Abstract

In spite of favorable economic projections, stable democracies, and a reduction in regional conflicts since the turn of the century, Africa continues to be plagued by poverty, poor infrastructure, and a huge burden of infectious diseases such as HIV, malaria, tuberculosis, and diarrhea. As the incidence of chronic kidney disease and kidney failure continues to rise worldwide, these factors continue to impede the ability to provide kidney care to millions of people on the continent.

Introduction

The International Society of Nephrology Global Kidney Health Atlas project was established to assess the global burden of kidney disease and measure the global capacity for renal replacement therapies (dialysis and kidney transplantation). The purpose of the second iteration of the IFN Global Kidney Health Atlas was to assess the availability, accessibility, affordability, and quality of global renal care. We identified a number of gaps in renal care in Africa, most notably (i) significant workforce shortages, particularly in terms of the number of nephrologists; (ii) low government funding for renal care; (iii) limited availability, accessibility, reporting and quality of renal replacement therapies provided; and (iv) poor national strategies and advocacy for renal disease. We also found that the availability and accessibility of renal replacement therapy varied widely within Africa, with North African countries faring much better than sub-Saharan African countries. This evidence suggests an urgent need to increase the renal care workforce and government funding, to collect adequate information from African countries on the burden of renal disease, and to develop and implement strategies to enhance disease prevention and control across the continent.

Keywords: chronic kidney disease, quality of global renal care, Cistanche extract

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Study setting

Africa is the second largest and second most populous continent in the world after Asia. Including neighboring islands, Africa has a land area of approximately 30.3 million square kilometers, which represents 6% of the Earth's total surface area and 20% of the planet's total land area. In 2019, Africa's population was 1.3 billion people, or 17% of the world's population. It consists of 54 countries divided into 5 geographical and economic regions: northern Africa, central Africa, eastern Africa, southern Africa, and western Africa. There are also 8 territories and 2 independent states with limited recognition on the continent. Algeria has the largest land area in Africa (2.4 million square kilometers), while Nigeria has the largest population (206 million). Africa contains a rich variety of peoples, cultures, religions, and languages, with English, French, and numerous native languages being the most common forms of communication.

Despite its rich natural resources, Africa is the world's poorest and least developed continent, excluding Antarctica; its total nominal GDP is lower than many individual countries, including the United States, China, Japan, Germany, the United Kingdom, India, and France. According to the World Bank, more than half of the extremely poor live in sub-Saharan Africa, with 413 million people living on less than $1.90 a day in 2015.

Although Sub-Saharan Africa's score on the Human Development Index - a statistical composite of life expectancy, education, and per capita income indicators - rose from 0.402 in 1990 to 0.541 in 2018, it is still the lowest of all developing regions in the world. Sub-Saharan Africa's score ranges from 0.377 in Niger to 0.801 in Seychelles. Six of the 10 countries with the highest Gini Index scores are in Africa (Lesotho, South Africa, Botswana, Namibia, Zambia, and Comoros), highlighting the large disparities in wealth distribution. In addition, the proportion of government spending on health is low in Africa. In 2017, the World Health Organization reported a 70-fold difference in healthcare spending between high- and low-income countries, with the lowest spending in West, Central, and East African countries. In the same year, more than half of donor funding for health went to 14 countries and one-fifth went to only four countries, three of which were African (Kenya, Nigeria, and Uganda).

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The current state of kidney care in Africa

Several reviews have been published on the current status of nephrology in Africa. However, no continent-wide or regional studies from Africa have data on CKD, KF, or KRT. A major reason for this situation is the lack of continent-wide renal disease registries. Recognizing the importance of establishing a continent-wide renal registry, the African Society of Nephrology (AFRAN) and the African Society of Pediatric Nephrology began work in 2015 to establish a continent-wide renal registry. It is believed that this initiative may have a significant impact on the practice of nephrology and the provision of services for adults and children with KF in many African countries. Currently, the only source of comprehensive information on kidney disease in Africa is the 2017 ISN-GKHA.

Characteristics of participating countries

Among the ISN regions, Africa has the largest number of survey respondents (n =63); these countries represent 42 countries of 1.2 billion people (95.04% of Africa's population)(Figure 1). The World Bank classified 7 (16.7%) of these countries as upper-middle-income, 16 (38.1%) as lower-middle-income, and 19 (45.2%) as low-income countries Seychelles, the only high-income country in Africa, did not respond to the survey. Health care expenditures as a percentage of GDP ranged from 2.7% in Gabon to 18.3% in Sierra Leone (Table 1) Respondents included nephrologists (n=48,76%), non-nephrologists (n=8,13%), non-internal health care professionals (n=3,5%), hospital managers or policymakers (n=2,3%), and others (n=2,3%), with a regional response rate of 70%.

The burden and risk factors of CKD, KF in Africa

The prevalence of CKD in Africa is 6.28%, which is lower than the global prevalence of 9.46%. The middle- and high-income countries of Mauritius had the highest CKD prevalence in Africa (17.63%), while the low-income country of Uganda had the lowest CKD prevalence (4.87%). The percentage of deaths attributable to CKD ranged from 0.57% in Zambia to 10.36% in Mauritius, while the percentage of disability-adjusted life years ranged from 0.58% in Nigeria to 6.85% in Mauritius. Among the risk factors for CKD, obesity was most prevalent in Libya (31.8%), hypertension in Niger (33.4%), and smoking in Tunisia (19.9%) (Supplementary Table S1). Although few data are available on the prevalence of treated KF, significant differences were observed in reported prevalence across countries, ranging from as low as 4.4 ppm per million population in Rwanda to 1018 pmp in Tunisia (Table 2).

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Capacity for KRT service provision in Africa

Of the African countries that responded, 100% reported providing long-term health care services, while only 41% reported providing long-term PD services. The region with the highest prevalence of long-term dialysis (HD and PD) was North Africa, with Tunisia (759.6 pmp), Egypt (610.0 pmp), Libya (360.1 pmp), Algeria (251.4 pmp), and Morocco (185.6 pmp). Tanzania had the lowest prevalence of long-term dialysis (0.5 pmp) (Table 2). Only 51% of countries reported universal availability of HD as an option (10% for PD); there was no home HD in Africa (Figure 3). Only 44% of countries reported the ability to adhere to a standard HD prescription (3 treatments per week for 3 to 4 hours) and only 17% reported the ability to perform 3 to 4 PD exchanges per day. Only 15% of countries in the region generally provide efficient transport services for people with Parkinson's disease. Dialysis is not the dominant form of dialysis in any country and is not readily available in many countries. In Africa, the median for HD centers is 0.53 pmp (compared to 4.46 pmp globally) and for PD centers is 0.09 pmp (compared to 1.27 pmp globally) (Figure 3).

African capacity to diagnose KF complications is comparable to, but below, global capacity. simulated and automated blood pressure monitoring and measurement of hemoglobin and serum electrolytes are generally available in 75% of countries. However, basic treatments for KF complications are not readily available; oral sodium bicarbonate, potassium exchange resin, parenteral iron, and non-calcium-based phosphate binders are available in only 32%, 39%, 56%, and 12% of countries, respectively (Figure 4). In Africa, access to KRT is very limited. In only 34% of countries, more than 50% of patients have access to HD, while in only 2% of countries, 26% - 50% of patients are able to start KRT with PD (Figure 3). When considering factors influencing dialysis access, geography played a significant role in 54% of countries. Patient characteristics played a limited role in determining access to HD and PD (Figure 4).

Discussion

Chronic kidney disease is a public health problem. This is most true in low- and middle-income countries, particularly in Africa, where resources to address the severe burden of chronic kidney disease are severely lacking. Furthermore, due to challenges associated with health transition, Africa is experiencing a severe double burden of communicable and non-communicable diseases that many healthcare systems are not yet ready to address. Thus, despite the expected increase in CKD prevalence in Africa, the gap between those who need KRT and those who receive it is greatest in Africa compared to other regions, and mortality rates for KF patients in Africa remain alarmingly high.

Our findings highlight significant gaps in the capacity to provide kidney care in Africa. The gaps are significant when compared to global data; however, there are significant differences between African countries in the ability to provide KRT and the ability to access KRT. The main findings of our study were (i) severe workforce shortages, especially regarding the number of nephrologists; (ii) low government funding for renal care; (iii) limited availability, accessibility, reporting, and quality of KRT provided; and (iv) weak national strategies and advocacy for renal disease.

Labor shortage, especially of nephrologists, is a major constraint in the provision of renal care in Africa. Compared to an average of 9.95 nephrologists/hour in the rest of the world, the figure for Africa is 0.62 nephrologists/hour, with a significant difference between North Africa and Sub-Saharan Africa. An adequate health workforce is considered the cornerstone of a country's healthcare system, without which universal health coverage and sustainable development goals cannot be achieved. Health workers often provide leadership and advice to government decision-makers responsible for policy development and setting health care priorities. The shortage of nephrologists in many African countries may explain why renal care remains weak in all aspects across the continent. Among several factors contributing to the low number of nephrologists globally, several are relevant to Africa, including the growing burden of CKD, lack of exposure to nephrology among students and residents, inflexible work schedules, and inadequate training due to lack of trainers and necessary training infrastructure.

In conclusion, this study reveals many gaps in the care for kidney disease in Africa. While it is important to address needs in all areas, there is an urgent need to focus on issues such as addressing workforce shortages, increasing government funding, reporting more information on kidney disease, and implementing disease prevention and control strategies in Africa.

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REFERENCES

1. United Nations. Global issues (Africa).

2. Okpechi IG. ESKD in sub-Saharan Africa: will governments now listen? Lancet Glob Health. 2017;5:e373–e374.

3. Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet. 2015;385:1975– 1982.

4. Bello AK, Levin A, Tonelli M, et al. Assessment of global kidney health care status. JAMA. 2017;317:1864–1881.

5. Bello AK, Okpechi IG, Jha V, et al. Understanding distribution and variability in care organization and services for the management of kidney care across world regions. Kidney Int Suppl. 2021;11:e4–e10.

6. World Bank. GDP ranking. June 2019. Published 2019. Accessed June 15, 2020.

7. Central Intelligence Agency. The world factbook. Published 2019. Accessed March 11, 2021.

8. Abu-Aisha H, Elamin S. Peritoneal dialysis in Africa. Perit Dial Int. 2010;30: 23–28.

9. Jain AK, Blake P, Cordy P, Garg AX. Global trends in rates of peritoneal dialysis. J Am Soc Nephrol. 2012;23:533–544.

10. Mahmoud KM, Sheashaa HA, Gheith OA, et al. Continuous ambulatory peritoneal dialysis in Egypt: progression despite handicaps. Perit Dial Int. 2010;30:269–273.

11. Matri A, Elhassan E, Abu-Aisha H. Renal replacement therapy resources in Africa. Arab J Nephrol Transplant. 2008;1:9–14.

12. Soliman AR, Fathy A, Roshd D. The growing burden of end-stage renal disease in Egypt. Ren Fail. 2012;34:425–428.

13. Sumaili EK, Krzesinski JM, Zinga CV, et al. Prevalence of chronic kidney disease in Kinshasa: results of a pilot study from the Democratic Republic of Congo. Nephrol Dial Transplant. 2009;24:117–122.

14. Tshamba HM, Van Caillie D, Nawej FN, et al. Risk of death and the economic accessibility at dialysis therapy for renal insufficient patients in Lubumbashi city, Democratic Republic of Congo. Pan Afr Med J. 2014;19:61.

15. van der Tol A, Lameire N, Morton RL, et al. An international analysis of dialysis services reimbursement. Clin J Am Soc Nephrol. 2019;14: 84–93.

16. World Health Organization. The global health observatory. Published 2019. Accessed June 22, 2020.

17. United States Renal Data System. 2018 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2018.

18. Bello AK, Levin A, Lunney M, et al. Status of care for end-stage kidney disease in countries and regions worldwide: an international cross-sectional survey. BMJ. 2019;367:l5873.

19. United Nations. Global issues: population. Published 2019. Accessed June 22, 2020.

20. United Nations Population Fund. World population dashboard. Published 2020. Accessed March 15, 2020.

21. World Bank. Understanding poverty. Published 2019. Accessed June 22, 2020.

22. UNDP-United Nations Development Programme. Human development data (1990-2018). Published 2018. Accessed March 15, 2020.

23. Central Intelligence Agency. Distribution of family income - GINI Index. Published 2019. Accessed March 15, 2020.

24. World Health Organization. Global spending on health: a world in transition. Geneva. Published 2019. Accessed March 8, 2020.

25. Swanepoel CR, Wearne N, Okpechi IG. Nephrology in Africa—not yet uhuru. Nat Rev Nephrol. 2013;9:610–622.

26. Naicker S. Burden of end-stage renal disease in sub-Saharan Africa. Clin Nephrol. 2010;74(suppl 1):S13–S16.

27. Barsoum RS, Khalil SS, Arogundade FA. Fifty years of dialysis in Africa: challenges and progress. Am J Kidney Dis. 2015;65:502–512.

28. Wearne N, Okpechi IG, Swanepoel CR. Nephrology in South Africa: not yet ubuntu. Kidney Dis (Basel). 2019;5:189–196.

29. Okpechi IG, Swanepoel CR, Venter F. Access to medications and conducting clinical trials in LMICs. Nat Rev Nephrol. 2015;11:189–194.

30. Davids MR, Eastwood JB, Selwood NH, et al. A renal registry for Africa: first steps. Clin Kidney J. 2016;9:162–167.

31. Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: global dimension and perspectives. Lancet. 2013;382:260–272.

32. Maher D, Smeeth L, Sekajugo J. Health transition in Africa: practical policy proposals for primary care. Bull World Health Organ. 2010;88(12): 943–948.

33. Kushitor MK, Boatemaa S. The double burden of disease and the challenge of health access: evidence from access, bottlenecks, cost, and equity facility survey in Ghana. PLoS One. 2018;13:e0194677.

34. Ashuntantang 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;5: e408–e417.

35. World Health Organization. Health workforce requirements for universal health coverage and sustainable development goals. Published 2016. Accessed March 15, 2020.

36. Reich MR, Harris J, Ikegami N, et al. Moving towards universal health coverage: lessons from 11 country studies. Lancet. 2016;387:811–816.

37. Osman MA, Alrukhaimi M, Ashuntantang GE, et al. Global nephrology workforce: gaps and opportunities toward a sustainable kidney care system. Kidney Int Suppl. 2018;8:52–63.

38. Sharif MU, Elsayed ME, Stack AG. The global nephrology workforce: emerging threats and potential solutions! Clin Kidney J. 2016;9(1):11–22