Background
Post-kala-azar dermal leishmaniasis (PKDL) is a neglected complication of visceral leishmaniasis (VL) treatment with significant public health implications, particularly in Eastern Africa where it can sustain interepidemic transmission. Despite its importance, no comprehensive synthesis of PKDL burden, risk factors, and treatment outcomes specific to the region exists.
Methods
This systematic review and meta-analysis followed PRISMA 2020 guidelines and JBI methodology. A comprehensive search was conducted across PubMed/MEDLINE, Scopus, AJOL, and the Cochrane Library from database inception through May 12, 2026. Studies reporting PKDL incidence, risk factors, or treatment outcomes among VL patients in Eastern Africa were eligible. Random-effects meta-analysis was used to pool cumulative incidence estimates, and heterogeneity was assessed using the I 2 statistic. For risk factor and treatment outcome studies, a narrative synthesis were performed. Meta-analyses were performed using the meta package in R version 4.5.2 (2025-10-31).
Results
Eleven studies encompassing 4,699 patients from Sudan, Ethiopia, Kenya, and Uganda were included. The pooled cumulative PKDL incidence was 18.2% (95% CI: 4.7%–49.7%), with substantial heterogeneity (I 2 = 98.1%). Follow-up duration for PKDL assessment varied across studies, ranging from 6 to 24 months. Significant geographic and temporal variation was observed. Sudan reported the highest pooled incidence (56.7%) in studies conducted during the SSG-monotherapy era (1994–2000), compared to Ethiopia (4.6%, 2021) and multi-country cohorts (8.2%, 2022), with more recent supervised treatment data from Sudan and Kenya (2024) showing substantially lower incidence. A temporal decline was noted, from 56.7% pre-2010 to 6.4% post-2010, coinciding with the transition away from sodium stibogluconate monotherapy. Key risk factors included VL treatment regimen, younger age, geographic location, and HIV co-infection. The miltefosine plus paromomycin (MF + PM) combination achieved a clinical cure rate of 98.2% in a Phase II trial, outperforming liposomal amphotericin B combinations.
Conclusion
PKDL remains a significant post-treatment complication in Eastern Africa, with treatment regimen as the most critical modifiable risk factor. MF + PM shows promise as a preferred first-line PKDL therapy. Standardized surveillance and multicountry prospective studies are urgently needed to support regional elimination goals.
BT - PLOS Neglected Tropical Diseases DA - 08/2026 DO - 10.1371/journal.pntd.0014666 IS - 8 LA - ENG M3 - Article N2 -Background
Post-kala-azar dermal leishmaniasis (PKDL) is a neglected complication of visceral leishmaniasis (VL) treatment with significant public health implications, particularly in Eastern Africa where it can sustain interepidemic transmission. Despite its importance, no comprehensive synthesis of PKDL burden, risk factors, and treatment outcomes specific to the region exists.
Methods
This systematic review and meta-analysis followed PRISMA 2020 guidelines and JBI methodology. A comprehensive search was conducted across PubMed/MEDLINE, Scopus, AJOL, and the Cochrane Library from database inception through May 12, 2026. Studies reporting PKDL incidence, risk factors, or treatment outcomes among VL patients in Eastern Africa were eligible. Random-effects meta-analysis was used to pool cumulative incidence estimates, and heterogeneity was assessed using the I 2 statistic. For risk factor and treatment outcome studies, a narrative synthesis were performed. Meta-analyses were performed using the meta package in R version 4.5.2 (2025-10-31).
Results
Eleven studies encompassing 4,699 patients from Sudan, Ethiopia, Kenya, and Uganda were included. The pooled cumulative PKDL incidence was 18.2% (95% CI: 4.7%–49.7%), with substantial heterogeneity (I 2 = 98.1%). Follow-up duration for PKDL assessment varied across studies, ranging from 6 to 24 months. Significant geographic and temporal variation was observed. Sudan reported the highest pooled incidence (56.7%) in studies conducted during the SSG-monotherapy era (1994–2000), compared to Ethiopia (4.6%, 2021) and multi-country cohorts (8.2%, 2022), with more recent supervised treatment data from Sudan and Kenya (2024) showing substantially lower incidence. A temporal decline was noted, from 56.7% pre-2010 to 6.4% post-2010, coinciding with the transition away from sodium stibogluconate monotherapy. Key risk factors included VL treatment regimen, younger age, geographic location, and HIV co-infection. The miltefosine plus paromomycin (MF + PM) combination achieved a clinical cure rate of 98.2% in a Phase II trial, outperforming liposomal amphotericin B combinations.
Conclusion
PKDL remains a significant post-treatment complication in Eastern Africa, with treatment regimen as the most critical modifiable risk factor. MF + PM shows promise as a preferred first-line PKDL therapy. Standardized surveillance and multicountry prospective studies are urgently needed to support regional elimination goals.
PB - Public Library of Science (PLoS) PY - 2026 SP - 1 EP - 19 T2 - PLOS Neglected Tropical Diseases TI - From visceral to visible: A systematic review and meta-analysis of post-kala-azar dermal leishmaniasis incidence, risk factors, and treatment outcomes in Eastern Africa UR - https://journals.plos.org/plosntds/article/file?id=10.1371/journal.pntd.0014666&type=printable VL - 20 SN - 1935-2735 ER -