The very high mortality seen in this study is a combination of several factors namely, late presentation, co morbid conditions and inability to pay for the recommended adequate dialysis owing to high cost. Cost of dialysis averages $160 per session in most centres in Nigeria with an estimated GDP of 5.6% for 2009  and lack of health insurance for a majority of people. Indeed, studies in other parts of the country show a similar situation [5, 7, 10]. The main predictor of mortality in this study was low dialysis frequency due to the inability to pay for more than a small number of dialysis sessions. This has been demonstrated in similar studies in countries with similar health indices [11, 12]. An analysis of survival on dialysis in a facility in Ghana shows that duration on dialysis and number of dialysis sessions were very strong predictors of survival among their cohort of patients . Similarly, dialysis frequency and weekly duration of haemodialysis less than 8 hours per week were independent risk factors for mortality in a cohort in Lithuania . Even in resource rich settings, data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) has shown that non adherence among dialysis patients including skipping as little as a dialysis session per month predicts mortality . In our study, even when we considered adequate dialysis as meeting 70% of scheduled sessions which in many cases is still sub optimal, there was a reduction in mortality in those who had at least 70% of their scheduled dialysis sessions. This suggests that more dialysis would have been beneficial. Unfortunately, not many of our patients were able to afford dialysis regularly and for a long time resulting in the high mortality rates seen. Some patients have to commute long distances to access this service. This trend will obviously continue unless there is remarkable expansion of renal care services to many more places, a liberalization of the import regime for dialysis software and consumables to force down the cost of dialysis and the expansion of Health Insurance coverage to include renal replacement therapy especially haemodialysis.
It bears repeating therefore that the high cost of dialysis has militated against access to adequate dialysis. The ethical aspects of initiating dialysis in those with ESRD who presumably may be unable to afford more than a few sessions needs to be further studied in our environment. Often, patients, their relatives or sponsors are provided information on the prognosis and the huge long term cost of RRT before initiating dialysis. In spite of this, they still opt for the initial treatment. Not minding the obvious fact that they may not be able to sustain the therapy in the long term.
The baseline demographic characteristics of our incident patients on dialysis in terms of the age and sex are similar with earlier reports in Nigeria and elsewhere [5, 7, 10]. It is worrisome that in a developing country such as ours, the economically productive age group is the most affected.
The aetiology of chronic kidney disease still reflects present trends in Nigeria and sub Saharan Africa where chronic glomerulonephritis (CGN) is the commonest cause of CKD [5, 10]. Data from Europe and Australia are similar although diabetes rather than hypertension is the second common cause of ESRD. This may reflect lifestyle differences, nutritional variability and a greater control of infectious diseases. The diagnoses of CGN were presumptive based on the relatively young age of the patient, severely impaired serum creatinine levels and markedly shrunken kidney sizes on ultrasound scan.
Predialysis anemia was common in our patients unarguably because of late presentation and poor anaemia management practices before referral for dialysis. Historically, our patients present late preferring to resort to herbal remedies and over the counter medications. Even then, studies from Europe and Asia also show a high prevalence of predialysis anaemia (68% and 75% respectively) in spite of availability of better and affordable renal care services [16–18]. Although anaemia is both a risk factor for CKD as well as a factor that accelerates progression of CKD leading to a worsening of the cardiovascular state, it did not predict mortality in our cohort.