African Journal of Nephrology

Editorial note: Welcome to the year 2025 and Volume 28 - Time to detect kidney disease and protect our kidneys

Alain G Assounga — 2025-03-10

On behalf of the African Journal of Nephrology (AJN) editorial board, I thank all the contributors and readers and wish everyone a very productive 2025.

In July 2024, AJN reached a significant milestone by achieving accreditation with CAMES (Conseil Africain et Malgache pour I’Enseignement Supérieur). AJN publications are now accepted for the evaluation of academics from Frenchspeaking African countries. The CAMES accreditation will, therefore, encourage the submission of articles in French. We look forward to receiving, evaluating, and publishing more French manuscripts.

Volume 27 included many highlights. An editorial by Luyckx et al. focused on the need to translate knowledge into action to improve kidney care. Several original articles reported on research on kidney diseases in various parts of Africa. I wish to mention the publication on living kidney donors, a report on CKD screening on World Kidney Day in Nigeria and a publication on acute kidney injury in Zambian children. Finally, a report on the South African Renal Registry summarised the latest data on the treatment of kidney failure in South Africa.

Last year, we proposed that society and the nephrology community should support individuals in taking primary responsibility for their kidneys. Education programmes which ensure the provision of appropriate information would yield better outcomes [1]. Taking a leaf from HIV management, large-scale educational activities could empower patients and improve treatment adherence. HIV is the third-leading cause of CKD in the province of KwaZulu-Natal, South Africa; hence, strategies to detect CKD and delay CKD progression need to be incorporated in HIV clinics [2].

I am impressed to note that patients living with HIV know their viral load and CD4 counts. They are, therefore, empowered to take their treatment seriously to maintain or improve the control of HIV and immune function. Similarly, I invite everyone to check and take note of their eGFR and proteinuria status annually, as these are key markers of kidney health. Half of the work is done by knowing the kidney’s health status. The nephrology community should contribute by supporting individuals in managing and improving the above parameters.

On March 13, 2025, the world will celebrate World Kidney Day. This year, the theme is “Are your kidneys ok? Detect early, protect kidney health”. Therefore, let us move to detect kidney disease early and protect our kidneys.

Extent of depression among dialysis patients in Africa: a scoping review

Siyanda A Ngema — 2025-02-13

Background: The diagnosis of kidney failure has a significant impact on the quality of life of dialysis patients in various healthcare-related aspects, potentially leading to the development of depression and anxiety. Conversely, depression and the effects of dialysis adversely affect caregivers and families of dialysis patients. These patients experience depression for a variety of reasons, including the psychological effects of chronic illness, lifestyle constraints, and the physical difficulties of therapy. Research on the prevalence and effect of depression in dialysis patients in Africa is limited, highlighting the need for comprehensive studies to address them. This study synthesizes current evidence on depression among dialysis patients in Africa using a scoping review.
Method: A systematic review of articles in PubMed, EMBASE, PsycINFO, African Journals Online (AJOL), and the Cochrane Library was conducted using keywords related to depression, dialysis, and renal disease in Africa, listing studies published between 2014 and 2024. A Microsoft spreadsheet was used to record the details of selected studies. Thirteen surveys met the criteria for final review, which followed the PRISMA-ScR guidelines, descriptive analysis and thematic analysis.
Results: We found that the prevalence of depression in African dialysis patients ranged from 32.4% to 80%, depending on the country and study population. This evidence was categorised into four main themes: mental health and quality of life; socio-economic and treatment factors; self-management and psychosocial support; and geographic, cultural, and clinical implications. The limited number of peer-reviewed research papers identified is of concern, considering the topic’s significance and growing importance.
Conclusion: Depression is prevalent among patients undergoing renal replacement therapies, such as haemodialysis and peritoneal dialysis. Regular assessments of depression are crucial for new dialysis patients to ensure early detection and optimal intervention. Further research is needed to improve the screening, diagnosis, and management of depression among dialysis patients in Africa.

Peritoneal dialysis in a crisis: Navigating a severe drought and pandemic in South Africa

Bianca Davidson — 2025-04-18

Background: A severe drought, followed by the COVID-19 pandemic, posed significant challenges to a South African peritoneal dialysis (PD) programme in Cape Town. The study reported here assessed the impact of these crises on peritonitis rates, bacterial organisms cultured, and patient and technique survival.
Methods: This observational cohort study used data from a peritoneal dialysis registry from 2007 to 2022. The study population was categorized according to three periods: “Baseline” (2007–2014), “Drought” (2015–2019), and “COVID-19” (2020–2022). Baseline characteristics were recorded when PD began. Trends in peritonitis rates, organisms cultured and causes of technique failure were evaluated during each period. A drought-specific questionnaire explored water quality and source.
Results: The cohort comprised 405 patients, representing 559 peritonitis events. There was no statistical difference overall in peritonitis rates, nor peritonitis-free survival at one year among the three periods. Despite Gram-positive organisms being the predominant species cultured, there was an increasing trend in Gram-negative peritonitis during the drought (24%, 46/195) compared to baseline (16%, 37/230) and COVID-19 (15%, 20/134) periods. Klebsiella pneumoniae was the predominant Gram-negative organism cultured overall. However, there was a rise in the proportion Escherichia coli cultured in the drought (17%) compared to the pre-drought (3%) periods. The proportion of Gram-negative catheter-related infections increased during the drought and COVID-19 periods (P = 0.001), with a predominance of Pseudomonas aeruginosa. Only 18% of patients boiled their water as instructed.
Conclusion: The similarity in overall peritonitis rates for the three periods highlights the adaptability and sustainability of peritoneal dialysis as a treatment option, especially at a time of increasing environmental and public-health crises.

Prevalence and outcome of hospitalised patients with unexplained hyperkalaemia at a tertiary centre in South Africa

Florentius Ndinya — 2025-05-13

Background: Hyperkalaemia is frequently encountered in hospitalised patients and is associated with high morbidity and mortality. There is a lack of data on the prevalence and outcomes of hospitalised patients with unexplained hyperkalaemia in Africa. This study aimed to address this knowledge gap.

Methods: We conducted a retrospective cohort study of all adult patients hospitalised with hyperkalaemia, defined as a potassium concentration of ≥5.5 mmol/L, between 1 January 2019 to 31 December 2019. Patients with kidney disease, rhabdomyolysis, tumour lysis syndrome, or who were taking medications that interfere with renal potassium elimination were excluded.

Results: Hyperkalaemia prevalence was 8.2% (184/2256). The median age of the patients was 40 years (interquartile range: 30–56), and 67% were men. In-hospital death was 8%, with no difference in potassium concentration between patients who died or were discharged alive (5.8 mmol/L vs 5.7 mmol/L, P=0.11). Only older age (adjusted odds ratio: 1.04; 95% confidence interval: 1.01–1.08) was associated with in-hospital death. There was no association between in-hospital death and potassium concentration range on survival analysis (P=0.85). Regression analysis revealed associations between potassium concentration and leukocyte counts in patients requiring emergency surgery and those with haematological disorders. A blood gas was performed in 17%, with a mean laboratory-to-blood gas potassium concentration bias of +1.3 mmol/L. Insulin therapy was prescribed in 7% with one episode of hypoglycaemia.

Conclusion: Unexplained hyperkalaemia was associated with low in-hospital deaths. We speculate that the elevated potassium concentrations were spurious and likely due to preanalytical errors.

Effect of dialysis modality on kidney transplant outcomes in South Africa: a single-centre experience

Reese Boosi — 2025-05-09

Background: The effect of dialysis modality on transplant outcomes is disputed, with reduced long-term graft survival in patients receiving peritoneal dialysis reported in some studies. Resource constraints in South Africa limit patient choice of modality, with most state-funded units pursuing a policy of “peritoneal dialysis first”. Application of transplant eligibility as an entrance criterion for dialysis in these settings requires analysis of the effect of modality on transplant outcomes. We therefore undertook the first South African analysis of the effect of antecedent dialysis modality on the development of delayed graft function, rejection and graft function at long-term follow-up.

Methods: A retrospective review of all kidney transplants at Charlotte Maxeke Johannesburg Academic Hospital between 1 January 2006 and 31 December 2011 was undertaken. Graft outcome parameters (development of delayed graft function, graft function as indicated by eGFR, development of rejection, and graft survival) were compared between peritoneal dialysis (PD) and haemodialysis (HD) modalities using logistic regression and Cox proportional hazard modelling.

Results: Delayed graft function was more frequent in HD than PD recipients (66% versus 34%, P = 0.004); HD increased the odds of DGF independently of donor type (OR 3.82, 95% CI 1.46–9.99, P = 0.006). Graft function as indicated by eGFR was comparable between HD and PD subgroups on follow-up. Rejection was numerically more frequent in PD recipients (49% versus 35%, P = 0.135); PD was associated with an increased risk of rejection over 10-year follow-up (HR 3.32, 95% CI 1.40–7.91, P = 0.007). Overall, graft survival was not dissimilar between dialysis modalities (P = 0.737).

Conclusions: Haemodialysis may increase the risk of delayed graft function, possibly due to haemodynamic aberrations associated with this modality, as reported elsewhere. Peritoneal dialysis appears to be associated with increased risk and earlier occurrence of rejection, consistent with previous studies, suggesting accelerated immune reconstitution in this modality. Despite these associations, no effect was observed for dialysis modality on long-term graft function or survival, mirroring previous findings from the developed world.

Prevalence and factors associated with restless legs syndrome in hemodialysis patients at Muhimbili National Hospital, Tanzania

Shaneabbas Mohamed — 2025-05-12

Background: Restless legs syndrome (RLS) is a common motor-sensory disorder among chronic kidney disease patients on hemodialysis, significantly affecting quality of life. While its prevalence varies widely, there is a lack of research on RLS in African hemodialysis patients. This study aims to address this gap by assessing the prevalence, severity, and associated factors of RLS in patients undergoing HD at Muhimbili National Hospital (MNH) in Tanzania.

Methods: A six-month cross-sectional study (August 2023 - January 2024) was conducted at the Muhimbili National Hospital hemodialysis unit, enrolling 348 end-stage kidney disease patients aged ≥18 years. RLS was diagnosed using the 2012 revised International Restless Legs Syndrome Study Group (IRLSSG) questionnaire, with severity assessed via the IRLSSG severity rating scale. Data were analyzed using SPSS version 23, with chi-square or Fisher's exact tests for categorical variables and binary logistic regression for associations. Statistical significance was set at p < 0.05, and ethical approval was obtained from the MUHAS ethics committee.

Results: A total of 348 ESKD patients on HD at MNH were recruited, with a median age of 50 (±12) years; 244 (70.1%) were male. RLS prevalence was 10.1%, and 91% had moderate to severe RLS, with a mean score of 18 (±5). Multivariate analysis identified age ≥ 60, being underweight, HIV infection, HD inadequacy (URR <65%), and higher predialysis blood urea nitrogen (BUN) levels as independent factors associated with RLS (p < 0.05).

Conclusions: Approximately 10% of ESKD patients undergoing hemodialysis at MNH experience moderate to severe RLS. Key factors include age ≥ 60, underweight status, HIV infection, HD inadequacy, and high predialysis urea levels. Regular screening for RLS and addressing these risk factors through a multidisciplinary approach involving nephrologists, nutritionists, and other healthcare professionals is recommended.

Acknowledgement to reviewers 2024

M Razeen Davids — 2025-03-17

The editors of AJN wish to thank the colleagues who generously gave of their time and expertise to review manuscripts for us during 2024. We greatly appreciate their contribution to the quality of the work that we publish.