readily are their patients with ESRD likely to agree to kidney transplantation as a modalities of treatment, 15 (12.5%) respondents reported that most of the patients will strongly agree to kidney transplantation, 56 (46.3%) reported that most patients will agree, 24 (20.0%) reported that most will be undecided, 6 (5.0%) reported that most will disagree while 11 (9.1%) reported that most patients will strongly disagree to kidney transplantation. The following factors influence the willingness of their patients to agree to kidney transplantation: 59 (48.8%) reported awareness of its benefits, 69 (57%) reported cost of surgery and post-transplantation immunosuppression, 25 reported family decision (20.8%), 66 reported availability of donor (54.5%), 45 reported risk of surgery (37.5%), and 28 reported other reasons (32.3%).
Types of donors commonly encountered in their centers
When asked about the types of life kidney donors they have encountered in their practice, 56 (46.4%) reported blood-related donors, 54 (44.6%) reported emotionally related donors while only 11 (9.0%) reported paid donors. Among the 55 respondents who encountered mostly blood-related kidney donors, 25 (45.6%) reported that parents were most likely to be the donors, 13 (23.6%) reported of the second-degree relatives while 10 (18.2%) and 7 (12.7%) reported siblings and children, respectively. Among those who reported emotionally related donors as being commonly encountered, majority (47 [87.0%]) reported the spouses as the mostly likely donors while friends were reported as the most likely donor by 7 (13.0%) health-care providers. None reported encountering altruistic donors.
Perceived willingness and factors associated with acceptance of kidney donation
When health-care providers were asked to rate the willingness of patients' relations and other prospective kidney donors to donate their kidneys to the affected individuals, 16 (13.2%) reported that most donors were highly motivated, 50 (41.3%) reported that most donors were willing but with some reservations, 14 (11.6%) reported that most donors were undecided, 16 (13.2%) reported that most were unwilling to donate their kidneys while 25 (20.7%) said most were strongly unwilling to donate their kidneys.
When the respondents were asked about the perceived factors that influenced kidney donation among prospective kidney donors in their practice, 61 (50.4%) reported pressure from the family, 42 (34.7%) reported relationship with the prospective recipient, 36 (27.8%) reported financial benefits, 21 (17.4%) reported religion influence, while 7 (5.8%) reported altruism.
Perceived reasons for unwillingness to accept kidney donation
When health-care providers' perceptions of factors that influence prospective kidney donors unwillingness to donate their kidneys were assessed, 50 (41.3%) of the health-care providers believed that there is a lack of awareness of the details about kidney donation and perceived risks, 36 (29.0%) believed that most donors fear the risk of kidney disease in future, 33 (27.3%) reported that most donor feared surgical procedures, while 20 (16.5%) reported other reasons.
Awareness of center with expertise in human leukocyte antigen histocompatibility matching tests in Nigeria
More than half of the respondents (70 [57.9%]) were aware of centers with facilities and expertise for carrying out human leukocyte antigen (HLA) genotyping and T-cell crossmatch tests. while 51 (42.1%) were not aware of such services in the country. Nine respondents (7.4%) preferred to carry out the HLA genotyping and T-cell crossmatch tests in their center, 24 (19.8%) preferred other centers within Nigeria, while 58 (47.9%) preferred centers outside the country. The reasons given for the preference of centers outside Nigeria for the tests were reliability, easy accessibility, previously existing partnership with the foreign centers, and lack of awareness of the existence of the services in Nigeria.
Preferred destination of kidney transplantation for their patients
When the health-care providers were asked for the preferred destinations for their patients' kidney transplantation, only 27 (22.3%) preferred Nigeria, while majority (94 [77.7%]) recommended centers outside the country for their patients [Table 3]. The three leading reasons for preferring destinations outside the country for their patients' kidney transplantation were patient's preference, high cost of surgery, and poor infrastructure in the locally available programs [Table 3].
|Table 3: Health-care providers' preferred kidney transplantation surgery destinations for their patients and reasons for the choices (n=121)|
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Barriers to the growth of kidney transplantation programs in Nigeria
When the respondents were asked for their perceived barriers to the growth of kidney transplantation programs in the country, most of the respondents agreed that lack of trust by the patients in the local kidney transplantation programs, failure of collaboration between centers across the country, and lack of governmental supports were the three leading barriers to the growth of the program in Nigeria [Figure 1].
|Figure 1: Perceived barrier to the growth of kidney transplantation programs in Nigeria by the health-care providers|
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Suggested steps to boost the growth of kidney transplantation programs in the country
When asked to suggest ways to boost kidney transplantation program growth in the country, 88 respondents (72.7%) believed that government support is critical to the growth of kidney transplantation program in Nigeria; other suggested steps were reported as follows: capacity building reported by 44 (36.4%) respondents, creating awareness and public education on kidney transplantation suggested by 57 (47.1%) respondents, intercenter collaboration reported by 55 (44.6%) respondents, appropriate legislation was suggested by 35 (28.9%), and other reasons were suggested by 32 (26.5%) respondents.
| Discussion|| |
This study looked at the barriers and solutions to the growth of kidney transplantation program in Nigeria from the perspective of the health-care providers. Most of the respondents practiced in the public hospitals. The socioeconomic status of patients is an important factor that determines the patronage of either public or private facilities for their kidney transplantation such that most indigent patients prefer the public hospital while the rich patronize the private hospitals for their kidney transplantation. This is not surprising as the two private hospitals in Nigeria have carried out more kidney transplantations than all the public hospitals combined over the last 10 years. Socioeconomic strata has been shown to be an important factor in access to kidney transplantation. Most of the respondents reported hypertension, CGN, and diabetes mellitus as the leading causes of ESRD in their center. This is in keeping with findings from previous epidemiological studies of etiology of ESRD in Nigeria. Only one-fifth of the respondents practiced in centers that had an active kidney transplantation program, this may suggest an inadequate spread of kidney transplantation program across the country.
Respondents reported that over 30% of their patients will most likely not accept kidney transplantation as a treatment option and also reported that awareness of the benefits of kidney transplantation is the single most import factor that influenced patients' acceptance of kidney transplantation as a treatment option. These findings emphasize the need for early patients' education on treatment options for ESRD, and the effectiveness of early patient education in acceptance of kidney transplantation as a treatment option for ESRD has been observed in previous studies.,
Most kidney donors encountered by the respondents in their practice were either blood-related donors or emotionally related donors. The blood-related donors were mostly the parents, particularly mothers, this report is in agreement with our previous findings on willingness of the first-degree relatives to donate kidneys to affected member of the family. Most respondents reported the spouse as the commonly encountered emotionally related kidney donors in their practice, spouses have been documented to have the highest logical motive to kidney donation and most were highly motivated to donate kidneys to their loved ones.
Only 13% of the respondents had encountered mostly highly motivated donors who were willing to donate kidney to the affected individuals, while majority encountered mostly either willing donors with some reservation or undecided or totally unwilling. Lack of awareness and knowledge of risk involved in kidney, perceived fear of kidney disease in the future, and risk associated with surgery were the leading factors reported to influence the willingness to agree to kidney donation. The attitude of the public toward kidney donation in the country is at present discouraging and it has contributed to the scarcity of donors, in a country where the deceased donor kidney transplantation is not yet available. This attitude is largely influenced by the level of awareness and knowledge of kidney transplantation; the effectiveness of public education in boosting the willingness to kidney donation has been well established., In order to overcome this barrier, well mapped out strategies for creating awareness and educating the public on kidney donation should be put in place in every parts of the country. New initiatives to boost kidney donor pool in the country should be employed; one of such policies could be allowing paid kidney donors in a well-regulated fashion by the appropriate authorities. This model has been successfully implemented in Iran to reduce organ shortage, offering financial incentives to the donors rather than hope for altruistic donors was shown to boost organ donation in the country. In this survey, 9% of health-care providers reported encountering paid kidney donors in their practice, paid donors are not accepted by all the kidney transplantation programs in Nigeria, most programs accept only relatives with legal and biological evidence of relationship between donors and recipients. At present, there is no national policy on kidney transplantation, and regulation is carried out by the individual institutional ethics committee. In 2014, a national health bill that contains a comprehensive policy on organ transplantation was submitted by the federal government to the legislators for passage; however, political and economic considerations have hampered the rapid passage of the bill.
Surprisingly, more than three-quarter of the health-care providers reported that they would prefer their patients' kidney transplantation to be carried out at centers outside Nigeria. This may be a reflection of an objective assessment of the current status of the kidney transplantation programs in the country, particularly the infrastructure deficit and inadequately trained workforce or perhaps as a by-product of long-term interaction with patients, the relatives, and their preferred destinations for the kidney transplantation. The respondents reported that the reasons for the low patient patronage in the kidney transplantation program were lack of confidence in the local program and expertise, non-acceptance of paid donor, and unusually long delay from the period of patient and donor workup to the point of surgery. This perception by the patients encourage medical tourism and low patronage in the local programs. As part of the process of confidence building, the success stories so far recorded by the kidney transplantation programs in the country should be well publicized to boost confidence and patronage by the patients.
Other barriers to sustainable growth of the kidney transplantation program identified by the respondents include lack of government supports and failure of collaboration between and among units and centers in the country. Bamgboye in his previous review had earlier identified these factors as hindrances to the growth of kidney transplantation program in Nigeria. Building patients' trust requires deliberate and concerted efforts of all the stakeholders, vis-a-vis the government, the health-care providers, the patients, and the public. Moreover, each must be committed to his/her roles in changing the present trends. Government commitment to funding, equipping, and building human capacity for the kidney transplantation program will pave the way for accelerated growth of the program in the country, thus leading to gradual confidence building in the system.
Majority of the health-care providers in this study also believed that the ingredients for sustainable kidney transplantation program in the country will require adequate governmental support through building infrastructure and capacity and subsidizing cost of kidney transplantation for patients. Effective awareness and public education on kidney transplantation and donation, with excellent inter- and intraprogram collaborations, are needed, and if implemented well, will discourage medical tourism and its attendant economic loss for the country. As part of capacity building, establishment of regional transplantation centers as previously suggested by the Nigerian Nephrology Association will be a cost-effective way of pooling the scarce resources together; it is imperative that the government and other stakeholders should follow through on its implementation. Furthermore, public–private partnership initiatives will be an adaptive model that will go a long way in solving the problem of laboratory backup for the kidney transplantation programs. Since the cost of kidney transplantation is unaffordable by most ESRD patients in the country, inclusion of kidney transplantation in the National Health Insurance Scheme will be an important step toward creating access for the indigent ESRD population in the country.
This study has some limitations which include being a survey, the health-care providers' perceptions may be different from the actual treatment decisions, since other factors such as patients' and relatives' preference and availability of funds may be involved in the interplay for treatment decisions. Second, the study was not powered enough to allow for subgroup analysis of the health-care providers. Finally, the findings of the study cannot be generalized to other populations except that they share similar health, economic, and sociocultural environment with Nigeria.
| Conclusions|| |
Health-care providers are important key stakeholders in the success of kidney transplantation programs. The nephrology community in the country perceived inadequate governmental supports, lack of trust in the program by the patients and public, and failure of collaboration among programs across the country as the main barriers to sustainable growth of kidney transplantation programs in Nigeria.
The authors acknowledged the efforts of Mrs. Oluwakemi Raji who assisted in the data entry.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]