Noubiap JJN, Naidoo J, Kengne AP. Diabetic nephropathy in Africa: A systematic review. World J Diabetes 2015; 6(5): 759-773 [PMID: 26069725 DOI: 10.4239/wjd.v6.i5.759]
Corresponding Author of This Article
Andre P Kengne, Professor, Medical Research Council of South Africa, PO Box 19070 Tygerberg, 7505 Cape Town, South Africa. andre.kengne@mrc.ac.za
Research Domain of This Article
Endocrinology & Metabolism
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Jean Jacques N Noubiap, Internal Medicine Unit, Edéa Regional Hospital, PO BOX 100 Edéa, Cameroon
Jashira Naidoo, Department of Medicine, Groote Schuur Hospital, University of Cape Town, 7925 Observatory, Cape Town, South Africa
Jashira Naidoo, Andre P Kengne, Non-Communicable Diseases Research Unit, South African Medical Research Council, 7505 Cape Town, South Africa
ORCID number: $[AuthorORCIDs]
Author contributions: All authors contributed to this work.
Conflict-of-interest: None for all co-authors.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Andre P Kengne, Professor, Medical Research Council of South Africa, PO Box 19070 Tygerberg, 7505 Cape Town, South Africa. andre.kengne@mrc.ac.za
Telephone: +27-21-9380529 Fax: +27-21-9380460
Received: December 8, 2014 Peer-review started: December 9, 2014 First decision: January 20, 2015 Revised: February 18, 2015 Accepted: March 16, 2015 Article in press: March 18, 2015 Published online: June 10, 2015
Abstract
AIM: To determine the prevalence and incidence of diabetic nephropathy in Africa.
METHODS: We performed a systematic narrative review of published literature following the MOOSE Guidelines for Meta-Analysis and Systematic Reviews of Observational Studies. We searched PubMed-MEDLINE for all articles published in English and French languages between January 1994 and July 2014 using a predefined strategy based on the combination of relevant terms and the names of each of the 54 African countries and African sub-regions to capture the largest number of studies, and hand-searched the reference lists of retrieved articles. Included studies reported on the prevalence, incidence or determinants of chronic kidney disease (CKD) in people with diabetes within African countries.
RESULTS: Overall, we included 32 studies from 16 countries; two being population-based studies and the remaining being clinic-based surveys. Most of the studies (90.6%) were conducted in urban settings. Methods for assessing and classifying CKD varied widely. Measurement of urine protein was the most common method of assessing kidney damage (62.5% of studies). The overall prevalence of CKD varied from 11% to 83.7%. Incident event rates were 94.9% for proteinuria at 10 years of follow-up, 34.7% for end-stage renal disease at 5 years of follow-up and 18.4% for mortality from nephropathy at 20 years of follow-up. Duration of diabetes, blood pressure, advancing age, obesity and glucose control were the common determinants of kidney disease.
CONCLUSION: The burden of CKD is important among people with diabetes in Africa. High quality data from large population-based studies with validated measures of kidney function are still needed to better capture the magnitude and characteristics of diabetic nephropathy in Africa.
Core tip: Chronic kidney disease is a serious health threat for people with diabetes in Africa, with prevalence figures ranging from 11% to 83.7%. The incidence estimates suggest that 95% of people with diabetes may have proteinuria after 10 years from diabetes diagnosis; about 35% may develop end-stage renal disease after 5 years and 18% die from nephropathy after 20 years of disease duration. Hypertension, obesity, poor glycemic control and diabetes duration are the main risk factors of chronic kidney disease among diabetic patients in Africa. High quality data are needed to refine the epidemiology of diabetic nephropathy on the continent.
Citation: Noubiap JJN, Naidoo J, Kengne AP. Diabetic nephropathy in Africa: A systematic review. World J Diabetes 2015; 6(5): 759-773
Africa, like the rest of the world, is experiencing an increasing prevalence of diabetes alongside other non-communicable diseases, mainly as a result of urbanization, sedentary lifestyles, obesity and population growth and ageing[1]. Estimates for 2013 by the International Diabetes Federation (IDF) indicate that the number of adults with diabetes in the world will expand by 55%, from 381.8 million in 2013 to 591.9 million in 2035[2]. The largest increase of the population with diabetes will occur in sub-Saharan Africa, with a projected growth of 109.6%, from 19.8 million in 2013 to 41.5 million in 2035[2].
Diabetes causes significant morbidity, disability and early mortality. Diabetes has been identified as a major contributor in several other important diseases, both non-communicable diseases such as cardiovascular disease and renal disease[3,4], and communicable diseases such as invasive bacterial infections[5,6]. Mortality attributable to diabetes in sub-Saharan Africa was estimated to account for 8.6% of the total death in 2013[7]. Diabetic nephropathy (DN) is one of the most common complications of diabetes. The prevalence of DN is increasing steeply along with the diabetes epidemic[8]. Approximately one third to half of patients with diabetes develops renal manifestations[8-11]. DN is associated with increased premature mortality, end-stage renal disease and need to renal replacement therapy, cardiovascular diseases, and escalating health-care costs[8].
DN has been suggested to be more frequent among patients with diabetes in Africa as compared to those in the developed world due to delayed diagnosis, limited screening and diagnostic resources, poor control of blood sugar and other risk factors, and inadequate treatment at an early stage[7,12,13]. However, evidence to support the burden of kidney diseases in people with diabetes in Africa remains very patchy, and we are not aware of any effort to synthesize existing data on the occurrence of kidney disease in African populations with diabetes. Accordingly, the aim of this review is to provide a comprehensive overview of the published evidence on the occurrence of nephropathy in African people with diabetes.
MATERIALS AND METHODS
Data sources and search strategy
A systematic narrative review of published literature was performed following the MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies[14]. We searched MEDLINE via PubMed for articles published in English and French on DN in Africa between January 1994 and July 2014, using a predefined strategy based on the combination of relevant terms and the names of each of the 54 African countries and African sub-regions to capture the largest number of studies. The data search was limited to human studies. The last search date was October 22, 2014. Search histories are provided in Table 1. Once duplicate references were removed the titles and abstracts of the references were screened. The references of included articles were scanned to identify additional articles of interest.
Diabetes[tw] OR Diabetes mellitus[tw] OR Type 1 diabetes[tw] OR Type 1 diabetes mellitus[tw] OR T1DM[tw] OR Type 2 diabetes[tw] OR Type 2 diabetes mellitus[tw] OR T2DM[tw] OR Hyperglycemia[tw] OR Glucose intolerance[tw]
445204
2
Renal insufficiency[tw] OR Renal failure[tw] OR Renal injury[tw] OR Renal disease[tw] Kidney insufficiency[tw] OR Kidney failure[tw] OR Kidney injury[tw] OR Kidney disease[tw] OR End-stage renal disease[tw] OR End-stage renal failure[tw] OR End-stage kidney disease[tw] OR End-stage kidney failure [tw] OR End stage renal disease[tw] OR End stage renal failure[tw] OR End stage kidney disease[tw] OR End stage kidney failure [tw] OR Microalbuminuria [tw] OR Micro-albuminuria OR Macroalbuminuria [tw] or Macro-albuminuria [tw]
154354
3
# 1 AND # 2
20388
4
Diabetic nephropathy [MeSH Terms]
19406
5
# 3 OR # 4
34221
6
((((("Africa"[MeSH] OR Africa*[tw] OR Algeria[tw] OR Angola[tw] OR Benin[tw] OR Botswana[tw] OR "Burkina Faso"[tw] OR Burundi[tw] OR Cameroon[tw] OR "Canary Islands"[tw] OR "Cape Verde"[tw] OR "Central African Republic"[tw] OR Chad[tw] OR Comoros[tw] OR Congo[tw] OR "Democratic Republic of Congo"[tw] OR Djibouti[tw] OR Egypt[tw] OR "Equatorial Guinea"[tw] OR Eritrea[tw] OR Ethiopia[tw] OR Gabon[tw] OR Gambia[tw] OR Ghana[tw] OR Guinea[tw] OR "Guinea Bissau"[tw] OR "Ivory Coast"[tw] OR "Cote d'Ivoire"[tw] OR Jamahiriya[tw] OR Jamahiryia[tw] OR Kenya[tw] OR Lesotho[tw] OR Liberia[tw] OR Libya[tw] OR Libia[tw] OR Madagascar[tw] OR Malawi[tw] OR Mali[tw] OR Mauritania[tw] OR Mauritius[tw] OR Mayote[tw] OR Morocco[tw] OR Mozambique[tw] OR Mocambique[tw] OR Namibia[tw] OR Niger[tw] OR Nigeria[tw] OR Principe[tw] OR Reunion[tw] OR Rwanda[tw] OR "Sao Tome"[tw] OR Senegal[tw] OR Seychelles[tw] OR "Sierra Leone"[tw] OR Somalia[tw] OR "South Africa"[tw] OR "St Helena"[tw] OR Sudan[tw] OR Swaziland[tw] OR Tanzania[tw] OR Togo[tw] OR Tunisia[tw] OR Uganda[tw] OR "Western Sahara"[tw] OR Zaire[tw] OR Zambia[tw] OR Zimbabwe[tw] OR "Central Africa"[tw] OR "Central African"[tw] OR "West Africa"[tw] OR "West African"[tw] OR "Western Africa"[tw] OR "Western African"[tw] OR "East Africa"[tw] OR "East African"[tw] OR "Eastern Africa"[tw] OR "Eastern African"[tw] OR "North Africa"[tw] OR "North African"[tw] OR "Northern Africa"[tw] OR "Northern African"[tw] OR "South African"[tw] OR "Southern Africa"[tw] OR "Southern African"[tw] OR "sub Saharan Africa"[tw] OR "sub Saharan African"[tw] OR "subSaharan Africa"[tw] OR "subSaharan African"[tw]) NOT ("guinea pig"[tw] OR "guinea pigs"[tw] OR "aspergillus niger"[tw])))))
354928
7
# 5 AND # 6
1065
8
#4 Limits: 1994/01/01 to 2014/10/22 and studies done in Humans
918
Study selection and data extraction
We included cross-sectional, case-control or cohort studies of subjects with diabetes mellitus resident in African countries reporting the prevalence or incidence or progression of DN. We excluded studies of populations of African origin residing outside Africa; case series (sample size less than 50 subjects), letters, comments and editorials; studies not published in English or French. Two investigators (JJNN, APK) independently identified articles and sequentially screened them for inclusion (Figure 1). Disagreements were solved by a third investigator (JN). Full text articles were reviewed by two investigators (JJNN and APK) who independently extracted data regarding study setting and design, study population characteristics and prevalence or incidence of DN.
We identified 730 articles, of which 73 were reviewed in full-text; 32 met the inclusion criteria (Figure 1)[15-46].
Characteristics of included studies
Characteristics of the included studies are summarized in Table 2. The 32 studies were performed in 16 countries, with a geographical distribution covering all the African regions. However, more than half the studies [18 (56.3%)] were from South Africa (five), Nigeria (four), DR Congo (three) and Ethiopia (three).
Table 2 General characteristics of studies of chronic kidney disease in people with diabetes in Africa.
Case (T2DM with persistent proteinuria-control (T2DM patients nephropathy)
Clinic, urban
162
53.4
50
T2DM9.4 cases, 5.5 controls
NA
Only two population-based studies were identified. In Democratic Republic of Congo, between March and April 2007, Makulo et al[35] studied pathologic albuminuria among 81 diabetic patients identified through a population-based survey on the prevalence of diabetes involving 1898 participants[35]. Pruijm et al[39] in Seychelles in 2004, conducted a large-scale population-based estimate of the prevalence of microalbuminuria among 1218 adults. All other studies were clinic-based surveys conducted mostly in diabetic clinics. There were three cohort studies (two prospective and one retrospective), one case-control study and the other 28 studies were cross-sectional with non-random sampling. Only three (9.4%) studies were conducted in rural settings.
Methods of assessment and classification of chronic kidney disease (CKD) varied widely. The studies assessed kidney function by urine protein [20 (62.5%) studies], urine albumin-to-creatinine ration (ACR) [9 (28.1%) studies], and estimation of glomerular filtration rate (GFR) by Cockcroft-Gault formula [3 (9.4%) studies] or by MDRD formula [4 (12.4%) studies]. Six studies (18.8%) measured kidney function by two methods, and renal biopsy was not performed in any study.
Prevalence of CKD
As depicted in Table 3, the overall prevalence of CKD varied from 11% in Tunisia to 83.7% in Tanzania[20,29]. In studies where proteinuria was used to assess CKD, the prevalence varied from 5.3% in South Africa to 53.1% in Cameroon (study with a small sample size)[32,44]. When considering the estimation of the GFR, the prevalence ranged from 4.6% in Tanzania to 43.1% in Nigeria (study with a small sample size)[15,33].
Table 3 Prevalence and incidence of chronic kidney disease in people with diabetes across studies in Africa.
Nephropathy: ACR> 25.0 mg/mmol and retinopathy presentMicroalbuminuria: ACR> 2.5 and < 25.0 mg/mmol in men and > 3.5 and< 25.0 mg/mmol in women
Nephropathy: 2%Microalbuminuria: 51%
Urinary ACR levels (toassess microalbuminuria and nephropathy) were done on59 patients, as those with haematuria and/or urinary infection were excluded
The study did not assess the prevalence or incidence of diabetic nephropathy, but its predictors
Incidence of CKD
A study in South Africa investigated the long-term incidence of proteinuria among T2DM patients. After 12 years of follow-up or death, 94.9% (56/59) had a proteinuria with a mean duration from diabetes onset to proteinuria of 9.7 (5.9) years[31]. In another study in South Africa, found that 18.4% of T1DM patients had died from renal nephropathy after 20 years of follow-up[28]. In a recent study in Morocco, the incidence of end-stage renal disease after 5 years was 34.7%[19].
Risk factors of CKD
Twenty studies (62.5%) reported factors associated with CKD in diabetic patients (Table 4). However, in most studies the method to assess this association was imprecise. In cross-sectional studies, correlates of CKD included systolic and diastolic high blood pressure, long duration of diabetes, older age, dyslipidemia, obesity[16-22,25,26,29-31,33,36,40,42-44,46]. In a study in Cameroon, T2DM patients with systolic hypertension and diastolic hypertension were respectively 1.45 (95%CI: 1.15-1.84; P = 0.006) and 1.33 (95%CI: 1.06-1.66; P = 0.026) times more likely to have nephropathy[22]. Two studies in Rwanda and South Africa respectively showed that a one year increase in the duration of T1DM increased by 0.86 (95%CI: 0.77-0.96; P = 0.008) the odds of microalbuminuria[36], and that T1DM and T2DM patients with a duration of diabetes greater than 10 years were 4.19 times (95%CI: 1.93-9.10; P < 0.001) more likely to have microalbuminuria[43]. Poor glycemic control as measured by HbA1c was also a strong predictor of nephropathy. For instance, HbA1c level greater than 10% and 14% were respectively associated with a 2.6 fold (95%CI: 1.1-6.4) and a 4.69 (95%CI: 1.65-13.3; P = 0.004)[42,43]. A 1 g/dL decrease in hemoglobin level has been found to be associated with end-stage renal disease (OR 3.18, 95%CI: 1.47-6.87; P = 0.003)[19]. Studies in Nigeria showed that left ventricular hypertrophy, stroke, myocardial infarction and peripheral arterial disease were more frequent in T2DM patients with nephropathy, especially those with advanced stages[17,18].
Table 4 Risk factors for chronic kidney disease in people with diabetes.
These are risk factors for death from chronic renal failure (compared with the patients who were still alive at follow-up)By the end of study 47 of the 59 patients had died; the cause of death not established in 2 patients. Death was due to chronic renal failure in 17 cases
Proteinuria was more frequent in insulin-treated patients compared those on oral antidiabetic treatment. The prevalence of proteinuria also increased with the duration of diabetes
The study assessed the predictors of diabetic nephropathy comparing T2DM patients with and without nephropathy
Serum total cholesterol
< 0.05
Alcohol > 30 mg/d
< 0.05
Peripheral vascular disease
< 0.05
Stroke
< 0.05
DISCUSSION
Diabetic nephropathy is a common and morbid complication of diabetes and the leading cause of CKD in the developed world. The lack of renal registries means that there are no reliable statistics about the burden of CKD in people with diabetes in the majority of African countries. The current systematic review identified 32 relevant studies published over the last 20 years on kidney diseases in people with diabetes residing in Africa. Prevalence rates ranged from 11% to 83.7% for the overall CKD, 5.3% to 53.1% for CKD based on proteinuria, and 4.6% to 43.1% for CKD based on eGFR. Incident event rates were 94.9% for proteinuria at 10 years for follow-up, 34.7% for ERSD at 5 years of follow-up and 18.4% for mortality from nephropathy at 20 years of follow-up. Diagnosed duration of diabetes, blood pressure variables, advancing age, obesity and to some extend glucose control were the common determinants of kidney disease in people with diabetes. Studies were overwhelmingly hospital-based studies; half of them originated from four countries while variable definitions and methods for assessing nephropathy had been used across studies.
The most recent overview of CKD in populations within Africa was completed in 2012, and was restricted to sub-Saharan African Countries[47]. This review identified 90 articles representing data from 21 countries, with over half of the studies originating from South Africa, Nigeria and Ethiopia alones. Across 21 studies deemed to be of medium to high quality by the investigators, the pooled prevalence of CKD was 13.9% (95%CI: 12.2-15.7), with substantial heterogeneity across studies. The prevalence in people with diabetes ranged from 4% to 24% based essentially on proteinuria defined CKD[47]. In our review without applying quality criteria, we found much higher prevalence of CKD, regardless of the definition. In four studies published in 2013 for instance, the prevalence of microalbuminuria ranged between 21% and 45%. Although issues with the quality of the studies preclude direct comparisons, it is likely that nephropathy is more frequent in population with diabetes within Africa than in developed countries. The review by Stanifer et al[47] also identified many challenges and limitations, which largely apply to the current study.
The most important aspect in assessing incidence and prevalence of diabetic nephropathy in Africa is currently different diagnostic criteria for CKD. There are no clear definitions on DN. The 2012 KDIGO CKD classification assesses diabetes related kidney changes according to urinary albumin-to-creatinine ratio based on early morning spot urine samples[48]. Quantification of proteinuria in assessing CKD is controversial as no optimal test exists. The National Institute for Health and Clinical Excellence (NICE) guidance has recommended that an early morning urinary ACR should be preferred to other tests of proteinuria, because ACR offers greater sensitivity for the detecting lower, but clinically significant, levels of proteinuria[49]. Almost all the studies included in our review utilized urine tests to diagnose CKD, but only nine studies used ACR. Inconsistencies in the way and manner of reaching a diagnosis of DN in Africans are explained at least in part by issues relating to availability and accessibility of screening or diagnostic tools. Swanepoel et al[50] have reviewed in detail some of the problems associated with nephrology in Africa and discussed the role of lack of amenities in diagnosing renal diseases. Another challenge to making the diagnosis of diabetic nephropathy in Africa is the degree to which other causes of chronic kidney disease have been excluded. A standard armamentarium of tests would include tests looking for HIV, hepatitis B and C, brief collagen screen, syphilis exclusion and other tests would have to be based on history and physical exam.
The classification of CKD is important in the definition of DN and has a few limitations that are universally acknowledged: eGFR underestimates kidney function and there is discordance in the estimates across different estimators[51]; isolated microalbuminuria is a normal feature of aging, inflammation, vascular pathologies, smoking, diet and obesity which are all frequent in diabetes; decline in kidney function is an expected phenomenon with advanced age, just like diabetes risk increases with age. Further considerations to CKD classifications and DN definition limitations is that current guidelines take no notice of the single most important risk factor associated with CKD namely hypertension, which is present in over 50% of people with type 2 diabetes.
Risk factor association was not assessed in 12 of the 32 studies, however common risk factors included were hypertension, raised BMI, HbA1c and duration of diabetes. Despite advances in management over the last three decades, many people with diabetes still develop CKD. This may be partly explained by the poor achievement of blood pressure and blood glucose targets. Recently the JNC 8 guidelines have added to the controversy of various blood pressure targets needed for diabetic patients that would assist in preventing progression to CKD. Optimal targets when reached, however have shown to aid in progression to progression. Another risk factor pertinent to the developing world is the socioeconomic status of individuals in the causative role of diabetic nephropathy. Weil et al[52], in 2010 reviewed factors associated with disadvantage that may increase the risk of diabetic kidney disease, and the barriers to care that hinder attempts to provide an adequate therapeutic response[52].
Several mechanisms underlying the pathogenesis of diabetic nephropathy have been suggested and include glomerular hyperfiltration; hyperglycemia and the increased production of advanced glycation end products; hypoxia-inflammation and the activation of cytokines. Hyperfiltration commonly occur in early in the course of diabetes and involves glucose-dependent dilation of the afferent arteriolar dilation, and the enhanced filtration area secondary to the increase in the number of mesangial cells and capillary loops. Molecular level action involves vasoactive mediators like insulin-like growth factor 1, transforming growth factor beta, nitric oxide, prostaglandin, glucagon and vascular endothelial growth factor[53]. Other hallmarks of diabetic nephropathy include nodular diabetic glomerulosclerosis and diffuse glomerulosclerosis, mediated at least in part by inflammatory processes and immune cells activity[53]. Interstitial fibrosis and tubular atrophy are also seen early in DN, with the underlying pathogenetic mechanism being similar to those in progressive non diabetic renal disease[54].
Diabetic nephropathy ultimately occurs only in susceptible individuals with diabetes; which susceptibility is determined by the combined effect of genetic predisposition and non-genetic factors. Genetic susceptibility to diabetic nephropathy is by nature polygenetic. Whole-genome scanning studies have identified several chromosomal regions linked with diabetic nephropathy; however, the pathophysiologic function of such genetic regions has yet to be fully elucidated. Genetic polymorphisms may explain the familial clustering of diabetic nephropathy[55]. Some studies have suggested some detrimental effect of the double-deletion (DD) polymorphism of the angiotensin-converting enzyme (ACE) genotype on disease progression[56]. Non-genetic determinants of diabetic nephropathy include among others socioeconomic factors, dietary factors, poor hyperglycemic control, hypertension, obesity and early life factors[57,58]. Hypertension appears to be a strong correlate of disease progression in Black people[59,60].
The current review has some limitations. Included studies were mostly based on small samples, with different study designs and most of the studies were cross sectional with only two being retrospective cohorts and one case-control. A large proportion were based in urban clinics with and most of the populations studied were that attending a general diabetic clinic and the results may not be generalizable to primary care populations. Ideally chronic kidney disease should not be diagnosed on the basis of single measurements of serum creatinine and albuminuria, and standard baseline investigations are needed to exclude other causative kidney disease, although there is precedence for this in other studies in the West as well. Finally, detection of microalbuminuria was one the most frequent method to assess the presence of diabetic nephropathy. As microalbuminuria is more a quantitative estimate of endothelial/vascular dysfunction than of diabetic nephropathy, the incidence and prevalence rate of diabetic nephropathy have probably been overestimated when assessing kidney function by urine protein.
In conclusion, the current review gives a small glimpse of the larger numbers of CKD in diabetics in Africa compared to Western society. CKD is a substantial health burden among diabetic patients on the African continent, with prevalence varying from 11% to 83.7% depending on the method of assessment. Estimates suggest that 95% of diabetics may have proteinuria after a 10 years duration of diabetes, about 35% may have an end-stage renal disease after 5 years and 18% die from nephropathy after 20 years of disease duration. Risk factors of CKD include mainly hypertension, obesity, poor glycemic control and disease duration. Better surveillance of diabetes is a necessary first step toward its prevention and control, which is now recognized as an urgent priority. An electronic database in African regions would be ideal to assist in this entity although it is presumed that we are light years away from that. At a primary care level it is very plausible that with early detection, proper screening, and management, the impact of diabetic nephropathy may be better mitigated to lessen its impact on society and healthcare.
COMMENTS
Background
African countries are experiencing an epidemics of diabetes mellitus. Diabetic nephropathy is one the most frequent complications of diabetes mellitus. Several studies on the epidemiology of diabetic nephropathy have been conducted in Africa, but there is no previous published work which synthesizes evidences from this study to provide an overview of the disease on the continent.
Research frontiers
Epidemiological data on diabetic nephropathy in Africa are sparse. These data are important to quantify the magnitude of the disease and assist the formulation of strategies to reduce the impact of nephropathy on people with diabetes in Africa.
Innovations and breakthroughs
This review is the first to synthesize relevant data on diabetic nephropathy in Africa. The authors performed extensive electronic and manual bibliographic searches to determine the prevalence and incidence of diabetic nephropathy on the continent. Although the quality of data was not optimal, estimates suggest that the prevalence of diabetic nephropathy vary between 11%-83.7%. About one third of diabetic patients have end-stage renal disease after 5 years and about one fifth die from nephropathy after 20 years of disease duration. Hypertension, obesity, poor glycemic control and disease duration are the main risk factors of chronic kidney disease among diabetic patients in Africa.
Applications
This review shows that the burden of chronic kidney disease is important among people with diabetes in Africa. The findings will have implications for policy, practice and future research on diabetic nephropathy on the continent.
Terminology
Diabetic nephropathy is an alteration of the function of the kidneys due to diabetes mellitus. It is associated with substantial morbidity and mortality.
Peer-review
The authors of the present manuscript performed extensive electronic and manual bibliographic research to determine the prevalence and incidence of kidney disease in people with diabetes mellitus within countries in Africa. Overall the review is well written.
Footnotes
P- Reviewer: de Oliveira JMF, Laghmani K S- Editor: Ji FF L- Editor: A E- Editor: Zhang DN
Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic.Nature. 2001;414:782-787.
[PubMed] [DOI][Cited in This Article: ]
Aguiree F, Brown A, Cho NH, Dahlquist G, Dodd S, Dunning T, Hirst M, Hwang C, Magliano D, Patterson C. IDF Diabetes Atlas: sixth edition. 6th ed. Basel, Switzerland: International Diabetes Federation 2013; .
[PubMed] [DOI][Cited in This Article: ]
Seshasai SR, Kaptoge S, Thompson A, Di Angelantonio E, Gao P, Sarwar N, Whincup PH, Mukamal KJ, Gillum RF, Holme I. Diabetes mellitus, fasting glucose, and risk of cause-specific death.N Engl J Med. 2011;364:829-841.
[PubMed] [DOI][Cited in This Article: ]
Fox CS, Matsushita K, Woodward M, Bilo HJ, Chalmers J, Heerspink HJ, Lee BJ, Perkins RM, Rossing P, Sairenchi T. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis.Lancet. 2012;380:1662-1673.
[PubMed] [DOI][Cited in This Article: ]
Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies.PLoS Med. 2008;5:e152.
[PubMed] [DOI][Cited in This Article: ]
Muller LM, Gorter KJ, Hak E, Goudzwaard WL, Schellevis FG, Hoepelman AI, Rutten GE. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus.Clin Infect Dis. 2005;41:281-288.
[PubMed] [DOI][Cited in This Article: ]
Kengne AP, Echouffo-Tcheugui JB, Sobngwi E, Mbanya JC. New insights on diabetes mellitus and obesity in Africa-part 1: prevalence, pathogenesis and comorbidities.Heart. 2013;99:979-983.
[PubMed] [DOI][Cited in This Article: ]
Assogba GF, Couchoud C, Roudier C, Pornet C, Fosse S, Romon I, Druet C, Stengel B, Fagot-Campagna A. Prevalence, screening and treatment of chronic kidney disease in people with type 2 diabetes in France: the ENTRED surveys (2001 and 2007).Diabetes Metab. 2012;38:558-566.
[PubMed] [DOI][Cited in This Article: ]
Bakris GL. Recognition, pathogenesis, and treatment of different stages of nephropathy in patients with type 2 diabetes mellitus.Mayo Clin Proc. 2011;86:444-456.
[PubMed] [DOI][Cited in This Article: ]
Thomas MC, Weekes AJ, Broadley OJ, Cooper ME, Mathew TH. The burden of chronic kidney disease in Australian patients with type 2 diabetes (the NEFRON study).Med J Aust. 2006;185:140-144.
[PubMed] [DOI][Cited in This Article: ]
Kengne AP, Sobngwi E, Echouffo-Tcheugui JB, Mbanya JC. New insights on diabetes mellitus and obesity in Africa-Part 2: prevention, screening and economic burden.Heart. 2013;99:1072-1077.
[PubMed] [DOI][Cited in This Article: ]
Mbanya JC, Motala AA, Sobngwi E, Assah FK, Enoru ST. Diabetes in sub-Saharan Africa.Lancet. 2010;375:2254-2266.
[PubMed] [DOI][Cited in This Article: ]
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000;283:2008-2012.
[PubMed] [DOI][Cited in This Article: ]
Ajayi S, Mamven M, Ojji D. eGFR and chronic kidney disease stages among newly diagnosed asymptomatic hypertensives and diabetics seen in a tertiary health center in Nigeria.Ethn Dis. 2014;24:220-225.
[PubMed] [DOI][Cited in This Article: ]
Alebiosu CO, Odusan O, Familoni OB, Jaiyesimi AE. Cardiovascular risk factors in type 2 diabetic Nigerians with clinical diabetic nephropathy.Cardiovasc J S Afr. 2004;15:124-128.
[PubMed] [DOI][Cited in This Article: ]
Alebiosu CO, Odusan O, Jaiyesimi A. Morbidity in relation to stage of diabetic nephropathy in type-2 diabetic patients.J Natl Med Assoc. 2003;95:1042-1047.
[PubMed] [DOI][Cited in This Article: ]
Bentata Y, Haddiya I, Latrech H, Serraj K, Abouqal R. Progression of diabetic nephropathy, risk of end-stage renal disease and mortality in patients with type-1 diabetes.Saudi J Kidney Dis Transpl. 2013;24:392-402.
[PubMed] [DOI][Cited in This Article: ]
Bouaziz A, Zidi I, Zidi N, Mnif W, Zinelabidine HT. Nephropathy following type 2 diabetes mellitus in Tunisian population.West Indian Med J. 2012;61:881-889.
[PubMed] [DOI][Cited in This Article: ]
Bouzid C, Smida H, Kacem A, Turki Z, Ben Salem L, Ben Rayana C, Slama BC. [Renal failure in Tunisian patients with type 2 diabetes: frequency and related factors].Tunis Med. 2011;89:10-15.
[PubMed] [DOI][Cited in This Article: ]
Choukem SP, Dzudie A, Dehayem M, Halle MP, Doualla MS, Luma H, Kengne AP. Comparison of different blood pressure indices for the prediction of prevalent diabetic nephropathy in a sub-Saharan African population with type 2 diabetes.Pan Afr Med J. 2012;11:67.
[PubMed] [DOI][Cited in This Article: ]
Danquah I, Bedu-Addo G, Terpe KJ, Micah F, Amoako YA, Awuku YA, Dietz E, van der Giet M, Spranger J, Mockenhaupt FP. Diabetes mellitus type 2 in urban Ghana: characteristics and associated factors.BMC Public Health. 2012;12:210.
[PubMed] [DOI][Cited in This Article: ]
Djrolo F, Attolou VG, Avode DG, Houngbe F, Akpona S, Addra B, Kodjoh N. [Diabetic nephropathy: an epidemiological study based on proteinuria in a population of black African diabetics in Cotonou, Benin].Sante. 2001;11:105-109.
[PubMed] [DOI][Cited in This Article: ]
Eghan BA, Frempong MT, Adjei-Poku M. Prevalence and predictors of microalbuminuria in patients with diabetes mellitus: a cross-sectional observational study in Kumasi, Ghana.Ethn Dis. 2007;17:726-730.
[PubMed] [DOI][Cited in This Article: ]
Elbagir MN, Eltom MA, Mahadi EO, Berne C. Pattern of long-term complications in Sudanese insulin-treated diabetic patients.Diabetes Res Clin Pract. 1995;30:59-67.
[PubMed] [DOI][Cited in This Article: ]
Gill G, Gebrekidan A, English P, Wile D, Tesfaye S. Diabetic complications and glycaemic control in remote North Africa.QJM. 2008;101:793-798.
[PubMed] [DOI][Cited in This Article: ]
Gill GV, Huddle KR, Monkoe G. Long-term (20 years) outcome and mortality of Type 1 diabetic patients in Soweto, South Africa.Diabet Med. 2005;22:1642-1646.
[PubMed] [DOI][Cited in This Article: ]
Janmohamed MN, Kalluvya SE, Mueller A, Kabangila R, Smart LR, Downs JA, Peck RN. Prevalence of chronic kidney disease in diabetic adult out-patients in Tanzania.BMC Nephrol. 2013;14:183.
[PubMed] [DOI][Cited in This Article: ]
Katchunga P, Hermans MP, Manwa B, Lepira F, Kashongwe Z, M’Buyamba-Kabangu JR. [Hypertension, insulin resistance and chronic kidney disease in type 2 diabetes patients from South Kivu, DR Congo].Nephrol Ther. 2010;6:520-525.
[PubMed] [DOI][Cited in This Article: ]
Keeton GR, Smit Rv, Bryer A. Renal outcome of type 2 diabetes in South Africa--a 12-year follow-up study.S Afr Med J. 2004;94:771-775.
[PubMed] [DOI][Cited in This Article: ]
Levitt NS, Bradshaw D, Zwarenstein MF, Bawa AA, Maphumolo S. Audit of public sector primary diabetes care in Cape Town, South Africa: high prevalence of complications, uncontrolled hyperglycaemia, and hypertension.Diabet Med. 1997;14:1073-1077.
[PubMed] [DOI][Cited in This Article: ]
Lutale JJ, Thordarson H, Abbas ZG, Vetvik K. Microalbuminuria among Type 1 and Type 2 diabetic patients of African origin in Dar Es Salaam, Tanzania.BMC Nephrol. 2007;8:2.
[PubMed] [DOI][Cited in This Article: ]
Majaliwa ES, Munubhi E, Ramaiya K, Mpembeni R, Sanyiwa A, Mohn A, Chiarelli F. Survey on acute and chronic complications in children and adolescents with type 1 diabetes at Muhimbili National Hospital in Dar es Salaam, Tanzania.Diabetes Care. 2007;30:2187-2192.
[PubMed] [DOI][Cited in This Article: ]
Makulo R, Nseka MN, Jadoul M, Mvitu M, Muyer MT, Kimenyembo W, Mandja M, Bieleli E, Mapatano MA, Epira FB. [Albuminuria during the screening for diabetes in a semi-rural area (Kisantu City, DR Congo)].Nephrol Ther. 2010;6:513-519.
[PubMed] [DOI][Cited in This Article: ]
Marshall SL, Edidin D, Sharma V, Ogle G, Arena VC, Orchard T. Current clinical status, glucose control, and complication rates of children and youth with type 1 diabetes in Rwanda.Pediatr Diabetes. 2013;14:217-226.
[PubMed] [DOI][Cited in This Article: ]
Motala AA, Pirie FJ, Gouws E, Amod A, Omar MA. Microvascular complications in South African patients with long-duration diabetes mellitus.S Afr Med J. 2001;91:987-992.
[PubMed] [DOI][Cited in This Article: ]
Nambuya AP, Otim MA, Whitehead H, Mulvany D, Kennedy R, Hadden DR. The presentation of newly-diagnosed diabetic patients in Uganda.QJM. 1996;89:705-711.
[PubMed] [DOI][Cited in This Article: ]
Pruijm MT, Madeleine G, Riesen WF, Burnier M, Bovet P. Prevalence of microalbuminuria in the general population of Seychelles and strong association with diabetes and hypertension independent of renal markers.J Hypertens. 2008;26:871-877.
[PubMed] [DOI][Cited in This Article: ]
Rahlenbeck SI, Gebre-Yohannes A. Prevalence and epidemiology of micro- and macroalbuminuria in Ethiopian diabetic patients.J Diabetes Complications. 1997;11:343-349.
[PubMed] [DOI][Cited in This Article: ]
Rasmussen JB, Thomsen JA, Rossing P, Parkinson S, Christensen DL, Bygbjerg IC. Diabetes mellitus, hypertension and albuminuria in rural Zambia: a hospital-based survey.Trop Med Int Health. 2013;18:1080-1084.
[PubMed] [DOI][Cited in This Article: ]
Rissassi JR, Nseka M, Jadoul M, Lepira FB, Mvitu M, Mbenza G, Yekoladio D, Aloni M, Nge OO. [Prevalence and determinants of microalbuminuria and macroalbuminuria in children and young adults with type 1 diabetes in Kinshasa].Nephrol Ther. 2010;6:40-46.
[PubMed] [DOI][Cited in This Article: ]
Rotchford AP, Rotchford KM. Diabetes in rural South Africa--an assessment of care and complications.S Afr Med J. 2002;92:536-541.
[PubMed] [DOI][Cited in This Article: ]
Sobngwi E, Mbanya JC, Moukouri EN, Ngu KB. Microalbuminuria and retinopathy in a diabetic population of Cameroon.Diabetes Res Clin Pract. 1999;44:191-196.
[PubMed] [DOI][Cited in This Article: ]
Wanjohi FW, Otieno FC, Ogola EN, Amayo EO. Nephropathy in patients with recently diagnosed type 2 diabetes mellitus in black Africans.East Afr Med J. 2002;79:399-404.
[PubMed] [DOI][Cited in This Article: ]
Worku D, Hamza L, Woldemichael K. Patterns of diabetic complications at jimma university specialized hospital, southwest ethiopia.Ethiop J Health Sci. 2010;20:33-39.
[PubMed] [DOI][Cited in This Article: ]
Stanifer JW, Jing B, Tolan S, Helmke N, Mukerjee R, Naicker S, Patel U. The epidemiology of chronic kidney disease in sub-Saharan Africa: a systematic review and meta-analysis.Lancet Glob Health. 2014;2:e174-e181.
[PubMed] [DOI][Cited in This Article: ]
Levin A, Stevens PE. Summary of KDIGO 2012 CKD Guideline: behind the scenes, need for guidance, and a framework for moving forward.Kidney Int. 2014;85:49-61.
[PubMed] [DOI][Cited in This Article: ]
Weil EJ, Curtis JM, Hanson RL, Knowler WC, Nelson RG. The impact of disadvantage on the development and progression of diabetic kidney disease.Clin Nephrol. 2010;74 Suppl 1:S32-S38.
[PubMed] [DOI][Cited in This Article: ]
Ruster C, Wolf G. The role of chemokines and chemokine receptors in diabetic nephropathy.Front Biosci. 2008;13:944-955.
[PubMed] [DOI][Cited in This Article: ]
Iwano M, Plieth D, Danoff TM, Xue C, Okada H, Neilson EG. Evidence that fibroblasts derive from epithelium during tissue fibrosis.J Clin Invest. 2002;110:341-350.
[PubMed] [DOI][Cited in This Article: ]
Seaquist ER, Goetz FC, Rich S, Barbosa J. Familial clustering of diabetic kidney disease. Evidence for genetic susceptibility to diabetic nephropathy.N Engl J Med. 1989;320:1161-1165.
[PubMed] [DOI][Cited in This Article: ]
Marre M, Jeunemaitre X, Gallois Y, Rodier M, Chatellier G, Sert C, Dusselier L, Kahal Z, Chaillous L, Halimi S. Contribution of genetic polymorphism in the renin-angiotensin system to the development of renal complications in insulin-dependent diabetes: Genetique de la Nephropathie Diabetique (GENEDIAB) study group.J Clin Invest. 1997;99:1585-1595.
[PubMed] [DOI][Cited in This Article: ]
Nelson RG, Morgenstern H, Bennett PH. Intrauterine diabetes exposure and the risk of renal disease in diabetic Pima Indians.Diabetes. 1998;47:1489-1493.
[PubMed] [DOI][Cited in This Article: ]
Zandi-Nejad K, Luyckx VA, Brenner BM. Adult hypertension and kidney disease: the role of fetal programming.Hypertension. 2006;47:502-508.
[PubMed] [DOI][Cited in This Article: ]
Brancati FL, Whittle JC, Whelton PK, Seidler AJ, Klag MJ. The excess incidence of diabetic end-stage renal disease among blacks. A population-based study of potential explanatory factors.JAMA. 1992;268:3079-3084.
[PubMed] [DOI][Cited in This Article: ]
Chaiken RL, Palmisano J, Norton ME, Banerji MA, Bard M, Sachimechi I, Behzadi H, Lebovitz HE. Interaction of hypertension and diabetes on renal function in black NIDDM subjects.Kidney Int. 1995;47:1697-1702.
[PubMed] [DOI][Cited in This Article: ]
