Fatiu A. Arogundade

CKD Prevention in Sub-Saharan Africa: A Call for Governmental, Nongovernmental, and Community Support

The upsurge in incidence and prevalence of chronic kidney disease (CKD) in both developed and developing nations has necessitated a renewed interest in global CKD prevention because it is now regarded as a public health threat. Although CKD management is consuming a huge proportion of health care finances in developed countries, it is contributing significantly to morbidity, mortality, and decreased life expectancy in developing ones. CKD epidemiological characteristics in Sub-Saharan Africa (SSA) are strikingly different from those observed in other regions. Although middle-aged and elderly populations are predominantly affected in developed countries, in SSA, CKD mainly affects young adults in their economically productive years, with hypertension and infection-related chronic glomerulonephritis as the major causes. Morbidity and mortality are high because most affected individuals cannot access renal replacement therapy. Other contributory factors for this dismal picture include late presentation, limited renal replacement therapy and its unaffordability, absence of kidney disease prevention programs, and the poor literacy level. This gloomy outlook of CKD in the subregion makes prevention the only viable option in the long term while struggling to improve access to renal replacement therapy in the short term. Unfortunately, most countries in SSA have no prevention programs, and where available, they are either institutions or individual based with very little or no governmental support. This review focuses on the burden of CKD in SSA and reviews the available prevention programs with a view to stimulating governments, communities, and organizations to establishing an inexpensive and affordable program in the entire subregion.

Relationship of ultrasonographically determined kidney volume with measured GFR, calculated creatinine clearance and other parameters in chronic kidney disease (CKD).

INTRODUCTION Kidney length has traditionally been used as a predictor of chronic kidney disease (CKD); however, kidney volume (KV) rather than length has been emphasized by researchers as a true predictor of kidney size in states of good health and disease. Since KV can be assumed to be a predictor of kidney mass or remaining surviving nephrons in CKD patients, we theorized that the KV should reflect the functional capacity of the kidneys, i.e. the glomerular filtration rate (GFR). METHODOLOGY Forty CKD patients were recruited and investigated. Measured GFR was determined by calculating the average of endogenous creatinine clearance (mCrCl) and urea clearance (mUrCl) while predicted GFR was determined using Cockcroft and Gault, Hull and Modification of Diet in Renal Disease (MDRD) equations. KV was assessed ultrasonographically using the formulae of Dinkel et al. and Solvig et al. for ellipsoid organ. The relationship between the KV and GFR was assessed using Spearmans correlation coefficient while Bland and Altman tests were used to assess intraobserver variation and agreement between measured and predicted GFR. RESULTS The results showed a weak but positive correlation between KV and various indices of GFR, best with measured CrCl (correlation coefficient ranged between 0.408 and 0.503; P < 0.05), and which was not improved after normalization for body surface area (BSA). We also found a significant correlation between the measured CrCl and various values of estimated CrCl. CONCLUSION Ultrasonographically determined KV was found to correlate with GFR and hence can be used to predict it in established CKD, particularly in resource-poor settings.

Outcomes of acute kidney injury in children and adults in sub-Saharan Africa: a systematic review

BACKGROUND Access to diagnosis and dialysis for acute kidney injury can be life-saving, but can be prohibitively expensive in low-income settings. The burden of acute kidney injury in sub-Saharan Africa is presumably high but remains unknown. We did a systematic review to assess outcomes of acute kidney injury in sub-Saharan Africa and identify barriers to care. METHODS We searched PubMed, African Journals Online, WHO Global Health Library, and Web of Science for articles published between Jan 1, 1990, and Nov 30, 2014. We scored studies, and all were of medium-to-low quality. We made a pragmatic decision to include all studies to best reflect reality, and did a descriptive analysis of extracted data. This study is registered with PROSPERO, number CRD42015015690. FINDINGS We identified 3881 records, of which 41 met inclusion criteria, including 1403 adult patients and 1937 paediatric patients. Acute kidney injury in sub-Saharan Africa is severe, with 1042 (66%) of 1572 children and 178 (70%) 253 of adults needing dialysis in studies reporting dialysis need. Only 666 (64%) of 1042 children (across 11 studies) and 58 (33%) of 178 adults (across four studies) received dialysis when needed. Overall mortality was 34% in children and 32% in adults, but rose to 73% in children and 86% in adults when dialysis was needed but not received. Major barriers to access to care were out-of-pocket costs, erratic hospital resources, late presentation, and female sex. INTERPRETATION Patients in these studies are those with resources to access care. In view of overall study quality, data interpretation should be cautious, but high mortality and poor access to dialysis are concerning. The global scarcity of resources among patients and health centres highlights the need for a health-system-wide approach to prevention and management of acute kidney injury in sub-Saharan Africa. FUNDING None.

Prevalence of chronic kidney disease in a Nigerian family practice population

Abstract Background: Chronic kidney disease (CKD) is a global public health problem, with a greater burden and prohibitive cost of care particularly in developing countries. This study determined the prevalence of chronic kidney disease and identified its associated risk factors in patients attending the Family Practice Clinic, Wesley Guild Hospital, Ilesa, Nigeria. Method: Consecutive newly-registered patients who attended the Family Practice Clinic of Wesley Guild Hospital, Ilesa from August 2005 to January 2006 were recruited and studied. Relevant data were collected by using an interviewer-administered questionnaire, and determining the spot urinary ACR (albumin-creatinine ratio) of the subjects by using Microalbustix™ reagent strips and using their serum creatinine concentration. The glomerular filtration rate (GFR) of each subject was estimated using the Modification of Diet in Renal Disease (MDRD) formula. A repeat urine test was done three months after the initial screening to identify subjects with persistent microalbuminuria. Results: The age of the study subjects ranged from 20 to 74 years, with a mean age of 50.52 + 13.03 years. There were 68 males and 182 females in the sample population, showing a male to female ratio of 1:2.7. One hundred and thirteen of the 250 subjects (45.2%) were found to have pathologic albuminuria at the initial screening, while 31 (12.4%) had persistent albuminuria three months later. Also, 51 subjects (20.4%) had estimated low GFR at the initial screening and 26 (10.4%) had persistent low GFR three months later. Significant risk factors for CKD in the study subjects were increasing age, elevated blood pressure, history of diabetes mellitus (DM), habitual intake of analgesics and herbs, and an abnormal waist to hip ratio (p < 0.05). The association between persistent abnormal ACR and low GFR did not reach statistical significance (p = 0.053). Habitual analgesic intake (p = 0.002) and age group (p = 0.0027) were true predictors of CKD among the study subjects. Conclusions: The prevalence of CKD in the study population was high and its association with modifiable risk factors was demonstrated. Family physicians have a unique opportunity to identify and address these factors in their patients. Routine screening for CKD in family practice clinics is indicated to reduce the burden of renal disease in the population.

An appraisal of kidney dysfunction and its risk factors in patients with sickle cell disease.

Sickle cell disease (SCD), a genetically inherited disease of blacks, often presents with disabling acute complications which can occasionally be fatal. Its renal manifestations are increasingly being recognized as affected patients now survive to middle and rarely old age. We set out to determine the magnitude of kidney dysfunction in our SCD patient population and evaluate its predictive factors. We reviewed the available case records of SCD patients managed in our hospital. Information on socio-demographic, clinical and laboratory data were retrieved and collated. A total of 374 (99.46%) were reviewed with complete data; the median age was 23 years (range 7–62), while median age at diagnosis of SCD was 4 years (range 0.25–31). 235 patients (68.2%) had no kidney disease while the remaining 139 (37.2%) had proteinuria, hematuria or reduced glomerular filtration rate (GFR) <60 ml/min. The age of patients was a significant predictor of kidney disease (p = 0.002) and correlated with the level of serum creatinine (r = 0.188, p < 0.001), GFR (r = 0.245, p < 0.0001) and the degree of proteinuria (r = 0.174, p = 0.006). Patients with kidney disease had a significantly higher number of crises/hospitalizations (p < 0.001). Seven patients died in all and 4 (57%) of them had end-stage renal disease. We concluded that kidney disease is a common complication of SCD and significantly contributes to mortality. The age of the patients, duration of SCD and frequency of crises/hospitalizations are strong predictors of development of kidney disease.

Understanding kidney care needs and implementation strategies in low- and middle-income countries: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference

Evidence-based cinical practice guidelines improve delivery of uniform care to patients with and at risk of developing kidney disease, thereby reducing disease burden and improving outcomes. These guidelines are not well-integrated into care delivery systems in most low- and middle-income countries (LMICs). The KDIGO Controversies Conference on Implementation Strategies in LMIC reviewed the current state of knowledge in order to define a road map to improve the implementation of guideline-based kidney care in LMICs. An international group of multidisciplinary experts in nephrology, epidemiology, health economics, implementation science, health systems, policy, and research identified key issues related to guideline implementation. The issues examined included the current kidney disease burden in the context of health systems in LMIC, arguments for developing policies to implement guideline-based care, innovations to improve kidney care, and the process of guideline adaptation to suit local needs. This executive summary serves as a resource to guide future work, including a pathway for adapting existing guidelines in different geographical regions.

Kidney transplantation in a low-resource setting: Nigeria experience

The incidence and prevalence of chronic kidney disease and end-stage renal disease (ESRD) have continued to increase exponentially all over the world in both developed and developing countries. While the majority of patients in developed countries benefit from various modalities of renal replacement therapies, those from developing economies suffer untimely deaths from uremia and cardiovascular disease. Kidney transplantation (KT) leads to improvement in both the quantity and quality of life. Unfortunately, it is not exploited to its full potential in most countries and this is particularly the case in developing economies. Only a very small fraction of the ESRD population in emerging countries ever gets transplanted because of the many constraints. This review focuses on KT in Nigeria between 2000 and 2010 and assessed particular challenges that need be addressed for KT potential to be fully harnessed in such resource-constrained settings. A total of 143 KTs were performed in 5 transplant centers, some of which have only recently opened. One-year graft and patient survival was 83.2% and 90.2%, respectively, while the 5-year graft and patient survival was 58.7% and 73.4%, respectively. Mortality was reported in 38 (27%) of recipients. The complications recorded included acute rejection episodes in 15–30%, chronic allograft nephropathy in 21(14.7%) and malignancies, particularly Kaposi Sarcoma, which was reported in 8 (5.6%) recipients. It was concluded that KT has led to an improved survival but is bedevilled with unaffordability, inaccessibility, a shortage of donor organs and poor legislative support. Enactment of relevant organ transplant legislation, subsidization of renal care, and further development of local capacities would improve KT utilization and thus lead to better outcomes.

A renal registry for Africa: first steps

There is a dearth of data on end-stage renal disease (ESRD) in Africa. Several national renal registries have been established but have not been sustainable because of resource limitations. The African Association of Nephrology (AFRAN) and the African Paediatric Nephrology Association (AFPNA) recognize the importance of good registry data and plan to establish an African Renal Registry. This article reviews the elements needed for a successful renal registry and gives an overview of renal registries in developed and developing countries, with the emphasis on Africa. It then discusses the proposed African Renal Registry and the first steps towards its implementation. A registry requires a clear purpose, and agreement on inclusion and exclusion criteria, the dataset and the data dictionary. Ethical issues, data ownership and access, the dissemination of findings and funding must all be considered. Well-documented processes should guide data collection and ensure data quality. The ERA-EDTA Registry is the worlds oldest renal registry. In Africa, registry data have been published mainly by North African countries, starting with Egypt and Tunisia in 1975. However, in recent years no African country has regularly reported national registry data. A shared renal registry would provide participating countries with a reliable technology platform and a common data dictionary to facilitate joint analyses and comparisons. In March 2015, AFRAN organized a registry workshop for African nephrologists and then took the decision to establish, for the first time, an African Renal Registry. In conclusion, African nephrologists have decided to establish a continental renal registry. This initiative could make a substantial impact on the practice of nephrology and the provision of services for adults and children with ESRD in many African countries.

Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review

BACKGROUND The burden of end-stage kidney disease (ESKD) in sub-Saharan Africa is unknown but is probably high. Access to dialysis for ESKD is limited by insufficient infrastructure and catastrophic out-of-pocket costs. Most patients remain undiagnosed, untreated, and die. We did a systematic literature review to assess outcomes of patients who reach dialysis and the quality of dialysis received. METHODS We searched PubMed, African Journals Online, WHO Global Health Library, and Web of Science for articles in English or French from sub-Saharan Africa reporting dialysis outcomes in patients with ESKD published between Jan 1, 1990, and Dec 22, 2015. No studies were excluded to best represent the current situation in sub-Saharan Africa. Outcomes of interest included access to dialysis, mortality, duration of dialysis, and markers of dialysis quality in patients with ESKD. Data were analysed descriptively and reported using narrative synthesis. FINDINGS Studies were all of medium to low quality. We identified 4339 studies, 68 of which met inclusion criteria, comprising 24 456 adults and 809 children. In the pooled analysis, 390 (96%) of 406 adults and 133 (95%) of 140 children who could not access dialysis died or were presumed to have died. Among those dialysed, 2747 (88%) of 3122 adults in incident ESKD cohorts, 496 (16%) of 3197 adults in prevalent ESKD cohorts, and 107 (36%) of 294 children with ESKD died or were presumed to have died. 2508 (84%) of 2990 adults in incident ESKD cohorts discontinued dialysis compared with 64 (5%) of 1364 adults in prevalent ESKD cohorts. 41 (1%) of 4483 adults in incident ESKD cohorts, 2280 (19%) of 12 125 adults in prevalent ESKD cohorts, and 71 (19%) of 381 children with ESKD received transplants. 16 studies reported on management of anaemia, 17 on dialysis frequency, eight on dialysis accuracy, and 22 on vascular access for dialysis INTERPRETATION: Most 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. FUNDING None.

Fifty Years of Dialysis in Africa: Challenges and Progress

This review addresses the development of dialysis services in Africa in the face of past and contemporary challenges. Maintenance dialysis treatment programs developed in 29 countries over the past 50 years, usually many years after their independence and the end of subsequent territorial and civil wars. Eight countries had the resources to launch national dialysis programs, conventionally defined as those accommodating at least 100 patients per million population. Additionally, based on information obtained from international and local publications, conference proceedings, and personal communications, it appears that limited short-term dialysis therapy currently is available in most African countries. Currently, the prevalence of and outcomes associated with dialysis in Africa are influenced significantly by the following: (1) local health indexes, including the prevalence of undernutrition and chronic infections; (2) per capita gross domestic product; (3) national expenditures on health and growth of these expenditures with incremental demand; (4) availability and adequate training of health care providers; and (5) literacy. In an attempt to reduce the socioeconomic burden of maintenance dialysis treatment, 12 countries have adopted active transplantation programs and 5 are striving to develop screening and prevention programs. Our recommendations based on these observations include optimizing dialysis treatment initiatives and integrating them with other health strategies, as well as training and motivating local health care providers. These steps should be taken in collaboration with regulatory authorities and the public.