The Case for Prevention of CKD in India

The Case for Prevention of CKD in India SK Agarwal

All India Institute of Medical Sciences § Established in 1956 § Made by a separate act of parliament § An autonomous institute AIIMS § 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 § 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 AIIMS

The Case for Prevention of CKD in India Outline § Introduction § Magnitude of problem of CKD in Indians • 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 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/DOQI Stages 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 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, 000, Or 100 / pmp / year ( Extrapolation from western data )

Screening & management of kidney disease Kidney Help Trust of Chennai With ‘ Tulsi Rural Development Trust ’ MK Mani Kidney Int 63(Suppl 83); S 86 -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 & Hb. A 1 c • If required, further tests were done in the hospital Kidney Int 63(Suppl 83); S 86 -689, 2003

Screening & management of kidney disease Cont… • 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 Kidney Int 63(Suppl 83); S 86 -689, 2003

Screening & management of kidney disease Results: § Hypertension 5. 26 % § Diabetes 3. 6 % § Kidney Diseases (Not CRF) 0. 7 % § Chronic Renal Failure 0. 16 % § BP control achieved 96 % § Diabetes controlled (Hb. A 1 c<7%) 50 % § Overall persons required help 7. 5% § New diabetes 0. 32% § New Hypertension 0. 55% Kidney Int 63(Suppl 83); S 86 -689, 2003

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

Material & Methods § 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

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

Material & Methods (cont. ) Sample size estimation 4 x p x q / d 2 Prevalence study p q d = = = Presumed Prevalence = 1 -p = 25% of p 5, 056 (Random sample technique) 10, 112 (Multi stage cluster sample) Presumption § Incidence of ESRD / year 1, 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 § Diabetes Normal < 140 < 90 Stage 1 140 -159 90 -99 Stage 2 > 160 > 99 Known diabetes on drug Random sugar > 200 mg% + +ve urine

Results § 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

Other Important Observations § 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 %

Increasing Prevalence of Diabetes in India Year Place Authors Prevalence (%) 1979 1988 1997 2000 2001 ICMR Kudermukh Chennai Thiruvananthpuram Kashmir Dombivilli New Delhi Chennai (CUSP) Chennai Ahuja et al Ramachandran Kutty et al Zargar et al Lyer et al Misra et al Mohan et al Ramachandrar 2. 1 (2. 3/1. 5) 5. 0 11. 6 12. 4 6. 1 7. 5 10. 3 12 12. 1 2003 Delhi Agarwal et al > 11. 16 Mohan V et al IJMR 2001; 116: 121 -132

Results (cont. ) Etiology of CRF § 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%)

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% § 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% Our study represent unbiased data and sample collection

Extrapolation of ESRD § Prevalence of CRF in adult § NHANES III USA 88 -94, Scr > 1. 7 § Prevalence of ESRD in adults 7852 / pmp ESRD 1/12 of CRF 785 / pmp • 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 Cs. A 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 § Incidence of ESRD in India 785/3 = 261 / pmp

Outline § Introduction § Magnitude of problem of CKD in Indians • In Indian in other countries § Status of RRT in India § Cost of RRT in India § Economic facts of the country § Summary

No / pmp / Yr Incidence of ESRD in Indo-Asian in UK • 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) Ball S. et al Q J Med 2001; 94: 187 -193

No / pmp / Yr Incidence of ESRD by etiology in Indo-Asian in UK 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 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

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 • Cs. A+Pred+AZA usual immunosuppression • FK, MMF, Monoclonal are in few and Pvt. Set-up

Growth of Cadaver RT in India 1994 -2003 (June) Total number 518 441 377 312 272 182 99 48 133

i hi M um ba A i hm ed ab ad Pu ne Ve Co llor im e ba to re Ba ng lo re H yd er ab ad O th er s el D na en Ch Current Status of Cadaver RT in India: State wise 1994 -2003 (June)

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 Indian in other countries § Status of RRT in India § Cost of RRT in India § Economic facts of the country § Summary

Economics of Dialysis in India US $ / month 400 500 250 150

Economics of Renal Transplant in India US $ / month 6000 3000 2500 800 200 600

Outline § Introduction § Magnitude of problem of CKD in Indians • 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

Summary Incidence of ESRD 260 / pmp RT 3 / pmp CAPD 1 / pmp Govt. spend 8$/capita/yr What to rest 254 pmp ? HD 2 / pmp RRT /person /yr 750 -3000 $ Death Prevention is only solution