Chronic Kidney Disease (CKD), with its asymptomatic early stages is a global “silent killer” (1). Structural and functional abnormalities of the kidney often remain undetected, and even when identified, are frequently unaddressed) (2). As a result, critical opportunities to prevent disease progression are often missed or deprioritised by both patients and the health systems on which they rely.

The silent nature of disease progression means that improvements in outcomes are inextricably linked to greater awareness and earlier detection. Pragmatically, these must be delivered through cost-effective interventions that can be implemented at the primary care level. Early identification of CKD creates opportunities to slow disease progression, reduce cardiovascular complications, and avert catastrophic health expenditure for individuals and health systems alike (1).

Silent Progression and Low Awareness - The Interconnected Reality

According to the Global Burden of Disease 2023 report, CKD is now the ninth leading cause of death worldwide, accounting for nearly 1.5 million deaths annually, and from a societal burden perspective, it is the 12^th leading cause of disability‑adjusted life years (DALYs) (3). Most mortality among people with CKD is driven by cardiovascular causes. Indeed, kidney dysfunction alone is estimated to contribute to almost 12% of all global cardiovascular deaths, underscoring the profound interrelatedness of cardiorenal‑metabolic conditions and the urgent need for holistic, integrated management approaches to improve health outcomes (3). At the same time, this presents an ideal opportunity to implement public health interventions that are greater than the sum of their parts.

Public attention around CKD is often focused on those receiving kidney replacement therapy, which represents only the tip of the iceberg. Globally,1.48 million deaths were attributed to CKD, while only approximately 2 million people were receiving dialysis or had a kidney transplant (3). This highlights that the majority of people with CKD die before reaching kidney replacement therapy, largely due to cardiovascular disease, acute kidney injury, and infectious causes. Even where access to dialysis theoretically exists through national health systems, multiple barriers limit uptake in practice, including distance to dialysis centres, the need for carers, and fatalism associated with the diagnosis.

Sub‑Saharan Africa (SSA) is undergoing a rapid epidemiological transition, with non‑communicable diseases (NCDs) accounting for an increasing share of mortality and projected to overtake communicable, maternal, neonatal, and nutritional diseases as the leading cause of death in the region (4). In Kenya, CKD is now the fourth leading cause of death and rising, preceded only by communicable diseases which are themselves declining (3). At the same time, data from the Ghana Renal Registry show that patients requiring kidney replacement therapy are relatively young, with a median age of 45.5 years, compared to 51.5 years in South Africa (5). Concerningly, this positions CKD as a disease affecting young, economically active individuals in Ghana, posing a significant public health challenge with implications for workforce productivity.

CKD screening, using relatively inexpensive blood and urine tests as a minimum, with significant potential for integrating of digital tools, is an effective approach for identifying individuals with established disease or at high risk of progression (6). However, population‑wide screening programmes are rarely sustainable, particularly in low‑resource settings (7). A more pragmatic approach lies in targeted, real‑world evidence (RWE)‑informed strategies to guide national kidney health priorities.

RWE plays a critical role not only in identifying priorities, but also in defining the appropriate approach. By answering fundamental questions - why, who, how, and when – it provides actionable insights into disease burden, risk profiles, local aetiologies, diagnostic and treatment pathways, and gaps in care. These insights enable the kidney health community, including policymakers and broader health‑system stakeholders, to align efforts around shared risk factors, prioritise high‑impact and equitable interventions, maximise the use of cost-saving technologies, and allocate resources more effectively to detect CKD earlier, slow progression, and improve long‑term outcomes.

The Case for Real-World Evidence in CKD

While hypertension and diabetes remain the principal causes of CKD in the region (8), evidence highlights additional drivers of CKD in SSA that must be considered as part of risk assessment, clinical guideline development, and health-economic evaluations.

Studies from Ghana and Nigeria demonstrate that individuals with high-risk APOL1 variants have a 25% higher risk of CKD-progression to kidney failure compared with non‑carriers (9). Additionally, prolonged exposure to harsh environmental conditions and hot climates, particularly in agricultural and manual labour settings as opposed to mechanised labour, has also been identified as a significant contributor to CKD (10).

Globally, overall CKD prevalence is similar in women and men (approximately 13%); however, higher prevalence of CKD stages 1 to 3 has been observed among women, while mortality is higher among men. This raises questions about the apparently faster progression to end-stage kidney disease (ESKD) in men (11). In contrast, women in low‑ and middle‑income countries (LMICs) often face a dual burden linked to pregnancy-associated risks. Pregnancy‑associated acute kidney injury accounts for approximately 10–25% of acute kidney injury among women of reproductive age in LMICs, with hypertensive disorders of pregnancy responsible for up to half of cases, and 20–40% of affected women subsequently developing chronic kidney disease (12). This dual burden further exacerbates socio-economic disparities in healthcare access and outcomes in SSA.

A significant proportion of patients in SSA are diagnosed with CKD at advanced stages, often as an incidental finding. In a retrospective study of 960 CKD patients attending a nephrology clinic in South Africa, 47.8% were referred with established CKD stage G4 or G5(13). Longitudinal studies in SSA also point to accelerated CKD progression. Evidence from the Ghana Renal Registry reports kidney failure occurring at a younger age (median of 45.5 years) compared with global CKD populations, suggesting faster disease progression (5). Similarly, a 2024 hospital-based study in Rwanda found that uncontrolled hypertension for more than 5 years increased the odds of CKD by 12‑ to 15‑fold (14).

Investing in early detection and prevention offers a clear opportunity to improve and sustain kidney health outcomes. Well-established community health systems can be leveraged, referral pathways optimised, electronic medical records integrated, and emerging technologies adopted. However, the paucity of CKD data in SSA, coupled with the heterogeneity of existing studies, limits meaningful generalisation across the region’s diverse CKD populations. Consequently, there is an urgent need to generate local RWE to inform the design and evaluation of interventions, using more accurate insights into risk‑factor patterns, disease trajectories, and health‑system barriers, and to inform health policy (16). Generating local real-world data offers valuable guidance for evidence-based policies, guidelines, and programmes tailored to local contexts and focused on CKD prevention.

Reducing Future Costs Through Early Intervention and Reduced CKD Progression

At the 78th World Health Assembly, the World Health Organization (WHO) adopted its first-ever resolution dedicated to kidney disease (17), positioning kidney health as a global public health priority. The resolution recognises World Kidney Day as a formal observance and calls for action on prevention, awareness, treatment access, and environmental risk reduction. For SSA, achieving these goals requires a more inclusive, multi-stakeholder engagement and a firm commitment to bridge the health inequity gap in CKD management.

The annual cost of haemodialysis - the most common form of kidney replacement therapy in SSA - is several times higher than the average patient’s annual income, with a median cost of USD 18,741, largely driven by direct medical expenses such as medications and laboratory investigations (18). The rising prevalence of CKD among younger individuals in SSA underscores the urgency of mitigating “missed opportunities” for early diagnosis, to prevent catastrophic health expenditure associated with late-stage disease and significant economic losses affecting the most productive segments of the population. A one-year delay in diagnosing early-stage CKD is associated with a 40% higher risk of progression to stage 4-5, a 63% higher risk of kidney failure, and nearly a 10% higher risk of major cardiovascular events (19).

At the same time, sustainable models of kidney care in SSA must address the dual challenges of financing chronic kidney disease management and reducing the environmental impact of kidney care services, while ensuring the delivery of high-quality, equitable care.

Encouraging progress is being made across SSA. Countries such as Rwanda (78.7%) and Ghana (58.2%) have achieved high levels of national health insurance coverage (20) and implemented significant policy reforms to sustainably finance kidney replacement therapy through schemes such as Mutuelle de Santé and MahamaCares (Ghana Medical Trust Fund), respectively. Kenya, one of the few LMICs offering a fully publicly funded chronic haemodialysis (15), has also recently enacted major policy reforms under the Social Health Authority (SHA), expanding coverage to include pre- and post-transplant care and immunosuppressive medications (21).

As countries around the world commemorate the 20th anniversary of World Kidney Day, we call on stakeholders in SSA - including governments, health systems, industry, and communities - to leverage actionable data, including disease registries and implementation research, to build a healthier, more equitable, and more sustainable future for kidney health in Africa.

I. CRM Patient Africa program- is a long-term initiative by Boehringer Ingelheim designed to prevent the onset or progression of chronic kidney disease (CKD) in Sub-Saharan Africa. It takes a holistic approach based on four interrelated modules 1) a Real-World Evidence study to assess medical needs of CRM patients, 2) a screenings and diagnostic intervention to enable better early detection of CKD, 3) tailored trainings of healthcare practitioners to improve awareness and capabilities, and 4) a program to address access challenges, to ensure medicines are available to those in need
II. Collaboration with IQVIA- alongside IQVIA, the aim is to strengthen existing local healthcare systems, by working with local partners, the public sector and communities, building on existing programs and infrastructure to improve access to qualitative healthcare for CRM patients

References

1. Future of Kidney Care in LMICs — PMC / NIH article.
2. CKD in Sub Saharan Africa — The Lancet Global Health
3. Global Burden of CKD 1990–2023 — The Lancet, GBD 2023 Study.
4. Public Health Impact of CKD in SSA — ScienceDirect article
5. The Ghana Renal Registry – a First Annual Report- Boima V. et al., African Journal of Nephrology (2021
6. KDIGO CKD Evaluation & Management Guidelines — Kidney Disease: Improving Global Outcomes (KDIGO).
7. Ethical Issues in Early Screening in Low Resource Settings — Yadla M. et al., Kidney International Reports (2024).
8. Yirga GK et al. Chronic kidney disease among hypertensive patients in sub‑Saharan Africa. BMC Public Health, 2025.
9. Genetic Variant Increasing Kidney Disease Risk in Africans — News report (genomics research finding).
10. CKD Burden from Air Pollution — Bowe B. et al., BMJ Global Health (2020).
11. Global Health Inequalities in CKD — Nephrology Dialysis Transplantation
12. Pregnancy Related AKI in LMICs — Tran P.N.T. et al., Bulletin of the WHO (2025).
13. CKD Epidemiology in Johannesburg — PLOS Global Public Health.
14. Ndatumuremyi J et al. African Journal of Biological Sciences, 2024.
15. Global Kidney Health Atlas — International Society of Nephrology (ISN).
16. Advances in CKD in Africa — Rayner B. et al., Applied Sciences (2023).
17. WHO Policy Brief on Reducing NCD Burden via Kidney Health — World Health Organization (2025).
18. Economic Costs of End Stage Renal Disease in Africa — Yakubu A. et al., BMC Nephrology (2025).
19. Kushner P et al. Early identification and management of chronic kidney disease. Advances in Therapy, 2024.
20. Health Insurance Inequality in SSA — Barasa E. et al., BMJ Global Health (2021).
21. Social Health Insurance Tariff Document — “Tariffs to the Benefit Package under the Social Health Insurance Act.”