Capacity for the management of kidney failure in the International Society of Nephrology Africa region: report from the 2023 ISN Global Kidney Atlas (ISN-GKHA).

The burden of chronic kidney disease and associated risk of kidney failure are increasing in Africa. The management of people with chronic kidney disease is fraught with numerous challenges because of limitations in health systems and infrastructures for care delivery. From the third iteration of the International Society of Nephrology Global Kidney Health Atlas, we describe the status of kidney care in the ISN Africa region using the World Health Organization building blocks for health systems. We identified limited government health spending, which in turn led to increased out-of-pocket costs for people with kidney disease at the point of service delivery. The health care workforce across Africa was suboptimal and further challenged by the exodus of trained health care workers out of the continent. Medical products, technologies, and services for the management of people with nondialysis chronic kidney disease and for kidney replacement therapy were scarce due to limitations in health infrastructure, which was inequitably distributed. There were few kidney registries and advocacy groups championing kidney disease management in Africa compared with the rest of the world. Strategies for ensuring improved kidney care in Africa include focusing on chronic kidney disease prevention and early detection, improving the effectiveness of the available health care workforce (e.g., multidisciplinary teams, task substitution, and telemedicine), augmenting kidney care financing, providing quality, up-to-date health information data, and improving the accessibility, affordability, and delivery of quality treatment (kidney replacement therapy or conservative kidney management) for all people living with kidney failure.

Regional Variation in Hemoglobin Distribution Among Individuals With CKD: the ISN International Network of CKD Cohorts.

Introduction: Despite recognized geographic and sex-based differences in hemoglobin in the general population, these factors are typically ignored in patients with chronic kidney disease (CKD) in whom a single therapeutic range for hemoglobin is recommended. We sought to compare the distribution of hemoglobin across international nondialysis CKD populations and evaluate predictors of hemoglobin. Methods: In this cross-sectional study, hemoglobin distribution was evaluated in each cohort overall and stratified by sex and estimated glomerular filtration rate (eGFR). Relationships between candidate predictors and hemoglobin were assessed from linear regression models in each cohort. Estimates were subsequently pooled in a random effects model. Results: A total of 58,613 participants from 21 adult cohorts (median eGFR range of 17-49 ml/min) and 3 pediatric cohorts (median eGFR range of 26-45 ml/min) were included with broad geographic representation. Hemoglobin values varied substantially among the cohorts, overall and within eGFR categories, with particularly low mean hemoglobin observed in women from Asian and African cohorts. Across the eGFR range, women had a lower hemoglobin compared to men, even at an eGFR of 15 ml/min (mean difference 5.3 g/l, 95% confidence interval [CI] 3.7-6.9). Lower eGFR, female sex, older age, lower body mass index, and diabetic kidney disease were all independent predictors of a lower hemoglobin value; however, this only explained a minority of variance (R2 7%-44% across cohorts). Conclusion: There are substantial regional differences in hemoglobin distribution among individuals with CKD, and the majority of variance is unexplained by demographics, eGFR, or comorbidities. These findings call for a renewed interest in improving our understanding of hemoglobin determinants in specific CKD populations.

Challenges in Diagnosis and Management of Glomerular Disease in Resource-Limited Settings.

Introduction: Glomerular diseases are the leading drivers of nondiabetic chronic kidney disease disability-adjusted life years in resource-limited countries. Proper diagnosis and treatment relies on resources including kidney biopsy, ancillary testing, and access to evidence-based therapies. Methods: We conducted a cross-sectional internet-based survey cascaded through society mailing lists among nephrologists in countries of Asia, Africa, and Eastern Europe. We collected the data on respondent demographics, their ability to perform and appropriately interpret a kidney biopsy, and their access to complementary investigations and treatment practices. Results: A total of 298 kidney care specialists from 33 countries (53.3% from Asia and 44.6% from Africa; 64% from academic or university hospitals) participated in the survey. Of these specialists, 85% performed kidney biopsy. About 61% of the respondents could not obtain a kidney biopsy in more than 50% of patients with suspected glomerular disease. About 43% of the respondents from Africa had access to only light microscopy. Overall, the inability to undertake and fully evaluate a biopsy and perform ancillary investigations were more profound in Africa than in Asia. Overall, 59% of participants reported that more than 75% of their patients meet the cost of diagnosis and treatment by out-of-pocket payments. Empirical use of immunosuppression was higher in Africa than in Asia. The main barriers for diagnosis and treatment included delayed presentation, incomplete diagnostic work-up, and high cost of treatment. Conclusion: Major system-level barriers impede the implementation of guideline-driven approaches for diagnosis and treatment of patients with glomerular disease in resource-limited countries.

Epidemiology and Outcomes of Glomerular Diseases in Low- and Middle-Income Countries.

Glomerular diseases account for a significant proportion of chronic kidney disease in low-income and middle-income countries (LMICs). The epidemiology of glomerulonephritis is characterized inadequately in LMICs, largely owing to unavailable nephropathology services or uncertainty of the safety of the kidney biopsy procedure. In contrast to high-income countries where IgA nephropathy is the dominant primary glomerular disease, focal segmental glomerulosclerosis is common in large populations across Latin America, Africa, Middle East, and South East Asia, while IgA nephropathy is common in Chinese populations. Despite having a high prevalence of known genetic and viral risk factors that trigger focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis also is common in adults and children in some African countries. Treatment of glomerular diseases in adults and children in LMICs largely is dependent on corticosteroids in combination with other immunosuppressive therapy, which often is cyclophosphamide because of its ready availability and low cost of treatment, despite significant adverse effects. Partial and/or complete remission status reported from studies of glomerular disease subtypes vary across LMIC regions, with high rates of kidney failure, mortality, and disease, and treatment complications often reported. Improving the availability of nephropathology services and ensuring availability of specific therapies are key measures to improving glomerular disease outcomes in LMICs.

The Impact of Low Socioeconomic Status on Progression of Chronic Kidney Disease in Low- and Lower Middle-Income Countries.

Chronic kidney disease (CKD) is increasing in prevalence and is associated with increased morbidity and mortality, especially in low- and lower middle-income countries (LLMICs). Risk factors for CKD are numerous and may start in utero through to adulthood. Low socioeconomic status increases the risk of CKD and contributes to late presentation and suboptimal management especially in LLMICs. This leads to progression to kidney failure with associated increased mortality when kidney replacement therapy is required. Poor socioeconomic status may be the most important contributor to disease progression to kidney failure, especially in LLMICs, and may complicate other risk factors such as acute kidney injury, genetic risk, sickle cell disease, cardiovascular risk, and infections such as HIV. In this review, we explore the impact of low socioeconomic status on the increase in incidence and prevalence of CKD in LLMICs from in utero to adulthood, as well as mechanisms leading to increased burden, faster progression, and significant morbidity and mortality from CKD, especially in the absence of affordable, accessible, and optimum kidney replacement therapy.

Screening for Kidney Disease in Low- and Middle-Income Countries.

Kidney disease is the 10th leading cause of death worldwide and disproportionately increases morbidity and mortality for people residing in low- and middle-income countries (LMICs). Considering the high burden of chronic kidney disease (CKD) on patients, society, and health care systems, strategies to improve screening for CKD need to be prioritized. With appropriate interventions, screening could prevent progression of early stages of CKD and, ultimately, reduce the need for kidney replacement therapy. Unfortunately, few data exist to inform screening strategies for early detection and management of CKD in LMICs, where risk factors for CKD may differ from those in high-income countries. We review here the epidemiology of kidney disease in LMICs, current practices for screening for kidney disease, and challenges and opportunities available to LMICs. We also recommend ways in which screening could be improved for early identification and care for patients with kidney disease in LMICs and highlight critical gaps in knowledge.

Posttransplant Care of Kidney Transplant Recipients and Their Donors in Nigeria.

OBJECTIVES: Kidney transplantation is not readily available in low-resource settings because of poor health structure, dearth of experts, and pervading poverty. Although many centers now offer kidney transplant, patients still travel outside Nigeria for this service for many reasons and many return home without a detailed medical report. MATERIALS AND METHODS: Medical records of individuals who underwent kidney transplant in Nigeria and elsewhere and who were presently receiving posttransplant care or had received such care from 2002 to 2018 at 4 Nigerian hospitals were retrospectively reviewed and analyzed. RESULTS: Of 35 patients (30 males; 85.7%) analyzed (mean ages of 42 ± 16 and 47 ± 8 years for men and women, respectively; P = .54), common primary kidney diseases included hypertension (27.2%), glomerulonephritis (24.2%), and diabetes mellitus/hypertension (18.3%). Most patients received transplants in India (48.6%), with others in Nigeria (23.0%) and Pakistan (8.6%). Relationships to recipient were unrelated (28.5%), living related (22.9%), and unknown (48.6%). Less than 30% of recipients had care details in their hospital records. Almost all transplant patients were treated with prednisolone (81.8%); cyclosporine (40.0%), mycophenolate mofetil (31.4%), tacrolimus (20.0%), and azathioprine (9.1%) were also used. Complications were documented in 88.9%, with 57.0% due to bacterial infections/sepsis. Many (88.9%) had more than 2 complications. In follow-up, median first transplant duration was 24 months (interquartile range, 6-44). Of total patients, 25.7% were still alive, 17.1% had died, and 54.2% were lost to follow-up. Follow-up data for only 2 donors were available. CONCLUSIONS: Lapses in follow-up care of kidney transplant recipients and donors continue in lowresource settings where transplant tourism is still rife, resulting in poor graft/patient survival. Adherence to transplant guidelines is advocated. We propose a transplant stratification model according to level of development and resources of countries or regions. This model will encourage customizing strategies for improving patient outcomes.