THE NEED OF PREVENTION PROGRAMMES IN AFRICA

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THE NEED OF PREVENTION PROGRAMMESIN AFRICA

• SARALA NAICKER
• Division of Nephrology
• University of Witwatersrand
• Johannesburg, South Africa

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MAJOR PROBLEMS IN AFRICA

• Poverty
• Rapid urbanization
• Overcrowding
• Lack of clean water
• Inadequate sanitation
• Wars, crime, violence

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HEALTH PROBLEMS IN AFRICA

• Infectious diseases
• 43 in Africa
• 1.2 in developed world
• tuberculosis
• malaria
• acute respiratory infections
• diarrhoeal diseases
• HIV/AIDS
• Trauma/ violence
• Increase in non-communicable/ chronic disease

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Major causes of death
Developed world ()
Developing World ()
Causes of death
1.2
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1. Infections parasitic diseases
45.6
24.5
2. Disease of the circulatory system
21
9.5
3. Cancers
8.1
4.8
4. Respiratory diseases
1
9.1
5. Perinatal Neonatal causes
0
1.5
6. Maternal causes
23.1 WHO,1997
7.7
7. Other/unknown
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THE GLOBAL BURDEN OF CARDIOVASCULAR DISEASE
MORTALITY (1990-2020)
5.7
3.9
4.1
2.0
2.1
96
3.6
0.8
37
1.6
157
119
1.3
2.0
0.6
0.8
1.4
130
139
0.6
144
In million subjects
World
Developed
Developing
1990 2020
10.6 m 20.2 m
4.1 m 5.6 m
6.5 m 14.5 m
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CHRONIC RENAL FAILURE

• High incidence in Afro-Americans (Easterling
  1977 Mausner et al, 1978 Rostand et al, 1982)
• Impression 3 - 4 x more prevalent in Africa
  (Barsoum et al, 1974 Abdulla, 1979 Abdullah
  1981).

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Birth weight and Renal disease

• 2000 Lackland et al. USA
• Black 30 of population but 69 of ESRD
  population
• 70 of ESRD attributed to HT
• Low birth weight associated with ESRD of all
  causes
• 1998 Hoy et al. Australia Aborigines
• 21 x renal disease
• High rate of low BW, HT, T2 DM, CVD, obesity

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People of African Origin

• 1996 Forrester et al. Jamaica 1610 kids 6-16y
• SBP inversely related to BW
• ? HbA1c in children shorter at birth
• 1999 Levitt et al. Soweto 849 5y olds
• SBP ? by 3.4 mmHg for every 1Kg ? BW
• 1999 Longo-Mbenza et al. DRC 2648 school
  children
• Odds ratio of 2 for ? BP with low birth weight

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People of African Origin

• 1998 Woelk et al. Zimbabwe 756 6-7y.o.
• SBP ? by 1.73 mmHg for every 1Kg ? BW
• 2000 Olatunbosun et al. Nigeria 988 adults
• Negative correlation with height and IGT but not
  BP
• 2000 Steyn et al. Soweto (BTT) 964 5y.o.
• SBP and DBP significantly higher in black
  children

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POVERTY, MATERNAL MALNUTRITION, MATERNAL HT
LOW BIRTH WEIGHT AND IMPAIRED RENAL DEVELOPMENT
OTHER HITS DM, HT, Pyelonephritis, obesity,
environmental factors, diet, stress
REDUCED FILTRATION SURFACE AREA
ACQUIRED GLOMERULOSCLEROSIS
GLOMERULAR/SYSTEMIC HYPERTENSION
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GN IN CHILDREN

• 20 year review- 636 children with NS
  Indian Total 286
  
  minimal change 46.8
• FSGS 20.6 (prev. 1.8)
• Black Total 306
• minimal change 14.4
• FSGS 28.4 (prev. 5)
• Bhimma et al,
  Ped Nephrol,1997

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CRF IN NIGERIA

• 10 year study
• 368 patients / 10 of medical admissions
• Aetiology Undetermined 62
• Rest- Hypertension 61
• DM 11
• Chronic GN 5.9
• (Mabayoje et al,1992)

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CRF IN TROPICAL AND EAST AFRICA

• Aetiology
• Chronic GN
• Hypertension
• (Nseka and Tshiani, 1989
• McLigeyo and Kaying,1993)

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PRIMARY RENAL DISEASE CAUSING ESRD IN S AFRICA
Hereditary
Other
Cystic disease
Drugs
CIN
Multisystem
Unknown
HPT
GN
0
500
1000
1500
2000
Number of Patients
SADTR 1994
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SADTR DATA

• Causes of ESRD in 8576 patients
• GN 23
• Hypertension 21
• 25 of adult population
• Malignant hypertension 16 of hospital
  admissions
• SADTR, 2000

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THE FACTS
40 of diabetics are at risk of overt
nephropathy Diabetic patients with renal disease
have a 5-6 fold increased mortality rate as
compared to diabetic patients with no signs of
renal disease or healthy subjects
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THE GLOBAL BURDEN OF DIABETES (2000-2025)
38.4
37.5
30.7
18.6
24.5
57.2
16.7
25
102
22.8
47
21.8
150
9.1
39.3
140
18.2
0.4
0.7
64
116
In million subjects
World
Developed
Developing
2000 2025
154 m 300 m
55 m 72 m
99 m 228 m
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DIABETIC NEPHROPATHY

• South Africa 14-16
• Zambia 23.8
• Egypt 12.4
• Sudan 9
• Ethiopia 6.1
• Amos et al (1997). Diabetic Medicine

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Type 2 Diabetes Mellitus
90.00
Blacks
80.00
Indians
70.00
Total (n172)
60.00
50.00
40.00
30.00
20.00
10.00
0.00
Retinal
Prot.-uria
HPT
GFR
Creat.
Type 2 DM prevalence 13.7 I
6.7 B
Amod, SEMDSA abstracts 1996
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MICROVASCULAR COMPLICATIONS of DIABETES MELLITUS
60
Blacks
Indians
50
Total (n47)
40
30
20
10
0
Prot.-uria
HPT
GFR
Retinal
Creat.
Type 1 DM
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NEPHROTIC SYNDROME

• greater frequency, compared to temperate regions
• hospital admissions
• Zimbabwe 0.5
• Kwazulu Natal , S Africa 0.2
• Uganda 2
• Nigeria 2.4
• Seedat,1996

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RENAL DISEASE IN EAST AFRICA

• 2-3 of medical admissions
• poor response to treatment
• progression to renal failure
• Presentation commonly nephrotic syndrome age
  of onset 5-8 years
• Infectious aetiology p malariae,
  schistosomiosis, HBV, streptococcal infections,
  syphilis, leprosy, filariasis, hydatid disease
• Mc
  Ligeyo, 1990

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GN

• Sudan 36.6
• Cote dIvoire 49.1
• Egypt 11
• Saudi Arabia 28
• Barsoum, 2002

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RENAL DISEASE IN NORTH AFRICA

• GN 18-24
• Interstitial nephritis 14-32
• Diabetic nephropathy 5-20
• Nephrosclerosis 5-18
• Barsoum, 1998

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PREVALENCE OF HbsAg in CHILDREN

• Urban 6.3
• Rural 18.5
• Institutionalised 35.4

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MEMBRANOUS GN

• 306 Black children with NS
• 43 with membranous GN
• 86.2 HBV antigens

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HIV AND RENAL DISEASE

• Asymptomatic patients screened 76
• Proteinuria gt 1gm 17
• Proteinuria lt 1gm 6
• Microalbuminuria 27
• Haematuria 9
• Histology
• HIVAN 48
• Han et al, 2004

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RRT IN SUB-SAHARAN AFRICA HD
CAPD IPD TP
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Table 2. Renal replacement therapy in Africa
(1993 1996)
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Frequency of HD
Barsoum, 2002
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DIALYSIS PATIENTS WORLD-WIDE (1996)
10,000
South Africa 2560 (25)
Schena, Kidney Int (Suppl 74), 2000
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United States
700
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Costs
Dialysis
600
25
Patients ( x 1,000)
500
20
( billions)

400
15
300
10
2000
2005
2010
2000
2005
2010
Growth to year 2010 projected on the basis of
historical data (1982-1997) by stepwise
autoregression and exponential smoothing models
Xue et al., J Am Soc Nephrol, 2001


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• Renal replacement therapy is so costly that
  there is minimal probability for the vast
  majority of the worlds population to take
  advantage from it

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Prevention Tackling the problems

• Diabetes
• Hypertension
• Glomerular Disease

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LIFESTYLE MEASURES

• Public education and commitment to health
• Smoking ?
• hypertension
• hastens progression to kidney failure
• Dietary salt
• Obesity
• Prudent diet
• Exercise

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HIGH RISK GROUPS

• Identified at early stage
• Effective management at all levels

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Kidney Disease Renoprotection Programmes
Chronic Kidney Disease
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Study before PPP was startedBlood Pressure was
poorly controlled
Percentage of controlled patients if 80 of the
readings are or lt 140/90
Gauteng Health Department Report 2000
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Kidney disease detection and renoprotection
programme in Johannesburg

• 11 intervention clinics
• 4 usual care clinics
• 795 pts evaluated
• 35 proteinuria
• 25 albuminuria
• 10 micro-albuminuria

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HBV VACCINE

• Vaccine coverage rates
• 1st dose 85.4
• 2nd dose 78.2
• 3rd dose 62

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Impact of HBV vaccination on NS in children

• 1984 2001 119 children with HBV MN
• aRR 0.25/ 105
• 1984 1994 0.22
• 2000 2001 0.03
• pre-vaccine post-vaccine
• 0 4 years 0.16 0.00
• 5 10 years 0.46 0.19
• Bhimma et al, 2003

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WHAT IS THE GLOBAL STRATEGY NEEDED IN
LESS-DEVELOPED WORLD?

• Identify apparently healthy subjects at risk of
  developing renal and cardiovascular diseases
  later in life
• Build regional or national prevention strategies
  by developing therapeutic intervention programs

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PREVENTION STRATEGIES

• Public education
• Free antenatal care for pregnant women and
  children
• Ban on smoking
• Screening for hypertension and diabetes
• Eradication of Schistosomiasis
• HBV vaccine in EPI since 1995
• Effective intervention programmes

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A WORLD-WIDE STRATEGY REQUIRING INTERNATIONAL
PARTNERSHIPS

• Government ministries of health (and education)
• International Agencies
• Academic centers
• Foundations