| | CKD Prevention in Sub-Saharan Africa: A Call for Governmental, Nongovernmental, and Community SupportReceived 18 September 2007 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. The incidence and prevalence of chronic kidney disease (CKD) has increased exponentially in recent years in both developed and developing nations and is consuming a huge proportion of health care finances in developed countries, while contributing significantly to morbidity, mortality, and decreased life expectancy in developing ones. This has necessitated renewed interest in global CKD prevention because it is now regarded as a public health threat.1, 2 CKD in Sub-Saharan Africa (SSA) principally affects young adults in their economically productive years and is a leading cause of mortality. Contributory factors for this dismal picture include late presentation to the hospital, limited renal replacement therapy (RRT), limited capacity of health workers in kidney disease prevention, and poor awareness of kidney disease in the community.3, 4 In a previous report, we identified 5 factors responsible for this rejuvenated attention that included a rapid increase in its prevalence, enormous cost of treatment, and recent data indicating that overt disease is just the tip of the CKD iceberg. In addition, the recent appreciation of its role in increasing cardiovascular disease risk and the detection of successful measures to halt or prevent its progression are also key factors contributing to this renewed interest. Based on these, the developed countries now made CKD prevention the center of attention in their health care planning. Unfortunately, in the developing world, where about 85% of the world population lives, CKD prevention programs are either rudimentary or virtually nonexistent.1 In appreciation of the enormity of the pandemic of renal and cardiovascular disease, particularly in resource-poor settings, the International Society of Nephrology (ISN) convened a workshop in Bellagio, Italy, to stem the increasing trend. The Bellagio Declaration concluded that screening and treatment should focus on cost-beneficial strategies that ought to be affordable by all countries. Vital components of the recommended screening include blood pressure and urinary albumin measurement, as well as effective and affordable treatment strategies to decrease blood pressure and decrease or halt albuminuria.5, 6 Burden of CKD in SSA  The SSA region comprises nearly 50 sovereign African states that lie south of the Sahara Desert. Geographically, the demarcation line is the southern edge of the Sahara Desert, which cuts through Sudan, Chad, Niger, Mali, and Mauritania. SSA countries are grouped into 5 subregions: Eastern Africa, Southern Africa, West Africa, Central Africa, and the islands of the eastern coast of the continent, Madagascar, Mauritius, the Comoros, and the Seychelles (Fig 1). SSA contains approximately 70% of the least developed countries of the world, which have huge debt burdens and poor governmental policies. With an estimated population of about 800 million, predominantly rural (65%), most of the countries have a gross domestic product per capita of less than $1,500, and about half the population lives on less than $1 per day; management of CKD is not just difficult, but impracticable.7 This extreme poverty, the increasing prevalence of noncommunicable diseases (such as hypertension and diabetes mellitus), and the ever increasing prevalence of communicable or infectious diseases—exemplified by the scourge of human immunodeficiency virus/acquired immunodeficiency syndrome and hepatitis B virus infection—has led to a phenomenal increase in the incidence and prevalence of CKD in SSA. The overall life expectancy in SSA has decreased significantly in the last 10 years and now averages 46.3 and 44.8 years for women and men, respectively. Although CKD prevalence is on the increase globally, the US Third National Health and Nutrition Examination Survey5 showed that only 0.2% of the studied population (16,800) were in end-stage renal disease (ESRD), whereas 4.5% were in overt CKD (stages 3 and 4) and the remaining 6.3% had covert CKD (stages 1 and 2). The implication of this is that for every patient with ESRD, there are more than 200 with overt disease and almost 5,000 with covert disease.8 The Australian Diabetic Study found that 16% of the 11,247 individuals screened had renal disease, 9.7% of whom had varying degrees of renal impairment.9 This clearly indicates that patients with ESRD are undoubtedly a very small fraction of the CKD population in these studies, and this can be extrapolated to most, if not all, communities. Unfortunately, information for CKD prevalence is lacking for most countries and worse still in countries without a renal disease registry, where most countries in SSA belong. Consequently, international comparisons are better hinged on ESRD prevalence than CKD. The exact ESRD prevalence in SSA is difficult to compute; hence, the reliance on hospital prevalence reports in most instances. We earlier assessed the magnitude of chronic renal failure (CRF; including patients with advanced CKD to ESRD) in Nigeria through a questionnaire survey of renal care centers.3 We found that CRF was very prevalent, with an overall average of 2% to 4% of medical admissions and between 100 and 120 new patients seen per year. A conservative estimate from this would put the incidence at about 1,000 new cases per year. However, we believed this was a gross underestimation of occurrence because only 60% of the centers responded and only admitted patients, certainly the very ill, were taken into consideration. In our recent retrospective review of ESRD cases managed during a 15-year period, we found an exponential increase from 6% of medical admissions in 1989 to 16% in 2003 (Fig 2).10 Diouf et al11 in Dakar University Hospital Internal Medicine Department retrospectively analyzed 243 in-patients with CRF managed during a 3-year period and found that the majority were young and about a third were in ESRD, but only 8.23% received RRT. Naicker,12 in her review of ESRD in SSA and South Africa, berated the lack of reliable statistics in SSA, although reported that an estimated 2% to 3% of medical admissions in tropical countries are for renal-related symptoms, with the majority being the glomerulonephritides. Plange-Rhule et al13 assessed renal disease– and blood pressure–related admissions and deaths among acute medical admissions during an 8-month period and found that 166 of 593 acute medical admissions (5%) were ascribable to renal disease, of whom 45 patients (27.1%) died, usually of ESRD. In an effort to determine the prevalence of renal disease and consequently the need for renal care and training, Fogazzi et al14 established a successful renal care program in 2 West African states (Benin and Togo). They found that 3.3% of all admitted patients had serum creatinine values of 2.0 mg/dL or greater during a 12-month period in a Benin hospital, whereas 1% of all admissions in the same hospital had 3+ or greater albuminuria during the same period (Table 1). Screening aimed at detecting early CKD or its risk factors was conducted in different parts of SSA. The Nigerian Association of Nephrology conducted routine screening during a kidney disease awareness and sensitization campaign and found that 13.6% and 19% of participants had hypertension and proteinuria, respectively.15 Asinobi et al16 conducted a cross-sectional population survey in a multitribal urban community in Ibadan, Nigeria, and found systemic hypertension in 28.2% of 2,348 adults and 10.8% of 1,152 pediatric participants aged 3 years and older. They also found proteinuria in 2.9% of the 3,500 screened participants. Amira et al17 assessed the prevalence of CKD risk factors in unselected subjects in Lagos, Nigeria, and found hypertension in 36.3% of the 1,416 respondents (514 persons) for whom data were analyzed. They also found that 2.6% (37 persons) had diabetes and 23.9% (338 persons) had overt proteinuria. Abioye-Kuteyi et al18 reported a prevalence of 19.9% of undetected renal diseases in a rural populace in western Nigeria. A National Non-Communicable Disease Survey report published in 1997 found the prevalence of hypertension in Nigeria to be 11.2% using 160/95 mm Hg as a cutoff value; hence, the figures could be much higher if 140/90 mm Hg had been used.19 From the foregoing, the prevalence of both early and advanced CKD, as well as its risk factors, in SSA are enormous and the cost implication is colossal and beyond the reach of individual patients, thus making prevention the only plausible option, as repeatedly proposed by several investigators.10, 11, 12, 13, 14, 15, 16, 17, 18 Cause of CKD in SSA Although diabetic nephropathy has now emerged as the most common cause of ESRD, accounting for the greatest proportion of patients in RRT programs in developed countries and some developing ones, it is still a distant third common cause of ESRD in SSA. Several studies in Nigeria established that hypertensive nephrosclerosis and chronic glomerulonephritis are leading causes of CRF in Nigeria, but the prevalence of diabetic nephropathy is increasing, and obstructive uropathy also contributes significantly, corroborating reports from other indigenous African patients (Table 2; Fig 3).3, 10, 20, 21, 22, 23, 24, 25, 26 | | |  | Cause of ESRD | Nigeria (Arogundade et al10) | Ghana (Matekole et al23) | Sudan (Abboud et al24) | Senegal (Diouf et al25) | South Africa (South African Dialysis and Transplant Registry, 199426) | |
|---|
| Hypertension (%) | 29.8 | 48.7 | — | 25 | 45.6 | | | Chronic glomerulonephritis (%) | 27.8 | 42.3 | 38 | 16 | 52.1 | | | Diabetes mellitus (%) | 3.1 | — | 9 | 20.7 | — | | | Obstructive uropathy (%) | 5 | — | 12 | — | — | | | Unknown (%) | 30 | — | 20 | 34.2 | — | | | Others (%) | 3.9 | — | — | 4 | — | | | | |
Various reports of CKD in different parts of SSA showed it is a disease of young adults between the ages of 20 and 50 years, unlike the relatively older age groups affected in developed countries.3, 4, 12, 23, 24, 25, 26 Reports from most centers in SSA showed a male preponderance, possibly a reflection of the background prevalence of predisposing illnesses and recognized risk factors.3, 10, 27 ESRD Management in SSA A major bedrock of management of advanced CKD (ESRD) is RRT, which typically is unavailable, and where rarely available, is cost intensive and therefore inaccessible by the majority of affected individuals in SSA. Grassman et al28 reported that about 1.8 million people worldwide were undergoing treatment for ESRD at the end of 2004, 77% of whom were on dialysis treatment, whereas the remaining 23% were living with a functioning renal transplant. In North America, Europe, and the Middle East, about 30% of patients live with a functional transplant, whereas the proportion is significantly lower in Asia, Latin America, and Africa, with the majority of patients with ESRD in these regions remaining on dialysis therapy. Despite the staggering magnitude of ESRD in SSA, the region contributes less than 5% of patients on RRT worldwide. The availability of RRT is variable in Africa, but generally is better in North Africa, where figures ranging between 30 to 186.5 per million population have been recorded. Available data indicate that South Africa seems to have the highest treatment rate (about 99 per million population) in SSA.12 Dialysis and transplant programs in the rest of Africa are dependent on the availability of funding and donors, with the result that less than 5% of patients with diagnosed ESRD are able to support treatment for longer than 3 months.3, 10, 12, 29, 30 This makes preventive nephrology paramount in this subregion. Hemodialysis is the most common modality in SSA, with about 150 dialysis units spread over 13 countries. The majority of the centers are located in 4 countries, namely Nigeria, South Africa, Sudan, and Mauritius. Other countries in the subregion have fewer than 5 such facilities.27 Problems encountered in these facilities include a limited number of machines, poor technical support, and inadequately trained and poorly motivated staff.3, 12, 27 Despite the availability of peritoneal dialysis therapy in the region during the last 4 decades, continuous ambulatory peritoneal dialysis is largely unavailable, with very few centers offering this service.31 The existing centers are in South Africa, Nigeria, Kenya, Senegal, Sudan, Namibia, and Botswana. Major limitations to continuous ambulatory peritoneal dialysis include unavailability of consumables, including catheters and fluids; inadequate exposure of nephrology fellows; and predominance of infectious complications.32, 33 We assessed the cost-effectiveness of peritoneal dialysis using locally manufactured fluids and established that indigenous production could significantly reduce the cost of peritoneal dialysis therapy.34 Renal transplantation is largely unavailable to the majority of patients with ESRD in SSA because it is available in only 5 countries. Although about 30% of patients with ESRD in the United States, Europe, and the Middle East undergo renal transplantation, less than 1% of patients in Nigeria could afford the procedure. In South Africa, about 415 patients with ESRD underwent successful transplantation in 2004 alone.27, 35 In addition to cost, donor shortage, poorly developed facilities, manpower shortage, and lack of appropriate legislation remain significant limiting factors for renal transplantation in SSA.27, 35 Constraints to RRT in the subregion include exorbitant cost, lack of facilities and manpower, and the predominantly urban location of renal care centers. In a bid to address this problem, Dirks and Levin36 and Eastwood et al37 suggested ways to limit “brain drain” from the low- and middle-income countries in Africa to high-income and better developed countries. They also observed that although prevention of kidney disease is an essential long-term approach to stemming the increasing trend of CKD, in the short term, it is necessary to increase access to dialysis therapy and transplantation and seek ways to limit the brain drain to the developed world.4, 36, 37 CKD Prevention Programs in SSA Unfortunately, despite the dismal outcome of ESRD in SSA, there is as yet no government-funded/aided national prevention program in the entire subregion. Efforts in different parts of the subcontinent are disjointed, uncoordinated, and selective. The most well-established program in SSA is the Chronic Disease Outreach Primary Prevention Program (CHOPPP) established in Soweto by Dr Katz, patterned along the Australian Chronic Disease Outreach Programme described by Dr Wendy Hoy et al.38 The CHOPPP network was established with the assistance of ISN and the Australian program. It involved use of trained nonphysician health workers who may be primary health care nurses, registered nurses, health educators, or even volunteers from the community at the primary health care level. They assess individuals and carry out basic checks of blood pressure and blood glucose, and perform urine analysis, in addition to obtaining a basic history and physical examination. They report findings to a program manager or program nurse coordinators, who then report to the physician. The program was implemented in 16 primary health clinics in Soweto and nearby regional clinics, whereas the data collation and program management activities were located in Dumisane Mzamane African Institute of Kidney Disease and Guateng Health Department.39, 40 Phase 1 of the program served as the baseline surveillance assessment of the community, but also achieved quantitative clinical targets. However, this phase was unable to assess end point improvement, which is the target of the ongoing phase 2.39 Even so, there are major limitations, particularly at the outset, which include poor funding, poor epidemiological skills, limited understanding of the magnitude of CKD in the community, and minimal consultation with government, community, and other experts.39, 40 All these need to be properly appraised before initiating any prevention program. Another lesson from the CHOPPP experience is that preventive programs should be kept as simple as possible and communication networks should be open.39, 40 The 2 screening programs in Ibadan and Lagos in Nigeria are not community based, and treatment is borne by the patients, with the result that those unable to afford drugs may not access treatment.16, 17 The screening program in Lagos started in 2004 and mainly used facilities in 2 private clinics in Lagos metropolis. Participants had blood pressure measured, urinalysis conducted, and random blood glucose assessed, but a major limitation was the absence of a treatment arm because participants were fully responsible for their treatment.16 In the Ibadan-based program, screening was carried out in a small community (Mokola Area), but with no treatment arm. Symptomatic patients, as well as those newly diagnosed, were referred to nearby medical centers for treatment17 (Table 3). There is also an ongoing institution-based screening program in Ghana coordinated by Dr Charlotte Osafo, but the screening programs in Tanzania and Kenya have not taken off. In Senegal, Cameroon, Guinea, Benin, Togo, and Burkina Faso, there are no active CKD screening/treatment programs, although sporadic screening exercises had been carried out in some of them in the past.14 Krzesinski et al4 in the Democratic Republic of Congo proposed a model CKD prevention program considering the peculiarities of the region’s underdevelopment, poverty, and heavy disease burden. Their suggested protocol for a prevention program would start with trained nonphysician health workers who would first assess participants, after which medical doctors would check those at risk or with hypertension or CKD. The manpower shortage in SSA would make this difficult, and unless governments and local health authorities and the local community are involved, implementation and funding will be difficult. Mani41 in India implemented a prevention program termed Kidney Help Trust, now 11 years old, which used the services of trained volunteers who conducted screening/examination of participants in their homes. He and his colleagues achieved excellent results at very low cost with limited emphasis on such highly skilled manpower as doctors and nurses. A model that will be adaptable for most regions in SSA must be inexpensive and require a minimal number of highly skilled personnel. In countries in which the backbone of their health care delivery is based on primary health care, an approach can be based on the existing primary health care infrastructure, where screening and treatment can be carried out by trained volunteers based on an approved treatment manual and referral to bigger centers for serious cases. This model will be less reliant on highly skilled manpower, which in any case is in short supply in SSA. Considering the epidemiology of CKD in SSA, prevention efforts should be built around prevention and control of infections and hypertension through individual and environmental hygiene, provision of pipe-borne water, and regulation and control of drug use. Routine immunization for common infections such as hepatitis B, now included in some national immunization programs, eg, the Nigerian National Program on Immunization, will also assist in decreasing the CKD burden. In addition, the increasing incidence and prevalence of diabetes mellitus should be curtailed by using lifestyle modification measures. Since the clarion call for global CKD prevention in the last few years, some screening programs have been established with the aim of early detection of CKD and its risk factors, as well as halting or preventing its progression, but most of them lack governmental support. The recent establishment and commemoration of World Kidney Day should assist in sensitizing governments, individuals, and corporate and nongovernmental organizations to the devastating medical and socioeconomic consequences of the global CKD scourge. It has succeeded in increasing awareness of the public to CKD, but governmental response is still limited. Various screening efforts have sprung up in response to this call, which led to support of preventive nephrology programs in SSA by the ISN, the ISN program for Detection and Management of Chronic Kidney Disease, Hypertension, Diabetes, and Cardiovascular Disease in Developing Countries (KHDC) initiative; 2 of such programs in SSA are located in Enugu, Nigeria, and Kenya. In conclusion, stemming the menace of CKD in SSA is a Herculean task considering the state of poverty and underdevelopment. A practical approach would be to engage in general screening of all inhabitants of this region attending hospitals for any reason. The focus of the screening would be assessment of blood pressure to detect hypertension and urine analysis to detect occult proteinuria because hypertension and postinfectious glomerulonephritis are the leading causes of ESRD in this setting. Serum creatinine assessment may be added in the secondary and tertiary centers, and those discovered to have derangements may be referred for additional treatment. On the other hand, it may be possible to sensitize some of the governments in SSA to undertake nationwide screening by using existing primary health care infrastructures. Acknowledgements We acknowledge the support of the following for providing information about their programs: Professor A. Akinsola (Nigeria), Dr A.A. Sanusi (Nigeria), Dr I. Katz (South Africa), Professor S. Naicker (South Africa), Dr C.O. Amira (Nigeria), Dr A. Asinobi (Nigeria), Professor Boucar Diouf (Senegal), Dr Dwomoa Adu (Ghana), Dr Gloria Ashuntantan (Cameroon), and Dr Linda Ezekiel (Tanzania). Support: None. 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38. 38Hoy WE, Baker PR, Kelley AM. Reduction in natural death and renal failure from a systematic screening and treatment program in an Australian Aboriginal community. Kidney Int Suppl. 2003;83:S66–S73. 39. 39Katz I. Chronic Kidney Disease Prevention Programme. In: El Nahas M editors. Kidney Diseases in Developing World and Ethnic Minorities. London, UK: Taylor & Francis; 2005;p. 435–455. 40. 40Katz I. Kidney and kidney related chronic diseases in South Africa and chronic disease intervention program experiences. Adv Chronic Kidney Dis. 2005;12:14–21. Abstract | Full Text |
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41. 41Mani M. Prevention of chronic renal failure at community level. Kidney Int. 2003;83(Suppl):S86–S89. 1 Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria 2 Cairo Kidney Center, Bab El-Louk, Cairo, Egypt.  Address correspondence to Fatiu A. Arogundade, MBBS, FMCP, FWACP, Senior Lecturer, Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria.
PII: S0272-6386(07)01599-5 doi:10.1053/j.ajkd.2007.12.006 © 2008 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved. | |
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