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.

Kidney adolescent and young adult clinic: A transition model in Africa.

Adolescents and Young Adults (AYAs) with chronic kidney disease (CKD) have challenges unique to this developmental period, with increased rates of high-risk behavior and non-adherence to therapy which may impact the progression of kidney disease and their requirement for kidney replacement therapy (KRT). Successful transition of AYA patients are particularly important in low- and middle-income countries (LMICs) where KRT is limited, rationed or not available. Kidney AYA transition clinics have the potential to improve clinical outcomes but there is a paucity of data on the clinical translational impact of these clinics in Africa. This review is a reflection of the 20-year growth and development of the first South African kidney AYA transition clinic. We describe a model of care for patients with CKD, irrespective of etiology, aged 10-25 years, transitioning from pediatric to adult nephrology services. This unique service was established in 2002 and re-designed in 2015. This multidisciplinary integrated transition model has improved patient outcomes, created peer support groups and formed a training platform for future pediatric and adult nephrologists. In addition, an Adolescent Centre of Excellence has been created to compliment the kidney AYA transition model of care. The development of this transition pathway challenges and solutions are explored in this article. This is the first kidney AYA transition clinic in Africa. The scope of this service has expanded over the last two decades. With limited resources in LMICs, such as KRT, the structured transition of AYAs with kidney disease is not only possible but essential. It is imperative to preserve residual kidney function, maximize the kidney allograft lifespan and improve adherence, to enable young individuals an opportunity to lead productive lives.

Better Together: acceptability, feasibility and preliminary impact of chronic illness peer support groups for South African adolescents and young adults.

INTRODUCTION: Peer support can help navigate the isolation and psychological strain frequently experienced by youth living with chronic illness. Yet, data are lacking on the impact of providing support for youth living with mixed chronic conditions. We assessed the acceptability, feasibility and preliminary mental health impacts of a clinic-based peer support group for South African youth living with chronic illnesses, including HIV. METHODS: This mixed-methods pilot study (September 2021-June 2022) enrolled 58 young patients, ages 13-24, at an urban hospital in Cape Town, South Africa. In-depth interviews elicited the perspectives of 20 young people in relation to their participation in the Better Together programme, a recurring clinic-based peer support group for patients with mixed chronic illnesses. Self-reported resilience, attitudes towards illness, stigma and mental health were captured via established measures. T-tests and multivariate analysis of variance compared psychosocial outcomes for 20 group participants and 38 control patients, controlling for socio-demographic characteristics at enrolment. Logistic regression analyses estimated the predicted probability of a positive depression or anxiety screening given peer group participation. RESULTS: All interviewees valued being able to compare treatment regimens and disease management habits with peers living with different conditions. Adolescents living with HIV stated that understanding the hardships faced by those with other conditions helped them accept their own illness and lessened feelings of isolation. Compared to patients who did not participate in Better Together, those who attended ≥5 groups had statistically significantly higher individual-level resilience, a more positive attitude towards their illness(es), lower internalised stigma and a more positive self-concept. The probability of being screened positive for depression was 23.4 percentage points lower (95% CI: 1.5, 45.3) for Better Together participants compared to controls; the probability of a positive anxiety screening was 45.8 percentage points lower (95% CI: 18.1, 73.6). CONCLUSIONS: Recurring, clinic-based peer support groups that integrate youth living with HIV and other chronic diseases are novel. Group sustainability will depend on the commitment of experienced peer leaders and providers, routine scheduling and transportation support. A fully powered randomised trial is needed to test the optimal implementation and causal mental health effects of the Better Together model.

Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics.

Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.

Management of Type 2 Diabetes Mellitus and Kidney Failure in People with HIV-Infection in Africa: Current Status and a Call to Action.

There is an increasing global burden of diabetes mellitus (DM) and chronic kidney disease (CKD), coupled with a high burden of people with HIV (PWH). Due to an increased lifespan on ART, PWH are now at risk of developing non-communicable diseases, including DM. Africa has the greatest burden of HIV infection and will experience the greatest increase in prevalence of DM over the next two decades. In addition, there is a rising number of people with CKD and progression to kidney failure. Therefore, there is an urgent need for the early identification and management of all 3 diseases to prevent disease progression and complications. This is particularly important in Africa for people with CKD where there is restricted or no access to dialysis and/or transplantation. This review focuses on the epidemiology and pathophysiology of the interaction between HIV infection and DM and the impact that these diseases have on the development and progression of CKD. Finally, it also aims to review the data on the management, which stems from the growing burden of all three diseases.

Task shifting roles, interventions and outcomes for kidney and cardiovascular health service delivery among African populations: a scoping review.

BACKGROUND: Human resources for health (HRH) shortages are a major limitation to equitable access to healthcare. African countries have the most severe shortage of HRH in the world despite rising communicable and non-communicable disease (NCD) burden. Task shifting provides an opportunity to fill the gaps in HRH shortage in Africa. The aim of this scoping review is to evaluate task shifting roles, interventions and outcomes for addressing kidney and cardiovascular (CV) health problems in African populations. METHODS: We conducted this scoping review to answer the question: "what are the roles, interventions and outcomes of task shifting strategies for CV and kidney health in Africa?" Eligible studies were selected after searching MEDLINE (Ovid), Embase (Ovid), CINAHL, ISI Web of Science, and Africa journal online (AJOL). We analyzed the data descriptively. RESULTS: Thirty-three studies, conducted in 10 African countries (South Africa, Nigeria, Ghana, Kenya, Cameroon, Democratic Republic of Congo, Ethiopia, Malawi, Rwanda, and Uganda) were eligible for inclusion. There were few randomized controlled trials (n = 6; 18.2%), and tasks were mostly shifted for hypertension (n = 27; 81.8%) than for diabetes (n = 16; 48.5%). More tasks were shifted to nurses (n = 19; 57.6%) than pharmacists (n = 6; 18.2%) or community health workers (n = 5; 15.2%). Across all studies, the most common role played by HRH in task shifting was for treatment and adherence (n = 28; 84.9%) followed by screening and detection (n = 24; 72.7%), education and counselling (n = 24; 72.7%), and triage (n = 13; 39.4%). Improved blood pressure levels were reported in 78.6%, 66.7%, and 80.0% for hypertension-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Improved glycaemic indices were reported as 66.7%, 50.0%, and 66.7% for diabetes-related task shifting roles to nurses, pharmacists, and CHWs, respectively. CONCLUSION: Despite the numerus HRH challenges that are present in Africa for CV and kidney health, this study suggests that task shifting initiatives can improve process of care measures (access and efficiency) as well as identification, awareness and treatment of CV and kidney disease in the region. The impact of task shifting on long-term outcomes of kidney and CV diseases and the sustainability of NCD programs based on task shifting remains to be determined.

The Evolving Spectrum of Kidney Histology in HIV-Positive Patients in South Africa.

Introduction: Sub-Saharan Africa remains challenged by the highest burden of human immunodeficiency virus (HIV), an epidemic of tuberculosis (TB), and increasing number of people with HIV (PWH) on antiretroviral therapy (ART), all of which may result in kidney injury. Methods: This observational cohort study describes the spectrum of kidney disease in PWH in South Africa, between 2005 and 2020. Kidney biopsies were analyzed in 4 time periods as follows: early ART rollout (2005-2009), tenofovir disoproxil (TDF) introduction (2010-2012), TDF-based fixed dose combination (2013-2015), and ART at HIV diagnosis (2016-2020). Logistic regression was used to identify factors associated with HIV-associated nephropathy or focal segmental glomerulosclerosis (HIVAN/FSGS) and tubulointerstitial disease (TID). Results: We included 671 participants (median age 36, interquartile range, 21-44 years; 49% female; median CD4 cell count 162 [interquartile range, 63-345] cells/mm3). Over time, ART (31%-65%, P < 0.001), rate of HIV suppression (20%-43%, P < 0.001), nonelective biopsies (53%-72%, P < 0.001), and creatinine at biopsy (242-449 µmol/l, P < 0.001) increased. A decrease in HIVAN (45%-29% P < 0.001) was accompanied by an increase in TID (13%-33%, P < 0.001). Granulomatous interstitial nephritis accounted for 48% of TID, mostly because of TB. Exposure to TDF was strongly associated with TID (adjusted odds ratio 2.99, 95% confidence interval 1.89-4.73 P < 0.001). Conclusion: As ART programs intensified and increasingly used TDF, the spectrum of kidney histology in PWH evolved from a predominance of HIVAN in the early ART era to TID in recent times. The increase in TID is likely due to multiple exposures that include TB, sepsis, and TDF as well as other insults.

Primary Sjögren's syndrome with renal tubular acidosis and central pontine myelinolysis: An unusual triad.

Primary Sjögren's syndrome (pSS) is a complex, multisystem autoimmune disorder. It is characterized by lymphocytic infiltration of the exocrine glands. In the setting of pSS, the presence of systemic disease is an important prognostic determinant, but involvement of the kidney is uncommon. The triad of pSS, distal renal tubular acidosis (dRTA), and central pontine myelinolysis (CPM) is rare and potentially fatal. A 42-year-old woman presented with dRTA, profound hypokalemia, and CPM characterized by progressive global quadriparesis, ophthalmoplegia, and encephalopathy. Sjögren's syndrome was diagnosed based on sicca symptoms, clinical features, and strongly positive anti-SSA/Ro and anti-SSB/La autoantibodies. The patient responded well to electrolyte replacement, acid-base correction, corticosteroids, and subsequent cyclophosphamide therapy. Early recognition and appropriate treatment resulted in good kidney and neurological outcomes in this case. This report highlights the need to consider the diagnosis of pSS in unexplained dRTA and CPM, as it has a favorable prognosis if recognized and managed timeously.

Scope and Consistency of Cancer Outcomes Reported in Randomized Trials in Kidney Transplant Recipients.

Introduction: Cancer is an important outcome in kidney transplantation, but the scope and consistency of how cancer is defined and reported in trials involving kidney transplant recipients has not been evaluated. This study aimed to assess the range and variability of cancer outcomes in trials involving kidney transplant recipients. Methods: The ClinicalTrials.gov database was searched from February 2000 to July 2021 to identify all randomized controlled trials (RCTs) in adult kidney transplant recipients, and which included cancer as a specified outcome. The definition of cancer, types of cancer (if any), timepoint(s) of measurement and method of aggregation were extracted for each cancer outcome. Results: Of the 819 trials in kidney transplantation, only 84 (10%) included 1 or more cancer outcomes. Of these, 72 of 84 (86%) trials included cancer as a secondary outcome and 12 of 84 (14%) considered cancer as a primary outcome. The most frequent description of cancer was "malignancy" (n = 44, 43%), without reference to diagnostic criteria, histology, grade, or stage. The 2 most common cancer types were posttransplant lymphoproliferative disorder (PTLD) (n = 20, 20%) and nonmelanoma skin cancer (n = 10, 10%). Several methods of aggregation were identified, including incidence or rate (n = 47, 46%), frequency or proportion (n = 30, 29%), and time to event (n = 5, 5%). Approximately half the cancer outcomes were measured at a single time point (n = 44, 52%). Conclusion: Cancer is an infrequently reported outcome and is inconsistently defined in trials of kidney transplant recipients. Consistent reporting of cancer outcomes using standardized definitions would provide important information on the impact of cancer in patients after kidney transplantation.

Disseminated Mycobacterium Tuberculosis and IgA Nephropathy.

Mycobacterium tuberculosis (MTB) is an under-recognised cause of genitourinary disease. IgA nephropathy (IgAN), a leading cause of glomerulonephritis worldwide, has been described as a rare consequence of disseminated MTB infection. In this case report, we present the first case of MTB associated IgAN in Africa. Finding IgAN on kidney biopsy in an MTB endemic area should prompt a thorough investigation for MTB to increase the chance of remission of IgAN and prevent inappropriate use of immunosuppression.

A multi-faceted approach to sex and gender equity in solid organ transplantation: The Women in Transplantation Initiative of The Transplantation Society.

The advancement of women's careers in transplantation continues to be challenging. Academic careers in both basic and clinical disciplines in transplantation, such as surgery and management of end organ failure in medical specialties, have been underrepresented by diverse genders and ethnicities. Over the last decade, the Women in Transplantation Initiative (WIT) has solidified to becoming an internationally recognized organization with activities focused on diversity and inclusion in terms of the sexes. The WIT organization is divided into 3 pillars that address career advancement and networking (Pillar 1), scientific investigation and presentations on sex and gender in transplantation (Pillar 2) and investigating and facilitating equitable access to transplantation for women throughout the world (Pillar 3). By taking this multipronged approach of collaborating across continents, leveraging virtual platforms for information dissemination and discussion, and providing financial support for research, WIT has become a highly visible grass roots organization that aims to improve the experience of women as transplant professionals as well as transplant donors and recipients.

Pregnancy-Associated Acute Kidney Injury in Low-Resource Settings: Progress Over the Last Decade.

Despite immense global effort, the maternal mortality rate in low-resource settings remains unacceptably high. Globally, this reflects the grave inequalities in access to health and reproductive services. Pregnancy-associated acute kidney injury (PRAKI) is an independent risk factor for mortality. The reported incidence of PRAKI in low- and middle-income countries is higher than that of high-income countries (4%-26% versus 1%-2.8%, respectively). Hypertensive disorders are now the leading cause of PRAKI in many regions, followed by hemorrhage and sepsis. PRAKI in low-resource settings carries a high mortality for both mother and child. Outcome studies suggest that PRAKI is associated with residual kidney dysfunction and may lead to dialysis dependence. This can be a death sentence in many regions with limited kidney replacement therapy. This review will summarize data on PRAKI on the African, Latin American, and Asian continents over the past decade. It will include the progress in published data, mortality, and treatment interventions and provide recommendations for the next decade.

The repeatability and reproducibility of four techniques for measuring horizontal heterophoria: Implications for clinical practice

Purpose: Convergence insufficiency, the most common binocular vision anomaly, is characterised by a receded near point of convergence and an exophoria which is at least 4 prism dioptres (Δ) larger at near than at distance. However, the repeatability of standard heterophoria measures are poorly understood. This study assessed the ability of four common heterophoria tests to detect differences of 4Δ by evaluating the inter- and intra-examiner variability of the selected techniques. Methods: Distance and near horizontal heterophorias of 20 visually-normal adults were measured with the alternating prism cover test, von Graefe prism dissociation, Howell Card and Maddox Rod by two examiners at two separate visits using standardised instructions and techniques. We investigated inter- and intra-examiner variability using repeatability and reproducibility indices, as well as Bland-Altman analysis with acceptable limits of agreement defined as ±2Δ. Results: The Howell card test had the lowest intra-examiner variability at both distance and near, as well as the best 95% limits of agreement (±1.6Δ for distance and ±3.7Δ for near). Inter-examiner reproducibility results were similar, although at near the alternating prism cover test had better repeatability (1.1Δ, 95% confidence intervals −1.1Δ to 4.0Δ) than the Howell card (1.4Δ, 95% confidence intervals −1.9Δ to 5.9Δ). Conclusion: The low repeatability of many standard clinical heterophoria tests limits the ability to reliably detect a 4Δ difference. The Howell Card provided the most repeatable and reproducible results indicating that this technique should be used to detect small changes in heterophoria magnitude and direction. (AU)

Radically Rethinking Renal Supportive and Palliative Care in South Africa.

The incidence of end-stage kidney disease (ESKD) is increasing worldwide; however, because of resource constraints, access to lifesaving kidney replacement therapy (KRT) remains limited in the state sector in South Africa. National guidelines mandate that only patients who are transplantable be accepted into state chronic dialysis programs. Once a patient is transplanted, there is an opportunity for a new patient to access a chronic dialysis slot. Given the resource scarcity, the South African Constitutional Court has ruled that rationing of dialysis is appropriate; however, this is not without cost both to patients and decision makers. Patients, both adults and pediatric, are often placed on a palliative care (PC) pathway not through choice but through circumstance. Renal supportive care (RSC) and PC involve an interdisciplinary approach to manage patients with ESKD to ensure that symptoms are managed optimally and to provide support during advanced disease. Innovative ways to address patient care at any age must be sought to ensure nonabandonment and adequate care with our limited resources.

"Those People Motivate and Inspire Me to Take My Treatment." Peer Support for Adolescents Living With HIV in Cape Town, South Africa.

Adherence to antiretroviral therapy (ART) and psychosocial support to manage stigma and disclosure is essential for adolescents living with HIV (ALHIV). Peer support groups can help ALHIV and their families live successfully with HIV. This qualitative study aimed to examine adolescent and caregiver perspectives on peer support groups. Three themes emerged: (1) peer support encouraged adherence to ART, (2) serostatus disclosure outside the family was perceived as difficult, and (3) the peer support group fostered fundamental and meaningful peer relationships for ALHIV. Caregivers felt peer support groups increased self-acceptance and adherence for ALHIV across 3 domains: (1) as motivation for families and adolescents, (2) to increase adolescent independence and maturity, and (3) to help adolescents accept their HIV status and live successfully with HIV. These data highlight the importance of psychosocial support groups for ALHIV and caregivers, illustrating the benefits of a safe space with trusted relationships and open communication.

COVID-19 and the kidney: A South African state healthcare experience.

The first documented case of SARS-CoV-2 infection was confirmed in South Africa (SA) in March 2020. The Western Cape (WC) province was the initial epicenter. The pandemic peaked in July 2020 when 76,851 cases were documented and 2,323 deaths reported. COVID-19 can have multisystem involvement. Acute kidney injury (AKI) is well-documented and associated with increased mortality. We report our experience as the pandemic evolved in the WC province, focusing on those patients with a SARS-CoV-2 positive test presenting with AKI. We also reviewed our chronic dialysis cohort and renal transplant recipients who tested positive to assess incidence and outcomes. All patients presenting to nephrology services at the four main public hospitals were included. Information regarding demographics, co-morbidities, medical care, laboratory data, and outcomes were recorded. There were 86 patients referred with AKI, 48 required dialysis, and 47 died. There were 52 patients admitted to the intensive care unit with AKI (37 received dialysis, 1 of whom survived). In those presenting with AKI, diabetes, obesity, hypertension, and HIV were the most common comorbidities. Of the 295 patients receiving chronic dialysis within our services, 31 tested positive for SARS-CoV-2, and 6 died. Of the 45 kidney transplant recipients who tested positive, 9 died. Only 3 required dialysis. In conclusion, we report a high rate of AKI and poor prognosis in those requiring kidney replacement therapy, a better prognosis than anticipated was found in our chronic dialysis cohort, and high numbers of admissions were required for renal transplant recipients.

The repeatability and reproducibility of four techniques for measuring horizontal heterophoria: Implications for clinical practice.

PURPOSE: Convergence insufficiency, the most common binocular vision anomaly, is characterised by a receded near point of convergence and an exophoria which is at least 4 prism dioptres (Δ) larger at near than at distance. However, the repeatability of standard heterophoria measures are poorly understood. This study assessed the ability of four common heterophoria tests to detect differences of 4Δ by evaluating the inter- and intra-examiner variability of the selected techniques. METHODS: Distance and near horizontal heterophorias of 20 visually-normal adults were measured with the alternating prism cover test, von Graefe prism dissociation, Howell Card and Maddox Rod by two examiners at two separate visits using standardised instructions and techniques. We investigated inter- and intra-examiner variability using repeatability and reproducibility indices, as well as Bland-Altman analysis with acceptable limits of agreement defined as ±2Δ. RESULTS: The Howell card test had the lowest intra-examiner variability at both distance and near, as well as the best 95% limits of agreement (±1.6Δ for distance and ±3.7Δ for near). Inter-examiner reproducibility results were similar, although at near the alternating prism cover test had better repeatability (1.1Δ, 95% confidence intervals -1.1Δ to 4.0Δ) than the Howell card (1.4Δ, 95% confidence intervals -1.9Δ to 5.9Δ). CONCLUSION: The low repeatability of many standard clinical heterophoria tests limits the ability to reliably detect a 4Δ difference. The Howell Card provided the most repeatable and reproducible results indicating that this technique should be used to detect small changes in heterophoria magnitude and direction.

The primary care provider's role in providing supportive and palliative care for patients in chronic renal failure.

Primary care providers are at the core of providing supportive and palliative care to patients with chronic kidney disease in South Africa. Although dialysis is not always needed, and sometimes not appropriate, for all patients with end-stage kidney disease, there is always supportive and palliative care that can be provided to patients and families to improve outcomes. This article explores the referral pathways, renal preservation, supportive and palliative care and, finally, health system interventions that can improve comprehensive care. The integration of renal supportive and palliative care is a relatively new concept in the paradigm of care and will require advocacy and research to ensure all South African patients have access throughout the trajectory of illness.