Kidney transplantation in Africa: a systematic review of treatment outcomes, and strategies for enhancing care and sustainability.

backgroundKidney transplantation remains the most effective treatment for end-stage renal disease (ESRD), yet its application and outcomes across Africa are poorly consolidated. This systematic review and meta-analysis evaluated treatment outcomes of kidney transplantation in African countries, identifying challenges and strategies to enhance sustainability.

methodsWe searched PubMed, Scopus, Web of Science, African Journals Online (AJOL), and African Index Medicus databases for relevant literature published between 2010 and 2025. A protocol was registered on PROSPERO with CRD420251112690. A total of 24 studies from various African regions were systematically reviewed, including prospective, retrospective, observational, and cross-sectional designs. Data were extracted on study characteristics, transplant details, immunosuppressive protocols, clinical outcomes, and reported challenges.

resultsThe included studies encompassed 27 to 6,187 participants, spanning both adult (28.5 to 49 years) and pediatric (8.9 to 10.3 years) populations. Most transplants were performed using living donors, primarily first-degree relatives. Common immunosuppressants included tacrolimus, cyclosporine, mycophenolate, and prednisolone. Graft and patient survival rates were generally favorable and often comparable to global benchmarks, with some studies reporting survival rates at 1, 5, and 10 years. Kidney transplant outcomes across sub-Saharan Africa demonstrated strong survival rates despite limited resources. One-year patient survival reached 90.7% in Nigeria, 91.2% in Tanzania, 90.4% in South Africa, 92.3% in Ethiopia, and 98.4% in Egypt. Living donor transplants consistently outperformed deceased donor cases, with one-year graft survival rates of 87% in Nigeria and 96.7% in Tanzania. HIV-positive to HIV-positive programs achieved 84% survival at both 1 and 3 years. Immunological challenges remain, with acute rejection rates ranging from 8% to 43.4%. Delayed graft function and human leukocyte antigen (HLA) mismatches significantly predicted poorer outcomes. New-onset diabetes, more common with tacrolimus, affected up to 36% of recipients. Chronic dysfunction and metabolic complications were also prevalent, particularly in long-term follow-up. Predictors of poor outcomes included older age, diabetes, female sex, and delayed graft function. Key challenges reported included high cost, with up to 98% of patients discontinuing dialysis within 12 weeks due to affordability; limited infrastructure such as tissue typing facilities and reliance on external support; insufficient access to modern immunosuppressants; weak follow-up systems with loss to follow-up rates as high as 20.9%; and ethical concerns regarding donor policies with donor consent rates as low as 26.3%.

conclusionKidney transplantation in Africa shows promising outcomes despite systemic barriers. Addressing infrastructural gaps, improving access to immunosuppressive therapy, and strengthening national transplant programs are critical for sustainable kidney care on the continent.