End-stage renal disease (ESRD) represents a major global public health issue due to its increasing prevalence, high mortality, and the substantial costs associated with its management. Over time, chronic kidney disease (CKD) has been recognized as an increasing burden on society. According to the study by Xie K. et al. [1], the average annual percentage change in CKD prevalence and mortality rates over the period from 1990 to 2021 was 0.92 and 2.66, respectively. A significant increase in disability-adjusted life years (DALYs) and DALY rates related to CKD has also been observed. Furthermore, age-standardized prevalence and mortality rates of CKD are projected to rise to 8773.85 and 21.26 per 100,000 individuals, respectively, by 2032. CKD leads to a substantial increase in public health expenditures, particularly in its advanced stages, which require intensive management such as dialysis or kidney transplantation. This financial burden is even more pronounced in low-resource settings [2].

In many African countries, mortality related to CKD remains high due to limited material, financial, and human resources. Renal replacement therapies (RRT) are often scarce, expensive, and concentrated in major urban centers [3][4].

In Burundi, hemodialysis was introduced in 2014 and remains the only available RRT to date. A study conducted in 2019 among chronic hemodialysis patients between 2014 and 2017 reported a mortality rate of 77.7% [5]. Identifying factors associated with this high mortality is crucial to improving patient survival. Therefore, the aim of this study was to assess mortality and the factors influencing survival among patients undergoing chronic hemodialysis in Burundi.

This study provides a comprehensive overview of the characteristics, outcomes, and determinants of mortality among patients undergoing chronic hemodialysis in Burundi. The findings highlight a relatively young patient population, a high burden of comorbidities, limited access to optimal dialysis, and markedly high mortality, with diabetes emerging as the most consistent predictor of poor survival.

The mean age of patients in this study (51.46 ± 14.45 years) reflects the young population of Burundi and is considerably lower than that reported in high-income countries, where the average age of patients on dialysis often exceeds 60 years [6]-[8]. This pattern is consistent with previous studies from sub-Saharan Africa and reflects the earlier onset and faster progression of chronic kidney disease (CKD), often due to delayed diagnosis and suboptimal management of risk factors such as hypertension and diabetes.

A marked male predominance (73.57%) was observed, in line with findings from other African cohorts. While biological differences may partly explain this trend, disparities in access to healthcare and financial resources likely play a major role, with men more likely to receive costly treatments such as hemodialysis [9].

Although 64.58% of patients had some form of health insurance, more than one-third remained uninsured, underscoring persistent financial barriers to care. In low- and middle-income countries (LMICs), out-of-pocket expenditure remains a major obstacle to accessing RRT and is associated with delayed initiation and reduced treatment adherence [10].

Hypertension (97.55%) and diabetes (51.23%) were the most prevalent comorbidities and the leading causes of ESRD in this cohort. These findings are consistent with global epidemiological trends, where these two conditions account for the majority of ESRD cases [11]. However, the higher prevalence of hypertension suggests poor control and late-stage presentation, which is a common issue in sub-Saharan Africa due to limited screening and treatment resources [12].

The high frequency of catheter-related bloodstream infections (42.23%) is particularly concerning. This rate is substantially higher than that observed in high-income settings, where arteriovenous fistulas are more commonly used and are associated with lower infection risk [13]. The reliance on central venous catheters in resource-limited settings has been identified as a major contributor to infection-related morbidity and mortality [14].

Only 11.44% of patients received the recommended minimum of three hemodialysis sessions per week. This reflects significant structural and financial constraints and has important clinical implications. Inadequate dialysis has been strongly associated with poor toxin clearance, fluid overload, and increased mortality [15].

The mortality rate of 62.1% observed in this study is markedly high and underscores the substantial challenges facing hemodialysis care in Burundi and, more broadly, in sub-Saharan Africa. This finding is consistent with previous studies from the region reporting poor survival outcomes, largely driven by late diagnosis, limited resources, and restricted access to specialized care [16]. In view of the high mortality associated with chronic dialysis in sub-Saharan Africa, kidney transplantation represents a more effective long-term therapeutic option. However, only a limited number of African countries have developed sustainable transplantation programs [17][18]. Similarly, the median survival time of approximately 30 months is shorter than the 3 - 5 years commonly reported in high-income settings [19]. Patients receiving chronic dialysis in sub-Saharan Africa generally experience poor median survival, with reports of 345 days in a multicenter survey across three hospitals in Ethiopia in 2021 [20], and 17 months in the Congo [21]. These findings highlight the substantial gap in outcomes between high-resource and low-resource environments.

Infections (35.80%) and cardiovascular diseases (32.92%) were the leading causes of death. This pattern is consistent with global data indicating that cardiovascular disease is the primary cause of death among dialysis patients, while infections remain a major contributor, particularly in LMICs [22]. The high burden of infection-related mortality in this study is likely linked to frequent catheter use and suboptimal infection control practices. The notable proportion of deaths attributed to cerebrovascular events further reflects the impact of poorly controlled cardiovascular risk factors. Meanwhile, the relatively high percentage of deaths with unknown causes suggests limitations in diagnostic capacity and medical record documentation.

The analysis of risk factors revealed that inadequate dialysis frequency, hypertension, and diabetes were significantly associated with mortality in multivariate logistic regression. The association between receiving fewer than three dialysis sessions per week and increased mortality (aOR = 2.81) is well established. According to the National Kidney Foundation KDOQI guidelines, thrice-weekly dialysis is the standard of care for adequate treatment [23]. Reduced dialysis frequency, often driven by financial constraints, has been consistently associated with worse outcomes in LMICs [10].

Hypertension was also independently associated with mortality in logistic regression. However, this association was not confirmed in survival analysis, where Kaplan-Meier curves showed no significant difference between hypertensive and non-hypertensive patients. This apparent discrepancy may reflect the complex relationship between blood pressure and mortality in dialysis populations, including the phenomenon of reverse epidemiology, where lower blood pressure may paradoxically be associated with higher mortality [24].

Diabetes emerged as a consistent and robust predictor of mortality across all analytical approaches. In logistic regression, diabetic patients had significantly higher odds of death (aOR = 1.70), while survival analysis demonstrated a clear separation of Kaplan-Meier curves, with a significantly shorter median survival (28 vs. 34 months). In the Cox proportional hazards model, diabetes remained the only independent predictor of mortality (aHR = 2.08), indicating more than a twofold increased risk of death over time.

These findings are consistent with extensive literature showing that diabetes is a major determinant of poor outcomes in ESRD patients. Diabetic patients are more prone to cardiovascular complications, infections, and accelerated disease progression, all of which contribute to increased mortality [25][26].

This study has several limitations. First, its retrospective design may be subject to information bias and limit the ability to establish causal relationships. Second, although an exhaustive sampling approach was used, the exclusion of patients with incomplete records may have introduced selection bias. Third, some potentially important variables—such as biological parameters, dialysis adequacy measures (e.g., Kt/V), nutritional status, and medication adherence—were not available, leading to possible residual confounding. In addition, the relatively small sample size for certain subgroups may have reduced the statistical power to detect significant associations. Despite these limitations, the study provides valuable insights into the determinants of mortality among hemodialysis patients in a resource-limited context.

This study reveals a high mortality burden among chronic hemodialysis patients in Burundi, with limited survival and infections and cardiovascular diseases as leading causes of death. Diabetes emerged as the strongest independent predictor of mortality, while inadequate dialysis frequency and hypertension also contributed to poorer outcomes. These findings highlight the urgent need to improve access to adequate dialysis, strengthen the management of diabetes and hypertension, and enhance infection prevention strategies. A comprehensive approach addressing both clinical care and health system barriers is essential to improve survival in this population.