Advances in the management of chronic kidney disease – a South African perspective

Abstract

Chronic kidney disease (CKD) represents a significant public health problem globally, and there is evidence to suggest that the prevalence of CKD in sub-Saharan Africa is comparable to elsewhere. For many South African patients who progress to kidney failure (KF), life-sustaining kidney replacement therapy (KRT) is inaccessible due to strict rationing in a resource-limited public healthcare sector, upon which most South Africans are reliant. This shortage brings into focus the need for strategies for delaying CKD progression. This review aims to highlight significant developments in the management of CKD over the last few decades and to discuss these advances within a South African context. That is, to consider the profile of kidney disease locally and issues surrounding access to newer therapeutic agents. We summarise the mechanisms by which the newer therapeutic agents confer renal protection and the major trials supporting their efficacy. Notable advances include newer anti-diabetic agents such as sodium-glucose-transporter-2 (SGLT-2) inhibitors, endothelin-receptor antagonists (ERAs), and nonsteroidal mineralocorticoid antagonists (MRAs). In addition, experimental, targeted therapies in the setting of various glomerular diseases, polycystic kidney disease and APOL-1-mediated kidney disease are briefly discussed. We also highlight several locally relevant advances pertinent to patients on KRT, including newer therapies for managing anaemia in CKD and local experiences with ABO-incompatible kidney transplantation. Although many newer therapies for managing CKD have robust data supporting their use, many barriers exist to implementing them into daily clinical practice. Key messages Although there is a significant burden of CKD in South Africa many patients are unable to access life-sustaining kidney replacement therapy (KRT) due to the strict rationing of dialysis in a resource-limited public healthcare sector. Newer therapies such as sodium-glucose-transporter-2 (SGLT-2) inhibitors, non-steroidal mineralocorticoid receptor antagonists (MRAs) and endothelin receptor antagonists (ERAs) delay the progression of CKD, which is crucial in patients with CKD who may not be able to access KRT. It is therefore paramount that we address the barriers limiting access to these newer therapies.