Cameroon is a low–middle income sub-Saharan African country with a population of 22.5 million and a gross domestic product of 34 billion US dollars [1]. Life expectancy at birth is 58 years, infant mortality is 88 per 1000 births and maternal mortality is 590 per 100,000 live births. Health expenditure constitutes 5.1 % of the gross domestic product, and private health expenditure accounts for 67.6 % of this expenditure, of which 94.2 % is funded by the patients themselves [2]. About 46 % of the population have access to improved sanitation and 47 % live in rural areas. There is a huge deficit in manpower in the healthcare system with less than one physician and 4.4 nurses per 10,000 inhabitants [2].

While the true prevalence of chronic kidney disease (CKD) in Cameroon is unknown, CKD is common, with a prevalence of 13.2 % reported in one region [3]. There has also been a gradual increase in the number of Cameroonians receiving long-term haemodialysis [4, 5]. Although several measures are known to slow the progression of CKD, such as low protein diets (LPDs), the late presentation to nephrologists of patients with CKD often precludes their use. We have previously reported that 55.7 % of patients with CKD are seen for the first time in our clinic at stage 5, with one third of them requiring emergency dialysis [6].

Uncooked foods are sold mainly in markets that open daily in semi-urban and urban areas and periodically in rural areas. With the exception of beef, pork and fish, which are sold per weight, other indigenous foodstuffs are neither weighed nor labelled. Legumes and cereals are quantified for sale using standard containers for measurement such as 150 ml plastic bowls or empty cans of tomato paste or concentrated milk that are widely available.

Dieticians are scarce in Cameroon and when available are not dedicated to renal patients. Dietary prescriptions for the majority of CKD patients are therefore made by nephrologists who usually lack expertise in renal nutrition and who are often responsible for the care of a large number of patients. Only two of the nine hospitals in Cameroon with renal services have a dietician, and these dieticians service the entire hospital patient population. In a recent survey in our unit, less than a quarter of our patients in the pre-dialysis clinic had consulted a dietician about a renal diet (unpublished data). Nephrologists in Cameroon have thus learnt how to design diets for CKD patients during their clinical practice.

The prescription and design of LPDs in Cameroon are challenging because of resource limitations, a shortage of healthcare personnel and protean dietary practices. In our practice, only moderate LPDs of 0.6 g protein per kg bodyweight per day (moderate LPD) and relatively mild LPDs of 0.7–0.8 g protein per kg bodyweight per day (mild LPD) are prescribed for CKD patients. Several types of LPD have been well-described including the traditional LPD, vegan LPD, vegan LPD supplemented with amino and keto acids, LPD with protein-free food and a very low protein diet of 0.3 g protein per kg bodyweight per day [25]. Only the traditional LPD with mixed protein intake is feasible in Cameroon. Amino and keto acid supplements are not available locally and their cost precludes importation for the majority of patients. The moderate LPD is prescribed to patients with stage 3 or 4 CKD who have non-nephrotic proteinuria, no interrcurrent acute illnesses and no clinical evidence of malnutrition. The mild LPD is prescribed to patients with stage 3 or 4 CKD with nephrotic proteinuria but no signs of malnutrition, CKD with no uremic signs or symptoms and stage 5 CKD on non-dialysis treatment. In the absence of pre-weighed foods and meals, we have devised simple ways of enabling patients to estimate protein quantities, such as the distribution of photographs of 100 g portions of meat; fish and chicken to illustrate quantities. We have learnt, for instance, that the drumstick of an average-sized chicken weighs approximately 200 g, and an average egg provides about 6 g of protein. We have also found published data on the protein content of composite meals similar to those sold in roadside restaurants to be very useful for diet design [11, 16, 18, 21]. For instance, data on corn chaff (corn, beans, palm oil, crayfish, salt, Maggi cube), a composite meal commonly sold in roadside restaurants, reveal that it contains 11.7 g protein per100 g and that a serving at these restaurants typically weighs about 640 g [18].

The reliance on patient funds for healthcare means that we do not request additional clinic visits for patients on LPDs or use multiple Para clinical tests to assess or monitor their nutritional status, because they are generally unaffordable. However, before prescribing the diet, we do evaluate the body mass index of patients without oedema; and perform a subjective global assessment of nutritional status using a validated questionnaire. Para clinical assessments are limited to a serum albumin assay, which may be requested if the patient can afford it. This evaluation is performed at each follow-up visit, with the exception of serum albumin which is requested 6-monthly. We have also used haemoglobin and serum phosphorus and cholesterol levels as indicators of nutritional status, measured as part of routine patient care. Adherence to LPD is poor in our practice. Only 36 % of 28 patients prescribed a traditional 0.6–0.8 LPD in our outpatient clinic were adherent (Unpublished data). In our experience, assessments of patient nutritional status during their routine follow-up visits are sufficient and do not significantly increase consultation time.

In conclusion, the use of LPDs for CKD patients is challenging in Cameroon. There are no renal dieticians, and the nephrologists who play this role have limited nutritional expertise. Furthermore, the lack of amino and keto acid supplements as well as the composite nature of meals in Cameroon limit the type of LPD that can be prescribed. The high rate of late presentation for care observed in CKD patients and the high personal cost of healthcare precludes the use of this therapy for many patients. Several strategies may increase the use of LPDs in CKD patients in Cameroon, such as improving the knowledge and practice of nephrologists and nurses in nutrition and making amino and keto acid supplements accessible to patients.