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Nephrology in Africa—not yet uhuru

A Correction to this article was published on 14 January 2014

This article has been updated

Abstract

Nephrology is a 'Cinderella speciality', a disregarded area of health care, in Africa. Other health issues have relegated the treatment of kidney diseases to a low priority status, and the cost of treating the more common and widespread communicable diseases, financial mismanagement and corruption in many countries has sounded the death knell for expensive therapies such as dialysis. The communicable diseases that have devastated the health systems around Africa are tuberculosis and HIV/AIDS. Until recently, very little information was available on the impact of HIV on acute and chronic dialysis admissions. Patients with acute kidney injury (AKI) in most of Africa are seldom treated because of great distances to travel, lack of expertise, poverty and poor sustainable funding for health matters. An acute peritoneal dialysis (PD) programme has now been initiated in Tanzania but the sustainability of this project will be tested in the future. The International Society of Nephrology (ISN) has developed a training programme for nephrologists from developing countries, which may now be bearing fruit. A report from the sub-Saharan Africa region shows that the numbers of patients on dialysis and those diagnosed with chronic kidney disease (CKD) has increased significantly. Other ISN-sponsored programmes such as Continuing Medical Education activities for physicians and community screening projects have had far-reaching positive effects. Government funding for a dialysis programme is well established in South Africa, but this funding is limited so that the numbers accepted for public dialysis are restricted. Consequently in the Western Cape province of South Africa, a 'category system' has been formulated to attempt to cope with this unacceptable and restrictive ruling.

Key Points

  • Poverty, mismanagement of funds and lack of medical expertise have decimated the health-care capacity across most of Africa but the programmes sponsored by the International Society of Nephrology are increasingly making a difference

  • Cases of acute kidney injury (AKI) are often not treated because of travel logistics, lack of infrastructure and too few trained doctors; a peritoneal dialysis treatment programme for AKI cases has now been established in Tanzania

  • Communicable diseases, personified by HIV and tuberculosis infections, have drained scare resources in Africa away from costly treatments such as dialysis

  • Increasingly, much more information on HIV-associated nephropathy is coming out of Africa, mostly from South Africa.

  • Government funding for chronic maintenance dialysis is well established in South Africa although numbers permitted to be accepted for public dialysis are restricted; a 'category system' has been formulated in the Western Cape to cope with this ruling

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Figure 1: Percentage of ISN-sponsored renal fellows re-employed by their home institution.
Figure 2: Mortality rates from cardiovascular diseases, some respiratory diseases and common cancers in South Africa.
Figure 3: Renal replacement therapy in sub-Saharan Africa 2007–2011.
Figure 4: A collection of nephrotoxins obtained from patients presenting to Groote Schuur Hospital in Cape Town with acute kidney injury.
Figure 5: A young patient who presented with acute kidney injury from rhabdomyolysis following severe traumatic ('sjambok' whipping) injuries.
Figure 6: Groote Schuur Hospital data showing time to renal death for HIVAN over a 24-month period, with and without combined antiretroviral therapy.
Figure 7: Successful peritoneal dialysis in patients living in informal settlements in Africa.

Change history

  • 14 January 2014

    In the October 2013 issue of Nature Reviews Nephrology, an error was published in Table 3 of this paper. The data given for the number of renal transplants per year in the UK in 2008 and in the USA in 2010 are actually the number of prevalent renal transplant recipients in those years. This error has been corrected online.

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The authors contributed equally to all aspects of this article.

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Correspondence to Charles R. Swanepoel.

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Charles R. Swanepoel has received honoraria from Abbott, Amgen, Roche and Sanofi and is Director for Medical Affairs for Fresenius Medical Care (South Africa).

Nicola Wearne has received a travel grant from Fresenius Medical Care and an honorarium from Roche.

Ike Okpechi has received travel grants from Adcock Ingram, Roche and Fresenius Medical Care (South Africa).

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Swanepoel, C., Wearne, N. & Okpechi, I. Nephrology in Africa—not yet uhuru. Nat Rev Nephrol 9, 610–622 (2013). https://doi.org/10.1038/nrneph.2013.168

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