In View: Around the World
There is a growing burden of end-stage kidney disease (ESKD) in sub Saharan Africa, driven by a genetic predisposition to kidney disease and an increasing prevalence of hypertension and diabetes mellitus. It is estimated that 13.9% (95% confidence interval, 12.2-15.7) African Blacks have chronic kidney disease1 with a significant fraction progressing to ESKD, a harbinger of imminent death in Africa due to the scarcity and the lack of affordable dialysis. Kidney transplantation is the best treatment for ESKD, conferring superior survival, quality of life in addition to being more cost effective than dialysis.2 A recent systematic literature review in sub-Saharan Africa (excluding South Africa and Sudan) showed that only few adults (16 studies) and children (6 studies) received kidney transplants (1.1% and 2.5%, respectively).3 The report of The Transplantation Society meeting in 2013 emphasized the lack of kidney transplantation in sub-Saharan Africa.4
Ghana is a country in tropical West Africa with a population of 24.2 million (2010), and a life expectancy of 61.9 years (Figure 1). Ghana is a lower middle-income country with a Gross National Income per capita of US $1380. The country has a National Health Insurance Scheme that has been established in 2003, funded by a value added tax on goods and services, a portion of social security taxes, and individual premiums. The National Health Insurance Scheme, however, does not cover dialysis or organ transplants because these procedures are deemed to be too expensive. Costs of a kidney transplant have been estimated to be approximately ten thousand US dollars (fourteen thousand Ghana cedis) per recipient-donor pair (2008). The Ghana Kidney Association is currently working with the Ghana Health Service to build a more sustainable model of renal replacement therapy that is in part funded by the government.
Transplant Activities in Ghana
Live donor kidney transplantation is the only option for organ transplantation available in Ghana at this time. The kidney transplant program was started at Korle Bu Teaching Hospital, Accra in 2008, with support by the University Hospital in Birmingham, UK and Transplant Links Community (TLC), a UK-registered charity that supports the development of sustainable kidney transplant programs in developing countries through on-hands teaching and advice of volunteer medical and surgical specialists in transplantation.5
Prevalence of ESRD in Ghana
There are 13 dialysis centers in Ghana; of the estimated 4000 new ESKD cases seen annually, only 550 receive dialysis in the 13 units across the country. Between 2008 and 2014, 17 live donor renal transplants were carried out in Ghana. Critical steps for the implementation of a sustainable program included an ethical framework for organ donation, engagement with the hospital administration to ensure that logistical requirements were met in addition to a comprehensive donor and recipient workup and treatment protocols and the availability of affordable immunosuppressants. Ghana established a national registry for ESKD and kidney transplantation in 2015 in conjunction with the African Renal Registry.6
Barriers to Living/Deceased Donation and Recent Achievements
A recent survey in Accra, Ghana documented that approximately 50% of 480 participants were willing to proceed with a living donation; 70% considered donation after death to be acceptable.7 Most recipients of live donor kidney transplants in Ghana had at least 2 relatives coming forward to donate.
Clinical expertise in renal transplantation has been achieved through focused periods of surgical training at the Groote Schuur Hospital in Cape Town, South Africa; Ghanaian physicians have been trained at the University Hospital Birmingham, UK. 17 live donor transplants have been performed over a 6-year period. The mean duration of hemodialysis before transplantation was 23.3 months (range, 4-54 months); mean recipient age was 37.4 ± SD 11.3 years and mean donor age 40.9 ± SD 10.5 years. Sixteen of the seventeen recipients were male. Two patients received kidneys from their wives with the remaining recipients receiving kidneys from first degree relatives (4 parents, 7 siblings, 1 niece, and 3 aunts/uncles). There was 1 early graft loss (within 2 weeks due to poor perfusion) and another graft was lost in the second year because of noncompliance with treatment. One-year patient survival was 100% and graft survival was 91.7%; 5-year patient and graft survival were 72.9% and 64.3%, respectively. All donors continue to enjoy good renal function and continue to attend follow-up (Table 1).
Challenges and Solutions
- Initial lack of institutional support. Even though the plan to start a transplant program had long been written up, it took 5 years of ongoing engagement to obtain institutional support for the program to start.
- Lack of a legal framework for transplantation and a hospital policy on transplantation. In the absence of a National legal framework for transplantation, the Hospital and the Ministry of Health, decided to adapt the Istanbul Declaration on organ trafficking, transplant tourism and commercialism to ensure best practices and prevent transplant commercialization.8 A Transplant Ethics Committee was established to assess the transplantation process independently ensuring an altruistic motivation of donors while preventing organ trafficking. Members of the Transplant Ethics Committee include a MD, a priest, a lawyer, a clinical psychologist, and a Professor in Public Health. The Transplant Ethics Committee has been guided by the United Kingdom Human Tissue Act 2004.9 An additional committee was tasked to develop a National legal framework for organ transplantation which was presented to the Ministry of Health for onward submission to Parliament for legislation.
- Inadequate infrastructure. The absence of a local laboratory performing HLA tissue typing and cross matching has been a logistical challenge. The hospital therefore engaged the services of a private laboratory (MDS Lancet) that processed samples and sent them by courier to a laboratory in the United Kingdom. Immunosuppressive drug levels were processed in South Africa and results returned within 72 hours.
- Lack of local clinical expertise. The lack of a local surgeon with expertise in minimal-invasive surgery has been a major challenge particularly as our goal had been to reduce costs for the donor surgery. This challenge was overcome by TLC initially bringing in an entire transplant team from Birmingham including transplant surgeons, anesthetist, theatre, and transplant nurses. The continuing lack of an experienced local transplant surgeon has contributed to the slow growth of the transplantation program.
- Lack of clinical protocols. Clinical protocols from the University Hospital, Birmingham were adapted for local circumstances.
- Availability and costs for immunosuppressive agents locally. Using generic products including cyclosporine, tacrolimus and mycophenolate mofetil from India has helped in overcoming this issue.
- Economic constraints. Economic constraints in sub-Saharan Africa make transplantation a most challenging endeavor. However, our hospital overcame the financial barrier by hospital leadership engaging stakeholders including the Ministry of Health, National Health Insurance, and Ecobank among others in addition some nongovernmental organizations like the National Kidney Foundation (Ghana) and TLC UK. Recently the Ghana Health Service has embarked on developing a national framework for kidney transplantation.
- Sustainability. There have been no kidney transplants in Ghana during the last 2 years. Building kidney transplantation in low-income and low middle-income countries tends to be a stepwise process. Key personnel have been undergoing additional training abroad, and the long-term goal of establishing a kidney transplant program remains in sight.
The authors would like to thank the patients and their donors who made transplantation possible in Ghana and also acknowledge the support of Professor Nii Otu Nartey who was the CEO of Korle Bu Hospital at the time.
1. Stanifer JW, Jing B, Tolan S, et al. The epidemiology of chronic kidney disease in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Glob Health
2. Abecassis M, Bartlett ST, Collins AJ, et al. Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference. Clin J Am Soc Nephrol
3. Ashuntantang G, Osafo C, Olowu WA, et al. Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review. Lancet Glob Health
4. Muller E, White S, Delmonico F. Regional perspective: developing organ transplantation in sub-saharan Africa. Transplantation
5. Ready AR, Nath J, Milford DV, et al. Establishing sustainable kidney transplantation programs in developing world countries: a 10-year experience. Kidney Int
6. Davids MR, Eastwood JB, Selwood NH, et al. A renal registry for Africa: first steps. Clin Kidney J
7. Boima V, Ganu V, Dey D, et al. Kidney transplantation in Ghana: is the public ready? Clin Transplant
8. Do Istanbul. The Declaration of Istanbul on organ trafficking and transplant tourism. Transplantation