Conservative therapy is associated with worse clinical features and biochemical derangements than renal replacement therapy: a retrospective study in Kumasi, Ghana

This study compared the sociodemographic features, diagnostic characteristics (clinical, biochemical and imaging) and clinical outcomes of ESKD patients who chose either RRT or conservative therapy as well as the factors that influenced their choice. Bipedal swelling (16.8%), fatigue (10.4%) and facial swelling (9.2%) were the major clinical features. Chronic glomerulonephritis (31.4%), hypertension (30.3%) and diabetes mellitus nephropathy (28.2%) were the most frequent predisposing conditions. Nifedipine (82.0%), bisoprolol (32.8%), aspirin (19.7%), ranitidine (26.2%), metformin (13.1%) and lasix (78.7%) were commonly used by the RRT patients than their conservative therapy counterparts. Compared to their RRT counterparts, patients on conservative therapy were more on irbesartan/lisinopril (57.9%) and sodium hydro carbonate (NaHCO₃) (52.0%). Diastolic blood pressure (DBP) (p = 0.047), uremic gastritis (p = 0.007), anaemia, uraemia, haematuria and hyperkalaemia (p < 0.001) were more common in conservative therapy patients than RRT patients with RRT patients showing better corticomedullary differentiation (38.1% vs. 27.7%, p < 0.001) and normal echotexture (15.0% vs. 11.6%, p = 0.005). In agreement with previous studies, majority of our participants were aged 40–69 years with a male preponderance [20, 21]. ESKD is known to occur in advanced ages where risk factors are high with more comorbidities [22]. The male preponderance is likely due to hypertension, a major risk factor, occurring more in males than in females with the incidence of uncontrolled BP often in males[23]. Male prevalence in incidents of primary renal diseases [11, 24] also plays a role.

At diagnosis, the most prevalent causes of ESKD were CGN, hypertension and diabetes nephropathy (Table 2) with majority of the participants presenting with pedal, facial and bodily swelling as well as fatigue (Fig. 1) as observed in other studies [25][20]. Conservative therapy patients had higher occurrence of uremia, hyperkalemia and hematuria with more DBP measurements. A lot of these patients were on ACEis/ARBs which are known to reduce GFR and cause some electrolyte imbalances as their adverse effects [26] could explain the uremia and hyperkalemia observed.

Complications like uncontrolled hypertension, anemia (Table 4) and hematuria (Table 3) are all associated with ESKD progression [5][27][10]. Hence, from our data, we can infer that disease progression is faster in the conservative therapy participants than the RRT participants. Ergo, the RRT patients showed better corticomedullary differentiation and normal echotexture (Table 5). Nevertheless, some complications such as fluid overload and pulmonary edema slightly dominated in the RRT patients. These are common occurrences in dialysis patients [28, 29] mostly resulting from inaccuracies in the dialysis process and patient lifestyle [30].

One major objective in CKD and ESKD management is to control BP to a target level of < 130/80 mmHg [27], which is why blood pressure drugs dominated among the medication administered. Nifedipine (a calcium channel blocker) was the most used BP drug among hydralazine, methyldopa and bisoprolol in both groups because they are highly bound and excreted through hepatic metabolism hence unaffected by kidney dysfunction. Other drugs administered include gliclazide and metformin for Type 2 diabetes mellitus, CaCO₃, fersolate and folic acid as nutrient supplements, aspirin and prednisolone for pain and allergies among others.

Ideally, ESKD is managed with dialysis or kidney transplantation and sometimes conservative therapy for very old patients with many comorbidities [31]. We noted that none of our participants had kidney transplant. Also, majority of our patients were on conservative therapy rather than RRT (Table 1). This finding proves the point made by Antwi, (2015) [2] that “the current state of RRT services in Ghana is inadequate and calls for serious national consideration”. In his paper, he attributed this to several reasons including limited dialysis facilities in the country, unavailability of insurance schemes to cover cost despite the high cost of these therapies and lack of constant electricity supply. We conducted this study in one of the only 6 public dialysis centers available in the country, all of which are in the southern zone. This shows how scarce the treatment is to the general public especially those in the northern and central zones. Most people who opt for RRT may have to travel several kilometers away from home to access treatment. Considering the fact that majority of our participants are either unemployed or in the informal sector (Table 1) and with the unavailability of insurance coverage for citizens, the collective cost of travelling, laboratory investigations, drugs as well as dialysis sessions is unaffordable to most of them and they would have to settle for conservative therapy.

From Table 4, we noticed that age and gender are variables significantly associated with the decision to opt for conservative therapy. Looking at the majority age range (40–69 years) with most being males, it is likely that these individuals are breadwinners with many financial responsibilities and may not have the luxury or support to finance RRT. Duration of illness was also a significant variable; more of the patients who had had the disease for longer periods opted for conservative therapy. This is likely because hemodialysis is an awfully burdensome intervention especially in Ghana and chronic hemodialysis patients often opt out and resort to conservative care as disease progresses and resources are depleted.

A major limitation in our study was that some participants did not complete their data and were disqualified. Thus, we lost about 80% of our participants to follow up and we could also not access and contrast the quality of life of both groups during treatment.