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. 2026 Sep 18;88(10):6543–6550. doi: 10.1097/MS9.0000000000005714

Outcomes of renal transplantation in Africa: a systematic review and meta-analysis

Bekalu Mekonen Belay a,*, Yeshiambaw Eshetie a, Mengistu Ewunetu a, Abraham Tsedalu Amare a, Gebrie Kassaw a, Tigabu Munye Aytenew a, Birara Ayichew Tilaye b, Gebrehiwot Berie Mekonnen b, Kumlachew Geta Belete c, Yirgalem Abere a
PMCID: PMC13657478  PMID: 42866756

Abstract

Background:

Although transplantation is considered a treatment for end-stage renal disease, data on post-transplant outcomes remain fragmented.

Objective:

This study aims to assess the outcomes of renal transplantation in Africa.

Design:

Studies were searched in MEDLINE, EMBASE, CINAHL, Scopus, Google Scholar, the Transplantation Library, and African Journals Online. A random-effects model was employed to calculate the pooled effect size of each outcome. Heterogeneity was assessed with the I2 test, and publication bias was evaluated using Egger’s regression test. Trim-and-fill analysis was employed to manage publication bias. The protocol was registered in the International Prospective Register of Systematic Reviews.

Studies:

Studies conducted in Africa.

Participants:

In this study, 16 articles were included, with a total of 3617 participants.

Result:

Pooled mortality among renal transplant recipients was 14.3% (95% CI: 8.77%–19.84%). Graft survival rates at 1 and 5 years were 91.74% (95% CI: 88.56%–94.93%) and 69.15% (95% CI: 57.39%–80.91%), respectively. Patient survival at 1 and 5 years was 94.72% (95% CI: 92.17%–97.26%) and 81.26% (95% CI: 72.11%–90.4%), respectively. Diabetes mellitus, delayed graft function, acute rejection, and infection were observed as post-transplantation complications.

Conclusion:

With a few important exceptions, both graft and patient survival were comparable to reports from other nations. Thus, we recommend that clinical practitioners prioritize infection prevention and early screening for complications. Furthermore, policymakers should develop and implement strategies to prevent and screen for post-transplant complications, and improve the accessibility of the service.

Keywords: Africa, graft rejection, graft survival, outcome, renal transplant

Strengths and limitations of this study

  • This is the first review to assess the outcomes of renal transplantation in Africa.

  • The protocol for this study was registered in the Prospective Register of Systematic Reviews (PROSPERO).

  • It is based solely on articles written in English.

Introduction

Chronic kidney disease (CKD), a common and rapidly growing disorder, affected approximately 697.5 million people worldwide in 2017[1]. In Africa, prevalence estimates range from 2% to 41%, posing a significant public health challenge[2,3].

HIGHLIGHTS

  • This systematic review synthesizes renal transplant outcomes across Africa.

  • One-year graft and patient survival were high at 91.7% and 94.7%, respectively.

  • Five-year graft (69.2%) and patient (81.3%) survival showed marked regional variability.

  • Mortality among renal transplant recipients was 14.3% across the included studies.

  • Infection, acute rejection, delayed graft function, and diabetes were key complications.

Renal replacement therapies (RRT), such as hemodialysis, peritoneal dialysis, and renal transplantation from living or deceased donors, are the current management options for renal failure[4]. Transplantation confers significantly better long-term survival than dialysis[5,6]. It has been associated with a 50% reduction in mortality within 5 years[7]. As a result, transplantation is considered the recommended course of treatment for end-stage renal disease (ESRD)[4].

Despite the significant burden of ESRD in Africa, access to kidney transplantation (KT) remains limited for many patients[8]. Only 9%–16% of patients requiring RRT receive it[9]. This highlights substantial treatment gaps in low-income countries, particularly in Africa[8], where mortality among hemodialysis patients remains considerably high[10]. This is driven by limited funding, workforce shortages, high medical costs, and underutilization of cost-effective dialysis therapies[11]. Furthermore, low socioeconomic status adversely affects transplant outcomes[12]. A persistent challenge in the region is the high cost of the procedure, post-transplant care, and, most notably, maintenance immunosuppression[13].

Transplantation is not free from complications[14]. Common complications include infections, rejection, surgical issues[15], and delayed graft function (DGF)[16,17]. Infections are the leading cause of death, accounting for 43.2% of all fatalities[18]. Furthermore, acute rejection has been shown to increase the risk of graft loss[15].

Although the survival rate for kidney transplant recipients is lower than that of the general population[7], post-transplant outcomes have greatly improved in recent decades. Allograft and patient survival rates at 1 year are currently above 90%[19]. In developed countries, graft survival has seen a substantial improvement compared to the 1995–1999 period[20].

Although renal transplantation is the preferred treatment for end-stage kidney disease, evidence from Africa remains fragmented and largely based on single-center reports, and most studies focus on single-institution cohorts, making it difficult to draw definitive conclusions; moreover, there has been no comprehensive synthesis of survival outcomes across African settings. This systematic review and meta-analysis aims to bridge this gap by pooling existing data to provide a robust estimate of patient and graft survival following renal transplantation in Africa, thereby strengthening the regional evidence base and informing context-specific strategies to improve transplant outcomes. Accordingly, this study assesses outcomes of renal transplantation in Africa.

Method

Protocol and registration

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines for systematic reviews and meta-analyses [21] (Supplemental Digital Content 1 PRISMA checklist, available at: https://links.lww.com/MS9/B384). The review protocol, identified as CDR42025642706, has been registered in the International Prospective Register of Systematic Reviews.

Eligibility criteria

All research articles that reported on any type of KT outcome (survival, death, and complications) conducted in African countries were eligible for inclusion in this review. Studies were included irrespective of study design, provided they reported relevant patient or graft outcomes. We included all English-language articles published up to the last search date on 5 February 2025. Articles that were inaccessible after reasonable efforts to obtain the full text were excluded. In addition, studies conducted outside the African continent were excluded from the analysis.

Search strategy

Electronic databases including MEDLINE, EMBASE, CINAHL, Scopus, Google Scholar, the Transplantation Library, and African Journals Online were searched using population, exposure, context, and outcome terms. A comprehensive literature search was conducted from each database’s inception to 5 February 2025 using the keywords “mortality,” “survival,” “graft survival,” “allograft,” “renal transplantation,” “kidney transplantation,” “transplantation complication,” “graft outcome,” and “Africa.” All 54 African nations were included in the search theme “Africa” to ensure broader coverage of the research. To integrate these keywords, Boolean operators “AND” and “OR” were used (Supplemental Digital Content 2, available at: https://links.lww.com/MS9/B385).

Outcomes

This systematic review and meta-analysis primarily aimed to determine the pooled estimates of renal transplantation outcomes in Africa. Graft and patient survival were measured at 1 and 5 years. Because primary studies reported post-transplantation complications and mortality at varying follow-up periods, the overall cumulative estimate from each study was extracted and analyzed. Variations in follow-up duration were statistically accounted for using a random-effects model.

Patient survival refers to the proportion of transplant recipients who remained alive at the end of the study’s follow-up period, regardless of graft function.

Graft survival refers to the proportion of functioning transplanted kidneys at the end of the study follow-up period and is defined as the absence of a return to dialysis or re-transplantation.

Mortality was defined as death from any cause following KT during the follow-up period reported in each study.

Post-transplant complications included any medical or surgical events occurring after transplantation, such as acute rejection (biopsy-proven), infection, DGF, or diabetes.

Data extraction

First, abstracts were assessed to ensure compliance with the inclusion criteria. Articles outside the scope of the study were excluded. All retrieved records were imported into Rayyan for duplicate removal and title and abstract screening. Two reviewers independently screened studies, and disagreements were resolved through discussion or by a third reviewer.

Two authors (Y.A. and Y.E.) independently extracted data from each included study, covering the first author, publication year, region, study design, population, follow-up period, mortality, survival, and complications (rejection, DGF, new-onset diabetes mellitus, hypertension, infection, and stenosis). Other authors (G.K., M.E., and B.M.) took responsibility for checking for and resolving any disagreements. The extracted data were then presented in a summary table in Microsoft Excel using a standardized data extraction format, and were finally exported to STATA 17 for analysis.

Quality appraisal

Two reviewers (B.M., Y.A.) independently evaluated the quality of each study using the Newcastle–Ottawa Scale for cohort studies. Disagreements were resolved through discussion and consensus between the two reviewers. The quality assessment tool comprised three sections: methodological quality (up to five stars), comparability of study groups (up to two stars), and outcomes with statistical analysis (up to three stars). Studies scoring below six out of ten were categorized as low quality (Supplemental Digital Content 3, available at: https://links.lww.com/MS9/B386).

Data processing and analysis

First, relevant data were extracted from each included study and compiled for analysis. The pooled estimate with a 95% confidence interval was calculated and presented using a forest plot. Publication bias was assessed using Egger’s weighted regression test. When publication bias was detected, a trim-and-fill analysis was employed to address publication bias. Furthermore, a sensitivity analysis was conducted using the leave-one-out method to evaluate the influence of a particular study.

Handling heterogeneity

The heterogeneity across the included studies was evaluated using the I2 test and its P-values, with I2 values below 25%, 25–75%, and above 75% indicating low, medium, and high heterogeneity, respectively[22]. As the test statistic showed significant heterogeneity among studies, a random-effects model was used[23]. Hence, sensitivity and subgroup analyses were performed to investigate the presence of a potential effect.

Publication bias

Egger’s regression test was used to assess the presence of publication bias. When the result is <0.05, we consider it evidence of bias. Therefore, a trim-and-fill analysis was conducted.

Certainty of evidence

The certainty of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, a streamlined tool for evaluating confidence in effect estimates following a meta-analysis. Each outcome was rated across the standard GRADE domains: risk of bias, inconsistency, indirectness, imprecision, and publication bias; overall certainty was categorized as high, moderate, low, or very low.

Result

Overview of the search

The database searches of the literature yielded a total of 377 primary articles; 133 duplicates were excluded after reviewing the titles and abstracts, and 222 articles were removed due to ineligible objectives and populations after assessing the abstracts. As a result, 22 articles underwent full-text assessment; however, four were excluded because they were outside the study objective (they focused on surgical wound healing by type of surgery), and two were excluded because they were not in English. Finally, 16 studies were included in this systematic review and meta-analysis (Fig. 1).

Figure 1.

Figure 1.

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PRISMA flow diagram showing the screening and selection processes of articles for a systematic review and meta-analysis, 2025.

Characteristics of the included study

In this review, 16 relevant studies were included, with a total sample size of 3617, where the smallest sample size was 16 in Ivory Coast, and the largest sample size was 1499 in Egypt. All included articles[16,24–38] were institution-based studies. Regarding geographical areas, two studies were conducted in Southern Africa[16,31], three studies were from North Africa[32,34,36], four articles were from West Africa[24,25,29,30], and seven articles were from East Africa[26–28,33,35,37,38]. All studies in this review were published in the years between 2003 and 2024 (Table 1).

Table 1.

Characteristics of included studies among post-renal transplant patients in Africa, 2025.

Authors Pub. year Country Sample Study design Mortality 1 yr graft sur. 1 yr pt sur. Post-transplantation complication Quality
Acute rejection Infection Delayed graft function Post-transplantation DM
Abu Gharbia et al[36] 2024 Egypt 1499 Retrospective cohort 19% – – 27 31.3 – 22.9 Good
Ackoundou-N’Guessan et al[25] 2015 Ivory Coast 16 Retrospective – 93% 93% – – – – Good
Ahmed et al[26] 2018 Sudan 150 Retrospective – – – 11.37 – 4 – Good
Arogundade[30] 2013 Nigeria 143 Retrospective 27% 83.2% 90.2% 22.5 – – – Good
Chhiba et al[16] 2022 South Africa 165 Retrospective 4.3% 85.9% 98.8% – – – – Good
Davidson et al[31] 2019 South Africa 198 Retrospective cohort 12.12% 89.4% 90.4% 29.8 33.3 – – Good
Haddiya et al[24] 2012 Morocco 67 Retrospective – 92.6% 97% 16.4 20.8 10.4 – Good
Hassan and Ndonga[28] 2003 Kenya 45 Retrospective cohort 37.8% 77.8% 77.8% – 26 – – Good
Mohmmed et al[35] 2023 Sudan 105 Prospective cohort 5% 92.4% 95.2% 12.4 12.4 – 16.2 Good
Okafor[29] 2016 Nigeria 47 Prospective cohort 29.8% 95.3% 97.7% 29.8 27.6 – – Good
Sharafeldeen et al[32] 2020 Egypt 104 Retrospective cohort 2.88% 96% 100% – – – – Good
Shigidi et al[37] 2021 Sudan 792 Retrospective cohort – – – – 54.5 2.53 42.4 Good
Shoo et al[33] 2024 Tanzania 68 Retrospective 8.82% 96.7% 91.2% – 7.4 30.8 – Good
Sumbiri et al[38] 2023 Rwanda 31 Retrospective – – – – – – 19.35 Good
Usta et al[34] 2008 Libya 135 Retrospective cohort 6.67% – – 4.4 12.5 – – Good
Worku[27] 2020 Ethiopia 52 Retrospective cohort 7.69% 97.9% 92.3% 27 36.5 – 7.69 Good
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RR, response rate; sur, survival; pt, patient; yr, year.

Meta-analysis

Mortality outcome

To estimate the pooled prevalence of mortality among renal transplant recipients, 10 primary studies were included. Accordingly, the pooled effect size of mortality was 14.3% (95% CI: 8.77%–19.84%). The heterogeneity test indicated substantial heterogeneity among the studies (I2 = 92.76%, P < 0.001). As a result, a random-effects model was used to estimate the pooled effect size of mortality (Supplemental Digital Content, Figure 1, available at: https://links.lww.com/MS9/B383).

Publication bias was assessed using Egger’s regression test. Egger’s regression test (P = 0.0061) showed the presence of publication bias. Consequently, a trim-and-fill analysis was performed (Supplemental Digital Content, Figure 2, available at: https://links.lww.com/MS9/B383).

Additionally, in this review, a subgroup analysis was performed based on the follow-up period. Accordingly, for studies with a follow-up period of ≤5 years, the pooled mortality was 12.60% (95% CI: 7.09–18.11), with substantial heterogeneity (I2 = 81.39%, P < 0.001). In contrast, studies with a follow-up period of >5 years reported a higher pooled mortality of 16.44% (95% CI: 4.65–28.22), with moderate heterogeneity (I 2 = 47.21%, P < 0.001). (Supplemental Digital Content Figure 3, available at: https://links.lww.com/MS9/B383).

To determine the influence of a particular primary study on the overall meta-analysis, a sensitivity analysis using a leave-one-out model was performed. The analysis revealed that no single study had a significant impact on the pooled estimate, as the overall estimate (14.3%) was within the confidence intervals of all included studies. Thus, no studies unduly influenced the pooled prevalence of mortality among renal transplant recipients in the sensitivity analysis (Supplemental Digital Content, Figure 4, available at: https://links.lww.com/MS9/B383).

Patient survival outcomes

In this study, the pooled 1-year and 5-year survival rates of renal transplant recipients were analyzed.

One-year patient survival

Eleven studies were used to estimate the 1-year patient survival rate. The pooled 1-year recipient survival rate was 94.72% (95% CI: 92.17%–97.26%) (Supplemental Digital Content Figure 5, available at: https://links.lww.com/MS9/B383). Since Egger’s regression test (P = 0.001) indicated publication bias, a trim-and-fill analysis was performed (Supplemental Digital Content Figure 6, available at: https://links.lww.com/MS9/B383).

Five-year patient survival

Six eligible studies were used to assess the pooled prevalence of 5-year survival among renal transplant recipients in Africa. The pooled prevalence was 81.26% (95% CI: 72.11%–90.4%) (Supplemental Digital Content Figure 7, available at: https://links.lww.com/MS9/B383). Egger’s regression test (P = 0.001) indicated the presence of publication bias. Consequently, a trim-and-fill analysis was performed (Supplemental Digital Content Figure 8, available at: https://links.lww.com/MS9/B383).

Graft survival outcome

According to 11 eligible articles, the pooled effect size of 1-year graft survival was 91.74% (95% CI: 88.56%–94.93%) (Supplemental Digital Content Figure 9, available at: https://links.lww.com/MS9/B383). A random-effects model was used due to moderate heterogeneity (I2 = 73.30%; P < 0.001). Egger’s regression test showed no publication bias (P = 0.06).

We also assessed 5-year graft survival using six studies. Consequently, the pooled 5-year graft survival was 69.15% (95% CI: 57.39%–80.91%) (Supplemental Digital Content, Figure 10, available at: https://links.lww.com/MS9/B383). Due to significant heterogeneity (I2 = 95.84%), a random-effects model was implemented. Publication bias was assessed using Egger’s regression test (P = 0.5472).

Post-transplant complications

Post-transplant complications were assessed based on 14 eligible articles. From eight primary studies, the incidence of acute rejection was 18.89% (95% CI: 10.80%–26.98%) with significant heterogeneity (I2 = 95.15%) (Supplemental Digital Content, Figure 11, available at: https://links.lww.com/MS9/B383). Egger’s regression test (P = 0.4884) showed no significant publication bias.

Pooled incidence of post-transplant infection was assessed using 10 eligible studies. It was estimated to be 26.21% (95% CI: 15.66%–36.76%) with significant heterogeneity (I2 = 97.12%) (Supplemental Digital Content Figure 12, available at: https://links.lww.com/MS9/B383). As a result, a random-effects model was applied. Publication bias was assessed by Egger’s regression test (P = 0.8518), which indicated no evidence of bias.

DGF was reported in six eligible studies. Its pooled incidence was 5.91% (95% CI: 2.61%–9.21%) with significant heterogeneity (I2 = 80.38%) (Supplemental Digital Content Figure 13, available at: https://links.lww.com/MS9/B383). According to Egger’s regression test (P = 0.0002), publication bias was detected. As a result, a trim-and-fill analysis was conducted (Supplemental Digital Content Figure 14, available at: https://links.lww.com/MS9/B383).

According to seven eligible studies, the pooled effect size of post-renal transplantation diabetes mellitus was 22.05% (95% CI: 10.06%–34.04%) among recipients (Supplemental Digital Content Figure 15, available at: https://links.lww.com/MS9/B383). The I2 statistic indicated significant heterogeneity (I2 = 96.88%); consequently, a random-effects model was employed. Publication bias was assessed using Egger’s regression test (P = 0.4610), with no evidence of bias.

Quality of evidence according to GRADE

According to the GRADE assessment, all included studies were observational in design. The overall certainty of evidence across outcomes ranged from moderate to highly suggestive. The certainty of evidence for mortality, 1-year patient survival, and 5-year patient survival was rated as moderate. Conversely, the certainty of evidence for 1-year graft survival, 5-year graft survival, acute rejection, post-transplant infection, DGF, and post-transplant diabetes mellitus was rated as highly suggestive (Supplemental Digital Content 4, available at: https://links.lww.com/MS9/B387).

Discussion

The WHO aims to achieve universal health coverage by 2030 as part of the Sustainable Development Goals; however, the provision of kidney care varies across the globe[39]. However, substantial variations exist in KT accessibility and quality, with the lowest rates evident in low- and lower-middle-income countries[40]. As a result, post-transplantation outcomes may vary. Therefore, this study aimed to assess outcomes of renal transplantation in Africa.

The pooled effect size of mortality was found to be 14.3% (95% CI: 8.77%–19.84%) among renal transplant recipients in Africa. This result was consistent with the studies conducted in Indonesia[41] and India (15%)[42] but higher than the report from Russia[43]. The difference might be due to the limited quality of RRT[44] and lower socio-economic status on the continent.

According to our findings, 94.72% (95% CI: 92.17%–97.26%) of renal transplant recipients survived for 1 year, which was comparable to the results of two Indian studies (90%)[42] and (92%)[45]. However, our result was lower than the reports from Australia (98%)[46] and China (97.8%)[47]. Recipient survival at 5 years was 81.26% (95% CI: 72.11%–90.4%), which was in line with findings from India (83%)[45] and Spain (86%)[48] but lower than the report from the USA (94%)[49]. The difference might be attributable to financing and accessibility differences. Developed nations have better financing and transplant center accessibility[50], which is not true for African nations[8,51].

Kidney allograft failure is a serious condition, as it necessitates the re-initiation of dialysis, which is associated with morbidity and mortality[52]. The findings of this study revealed that 1-year and 5-year graft survival rates were 91.74% (95% CI: 88.56%–94.93%) and 69.15% (95% CI: 57.39%–80.91%), respectively. These results were comparable to those reported in Iran (1 year: 92.48%; 5 years: 79.96%)[53]. However, 5-year survival was lower than the reported rates in Europe (84.4%)[54] and Korea (97%)[55]. The difference might be due to kidney care resource gaps (nephrologists, government funding, RRT centers, and strategic plans) in Africa[44]. Rejection, infection, diabetic nephropathy[56,57], DGF[58], and other cardiovascular diseases were[59] the major determinants of graft survival.

Graft rejection is a pathological alteration in the allograft resulting from the recipient’s immune system detecting non-self antigens[60]. In this study, the incidence of acute rejection was 18.89% (95% CI: 10.8%–26.98%). This result was comparable to reports from Colombia (14.3%)[61], Iran (18.20%)[62], and New Zealand (21.4%)[63]. Through comprehensive pre-transplant matching and post-transplant immunosuppressive treatment, the rejection rate can be decreased.

DGF arises from various risk factors throughout the transplant process, from donor selection to recipient allocation, and negatively impacts post-transplant outcomes by increasing the risk of graft failure[64,65]. The pooled incidence of DGF was 5.91% (95% CI: 2.61%–9.21%), which was lower than the reported rates in Colombia (14.3%)[61] and Brazil (54.2%[66]. This difference might be due to variations among transplantation centers, as most African patients undergo renal transplantation abroad[51], leading to poor reporting.

The incidence of post-transplant infection was 25.13% (95% CI: 15.01%–35.25%). Our finding was consistent with a Canadian study that reported an incidence of 31.0%[67]. However, our result was lower than reports from Saudi Arabia (44.2 %)[68] and the USA (36.9%)[69]. This difference might be due to limited laboratory infrastructure in low-resource settings, leading to underdiagnosis of infection[70]. Susceptibility to infection is increased due to active immunosuppression with steroids[27]. As a result, attention to pre-transplant screening of both the potential organ donor and recipient is essential for optimizing outcomes[71].

In our study, DM was observed in 22.05% (95% CI: 10.06%–34.04%) of recipients. The results were in line with reports from the USA (29%)[72], India (17.2%)[73], and Norway (10–20%)[74]. Corticosteroids are well known to cause hyperglycemia and increase the risk of developing diabetes[75]. Preventing post-transplant DM has the potential to reduce both short- and long-term complications[76].

Strength and limitation of the study

To the best of our knowledge, this is the first review to assess the outcomes of renal transplantation in Africa. As a result, it provides valuable insight into post-transplant outcomes. Variation in follow-up periods across studies limited the ability to define a uniform time frame for mortality and post-transplant complications. With a small number of studies, both heterogeneity estimates and pooled effects should be interpreted cautiously. The high heterogeneity (I2 > 75%) indicates substantial variability across studies, which must be considered when interpreting the pooled results. This systematic review and meta-analysis has limitations, as it is based solely on articles written in English.

Conclusion and recommendation

Despite significant poverty and limited access to immunosuppression and tissue typing, with a few important exceptions, both graft and patient survival were comparable to reports from other nations. Therefore, transplantation continues to be a viable and crucial therapeutic option for CKD in low-resource settings with limited access to RRT.

Diabetes mellitus, DGF, acute rejection, and infection were identified as post-transplantation complications. Thus, we recommend that clinical practitioners prioritize infection prevention and early screening of complications. Furthermore, policymakers should develop and implement strategies for the prevention and screening of post-transplant complications and improve service accessibility. For future researchers, it is suggested that they address the limitations of this study and examine changes over time (longitudinal studies) in their investigations.

Acknowledgements

We are grateful to the authors of the primary studies that were part of our review.

Footnotes

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.lww.com/annals-of-medicine-and-surgery.

Contributor Information

Bekalu Mekonen Belay, Email: bekalumekonen20@gmail.com.

Yeshiambaw Eshetie, Email: yeshiambaweshetie3@gmail.com.

Mengistu Ewunetu, Email: mengistue113@gmail.com.

Abraham Tsedalu Amare, Email: tsedalu1363@gmail.com.

Gebrie Kassaw, Email: gebriekassaw273@gmail.com.

Tigabu Munye Aytenew, Email: tigabumunye213@gmail.com.

Birara Ayichew Tilaye, Email: biraraa153@gmail.com.

Gebrehiwot Berie Mekonnen, Email: geberehwot20043@gmail.com.

Kumlachew Geta Belete, Email: kumlachew.kg3@gmail.com.

Yirgalem Abere, Email: yirgalemabere123@gmail.com.

Ethical approval

Not applicable because it is not a primary study.

Consent

Not applicable.

Sources of funding

No funding was received for this manuscript.

Author contributions

Conception of research protocol, study design: B.M.; quality assessment and data extraction: Y.E., A.T., and Y.A.; data analysis, interpretation: T.M., Y.E., G.B., and B.A. Finally, B.M., G.K., and M.E. drafted the manuscript. All authors have read and approved the manuscript.

Conflicts of interest disclosure

The authors declare that they have no competing interests.

Research registration unique identifying number (UIN)

The review protocol identified by CRD42025642706 has been registered in an international prospective register of systematic reviews (PROSPERO).

Guarantor

Bekalu Mekonen Belay.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

The data are available upon reasonable request.

Clinical trial number

Not applicable.

Patient and public involvement

None.

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