End stage kidney disease in sub-Saharan Africa , is kidney transplantation the answer ?

Since the first successful kidney transplantation on Dec 23, 1954 at Brigham hospital in Boston, Massachusetts across identical twins, kidney transplantation has become the ultimate choice for patients with end stage kidney disease near or requiring dialysis conferring improved survival advantages, a better quality of life and decreased long term health care costs compared to dialysis.
While infection such as malaria , tuberculosis, HIV are still the leading causes of death in sub-Saharan Africa ( comprises of 47 countries with over 80% of the land mass of the African continent), non-communicable diseases such as diabetes mellitus and hypertension are becoming more prevalent contributing to the health care burden of these countries. Both diabetes and hypertension are leading cause of kidney failure. The prevalence of diabetic kidney disease is as high as 23.8% in Zambia, 14-16% in South Africa, 12.4% in Egypt, 9% in Sudan and about 6.1% in Ethiopia with overall estimate of 6-16% in sub-Saharan Africa.(1). Glomerular disease is also a common cause of end stage kidney disease with the nephrotic syndrome many fold higher in Africa (2). Chronic glomerulonephritis, diabetes and hypertension are also the leading causes of chronic kidney disease in Ethiopia as is true in the rest of sub-Saharan Africa (3). There is limited availability of dialysis and transplantation in sub-Saharan Africa, both cost and shortage of skilled personnel as main limitations. Many parts of sub-Saharan Africa lack nephrologists ranging from 0.5 per million populations in Kenya to 1.1 per million populations in South Africa. Funding for dialysis or transplantation in sub-Saharan Africa is mainly private and most patients can’t afford dialysis three times per week. For example only about 20% of patients in one Nigerian center can afford hemodialysis three times a week (1). Some countries such as Mali, Mauritius, South Africa and Sudan have government programs for some patients. For example South African covers for dialysis cost for patients who are eligible for transplantation. Peritoneal dialysis is limited in sub-Saharan Africa to few countries such South Africa because of the cost of the fluid and perceived risk of infection (peritonitis). Only a handful of countries such as South Africa and Kenya manufacture dialysis solutions. In Sub-Saharan Africa where 65% of the population lives in rural areas, although peritoneal dialysis seems a better option, there are other challenges such difficulty arranging transportation of dialysis supplies, lack of availability of space for storing dialysis supplies compounded by lack of access to clean water, electricity, etc. The average cost of hemodialysis in Africa is about $100 per session.

Transplantation is carried out in few countries in Sub-Saharan Africa such as South Africa, Nigeria, Mauritius, and Ghana. Most kidney transplantations are from living kidney donors although South Africa has deceased kidney donor program. Based on published reports, Sudan with a prevalence rate of end stage kidney disease about 106 patients per million populations has a dialysis population of about 2700 patients with kidney transplantation accounting for about 28% and with 26.4 % on active transplant list. Sudan has a program for organ transplantation that allows for 120 kidney transplants per year with full financial support. Between the period of 2000-2009, 588 transplant operations were performed through the government fund (4).

The treatment of end stage kidney disease in Ethiopia is limited to few dialysis centers in major cities such as Addis Ababa with about 180 patients getting some dialysis care. There were no patients on chronic peritoneal dialysis and no kidney transplant services exist in Ethiopia although a growing number of patients, about 150, had kidney transplants done in centers abroad (3) as outlined in a blog article on this page on Dec 18, 2013 by the head of the renal unit in Addis Ababa University, the main teaching hospital in Ethiopia.

As the second most populous country in sub-Saharan Africa, Ethiopia need a coordinated effort between the government ,the diaspora, the private sector and donor organizations to improve the care of patients with kidney disease that involves prevention and treatment of infections and chronic conditions such as diabetes and hypertension, investing on education and early awareness of chronic kidney disease, designing cost-effective strategies such as local production of dialysis fluid to initiate and expand peritoneal dialysis, and more importantly establishing a living donor kidney transplantation program after appropriate ethical issues such as organ trafficking and organ tourism are addressed. Kidney transplatation not only confers improved quality of life and long term survival but it is cost effective comparted to dialysis after the first few years.

1. Ethn Dis.2009 Spring; 19(1 Suppl 1):S1-13-5
2. Clinical Nephrology, Vol 74-Suppl.1/2010 (S13-S16)
3. Challenges of kidney disease in Ethiopia, a call for diaspora involvement ( http://tenayistilign.com)
4. Saudi J Kidney Dis Transpl 2013 :24(5):1044-1049
5. Peritoneal dialysis international,Vol.30,pp.23-28

About Tenayistilign

I am a physician trained at Jimma Institute of Health Sciences ( now Jimma University, in Jimma, Ethiopia) and Wayne State University ( Detroit, MI, USA). I teach and practice General Nephrology/Hypertension and Kidney Transplantation in the USA.
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