Integrated management: chronic kidney disease, diabetes mellitus, hypertension

The increasing burden of chronic kidney disease and end stage kidney failure presents a challenge for both developed and emerging countries. While dialysis and transplantation consumes an ever-increasing proportion of the health budget in countries such as the United States, Japan and Taiwan, there is limited availability of these expensive therapies in the majority of emerging countries and more so in African nations. Aims: To review the prevalence, causes and integrated strategies for treatment and prevention of end stage renal disease (ESRD) in Sub-Saharan Africa (SSA).Materials and Methods: Review of literature and information received from colleagues in Africa. Results: Approximately 70% of the least developed countries of the world are in SSA. Rapid urbanisation is occurring in many parts of the continent, contributing to overcrowding and poverty. While infections and parasitic diseases are still the leading cause of death in Africa, non-communicable diseases are coming to the forefront. There is a continuing brain drain of healthcare workers (physicians and nurses) from Africa to more affluent regions, resulting in large rural areas of Africa having no health professionals to serve these populations. There are no nephrologists in many parts of SSA; the numbers vary from 0.5 per million population (pmp) in Kenya to 0.6 pmp in Nigeria, 0.7 pmp in Sudan and 1.1 pmp in South Africa. Chronic kidney disease (CKD) affects mainly young adults aged 20-50 years in SSA and is primarily due to hypertension and glomerular diseases. HIV-related chronic kidney disease is assuming increasing prominence and often presentslate, with patients requiring dialysis. Diabetes mellitus affects 9.4-million people in Africa. The prevalence of diabetic nephropathy is estimated to be 6-16% in SSA. The current dialysis treatment rate is <20pmp (and nil in many countries of SSA), with in-centre haemodialysis the modality of renal replacement therapy (RRT) for the majority. Transplantation is carried out in a few SSA countries: South Africa, Sudan, Nigeria, Mauritius, Kenya, Ghana and Rwanda, with most of the transplants being living donor transplants, except in South Africa where the majority are from deceased donors.Prevention programmes are in their infancy in most of SSA, due to lack of personnel and resources. Conclusion: Chronic kidney disease care is especially challenging in SSA, with large numbers of ESRD patients, inadequate facilities and funding, and lack of national or regional registries. Integrated management of CKD and its risk factors is necessary to impact on the burden of ESRD.