#2979 Patients referred to nephrology consultation from African countries of Portuguese official language: a Portuguese single-center cohort study
Authors: Domingos Diogo , Ávila Gonçalo , Laranjinha Ivo , Matias Patrícia , Gil Célia , Gonçalves Margarida , Gaspar Augusta 
Published: May 2024

Abstract

Background and Aims
Chronic kidney disease (CKD) is a main cause of morbidity and mortality worldwide, with African population being at increased risk. Nevertheless, access to treatment for CKD is restricted in African countries resulting in premature death. The latest statistics point to an annual referral to Portugal of around 900 patients from those countries for medical reasons—of which only 5% corresponds to Nephrology referrals. However, this protocol is burdened with high social and economic impact, consuming 50% of the funds budgeted by the Portuguese government (estimated at 3 million euros annually).
The aim of this study was to describe the clinical characteristics, reasons for the referral and outcomes of patients from African Countries of Portuguese Official Language (ACPOL) to a nephrology consultation in a tertiary hospital in Portugal under a cooperation protocol.

Method
Single-center retrospective analysis of 131 African patients referred to our nephrology department between 2014 and 2023.

Results
Only 84 patients (64%) ended up being evacuated from their country of origin and attended the nephrology consultation in Portugal. The mean age was 46 ± 14 years and 55% were male. Thirty-two patients were from Guinea-Bissau (38%), 24 from São Tomé and Príncipe (29%), 22 from Cape Verde (26%), and 6 from Angola (7%). The motives for referral to a tertiary center were advanced CKD in 58 patients (69%), nephrotic syndrome in 21 patients (25%), and hemodialysis (HD) vascular access dysfunction in 5 of the cases (6%).
In the group of patients referred with advanced CKD the mean eGFR was 16 ± 10 ml/min, all patients had hypertension, 20% had diabetes and 9% presented heart failure. More than half (56%) needed hospitalization with urgent need of dialysis and all patients started HD with a central venous catheter. During the follow-up, four patients died (5%), two patients (2.3%) transitioned to peritoneal dialysis and 70% were on kidney transplant waiting list.
Patients referred with nephrotic syndrome had a mean eGFR of 71 ± 49 ml/min/1,73 m2 and a median urine albumin/creatinine ratio (uACR) of 6.9 [IQR 4.7-8.8] g/g. Kidney biopsy was performed in 90% of the cases, with membranous nephropathy (37.5%) and focal segmental glomerulosclerosis (25%) being the two most frequent diagnosis.
Only two patients returned to their origin country; the remaining prolonged their stay due to unavailability of resources for appropriate treatment in their country of origin.

Conclusion
These data emphasize the inequality in access to healthcare in African countries and highlights the urgent need for investment, especially in CKD, as it contributes to serious consequences in these patients’ survival and morbidity. With the cooperation protocol, Portugal provides the possibility for these patients to be evacuated and treated in specialized nephrology departments, improving their outcomes. However, our study shows that there is still a lot to be done since just over 60% of referred patients manage to reach Portugal. The entire evacuation process remains extremely delayed, a fact shown by the need for patients to start urgent HD and that more than half of them require hospitalization upon arrival at the nephrology department, with a high economic burden.