Kidney disease is a global health problem with a growing disease burden in both developed and undeveloped countries. The magnitude and the impact of kidney disease are unknown and will remain so if a concerted effort is not made to develop a national data collection system to acquire data on surveillance practices (screening and preventive care) and access to treatment. 

In South Africa, as in many countries in the world, poor socio-economic circumstances and cultural and political factors lead to significant disparities in the burden of disease and availability of care. A case in point, is the 2016 Report of the  South African Dialysis and Transplantation Registry, which found that of the 1 472 patients who started renal replacement therapy, 86% received treatment in the private sector and 14% in the public sector.

The drivers behind the growing kidney disease burden include adult essential hypertension, obesity and diabetes mellitus. Hypertension and cardiovascular disease are both recognised non-communicable diseases worldwide. However, chronic kidney disease is not, and neither is it given the attention needed at a national or international policy level.  The WHO Global Action Plan 2013-2020 for non-communicable diseases (NCDs) only briefly mentions chronic kidney disease (CKD). It fails to address the important interaction between CKD and other major NCDs, particularly hypertension, cardiovascular disease and diabetes mellitus. CKD is an major cause and consequence of these diseases. There is evidence suggesting that the coexistence of diabetes and CKD increases the risk of cardiovascular diseases, whereas overall mortality rates are tripled for diabetes patients who also have kidney disease.

Therefore we believe and strongly motivate that kidney disease should be included in our national NCD policy as one of the main NCDs to be dealt with in the imminent future.

Prevention strategies should begin with educational programmes of school children, including information on healthy lifestyles, increase in physical activity, less sedentary behaviours and dietary advice. Universal screening programmes to measure the blood pressure of all school children and young adults should be implemented along with the assessment of anthropometry. Preferably, urine dipsticks should also be used during the assessments.  There are, however, many constraints that should be addressed before these suggestions can be put into action.

According to guidelines, the correct measurement of blood pressure in children requires three blood pressure measurements at each health visit and then the average should be taken. Hypertension is defined as systolic and / or diastolic BP ³ 95th percentile for age, gender and height on three occasions.  These guidelines are not feasible in the South African health setting. It will require more health personnel, equipment for measurement of height and BP, and health personnel will need to be trained to use standard blood pressure percentile charts. The MRC Research group suggested that cut-off values be used for the screening. The aim of screening is to identify children with hypertension, particularly those with other positive risk factors, who can then be referred for further management and implementation of preventative measures.

The ultimate aim is to prevent the consequences of unidentified and untreated hypertension in children, in order to prevent the development of end-organ damage and an ever- increasing adult population with cardiovascular disease and CKD.

Since 2016, South African legislation has enforced a decrease in the maximum sodium content in a range of processed foods, with a further decrease becoming mandatory later this year (2019). Rapid urbanisation has led to a change in the lifestyle of the SA population, with many families eating unhealthy high-carbohydrate, high-fat foods with little fibre, coupled with a lack of exercise. The consequence is an increased prevalence of overweight and obese family members. In turn, these factors are the major drivers in the development of insulin resistance, diabetes and metabolic disease, all of which are linked to hypertension.

The NKF of SA, along with the entire nephrology community in SA, requests an increase in the investment in kidney disease.  A plea is made to the National Department of Health for a change in policies and intervention strategies. An integrated national NCD strategy should focus on prevention, early detection and the management of early stages of all relevant NCDs, including CKD. Failing to do so, translates into kidney disease being neglected, so that patients will only be identified once they have reached end-stage renal failure (ESRF).

Once a patient has ESRF, all opportunities for preventive care have been missed!

Prof Gertruida van Biljon is a Paediatric Nephrologist in Department of Paediatrics at University of Pretoria and the Steve Biko Academic Hospital