Chronic kidney disease in Sub-Saharan Africa

Abstract

Chronic kidney disease has been observed to be a major threat to the world's health, and in some African countries, it is a death sentence. It affects economically productive young adults between the ages of 20-50 in Sub-Saharan Africa as against the middle age and elderly in the developed world. Challenges of renal care in Africa are numerous among which are equity, accessibility, financial constraint, and lack of workforce to mention a few. Therefore, Africa countries must prioritize renal care and include it in the health agenda to cater for the present and future health need of the people.

Full text

Saudi J Kidney Dis Transpl 2018;29(5):1188-1191
© 2018 Saudi Center for Organ Transplantation
Renal Data from Asia–Africa
Chronic Kidney Disease in Sub-Saharan Africa
Samuel B. Ogundele
Department of Nursing, Afe Babalola University, Ado-Ekiti, Nigeria
ABSTRACT. Chronic kidney disease has been observed to be a major threat to the world’s
health, and in some African countries, it is a death sentence. It affects economically productive
young adults between the ages of 20–50 in Sub-Saharan Africa as against the middle age and
elderly in the developed world. Challenges of renal care in Africa are numerous among which are
equity, accessibility, financial constraint, and lack of workforce to mention a few. Therefore,
Africa countries must prioritize renal care and include it in the health agenda to cater for the
present and future health need of the people.
Introduction
Africa is the second largest continent in the
world, and it accommodates 53 countries
hosting about one billion people.1Sub-Saharan
Africa (SSA) accounts for >80% of the land-
mass of the African continent with an esti-
mated population of 800 million. About 65%
of the population lives in rural settings, a
significant distance from cities where most of
the organized health-care delivery systems exist.2
Over a time, there has been a recent change
in the world’s disease profile and chronic
diseases are now becoming the leading cause
of morbidity and mortality in the world and
chronic kidney disease (CKD), which recently
has an increased prevalence in SSA, has been
Correspondence to:
Mr. Samuel B. Ogundele,
Department of Nursing, Afe Babalola
University, Ado-Ekiti, Nigeria.
E-mail: tosley2000@gmail.com
identified as one of the chronic diseases with
public health problem.3CKD is increasingly
recognized as a global public health problem
and a key determinant of the poor health
outcomes.4 Despite the global threat of CKD,
the scale of the problem is not fully appre-
ciated, especially in developing countries.
With an aging population, lifestyle changes
and rapid urbanization, the importance of non-
communicable diseases in the low- and middle-
income countries cannot be over emphasized.
It has been estimated that by 2030, >70% of
patients with end-stage renal disease will be
living in developing countries like SSA.5Lack
of kidney disease registry in SSA makes it
difficult to estimate the problem of CKD but
data from the United State of America suggest
that for every patient with end-stage renal
disease (ESRD) there are >200 with overt
CKD and almost 5000 with unknown renal
disease.2 Kidney disease impose a great human
suffering, and economic burden on African
continent and ESRD is projected to increase at
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the rate of 6%–8% in Africa.6
Risk Factors
Hypertension is an important worldwide public
health challenge because of its frequency and
associated risk of cardiovascular and kidney
disease,7 and it has been estimated that about
three-quarter of people living with hyper-
tension lives in developing world.8 Diabetes,
on the other hand, affect 2.8% of global popu-
lation in 2000 and this is estimated to triple to
6.8 by 2030 and by that time, 81% of those
with diabetes will be living in developing
countries.9 Africa is experiencing an accele-
rated increase in hypertension and diabetes
which are the underlying cause of CKD.6 HIV
associated nephropathy, acute kidney injury,
and CKD are some of the complication of HIV
infection and may become more pronounced
as patient live longer, especially in the era of
combined antiretroviral therapy.10 The rela-
tionship between intra-uterine factor and
development of CKD in adulthood has been
postulated but not well explored, for example,
low birth weight due to maternal nutritional
status and traditional herbal medicine is a
common issue among the disadvantaged popu-
lations, and it has been found to be associated
with kidney disease.11 More than 80% of the
population in SSA is estimated to use herbal or
traditional medicines which are thought to
have been associated with 35% of all new
cases of acute kidney injury.5
Renal Replacement Therapy in Sub-
Saharan Africa
Renal replacement therapy (RRT) which is
the treatment of choice is expensive, and it
contributes a heavy burden on the healthy
system even in wealthy countries. RRT for
kidney failure includes hemodialysis (HD),
peritoneal dialysis (PD), and renal transplant.
In Africa, in-center HD is the most common
modality, PD is seldom used because of the
cost of importing fluids whereas only seven
countries in SSA offer renal transplant to their
patient and it is mostly living donor transplant.1
There is increased prevalence of ESRD in
Africa and access to RRT is often expensive
and usually unavailable.12 Over 3.3 million
people have been estimated to be receiving
RRT globally, and majority of the patient are
treated in developed world, for example, more
than half of the population of patients on
dialysis are treated in just five countries (USA,
China, Japan, Brazil and Mexico).13 A global
study conducted in 2010, have shown that
Africa has a high disparity between demand
and supply of RRT.12
Government provides financial support for
patients on HD in some African countries such
as South Africa, Malawi, Sudan, Tanzania,
and Nigeria,13 but the reverse is the case in
other countries for example a study conducted
in Nigeria shows that <1% of patients can
afford treatment for more than three months
mainly because of financial constraint.12
Globally, the cost of dialysis care ranges from
USD $100 and $200, but in some countries in
SSA, it ranges from USD $80 to $160, USD
$130 to $200, USD $10 to $120, USD $50 to
$100, USD $70 to $110, and USD $120 in
South Africa, Uganda, Cameroon, Kenya,
Ethiopia, and Nigeria, respectively.13 PD is
still at its infancy stage in most countries in
SSA and kidney transplant is also available in
few countries such as South Africa, Sudan,
Nigeria, Kenya, Mauritius, and Cameroon.13,14
Out of 47 countries in SSA, only 6.3% have a
functioning renal transplant program2and the
cost of renal transplant in SSA ranges between
$3,000 and $20,000.13
In Africa like the rest of the world, the need
for renal care and RRT is on the increase, but
only a few countries can meet the need of their
citizen.1 The number of people requiring RRT
globally was estimated to be 4.9–9 million and
only 2.6 million people are on dialysis which
suggests that at least 2.3 million died pre-
maturely because of lack of access to RRT.4In
Asia and Africa, people receiving RRT are
likely to double from 2010 to 2030, and the
number of people without access to RRT is
projected to increase concurrently.12 CKD is a
progressive disease which jeopardizes survival
and quality of life but can be managed thera-
CKD in sub-Saharan Africa 1189
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peutically by RRT.15 In developing world
ESRD is a death sentence to a lot of people
because RRT is often unavailable or unaffor-
dable.16 Considering the problem of hyper-
tension, diabetes, obesity, and HIV/AIDS in
SSA, it is expected that population in need
RRT over the next few years will increase
drastically. Renal care in Africa is quite
challenging and is in a critical stage as there is
a short supply of health workers across the
board coupled with heavy financial burden of
RRT. Nephrologists are scarce in Africa
generally, but this is likely to get worse
because there is serious migration of health
care professionals across the board and this
has created a great threat to the public health
system in the region.
Summary
Economic burden of CKD is enormous and
can be in the form of direct loss of gross
domestic product, losses due to household
financing of care, consumption pattern, and
financial cost of managing the disease.11
Africa as a continent may be sitting on a keg
of gunpowder unknowingly and therefore must
reconsider how she views this silent killer.
Preventive measures have been recognized as
a key strategy in the management of CKD, but
it is still in its infancy stage in most Africa
country which is mainly due to lack of
workforce and funding.
Conclusion
There is need to establish CKD screening
center/clinic in all primary health care centers
and not as a standalone program but rather
incorporated into the already established pro-
gram for other chronic diseases. To overcome
this burden, there is a need for competent
workforce, therefore, the government need to
focus on training and retention of more
nephrologists and nephrology nurses. It is of a
truth that we cannot appreciate the extent of
this problem until we have a good record
system. Therefore, a district database should
be established to capture patient diagnosed
with kidney disease, and a proper channel
must be established for the referral system and
follow-up. The government should look for-
ward to developing policies and strategies to
increase the number of RRT centers available
in other to prepare for the potential need for
RRT.
Conflict of interest: None declared.
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