Peritoneal Dialysis International, Vol. 30, pp. 23–28
doi: 10.3747/pdi.2008.00226
0896-8608/10 $3.00 + .00
Copyright © 2010 International Society for Peritoneal Dialysis
PERITONEAL DIALYSIS IN AFRICA
Hasan Abu-Aisha and Sarra Elamin
Sudan Peritoneal Dialysis Program, Khartoum, Sudan
Perit Dial Int 2010; 30:23–28
est and most underdeveloped continent. About 80% of
Africa’s total area is occupied by so-called sub-Saharan
Africa. This is a geographical term that describes African countries fully or partially located south of the Sahara Desert (Figure 1) (1). The sub-Saharan region is also
known as “Black” Africa, in contrast to the “Caucasoid”
inhabitants of North Africa. The Horn of Africa and large
parts of Sudan are geographically part of sub-Saharan
Africa but resemble North Africa in being part of the Arab
world.
ECONOMIC INDICATORS
The Human Development Index (HDI) is an index that
combines normalized measures of life expectancy, literacy, educational attainment, and gross domestic product (GDP) per capita for countries worldwide and provides
a standard means of measuring human development.
Countries fall into three broad categories based on their
HDI: high, medium, and low human development.
www.PDIConnect.com
KEY WORDS: Africa; developing countries; end-stage
renal disease.
A
frica is the world’s second-largest and second most
populous continent, after Asia. Although it has abundant natural resources, Africa remains the world’s poorCorrespondence to: S. Elamin, Sudan PD Program, P.O. Box
363, Khartoum, 11111 Sudan.
[email protected]
Received 13 September 2008; accepted 4 March 2009.
Figure 1 — Map of Africa shows the regions belonging to subSaharan Africa (dark gray) and North Africa (light gray).
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♦♦Background: Africa is the world’s second-largest and second most populous continent. It is also the poorest and
most underdeveloped continent. Struggling to provide the
essential health interventions for its occupants, the majority of African countries cannot regard renal replacement
therapy a health priority.
♦♦Review: In 2007, Africa’s dialysis population constituted
only 4.5% of the world’s dialysis population, with a prevalence of 74 per million population (pmp), compared to a
global average of 250 pmp. In almost half the African countries, no dialysis patients are reported. The prevalence of
peritoneal dialysis (PD) was 2.2 pmp, compared to a global prevalence of 27 pmp, with the bulk of African PD patients (85%) residing in South Africa. In North African
countries, which serve 93% of the African dialysis population, the contribution of PD to dialysis is only 0% – 3%.
Cost is a major factor affecting the provision of dialysis
treatment and many countries are forced to ration dialysis
therapy. Rural setting, difficult transportation, low electrification rates, limited access to improved sanitation and
improved water sources, unsuitable living circumstances,
and the limited number of nephrologists are obstacles to
the provision of PD in many countries.
♦♦Conclusion: The potential for successful regular PD programs in tropical countries has now been well established.
Cost is a major prohibitive factor but the role of domestic
manufacture in facilitating widespread use of PD is evidenced by the South African example. Education and training are direly needed and these are areas where
international societies can be of great help.
ABU-AISHA and ELAMIN
According to the United Nations Development
Programme’s Human Development Report 2007/2008,
only 3 of the 70 countries listed in the high human development group are African countries: Seychelles,
Libya, and Mauritius. All 22 countries listed in the low
human development group are African countries (2).
Sub-Saharan Africa has the highest proportion of
people living in extreme poverty: 300 million people,
over 40% of the population, were estimated to live on
less than one dollar per day in 2004 (3).
HEALTH INDICATORS
ECONOMICS AND HEALTH
In 2004, only one third of sub-Saharan countries
spent more than US$30 per person per year on health;
US$30 – 40 per person per year is estimated to be the
minimum expenditure on health required for essential
health interventions in low-income countries (Figure 2)
(3,4).
Under such conditions it is to be expected that renal
replacement therapy can hardly be regarded a health
priority in the majority of African countries. Even in relatively wealthy economies, the provision of dialysis constitutes a heavy burden on health systems. Global surveys
have long revealed the positive correlation between the
national GDP and the prevalence of dialysis treatment,
particularly in countries with a GDP of <US$10000 per
person per year (5).
DIALYSIS IN AFRICA
Renal registries are not available in almost all African countries and there are often no official reports on
the number of dialysis patients. Data presented here
about the number of dialysis patients in African countries were generously provided by Fresenius Medical Care
as part of the information gathered during its annual
global survey. Data relating to the cost of dialysis and
the proportion of renal failure patients that are denied
dialysis treatment in African countries were collected by
electronic mail from medical practitioners in corresponding countries.
The positive correlation between GDP and the prevalent dialysis population is also observed among African
countries but the situation here is more complex (see
Figure 3).
The prevalence of dialysis in relatively wealthy African countries (Botswana, South Africa, Namibia, and
Swaziland) is much lower than expected from the GDP.
These countries belong to southern Africa, a subregion
that accommodates 35% of all people living with HIV in
the world. For instance, the adult HIV prevalence in
Botswana exceeded 25% in 2005, a fact that has obvious implications for health system priorities (6).
Figure 2 — Total expenditure on health per person per year (2005) in different African countries (4).
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Among developing regions, sub-Saharan Africa has
the least favorable health indicators and the majority of
its countries are unlikely to achieve any of the Millennium Development Goals. Life expectancy at birth in subSaharan Africa is the lowest among developing regions,
at 47 years; prevalence of child malnutrition is highest,
at 30%; under 5 years mortality rate is highest, at 163
per 1000; and prevalence of HIV among adults aged 15 –
49 years is highest, at 5.8% (1).
JANUARY 2010 – VOL. 30, NO. 1
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JANUARY 2010 – VOL. 30, NO. 1
PERITONEAL DIALYSIS IN AFRICA
Figure 3 — GDP per capita (2005) versus prevalence of dialysis patients in different African countries (2007) (2).
PERITONEAL DIALYSIS IN AFRICA
Most African PD patients reside in South Africa, where
1170 (32%) dialysis patients are maintained on PD. This
contributes 85% to the African PD population. It is noteworthy that, excluding South Africa, PD is only well represented in countries that have small numbers of dialysis
patients. In North African countries, which serve 93%
of the African dialysis population, the contribution of
PD to dialysis is only 0% – 3%.
Peritoneal dialysis costs more than HD in South Africa,
Sudan, and Nigeria; in Sudan, almost all patients are offered two sessions of HD per week. In Senegal and Kenya,
PD costs less than HD (Table 2).
Only South Africa and Kenya are identified to manufacture dialysis solutions. Cost is a major factor affect-
ing the provision of dialysis treatment. With few exceptions, patients bear the largest and sometimes the whole
burden of treatment cost. Only South Africa, Mauritius,
and Sudan are identified to provide dialysis treatment
at low or no cost (9,10).
The constraints on capital and human resources combined with a rapidly escalating burden of chronic kidney disease (CKD) have forced many countries to ration
dialysis therapy. It is estimated a large proportion of
kidney failure patients that reach healthcare facilities
are denied dialysis therapy in African countries
(Table 3).
In South Africa, only patients eligible for a kidney
transplant are offered dialysis at no/low cost by the state
(10). A recently published article reflected on the experience of a South African center in rationing dialysis
therapy over a 15-year period (1988 – 2003). Of 2442
end-stage renal disease (ESRD) patients that were referred for dialysis, only 48% were offered dialysis
therapy. Among patients that were denied dialysis
therapy, social factors associated with poverty contributed significantly to the decision to deny dialysis therapy
in almost 60% of cases. These factors included living circumstances unsuitable for PD, inability to travel to dialysis centers, lack of insight into illness, and illiteracy
(11).
In sub-Saharan Africa, 65% of the population live in
a rural setting (2). In such circumstances, PD would
seem a better option than HD because patients would
not need to travel regularly or relocate near to dialysis
centers. However, this is counterbalanced by the
difficulty encountered in transporting PD supplies.
Transportation is limited and expensive, and patients
often face difficulties in arranging transport of PD supplies. In addition, less than 30% of the sub-Saharan
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In 2007, Africa’s population constituted about 14%
of the world’s population, while Africa’s dialysis population constituted only 4.5% of the world’s dialysis population. The total dialysis population of Africa was
estimated at 69800 patients in 2007; this equates to a
prevalence of 74 per million population (pmp), compared
to a global average of 250 pmp. The total number of hemodialysis (HD) patients in Africa in 2007 was estimated
at 67700; this equates to a HD prevalence of 71.6 pmp,
compared to a global prevalence of 223 pmp. The total
number of peritoneal dialysis (PD) patients in Africa in
2007 was estimated at 2050; this equates to a PD prevalence of 2.2 pmp, compared to a global prevalence of
27 pmp (7,8).
Availability of dialysis services in African countries is
variable. In general, HD is more prevalent than PD in almost all countries. In almost half the African countries,
no dialysis patients are reported (see Table 1).
ABU-AISHA and ELAMIN
JANUARY 2010 – VOL. 30, NO. 1
TABLE 1
TABLE 2
Number of Prevalent Hemodialysis (HD) and Peritoneal
Dialysis (PD) Patients in Different African Countries (2007)a
Cost of Hemodialysis Versus Peritoneal
Dialysis in Some African Countriesa
Dialysis
HD
PD
Dialysis patients
patients patients patients
on PD (%)
Egypt
Algeria
Tunisia
Morocco
South Africa
Sudan
Libya
Nigeria
Mauritius
Cote d’Ivoire
Ethiopia
Kenya
Angola
Benin
Mauritania
Cameroon
Gabon
Senegal
Ghana
Madagascar
Botswana
DR Congo
Mali
Namibia
Togo
Uganda
Zambia
Zimbabwe
Mozambique
Swaziland
Tanzania
Total
33110
10160
7160
5680
3660
2850
2150
1130
820
460
460
380
290
250
240
220
150
130
51–100
51–100
20–50
20–50
20–50
20–50
20–50
20–50
20–50
20–50
<20
<20
<20
69800
a
33000
9900
6880
5660
2450
2750
2100
1130
820
460
460
340
290
250
240
220
150
110
51–100
51–100
—
<20
20–50
20–50
20–50
20–50
<20
20–50
<20
<20
<20
67700
<20
260
280
20–50
1170
100
51–100
—
—
—
—
20–50
—
—
—
—
—
20–50
—
—
20–50
<20
—
<20
—
<20
<20
20–50
<20
—
—
2050
0
3
4
0
32
3
2
0
0
0
0
12
0
0
0
0
0
18
0
0
100
25
0
43
0
14
50
44
25
0
0
3
Figures presented in this table are unpublished data extracted from the 2007 Fresenius Medical Care global survey
of end-stage renal disease patients, with courtesy of Fresenius Medical Care Deutschland GmbH. Figures for Sudan are
current and are from our data files.
population has electricity supply at the household level,
only 37% use improved sanitation, and only 55% have
access to improved water source (2). Large families are
often crowded into limited space and have no available
area for storing dialysis supplies. As a result, regular
PD is demanding, even to willing and enthusiastic
patients.
A previous study explored factors contributing to the
high incidence of PD-related peritonitis in the African
setting. It concluded that, among other factors, a high
26
Annual cost per patient (US$)
Peritoneal dialysis
Hemodialysis
Country
South Africa
Sudan
Kenya
Senegal
Nigeria
Namibia
a
12000
11500
12000
19500
25000–55000
24500
7000
10500
16000
27000
20000–49000
24500
Figures presented in this table are estimates provided by
Sarala Naicker (South Africa), Ahmed Twahir (Kenya), Abdou
Niang (Senegal), Felicia Eke (Nigeria), Ebun Bamgboye (Nigeria), and Sr. A. Prins (Namibia) in response to an e-mailbased survey conducted by the authors.
TABLE 3
Estimated Percentage of Advanced Renal Failure (ARF) and
Chronic Renal Failure Patients Needing but Not
Receiving Dialysis Therapya
Country
Patients needing but not receiving dialysis therapy
ARF
ESRD
Ethiopia
Senegal
Nigeria
Kenya
South Africa
Sudan
90%
50%
30%–60%
60%
0%
0%
99%
95%
10%–99%
90%
50%
0%
ESRD = end-stage renal disease.
a Figures presented in this table are estimates provided by
Yewondwossen Tadesse (Ethiopia), Abdou Niang (Senegal),
Felicia Eke (Nigeria), Ebun Bamgboye (Nigeria), Ahmed
Twahir (Kenya), and Sarala Naicker (South Africa) in response
to an e-mail-based survey conducted by the authors.
occupant-to-bedroom ratio, no electricity, and informal
housing were significantly associated with peritonitis
rate (12).
Successful PD depends, among other variables, on a
willing and cooperative patient. In African countries
with poorly structured healthcare systems, ESRD patients are often referred late, in extreme stress, and have
no time for patient counseling or adequate planning for
dialysis therapy. Such ill patients are often very malnourished and physically incapable of performing selfdialysis. Extreme stress and low educational level often
render patients unwilling to play an active role in their
own management.
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Country
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JANUARY 2010 – VOL. 30, NO. 1
WHAT NEEDS TO BE DONE
Education and training are direly needed. Africa has
benefited from different schemes supported by the Commission for the Global Advancement of Nephrology
(COMGAN) but more focus on sub-Saharan Africa is required to fulfill the pressing need for nephrology training. Also, healthcare authorities need to be encouraged
to develop their own training programs with the support
and recognition of the International Society for Peritoneal Dialysis (ISPD) and the International Society of
Nephrology (ISN). Focusing on local and regional conferences and teaching courses may serve two purposes:
to draw the attention of local governments to the growing problem of CKD and to deliver educational messages
to a wider base of local practitioners.
Healthcare authorities are required to develop national renal registries with technical support from the
ISPD and ISN. Renal registries would help guide judicious
utilization of meager resources and monitor the performance of established renal services, with the goal of
continuous quality improvement.
Doctors working in the primary care setting need to
be educated on the importance of early diagnosis and
timely referral of CKD patients to the nephrologist. This
would help delay or prevent the progression of CKD to
ESRD. It would also allow time for adequate patient education and counseling, which is the cornerstone of a successful PD program. The local medical community needs
to be informed of the available options of renal replacement therapy. The potential for successful regular PD
programs in tropical countries has now been well established. Suitable patients should not be denied the benefits of PD because of unfounded fears.
Domestic manufacture might significantly reduce
costs of dialysis, as evidenced by the South African example. To overcome the obstacle of limited local demand, domestic manufacture may serve both export
and local markets. Governments might provide incentives by facilitating licensing and registration for dialysis items. By reducing the cost of dialysis and
allowing expansion of dialysis programs, industry can
still realize financial gain through larger numbers of
treated patients, while easing the burden on healthcare systems.
FUTURE PROSPECTS
The global increase in the dialysis population is largely
driven by the growth of dialysis in developing country
regions. Growth of dialysis is much higher in developing
countries than in the USA, the European Union, and
Japan, countries that currently serve the bulk of the global dialysis population (Table 4). Extrapolations based
on current growth rates suggest that, by the year 2010,
a significantly higher proportion of patients may undergo dialysis treatment in Asia, Latin America, Eastern
Europe, the Middle East, and Africa (8).
CONCLUSION
Although PD has proved to be a viable treatment option for ESRD in Africa, it is scarcely provided in most
African countries. Training and provision of PD supplies
at subsidiary costs are required to support the growth of
local PD programs.
TABLE 4
Annual Growth Rate of Dialysis Population in 2007 (8)
Region
USA
European Union
Japan
Others
Total
Annual population growth rate
Hemodialysis Peritoneal dialysis
3%–4%
3%–4%
3%–4%
8%–10%
6%–7%
–1%
1%–2%
0%
8%–10%
5%–6%
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Technical difficulties are not uncommon. Manual intermittent PD using hard catheters is extensively utilized
in the management of advanced renal failure as well as
ESRD in many countries; however, accurate estimates of
the prevalence of this form of therapy are lacking. Intermittent hard catheter PD entails an extremely high
risk of peritonitis, which may compromise the peritoneal
membrane and undermine the patient’s chance of utilizing regular PD in the future. This may also increase the
possibility of adhesions and render permanent catheter
placement more difficult.
Lack of facilities for proper culture technique often
leads to an unacceptably high rate of culture-negative
peritonitis. Rates of culture-negative peritonitis as high
as 53% have been reported from Sudan (13).
In 2006, the total number of nephrologists in subSaharan Africa was estimated to be 172. This equates to
a prevalence of 0.2 pmp, compared to a prevalence of
20.0 pmp in Western Europe (14). Lack of adequate
chance for career development and poor salaries cause
health professionals to leave for private sector employment or, more commonly, for wealthier countries. In
addition to staff shortages, high personnel turnover results in constant replacement of renal professionals by
younger less experienced specialists.
PERITONEAL DIALYSIS IN AFRICA
ABU-AISHA and ELAMIN
JANUARY 2010 – VOL. 30, NO. 1
DISCLOSURE
The authors declare no conflict of interest.
6.
ACKNOWLEDGMENT
7.
Gratitude is extended to Fresenius Medical Care for the generous contribution of information to this report. We also thank
Joachim Seyfang (Fresenius Medical Care), Sarala Naicker
(South Africa), Felicia Eke (Nigeria), Ebun Bamgboye (Nigeria), Abdou Niang (Senegal), Yewondwossen Tadesse (Ethiopia), Ahmed Twahir (Kenya), and Sr. A. Prins (Namibia).
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