Challenges for nephrology practice in Sub-Saharan Africa

The burden of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) presents a challenge for both developed and emerging countries. While dialysis and transplantation consumes an ever-increasing proportion of the health budget in countries such as the United States, Japan and Taiwan, there is limited availability of these expensive therapies in the majority of emerging countries and even less in Sub-Saharan Africa (SSA) where diseases such as HIV/AIDS, tuberculosis and malaria account for much of the available funding. The lack of renal registries in most African countries makes it difficult to obtain accurate statistics about CKD. Recently, CKD was reported to account for 8–12% of hospital admissions in Nigeria [1]; it affects mainly young adults aged 20–50 years in SSA and is primarily due to hypertension and glomerulonephritis (GN), unlike developed countries where CKD presents in middle-aged and elderly patients and is predominantly due to diabetes mellitus and hypertension. The study by van Rensburg et al. adds to the available data on CKD in South Africa; the majority of patients presented late with presumed hypertensive nephropathy (51.2%) and chronic kidney failure of unknown aetiology (37.9%), requiring renal replacement therapy (RRT), and this is similar to other studies from Africa. Studies from Nigeria showed that 62% were of unknown aetiology, with hypertension accounting for 61%, diabetes mellitus for 11% and chronic GN for 5.9% of the remaining patients whose aetiology was ascertained [2]. Previous studies from South Africa reported on hypertension and GN as being the chief causes (45 and 52%, respectively) amongst RRT patients [3,4]. Hypertensive nephropathy is viewed as the major cause of ESKD in many parts of Africa. Hypertension is an important cause of CKD in SSA ranging from 25% in Senegal, 29.8% in Nigeria, 45.6% in South Africa to 48.7% in Ghana, especially in black patients [7]. Hypertension affects about 25% of the adult population and was the cause of ESKD in 21% of patients on RRT in South Africa [8]. This preponderance of hypertensive ESKD in black individuals may be attributed to genetic variants in the gene that encodes non-muscle myosin 2a protein (MYH9). Studies in African-American patients with hypertensive ESKD (without diabetes) suggest that much of the excess risk of ESKD is attributable to a MYH9 risk haplotype and suggest that hypertension may cause progressive kidney disease only in genetically susceptible individuals or be the result of a primary renal disease [9]. Lack of resources is a major constraint on the provision of renal care in many parts of Africa. Rationing of services is practiced in many parts of Africa, including South Africa, resulting in small numbers of patients selected for RRT [10]. Appropriate training and retention of healthcare workers is a challenge for many African countries [11] and is a prerequisite for screening and early detection programmes for CKD. Conflict of intereststatement. None declared.