SK Agarwal The Case for Prevention of CKD in India.

SK Agarwal

The Case for Prevention of

CKD in India

All India Institute of Medical Sciences

AIIMS

Established in 1956 Made by a separate act of parliament An autonomous institute First medical school in merit for years of survey Single center with max. no of medical publications Three aims

• Teaching• Research• Patient care

Provides undergraduate & Postgraduate training 550 faculty in various department Nearly 2000 beds www.aiims.ac.in

Department of Nephrology

AIIMS

Established as unit of medicine 1971

Separate department since 1989

5 faculty members

8 Registrars at a time

Doing haemodialysis since 1971

Doing renal transplant since 1972

Currently doing nearly 100 RT in a year

Has done 42 cadaver RT

First Kidney+Pancreas few days back

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

The Case for Prevention of CKD in India

Outline

Introduction


• In India

• In Indian in other countries




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


• In India





Summary

It is presumed that

incidence of ESRD in India is 1,00,000,

Or 100 / pmp / year

( Extrapolation from western data )

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



• 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


Cont…



Results:


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%

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


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


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


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


• In India





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


• In India





Summary

Status of HD

in India

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


• In India





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


• In India





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

SK Agarwal The Case for Prevention of CKD in India.

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