There are only 9 nephrologists in Ethiopia for a total of 90 million people!
Yewondwossen Tadesse Mengistu MD, consultant Nephrologist and Head, Renal Unit , Head, Department of Internal Medicine, School of Medicine
College of Health Sciences, Addis Ababa University
Addis Ababa, Ethiopia
The birth place of Australopithecus Afarensis (also called Dinkinesh or Lucy), the origin of the Blue Nile, Ethiopia is the second most populous country in Africa, with a population close to 90 million. The obelisk in Axum from the 4th century A.D., a northern city where the Ark of the Covenant is believed to be housed, monolithic rock-cut churches of Lalibela from the 12th century exemplify its ancient civilization and importance. It is a country that produced historical icons like the Queen Sheba, Emperor Menelik II, Emperor Haileselassie and more recently known for its legendary athletes such as Abebe Bikila, Haile Gebreslassie, and Derartu Tulu, to name a few. As the only independent country, it served as an inspiration for many freedom seekers from Patrice Lumumba to Nelson Mandela. Ethiopia is also the political capital of Africa where it serves as the seat of the African Union.
With this brief introduction, I would like to discuss the challenges of kidney disease in Ethiopia. There is not much out there about the extent of kidney disease in Ethiopia. If we look at two known risk factors for chronic kidney disease, diabetes mellitus and hypertension, for example, the available data is very limited, still we gather than the prevalence of hypertension varies from 10-30% in urban areas such as Addis Ababa, Gondar, Jimma to 1.8 to 10% in rural Gondar, Sidamo in the South with semi-urban areas falling in between. For example in one well done study involving 3713 adults in Addis Ababa City, 31.5% of males and 28.9% of females had hypertension defined as blood pressure ≥ 140/90 mmHg. The same study found that about 20% of males and 38% of females were overweight. The prevalence of diabetes is also high. In a cross sectional study involving over 2000 patients, the prevalence of diabetes mellitus was 6.5% and 6.6% among men and women respectively. Renal diseases accounted for 1.2-6 % of adult hospital medical admissions in reports from various parts of the country. Diseases of the genitourinary system were 5th in rank among the 10 leading causes of outpatient visits (4.45% of visits) in 2006/7. According to the latest WHO data published in April 2011, kidney disease deaths in Ethiopia reached 12,038 or 1.47% of total deaths.
Among adult patients with Acute Kidney Injury (AKI), septic abortion and falciparum malaria were the leading causes in studies in the 1980’s and 90’s. Among children with AKI in Addis Ababa, post-diarrheal hemolytic uremic syndrome (HUS) was the leading cause. Out of 30 patients with AKI, 23 were diagnosed to have HUS, very high mortality of 46.7%. Unpublished more recent data from Tikur Anbessa Hospital, the main teaching hospital of the AAU Medical School, indicates that chronic glomerulonephritis, diabetes and hypertension are the leading causes of chronic kidney disease. Mean age of patients with end stage kidney disease is much younger than reported from the developed world.
A renal (kidney) unit was opened in the Tikur Anbessa Hospital, Addis Ababa, in 1980 with the assistance of a Cuban team from the Institute of Nephrology in Havana. The unit provides outpatient and inpatient services including dialysis (when available), is involved in under and postgraduate training of doctors and research activities. The first peritoneal dialysis (PD) was done in April 1980 and the first hemodialysis was done in June 1981. The 1st private dialysis unit opened in Addis Ababa in 2001. There are presently 6 private dialysis units in A. Ababa (+ 1 in Adama) with a total of ~ 50 HD machines catering for a total of ~180 patients with end-stage renal failure. Two public hospitals in Ethiopia offer hemodialysis for patients with acute kidney failure. There are no patients on chronic peritoneal dialysis in Ethiopia. No kidney transplant services is available in Ethiopia although there is a growing number of patients with kidney transplants done in centers abroad which is close to 150 patients (most in India) over the last several years. More recently ~10 patients are transplanted annually. Ethiopia was a participant with 2 athletes at the World Transplant Games in Durban, RSA, in June 2013. Causes of end stage kidney disease among the transplant recipients’ are diabetes, hypertension, chronic glomerulonephritis and obstructive uropathy . Major problems are encountered in the provision of immunosuppressive medicines and follow-up. There are only 9 nephrologists in Ethiopia for a total of 90 million people. There are several Ethiopian nephrologists currently practicing in the US and Europe.
-An increasing patient load with renal diseases both acute kidney injury (or acute kidney failure) and chronic kidney disease ( CKD) but particularly CKD related to a rapid increase in the risk factors for kidney diseases such as hypertension and diabetes.
-Expansion of services commensurate with the country’s means is urgently needed. Initial emphasis need to focus on detection of risk factors and prevention to be followed by improvement in diagnostic services and programs for detection of kidney disease and slowing the progression of CKD. Renal replacement therapy i.e. dialysis and transplantation need to be introduced on a small scale and be expanded based on resources.
-Very low level of awareness about kidney diseases, their risk factors and the threat these pose to the health of the nation among health professionals, policy makers and the public. EDUCATION particularly tailored to each group is the key.
-Lack of data on kidney diseases for presentation to policy makers, planners; therefore, an urgent need to generate data on the magnitude of renal diseases-both institutions based and community based studies are needed.
– Limited resources available for the health sector in general and for non communicable diseases in particular. Finding resources for education, service expansion and research activities from public and private sources are vital.
-Very few qualified professionals working in the field in Ethiopia. Recruiting and training (and retaining) renal nurses, nephrologists and others is a major challenge.
And finally the involvement of Ethiopian nephrologists or friends of Ethiopia in the diaspora in education, research and patient care would go a long way to alleviate the problem in Ethiopia.
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