Introduction
December next year will mark 70 years since the first successful kidney transplant was performed by Joseph Murray in identical twins Ronald and Richard Henricks in Boston.1 After this, many more kidney transplants have now been performed all around the world with the United States, the leaders in transplantation worldwide, crossing the landmark of 1,000,000 transplants last year and currently averaging 25,000 kidney transplants yearly. Kidney transplantation is now recognized as one of the medical miracles of the century that confers reduced risks of morbidity and mortality, cost-saving benefits, and the best possible quality of life in patients with established ESKD in the absence of any contraindications.2
Kidney Transplants in Sub-Saharan Africa
The first kidney transplant in Africa was performed in Johannesburg in South Africa in 1966 by Thomas Starzl and Bert Myburgh.3 This was before the first indigenous South African Transplant performed the following year by Christian Barnard in Cape Town. Since then, several other countries on the continent have commenced and have been able to sustain kidney transplant programs in different parts of the continent. Most of the countries in the Maghreb (Egypt, Tunisia, Algeria, Morocco, and Libya) have reasonably active programs, but in sub-Saharan Africa, the take-off and sustenance of active programs have been a bit more of a challenge. Of the 54 countries in the continent, only eight in the sub-Saharan region have so far performed successful transplants. The names of these countries, their dates of onset, and the numbers performed in total and in the past 3 years are listed in Table 1.
Table 1.
Countries with kidney transplant programs in sub-Saharan Africa
| Country | Date of Onset | No. of Centers | Total Number Till Date | Number in the Past 3 yr |
|---|---|---|---|---|
| South Africa | 1966 | 15 | 9011 | 750 |
| Kenya | 1978 | 7 | 400 | 160 |
| Mauritius | 1980 | 1 | 389 | 0 |
| Nigeria | 2000 | 16 | 1425 | 609 |
| Ghana | 2008 | 1 | 21 | 4 |
| Cote d’Ivoire | 2012 | 3 | 75 | 7 |
| Ethiopia | 2015 | 1 | 137 | 102 |
| Tanzania | 2017 | 2 | 110 | 62 |
| Cameroon | 2021 | 1 | 4 | 4 |
The General Observatory on Donation and Transplantation reports that in 2021, Africa was responsible for only 1% of the total number of transplants performed in the world in that particular year, although Africa represents 17% of the world population.4 This is despite the fact that the incidence of CKD is believed to be highest among peoples of African origin, likely related to the high prevalence of the APO lipoprotein 1 gene in the region.5
These rather low transplant numbers are not unexpected as there is a clear relationship between the gross domestic product of any country and the country's capacity to establish and sustain active kidney transplantation programs (Figure 1). Not unexpectedly, the top countries listed by gross domestic product in Africa are also the countries with the capacity to perform successful transplants with a strong correlation between this capacity and the prevalence of kidney transplants in these countries. Political instability, interregional and intraregional wars, and conflicts have also contributed to the seeming delay in the progress with renal care programs on the continent.
Figure 1.
Prevalence of kidney transplantation and GDP per capita. GDP, gross domestic product.
One other major factor contributing to this disparity has been the relatively low numbers of trained nephrologists, urologists, and other necessary specialists in the region. While in Europe, there are approximately 30 trained nephrologists per million population, the numbers for the most of the continent are <1 per million population.6 This is further compounded by the recent upsurge in emigration to the developed world by trained personnel.7 Figure 2 presents the numbers of nephrologists trained in various countries in Africa currently practicing in the US in 2020.
Figure 2.
Licensed physicians in the United States with ABMS Certification in Nephrology by African Country (2020). ABMS, American Board of Medical Specialties.
The various nascent transplant programs on the continent have relied on the support of older and more mature programs from Europe (Sudan, Nigeria, Kenya, Tanzania, Ghana, Cameroon, and Cote d’Ivoire), India (Kenya, Nigeria, Tanzania), and the United States (South Africa, Ethiopia, Nigeria) in their initial developmental stages. This has usually consisted of both manpower training and support and also assistance with various investigations inclusive of the necessary HLA typing and crossmatch, drug levels in some instances, and also biopsy histology.
Most successful transplant programs are based in the private sector as many of the public hospitals on the continent are bedeviled with various problems inclusive of being overstaffed, understaffed, poor maintenance culture, poor work ethics, and poor attitude to patient care, interdisciplinary rivalry between the various professions, and recurrent strikes and work to rule among the staff.9
Almost all the kidney transplant programs have been with living donors as a deceased donor program is yet to be established in most countries. The only country in sub-Saharan Africa with an active deceased donor program remains South Africa.8 However, even in South Africa, the numbers of live donors are still greater than the number of deceased donors.3 Nigeria and Mauritius are however in advanced stages of developing possible deceased donor programs. In Nigeria, an enabling act of parliament has been signed into law, and efforts are in progress to ensure the commencement of a program early in the ensuing year.
The average ages of kidney transplant recipients on the continent have generally been younger than that seen in Europe and the United States and is a reflection of the relative prevalence of the causes of patients with CKD seen in the continent. More of chronic glomerulonephritis and hypertensive nephrosclerosis and less of type 2 diabetes. There is a clear male preponderance, and very few of these have been children younger than 18 years. This is in keeping with the patriarchal nature of the culture in the continent where the family is more willing to expend funds on the male and adult members of the family.
Poor compliance with medications and appropriate follow-up has been the commonest reasons for graft loss as the recipients have to pay out-of-pocket for the maintenance immunosuppressive medications in many of the countries in the subcontinent.
Infections have generally been common and range from gastroenteritis, respiratory tract infections, and various skin infections. Prophylaxis has ensured that we hardly see more severe transplant-related infections, such as cytomegalovirus and, strangely, Human Polyomavirus 1. However, the relatively lower doses of anti-thymocyte globulin used in induction might also be a fortuitous factor.
Post-transplant malignancies seen are also quite different from the pattern seen in the developed world with Kaposi sarcoma of the skin.
Long-term outcomes have generally been comparable with those in similar resource-constrained environments. In Nigeria, 1-year graft and patient survival range between 75% and 100% in different centers, while the 5-year graft and patient survival range between 55% and 70%. Overall, 1-year graft and patient survival were 83.2% and 90.2%, respectively, while the 5-year graft and patient survival were 58.7% and 73.4%, respectively.10
In conclusion, kidney transplantation is now increasingly becoming more widely available on the continent of Africa. The political and socioeconomic challenges on the continent have slowed the commencement and the wide availability and prevalence of kidney transplantation. The pattern observed and the outcomes are similar to that seen in other resource-constrained areas of the world.
Deceased donor kidney transplantation is not yet widely available, and except for South Africa, all the programs in various countries still depend on live donors with the attendant potential for possible commercial kidney donations. However, both Mauritius and Nigeria are in advanced stages of developing potential deceased donor programs.
There is the need for region-specific research and also the need to emphasize prevention and early detection programs for CKD as the resources to manage the surging numbers are certainly beyond the capacity of most countries on the continent.
Acknowledgments
The content of this article reflects the personal experience and views of the author(s) and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or Kidney360. Responsibility for the information and views expressed therein lies entirely with the author(s).
Disclosures
E.L. Bamgboye reports the following: Advisory or Leadership Role: MetroHealth HMO, Resources Intermediaries Ltd., and St. Nicholas Hospital Lagos.
Funding
None.
Author Contributions
Conceptualization: Ebunoluwa Ladipo Bamgboye.
Data curation: Ebunoluwa Ladipo Bamgboye.
Formal analysis: Ebunoluwa Ladipo Bamgboye.
Writing – original draft: Ebunoluwa Ladipo Bamgboye.
Writing – review & editing: Ebunoluwa Ladipo Bamgboye.
References
- 1.Snyder A. Joseph E. Murray. Lancet. 2013;381(9861):P110. doi: 10.1016/s0140-6736(13)60038-0 [DOI] [Google Scholar]
- 2.Axelrod DA Schnitzler MA Xiao H, et al. An economic assessment of contemporary kidney transplant practice. Am J Transplant. 2018;18(5):1168–1176. doi: 10.1111/ajt.14702 [DOI] [PubMed] [Google Scholar]
- 3.Moosa MR. The state of kidney transplantation in South Africa. S Afr Med J. 2019;109(4):235–240. doi: 10.7196/SAMJ.2019.v109i4.13548 [DOI] [PubMed] [Google Scholar]
- 4. Those 2021 Data are Based on the Global Observatory on Donation and Transplantation (GODT) Data, Produced by the WHO-ONT Collaboration.
- 5.Friedman DJ, Pollak MR. APOL1 nephropathy: from genetics to clinical applications. Clin J Am Soc Nephrol. 2021;16(2):294–303. doi: 10.2215/CJN.15161219 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Osman MA Alrukhaimi M Ashuntantang GE, et al. Global nephrology workforce: gaps and opportunities towards a sustainable kidney care system. Kidney Int Suppl (2011). 2018;8(2):52–63. doi: 10.1016/j.kisu.2017.10.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Moura-Neto JA, Divino-Filho JC, Ronco C, Nephrology Worldwide: the Vision, the Project, and the Mission. Springer; 2021:41–54. doi: 10.1007/978-3-030-56890-0_1 [DOI] [Google Scholar]
- 8.Muller E. Transplantation in Africa - an overview. Clin Nephrol. 2016;86(2016)(13):90–95. doi: 10.5414/CNP86S125 [DOI] [PubMed] [Google Scholar]
- 9.Bamgboye EL. Barriers to a functional renal transplant program in developing countries. Ethn Dis. 2009;19(1 suppl 1):S1–S56-9. PMID: 19484877. [PubMed] [Google Scholar]
- 10.Arogundade FA. Kidney transplantation in a low-resource setting: Nigeria experience. Kidney Int Suppl (2011). 2013;3(2):241–245. doi: 10.1038/kisup.2013.23 [DOI] [PMC free article] [PubMed] [Google Scholar]