End-stage kidney disease in LMICs: rising to the challenge
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2017)

This time last year, to coincide with World Kidney Day (March 9), The Lancet launched a campaign to highlight the rising burden of kidney disease and to encourage research partnerships to address gaps in knowledge and care, including the affordability of such care. Nephrology research and collaboration has come a relatively long way since 2002 when the first guidelines on the evaluation and classification of chronic kidney disease were published by the US National Kidney Foundation. The burden of kidney diseases in high-income and some middle-income countries is becoming much better understood. In their analysis of data from the nationally representative Million Death Study in India, published in the January issue, Anna Dare and colleagues estimated that renal failure (either from end-stage chronic kidney disease [ESKD] or acute kidney injury) was the cause of almost 3% of deaths in 2010–13, up from just over 2% a decade earlier. Yet knowledge is not keeping up with care. Dare and colleagues point out that the health system is poorly equipped to face the rising burden of ESKD, with only just over a third of patients being on any form of renal replacement therapy (RRT). If the numbers for some middle-income countries are becoming better known, those for low-income countries, particularly in sub-Saharan Africa, are still largely a matter of guesswork. In their systematic review in this month's issue, Gloria Ashuntantang and colleagues begin their summary with the damning statement: “The burden of end-stage kidney disease (ESKD) in sub-Saharan Africa is unknown”. Not a promising starting point from which to attempt a review of the outcomes of management, perhaps. Yet, as Ashuntantang and colleagues also note, “The increasing numbers of publications from sub-Saharan Africa in recent years is testament to the growing expertise in the region.” The authors were able to retrieve 68 studies, half of which met medium quality criteria, for their overview of patients' ability to access treatment for ESKD and the quality of that treatment. The findings are heartbreaking. 2% of adults and 17% of children diagnosed with ESKD received no dialysis at all and more than 95% of these patients died or were presumed to have died. Among patients with a new diagnosis of ESKD who actually received dialysis, more than 80% discontinued treatment, largely because of the inability to pay for it, and also subsequently died. Those with existing diagnoses fared much better, presumably because they had been able to afford to keep up treatment, however suboptimal it might have been. Optimal dialysis requires use of erythropoiesis-stimulating drugs and permanent vascular access (eg, by means of arteriovenous fistulae), yet both were scarce in the studies Ashuntantang and colleagues retrieved, and dialysis dose and frequency were highly variable. The ethical dilemmas surrounding the provision of RRT in low-income regions have been discussed repeatedly within nephrology circles, yet there has been limited wider debate—let alone guidance and recommendation—on balancing the needs and rights of a growing community of patients in areas where scarce resources restrict the availability of expensive and long-term therapies. The recent paper in The Lancet by members of the International Society of Nephrology's Ethical Dialysis Task Force is therefore welcome. It clearly sets out ethical principles and goals, practice recommendations for health professionals, and benchmarks for health authorities. No one could question the commitment of the international nephrology community to addressing these critical issues, including those few dedicated individuals working in resource-limited settings themselves. It is now up to governments to step up to the challenge. In his linked Comment, Ikechi Okpechi calls Ashuntantang and colleagues' findings “both alarming and outrageous” and is unflinching in his condemnation of sub-Saharan African governments' failure to engage with the issue. He challenges countries to develop strategies to increase access to RRT by means of subsidies to increase affordability to patients, training of more personnel, allocation of funds to adequately equip renal units, and support for screening programmes for early detection and prevention. These should not be extraordinary strategies for those truly committed to achieving Sustainable Development Goal 3, which includes universal health coverage, access to medicines, strengthening of the health workforce, and reducing mortality from non-communicable diseases through prevention and treatment. Governments must now listen, learn, and act. ESKD in sub-Saharan Africa: will governments now listen?A few years ago, my group published an article entitled Nephrology in Africa—not yet uhuru.1 Uhuru is the Swahili word for “freedom”. The idea was to highlight the plight of patients with end-stage kidney disease (ESKD) and the challenges and frustrations of their nephrologists in sub-Saharan Africa amidst health-care authorities that had not done enough to alleviate the problem. The absence of uhuru referred to in that article is not peculiar to nephrology; other medical specialties in sub-Saharan Africa have similar problems associated with a reduced size of and inadequately experienced workforce, diagnostic facilities, and access to treatment, often resulting in poor patient outcomes. Full-Text PDF Open AccessOutcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic reviewMost 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. Full-Text PDF Open Access