Although the exact prevalence of ESRD in Somalia is unknown, the prevalence is thought to be significantly high. Unlike most developed countries, Somalia has yet to develop a national renal registry. Due to this, accurate data on the prevalence of kidney diseases is lacking in the country. The availability of renal replacement therapy modalities is sparse in Somalia. There is no facility for peritoneal dialysis or kidney transplantation. This leaves haemodialysis as the only option. Haemodialysis centres in south Somalia are largely in the private sector, which is paid by the patients. On the contrary, in the north (Somaliland, a de facto state), haemodialysis centres are in public regional hospitals regulated by the Ministry of Health of Somaliland. This is free and paid by the government. In our study participants, the haemodialysis treatment cost was borne by patients in 9.4% of the cases, while in the remaining 90.6% it was free as shown in Fig. 3. The total unemployment rate among the patients was 61.7%. Previous studies have shown that many kidney failure patients are unemployed [12]. However, the vast majority of patients in Somalia lack access to dialysis services as it is only provided in large cities with a limited number of dialysis centres. The average cost per HD session in Somalia is between 35–65 USD, similar to neighbouring countries [13, 14].
In our study findings, the mean age of ESRD patients was 49.27 years, and 51.1% of ESRD patients were aged between 30–50 years, while 39.3% were 51–70 years of age. Hypertensive kidney diseases were the most common cause of ESRD, more frequent in the age group between 51–70 years effecting roughly 19.6% while in the same age group, diabetic nephropathy was the cause of 11.1%. Based on a recent Systematic Review and Meta-Analysis, the prevalence of CKD among patients with hypertension in sub-Saharan Africa was 17.8% (95% CI 13.0–23.3%, I2 = 95.5% [15]. According to a study from Ethiopia, 225 (51.6%) of ESRD patients receiving haemodialysis had hypertension as their main cause of CKD, followed by 130 (29.8%) diabetes and 137(31.4%) glomerulonephritis [16]. In Uganda, CKD is primarily caused by hypertension, diabetes mellitus, and infections, particularly HIV/AIDs [17]. In order to diagnose hypertensive nephropathy, it will be challenging to establish a clinical diagnosis of hypertensive nephropathy as hypertension contributes to the progression of any cause of established renal insufficiency and kidney disease itself can cause secondary hypertension [18]. We reviewed the clinical documentation of end-stage renal disease due to hypertension [19] and we utilized/used the following criteria: a long history of hypertension that existed prior to kidney dysfunction, proteinuria of less than 2 grams per day, existing left ventricular hypertrophy and an absence or no evidence of other kidney diseases. [20] Similar criteria were used among haemodialysis patients previously [21]. Hypertension associated with kidney diseases is problematic in black people compared to other ethnic groups, and genetic differences in the APOL1 gene are contributing to a significant portion of this disparity [22]. In the age group of < 50 years 16.5% were reported as having an unknown aetiology of ESRD or uncertain of the root cause of their kidney failure. The unavailability of kidney biopsy in the country contributes to the large number of unknown causes in this age group. As reported in the SSA regions compared to the rest of the globe, the primary causes of CKD are relatively distinct, with glomerulonephritis and infections, such as HIV/AIDS, accounting for an excessively high percentage of patients [23, 24]. In our study, the overall unknown causes of ESRD were 24.4%, while glomerulonephritis was the cause in 7.1%, where a proven diagnosis of GN was made upon kidney biopsy reports. Glomerular diseases are common in Africa and are a major cause of ESRD, as reported in Ethiopia (31.4%), Libya (21.1%), and South Africa (11%). In Nigeria, a study among haemodialysis patients reported that hypertension and chronic glomerulonephritis were the most common causes of kidney failure [25]. According to a recent study, the prevalence of HBV and HCV among haemodialysis patients in Somalia was 7.3% for HBV and 3.2% for HCV [26]. Similarly, we found in our study that HBV was more common among haemodialysis patients 7.9% HBV and (3.1%) HCV as shown in Fig. 4.
Due to the global rise in DM, diabetes is the leading cause of ESRD and CKD in industrialized countries, and developing countries are rapidly catching up with this trend [27]. In our findings, the second leading cause of ESRD in Somalia was T2DM, seen in 27.6% of patients. Risk factors for diabetic kidney disease include advancing age, male gender, long-term diabetes, smoking, obesity, high blood pressure, and genetic susceptibility [28]. Modifiable risk factors such as aging, physical inactivity and obesity tend to have an effect in this region. Many patients in Somalia are diagnosed with kidney diseases and get referred lately when their kidney disease is at an advanced stage. The number of patients with ESRD at the Hargeisa Group Hospital Dialysis Unit is rising, and practically majority of these individuals are obviously in urgent need of starting RRT. Misbelieve about dialysis is a huge contributor to mortality among HD patients in Somalia. Most patients with CKD are misinformed about their condition. Regular check-ups, lack of knowledge and lack of health awareness are one of the main contributing factors to the progression of CKD leading to ESRD.