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  • br A few years ago my group published an


    A few years ago, my group published an article entitled uhuru. is the Swahili word for “freedom”. The idea was to highlight the plight of patients with end-stage kidney disease (ESKD) and the challenges and frustrations of their nephrologists in sub-Saharan Africa amidst health-care authorities that had not done enough to alleviate the problem. The absence of referred to in that article is not peculiar to nephrology; other medical specialties in sub-Saharan Africa have similar problems associated with a reduced size of and inadequately experienced workforce, diagnostic facilities, and access to treatment, often resulting in poor patient outcomes. ESKD is a danger to global public health because of rising prevalence, excessive cost of treatment, reduced quality of life, and increased morbidity and mortality. The burden of ESKD is more pronounced in African countries, where access to treatment is often unaffordable and usually unavailable. Highlighting the problems of the scarcity of access to treatment, Liyanage and colleagues noted that the largest ESKD treatment gaps were present in low-income countries, particularly in Asia and Africa. However, they annexin v showed that, of all the world regions in 2010, Africa had the largest percentage difference between people needing and receiving renal replacement therapy (RRT): −84% (95% CI −86 to −82) using a conservatively estimated model and −91% (–92 to −90) using a high-estimated model. Even though they projected a doubling of people receiving RRT from 2010 to 2030 in Asia and Africa, the number of people without access to treatment was also expected to remain excessively high. In , Gloria Ashuntantang and colleagues report findings from a systematic review of outcomes in sub-Saharan African adults and children with ESKD who need dialysis. 24 456 adults and 809 children sourced from 68 studies in 15 sub-Saharan African countries were included. In the pooled analysis, 390 (96%) of 406 adults and 133 (95%) of 140 children who could not access dialysis had known or presumed mortality. Among those dialysed, 822 (80%) of 1031 adults with incident disease, 480 (15%) of 3197 adults with prevalent disease, and 90 (32%) of 284 children died. Ashuntantang and colleagues also reported that 2508 (84%) of 2990 adults with incident ESKD discontinued dialysis, mainly because of exhaustion of financial resources, and only 19 (1%) of 1472 continued treatment for at least 12 months. In adults, mean availability of erythropoietin for anaemia treatment was 38·4% (SD 35·9) and use of arteriovenous fistulae for dialysis was 49·0% (32·7), which are suboptimum. Transplantation rates were very low: 41 (1%) of 4483 in incident adults, 2280 (19%) of 12 125 in prevalent adults, and 71 (19%) of 381 in children. These findings are both alarming and outrageous and normally would be expected to motivate those able to influence health-care policies to act in meaningful ways that address the burden of ESKD in the region. I have doubts that these data will influence those in government in sub-Saharan Africa, since millions of people died as a result of HIV denialism even though there was sufficient proof linking HIV to AIDS. The common barriers reported by Ashuntantang and colleagues to be contributing to the high mortality can easily be linked to absence of policy concerning RRT in the region. Some governments in sub-Saharan Africa remain reluctant to allow any discussion about coverage of RRT or have made very slow progress with the issue. For instance, despite ample data from Nigeria showing that inability to pay for dialysis was the main reason for fewer than 1% of patients with ESKD continuing treatment for more than 3 months, the government in Nigeria only recently agreed to provide cover for the first six sessions (2 weeks) of dialysis after several years of negotiations with the local nephrology association. Such small, albeit positive, steps are a drop in the ocean. Notwithstanding, they are steps in the right direction because there are already discussions to lengthen the period of coverage to the first 3 months for those needing dialysis. Even in countries such as South Africa where RRT is offered, the existing rationing process is a major ethical hurdle imposed on clinicians needing to choose between life and death of their patients.