Long-Term Dialysis Vascular Access in East Africa: Unique Challenges and Novel Solutions

Challenges with Providing Kidney Replacement Therapy in EA

East Africa (EA) is a region in Sub-Saharan Africa comprising 13 countries¹ (Figure 1). CKD in EA remains a major public health problem with one of the highest noncommunicable disease global prevalence rates.² Ideal kidney care in this region requires an appropriately trained workforce for best possible patient outcomes. Current workforce in the region is shown in Table 1. Hemodialysis (HD) is the mainstay kidney replacement therapy in EA for most while transplantation remains a limited option. Trained nephrologists and vascular access (VA) surgeons are far and few,³ with many lacking basic experience or interest for VA-related procedures.

Figure 1.

East African Region includes the Sovereign States of Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mozambique, Rwanda, Seychelles, Somalia, South Sudan, Sudan, Tanzania, Uganda, Zambia, and Zimbabwe.

Table 1.

Incidence of CKD in East Africa and personnel available to run services in five major countries in the East African Region

Country	Population 2021	CKD Stage 1–4 and ESKD on HD Populationsa	GDP (BN USD) 2021	Nephrologist Total and per Million	Fellows Trained/Year	Renal-Trained Nurses	Renal-Trained Nutritionists/Dietitians
Kenya	53,005,614	CKD1–4 (2.8%–4.0%) ESKD on HD-100 pmp	99 billion USD	(41) 0.77	3–4	720	23
Uganda	45,853,778	CKD1–4 (1.9%); ESKD on HD −1 pmp	105 billion USD	(12) 0.26	None	33	None
Tanzania	63,588,334	CKD1–4 (3.03%); ESKD on HD −50 pmp	63 billion USD	(37) 0.58	4	300	11
Rwanda	13,276,517	CKD1–4 (0.72) ESKD on HD −75 pmp	30 billion USD	(10) 0.77	2	36	1
Burundi	12,909,526	CKD 1–4 (0.55%) ESKD on HD-1.6 pmp	9 billion USD	(3) 0.23	None	27	None

HD, hemodialysis; GDP, gross domestic product; BN, billion; USD, United States dollars.

Data Sources: Adapted from ref. 4.

^aData Sources: Africa Health Network internal data.

This poses three challenges: timely VA creation in those needing to start HD, the inability to perpetuate a workforce that is able to train others, and the inability to monitor VA dysfunction. In EA, because of the limited nephrology workforce, most patients crash-land needing dialysis therapy because advanced CKD care is virtually unavailable. The end result is an uninformed and unprepared patient who is treated by an overworked nephrologist who relegates the VA planning to the surgeon. In addition, an uninformed patient remains skeptical about switching to a long-tern arteriovenous fistula (AVF) once dialysis is commenced with a central vein catheter (CVC).

There are few trained health care professionals to perform line insertions and surgical procedures or perform regular monitoring of VA for dysfunction, infections, thrombosis, or aneurysm formation beyond major cities. Furthermore, cultural beliefs and practices influence patient compliance with the recommended care to prevent infection or complications (e.g., avoid lifting heavy weights).

Novel Solutions to Improve—VA Services

Despite these challenges, organizations such as the African Association of Nephrology and the East African Kidney Institute are making efforts to improve awareness and educate and train the dialysis workforce and patients about the importance of VA care. Telemedicine and digital health technologies are being used to improve access to specialized care and support patients in the remote areas.

Very few nephrologists in EA are trained in tunneled dialysis CVC placement and financial limitations prevent early conversion from nontunneled to tunneled CVC placement. One way to improve overall VA care is to identify interested surgeons who can be trained in creating long-term VA and perform troubleshooting interventions. The advantage in creating a proactive and engaged workforce can help build a referral center for the region and potentially invigorate nonchalant nephrologists to actively participate in early detection of a dysfunctional VA. The net result being improved efficiency, quality of care, and a satisfying experience for all stakeholders involved with providing dialysis treatment. With time, we also expect that more nephrologists will adopt point-of-care ultrasonography and practice tunneled CVC insertion.

Surgical Training Model

In 2022, an initiative to perform VA procedures in a surgical setting was established. This ensured a low incidence of infection, allowing timely and dedicated postoperative follow-up visits and helped build an environment for a coordinated multidisciplinary team approach to VA care. Junior surgeons in the region with an interest in VA surgery were identified and recruited for training. Using a surgical camp environment and apprenticeship model, training was quicker than the unrealistic approach of setting up a formal accredited training program in this environment.

Camps were set up in specifically identified hospitals with either of the following:

1. A proactive, committed, and interested local surgeon passionate about VA or

2. A committed and dedicated visiting surgeon from abroad or locally who devotes to train local staff ensuring a sustainable workforce and developing a high-quality VA service. Surgeons from abroad were identified from previous voluntary or missionary work performed in the region.

This novel way of creating a local trained workforce is far superior to training a workforce at a center of excellence in a developed country. The local training camp model eliminates multiple hurdles for training abroad such as travel restrictions, local licensing issues which prevents hands on training (e.g., GMC registration in the United Kingdom, USMLE in the United States), costs associated with training and sustenance, living expenses etc. Training camps can also facilitate multiple local surgeons being trained in their own environment rather than the traditional model of one surgeon at a time traveling to a center of excellence. A traditional training route would need approximately 4–6 months of training at a recognized center with adequate hands-on exposure to a significant volume of cases to learn AVF surgeries and familiarize with interventions needed for dysfunctional or failed VA. Furthermore, translating the experience of training at a well-organized center to a relatively under-resourced center can be a challenging and daunting experience.

Didactic Training

Surgical trainees receive didactic training on presurgery evaluation process enabling correct patient selection, VA assessment, and management of dysfunction and complications thus assuring favorable outcomes. These trainees with time will spread out in the region, which is the long-term goal of the program.

Hands-On Training

The trainee starts as a first assistant for two surgical procedures and graduates to become the primary surgeon under close supervision. Most trainees will learn to create a radiocephalic AVF rapidly followed by brachiocephalic AVF placement. With time, gradual expertise is built up with transposition surgery performed either as a single-stage or two-stage procedure based on the preference of the mentor surgeon. Trainees continue to perform surgeries at these centers ensuring ongoing professional development.

The surgical insertion of tunneled catheters at these camps is reserved for patients with exhausted AVF options and complex reinsertions and patients from remote dialysis units. All new catheters are used for at least one HD session to ensure adequate blood flow on HD before discharge. With proper planning, preassessment, and correct surgical technique, in experienced hands, VA procedures performed are successful. Our experience so far is shown in Table 2.

Table 2.

Africa Health Network experience of Surgical Training Camps in East Africa

City/Country	Trainers Country	No. of Trainees	Camp Duration (wk)	No. of AVF Procedures/Week	Funding Govt/Pvt/Charity
AHN Camp Chogoria, Kenya 33 surgeries	Visiting US Surgeon	Two senior surgeons week-1 and two senior surgeons week-2	2	∼18 surgeries (None on Sundays)	National Health Insurance Fund
AHN Camp, Kikuyu, Kenya 21 surgeries	Visiting US Surgeon	Two senior surgeons week-1 and two senior surgeons week-2	2	∼14 surgeries	National Health Insurance Fund

AVF, arteriovenous fistula; AHN, Africa Healthcare Network.

Maintaining a Waiting List for VA Creation

Each of the dialysis medical officers, nursing staff, and nephrologists are required by the coordinating center to evaluate and list patients for the next surgical camp. Once there are a reasonable number of procedures, a mentor visit is arranged. The duration of the camp is between 4 and 14 days on the basis of the number of patients and surgeons needing to be trained. A visiting surgeon may perform other non–VA-related surgeries over 4–8 weeks.

Patient Experience and Satisfaction

Patients are very grateful of this initiative, and most acknowledge that the alternative arrangement to travel to a nearest referral center with a caregiver, cost of an overnight stay, and loss of income for the family and/or caregiver remain impractical and unaffordable.

This innovative attempt to address the challenges with VA creation and care in EA includes a multifaceted approach, specific to training health care professionals, community education, and outreach to provide services in remote or underserved areas. By addressing these challenges, we hope to improve the quality of life for patients needing kidney replacement therapy and reduce the economic burden of kidney disease in the region.

Disclosures

T.J. Vachharajani reports the following: Employer: John D. Dingell VA Medical Center; Advisory or Leadership Role: Editorial Board—Journal of Vascular Access; Kidney International Reports, Seminars in Dialysis, Indian Journal of Nephrology, Kidney360; Associate Editor—Frontiers in Nephrology (Blood Purification Section); Member North American Regional Boards of ISN; Editor-in-Chief- The Open Urology and Nephrology Journal and Other Interests or Relationships: Deputy Chair, Core Programs Committee, International Society of Nephrology; International Board of Directors AVATAR Foundation, India. L. Vincent reports the following: Employer: CMO, Africa Healthcare Network, Rwanda, Kenya, Tanzania and Mauritius; Ownership Interest: Chief Medical Officer, Director, Africa Healthcare Network, Rwanda, Tanzania, Kenya and Mauritius; Renalyx Health Systems, Bangalore, India; Patents or Royalties: Patent: Low-cost spinning and fabrication of high efficiency (HE) hemodialysis fibers and method thereof; Patent date Issued Jul 12, 2014. Patent issuer and number in 754/KOL/2014; and Advisory or Leadership Role: Chief Medical Officer, Director, Africa Healthcare Network, Mauritius. The remaining author has nothing to disclose.

Funding

None.

Author Contributions

Conceptualization: Tushar J. Vachharajani, Lloyd Vincent.

Writing – original draft: Jyoti Baharani, Lloyd Vincent.

Writing – review & editing: Jyoti Baharani, Tushar J. Vachharajani, Lloyd Vincent.