Outcome of hemodialysis patients in one poorest country in the world: the Zinder experience.

Outcome of hemodialysis patients in one poorest country in the world: the Zinder experience. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Outcome of hemodialysis patients in one poorest country in the world: the Zinder experience. Hassane Moussa Diongolé, Djibril Ahmed Alatinine, Maman Bachir Goni dit Alassan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7566914/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Feb, 2026 Read the published version in BMC Nephrology → Version 1 posted 14 You are reading this latest preprint version Abstract Background/Objectives Chronic hemodialysis therapy is a well-recognized supportive therapy for patients with end-stage kidney disease. However, this therapy is poorly implemented in low-income countries due to its high cost. We herein report a single-center experience in one of the poorest countries in the world, i.e., Niger. Patients and methods: This is a cross-sectional study that included all incident patients presenting with serum creatinine greater than 1000 µmol/L (January 2018 to December 2022). They all agreed to be treated with self-funded chronic hemodialysis. Survival was evaluated as of December 2024. A total of 544 patients-initiated hemodialysis therapy. Among them, 423 (77.8%) underwent hemodialysis for less than 3 months: 240 (57%) died; 57 (13.5%) recovered renal function; and the others were lost to follow-up or decided to discontinue hemodialysis. Only 121 patients (22.2%) were able to embark on a chronic hemodialysis therapy program; most of them were males (sex ratio of 2.7). Their mean age was 48 years. Most (62%) were from rural areas. Additionally, 66% had low economic incomes, and 52% lived very far from our dialysis facility. Vascular access was predominantly a central venous catheter (75%). Non-adherence to hemodialysis was observed in 76% of patients. Dropouts and lost-to-follow-up occurred in 15.7% and 29% of cases, respectively. At the end of follow-up, only 10 patients (8.3%) were still alive. Conclusions These results question the utility of chronic hemodialysis in very low-income countries due to its high cost and significant mortality. Where possible, kidney transplantation abroad should be offered as supportive therapy as soon as it is known that there will be no renal recovery. patient survival Niger Zinder hemodialysis therapy withdrawal Figures Figure 1 1. Introduction Chronic kidney disease (CKD) is a significant global burden: recently, a study showed that, worldwide, the age-standardized incidence rate and age-standardized disability-adjusted life years rate are rising in almost all countries/regions, suggesting that the impact of CKD on global health is increasing. Indeed, population growth and aging are major factors contributing to the increasing burden of CKD, especially in China and low socio-demographic index regions ( 1 ). In Africa, CKD is a public health problem, mainly attributed to high-risk conditions such as hypertension, diabetes, and human immunodeficiency virus infection ( 2 ). Niger is one of the poorest countries in the world ( https://www.worldbank.org/niger ). We have already conducted a cross-sectional study over six months at the university hospital of Zinder (Niger); during that period, 497 patients were screened while hospitalized for reasons other than chronic kidney disease. We found 91 cases of CKD (stage 3 and below), representing a prevalence of 18.3% ( 3 ). We have also reported on 120 kidney biopsies performed in our center, essentially in young patients. The primary indication for kidney biopsy was glomerular syndrome in 62.5% of cases, including 50% with nephrotic syndrome. The most common findings were (i) glomerular diseases (58.4%) and (ii) tubulointerstitial changes (31.8%) ( 4 ). However, due to the lack of nephrologists in low-income countries—there is an 80-fold difference between low-income and high-income countries ( 5 )—and the fact that every patient with a kidney condition must self-pay for medications, very few are able to follow nephrologists' prescriptions, leading quite rapidly to end-stage kidney disease (ESKD). Additionally, when a patient presents with very high serum creatinine, it could be either an acute or a chronic condition ( 6 ); in such settings, renal ultrasound might help categorize the condition. Indeed, regarding acute kidney injury, approximately 85% of cases occur in low-resource settings where access to kidney replacement therapy may be limited or nonexistent ( 7 ). For those patients placed on chronic dialysis therapy in sub-Saharan countries, their median survival is poor, e.g., 345 days in a random survey across three hospitals in Ethiopia in 2021 ( 8 ), 17 months in Congo ( 9 ), and 46–47 months in longitudinal studies from Ethiopia ( 10 , 11 ). The aim of this prospective study was twofold: to determine i) patient outcomes within the 90 days after starting hemodialysis therapy, and ii) among those passing the 90-day mark, how many will survive in the long run. 2. Materials and Methods This is a single-center prospective study that took place between 01/01/2018 and 31/12/2022. We included all patients presenting with either acute kidney injury or end-stage kidney disease. Indeed, when the patients arrived at our center, they had high levels of serum creatinine (over 1000 µmol/L), but it was not possible to determine whether it was due to an acute kidney injury (AKI) or chronic kidney disease (CKD). However, every patient underwent a renal ultrasound examination to rule out obstructive nephropathy; in the majority of cases, renal size was diminished. Finally, because of reduced kidney size, none of them underwent a kidney biopsy. Therefore, in such a setting (very high levels of serum creatinine), we proposed hemodialysis as the renal replacement therapy, as we do not have a peritoneal dialysis program. Hemodialysis procedures were always initiated using a femoral venous catheter. Some patients who were started on chronic hemodialysis were offered the possibility of an arteriovenous fistula (self-funded procedure). We only included patients who accepted to undergo at least one session of hemodialysis. Hemodialysis sessions were scheduled according to the patient’s needs, i.e., symptoms of uremia and/or fluid overload. For those on chronic hemodialysis, we recommended two sessions of four hours twice a week; however, in many cases, patients attended their hemodialysis sessions only when they could afford to pay for them. All patients were followed up until 31/12/2024, or until death or lost-to-follow-up. We divided the patients into two categories: those who underwent less than 3 months of supportive therapy (i.e., hemodialysis), and those who were started on a chronic hemodialysis program, i.e., they did not recover from kidney failure, which was therefore assumed to be a chronic condition. We excluded patients who were subsequently transferred to another hemodialysis center. All patients provided informed written consent to publish their data; this was obtained when dialysis therapy was proposed as the only available option (see above). We collected the following variables: gender, age, cause of kidney injury/disease, level of education/diploma, social status, occupation, financial condition, residency (urban vs. rural), distance from home to our hemodialysis center, use of traditional medicines/herbs, past medical history including hypertension, diabetes, initial nephropathy (if a kidney biopsy had been performed), history of acute or chronic kidney disease, and previous surgery. Regarding hemodialysis parameters, we recorded hemoglobin levels at the start of the first hemodialysis session, type of vascular access, number of dialysis sessions per week, and adherence to dialysis therapy. When the patient was informed that dialysis therapy was required, a questionnaire was completed, which included the variables described above. Although we do not have electronic medical records for our patients, we used paper medical files to extract the data. We also established a dialysis registry, which includes the name, surname, and date of birth of patients referred to hemodialysis, even if therapy was never initiated. This registry also records the date of death, cause of death, and whether the patient decided to stop dialysis therapy or was lost to follow-up. The research was conducted in accordance with the Declaration of Helsinki. The study was submitted to local ethical committee and was approved: FSS_UASZ_Niger_No 011/06/05/2024. Finally, informed consent to participate was obtained from all of the participants in the study. 3. Statistical analysis A clinical nurse was trained to collect data. The data collector identified patient charts for the study using registry books from the dialysis unit and retrieved them from the medical records department. Patient medical records and dialysis charts were the sources of data collection. The data collection tools included socio-demographic characteristics (such as age, sex, and source of funds), patient clinical characteristics such as nausea and vomiting, shortness of breath, body swelling, oliguria, gross hematuria, hematuria, and blood pressure measurement), and laboratory features (such as serum creatinine, serum sodium, serum potassium, serum urea, hemoglobin, and proteinuria). Additionally, the indication for dialysis, the type of vascular access for HD initiation, the type of vascular access in patients on maintenance HD, frequency and duration of HD sessions, length of stay in the HD unit, and patient outcomes were recorded. Categorical variables were presented as frequencies and percentages, while continuous variables were described using median and ranges. 4. Results During the study period, 544 patients required dialysis therapy and underwent at least one hemodialysis session. Four hundred and twenty-three patients (77.8%) underwent hemodialysis for less than 3 months (cohort 1); the remaining patients (n = 121, i.e., 22.2%; cohort 2) were started on chronic hemodialysis (more than 3 months) (see flow chart, Fig. 1 ). Regarding cohort 1 (n = 423), 57 patients (13.5%) recovered (i.e., they had acute kidney injury and were discharged home). However, 240 patients (57%) died. Additionally, 60 patients (14.5%) decided to stop hemodialysis and returned home (no follow-up data), and 55 patients (13%) were lost to follow-up. We may assume that these 110 patients (27.5%) eventually died. We will now focus on those who underwent at least three months of dialysis therapy, i.e., cohort 2 (n = 121). Most of them were aged between 20 and 40 years (n = 45; 37.2%) and between 41 and 60 years (n = 50; 41.3%). There were 98 men (73.5%). Regarding their profession, most were farmers (n = 35; 29%), merchants/storekeepers (n = 27; 22.3%), or housewives (n = 27; 22.3%). Seventy-five patients (62%) lived in rural areas. Most of them had a low socio-economic status (n = 80; 66%). Ninety-five patients (78.5%) had no formal education. Most of the patients lived far (50 to 100 km; n = 33; 27.3%) or very far from the dialysis center (more than 100 km; n = 63; 52%), keeping in mind that in our region there are no asphalt roads. Regarding dietary habits, 56 patients (46.3%) were consuming herbal medicines and/or decoctions before dialysis therapy was initiated. Most patients (n = 99; 82%) did not follow the dietary counseling provided by the dietitian and nephrologist. Regarding past medical history, it was absent in 16 patients (13.2%), whereas hypertension, type 2 diabetes, and heart disease were present in 58 (48%), 14 (11.6%), and 12 (10%) patients, respectively. At the initiation of hemodialysis, hemoglobin levels were below 80 g/L in 63 patients (52%). Regarding patient outcomes, most of them, i.e., 80 (66%) have had less than 30 hemodialysis session (see Table 1 ). Fifty-seven patients (47%) died, 19 (15.7%) decided to stop hemodialysis therapy, 35 (29%) were lost to follow-up, and finally, 10 patients (8.3%) survived. Among the survivors (as of December 2024), 8 had started hemodialysis in 2019, one in 2021, and one in 2022. Table 1 Number of hemodialysis sessions per patient for those that were on hemodialysis therapy for more than 3 months Number of hemodialysis sessions Number of patients (n) Percentage (%) Less than < 30 80 66 [30–59] 25 20.7 [60 and above] 16 13.3 Regarding the 10 chronic hemodialysis patients who survived, 5 were aged 30 to 60 years old; 3 were above 60 and 2 were below 30. There were 7 males. All the patients were equipped with an arteriovenous fistula. Regarding their occupations there were 3 housewives; 1 farmer; the others were either state employees (n = 2) or merchants (n = 4). Regarding their social-economic level it was either average (n = 7) or high (n = 3); regarding their education level the 7 males had a very good level. Eight out of 10 patients were living nearby our hemodialysis facility. Finally, all the patients were adherent to dietetician counseling regarding water intake, potassium and restrictions. 5. Discussion Our single-center cross-sectional study, conducted over five years in one of the poorest countries in the world, has demonstrated that only a very small proportion of patients initiated on hemodialysis therapy survive in the long term—less than 10%. Throughout the study period, patients were required to self-fund both their hemodialysis sessions and all associated medications. Niger is among the world’s poorest nations ( https://www.aa.com.tr/fr/afrique/le-niger-l-un-des-pays-les-plus-pauvres-au-monde-face-aux-sanctions-%C3%A9conomiques/2961374 ). In 2022, the then-democratic government of Niger had launched an ambitious Sanitary and Social Development Plan (2022–2026). However, this initiative was abruptly halted by a military coup in 2023, which dismantled democratic governance and nullified all prior reforms—an event that has been catastrophic for the country's population. The Human Development Index of Niger in 2023 was 0.419, placing it 189th out of 193 countries. Furthermore, more than half of the population lives on less than USD 2.15 per day ( https://www.theglobaleconomy.com/Niger/human_development/ ). In such an economic context, the sustainability and relevance of allocating state resources to the management of chronic conditions such as end-stage kidney disease (ESKD), particularly for the reimbursement of costly therapies like hemodialysis, is a pressing concern. South Africa provides an illustrative example of a more pragmatic health policy regarding ESKD. There, patients presenting with significantly elevated serum creatinine levels (whether due to AKI or ESKD) are granted a one-month period of supportive dialysis therapy. If recovery does not occur within that timeframe, only patients eligible for kidney transplantation or with private health insurance are maintained on dialysis. Others are transitioned to conservative management ( 12 ). In South Africa, a country of approximately 60 million inhabitants, 822 new patients commenced kidney replacement therapy in 2022, an incidence of 13.3 per mil-lion population (pmp). Most of these patients (77%) were treated in private centers. By December 2022, 9,342 patients were undergoing chronic dialysis or had been trans-planted, resulting in an overall prevalence of 151 pmp. However, this prevalence was starkly divided between the private sector (771 pmp) and the public sector (45 pmp), reflecting major inequities ( 12 ). Conversely, in Morocco, the prevalence of dialysis patients reaches 1066.9 pmp, with hemodialysis fully covered by the national healthcare system as of 2025 ( 13 ). South Africa has opted to prioritize other chronic diseases with a broader public health impact, such as HIV and tuberculosis ( 14 ). In contrast, many African countries lack mid- or long-term health policies addressing the sustainability of maintaining large numbers of chronic hemodialysis patients, especially given the near absence of kidney transplantation programs across the continent. Tannor et al. have highlighted the situation in Ghana, where, despite the first hemodialysis session being performed over 50 years ago, there remain glaring inequities in the distribution of dialysis centers. Ghana faces a low dialysis prevalence and a nephrology workforce of only 0.44 nephrologists per million population, despite a high burden of CKD. Moreover, the prohibitive cost of dialysis (approximately USD 53.9 ± 8.8 per session) is predominantly paid out-of-pocket, severely limiting its accessibility ( 15 ). In Morocco, a country of 38.4 million people, nearly 41,000 patients are on hemodialysis, with treatment fully covered by the state. However, kidney transplantation remains underdeveloped, with fewer than 50 transplants performed annually, a policy that is unsustainable in both the short and long term. The late presentation of CKD patients in emergency departments, already at the ESKD stage, is a common phenomenon in low-income countries. This is largely due to a lack of nephrologists and the absence of CKD screening programs. In some cases, however, patients with severe renal dysfunction may have acute kidney injury (AKI) rather than chronic disease. Randrianarisoa et al. ( 6 ) from Madagascar reported that, among 124 emergency hemodialysis patients, 82.7% had ESKD while 17.3% had AKI and eventually recovered. Our own findings mirror this, with 13.5% of our patients recovering renal function after dialysis initiation. Conversely, Tafese et al. in Ethiopia reported an AKI recovery rate of 31% among emergency dialysis patients ( 16 ). Despite variations, these studies collectively underscore that in low-resource settings, the majority of patients initiating emergency dialysis are in fact suffering from ESKD. In sub-Saharan Africa, hypertension and diabetes mellitus are the leading causes of progression to ESKD ( 11 , 17 ). Tafese et al. reported hypertension (40.4%), chronic glomerulonephritis (27.7%), and diabetes (14.9%) as the primary etiologies of CKD ( 16 ). Our own cohort reflected a similar distribution, with most patients presenting with hypertension or diabetes. The self-funded nature of hemodialysis in many African countries inevitably leads to suboptimal dialysis quality, poor adherence, and high treatment abandonment rates. Halle et al. reported a non-adherence rate of 21.2% in a cohort of chronic hemodialysis patients over a two-month period, with only one patient (0.6%) having health insurance ( 18 ). In our cohort, non-adherence was observed in 44.7% of chronic hemodialysis patients: 15.7% voluntarily discontinued therapy, and 29% were lost to follow-up. Notably, in 23% of low-income countries, ESKD patients are required to pay more than 75% of dialysis costs, compared to only 4% in high-income nations ( 19 ). Until January 2025, all dialysis-related expenses in Niger—including arteriovenous fistula creation—were self-funded, significantly impacting patient adherence. The recent implementation of government-funded hemodialysis may help mitigate this issue. Another critical factor influencing adherence is the health-related quality of life (HRQL) of dialysis patients. Mathew et al. in South Africa found that hemodialysis patients reported higher anxiety and depression scores compared to those managed conservatively, alongside poorer physical and emotional well-being ( 20 ). Bagasha et al. in Uganda reported that 94.3% of ESKD patients scored below 50 (out of 100) on HRQL assessments, with no significant differences between dialysis and conservative management groups ( 21 ). Teuwafeu et al. in Cameroon reported that among 434 patients, 76.2% had HRQL scores below 50. Furthermore, school dropout rates, unemployment, and social isolation were prevalent after initiating dialysis ( 22 ). Similarly, Gebrie et al. in Ethiopia highlighted overwhelmingly negative narratives among chronic dialysis patients regarding their lived experiences ( 23 ). Given the poor quality of life and high mortality associated with chronic dialysis in low-income countries, the relevance of maintaining patients on long-term dialysis programs must be questioned. In Congo, Mokoli et al. reported a median survival of 17 months in a cohort of 250 chronic dialysis patients, with financial constraints leading to therapy withdrawal in 18.4% of cases ( 9 ). Workie et al. in Ethiopia reported a median survival of 345 days among 436 dialysis patients, with key mortality predictors including rural residence, hypertension-related ESKD, HIV infection, and use of central venous catheters ( 8 ). Two longitudinal Ethiopian studies reported survival durations of 46–47 months ( 10 , 11 ). In our series, only 10 out of 121 patients (8.3%) survived beyond three months of dialysis, all of whom had arteriovenous fistulas. Numerous studies have underscored that the type of vascular access significantly impacts survival. Catheter use is consistently associated with higher mortality rates compared to arteriovenous fistulas. Tafese et al. noted that in their Ethiopian cohort, nearly all CKD and AKI patients required emergency catheter-based access, whereas 94.3% of maintenance dialysis patients utilized AV fistulas ( 16 ). Given the high mortality of chronic dialysis patients in sub-Saharan Africa, kidney transplantation emerges as a more viable option. However, very few countries in the region have established sustainable transplant programs ( 24 , 25 , 26 ). Functional transplant programs are primarily found in North Africa ( 26 ), Nigeria ( 27 ), South Africa ( 28 ), and Egypt ( 29 ). In Cameroon, where living-donor transplantation has recently been implemented, Njamnshi et al. estimated that annual dialysis costs per patient are 12 times the national average income. By contrast, transplantation, especially when supported by generic immunosuppressive drugs, could reduce long-term follow-up costs by 89% ( 30 ). In Niger, no transplant program exists yet. However, in a cohort of 25 patients who underwent living-donor transplantation abroad, we report-ed a 5-year patient survival rate of 84%, a graft survival rate of 56%, and a death-censored graft survival rate of 67% ( 31 )—outcomes inferior to Western standards but considerably better than the 8.3% survival observed in our chronic dialysis cohort. The nephrology workforce in Africa remains critically insufficient, as highlighted by multiple surveys ( 15 , 19 , 32 ). The number of nephrologists per million population ranges from 1 pmp in South Africa to 40 pmp in Japan, with Senegal (2 pmp), Mexico (4 pmp), and Ukraine (9 pmp) also demonstrating severe shortages ( 32 ). In summary, low-income countries face a dual challenge: an insufficient number of nephrologists, largely confined to urban centers, and a lack of structured prevention strategies. Consequently, CKD patients are often diagnosed only at the terminal stage, when dialysis initiation becomes urgent and unavoidable, thereby precluding opportunities for early intervention, optimal vascular access planning, or timely evaluation for transplantation. 6. Conclusions Our study demonstrates that in a very low-income country, the vast majority of patients who commence self-funded hemodialysis in emergency settings are already at the stage of end-stage kidney disease. Slightly more than one in five patients will reach 90 days after initiating hemodialysis. Among those who continue beyond this thresh-old, fewer than 10% will achieve long-term survival, with the remainder either succumbing while on dialysis or discontinuing therapy due to financial constraints. These findings challenge the relevance and sustainability of chronic hemodialysis programs in extremely resource-limited settings, given the prohibitive costs and high mortality rates associated with this therapy. Where feasible, kidney transplantation should be prioritized as an alternative supportive strategy and offered promptly once it becomes evident that renal recovery is unlikely. Abbreviations The following abbreviations are used in this manuscript: AKI: Acute Kidney Injury CKD: Chronic Kidney Disease ESKD: End Stage Kidney Disease ACEI: Angiotensin Converting Enzyme Inhibitor HRQL: Health Related Quality of Life HIV: Human immunodeficiency virus HD: Hemodialysis AV fistula: Arteriovenous fistula Declarations Ethics approval and consent to participate: informed consent to participate was obtained from all of the participants in the study. FSS_UASZ_Niger_No 011/06/05/2024. The research was conducted in accordance with the Declaration of Helsinki Consent for publication: As hemodialysis therapy is a live-saving procedure we just informed the patient that hemodialysis procedure was needed. Availability of data and materials: provided reasonable demand. Any demand should be made to the corresponding author Pr Lionel Rostaing. Competing interests: None. Funding: None. Authors’ Contributions: Conceptualization, HMD, MBGDA, LR.; methodology; MBGDA.; software, MBGDA; validation, LR.; formal analysis, DAA, CL, AZH; investigation, DAA; resources, HMD; data curation, MBGDA; writing—original draft preparation, DAA, HMD; writing—review and editing, DB, LR; visualization, CL, AZH.; supervision, HMD; project administration, CL, AZH; funding acquisition, HMD. All authors have read and agreed to the published version of the manuscript. Institutional Review Board Statement: Research authorization was granted by the dean of University Salifou of Zinder (Niger) on December 5th, 2024. The approval letter is enclosed with the manuscript. Acknowledgments: none. References Guo J, Jiao W, Xia S, Xiang X, Zhang Y, Ge X, Sun Q. The global, regional, and national patterns of change in the burden of chronic kidney disease from 1990 to 2021. BMC Nephrol. 2025;26(1):136. 10.1186/s12882-025-04028-z . Abd ElHafeez S, Bolignano D, D'Arrigo G, Dounousi E, Tripepi G, Zoccali C. Prevalence and burden of chronic kidney disease among the general population and high-risk groups in Africa: a systematic review. BMJ Open. 2018;8(1):e015069. 10.1136/bmjopen-2016-015069 . Diongole H, Laouel HM, Magagi A, Garba AA, Tondi ZMM, Chaibou L, Waziri SB, Abdoulmadjid AI, Rostaing L. Screening of Chronic Kidney Diseases in Patients Hospitalized for Surgery at the National Hospital of Zinder in Niger. Liaquat Natl J Prim Care. 2025;7(2):140–5. 10.37184/lnjpc.2707-3521.7.39 . Diongolé HM, Tondi ZMM, Garba A, Ganiou K, Chaibou L, Bonkano D, Aboubacar I, Seribah AA, Abdoulaye Idrissa AM, Atanda A, Rostaing L. Implementation of Kidney Biopsy in One of the Poorest Countries in the World: Experience from Zinder Hospital (Niger). J Clin Med. 2024;13(3):664. 10.3390/jcm13030664 . Bello AK, Okpechi IG, Levin A, Ye F, Damster S, Arruebo S, Donner JA, Caskey FJ, Cho Y, Davids MR, Davison SN, Htay H, Jha V, Lalji R, Malik C, Nangaku M, See E, Sozio SM, Tonelli M, Wainstein M, Yeung EK, Johnson DW, ISN-GKHA Group. An update on the global disparities in kidney disease burden and care across world countries and regions. ISN-GKHA Group. Lancet Glob Healt. 2024;12(3):e382–95. 10.1016/S2214-109X(23)00570-3 . Randrianarisoa RMF, Mikkelsen Ranivoharisoa E, Randrianarisoa A, Ramilitiana B, Randriamarotia WFH. Emergency hemo-dialysis in the Joseph Raseta Befelatanana hospital, Antananarivo, Madagascar. Nephrol Ther. 2023;19(1):59–65. 10.1684/ndt.2023.5 . Cullis B, Calice da Silva V, McCulloch M, Ulasi I, Wijewickrama E, Iyengar A. Access to Dialysis for Acute Kidney Injury in Low-Resource Settings. Semin Nephrol. 2022;42(5):151313. 10.1016/j.semnephrol.2023.151313 . Workie SG, Zewale TA, Wassie GT, Belew MA, Abeje ED. Survival and predictors of mortality among chronic kidney disease patients on hemodialysis in Amhara region, Ethiopia, 2021. BMC Nephrol. 2022;23(1):193. 10.1186/s12882-022-02825-4 . Mokoli VM, Sumaili EK, Lepira FB, Makulo JR, Bukabau JB, Osa Izeidi PP, Luse JL, Mukendi SK, Mashinda DK, Nseka NM. Impact of residual urine volume decline on the sur-vival of chronic hemodialysis patients in Kinshasa. BMC Nephrol. 2016;17(1):182. 10.1186/s12882-016-0401-9 . Desta BZ, Dadi AF, Derseh BT. Mortality in hemodialysis patients in Ethiopia: a retrospective follow-up study in three centers. BMC Nephrol. 2023;24(1):3. 10.1186/s12882-022-03053-6 . Tesfaye AH, Birhanu A, Kolola T, Hamza L, Etana D. Time to death and its predictors among patients with chronic kidney disease on hemodialysis at dialysis unit in Addis Ababa, Ethiopia: a retrospective cohort study. BMC Nephrol. 2024;25(1):279. 10.1186/s12882-024-03719-3 . Davids MR, Marais N, Sebastian S, Jardine T, Chothia MY, Jacobs JC. South African Renal Registry Annual Report 2022. Afr J Nephrol. 2024; 27: 58–69. https://doi.org/10.21804/27-1-6749 https://www.cnops.org.ma Galvin M, Evans D, Moolla A, Coetzee L, Maluleke V, Leshabana P, Miot J. Adopting sustainable innovations for remote access to TB and HIV care in South Africa. PLOS Glob Public Health. 2024;4(10):e0003792. 10.1371/journal.pgph.0003792 . Tannor EK, Hutton-Mensah K, Opare-Addo P, Agyei MK, Gyan KF, Inusah AJ, Nyann BI, Amo-Antwi K, Luyckx V, Okpechi I. Fifty years of hemodialysis in Ghana—current status, utilization and cost of dialysis service. MC Health Serv Res. 2023;23(1):1170. 10.1186/s12913-023-10154-x . Tafese ST, Abera EG, Mersha MD, Woldemariam MB. Clinical characteristics and outcomes of patients on haemodialysis at Jimma medical center, Ethiopia: a 7-Year review. BMC Nephrol. 2024;25(1):420. 10.1186/s12882-024-03860-z . Rage HI, Ers SA, Kahin AY, Elmi MM, Mohamed AA, Kumar Jha P. Causes of kidney failure among patients un-der-going maintenance hemodialysis in Somalia: a multi-center study. BMC Nephrol. 2023;24(1):347. 10.1186/s12882-023-03402-z . Halle MP, Nelson M, Kaze FF, Jean Pierre NM, Denis T, Fouda H, Ashuntantang EG. Non-adherence to hemodialysis regimens among patients on maintenance hemodialysis in sub-Saharan Africa: an example from Cameroon. Ren Fail. 2020;42(1):1022–8. 10.1080/0886022X.2020.1826965 . Htay H, Bello AK, Levin A, Lunney M, Osman MA, Ye F, Ashuntantang GE, Bellorin-Font E, Gharbi MB, Davison SN, Ghnaimat M, Harden P, Jha V, Kalantar-Zadeh K, Kerr PG, Klarenbach S, Kovesdy CP, Luyckx VA, Neuen B, O'Donoghue D, Ossareh S, Perl J, Rashid HU, Rondeau E, See EJ, Saad S, Sola L, Tchokhonelidze I, Tesar V, Tungsanga K, Kazancioglu RT, Wang Y-M, Yang A, Zemchenkov CW, Zhao A, Jager MH, Caskey KJ, Perkovic FJ, Jindal V, Okpechi KK, Tonelli IG, Harris M, Johnson DC. Hemodialysis Use and Practice Patterns: An International Survey Study. Am J Kidney Dis. 2021;77(3):326–e3351. 10.1053/j.ajkd.2020.05.030 . Mathew N, Davies M, Kaldine F, Cassimjee Z. Comparison of quality of life in patients with advanced chronic kidney disease undergoing haemodialysis, peritoneal dialysis and conservative management in Johannesburg, South Africa: a cross-sectional, descriptive study. BMC Psychol. 2023;11(1):151. 10.1186/s40359-023-01196-1 . Bagasha P, Namukwaya E, Leng M, Kalyesubula R, Mutebi E, Naitala R, Katabira E, Petrova M. Comparison of the health-related quality of life of end stage kidney disease patients on hemodialysis and non-hemodialysis management in Uganda. BMC Palliat Care. 2021;20(1):52. 10.1186/s12904-021-00743-0 . Teuwafeu DG, Sehbing M, Halle MP, Mahamat M, Fouda H, Ashuntantang G. Quality of life and social reinsertion of patients on maintenance haemodialysis in four government funded hospitals in Cameroon. BMC Nephrol. 2024;25(1):335. 10.1186/s12882-024-03778-6 . Gebrie MH, Asfaw HM, Bilchut WH, Lindgren H, Wettergren L. Patients’ experience of undergoing maintenance hemodialysis. An interview study from Ethiopia. PLoS ONE. 2023;18(5):e0284422. doi.org/10.1371/journal.pone.0284422 . Bamgboye EL. Kidney Transplantation in Sub-Saharan Africa: History and Current Status. Kidney360. 2023; 4(12): 1772–5. 10.34067/KID.0000000000000293 Davis SO, Zubair A, Igbokwe M, Abu M, Chiedozie CA, Sanni Q, Jesuyajolu D. A Scoping Review of Kidney Transplantation in Africa: How Far have We Come ? World J Surg. 2023;47(9):2113–23. 10.1007/s00268-023-07042-0 . Hafez MH. Global Perspective: Kidney Transplantation in North Africa. Kidney 360. 2024;5(9):1370–3. 10.34067/KID.0000000000000497 . Popoola AA, Olanrewaju TO, Bolaji BO, Ajiboye TO. Expanding renal transplantation organ donor pool in Nigeria. Saudi J Kidney Dis Transpl. 2018;29(5):1181–7. 10.4103/1319-2442.243946 . Moosa MR, Afr Med J. 2019; 109(4): 235–40. 10.7196/SAMJ.2019.v109i4.13548 Farag YMK, Elsayed E. Global Perspective on Kidney Transplantation in Egypt. Kidney360. 2025. 10.34067/KID.0000000891 Njamnshi RK, Maimouna M, Ngarka L, Tomta AEN, Njamnshi WY, Ashuntantang GE, Djientcheu VPN, Njamnshi AK, Shepard DS. A retrospective cohort study on the cost-effectiveness analysis of kidney transplantation compared to dialysis in Cameroon: evidence for policy. Pan Afr Med J. 2023;46:27. 10.11604/pamj.2023.46.27.38706 . Bonkano D, Tondi ZMM, Diongolé HM, Illiassou A, Abdou I, Isaac OM, Mohamadou BR, Massi AWI, Omar AE, Rostaing L. Status Report of Renal Transplant Patients in Niger. Transplant Proc. 2023; 55(2): 332–336. 10.1016/j.transproceed.2023.01.009 Freedberg DE, Segall L, Liu B, Jacobson JS, Mohan S, George V, Kumar R, Neugut AI, Radhakrishnan J. International Variability in the Epidemiology, Management, and Outcomes of CKD and ESKD: A Systematic Review. Kidney 360. 2024; 5(1): 22–32, 2024. https://doi.org/10.34067/KID.0000000000000335 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Feb, 2026 Read the published version in BMC Nephrology → Version 1 posted Editorial decision: Revision requested 16 Nov, 2025 Reviews received at journal 15 Nov, 2025 Reviews received at journal 12 Nov, 2025 Reviewers agreed at journal 06 Nov, 2025 Reviewers agreed at journal 03 Nov, 2025 Reviews received at journal 02 Nov, 2025 Reviews received at journal 18 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers invited by journal 06 Oct, 2025 Editor assigned by journal 06 Oct, 2025 Editor invited by journal 06 Oct, 2025 Submission checks completed at journal 29 Sep, 2025 First submitted to journal 29 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7566914","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":530795568,"identity":"79e031ca-1ed7-41a1-88a1-3320f358f9d6","order_by":0,"name":"Hassane Moussa Diongolé","email":"","orcid":"","institution":"Université André Salifou","correspondingAuthor":false,"prefix":"","firstName":"Hassane","middleName":"Moussa","lastName":"Diongolé","suffix":""},{"id":530795569,"identity":"97fdf77b-46bb-4d66-ac00-62389a1ba3e5","order_by":1,"name":"Djibril Ahmed Alatinine","email":"","orcid":"","institution":"Hôpital National de Zinder","correspondingAuthor":false,"prefix":"","firstName":"Djibril","middleName":"Ahmed","lastName":"Alatinine","suffix":""},{"id":530795572,"identity":"2f52799a-1978-4eb8-9982-075aee4999e3","order_by":2,"name":"Maman Bachir Goni dit Alassan","email":"","orcid":"","institution":"Université André Salifou","correspondingAuthor":false,"prefix":"","firstName":"Maman","middleName":"Bachir Goni dit","lastName":"Alassan","suffix":""},{"id":530795574,"identity":"d6f8f44b-f178-4ff8-b305-62458a131d8e","order_by":3,"name":"Chaibou Laouali","email":"","orcid":"","institution":"Hôpital National de Zinder","correspondingAuthor":false,"prefix":"","firstName":"Chaibou","middleName":"","lastName":"Laouali","suffix":""},{"id":530795576,"identity":"a37096b2-732d-4e1d-ba73-2530497baafd","order_by":4,"name":"Djibrilla Bonkano","email":"","orcid":"","institution":"Amirou Boubacar Hospital","correspondingAuthor":false,"prefix":"","firstName":"Djibrilla","middleName":"","lastName":"Bonkano","suffix":""},{"id":530795578,"identity":"6a45085d-9bf2-4530-ae8a-8ca690c7b04d","order_by":5,"name":"Assoumane Zabeirou Hanahi","email":"","orcid":"","institution":"Hôpital National de Zinder","correspondingAuthor":false,"prefix":"","firstName":"Assoumane","middleName":"Zabeirou","lastName":"Hanahi","suffix":""},{"id":530795579,"identity":"eb0b5d91-33b0-4bcb-84c0-c1bfa326a5aa","order_by":6,"name":"Lionel Rostaing","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIie3PsUrDQBzH8R8I5/K3Wf8lQl/hpJAqCD6HW4JwLkUHlw4xBIS6OVss9BX0DU4C51L3gkug0MkhIHQMNpGWLpc6Ct53+XPHfbg7wOX6g7V+BgP7qVhvCuSAZyP1MV0R0lskBNppM6kuCn9L/Cz7KuLjq875fDEn3F57/p3JwwG4ZzGipRRrwzdHH6rXJbydjMbmUoZT8KG2EKIAWnD08tQX/kFppJz1A46GSNj2MKJuocsVGU2FTzDyrCYluIFIfh1yNGGqSCwlVyRtIkLx+wNHz6SC9hha8kyt/mLYSjzay4rBMokm99mCP5FI7/HC5EV8aiWbpK5Htl7vBEAnrUey+6TL5XL9u74BgABPY8vsvaoAAAAASUVORK5CYII=","orcid":"","institution":"CHU Grenoble-Alpes","correspondingAuthor":true,"prefix":"","firstName":"Lionel","middleName":"","lastName":"Rostaing","suffix":""}],"badges":[],"createdAt":"2025-09-08 18:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7566914/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7566914/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-026-04804-5","type":"published","date":"2026-02-05T15:59:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":93778866,"identity":"3f3a4859-8680-434a-b696-bd4758f5b886","added_by":"auto","created_at":"2025-10-17 12:49:43","extension":"jpg","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83034,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/df90ee2eccadb2db1e70cf99.jpg"},{"id":93777532,"identity":"6518414e-cae8-48c1-85b1-578473401c35","added_by":"auto","created_at":"2025-10-17 12:41:43","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":31232,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.doc","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/8128423d330dcd91a94759bf.doc"},{"id":93777533,"identity":"5ca89876-1aed-4b8d-85a0-53cf170c4f35","added_by":"auto","created_at":"2025-10-17 12:41:43","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":39425,"visible":true,"origin":"","legend":"","description":"","filename":"HemodialysissurvivalinNigerBMCNephrolv5.docx","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/cc672c51119a5e961bf26738.docx"},{"id":93778867,"identity":"12562599-6850-42cd-b0c3-ec062764fc86","added_by":"auto","created_at":"2025-10-17 12:49:43","extension":"json","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8487,"visible":true,"origin":"","legend":"","description":"","filename":"0657ca5382994a42b0b7a826a5138379.json","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/e0b9a8097f9d71040d37edb2.json"},{"id":93777539,"identity":"a5d11ad3-d6c2-4fbe-96f0-5689d7262faa","added_by":"auto","created_at":"2025-10-17 12:41:43","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":100049,"visible":true,"origin":"","legend":"","description":"","filename":"0657ca5382994a42b0b7a826a51383791enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/1ab4e4a5ed64fee4bc1ab659.xml"},{"id":93777538,"identity":"eba31fda-9088-407f-a88c-94bad32ad1e7","added_by":"auto","created_at":"2025-10-17 12:41:43","extension":"jpg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83034,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/6615dd9b5ff5483b049969aa.jpg"},{"id":93777535,"identity":"fc9e3274-f072-4f6c-b311-d7387ddfcfd3","added_by":"auto","created_at":"2025-10-17 12:41:43","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":24651,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/fc9d65b40039b05e01e39e9d.png"},{"id":93777536,"identity":"b55f3aee-93ac-42c2-94e9-b3fb7086fee4","added_by":"auto","created_at":"2025-10-17 12:41:43","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98652,"visible":true,"origin":"","legend":"","description":"","filename":"0657ca5382994a42b0b7a826a51383791structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/d70d2eb87bf2fddf31bf8758.xml"},{"id":93778868,"identity":"47a68100-9128-403f-8c10-f6a917aea119","added_by":"auto","created_at":"2025-10-17 12:49:43","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":107992,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/a55e4beab4049f9429653275.html"},{"id":93777530,"identity":"b920593f-1934-4d34-be98-83e1045b1222","added_by":"auto","created_at":"2025-10-17 12:41:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83034,"visible":true,"origin":"","legend":"\u003cp\u003eFlow-chart of patients presenting with serum creatinine \u0026gt;1000 µmol/L\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/e18ee0fe3351cbcc3d0ed7b1.jpg"},{"id":102234358,"identity":"fbd920e0-cbab-4afa-8c8f-223cd57a2d11","added_by":"auto","created_at":"2026-02-09 16:10:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":541473,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7566914/v1/78256f40-b9d4-4c9e-af54-b96b4dc6e05a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcome of hemodialysis patients in one poorest country in the world: the Zinder experience.","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) is a significant global burden: recently, a study showed that, worldwide, the age-standardized incidence rate and age-standardized disability-adjusted life years rate are rising in almost all countries/regions, suggesting that the impact of CKD on global health is increasing. Indeed, population growth and aging are major factors contributing to the increasing burden of CKD, especially in China and low socio-demographic index regions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Africa, CKD is a public health problem, mainly attributed to high-risk conditions such as hypertension, diabetes, and human immunodeficiency virus infection (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNiger is one of the poorest countries in the world (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.worldbank.org/niger\u003c/span\u003e\u003cspan address=\"https://www.worldbank.org/niger\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). We have already conducted a cross-sectional study over six months at the university hospital of Zinder (Niger); during that period, 497 patients were screened while hospitalized for reasons other than chronic kidney disease. We found 91 cases of CKD (stage 3 and below), representing a prevalence of 18.3% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). We have also reported on 120 kidney biopsies performed in our center, essentially in young patients. The primary indication for kidney biopsy was glomerular syndrome in 62.5% of cases, including 50% with nephrotic syndrome. The most common findings were (i) glomerular diseases (58.4%) and (ii) tubulointerstitial changes (31.8%) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, due to the lack of nephrologists in low-income countries\u0026mdash;there is an 80-fold difference between low-income and high-income countries (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u0026mdash;and the fact that every patient with a kidney condition must self-pay for medications, very few are able to follow nephrologists' prescriptions, leading quite rapidly to end-stage kidney disease (ESKD).\u003c/p\u003e\u003cp\u003eAdditionally, when a patient presents with very high serum creatinine, it could be either an acute or a chronic condition (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e); in such settings, renal ultrasound might help categorize the condition. Indeed, regarding acute kidney injury, approximately 85% of cases occur in low-resource settings where access to kidney replacement therapy may be limited or nonexistent (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). For those patients placed on chronic dialysis therapy in sub-Saharan countries, their median survival is poor, e.g., 345 days in a random survey across three hospitals in Ethiopia in 2021 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), 17 months in Congo (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and 46\u0026ndash;47 months in longitudinal studies from Ethiopia (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe aim of this prospective study was twofold: to determine i) patient outcomes within the 90 days after starting hemodialysis therapy, and ii) among those passing the 90-day mark, how many will survive in the long run.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eThis is a single-center prospective study that took place between 01/01/2018 and 31/12/2022. We included all patients presenting with either acute kidney injury or end-stage kidney disease. Indeed, when the patients arrived at our center, they had high levels of serum creatinine (over 1000 \u0026micro;mol/L), but it was not possible to determine whether it was due to an acute kidney injury (AKI) or chronic kidney disease (CKD). However, every patient underwent a renal ultrasound examination to rule out obstructive nephropathy; in the majority of cases, renal size was diminished. Finally, because of reduced kidney size, none of them underwent a kidney biopsy.\u003c/p\u003e\u003cp\u003eTherefore, in such a setting (very high levels of serum creatinine), we proposed hemodialysis as the renal replacement therapy, as we do not have a peritoneal dialysis program. Hemodialysis procedures were always initiated using a femoral venous catheter. Some patients who were started on chronic hemodialysis were offered the possibility of an arteriovenous fistula (self-funded procedure). We only included patients who accepted to undergo at least one session of hemodialysis. Hemodialysis sessions were scheduled according to the patient\u0026rsquo;s needs, i.e., symptoms of uremia and/or fluid overload. For those on chronic hemodialysis, we recommended two sessions of four hours twice a week; however, in many cases, patients attended their hemodialysis sessions only when they could afford to pay for them. All patients were followed up until 31/12/2024, or until death or lost-to-follow-up. We divided the patients into two categories: those who underwent less than 3 months of supportive therapy (i.e., hemodialysis), and those who were started on a chronic hemodialysis program, i.e., they did not recover from kidney failure, which was therefore assumed to be a chronic condition. We excluded patients who were subsequently transferred to another hemodialysis center.\u003c/p\u003e\u003cp\u003eAll patients provided informed written consent to publish their data; this was obtained when dialysis therapy was proposed as the only available option (see above).\u003c/p\u003e\u003cp\u003eWe collected the following variables: gender, age, cause of kidney injury/disease, level of education/diploma, social status, occupation, financial condition, residency (urban vs. rural), distance from home to our hemodialysis center, use of traditional medicines/herbs, past medical history including hypertension, diabetes, initial nephropathy (if a kidney biopsy had been performed), history of acute or chronic kidney disease, and previous surgery. Regarding hemodialysis parameters, we recorded hemoglobin levels at the start of the first hemodialysis session, type of vascular access, number of dialysis sessions per week, and adherence to dialysis therapy. When the patient was informed that dialysis therapy was required, a questionnaire was completed, which included the variables described above.\u003c/p\u003e\u003cp\u003eAlthough we do not have electronic medical records for our patients, we used paper medical files to extract the data. We also established a dialysis registry, which includes the name, surname, and date of birth of patients referred to hemodialysis, even if therapy was never initiated. This registry also records the date of death, cause of death, and whether the patient decided to stop dialysis therapy or was lost to follow-up.\u003c/p\u003e\u003cp\u003e The research was conducted in accordance with the Declaration of Helsinki. The study was submitted to local ethical committee and was approved: FSS_UASZ_Niger_No 011/06/05/2024. Finally, informed consent to participate was obtained from all of the participants in the study.\u003c/p\u003e"},{"header":"3. Statistical analysis","content":"\u003cp\u003eA clinical nurse was trained to collect data. The data collector identified patient charts for the study using registry books from the dialysis unit and retrieved them from the medical records department. Patient medical records and dialysis charts were the sources of data collection. The data collection tools included socio-demographic characteristics (such as age, sex, and source of funds), patient clinical characteristics such as nausea and vomiting, shortness of breath, body swelling, oliguria, gross hematuria, hematuria, and blood pressure measurement), and laboratory features (such as serum creatinine, serum sodium, serum potassium, serum urea, hemoglobin, and proteinuria). Additionally, the indication for dialysis, the type of vascular access for HD initiation, the type of vascular access in patients on maintenance HD, frequency and duration of HD sessions, length of stay in the HD unit, and patient outcomes were recorded. Categorical variables were presented as frequencies and percentages, while continuous variables were described using median and ranges.\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003eDuring the study period, 544 patients required dialysis therapy and underwent at least one hemodialysis session. Four hundred and twenty-three patients (77.8%) underwent hemodialysis for less than 3 months (cohort 1); the remaining patients (n\u0026thinsp;=\u0026thinsp;121, i.e., 22.2%; cohort 2) were started on chronic hemodialysis (more than 3 months) (see flow chart, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eRegarding cohort 1 (n\u0026thinsp;=\u0026thinsp;423), 57 patients (13.5%) recovered (i.e., they had acute kidney injury and were discharged home). However, 240 patients (57%) died. Additionally, 60 patients (14.5%) decided to stop hemodialysis and returned home (no follow-up data), and 55 patients (13%) were lost to follow-up. We may assume that these 110 patients (27.5%) eventually died.\u003c/p\u003e\u003cp\u003eWe will now focus on those who underwent at least three months of dialysis therapy, i.e., cohort 2 (n\u0026thinsp;=\u0026thinsp;121). Most of them were aged between 20 and 40 years (n\u0026thinsp;=\u0026thinsp;45; 37.2%) and between 41 and 60 years (n\u0026thinsp;=\u0026thinsp;50; 41.3%). There were 98 men (73.5%). Regarding their profession, most were farmers (n\u0026thinsp;=\u0026thinsp;35; 29%), merchants/storekeepers (n\u0026thinsp;=\u0026thinsp;27; 22.3%), or housewives (n\u0026thinsp;=\u0026thinsp;27; 22.3%). Seventy-five patients (62%) lived in rural areas. Most of them had a low socio-economic status (n\u0026thinsp;=\u0026thinsp;80; 66%). Ninety-five patients (78.5%) had no formal education.\u003c/p\u003e\u003cp\u003eMost of the patients lived far (50 to 100 km; n\u0026thinsp;=\u0026thinsp;33; 27.3%) or very far from the dialysis center (more than 100 km; n\u0026thinsp;=\u0026thinsp;63; 52%), keeping in mind that in our region there are no asphalt roads. Regarding dietary habits, 56 patients (46.3%) were consuming herbal medicines and/or decoctions before dialysis therapy was initiated. Most patients (n\u0026thinsp;=\u0026thinsp;99; 82%) did not follow the dietary counseling provided by the dietitian and nephrologist.\u003c/p\u003e\u003cp\u003eRegarding past medical history, it was absent in 16 patients (13.2%), whereas hypertension, type 2 diabetes, and heart disease were present in 58 (48%), 14 (11.6%), and 12 (10%) patients, respectively. At the initiation of hemodialysis, hemoglobin levels were below 80 g/L in 63 patients (52%).\u003c/p\u003e\u003cp\u003eRegarding patient outcomes, most of them, i.e., 80 (66%) have had less than 30 hemodialysis session (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Fifty-seven patients (47%) died, 19 (15.7%) decided to stop hemodialysis therapy, 35 (29%) were lost to follow-up, and finally, 10 patients (8.3%) survived. Among the survivors (as of December 2024), 8 had started hemodialysis in 2019, one in 2021, and one in 2022.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNumber of hemodialysis sessions per patient for those that were on hemodialysis therapy for more than 3 months\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of hemodialysis sessions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of patients (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than \u0026lt;\u0026thinsp;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e[30\u0026ndash;59]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e[60 and above]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRegarding the 10 chronic hemodialysis patients who survived, 5 were aged 30 to 60 years old; 3 were above 60 and 2 were below 30. There were 7 males. All the patients were equipped with an arteriovenous fistula. Regarding their occupations there were 3 housewives; 1 farmer; the others were either state employees (n\u0026thinsp;=\u0026thinsp;2) or merchants (n\u0026thinsp;=\u0026thinsp;4). Regarding their social-economic level it was either average (n\u0026thinsp;=\u0026thinsp;7) or high (n\u0026thinsp;=\u0026thinsp;3); regarding their education level the 7 males had a very good level. Eight out of 10 patients were living nearby our hemodialysis facility. Finally, all the patients were adherent to dietetician counseling regarding water intake, potassium and restrictions.\u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eOur single-center cross-sectional study, conducted over five years in one of the poorest countries in the world, has demonstrated that only a very small proportion of patients initiated on hemodialysis therapy survive in the long term\u0026mdash;less than 10%. Throughout the study period, patients were required to self-fund both their hemodialysis sessions and all associated medications.\u003c/p\u003e\u003cp\u003eNiger is among the world\u0026rsquo;s poorest nations (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aa.com.tr/fr/afrique/le-niger-l-un-des-pays-les-plus-pauvres-au-monde-face-aux-sanctions-%C3%A9conomiques/2961374\u003c/span\u003e\u003cspan address=\"https://www.aa.com.tr/fr/afrique/le-niger-l-un-des-pays-les-plus-pauvres-au-monde-face-aux-sanctions-%C3%A9conomiques/2961374\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). In 2022, the then-democratic government of Niger had launched an ambitious Sanitary and Social Development Plan (2022\u0026ndash;2026). However, this initiative was abruptly halted by a military coup in 2023, which dismantled democratic governance and nullified all prior reforms\u0026mdash;an event that has been catastrophic for the country's population. The Human Development Index of Niger in 2023 was 0.419, placing it 189th out of 193 countries. Furthermore, more than half of the population lives on less than USD 2.15 per day (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.theglobaleconomy.com/Niger/human_development/\u003c/span\u003e\u003cspan address=\"https://www.theglobaleconomy.com/Niger/human_development/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn such an economic context, the sustainability and relevance of allocating state resources to the management of chronic conditions such as end-stage kidney disease (ESKD), particularly for the reimbursement of costly therapies like hemodialysis, is a pressing concern. South Africa provides an illustrative example of a more pragmatic health policy regarding ESKD. There, patients presenting with significantly elevated serum creatinine levels (whether due to AKI or ESKD) are granted a one-month period of supportive dialysis therapy. If recovery does not occur within that timeframe, only patients eligible for kidney transplantation or with private health insurance are maintained on dialysis. Others are transitioned to conservative management (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn South Africa, a country of approximately 60\u0026nbsp;million inhabitants, 822 new patients commenced kidney replacement therapy in 2022, an incidence of 13.3 per mil-lion population (pmp). Most of these patients (77%) were treated in private centers. By December 2022, 9,342 patients were undergoing chronic dialysis or had been trans-planted, resulting in an overall prevalence of 151 pmp. However, this prevalence was starkly divided between the private sector (771 pmp) and the public sector (45 pmp), reflecting major inequities (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Conversely, in Morocco, the prevalence of dialysis patients reaches 1066.9 pmp, with hemodialysis fully covered by the national healthcare system as of 2025 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSouth Africa has opted to prioritize other chronic diseases with a broader public health impact, such as HIV and tuberculosis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In contrast, many African countries lack mid- or long-term health policies addressing the sustainability of maintaining large numbers of chronic hemodialysis patients, especially given the near absence of kidney transplantation programs across the continent.\u003c/p\u003e\u003cp\u003eTannor et al. have highlighted the situation in Ghana, where, despite the first hemodialysis session being performed over 50 years ago, there remain glaring inequities in the distribution of dialysis centers. Ghana faces a low dialysis prevalence and a nephrology workforce of only 0.44 nephrologists per million population, despite a high burden of CKD. Moreover, the prohibitive cost of dialysis (approximately USD 53.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 per session) is predominantly paid out-of-pocket, severely limiting its accessibility (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In Morocco, a country of 38.4\u0026nbsp;million people, nearly 41,000 patients are on hemodialysis, with treatment fully covered by the state. However, kidney transplantation remains underdeveloped, with fewer than 50 transplants performed annually, a policy that is unsustainable in both the short and long term.\u003c/p\u003e\u003cp\u003eThe late presentation of CKD patients in emergency departments, already at the ESKD stage, is a common phenomenon in low-income countries. This is largely due to a lack of nephrologists and the absence of CKD screening programs. In some cases, however, patients with severe renal dysfunction may have acute kidney injury (AKI) rather than chronic disease. Randrianarisoa et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) from Madagascar reported that, among 124 emergency hemodialysis patients, 82.7% had ESKD while 17.3% had AKI and eventually recovered. Our own findings mirror this, with 13.5% of our patients recovering renal function after dialysis initiation. Conversely, Tafese et al. in Ethiopia reported an AKI recovery rate of 31% among emergency dialysis patients (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Despite variations, these studies collectively underscore that in low-resource settings, the majority of patients initiating emergency dialysis are in fact suffering from ESKD.\u003c/p\u003e\u003cp\u003eIn sub-Saharan Africa, hypertension and diabetes mellitus are the leading causes of progression to ESKD (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Tafese et al. reported hypertension (40.4%), chronic glomerulonephritis (27.7%), and diabetes (14.9%) as the primary etiologies of CKD (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Our own cohort reflected a similar distribution, with most patients presenting with hypertension or diabetes.\u003c/p\u003e\u003cp\u003eThe self-funded nature of hemodialysis in many African countries inevitably leads to suboptimal dialysis quality, poor adherence, and high treatment abandonment rates. Halle et al. reported a non-adherence rate of 21.2% in a cohort of chronic hemodialysis patients over a two-month period, with only one patient (0.6%) having health insurance (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In our cohort, non-adherence was observed in 44.7% of chronic hemodialysis patients: 15.7% voluntarily discontinued therapy, and 29% were lost to follow-up. Notably, in 23% of low-income countries, ESKD patients are required to pay more than 75% of dialysis costs, compared to only 4% in high-income nations (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Until January 2025, all dialysis-related expenses in Niger\u0026mdash;including arteriovenous fistula creation\u0026mdash;were self-funded, significantly impacting patient adherence. The recent implementation of government-funded hemodialysis may help mitigate this issue.\u003c/p\u003e\u003cp\u003eAnother critical factor influencing adherence is the health-related quality of life (HRQL) of dialysis patients. Mathew et al. in South Africa found that hemodialysis patients reported higher anxiety and depression scores compared to those managed conservatively, alongside poorer physical and emotional well-being (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Bagasha et al. in Uganda reported that 94.3% of ESKD patients scored below 50 (out of 100) on HRQL assessments, with no significant differences between dialysis and conservative management groups (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Teuwafeu et al. in Cameroon reported that among 434 patients, 76.2% had HRQL scores below 50. Furthermore, school dropout rates, unemployment, and social isolation were prevalent after initiating dialysis (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Similarly, Gebrie et al. in Ethiopia highlighted overwhelmingly negative narratives among chronic dialysis patients regarding their lived experiences (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGiven the poor quality of life and high mortality associated with chronic dialysis in low-income countries, the relevance of maintaining patients on long-term dialysis programs must be questioned. In Congo, Mokoli et al. reported a median survival of 17 months in a cohort of 250 chronic dialysis patients, with financial constraints leading to therapy withdrawal in 18.4% of cases (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Workie et al. in Ethiopia reported a median survival of 345 days among 436 dialysis patients, with key mortality predictors including rural residence, hypertension-related ESKD, HIV infection, and use of central venous catheters (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Two longitudinal Ethiopian studies reported survival durations of 46\u0026ndash;47 months (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In our series, only 10 out of 121 patients (8.3%) survived beyond three months of dialysis, all of whom had arteriovenous fistulas.\u003c/p\u003e\u003cp\u003eNumerous studies have underscored that the type of vascular access significantly impacts survival. Catheter use is consistently associated with higher mortality rates compared to arteriovenous fistulas. Tafese et al. noted that in their Ethiopian cohort, nearly all CKD and AKI patients required emergency catheter-based access, whereas 94.3% of maintenance dialysis patients utilized AV fistulas (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGiven the high mortality of chronic dialysis patients in sub-Saharan Africa, kidney transplantation emerges as a more viable option. However, very few countries in the region have established sustainable transplant programs (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Functional transplant programs are primarily found in North Africa (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), Nigeria (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), South Africa (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and Egypt (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In Cameroon, where living-donor transplantation has recently been implemented, Njamnshi et al. estimated that annual dialysis costs per patient are 12 times the national average income. By contrast, transplantation, especially when supported by generic immunosuppressive drugs, could reduce long-term follow-up costs by 89% (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In Niger, no transplant program exists yet. However, in a cohort of 25 patients who underwent living-donor transplantation abroad, we report-ed a 5-year patient survival rate of 84%, a graft survival rate of 56%, and a death-censored graft survival rate of 67% (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u0026mdash;outcomes inferior to Western standards but considerably better than the 8.3% survival observed in our chronic dialysis cohort.\u003c/p\u003e\u003cp\u003eThe nephrology workforce in Africa remains critically insufficient, as highlighted by multiple surveys (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The number of nephrologists per million population ranges from 1 pmp in South Africa to 40 pmp in Japan, with Senegal (2 pmp), Mexico (4 pmp), and Ukraine (9 pmp) also demonstrating severe shortages (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn summary, low-income countries face a dual challenge: an insufficient number of nephrologists, largely confined to urban centers, and a lack of structured prevention strategies. Consequently, CKD patients are often diagnosed only at the terminal stage, when dialysis initiation becomes urgent and unavoidable, thereby precluding opportunities for early intervention, optimal vascular access planning, or timely evaluation for transplantation.\u003c/p\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eOur study demonstrates that in a very low-income country, the vast majority of patients who commence self-funded hemodialysis in emergency settings are already at the stage of end-stage kidney disease. Slightly more than one in five patients will reach 90 days after initiating hemodialysis. Among those who continue beyond this thresh-old, fewer than 10% will achieve long-term survival, with the remainder either succumbing while on dialysis or discontinuing therapy due to financial constraints.\u003c/p\u003e\u003cp\u003eThese findings challenge the relevance and sustainability of chronic hemodialysis programs in extremely resource-limited settings, given the prohibitive costs and high mortality rates associated with this therapy. Where feasible, kidney transplantation should be prioritized as an alternative supportive strategy and offered promptly once it becomes evident that renal recovery is unlikely.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eThe following abbreviations are used in this manuscript:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAKI: Acute Kidney Injury\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCKD: Chronic Kidney Disease\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eESKD: End Stage Kidney Disease\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eACEI: Angiotensin Converting Enzyme Inhibitor\u003c/li\u003e\n \u003cli\u003eHRQL: Health Related Quality of Life\u003c/li\u003e\n \u003cli\u003eHIV: Human immunodeficiency virus\u003c/li\u003e\n \u003cli\u003eHD: Hemodialysis\u003c/li\u003e\n \u003cli\u003eAV fistula: Arteriovenous fistula\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: informed consent to participate was obtained from all of the participants in the study.\u003c/p\u003e\n\u003cp\u003eFSS_UASZ_Niger_No 011/06/05/2024.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe research was conducted in accordance with the Declaration of Helsinki\u003c/p\u003e\n\u003cp\u003eConsent for publication: As hemodialysis therapy is a live-saving procedure we just informed the patient that hemodialysis procedure was needed.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: provided reasonable demand. Any demand should be made to the corresponding author Pr Lionel Rostaing.\u003c/p\u003e\n\u003cp\u003eCompeting interests: None.\u003c/p\u003e\n\u003cp\u003eFunding: None.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; Contributions: Conceptualization, HMD, MBGDA, LR.; methodology; MBGDA.; software, MBGDA; validation, LR.; formal analysis, DAA, CL, AZH; investigation, DAA; resources, HMD; data curation, MBGDA; writing\u0026mdash;original draft preparation, DAA, HMD; writing\u0026mdash;review and editing, DB, LR; visualization, CL, AZH.; supervision, HMD; project administration, CL, AZH; funding acquisition, HMD. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003eInstitutional Review Board Statement: Research authorization was granted by the dean of University Salifou of Zinder (Niger) on December 5th, 2024. The approval letter is enclosed with the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: none.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGuo J, Jiao W, Xia S, Xiang X, Zhang Y, Ge X, Sun Q. The global, regional, and national patterns of change in the burden of chronic kidney disease from 1990 to 2021. BMC Nephrol. 2025;26(1):136. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-025-04028-z\u003c/span\u003e\u003cspan address=\"10.1186/s12882-025-04028-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbd ElHafeez S, Bolignano D, D'Arrigo G, Dounousi E, Tripepi G, Zoccali C. Prevalence and burden of chronic kidney disease among the general population and high-risk groups in Africa: a systematic review. BMJ Open. 2018;8(1):e015069. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2016-015069\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2016-015069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiongole H, Laouel HM, Magagi A, Garba AA, Tondi ZMM, Chaibou L, Waziri SB, Abdoulmadjid AI, Rostaing L. Screening of Chronic Kidney Diseases in Patients Hospitalized for Surgery at the National Hospital of Zinder in Niger. Liaquat Natl J Prim Care. 2025;7(2):140\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.37184/lnjpc.2707-3521.7.39\u003c/span\u003e\u003cspan address=\"10.37184/lnjpc.2707-3521.7.39\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiongol\u0026eacute; HM, Tondi ZMM, Garba A, Ganiou K, Chaibou L, Bonkano D, Aboubacar I, Seribah AA, Abdoulaye Idrissa AM, Atanda A, Rostaing L. Implementation of Kidney Biopsy in One of the Poorest Countries in the World: Experience from Zinder Hospital (Niger). J Clin Med. 2024;13(3):664. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm13030664\u003c/span\u003e\u003cspan address=\"10.3390/jcm13030664\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBello AK, Okpechi IG, Levin A, Ye F, Damster S, Arruebo S, Donner JA, Caskey FJ, Cho Y, Davids MR, Davison SN, Htay H, Jha V, Lalji R, Malik C, Nangaku M, See E, Sozio SM, Tonelli M, Wainstein M, Yeung EK, Johnson DW, ISN-GKHA Group. An update on the global disparities in kidney disease burden and care across world countries and regions. ISN-GKHA Group. Lancet Glob Healt. 2024;12(3):e382\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(23)00570-3\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(23)00570-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRandrianarisoa RMF, Mikkelsen Ranivoharisoa E, Randrianarisoa A, Ramilitiana B, Randriamarotia WFH. Emergency hemo-dialysis in the Joseph Raseta Befelatanana hospital, Antananarivo, Madagascar. Nephrol Ther. 2023;19(1):59\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1684/ndt.2023.5\u003c/span\u003e\u003cspan address=\"10.1684/ndt.2023.5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCullis B, Calice da Silva V, McCulloch M, Ulasi I, Wijewickrama E, Iyengar A. Access to Dialysis for Acute Kidney Injury in Low-Resource Settings. Semin Nephrol. 2022;42(5):151313. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.semnephrol.2023.151313\u003c/span\u003e\u003cspan address=\"10.1016/j.semnephrol.2023.151313\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorkie SG, Zewale TA, Wassie GT, Belew MA, Abeje ED. Survival and predictors of mortality among chronic kidney disease patients on hemodialysis in Amhara region, Ethiopia, 2021. BMC Nephrol. 2022;23(1):193. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-022-02825-4\u003c/span\u003e\u003cspan address=\"10.1186/s12882-022-02825-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMokoli VM, Sumaili EK, Lepira FB, Makulo JR, Bukabau JB, Osa Izeidi PP, Luse JL, Mukendi SK, Mashinda DK, Nseka NM. Impact of residual urine volume decline on the sur-vival of chronic hemodialysis patients in Kinshasa. BMC Nephrol. 2016;17(1):182. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-016-0401-9\u003c/span\u003e\u003cspan address=\"10.1186/s12882-016-0401-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDesta BZ, Dadi AF, Derseh BT. Mortality in hemodialysis patients in Ethiopia: a retrospective follow-up study in three centers. BMC Nephrol. 2023;24(1):3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-022-03053-6\u003c/span\u003e\u003cspan address=\"10.1186/s12882-022-03053-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTesfaye AH, Birhanu A, Kolola T, Hamza L, Etana D. Time to death and its predictors among patients with chronic kidney disease on hemodialysis at dialysis unit in Addis Ababa, Ethiopia: a retrospective cohort study. BMC Nephrol. 2024;25(1):279. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-024-03719-3\u003c/span\u003e\u003cspan address=\"10.1186/s12882-024-03719-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavids MR, Marais N, Sebastian S, Jardine T, Chothia MY, Jacobs JC. South African Renal Registry Annual Report 2022. Afr J Nephrol. 2024; 27: 58\u0026ndash;69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21804/27-1-6749\u003c/span\u003e\u003cspan address=\"10.21804/27-1-6749\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cnops.org.ma\u003c/span\u003e\u003cspan address=\"https://www.cnops.org.ma\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGalvin M, Evans D, Moolla A, Coetzee L, Maluleke V, Leshabana P, Miot J. Adopting sustainable innovations for remote access to TB and HIV care in South Africa. PLOS Glob Public Health. 2024;4(10):e0003792. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pgph.0003792\u003c/span\u003e\u003cspan address=\"10.1371/journal.pgph.0003792\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTannor EK, Hutton-Mensah K, Opare-Addo P, Agyei MK, Gyan KF, Inusah AJ, Nyann BI, Amo-Antwi K, Luyckx V, Okpechi I. Fifty years of hemodialysis in Ghana\u0026mdash;current status, utilization and cost of dialysis service. MC Health Serv Res. 2023;23(1):1170. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-023-10154-x\u003c/span\u003e\u003cspan address=\"10.1186/s12913-023-10154-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTafese ST, Abera EG, Mersha MD, Woldemariam MB. Clinical characteristics and outcomes of patients on haemodialysis at Jimma medical center, Ethiopia: a 7-Year review. BMC Nephrol. 2024;25(1):420. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-024-03860-z\u003c/span\u003e\u003cspan address=\"10.1186/s12882-024-03860-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRage HI, Ers SA, Kahin AY, Elmi MM, Mohamed AA, Kumar Jha P. Causes of kidney failure among patients un-der-going maintenance hemodialysis in Somalia: a multi-center study. BMC Nephrol. 2023;24(1):347. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-023-03402-z\u003c/span\u003e\u003cspan address=\"10.1186/s12882-023-03402-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHalle MP, Nelson M, Kaze FF, Jean Pierre NM, Denis T, Fouda H, Ashuntantang EG. Non-adherence to hemodialysis regimens among patients on maintenance hemodialysis in sub-Saharan Africa: an example from Cameroon. Ren Fail. 2020;42(1):1022\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/0886022X.2020.1826965\u003c/span\u003e\u003cspan address=\"10.1080/0886022X.2020.1826965\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHtay H, Bello AK, Levin A, Lunney M, Osman MA, Ye F, Ashuntantang GE, Bellorin-Font E, Gharbi MB, Davison SN, Ghnaimat M, Harden P, Jha V, Kalantar-Zadeh K, Kerr PG, Klarenbach S, Kovesdy CP, Luyckx VA, Neuen B, O'Donoghue D, Ossareh S, Perl J, Rashid HU, Rondeau E, See EJ, Saad S, Sola L, Tchokhonelidze I, Tesar V, Tungsanga K, Kazancioglu RT, Wang Y-M, Yang A, Zemchenkov CW, Zhao A, Jager MH, Caskey KJ, Perkovic FJ, Jindal V, Okpechi KK, Tonelli IG, Harris M, Johnson DC. Hemodialysis Use and Practice Patterns: An International Survey Study. Am J Kidney Dis. 2021;77(3):326\u0026ndash;e3351. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.ajkd.2020.05.030\u003c/span\u003e\u003cspan address=\"10.1053/j.ajkd.2020.05.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMathew N, Davies M, Kaldine F, Cassimjee Z. Comparison of quality of life in patients with advanced chronic kidney disease undergoing haemodialysis, peritoneal dialysis and conservative management in Johannesburg, South Africa: a cross-sectional, descriptive study. BMC Psychol. 2023;11(1):151. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40359-023-01196-1\u003c/span\u003e\u003cspan address=\"10.1186/s40359-023-01196-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBagasha P, Namukwaya E, Leng M, Kalyesubula R, Mutebi E, Naitala R, Katabira E, Petrova M. Comparison of the health-related quality of life of end stage kidney disease patients on hemodialysis and non-hemodialysis management in Uganda. BMC Palliat Care. 2021;20(1):52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12904-021-00743-0\u003c/span\u003e\u003cspan address=\"10.1186/s12904-021-00743-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTeuwafeu DG, Sehbing M, Halle MP, Mahamat M, Fouda H, Ashuntantang G. Quality of life and social reinsertion of patients on maintenance haemodialysis in four government funded hospitals in Cameroon. BMC Nephrol. 2024;25(1):335. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-024-03778-6\u003c/span\u003e\u003cspan address=\"10.1186/s12882-024-03778-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGebrie MH, Asfaw HM, Bilchut WH, Lindgren H, Wettergren L. Patients\u0026rsquo; experience of undergoing maintenance hemodialysis. An interview study from Ethiopia. PLoS ONE. 2023;18(5):e0284422. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.1371/journal.pone.0284422\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0284422\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBamgboye EL. Kidney Transplantation in Sub-Saharan Africa: History and Current Status. Kidney360. 2023; 4(12): 1772\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.34067/KID.0000000000000293\u003c/span\u003e\u003cspan address=\"10.34067/KID.0000000000000293\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavis SO, Zubair A, Igbokwe M, Abu M, Chiedozie CA, Sanni Q, Jesuyajolu D. A Scoping Review of Kidney Transplantation in Africa: How Far have We Come ? World J Surg. 2023;47(9):2113\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00268-023-07042-0\u003c/span\u003e\u003cspan address=\"10.1007/s00268-023-07042-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHafez MH. Global Perspective: Kidney Transplantation in North Africa. Kidney 360. 2024;5(9):1370\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.34067/KID.0000000000000497\u003c/span\u003e\u003cspan address=\"10.34067/KID.0000000000000497\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePopoola AA, Olanrewaju TO, Bolaji BO, Ajiboye TO. Expanding renal transplantation organ donor pool in Nigeria. Saudi J Kidney Dis Transpl. 2018;29(5):1181\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/1319-2442.243946\u003c/span\u003e\u003cspan address=\"10.4103/1319-2442.243946\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoosa MR, Afr Med J. 2019; 109(4): 235\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7196/SAMJ.2019.v109i4.13548\u003c/span\u003e\u003cspan address=\"10.7196/SAMJ.2019.v109i4.13548\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFarag YMK, Elsayed E. Global Perspective on Kidney Transplantation in Egypt. Kidney360. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.34067/KID.0000000891\u003c/span\u003e\u003cspan address=\"10.34067/KID.0000000891\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNjamnshi RK, Maimouna M, Ngarka L, Tomta AEN, Njamnshi WY, Ashuntantang GE, Djientcheu VPN, Njamnshi AK, Shepard DS. A retrospective cohort study on the cost-effectiveness analysis of kidney transplantation compared to dialysis in Cameroon: evidence for policy. Pan Afr Med J. 2023;46:27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.11604/pamj.2023.46.27.38706\u003c/span\u003e\u003cspan address=\"10.11604/pamj.2023.46.27.38706\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBonkano D, Tondi ZMM, Diongol\u0026eacute; HM, Illiassou A, Abdou I, Isaac OM, Mohamadou BR, Massi AWI, Omar AE, Rostaing L. Status Report of Renal Transplant Patients in Niger. Transplant Proc. 2023; 55(2): 332\u0026ndash;336. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.transproceed.2023.01.009\u003c/span\u003e\u003cspan address=\"10.1016/j.transproceed.2023.01.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFreedberg DE, Segall L, Liu B, Jacobson JS, Mohan S, George V, Kumar R, Neugut AI, Radhakrishnan J. International Variability in the Epidemiology, Management, and Outcomes of CKD and ESKD: A Systematic Review. Kidney 360. 2024; 5(1): 22\u0026ndash;32, 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.34067/KID.0000000000000335\u003c/span\u003e\u003cspan address=\"10.34067/KID.0000000000000335\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"patient survival, Niger, Zinder, hemodialysis, therapy withdrawal","lastPublishedDoi":"10.21203/rs.3.rs-7566914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7566914/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChronic hemodialysis therapy is a well-recognized supportive therapy for patients with end-stage kidney disease. However, this therapy is poorly implemented in low-income countries due to its high cost. We herein report a single-center experience in one of the poorest countries in the world, i.e., Niger.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and methods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a cross-sectional study that included all incident patients presenting with serum creatinine greater than 1000 µmol/L (January 2018 to December 2022). They all agreed to be treated with self-funded chronic hemodialysis. Survival was evaluated as of December 2024. A total of 544 patients-initiated hemodialysis therapy. Among them, 423 (77.8%) underwent hemodialysis for less than 3 months: 240 (57%) died; 57 (13.5%) recovered renal function; and the others were lost to follow-up or decided to discontinue hemodialysis. Only 121 patients (22.2%) were able to embark on a chronic hemodialysis therapy program; most of them were males (sex ratio of 2.7). Their mean age was 48 years. Most (62%) were from rural areas. Additionally, 66% had low economic incomes, and 52% lived very far from our dialysis facility. Vascular access was predominantly a central venous catheter (75%). Non-adherence to hemodialysis was observed in 76% of patients. Dropouts and lost-to-follow-up occurred in 15.7% and 29% of cases, respectively. At the end of follow-up, only 10 patients (8.3%) were still alive.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese results question the utility of chronic hemodialysis in very low-income countries due to its high cost and significant mortality. Where possible, kidney transplantation abroad should be offered as supportive therapy as soon as it is known that there will be no renal recovery.\u003c/p\u003e","manuscriptTitle":"Outcome of hemodialysis patients in one poorest country in the world: the Zinder experience.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 12:41:38","doi":"10.21203/rs.3.rs-7566914/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-16T11:01:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-15T12:52:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-12T17:13:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163426073779851903370308219746581825141","date":"2025-11-06T22:39:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"292810731937408688876569584188584226272","date":"2025-11-03T10:21:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-02T07:16:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-18T21:41:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143183546470550849136905415763804725878","date":"2025-10-07T02:18:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"721981408845489956336218804381963864","date":"2025-10-06T17:25:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-06T17:13:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-06T14:55:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-06T09:59:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-29T17:39:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-09-29T17:36:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ce927a06-b69a-4f52-bc07-4c0a63a427f7","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:06:41+00:00","versionOfRecord":{"articleIdentity":"rs-7566914","link":"https://doi.org/10.1186/s12882-026-04804-5","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2026-02-05 15:59:41","publishedOnDateReadable":"February 5th, 2026"},"versionCreatedAt":"2025-10-17 12:41:38","video":"","vorDoi":"10.1186/s12882-026-04804-5","vorDoiUrl":"https://doi.org/10.1186/s12882-026-04804-5","workflowStages":[]},"version":"v1","identity":"rs-7566914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7566914","identity":"rs-7566914","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}