Global Dialysis Perspective: Kenya

Abstract

Introduction Kenya is a lower-middle-income country, with a population of 47.5 million people living in 12.2 million households. The administrative units of the country are the county governments, all drawing their budgetary allocation from central government. The most populous region is Nairobi County, with a population of 4.3 million, followed by Kiambu with 2.4 million and Nakuru with 2.1 million residents. The population pyramid (Figure 1) illustrates that the majority of the population are youths (1).Figure 1.: Age and sex distribution of the Kenyan population, 2019 ( 1 ).The prevalence of HIV is 5%, and life expectancy is 70 years (men 64.6 years and women 69.4 years) (2,3). The country's gross national income per capita was $1760 in 2020 (Atlas method, current US$) (4), and the health care expenditure is 9% of the total budget, which is less than the recommended 15% of the Abuja Declaration (5). The provision of health care is shared by the government, the private sector, faith-based organizations, and nongovernmental organizations. The private sector is profit oriented and serves the segment of the population who can afford out-of-pocket payments or have medical insurance, whereas the other funders are not profit oriented and mostly serve the poor. The establishment of the National Health Insurance Fund (NHIF) in 1966 has enabled access to various health care services by both the poor and the rich. In 2017, the NHIF started reimbursing outpatient services, including funding twice-weekly hemodialysis (HD) for patients with kidney failure. This has had a huge positive effect on affected patients and their families by saving them from the catastrophic financial burden of out-of-pocket payments for HD (6). Epidemiology The prevalence of chronic kidney disease (CKD) in sub-Saharan Africa is estimated to be 14%; in Kenya, it is estimated at 4% (7). According to a population-based study of CKD in rural East Africa, the prevalence of CKD in western Kenya was 4%. The risk factors for CKD in this study included age ≥60 years and HIV infection (8). Unpublished data from the Kenya Renal Registry indicates that hypertensive renal disease and diabetic nephropathy are the two most identified kidney diseases in patients receiving kidney replacement therapy (KRT). There are no formal studies of the incidence and prevalence of end-stage kidney disease (ESKD)/stage 5 CKD, but informal estimates are that KRT is accessed by fewer than half of the patients who need it. HD Table 1 provides a summary of the dialysis services in Kenya. HD was first introduced in Kenya in 1972, but it was not widely available and was only used for patients with acute kidney injury (AKI) where recovery was anticipated. Chronic dialysis was started in Kenyatta National Hospital in August 1984; however, the survival of patients was dismal. Private hospitals started HD and peritoneal dialysis (PD) in 1982 (9,10). Table 1. - Summary of dialysis services in Kenya Number of dialysis patients (total number and pmp in the general population) 5670 (100 pmp) % of patients on home dialysis 20–50 patients on PD (11) Dialysis funding National Health Insurance Fund funds two HD sessions per week Dialysis units Total units 214; public 54, private 143, faith-based 17 Are the dialysis units for-profit or nonprofit? Public sector is nonprofit; private sector is for-profit What is the reimbursement per dialysis session in $US? $95 Are all of the staff who deliver dialysis nurses, or do you also use patient care technicians? Dialysis nurses What is the typical patient/nurse ratio in the dialysis units? Approximately 1 nurse to 8 patients What is the average length of a dialysis session? 4 hours (twice weekly) Vascular access for HD patients Less than 2% have AV fistulae at initiation of HD; the majority use central venous catheters (both temporary and tunneled catheters) pmp, per million population; PD, peritoneal dialysis; HD, hemodialysis; AV, arteriovenous. The Kenya Renal Association has long advocated for more services for kidney care. Recommendations were made to the government, which led to the recent increase in access to HD services because county hospitals were equipped with dialysis machines, and twice-weekly HD was funded by the NHIF. The dialysis package included funding of the HD catheter and the insertion fee, surgery to create an arteriovenous fistula, and intravenous iron and erythropoietin (9). This initiative was launched in 2015, and by 2017, >90% of county hospitals were offering chronic HD (9). The number of treatment units has grown exponentially from four units in 1995 to 100 units by 2017. This was paralleled by the number of patients increasing from 120 in 1995 to more than 2300 patients in 2017 (9). The most recent unpublished data from the Kenya Renal Association indicates a total of 5670 patients on HD in 2021. Peritoneal dialysis PD utilization is very low in Kenya. In a 2007 survey, it was reported that approximately 40–50 patients were on PD (11). In the 1990s, most provincial public hospitals offered PD, but this modality of treatment fell out of favor because the dialysis fluid was not readily available and became very costly (10). PD as a treatment option is now mainly offered in Nairobi by private hospitals (9,10). Transplantation Kidney transplantation is funded by the NHIF to a maximum of $5000. The funding excludes the costs of the pretransplant workup and the post-transplant immunosuppressive medication, which makes it a huge financial burden for patients and their relatives (12). The first kidney transplant in Kenya was performed in 1978 (9). A total of 166 patients were transplanted in the period 2006–2019. The Moi Teaching and Referral Hospital, the second largest referral hospital, performed 65 of these transplants. The donor source for kidneys is mostly living-related or living nonrelated donors (the latter mainly refers to spousal donation). In 2017, the government passed legislation to allow deceased donor transplantation, although this has not yet been implemented. This positive step has the potential to increase the transplantation rate and improve the quality of life of many patients with ESKD (9). Outcomes Most international guidelines recommend dialysis three times a week for patients with ESKD; however, this is not attainable in many sub-Saharan African countries, including Kenya. There are concerns that twice-weekly HD may be suboptimal for many patients and may contribute to high mortality rates and poor quality of life (13). A Cochrane review is currently being conducted to examine the evidence around the use of twice-weekly dialysis (14). There is a paucity of data on the survival of patients with ESKD on KRT in Kenya. The Kenya Renal Association has recently established the Kenya Renal Registry, using the African Renal Registry platform (15), and this will provide much-needed information on the delivery and outcomes of KRT in Kenya in the near future. Human Resources Kenya has a shortage of medical personnel to serve its populace. The doctor/patient ratio is huge at 1:16,000. In 2006, Kenya had 16 nephrologists, and over the years, the numbers have increased, with the current number of nephrologists now standing at 41. This is a nephrologist density of 0.7 nephrologists per million population (pmp). By comparison, according to the International Society of Nephrology's Global Kidney Health Atlas (16), the median density of nephrologists worldwide is 10.0 pmp, and it is 1.6 pmp in lower-middle-income countries. The demand for more specialist services for kidney care has led to establishment of the East Africa Kidney Institute, funded by the African Development Bank. Its mandate is to train medical personnel in the areas of nephrology and urology, to promote research, and to improve kidney care services within and beyond Kenya. The Institute has established a fellowship program in nephrology with the aim of increasing nephrologist numbers in the country and the region (9). Current and Future Challenges Table 2 summarizes the challenges to providing comprehensive kidney care in Kenya (9). The Kenya Renal Association is actively participating in working groups of the International Society of Nephrology focused on strategies to increase access to integrated ESKD services as part of universal health coverage (17). Table 2. - Challenges to providing comprehensive kidney care in Kenya (9) Patient factors Late presentation Poverty—contributes to poor adherence, poor nutrition, and inability to afford medications More reliance on temporary vascular access Medications Iron and erythropoietin are expensive and paid for out-of-pocket Inadequate vaccination of patients on KRT Diagnostic tests Evaluation of anemia and mineral bone diseases limited Cost of serological screening (HIV, hepatitis B, hepatitis C) and screening for hepatitis B antibody responses Inadequate renal histopathology support, very limited access to electron microscopy Water quality analysis costly and availability limited Dialysis and transplantation Low usage of PD Only twice-weekly HD funded Low transplant rates Infrastructure Capacity of HD units not meeting demand Lack of a reliable supply chain for dialysis consumables Human resources Few nephrologists, vascular surgeons, renal nurses, and renal technologists HD, hemodialysis; PD, peritoneal dialysis; KRT, kidney replacement therapy. In addition to the existing challenges, the COVID-19 pandemic increased the strain on treatment centers because of lockdowns hindering patient access to dialysis units, the increase in the number of patients needing dialysis for AKI, and the effect of patients and dialysis unit staff contracting the disease. Disclosures M. Davids reports consultancy for National Renal Care, and other interests or relationships with the African Journal of Nephrology (deputy editor), the African Renal Registry (chair), and the South African Renal Registry (co-chair). A. Twahir reports an advisory or leadership role for the Kenya Medical Practitioners and Dental Council (co-opted member); participation in a speakers' bureau for Boehringer (lecture on DPP IV inhibitors in diabetic kidney disease); and other interests or relationships with the Kenya Renal Association (chair), the WHO Task Force on Organ Donation and Transplantation (member), and the ISN/ISPD (member). The remaining author has nothing to disclose. Funding None.

Topics & Concepts