Screening, Prevention and Intervention Programs for CRF in South Africa

1. Screening, Prevention and Intervention Programs for CRF in South Africa Sarala Naicker Division of Nephrology University of Witwatersrand Johannesburg, South Africa Chair, Africa Subcommittee ISN COMGAN Rabat 2 December 2005 Morocco

2. Need for screening?

3. In 2001, noncommunicable conditions were the leading cause of deaths in all WHO regions with the exception of Africa in 2001. Noncommunicable conditions caused 8.7 million deaths in Western Pacific region, 8.4 million deaths in the European region, and 7.2 million deaths in South-East Asia. In Americas 4.5 million deaths were caused by noncommunicable conditions. In Eastern Mediterranean region 1.9 million deaths were caused by noncommunicable conditions. In Africa communicable diseases, maternal and perinatal conditions and nutritional deficiencies were responsible for 7.6 million deaths. In 2001, noncommunicable conditions were the leading cause of deaths in all WHO regions with the exception of Africa in 2001. Noncommunicable conditions caused 8.7 million deaths in Western Pacific region, 8.4 million deaths in the European region, and 7.2 million deaths in South-East Asia. In Americas 4.5 million deaths were caused by noncommunicable conditions. In Eastern Mediterranean region 1.9 million deaths were caused by noncommunicable conditions. In Africa communicable diseases, maternal and perinatal conditions and nutritional deficiencies were responsible for 7.6 million deaths.

4. Deaths by cause in South Africa

6. ESRD Worldwide Incidence increasing - 6 % every year: cost anticipated>1 trillion $ by 2020 Population growth rate - 1.2% Prevalence worldwide 1,783,000 Estimate 100-1500/million population 89% on haemodialysis (1,222,000) 11% on CAPD (149,000) 412,000 post transplants

7. RRT Prevalence Worldwide

9. Dialysis Costs in Africa Togo : $100 public, $200 private. Kenya: $50 public, $100 private. Benin: $120 public Nigeria: $100 public $150 private. Ghana: $100 public Senegal: $100 public $200 private. Mauritius: Free to citizens. South Africa: Free to citizens but exclusions.

10. Renal Transplant Costs Kenya: Public $7,500.00 Private $15,000.00 Nigeria: Public $15,000.00 Private $20,000.00 Sudan: Public $15,000.00 South Africa: Private $20,000.00

11. CKD:A Clinical Action Plan

12. Who to screen? Whole population screening eg. Singapore, South India High risk patients

13. Aetiology of Kidney Failure

14. Hypertension

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

16. BP Control in South Africa SA Demographic Health Survey 1998 >13000 adults HPT prevalence 21.3% <50% treated <1/3 controlled Steyn et al. J Hypertens 2001; 19:1717-1725

17. Study by Gauteng Health Department 

18. Membranous GN 306 Black children with NS 43% with membranous GN 86.2% HBV antigens

19. Tackling the problems:Screening, Prevention,Intervention Diabetes Hypertension Glomerular Disease

20. Type 2 Diabetes Mellitus Diabetic Nephropathy among black South Africans: Preliminary data Screening January 2005 to March 2005 320 patients screened; 188 females; 132 males 37.7% had proteinuria Linda Ezekiel, ISN Fellow; unpublished data

21. HIV and Renal Disease Asymptomatic patients screened: 617 Urinalysis Proteinuria: 37 (6%) Microalbuminuria: 32/ 90; persistent 7 Haematuria: 9 Histology HIVAN 86.2% of proteinuric pts HIVAN 85.7% of MA pts (6/7) Han et al, EDTA Abstracts 2004

22. Urinalysis in HIV 575 HIV+ patients in OPD screened, ART-naive 219 male (38%) 356 female (62%) Abnormal dipsticks 270(47%) 205 proteinuric (36%) Microalbuminuria = 139 (24.2%) persistent= 33(5.7%) Overt proteinuria = 55 (9.6%) Nephrotic syndrome=11 (1.9%) Fabian, unpublished data

23. CDOPPP Pilot Phase  35% Patients With Renal Disease 25% Macroalbuminuria 10% Microalbuminuria From 1998 SADHS -35.5% of men and 10.8% of women are smokers in Gauteng Province Current smokers: 9-15% Mean cholesterol 5.2mmol/L+3.8

24. Prevention Strategies Public health measures: antenatal care/HIV/ HBV/ health education- smoking, diet, exercise, HIV Early detection of proteinuria and prevention of progression of chronic kidney disease in high risk patients Prevention of CKD in public health clinics Detection and Mx of HPT AND DM Optimal utilisation of healthcare personnel Partnerships: Govt, NKF, ISN, other

25. HBsAg in Children in S Africa

26. 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 0.09 Bhimma et al, 2002

27. Outcomes of ACEI therapy in HIVAN

28. CDOPPP Baseline Data1999 to 2005…..

29. Program Nurse Managers

30. Key Factors to monitor CDOPPP Group Highlight Australian support and reasons for choosing Australia initiallyHighlight Australian support and reasons for choosing Australia initially

31. Simplified Evidence Based Treatment Targets

32. No Significant difference in the distribution of BMI between the IC and the CC.No Significant difference in the distribution of BMI between the IC and the CC.

33. SBP and DBP change over time

34. Percent of patients at targets for glucose control

35. Albumin Creatinine Ratio (ACR) change over twenty months

36. Challenges Staff shortages Overwhelmed by burden of patients Delivery problems of drugs and infrastructure Data capture quality and efficiency Inadequate long term follow up and loss of patients Lack of Motivation amongst staff Showing participants the value of the program Focusing on problems with patients / patient education Improving patient care Early detection of problems Successful lowering of BP Better understanding of problems Link between 10 and 30 facilities Education of staff, management and patients Management gaining a better understanding of problems Clinics with good follow up are doing well! Management can see value of PHC

37. WHAT IS THE GLOBAL STRATEGY NEEDED IN THE DEVELOPING WORLD? Prevention 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; drugs should be freely available at low cost Optimise HCW and community participation Global partnerships

40. RRT in South Africa Private Sector: HD 80%; CAPD 20% Public Sector ARF CRF: no/low cost if eligible for TP (National Health Policy); >1000 new patients/ year HD : 60% CAPD: 40% TP 18% -CD: 60% -LD: 40%

41. ESRD Resource Availability.

42. WHAT IS THE GLOBAL STRATEGY NEEDED IN THE DEVELOPING WORLD? RRT Strategies to make dialysis affordable Partnerships with govts/ dialysis providers/ NGOs Initially for acute renal failure Dialysis for chronic renal failure should be integrated with transplantation

43. Recommendations Public Education Need for Legal Edict Set-up Foundations to fund dialysis/ transplants for the needy; partnership with Govt, NGOs, other Drug availability and possible subsidy Training of HCW Registry Research and Development

44. Special thanks to… Dr Ivor Katz, South Africa Dr Maung Han, South Africa Dr June Fabian, South Africa Dr Linda Ezekiel, ISN Fellow, Tanzania Dr Ebun Bamgboye, Nigeria Professor John Dirks, Canada

46. Numbers of doctors/ 100,000 Egypt 202 Algeria 84.6 Libya 128 Tunisia 70 South Africa 56.3 Morocco 46 Namibia 29.5 Kenya 13.2 Botswana 23.8 Congo Dem. 6.9 Nigeria 18.5 Cent Afr. Rep. 3.5 Sudan 9.0 Chad 3.3 Sierra Leone 7.3 Eritrea 3.0 Ghana 6.2 Ethiopia 2.0 Tanzania 4.1 Cameroon 7.4 Burkina Faso 3.4 Benin 5.7 Liberia 2.3 Niger 3.5 Togo 7.6 Uganda 3.0 Ivory Coast 9.0

47. Numbers of doctors per 100,000 Italy 554 Russian Federation* 421 Germany 350 France 303 USA 279 Canada 229 UK 164 Former Soviet States* >300

48. Glucose, HbA1c

49. BMI

50. Dialysis Patients World-wide (1996)

51. ESRD/RRT IN SOUTH AFRICA Prevalence ? 500 pmp Population 46million New patients treated annually: >1000 HD 42% PD 40%: JHB peritonitis rate 1/>12pm Tx 18% Eligibility for chronic dialysis in public sector: renal transplant- Policy of National Health Dept All patients receive dialysis for ARF in S Africa Prevention programmes in infancy

52. DIALYSIS IN S AFRICA 2005