EDITORIAL: Renal Replacement Therapy and Kidney Transplantation: Addressing Gaps in Access and Outcomes

West Afr J Med. May 2025; 42(5): 337-338 PMID: 41046450

Abstract

Each new issue of the journal represents more than a collection of articles; it reflects the collective effort of a community committed to advancing health. In these pages, readers will find new perspectives on persistent challenges, evidence to guide better practice, and ideas that point toward future innovations. Such progress is only possible through the tireless work of our authors, whose scholarship we are privileged to share, and the discerning contributions of our reviewers, who help shape and improve every manuscript. We remain grateful for their dedication, which sustains the quality and credibility of this journal.

This issue presents contributions spanning medical and surgical disciplines. Kuku-Kuye et al., in a study in Lagos, Nigeria, reported that antepartum risk stratification significantly predicts obstetric interventions and adverse neonatal outcomes, reinforcing the importance of early risk identification and adherence to WHO antenatal guidelines. Bamikefa et al. demonstrated that histologic activity and chronicity indices in glomerulonephritis correlate strongly with renal function, emphasizing their prognostic utility and relevance for guiding management. In a qualitative study, Wuraola and co-workers examined the lived experiences of colorectal cancer patients with colostomies, identifying profound psychosocial and financial challenges and highlighting the need for comprehensive perioperative support, while Okwuonu et al. provided a report of their seven-year experience of kidney transplantation at a tertiary institution in South-east Nigeria. Collectively, these studies, alongside others featured in this edition, offer valuable evidence to inform clinical practice and policy, with direct implications for improving health outcomes in the region.

The burden of chronic kidney disease is increasingly becoming a major public health concern in developing countries, including the West African region.^1,2 The rising prevalence of hypertension, diabetes, chronic glomerulonephritis, and infectious diseases, coupled with limited preventive strategies and late presentation, has created a growing demand for renal replacement therapy (RRT), which includes dialysis and transplantation.^1-4 Yet, access to these life-saving interventions remains grossly inadequate due to a combination of various factors. These include economic, infrastructural, policy-related, and sociocultural barriers. Haemodialysis services are concentrated in major urban tertiary hospitals, leaving vast rural populations underserved. Even where dialysis is available, treatment is often inconsistent, with poorly maintained machines, unreliable water treatment systems, and frequent supply chain disruptions for essential consumables. The financial burden is overwhelming, as most patients pay out-of-pocket for each dialysis session. Many begin treatment but are unable to sustain it, leading to high early mortality.^3-5

Kidney transplantation has made some progress in West Africa, though on a limited scale. Nigeria, Ghana, and Senegal have documented successful kidney transplants. Despite these achievements, the number of procedures remains strikingly low.^5-7 Most West African programs still rely exclusively on living-related donors, as the absence of enabling legislation and organ-sharing networks has stalled the development of deceased donor programs. Moreover, the long-term sustainability of transplantation is threatened by the high cost and inconsistent availability of immunosuppressive therapy, which frequently results in graft failure even after technically successful procedures.^5-7

The obstacles to improved access are multifaceted. Chief among them is the overwhelming economic burden. With no structured government subsidies or comprehensive health insurance coverage for RRT, the majority of patients are unable to afford treatment. Policy gaps are equally glaring. Few countries in West Africa have enacted comprehensive transplant legislation, and there are no national organ registries or transparent allocation systems. This vacuum has left the region heavily dependent on living donation, while also exposing it to risks of commercial transplantation and transplant tourism, with all their ethical and equity-related implications.^5-7

The report by Okwuonu et al., published in this issue, detailing their seven-year experience with kidney transplantation, underscores both the prospects and persistent challenges in expanding access to renal replacement therapy. The retrospective review showed that 93 were evaluated, of whom 12 underwent transplantation, yielding a conversion rate of 13%. Financial constraints accounted for 40% of cases where transplantation could not be achieved. Among recipients, hypertension, hyperkalaemia, anaemia, and urinary tract infections were the most frequent acute complications, while cytomegalovirus infection, recurrence of native disease, chronic graft loss, and death were the key long-term adverse events.

The significance of the report is twofold. First, it demonstrates that with institutional commitment, strategic partnerships, and multidisciplinary collaboration, effective kidney transplantation services are feasible in our resource-limited environments. It also highlights the enduring barriers that must be addressed to transform such programs into large-scale, sustainable services. Chief among these barriers are financial access, with most patients unable to afford the cost of surgery and lifelong immunosuppression, and systemic challenges, including limited organ donor availability, inadequate supportive infrastructure, and the absence of comprehensive insurance coverage.

The way forward requires a deliberate and coordinated approach across multiple fronts. Governments must prioritize kidney disease within national non-communicable disease strategies, providing financial protection through subsidies and inclusion of RRT in health insurance schemes. Investments are urgently needed to expand dialysis services beyond tertiary centers, to establish functional peritoneal dialysis programs, and to strengthen transplant capacity. Training of nephrologists, surgeons, nurses, and allied health professionals should be scaled up, and regional collaboration in training and service delivery should be encouraged. Importantly, comprehensive legal and policy frameworks are required to enable ethical and transparent organ donation and transplantation, including the establishment of deceased donor programs and regional organ-sharing networks.

The recent introduction of a government-led subsidy program for dialysis in Nigeria, alongside the development of national guidelines for organ donation, are commendable milestones in the quest to improve renal care. However, their true impact will depend on sustained and effective implementation across the country. Importantly, such efforts should be scaled up and expanded to ensure wider coverage so that more patients can benefit equitably. Beyond dialysis, similar subsidies or insurance coverage mechanisms need to be extended to kidney transplantation, which remains the definitive therapy for end-stage kidney disease. Such policy expansion would not only improve survival and quality of life for patients but also reduce the long-term economic burden on families and the health system.

As this issue demonstrates, the challenges before us are significant, yet so too are the opportunities for innovation, collaboration, and progress. We hope that the insights shared here will inspire action-whether in research, clinical care, education, or policy-that ultimately advances health and well-being across our communities. We also encourage our readers, contributors, and partners to continue bringing forward rigorous scholarship and innovative ideas, so that together we can expand the frontiers of medical knowledge and strengthen healthcare for the future.

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