Collaborates to combat kidney disease in Tanzania

Ruggajo took, together with 6 other candidates from sub-Saharan African countries, his nephrology specialization in NORAD’s Programme for Master Studies (NOMA).  In the programme, candidates from low-income countries took their master degree or medical training, in collaboration with Norwegian higher education institutions.

The program brought these students to Bergen and India, to learn nephrology in environments with different level of facilities, with the final mean to apply this knowledge back in their home countries. As the only one of these candidates, Ruggajo ended up taking a Ph.D.-degree on one of the biggest threats to the health of the sub-Saharan population: kidney diseases.

- It’s predicted that by the year 2030, 70 % of all cases of kidney disease will be from sub-Saharan Africa. This presents a medical challenge, says Ruggajo.

Traditional risk factors low in sub-Saharan Africa

Non communicable diseases are expensive both to diagnose and treat:

- Because we are poor, we don’t have a lot of resources to combat this once the disease is formed. It is much better to use our resources now, to prevent future calamities, says Ruggajo.

Traditional risks factors for kidney disease like hypertension and diabetes are proportionally low in sub-Saharan Africa.  So why are there so many kidney disease patients in these countries? Ruggajo, together with his supervisor Bjørn Egil Vikse, set out to find an answer to this question.

Links low birthweight to kidney disease

To take it few steps back: A researcher called David Barker from Southampton observed that non communicable disease rates in Europe were higher in places that had a high infant mortality rate 70 years before. This is the so called “Barker’s theory” saying that the nutrition in utero (the womb) programs the risk of getting non communicable diseases in the future.

Inspired by this theory Harvard professor David Brenner took it further and hypothesized that there is a connection between low birthweight and your chances of getting kidney disease in the future.

- Nephrons are the functioning units in the kidneys, and are formed in the womb. Brenner hypothesized that there were a link between birth weight and the number of nephrons in the kidneys, says Ruggajo.

In a grounding study Bjørn Egil Vikse found that low birthweight increases your chance of getting kidney disease by 70 %, but opponents to the Brenner’s theory claims that there might be a third and possible a fourth factor, affecting both low birthweight and the chances of evolving kidney disease: The family and the environment. Both low birth weight and renal diseases, are observed in certain families more than others.

Proving the hypothesis

Bjørn Egil Vikse and Pascal Ruggajo wanted to prove the functioning of this “Brenner hypothesis” in the Norwegian population. If the Brenner hypothesis holds true in the Norwegian population, where only 3,3 % of all babies born have a weight under 2,5 kg, would it not also hold true in a sub-Saharan country where 13- 15 % of all kids are born low weight?

- But by using the medical birth registry of Norway and the end-stage renal disease registry of Norway, we found that the birthweight of your sibling does not affect your chance of getting end-stage renal disease. We proved that low birthweight per se, not the genes, the family or the environment, increased the chance of getting the disease by 60 %.

They found the same result when looking into patients with a specific kidney disease, IgA nephropathy. These patients, when born underweight, had a much higher risk of progressing to end-stage renal disease, especially if they were males.

Specifically they also observed that IgA nephropathy patients born low weight had fewer and larger glomeruli. The glomeruli are the units in the kidneys that filter the blood to make urine, and if there is small number of glomeruli they grow bigger to compensate. In the end they get overworked, causing end-stage renal disease and kidney failure.

Learning how to walk

Ruggajo works at Muhimbili University of Health and Allied Sciences (MUHAS) and Muhimbili National Hospital (MNH) in Dar es Salaam in Tanzania, together with his four colleagues, all trained in the NOMA-programme. Also several cardiologists and microbiologists were trained trough NOMA and Ruggajo is, because of the program, now one on ten nephrologists in a country with over 50 million inhabitants. He praises the impact the NOMA-programme, and the collaboration with UiB, has had on the medical care in his home country:

- The collaboration was made on a need-basis: We came forth with our need to train experts in non communicable disease, and be have benefited a lot. Still we’re under capacity, but we’ve established programs in nephrology, cardiology and radiology and train experts locally – using resources and personnel trained in the NOMA-programme. It’s a testimony of holding someone’s hand, and then letting him walk independently, says Ruggajo.

Together with expertize and training, UiB and the Norwegian government also contributed with starting facilities, like analyses machines, biopsy guns and ultrasound machines.

- My Ph.D.-degree is also a testimony of another capacity in terms of research. I pay tribute to Professor Bjørn Egil Vikse, who has learned me a lot on how to conduct research. Now I can help my students in building research which have a public interest – I’ve seen and learned from the best.

“Time bomb”

- The factors contributing to low birthweight, as poor maternal health, poor after birth health and poor breastfeeding attitudes and poor growth during childhood – all these are higher in sub-Saharan Africa than in Norway. Following what we’ve now shown that low birthweight is a risk factor for kidney disease, we know we’re sitting on a time bomb, says Ruggajo. 

He’s a central part of The Nephrology Society of Tanzania (NESOT) a front runner for advocacy for kidney disease in Tanzania. 

- It cannot only be intervened from the medical perspective. War, conflicts, poor food security in the systems, poor policies, all this contribute to less nutrition in the families. It is so intertwined, so to combat this we need to adopt a multisectorial approach, to align our policies with the global development goals, making sure that by the year 2030 we have less malnutrition, less micronutrient deficiencies and fewer babies born low weight.

Hopes the collaboration will continue

Despite all these challenges, he remains positive about the future. He’s immensely proud of his students:

- Now I’m very inspired: I do have a responsibility to transform this good and meaningful work into influence public health polices back home – and this can be done through my students. I’ll inspire my students to do research pursuing the Brenner hypothesis in Tanzanian children. This will also be an avenue to convince the politicians to target the young girls and the future mothers, improve the preconception care, the pregnancy health of the mothers, the breastfeeding patterns, and also work to improve the national food security: Make the agriculture more mechanized and less dependent on seasonal rains. Make sure that the future mothers are appropriately fed, increasing their chance of having normal birthweight babies.

He also remains hopeful about a continued collaboration with the Norwegian government and the UiB:

- After the NOMA-programme closed, we still have a close relationship with the Norwegian government and especially the UiB. I have a plea: That we continue collaboration in terms of clinical care, medical education and clinical research. I remain optimistic that the collaboration will go on, he concludes.

Further reading: "Global collaboration bears fruit: Tanzania report", article published in Kidney International 

Here you may see a video describing their work in Tanzania: https://www.youtube.com/watch?v=EnRbERW2nDE