ESKD in sub-Saharan Africa: will governments now listen?

A few years ago, my group published an article entitled Nephrology in Africa—not yet uhuru.1Swanepoel CR Wearne N Okpechi IG Nephrology in Africa—not yet uhuru.Nat Rev Nephrol. 2013; 9: 610-622Crossref PubMed Scopus (47) Google Scholar Uhuru is the Swahili word for “freedom”. The idea was to highlight the plight of patients with end-stage kidney disease (ESKD) and the challenges and frustrations of their nephrologists in sub-Saharan Africa amidst health-care authorities that had not done enough to alleviate the problem. The absence of uhuru referred to in that article is not peculiar to nephrology; other medical specialties in sub-Saharan Africa have similar problems associated with a reduced size of and inadequately experienced workforce, diagnostic facilities, and access to treatment, often resulting in poor patient outcomes.2Sliwa K The heart of Africa: succeeding against the odds.Lancet. 2017; 388: e28-e36Summary Full Text Full Text PDF Scopus (10) Google Scholar, 3Kingham TP Alatise OI Vanderpuye V et al.Treatment of cancer in sub-Saharan Africa.Lancet Oncol. 2013; 14: e158-e167Summary Full Text Full Text PDF PubMed Scopus (150) Google Scholar ESKD is a danger to global public health because of rising prevalence, excessive cost of treatment, reduced quality of life, and increased morbidity and mortality. The burden of ESKD is more pronounced in African countries, where access to treatment is often unaffordable and usually unavailable. Highlighting the problems of the scarcity of access to treatment, Liyanage and colleagues4Liyanage T Ninomiya T Jha V et al.Worldwide access to treatment for end-stage kidney disease: a systematic review.Lancet. 2015; 385: 1975-1982Summary Full Text Full Text PDF PubMed Scopus (1116) Google Scholar noted that the largest ESKD treatment gaps were present in low-income countries, particularly in Asia and Africa. However, they showed that, of all the world regions in 2010, Africa had the largest percentage difference between people needing and receiving renal replacement therapy (RRT): −84% (95% CI −86 to −82) using a conservatively estimated model and −91% (–92 to −90) using a high-estimated model. Even though they projected a doubling of people receiving RRT from 2010 to 2030 in Asia and Africa, the number of people without access to treatment was also expected to remain excessively high. In The Lancet Global Health, Gloria Ashuntantang and colleagues5Ashuntantang G Osafo C Olowu WA et al.Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review.Lancet Glob Health. 2017; (published online Feb 17.)http://dx.doi.org/10.1016/S2214-109X(17)30057-8Summary Full Text Full Text PDF PubMed Scopus (97) Google Scholar report findings from a systematic review of outcomes in sub-Saharan African adults and children with ESKD who need dialysis. 24 456 adults and 809 children sourced from 68 studies in 15 sub-Saharan African countries were included. In the pooled analysis, 390 (96%) of 406 adults and 133 (95%) of 140 children who could not access dialysis had known or presumed mortality. Among those dialysed, 822 (80%) of 1031 adults with incident disease, 480 (15%) of 3197 adults with prevalent disease, and 90 (32%) of 284 children died. Ashuntantang and colleagues also reported that 2508 (84%) of 2990 adults with incident ESKD discontinued dialysis, mainly because of exhaustion of financial resources, and only 19 (1%) of 1472 continued treatment for at least 12 months. In adults, mean availability of erythropoietin for anaemia treatment was 38·4% (SD 35·9) and use of arteriovenous fistulae for dialysis was 49·0% (32·7), which are suboptimum. Transplantation rates were very low: 41 (1%) of 4483 in incident adults, 2280 (19%) of 12 125 in prevalent adults, and 71 (19%) of 381 in children. These findings are both alarming and outrageous and normally would be expected to motivate those able to influence health-care policies to act in meaningful ways that address the burden of ESKD in the region. I have doubts that these data will influence those in government in sub-Saharan Africa, since millions of people died as a result of HIV denialism even though there was sufficient proof linking HIV to AIDS.6Benatar SR Health care reform and the crisis of HIV and AIDS in South Africa.N Engl J Med. 2004; 351: 81-92Crossref PubMed Scopus (126) Google Scholar The common barriers reported by Ashuntantang and colleagues to be contributing to the high mortality can easily be linked to absence of policy concerning RRT in the region. Some governments in sub-Saharan Africa remain reluctant to allow any discussion about coverage of RRT or have made very slow progress with the issue. For instance, despite ample data from Nigeria showing that inability to pay for dialysis was the main reason for fewer than 1% of patients with ESKD continuing treatment for more than 3 months,7Okunola Y Ayodele O Akinwusi P Gbadegesin B Oluyombo R Haemodialysis practice in a resource-limited setting in the tropics.Ghana Med J. 2013; 47: 4-9PubMed Google Scholar the government in Nigeria only recently agreed to provide cover for the first six sessions (2 weeks) of dialysis after several years of negotiations with the local nephrology association.8Bamgboye EL The challenges of ESRD care in developing economies: sub-Saharan African opportunities for significant improvement.Clin Nephrol. 2016; 86: 18-22Crossref PubMed Scopus (20) Google Scholar Such small, albeit positive, steps are a drop in the ocean. Notwithstanding, they are steps in the right direction because there are already discussions to lengthen the period of coverage to the first 3 months for those needing dialysis.8Bamgboye EL The challenges of ESRD care in developing economies: sub-Saharan African opportunities for significant improvement.Clin Nephrol. 2016; 86: 18-22Crossref PubMed Scopus (20) Google Scholar Even in countries such as South Africa where RRT is offered, the existing rationing process9Moosa MR Kidd M The dangers of rationing dialysis treatment: the dilemma facing a developing country.Kidney Int. 2006; 70: 1107-1114Summary Full Text Full Text PDF PubMed Scopus (105) Google Scholar is a major ethical hurdle imposed on clinicians needing to choose between life and death of their patients. Ashuntantang and colleagues should have also highlighted other prominent factors in the region that contribute to such poor outcomes, including a dearth of workforce (<1 nephrologist per 1 million population in many countries) and the absence of early disease and risk factor detection and screening programmes. In view of the burden associated with the cost of ESKD care, perhaps efforts in sub-Saharan Africa should be devoted to early disease detection and prevention. Awareness of ESKD and its risk factors (eg, diabetes mellitus and hypertension) is low, and few countries in sub-Saharan Africa have early detection programmes; even fewer have a national maintenance dialysis programme for those with advanced disease.10Barsoum RS Khalil SS Arogundade FA Fifty years of dialysis in Africa: challenges and progress.Am J Kidney Dis. 2015; 65: 502-512Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar Early risk factor identification and initiation of treatment can delay onset of disease or slow progression to ESKD. Like for HIV/AIDS, countries in sub-Saharan Africa should stop burying their heads in the sand and realise that the burden of ESKD will worsen and every small step taken in the right direction now will help to save lives in future. I declare no competing interests. Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic reviewMost patients with ESKD starting dialysis in sub-Saharan Africa discontinue treatment and die. Further work is needed to develop equitable and sustainable strategies to manage individuals with ESKD in sub-Saharan Africa. Full-Text PDF Open AccessEnd-stage kidney disease in LMICs: rising to the challengeThis time last year, to coincide with World Kidney Day (March 9), The Lancet launched a campaign to highlight the rising burden of kidney disease and to encourage research partnerships to address gaps in knowledge and care, including the affordability of such care. Nephrology research and collaboration has come a relatively long way since 2002 when the first guidelines on the evaluation and classification of chronic kidney disease were published by the US National Kidney Foundation. The burden of kidney diseases in high-income and some middle-income countries is becoming much better understood.