| 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.
|How to cite this article:|
Ogundele SB. Chronic kidney disease in Sub-Saharan Africa. Saudi J Kidney Dis Transpl 2018;29:1188-91
| Introduction|| |
Africa is the second largest continent in the world, and it accommodates 53 countries hosting about one billion people. Sub-Saharan Africa (SSA) accounts for >80% of the land-mass of the African continent with an estimated 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.
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 identified as one of the chronic diseases with public health problem. CKD is increasingly recognized as a global public health problem and a key determinant of the poor health outcomes. Despite the global threat of CKD, the scale of the problem is not fully appreciated, especially in developing countries.
With an aging population, lifestyle changes and rapid urbanization, the importance of noncommunicable 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. Lack 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. Kidney disease impose a great human suffering, and economic burden on African continent and ESRD is projected to increase at the rate of 6%–8% in Africa.
| Risk Factors|| |
Hypertension is an important worldwide public health challenge because of its frequency and associated risk of cardiovascular and kidney disease, and it has been estimated that about three-quarter of people living with hypertension lives in developing world. Diabetes, on the other hand, affect 2.8% of global population 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. Africa is experiencing an accelerated increase in hypertension and diabetes which are the underlying cause of CKD. 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. The relationship 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 populations, and it has been found to be associated with kidney disease. 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.
| 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.
There is increased prevalence of ESRD in Africa and access to RRT is often expensive and usually unavailable. 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). A global study conducted in 2010, have shown that Africa has a high disparity between demand and supply of RRT.
Government provides financial support for patients on HD in some African countries such as South Africa, Malawi, Sudan, Tanzania, and Nigeria, 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. 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. 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., Out of 47 countries in SSA, only 6.3% have a functioning renal transplant program and the cost of renal transplant in SSA ranges between $3,000 and $20,000.
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. 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 prematurely because of lack of access to RRT. In 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. CKD is a progressive disease which jeopardizes survival and quality of life but can be managed therapeutically by RRT. In developing world ESRD is a death sentence to a lot of people because RRT is often unavailable or unaffordable. Considering the problem of hypertension, 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. 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 program 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 forward 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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Mr. Samuel B Ogundele
Department of Nursing, Afe Babalola University, Ado-Ekiti