Nephrology in Africa

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SNS 3rd Conference Khartoum Sudan 2009

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Nephrology in Africa

  1. 1. Nephrology in Africa: An Overview Omar Abboud MD, FRCP Khartoum, Sudan
  2. 2. Introduction <ul><li>Africa is a mosaic of 53 countries hosting 850 million people constituting 14% of the world population </li></ul><ul><li>All countries belong to the low income or lower middle income economical groups </li></ul><ul><li>Like the rest of the world, need for renal healthcare and RRT is regularly growing but few countries can afford meeting the need of all patients </li></ul>
  3. 3. AFRICA Population: 850 M Area: 30 M Sq KM
  4. 4. North Africa <ul><li>6 Countries </li></ul><ul><li>(Algeria, Egypt, Libya, Mauritania, Morocco, Tunisia) </li></ul><ul><li>Population: 156 millions </li></ul><ul><li>GDP per capita: US$ 1503 </li></ul>
  5. 5. West Africa <ul><li>15 Countries </li></ul><ul><li>Benin, Burkina Faso, Cap Vert, Côte d’Ivoire, Gambia, Ghana, Guinea,Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, Togo </li></ul><ul><li>Population: 252 millions </li></ul><ul><li>GDP per capita: US$ 334 </li></ul>
  6. 6. Central Africa <ul><li>10 Countries </li></ul><ul><li>Burundi, Cameroon, Central Africa, Chad, Congo, D R of Congo, </li></ul><ul><li>Gabon, Equatorial Guinea, Rwanda, Sao Tome e Principe </li></ul><ul><li>Population: 102.7 millions </li></ul><ul><li>GDP per capita: US$ 296 </li></ul>
  7. 7. East Africa <ul><li>8 Countries </li></ul><ul><li>Djibouti, Eritrea, Ethiopia, Kenya, Uganda, Somalia, Sudan, Tanzania </li></ul><ul><li>Population: 204 millions </li></ul><ul><li>GDP per capita: US$ 247 </li></ul>
  8. 8. Southern Africa <ul><li>10 Countries </li></ul><ul><li>Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, </li></ul><ul><li>South Africa, Zambia and Zimbabwe </li></ul><ul><li>Population: 117 millions </li></ul><ul><li>GDP per capita: US$ 1223 </li></ul>
  9. 9. Indian Ocean <ul><li>4 Countries </li></ul><ul><li>Comoros, Madagascar, Mauritius, Seychelles </li></ul><ul><li>Population: 19 millions </li></ul><ul><li>GDP per capita: US$ 522 </li></ul>
  10. 10. South Africa: 46 M 200-300 pmp Morocco: 30 M 110 pmp Tunisia: 10 M 133 pmp Egypt: 70 M 200 pmp Sudan: 38 M 150 pmp Incidence of ESRD
  11. 11. Incidence of KF (ESRD) (USRDS)
  12. 12. Burden of ESRD in Africa <ul><li>Average Incidence of ESRD: 150-200 pmp/yr </li></ul><ul><li>Total No of patients: 127,500- 170,000 pts/yr </li></ul>
  13. 13. Prevalence of HD and PD North Africa
  14. 14. Prevalence of HD and PD West Africa
  15. 15. Prevalence of HD and PD Central, East, Southern Africa
  16. 16. Renal Transplantation North Africa (6/6) 156 10 2.6 30 5.4 76 32.8 Population 698 70 0 18 50 500 60 R Tx /year 7 Tunisia 4.5 Total 0 Mauritania 0.6 Morocco 9.2 Libya 6.6 Egypt 1.8 Algeria Tx/Pmp/year Country
  17. 17. Renal Transplantation West Africa (11/15) 0 0 11.6 Mali 0 0 8.5 Guinea 0 0 20 Ghana 0 0 16.4 Côte d’Ivoire 0 0 0.5 Cape Verde 0 0 11.9 Burkina Faso 0 0 6.5 Benin Tx/Pmp/year R Tx /year Population Country
  18. 18. Renal Transplantation West Africa (15/15) 0.15 50 332 Total 0 0 5.5 Togo 0 0 98 Senegal 0.35 50 142 Nigeria 0 0 11.3 Niger Tx/Pmp/year R Tx /year Population Country
  19. 19. Renal Transplantation Central Africa 0 0 60 Congo 0 0 60 D. R. Congo 0 0 1.4 Gabon 0.02 3 136 Total 0.2 3 15 Cameroon Tx/Pmp/year R Tx /year Population Country
  20. 20. Renal Transplantation East Africa (5/8) 0 0 77.4 Ethiopia 0.6 20 34.3 Kenya 2.6 100 38 Sudan 0 0 38.4 Tanzania 0.55 120 217 Total 0 0 28.8 Uganda Tx/Pmp/year R Tx /year Population Country
  21. 21. Renal Transplantation Southern African and Indian Ocean (6/14) 0 0 12.9 Malawi 0 Yes? 1.1 Mauritius 0 ? 19.8 Mozambiq 0 0 1.9 Namibia 5.6 220 46 South Africa 2.4 220 92 Total 0 0 9.9 Zambia Tx/Pmp/year R Tx /year Population Country
  22. 22. Renal Tx in 5 African Countries 2.6 100 38 Sudan 7 70 10 Tunisia 5.6 220 46 South Africa 0.35 50 142 Nigeria 0.6 18 30 Morocco Transplants pmp/Year Transplants per Year Population Country
  23. 23. Donors in Renal Tx in 5 African Countries 0 0 100 Sudan 30 0 70 Tunisia 59.3 6.7 34 South Africa 0 0 100 Nigeria 0 0 100 Morocco Deceased % LURD % LRD % Country
  24. 24. Current Status of TX <ul><li>Renal transplantation is performed in 5 countries in North Africa and 5 in Sub-Saharan Africa mainly in the public sector. It is also available in private hospitals in Egypt, South Africa and Sudan. </li></ul><ul><li>All donors are LRD except in South Africa & Tunisia. </li></ul><ul><li>Less than 6 countries have sustained programmes and perform more than 70 transplants per year. </li></ul><ul><li>Even in these countries many patients have to travel abroad for a kidney transplant when they can afford it. </li></ul>
  25. 25. Renal Transplant Rates (pmp) (USRDS)
  26. 26. Cost of Renal Transplantation /Year (USD $) 8,000 12,000 Sudan 7,000 15,000 Tunisia 15,000 20,000 South Africa Subsequent years First year Country
  27. 27. Cost of RTT (US$) <ul><li>Haemodialysis / session </li></ul><ul><li>Tunisia (65), Sudan (75), South Africa (140) </li></ul><ul><li>Peritoneal dialysis / year </li></ul><ul><li>Egypt (7,000), D R Congo (24,000), S Africa (30,000) </li></ul><ul><li>Renal transplantation / year </li></ul><ul><ul><li>First year: Sudan (12,000), Tunisia (25,000), South Africa (20,000) </li></ul></ul><ul><ul><li>Following years: Tunisia (7,000), Sudan (8,000), South Africa (15,000) </li></ul></ul>
  28. 28. 0 2,000,000 4,000,000 6,000,000 8,000,000 Patients # ≥ 1.5 ≥ 1.7 ≥ 2.0 ESRD 6.2 2.5 0.8 0.326 S Creatinine Prevalence of CKD in USA
  29. 29. US Data <ul><li>1:9 Americans (20M) has KD (Most DK) </li></ul><ul><li>“ NKF: K/DOQI: Evaluation, Classification & Stratification. Am J Kidney Disease 2002;39S:1-266” </li></ul><ul><li>Another 20M are at increased risk (Most DK) </li></ul><ul><li>“ Burt et al. Prevalence of HT in the US. Results from the Third National Health & Nutrition Examination Survey, 1988-1991. Hypertension 1988;25:305-313” </li></ul>
  30. 30. Burden of ESRD & CKD in Africa <ul><li>Average Incidence of ESRD: 150-200 pmp/yr </li></ul><ul><li>Total No of patients: 127,500- 170,000 pts/yr </li></ul><ul><li>Prevalence of CKD 100,000,000 </li></ul>
  31. 31. Incidence of KF (1999-2005) (USRDS)
  32. 32. Health Expenditure $ 2000 Europe $ 150 South Africa $ 100 North Africa $ 29 Senegal $ 9 Nigeria Annual Per Capita Healthcare expenditure Country
  33. 33. Cost of ESRD/Total Medicare (USA) 91 93 95 97 99 01 03 05 7 6 5 4 3 2 1 0 0 50 100 150 200 250 300 350 Total Medicare
  34. 34.     Liberia No society 0 LESOTHO 16 16 KENYA No society   GUINEA BISSAU No society   GUINEA No society 3 GHANA No society   GAMBIA No society 4 GABON No Society 2 ETHIOPIA No society 0 ERITREA No society 3 EQUATORIAL GUINEA 850 300 EGYPT No society 0 - 1 DJIBOUTI   7 COTE D'IVOIRE No society 6 CONGO REPUBLIC No society 2 CONGO DEMOCRATIC REPUBLIC No society   COMORES No society 0 - 1 CHAD No society 0 - 1 CENTRAL AFRICAN REPUBLIC No society 7 CAMEROON No society 1 CABO VERDE No society 0 BURUNDI No society 0 BURKINA FASO No society 2 BOTSWANA No society 2 BENIN No society 5 ANGOLA 195 150 ALGERIA Societies Nephtologists countries No society 3 ZIMBABWE No society 2 ZAMBIA No society 2 ZAIRE No society 0 - 1 WESTERN SAHARA No society 2 UGANDA 70 31 TUNISIA No society 2 TOGO No society 2 TANZANIA No society 0 SWAZILAND 80 35 SUDAN 105 50 SOUTH AFRICA No society 0 SOMALIA No society   SIERRA LEONE     SEYCHELLES 30 6 SENEGAL No society 2 RWANDA 90 70 NIGERIA No society 1 NIGER No Society 1 NAMIBIA No Society 1 MOZAMBIQUE 190 184 MOROCCO   8 MAURITIUS   3 MAURITANIA No society 2 MALI No Society 0 MALAWI     MADAGASCAR 25 25 LIBYA Societies Nephtologists countries
  35. 35. Aetiology of Kidney Failure 26 20 62 26 22 U D 25 24 2 7 16 37 Other 14 9 --- 4 25 9 DM 15 38 52 4 14 11 GN 20 9 46 23 19 21 HT Tunisia Sudan SA Niger Moro Egypt
  36. 36. 0 25 50 % DM HT GN UD 30 26 15 15 Diseases Aetiology of CKD 43 18 11 12 1988 2001
  37. 37. Glomerulonephritis <ul><li>More prevalent in Africa </li></ul><ul><li>More severe forms than rest of the world </li></ul>“ Kibukamusoke JW. Kidney diseases in the tropics. East Afr Med J 1968; 45:77-91”
  38. 38. Glomerulonephritis <ul><li>Prevalence in Africa </li></ul><ul><li>2-3% of medical admissions in Tropical Africa are renal related mostly GN </li></ul><ul><li>Of all hospital admissions GN accounts for: </li></ul><ul><ul><li>Zimbabwe 0.5% </li></ul></ul><ul><ul><li>Uganda 2.0% </li></ul></ul><ul><ul><li>Nigeria 2.4% </li></ul></ul>
  39. 39. Glomerulonephritis <ul><li>Most common form of presentation is NS </li></ul><ul><li>Peak age: 5-8 yrs </li></ul><ul><li>MCD is low in SA children (13.5%) </li></ul>‘ Coovadia et al. Clinico-pathological features of the NS in SA children. Q J Med 1979.’
  40. 40. Glomerulonephritis <ul><li>6- year study of 252 black SA </li></ul><ul><li>35.7% Membranoproliferative </li></ul><ul><li>21.4% Membranous </li></ul><ul><li>10.7% MCD </li></ul><ul><li>0.8 % IgA </li></ul>“ Seedat YK et al. IgA nephropathy in Blacks and Indians of Natal. Nephron 1988;50:137-41”
  41. 41. Hypertension 20-25 South Africa 30 Tunisia 33.6 Morocco Up to 50 Egypt Prevalence % Country
  42. 42. Hyperten sion <ul><li>Malignant hypertension is common: </li></ul><ul><li>HT accounts for 16% of all black SA hospital admissions </li></ul><ul><li>Malignant HT was found in 49% of 70 renal biopsies of black SA with ESRD </li></ul><ul><ul><li>“ Gold et al. Pathological basis of ESRD in Blacks. S Afr Med J 1982;61:263-5” </li></ul></ul>
  43. 43. Screening For KD <ul><li>General </li></ul><ul><li>BP measurement </li></ul><ul><li>Urinalysis </li></ul><ul><li>Renal Function: </li></ul><ul><ul><li>S Creatinine / Clearance e-GFR (estimated) </li></ul></ul><ul><li>Fasting Blood Glucose </li></ul><ul><li>Specific </li></ul><ul><ul><li>HCV & Schistosomiasis (Egypt) </li></ul></ul><ul><ul><li>Urinary Calculi (Sudan) </li></ul></ul>
  44. 44. Screening Programs <ul><li>In India at community level (M K Mani) </li></ul><ul><li>25,000 persons </li></ul><ul><li>Screening: </li></ul><ul><ul><li>BP measurement </li></ul></ul><ul><ul><li>Urine for Albumin & Reducing Substances </li></ul></ul><ul><ul><li>(Sulphosalicylic acid & Benedict’s Reagent) </li></ul></ul>
  45. 45. Prevention Programs <ul><li>Tunisia </li></ul><ul><li>National Strategy for prevention of renal disease (in first line dispensaries M o H) </li></ul><ul><li>Egypt </li></ul><ul><li>National Sch. Control program & Educational Initiatives about HT & DM </li></ul><ul><li>Morocco </li></ul><ul><li>National Program: prevention & control of DM </li></ul><ul><li>Screening program Algadida & Kheimeisat </li></ul>
  46. 46. AKI in Africa
  47. 47. Major Causes of AKI in Africa Malaria, Obstetric, Toxins Malaria, HIV, Toxins Sepsis, Obstetric, Toxins Obstetric, Malaria, Herbal toxins Infections (especially Malaria), hypovolemia, Toxins Cent/West Africa Cameroon Cote d’Ivoire Nigeria Senegal DR Congo Toxins, Trauma/Surgery, Urologic Surgical, Toxins, Obstructive Haemodynamic, Sepsis, Obstructive, Toxins North Africa Algeria Egypt Morocco Causes of AKI Country
  48. 48. Major Causes of AKI in Africa Infections (Inc HIV), Toxins, Pregnancy Malaria, Dehydration, HIV Prerenal (HIV), Malaria, Obstetric Malaria, Obstetric Diarrhoeal Diseases, Malaria, Sepsis Southern Africa South Africa Mozambique Zimbabwe Zambia Malawi Infection, Obstetric, Surgical Malaria, Dehydration (HIV, Diarrhoea) Infection, Trauma, Toxins Malaria, Surgical, Acute GN Infection Infection, Toxins East Africa Kenya Burundi Rwanda Ethiopia Eritrea Sudan Causes of AKI Country
  49. 49. Malaria <ul><li>AKI occurs in 1-5% of natives in endemic areas </li></ul><ul><li>30% of Non-immune visitors </li></ul><ul><li>Mostly due to P falciparum </li></ul><ul><li>Few cases are due to vivax </li></ul>
  50. 50. Malaria (contd.) <ul><li>Features </li></ul><ul><li>Oliguria </li></ul><ul><li>Urine: </li></ul><ul><ul><li>Negative sediment </li></ul></ul><ul><ul><li>Mild proteinuria (< 1 gm/day) </li></ul></ul><ul><li>Hyperkalaemia (due to haemolysis, rhabdomyolysis & acidosis) </li></ul>
  51. 51. Malaria (contd.) <ul><li>Histological Features </li></ul><ul><li>Acute tubular necrosis (most common) </li></ul><ul><li>Interstitial nephritis </li></ul><ul><li>Glomerulonephritis </li></ul><ul><ul><li>Prominent mesangial cell proliferation </li></ul></ul><ul><ul><li>Modest mesangial matrix expansion </li></ul></ul><ul><ul><li>Segmental sclerosis (due to capillary occlusion) </li></ul></ul><ul><ul><li>IF: IgM & C3 deposits along capillary walls & the mesangium </li></ul></ul>
  52. 54. Malaria (contd.) <ul><li>Prognosis </li></ul><ul><li>Mortality ranges between 0-45% depending on the facilities </li></ul><ul><li>Study from Yemen: </li></ul><ul><ul><li>64 children aged (4.2- 11.2 yrs) who required dialysis for ARF with P falciparum: </li></ul></ul><ul><ul><li>43.8% died (bad prognostic features: high creatinine, hypertension, severe oliguria) </li></ul></ul><ul><ul><li> (Sheiban AK, Ren Fail 1999; 21:63-6) </li></ul></ul>
  53. 55. Salmonellosis <ul><li>AKI with enteric fever </li></ul><ul><li>Renal impairment occurs in about 16% </li></ul><ul><li>Pathology: </li></ul><ul><ul><li>Pyelonephritis </li></ul></ul><ul><ul><li>ATN </li></ul></ul><ul><ul><li>Glomerulonephritis is uncommon </li></ul></ul><ul><li>Almost always reversible; recovery in 1-2 weeks </li></ul>
  54. 56. Salmonellosis (contd.) <ul><li>Reports from South Africa </li></ul><ul><li>Severe disease: </li></ul><ul><ul><li>Fever, oedema and hypertension </li></ul></ul><ul><ul><li>Similar to post-infectious GN </li></ul></ul><ul><ul><li>Biopsy shows mesangioproliferative changes with deposits of IgG, IgM and C3 </li></ul></ul><ul><ul><li>Rhabdomyolysis may occur </li></ul></ul>
  55. 57. Shigellosis <ul><li>AKI may occur due to </li></ul><ul><li>ATN with dehydration in severe infections </li></ul><ul><li>Glomerulonephritis (usually proliferative) </li></ul><ul><li>Associated HUS may occur (in 34% of patients with ARF) </li></ul><ul><li>Cortical necrosis can occur (carries a high mortality- up to 60%) </li></ul>
  56. 59. Conclusions <ul><li>Incidence of ESRD in Africa is 127-170 K pmp/yr </li></ul><ul><li>Dialysis is available mainly in North African countries & RSA+ few other countries </li></ul><ul><li>Renal Tx is available in 5 North African countries and 5 Sub-Saharan countries with sustained programs in less than 6 countries. </li></ul><ul><li>Rate ranges between <1 and 9 Txs pmp/yr </li></ul>
  57. 60. Conclusions <ul><li>In 33 countries 19 countries there are no nephrologist, in another 14 there are between 1-2 nephtologists. </li></ul><ul><li>HTN, GN & calculi are the most common causes of CKD </li></ul><ul><li>Common causes of AKI: infections, toxins, obs </li></ul><ul><li>Main difficulties are absence of information and registeries, abscence of organized programs, shortage of staff, shortage of facilities, high cost of medications and treatment. </li></ul>
  58. 61. Thank you

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