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CHRONIC KIDNEY DISEASE PROBLEMS AND SOLUTIONS IN INDIAN SCENARIO
Outline
Introduction
Magnitude of problem of CKD in Indians
• In India
• In Indians of other countries
Status of RRT in India
Cost of RRT in India
Economic facts of the country
Summary
Outline
Introduction
Magnitude of problem of CKD in Indians
• In India
• In Indian in other countries
Status of RRT in India
Cost of RRT in India
Economic facts of the country
Summary
Why The Emphasis on CKD
World wide prevalence is high
It is a major public health problem
Global incidence of 1.8 million / year (WHO,2002)
Morbidity, mortality and resource utilization is
high
Sub-optimal care contributes to the further high
resource utilization and more mortality
Even mild disease is also a risk factor for death
NKF – K/DOQIStages of Chronic Kidney Disease
Stages Description GFR
1 Kidney Damage with N/ GFR
> 90
2 Mild GFR 60-89
3 Moderate GFR 30-59
4 Severe GFR 15-29
5 Kidney Failure < 15 or
Dialysis
Outline
Introduction
Magnitude of problem of CKD in Indians
• In India
• In Indian in other countries
Status of RRT in India
Cost of RRT in India
Economic facts of the country
Summary
It is presumed that
incidence of ESRD in India is 1,00,000,
Or 100 / pmp / year
( Extrapolation from western data )
Major Causes of Chronic Kidney Disease
0
10
20
30
40
50
60
Diabetes Ht Parenchymal
AIIMS, New Delhi
Apollo, Chennai
PGI, Chandigarh
(CGN+TID)
Agarwal
et al (2000)
Mittal et al
(1997)
Sakuja et al
(1994)
Mani MK
(1993)Mean Agarwal et
al ( 2002 )
No of Cases
7072 835 453 2028 10388
37
DN 28.4 23.2 23.8 26.7 25 41Ht 5.7 4.1 13.5 10 8.3 22GMn 48.5 28.6 36.6 18.2 32.9 16TID 7.5 16.5 14.3 27.8 16.5 5.4PKD 1.9 2 3.5 2 2.3 0
Etiology of CKD in India
Hospital based studies Field study
Top 10 Specific Causes of Death in India, 1998
Causes No in thousands
% India / World
CAD 1471 15.8 19.9
Acute LRT Inf. 969 10.4 28.1
Diarrhoeal Dis 711 7.6 32.1
CVA 557 6.0 10.9
TB 421 4.5 28.1
ESRD 250 ??? ???
RT Accidents 217 2.3 18.5
Measles 190 2.0 21.4
HIV/AIDS 179 1.9 7.8
Tetanus 165 1.8 40.3
COPD 153 1.6 6.8
Total Deaths 9337 100 17.3
Total Population 982223 100 16.7
Kidney Help Trust of Chennai
MK Mani
With ‘ Tulsi Rural Development Trust ’
Kidney Int 63(Suppl 83);S86-689, 2003
Screening & management of kidney disease
Screening & management of kidney disease
Kidney Int 63(Suppl 83);S86-689, 2003
• A village with 25,000 population was taken
• A card of each household with all members of family
• School passed girls trained as Prevent. Social Health Worker
• They use a cycle & apply a questionnaire
• Urine examined for Protein with Sulphosalicylic acid
Sugar with Benedict’s solution
• Blood pressure recorded for every one > 5 yr
• Persons with abnormal BP or test called to temporary center (7.5%)
• Blood taken for Urea, Creatinine & HbA1c
• If required, further tests were done in the hospital
• Samples were tested at Apollo hospital, Chennai
• Doctor went to makeshift center once a wk
• Nephrologist went to center once a month
• Ht treated with Reserpine, Thiazide and Hydrallazine
• Diabetes was treated with Glibenclamide & Metformin
Screening & management of kidney disease
Cont…
Kidney Int 63(Suppl 83);S86-689, 2003
Screening & management of kidney disease
Results:
Kidney Int 63(Suppl 83);S86-689, 2003
Hypertension 5.26 % Diabetes 3.6 % Kidney Diseases (Not CRF) 0.7 % Chronic Renal Failure 0.16 % BP control achieved 96 % Diabetes controlled (HbA1c<7%) 50 % Overall persons required help 7.5% New diabetes 0.32% New Hypertension 0.55%
PREVALENCE OF TYPE 2 DIABETES IN ASIA AND PACIFICPREVALENCE OF TYPE 2 DIABETES IN ASIA AND PACIFIC
Age-standardised to Segi’s world population 35-64 years except: * ³40 **30-59 ‡ 30-69 #20-64 § 40-69
0 10 20 30 40
Nauru
Urban PNG - Koki
Aboriginal Australian
Singapore
Urban Western Samoa
Pakistan
India
J apan
Indonesia
Malaysia
White USA
Taiwan
China
PNG Highlands
Prevalence diabetes (%)
#
*
**
§
To Study the Prevalence of CRF in India
Study funded by Indian Council of Medical Research, New Delhi
Agarwal SK et al, AIIMS New Delhi
Design Population based cross sectional
survey
Setting Persons in the community
Duration Three years
Inclusion All persons > 14 years of age
Exclusion Not willing to take part in study
Material & Methods
Multi-stage cluster sampling
Study done in urban area of city of Delhi
Target population was identified
Well defined geographical region identified
Set number of sample collected from each region
Went to center of region and moved in one direction
If number was not met, came back to center and
moved in other direction till number was completed
4 x p x q / d2 Sample size estimation
Prevalence study p = Presumed Prevalenceq = 1-pd = 25% of p= 5,056 (Random sample
technique)= 10,112 (Multi stage cluster
sample)
Presumption Incidence of ESRD / year 1,00,000 CRF cases are 15 times than ESRD Average survival of CRF in India is 5 years Adult population in India is 60% of total
population
Material & Methods (cont.)
Team of Doctor, Field investigator & Lab attendant
Study was explained to local community person for
cooperation
Team went to pre-fixed date & time to the field
Detail history taken and examination done, including
BP
Printed Performa was filled
Material & Methods (cont.)
Spot urine examined by dip stick for protein & sugar
Blood sample was drawn and taken to laboratory
Blood sample was examined for urea, creatinine and
sugar ( R )
Report of tests was given to person on next field visit
Person with abnormalities was asked to come to
hospital
Further check was done as per need in the hospital
Material & Methods (cont.)
Definitions
CRF Renal failure persisting for > 3 month
in
absence of reversible factor
Renal failure Serum creatinine > 1.8 mg%
Hypertension JNC VII criteria
Normal < 140 < 90
Stage 1 140-159 90-99
Stage 2 > 160 > 99
Diabetes Known diabetes on drug
Random sugar > 200 mg% + +ve
urine
Material & Methods (cont.)
Subjects evaluated 4972
Subjects gave blood sample 4712 (94.7%)
Mean age of subjects 42.38 12.54
years
Males 56.16 %
No of cases with CRF 37
Prevalence of CRF in adults 0.79 %
Prevalence per million population 7852
Results
Total Hypertension 22.82 %
• Known Hypertension 15.48 %
• New Hypertension 7.34 %
Total Diabetes > 11.16 %
• Known diabetes 8.17 %
• New Diabetes 2.99 %
Renal Stone Disease > 3.07 %
Recurrent UTI > 1.93 %
Other Important Observations
Increasing Prevalence of Diabetes in India
Year Place Authors Prevalence (%)
1979 ICMR Ahuja et al 2.1 (2.3/1.5)1988 Kudermukh Ramachandran 5.01997 Chennai Ramachandran 11.62000 Thiruvananthpuram Kutty et al 12.42000 Kashmir Zargar et al 6.1 2001 Dombivilli Lyer et al 7.52001 New Delhi Misra et al 10.32001 Chennai (CUSP) Mohan et al 122001 Chennai Ramachandrar 12.1
2003 Delhi Agarwal et al > 11.16
Mohan V et al IJMR 2001;116:121-132
Diabetic Nephropathy 15 (41 %)
Hypertension 8 (22 %)
CGN 6 (16 %)
TID 2 (5.4 %)
Ischaemic Nephropathy 2 (5.4 %)
Obstructive Nephropathy 1 (2.7 %)
Miscellaneous 3 (8.1%)
Results (cont.) Etiology of CRF
Conclusions
Prevalence of CRF in adult 7825 / pmp
Diabetes and Ht constitute 63% of cases
Diabetes & Ht as cause of CRF
• Diabetes and Ht constitute 63% of
cases
• Mean age of CRF Pts 59 yrs
• Males 48%
Our study represent unbiased data and sample collection
Males 56% as a whole (Census India 2001, 54%)
Mean age of study group as a whole 42 Yrs
In Hospital based study, mean age is 50 Yrs in
CRF due to DM & Ht
If see CRF in > 40 yrs, DM & Ht formed > 55%
Extrapolation of ESRD
• Prevalence / mean survival = Incidence
• Only 10% of ESRD gets any RRT in India
• < 50% gets RT with graft half life on conventional IS being
8 years
• With CsA and others, it will be better, say 10 years
• In India, Patients half life is same as graft half life
• Mean survival in MHD and CAPD definitely less than 10
years
• 90% who do not get any RRT, mean survival 2 years
• Combining 10% Pts with RRT & 90% without any RRT, total
mean survival of ESRD in India will be 3 years
Prevalence of CRF in adult 7852 / pmp
Prevalence of ESRD in adults 785 / pmp
Incidence of ESRD in India 785/3 = 261 / pmp
NHANES III USA 88-94, Scr > 1.7 ESRD 1/12 of CRF
Outline
Introduction
Magnitude of problem of CKD in Indians
• In India
• In Indian in other countries
Status of RRT in India
Cost of RRT in India
Economic facts of the country
Summary
Incidence of ESRD in Indo-Asian in UK
0
50
100
150
200
250
Overall Caucasian AfricanCarribean
Indo-Asian
No /
pm
p /
Yr
Ball S. et al Q J Med 2001;94:187-193
• RR of ESRD in Indo-Asian is 3.8 (2.7-5.3)• RR of ESRD adjusted for age is 6.6 (4.5-9.7)
Incidence of ESRD by etiology in Indo-Asian in UK
0102030405060708090
DM GMn PKD IIN Unknown
Caucasian
Indo-Asian
No /
pm
p /
Yr
Ball S. et al Q J Med 2001;94:187-193
ESRD in Asians in USA USRDS 2002
ESRD in Singapore
Incidence Prevalence
• Overall ESRD 158 646
• Chinese 216 923
• Malay 262 953
• Indian 148 492
• Data of 1997 Singapore renal Registry• Data is pmp• Personal communication Sylvia Ramirez
Incidence of ESRD in Indians
Data source No/pmp
UK Indians 220
USRDS 2000 393
Singapore 148
Our Study 260
Outline
Introduction
Magnitude of problem of CKD in Indians
• In India
• In Indian in other countries
Status of RRT in India
Cost of RRT in India
Economic facts of the country
Summary
Status of HD
in India
Diabetes50%
Hypertension27%
Glomerulonephritis13%
Other10%
Primary Diagnoses for Patients Who Start Dialysis
United States Renal Data System (USRDS) 2005 Annual Data Report • WWW.USRDS.ORG
USA: 283,000
Latin Am: 82,000
Eur: 317,000
India: 20.000
China: 30,000
AUS/NZL: 11,000
Japan: 167,000
Schena, Kidney Int (Suppl 74), 2000
World-ESRD (1996)PrevalenceIncidence
1,000,000 220,000
DIALYSIS PATIENTS WORLD-WIDE (1996)
Status of Haemodialysis in India
• HD in India started in 1970
• Usually first modality of RRT in most of patients
• HD centers 0.3/pmp (total 300 centers)
• Average 2-4 dialysis station in one unit
• 30% in government & 70% in Private sector
• Government sector only RT oriented HD
• Maintenance haemodialysis only in private sector
• Almost all hospital based HD, home HD exceptional
• 15% RT, 15% death and 70% drop out/Temporary
Status of Haemodialysis in India (Cont…)
• 80-90% start HD with in month of presentation
• Planned AVF only in 10-20%
• Graft are < 2% cases
• Usually twice a week, 4 hrs
• Mostly cellulose membrane of 1.2 sqm area
• 60% acetate
• Dialyser reuse 4-5 times average,mostly manual
• Water is usually treated with deionizer / softner
• RO available in 20% centers
Status of Haemodialysis in India (Cont…)
• Tuberculosis incidence in 20-25% cases
• HBV still seen but not common 2-5%
• HCV very common 10-40% prevalence
• Chest bacterial infection common cause of mortality
• HD society of India formed in 2003
• First meeting of society on 19-22 March 2004
Status of CAPD
in India
CAPD Status in India
• CAPD in Indian subcontinent started in 1990
• In India CAPD started in 1990
• First case of CCPD in 1991
• First child on CAPD in 1993
• Free import of bags & accessaries since 1993
• Local manufacture of bags since 1996
• Till now nearly 2500 patients have been initiated
• Straight double cuff mostly
• Initially majority were “O” set, now 50% double bag
• Majority use 3 exchanges of 2 liter fluid
CAPD Status in India Cont…
• Nearly 70% patients on CAPD are diabetics
• Co-morbidity is high, Pts taken as last option
• Peritonitis rate 1/18 patients months
• Drop out rate is 50% at 1 year
• Very few cases are on CAPD by > 2 yrs
• Very few are on cycler
• Training is provided by company nurse
• Peritoneal Dialysis Society formed in 1997
• Indian J of Peritoneal Dialysis twice a year
Status of RT
in India
Status of RT in India
• This is most feasible and popular RRT in India
• 100 centers with 100 surgeons
• 75% in private set-up
• Approximately 3000 RT done each year
• Living related 50%, unrelated 30% and spouse 20%
• Waiting period 1-4 moths, less in Pvt. Set-up
• No organised cadaver program, limited to few cities
• CsA+Pred+AZA usual immunosuppression
• FK, MMF, Monoclonal are in few and Pvt. Set-up
Growth of Cadaver RT in India
0
100
200
300
400
500
6001994-2003 (June)
Total number
377
272
518
4899
133182
312
441
Current Status of Cadaver RT in India: State wise
0
20
40
60
80
100
120
140
160
180
1994-2003 (June)
Chenn
aiDel
hiMum
bai
Ahmed
abad
Pune
Vellore
Coim
bato
reBan
glor
eHyd
erab
adOth
ers
Status of RT in India (Cont…)
• Infections very common 70-80%
• Bacterial chest infection most common cause of death
• TB, hepatitis, fungal and CMV all frequently seen
• Survival is not bad
Patient Graft
1 Yr 95 90
5 Yr 75 70
10 yr 55 55
Outline
Introduction
Magnitude of problem of CKD in Indians
• In India
• In Indian in other countries
Status of RRT in India
Cost of RRT in India
Economic facts of the country
Summary
0
50
100
150
200
250
300
350
400
450
500
HD CAPD Medicine
Govt
Pvt
US $ / month
Economics of Dialysis in India
150
400500
250
0
1000
2000
3000
4000
5000
6000
Procedure IS with CsA/Yr IS without CsA/Yr
Govt
Pvt
US $ / month
Economics of Renal Transplant in India
800
6000
2500
200
3000
600
Outline
Introduction
Magnitude of problem of CKD in Indians
• In India
• In Indian in other countries
Status of RRT in India
Cost of RRT in India
Economic facts of the country
Summary
Economic Facts Of India
Population > 1027 x 106
Per Capita Income = $ 460 / Yr
Tax Payer (> $1,000/yr) = 2.2 %
Below Poverty Line (<100$/yr) = 30%
Government Spends = 8$ / capita /yr
SummaryIncidence of ESRD
260 / pmp
RT3 / pmp CAPD
1 / pmp
HD2 / pmp
Govt. spend8$/capita/yr
RRT /person /yr750-3000 $
What to rest 254 pmp ? Death
Prevention is only solution
Who should be screened for CKD?Who should be screened for CKD?
Suggested Goals for CKD Patients esp. with Diabetes and High Blood Pressure
• Lifestyle modifications (no obesity, regular exercise)
• BP 130/80 mmHg or lower, esp in diabetes or proteinuria)
• Maximal reduction of proteinuria (<1 g/d)
• Multiple BP lowering meds(3-4 meds or more, if needed)
• ACEIs, ARBs, Diuretics, Beta-Blockers, Non-Dihydropyridine-CCBs
• HbA1c at <7% (in diabetics)
• Dietary protein restriction (0.6 - 0.8 kg/d)
• Dietary sodium restriction (<2-3 g/d sodium)
• Lipid-lowering therapy (diet, statins)
CKD is a public health problem in India
Diabetes and Hypertension are common causes
Risk factors for CKD & CKD itself is easy to detect
Prevention program is the only way to handle CKD
Education for CKD is urgently needed
Summary
Thank you