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

Outcomes of Tunneled and Nontunneled Internal Jugular Catheters for Hemodialysis at Zenith Medical and Kidney Centre, Nigeria

Objectives: Tunneled and nontunneled jugular access routes are the most widely used routes for hemodialysis (HD) in developing countries.This study was a retrospective review of the utility, safety, and outcomes of both tunneled and nontunneled curved internal jugular catheteruse in patients with end‑stage renal disease (ESRD) in Zenith Medical and Kidney Centre, Abuja, Nigeria. Materials and Methods: This is a retrospective study of 100 ESRD patients on maintenance HD at the center between June 2019 and December 2019. All patients on maintenance dialysis with tunneled and nontunneled curved internal jugular catheter were observed for immediate and short‑term complications associated with the catheter. Results: Among the patients, 90 (90.0%) had tunneled dialysis catheters placement and dialyzed with it, while 10 (10%) patients had nontunneled dialysis catheters use. While 90 (90%) of the patients with the dialysis catheters developed no complications, ten (10%) patients had catheter‑related complications either during catheter insertion or while it was being used for dialysis. The most common in this study was reactionary hemorrhage which occurred in 5% of the patients evaluated. Ten (10%) of the patients with catheter placement required ultrasonic guidance. No death was recorded during catheter placement. Conclusion: Internal jugular tunneled and Non tunneled dialysis catheters (NTDCs) are safe with good outcomes among our ESRD patients. Keywords: Catheters, hemodialysis, Nigeria, outcome, tunneled and nontunneled dialysis catheters, Zenith Medica

Factors influencing the development of transplantation in Africa

Background Access to dialysis and transplantation in Africa is very limited. The challenges vary in different countries across the continent from legislative, to political, to financial. Aim To assess factors influencing the development of organ donation and transplantation in the African context. Methods A structured interview was held with African delegates attending the 25th Southern African Transplantation Society Congress and Global Alliance for Transplantation Workshop in Durban from the 28th July to 2nd of August 2013. Data from workshop working group presentations for each African country were additionally analysed. Results 30 delegates from 10 African countries (Cameroon, Ethiopia, Ghana, Kenya, Malawi, Nigeria, Rwanda, Tunisia, Sudan and Zambia) participated in the working groups. Twenty-eight questionnaires were completed. The burden of disease and challenges were large and varied. With marked disparity between countries where kidney transplantation is paid for entirely out-of-pocket—such as Ghana, Kenya, and Nigeria (kidney transplant rates in 2012 of 0.1, 1.4 and 0.1 per million population respectively)—and countries where costs are covered by the government or by insurance schemes—such as Sudan and Tunisia (kidney transplant rates of 5.3, and11.5 per million population, respectively). For most countries, the cost of immunosuppressive drugs and the ability to perform adequate matching of donors and recipients were the main infrastructure concerns. Five countries (Cameroon, Nigeria, Ghana, Ethiopia, Zambia) did not have legislation governing organ transplantation. Conclusion There is need for major political transform which will to ensure that African populations achieve access to transplantation. This would allow international collaboration and willing local clinicians a framework within which to develop sustainable transplant systems

Abstracts of the 12th Congress of the African Association of Nephrology (Accra, Ghana, 20-23 February, 2013)

Accra, Ghana, 20-23 February, 201

Survival Analysis of Chronic Kidney Disease Patients with Hemodialysis in West Java. Indonesia, Year 2007 - 2018

The prevalence of chronic kidney disease on dialysis or CKD5D is increasing with a significant impact on disease burden in many countries. Patients are usually listed in the national renal registries, which report demographic data, incidence, prevalence, and outcome. The survival rate is an important outcome measure to characterize the impact of treatment in the CKD5 patient population in the national and international renal registries. Indonesian Society of Nephrology (InaSN) has the Indonesian Renal Registry program to collect data that was endorsed to monitor dialysis treatment quality in Indonesia.  IRR releases an annual report, but there is no survival analysis yet.   This study aimed to discover the five-year survival rate of CKD5D patients in West Java between 2007–2018 and its factor based on the IRR database. A retrospective cohort study was performed by gaining all patients' data from the IRR database, then data on all of the patients from West Java province who completed a 5-year follow-up on December 31, 2018.  Kaplan-Meier analysis and Cox proportional hazard's model were used to analyze the risk factors. There were 3,199 data included in this study. In total, the 1, 2, 3, 4, and 5 year survival rates are 82%, 70%, 62%, 58%, and 55 %, respectively.  Patients whose age is above 55 years and with unknown underlying kidney disease have a worse survival rate with a hazard ratio of 1.28 and 1.50, respectively. Further exploration of IRR data will provide better information on dialysis treatment in Indonesia. Ketahanan Hidup Pasien Penyakit Ginjal Kronis dengan Hemodialisis di Jawa Barat Indonesia tahun 2007-2018Prevalensi penyakit ginjal kronis pada dialisis atau PGK5D meningkat dan memberi beban penanganan penyakit di banyak negara. Pasien biasanya terdaftar dalam register ginjal nasional yang melaporkan data demografis, insiden, prevalensi dan luaran klisis. Tingkat ketahanan hidup merupakan parameter penting dalam registrasi ginjal untuk menggambarkan kualitas terapi pada  populasi pasien PGK stadium 5. Perhimpunan Nefrologi Indonesia (Pernefri) memiliki program Registri Ginjal Indonesia yang disebut Indonesian Renal Registry (IRR) untuk mengumpulkan data pasien PGK5D untuk  memantau kualitas pengobatan dialisis di Indonesia. IRR merilis laporan tahunan tetapi belum dilengkapi dengan  analisis ketahanan hidup. Tujuan penelitian ini adalah mengetahui angka ketahanan hidup lima tahun pasien PGK5D di Jawa Barat antara tahun 2007-2018 dan faktor risikonya berdasarkan basis data dari IRR. Studi kohort retrospektif dengan mengambil semua data pasien dari basis data IRR kemudian ditentukan data pasien Jawa Barat yang lengkap dan di follow up selama 5 tahun pada 31 Desember 2018.   Analisis Kaplan-Meier dan model proporsional hazard Cox digunakan untuk menganalisis faktor risiko. Subjek berjumlah 3199 data yang dimasukkan dalam penelitian ini. Kesimpulannya, angka harapan hidup satu, 2, 3, 4, dan 5 tahun berturut-turut adalah 82%, 70%, 62%, 58%, dan 55%. Usia lebih dari 55 tahun dan penyakit ginjal yang mendasari memiliki kelangsungan hidup yang lebih buruk dengan hazard ratio 1,28 dan 1,50. Eksplorasi lebih lanjut dari data IRR akan memberikan informasi yang lebih baik tentang perawatan dialisis di Indonesia

Kesintasan Penyakit Ginjal Kronik yang Menjalani Hemodialisis di Rumah Sakit Abdul Moeloek Lampung Tahun 2017-2018

Abstract Non-communicable diseases (NCD) have become health problems in various parts of the world. One of NCD which is a health problem is chronic kidney disease (CKD). CKD is a global public health problem with an increasing prevalence and incidence of kidney failure, poor prognosis and high cost of care. CKD is a cause of death globally, the biggest cause of CKD is coomorbidity with type 2 diabetes mellitus. The highest mortality occurred in less than the first 12 months of hemodialysis, which was 78,1%. The purpose of this study was to determine the age, sex, duration of survival of CKD patients undergoing hemodialysis based on comorbidity of type 2 diabetes mellitus. Retrospective cohort study designis used a, with a sample of 201 respondents. The study used data from the daily reports of the hemodialysis unit, namely patients who under went hemodialysis and then observed for 12 months. The outcome variable for mortality and its risks factors (diabetes, age, and gender). The analysis used survival analysis with cox regression. The results of the study were 37.8% of deaths occured, CKD patients with with diabetes mellitus comorbidity 24.9%. Respondents on hemodialysis are based on gender were male (45,3%) and female (54,7%) ages less than 45 years (27.4%).The Statistical test results obtained from non-diabetes mellitus group had a 3.1 times higher survival rate than the diabetes mellitus group (p value = 0.01). Abstrak Penyakit tidak menular (PTM) menjadi masalah kesehatan di berbagai belahan dunia. Salah satu PTM yang menjadi masalah kesehatan adalah penyakit ginjal kronik (PGK). PGK merupakan masalah kesehatan masyarakat global dengan prevalensi dan insidens gagal ginjal yang terus meningkat, prognosis yang buruk dan memerlukan biaya perawatan yang tinggi. PGK merupakan penyebab kematian secara global. Penyebab PGK terbesar adalah komorbiditas dengan diabetes melitus tipe 2. Kematian tertinggi terjadi pada kurang dari 12 bulan pertama menjalani hemodialisis yaitu sebesar 78,1%. Tujuan untuk mengetahui umur, jenis kelamin, lama ketahanan hidup pasien PGK yang menjalani hemodialisis berdasarkan komorbiditas diabetes melitus tipe 2. Desain penelitian kohort retrospektif dengan sampel sebesar 201 responden. Penelitian menggunakan data dari laporan harian unit hemodialisis yaitu pasien yang menjalani hemodialisis kemudian dilakukan observasi selama 12 bulan. Variabel outcome kematian dan faktor risikonya (diabetes, umur, dan jenis kelamin). Analisis yang digunakan analisis survival dengan cox regression. Hasil penelitian terjadi kematian sebesar 37,8%, pasien PGK dengan komorbiditas diabetes melitus 24,9%. Responden hemodialisis berdasarkan jenis kelamin Laki-laki (45,3%) dan perempuan (54,7%) umur kurang dari 45 tahun 27,4%. Hasil uji statistik diperoleh kelompok tidak diabetes melitus memiliki kesintasan 3,1 kali lebih tinggi dibandingkan kelompok diabetes melitus (p Value = 0,01). &nbsp

Confronting the growing burden of kidney disease: the sub-Saharan landscape

This report seeks to describe the status of kidney disease and renal replacement therapy in lower-resource settings, particularly sub-Saharan Africa. Acute kidney injury and transplantation are included on a limited basis because it is impossible consider the renal replacement therapy landscape at the exclusion of either. As in the rest of the developing world, chronic kidney disease and end-stage renal disease place a sizable and rapidly growing burden on sub-Saharan Africa, and Africans face a double-burden of disease from communicable and non-communicable diseases. Meanwhile, renal replacement therapy and the subspecialty of nephrology are expanding in sub-Saharan Africa, from non-existence in many countries to a limited, tentative subsistence, largely with the support of international organizations and the dedication of local nephrologists. Hemodialysis is the most common form of renal replacement therapy in sub-Saharan Africa, but peritoneal dialysis services, particularly for acute kidney injury, are growing and renal transplants are performed in a few sub-Saharan countries. Nonetheless, in the majority of sub-Saharan Africa, maintenance dialysis is still only available to the wealthy urban few. Although peritoneal dialysis may seem more feasible in the developing world than hemodialysis for multiple reasons, it is still fraught with challenges that make widespread implementation presently unadvisable. As renal replacement therapy is costly and currently unaffordable on a large scale for most of these countries, emphasis must be on identifying at-risk populations through screening and low-cost treatment or management of risk factors to mitigate chronic kidney disease

Bioimpedance as a predictor of survival in renal failure and associated comorbidities.

Background: Renal failure requiring dialysis is associated with a high mortality. One of the contributing causes is overhydration. Overhydration can be assessed by bioimpedance analysis (BIA)– the non-invasive electrical measure of small current through the tissues that estimates the proportion of fluid that is intracellular water (ICW, typically muscle which is healthy) and extracellular (ECW, which in excess causes tissue oedema and is potentially dangerous). Several studies indicate that a extracellular water to total body water (TBW) ratio is associated with increased risk of death in dialysis patients but it is not clear if this is independent of other risk factors for death, namely comorbidity. Aims and objectives: To establish the prognostic value of BIA in the prediction of survival on dialysis in the context of other known predictors of survival or hospitalisation. With further analysis of the applicability of the same scenario to heart failure patients. Methodology: To conduct a systematic review using a standardised approach including a prespecified research question, search terms and criteria for study inclusion. With independent selection for inclusion in the study and quality appraisal by multiple authors with different backgrounds and experience. Results: 2701 studies identified by literature search, plus an additional 4 through reference checking. 38 papers included in final analysis, 4 of which were regarding heart failure cohorts. Analysis of the research shows that BIA is an independent predictor of mortality. Conclusion: BIA shown to be an independent predictor of mortality in dialysis patients, further research needed to extrapolate to heart failure (HF) populations

Biochemical and genetic markers of mineral bone disease in South African patients with chronic kidney disease

A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand in fulfilment of the requirements for the degree of Doctor of Philosophy. Johannesburg, 2017.Background Abnormalities of mineral bone disease have been consistently associated with adverse clinical outcomes in patients with chronic kidney disease (CKD). The consequences of these changes have also been shown to differ across races. However, in Africa the impact of derangements of CKD -mineral and bone disorder (CKD-MBD) on patients with CKD is largely unknown. In addition, studies from the USA have reported racial variations in markers of CKD and it remains unclear whether genetic factors may explain this discrepancy in the levels of biochemical markers of CKD-MBD across ethnic groups. Therefore, this study has been conducted to determine the existence of racial differences in the levels of fibroblast growth factor 23(FGF23) and traditional markers of mineral bone metabolism in a heterogeneous African CKD population, and to provide important insights into the pattern and genetic variability of CKD-MBD in sub-Saharan Africa. Methods This was a cross sectional multicenter study carried out from April 2015 to May 2016, involving two hundred and ninety three CKD patients from three renal units in Johannesburg, South Africa. The retrospective arm of this study involved two hundred and thirteen patients undergoing maintenance haemodialysis (MHD) from two dialysis centers in Johannesburg between January 2009 and March 2016. The first part of this study described the pattern of CKD-MBD in MHD patients using traditional markers of CKD-MBD. The second part of the study looked into the spectrum of CKD-MBD and racial variations in markers of CKD-MBD in pre dialysis and dialysis patients. This was followed by the genetic aspect of the study that examined the influence of vitamin D receptor polymorphisms on biochemical markers of mineral bone disorders. Lastly, the study also evaluated the association between markers of CKD-MBD and mortality in MHD patients. Results The prevalence of hyperparathyroidism (iPTH>150 pg/mL), hyperphosphataemia, hypocalcaemia and 25-hydroxyvitamin D deficiency (150 pg/mL and total alkaline phosphatase > 112 U/L) suggestive of high turnover bone disease, was present in 47.3 % of the study population. The odds ratios for developing secondary hyperparathyroidism with hypocalcaemia and hyperphosphataemia were 5.32 (95% CI 1.10 - 25.9, P =0.03) and 3.06 (95 % CI 1.15 - 8.10, P =0.02) respectively. The 293 CKD patients (208 blacks, 85 whites) had an overall mean age of 51.1±13.6 years, and black patients were significantly younger than the white patients (48.4 ±.13.6 versus 57.1±15.5 years; p<0.001). In comparison to whites, blacks had higher median iPTH (498 [37-1084] versus 274[131-595] pg/ml; P=0.03), alkaline phosphatase (122[89-192] versus 103[74-144] U/L; P=0.03) and mean 25- hydroxyvitamin D (26.8±12.7 versus 22.7 ±12.2 ng/ml, P=0.01) levels, while their median FGF23 (100 [34-639] versus 233[80-1370] pg/ml; P=0.002) and mean serum phosphate (1.3±0.5 versus 1.5±0.5, P =0.001) levels were significantly lower. With the exception of vitamin D receptor (VDR) Taq I polymorphism, the distribution of the VDR polymorphisms differs significantly between blacks and whites. In hemodialysis patients, the BsmI Bb genotype was significantly associated with moderate secondary hyperparathyroidism (OR, 3.88; 95 CI 1.13-13.25, P=0.03) and severe hyperparathyroidism (OR, 2.54; 95 CI 1.08-5.96, P=0.03). Patients with high total alkaline phosphatase (TAP) had significantly higher risk of death compared to patients with TAP 2.75 mmol/L was associated with increased risk of death compared to patients within levels of 2.10–2.37 mmol/L (HR 6.34, 95% CI 1.40–28.76; P = 0.02). The HR for death in white patients compared to black patients was 6.88; 95% CI 1.82–25.88; P = 0.004. Conclusions Secondary hyperparathyroidism and 25–hydroxyvitamin D deficiency were common in our haemodialysis patients. The study also highlighted the existence of racial differences in the circulating markers of mineral bone disorders in our African CKD population. In addition, the study showed that both moderate and severe secondary hyperparathyroidism are predicted by the BsmI Bb genotype, and the over expression of this genotype in black patients may partly explain the ethnic variations in the severity of secondary hyperparathyroidism in the CKD population. High levels of serum alkaline phosphatase, hypercalcaemia, and white race are associated with increased risk of death in MHD patients.LG201

Biochemical and genetic markers of mineral bone disease in South African patients with chronic kidney disease

A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand in fulfilment of the requirements for the degree of Doctor of Philosophy. Johannesburg, 2017.Background Abnormalities of mineral bone disease have been consistently associated with adverse clinical outcomes in patients with chronic kidney disease (CKD). The consequences of these changes have also been shown to differ across races. However, in Africa the impact of derangements of CKD -mineral and bone disorder (CKD-MBD) on patients with CKD is largely unknown. In addition, studies from the USA have reported racial variations in markers of CKD and it remains unclear whether genetic factors may explain this discrepancy in the levels of biochemical markers of CKD-MBD across ethnic groups. Therefore, this study has been conducted to determine the existence of racial differences in the levels of fibroblast growth factor 23(FGF23) and traditional markers of mineral bone metabolism in a heterogeneous African CKD population, and to provide important insights into the pattern and genetic variability of CKD-MBD in sub-Saharan Africa. Methods This was a cross sectional multicenter study carried out from April 2015 to May 2016, involving two hundred and ninety three CKD patients from three renal units in Johannesburg, South Africa. The retrospective arm of this study involved two hundred and thirteen patients undergoing maintenance haemodialysis (MHD) from two dialysis centers in Johannesburg between January 2009 and March 2016. The first part of this study described the pattern of CKD-MBD in MHD patients using traditional markers of CKD-MBD. The second part of the study looked into the spectrum of CKD-MBD and racial variations in markers of CKD-MBD in pre dialysis and dialysis patients. This was followed by the genetic aspect of the study that examined the influence of vitamin D receptor polymorphisms on biochemical markers of mineral bone disorders. Lastly, the study also evaluated the association between markers of CKD-MBD and mortality in MHD patients. Results The prevalence of hyperparathyroidism (iPTH>150 pg/mL), hyperphosphataemia, hypocalcaemia and 25-hydroxyvitamin D deficiency (150 pg/mL and total alkaline phosphatase > 112 U/L) suggestive of high turnover bone disease, was present in 47.3 % of the study population. The odds ratios for developing secondary hyperparathyroidism with hypocalcaemia and hyperphosphataemia were 5.32 (95% CI 1.10 - 25.9, P =0.03) and 3.06 (95 % CI 1.15 - 8.10, P =0.02) respectively. The 293 CKD patients (208 blacks, 85 whites) had an overall mean age of 51.1±13.6 years, and black patients were significantly younger than the white patients (48.4 ±.13.6 versus 57.1±15.5 years; p<0.001). In comparison to whites, blacks had higher median iPTH (498 [37-1084] versus 274[131-595] pg/ml; P=0.03), alkaline phosphatase (122[89-192] versus 103[74-144] U/L; P=0.03) and mean 25- hydroxyvitamin D (26.8±12.7 versus 22.7 ±12.2 ng/ml, P=0.01) levels, while their median FGF23 (100 [34-639] versus 233[80-1370] pg/ml; P=0.002) and mean serum phosphate (1.3±0.5 versus 1.5±0.5, P =0.001) levels were significantly lower. With the exception of vitamin D receptor (VDR) Taq I polymorphism, the distribution of the VDR polymorphisms differs significantly between blacks and whites. In hemodialysis patients, the BsmI Bb genotype was significantly associated with moderate secondary hyperparathyroidism (OR, 3.88; 95 CI 1.13-13.25, P=0.03) and severe hyperparathyroidism (OR, 2.54; 95 CI 1.08-5.96, P=0.03). Patients with high total alkaline phosphatase (TAP) had significantly higher risk of death compared to patients with TAP 2.75 mmol/L was associated with increased risk of death compared to patients within levels of 2.10–2.37 mmol/L (HR 6.34, 95% CI 1.40–28.76; P = 0.02). The HR for death in white patients compared to black patients was 6.88; 95% CI 1.82–25.88; P = 0.004. Conclusions Secondary hyperparathyroidism and 25–hydroxyvitamin D deficiency were common in our haemodialysis patients. The study also highlighted the existence of racial differences in the circulating markers of mineral bone disorders in our African CKD population. In addition, the study showed that both moderate and severe secondary hyperparathyroidism are predicted by the BsmI Bb genotype, and the over expression of this genotype in black patients may partly explain the ethnic variations in the severity of secondary hyperparathyroidism in the CKD population. High levels of serum alkaline phosphatase, hypercalcaemia, and white race are associated with increased risk of death in MHD patients.LG201