SK Agarwal

1
The Case for Prevention of CKD in India
SK Agarwal
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All India Institute of Medical Sciences

• 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

AIIMS
3
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 KidneyPancreas few days back

AIIMS
4
The Case for Prevention of CKD in India
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

5
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

6
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

7
NKF K/DOQIStages of Chronic Kidney Disease
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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

9
It is presumed that incidence of ESRD in India
is 1,00,000, Or 100 / pmp / year (
Extrapolation from western data )
10
Screening management of kidney disease

• Kidney Help Trust of Chennai
• MK Mani

With Tulsi Rural Development Trust
Kidney Int 63(Suppl 83)S86-689, 2003
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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 Benedicts solution

• Blood pressure recorded for every one gt 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

Kidney Int 63(Suppl 83)S86-689, 2003
12
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)S86-689, 2003
13
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 (HbA1clt7) 50
• Overall persons required help 7.5
• New diabetes 0.32
• New Hypertension 0.55

Kidney Int 63(Suppl 83)S86-689, 2003
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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
15
Material Methods

• Design Population based cross sectional survey
• Setting Persons in the community
• Duration Three years
• Inclusion All persons gt 14 years of age
• Exclusion Not willing to take part in study

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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

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Material Methods (cont.)

• Sample size estimation
• Prevalence study
• p Presumed Prevalence
• q 1-p
• d 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

4 x p x q / d2
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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

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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

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Material Methods (cont.)

• Definitions
• CRF Renal failure persisting for gt 3 month in
• absence of reversible factor
• Renal failure Serum creatinine gt 1.8 mg
• Hypertension JNC VII criteria
• Normal lt 140 lt 90
• Stage 1 140-159 90-99
• Stage 2 gt 160 gt 99
• Diabetes Known diabetes on drug
• Random sugar gt 200 mg ve urine

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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

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Other Important Observations

• Total Hypertension 22.82
• Known Hypertension 15.48
• New Hypertension 7.34
• Total Diabetes gt 11.16
• Known diabetes 8.17
• New Diabetes 2.99
• Renal Stone Disease gt 3.07
• Recurrent UTI gt 1.93

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Increasing Prevalence of Diabetes in India

• Year Place Authors Prevalence ()
• 1979 ICMR Ahuja et al 2.1 (2.3/1.5)
• 1988 Kudermukh Ramachandran 5.0
• 1997 Chennai Ramachandran 11.6
• 2000 Thiruvananthpuram Kutty et al 12.4
• 2000 Kashmir Zargar et al 6.1
• 2001 Dombivilli Lyer et al 7.5
• 2001 New Delhi Misra et al 10.3
• 2001 Chennai (CUSP) Mohan et al 12
• 2001 Chennai Ramachandrar 12.1
• Delhi Agarwal et al gt 11.16

Mohan V et al IJMR 2001116121-132
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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)

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Conclusions
Prevalence of CRF in adult 7825 / pmp Diabetes
and Ht constitute 63 of cases
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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 gt 40 yrs, DM Ht formed gt 55

Our study represent unbiased data and sample
collection
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Extrapolation of ESRD

• Prevalence of CRF in adult 7852 / pmp

• NHANES III USA 88-94, Scr gt 1.7 ESRD
  1/12 of CRF

• Prevalence of ESRD in adults 785 / pmp

• Prevalence / mean survival Incidence
• Only 10 of ESRD gets any RRT in India
• lt 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

• Incidence of ESRD in India 785/3 261 / pmp

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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

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

• 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 200194187-193
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Incidence of ESRD by etiology in Indo-Asian in UK
No / pmp / Yr
Ball S. et al Q J Med 200194187-193
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ESRD in Asians in USA
USRDS 2002
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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

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Incidence of ESRD in Indians
34
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

35
Status of HD in India
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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

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Status of Haemodialysis in India (Cont)

• 80-90 start HD with in month of presentation
• Planned AVF only in 10-20
• Graft are lt 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

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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

39
Status of CAPD in India
40
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

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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 gt 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

42
Status of RT in India
43
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
• CsAPredAZA usual immunosuppression
• FK, MMF, Monoclonal are in few and Pvt. Set-up

44
Growth of Cadaver RT in India
1994-2003 (June) Total number
518
441
377
312
272
182
133
99
48
45
Current Status of Cadaver RT in India State wise
1994-2003 (June)
Pune
Vellore
Chennai
Others
Delhi
Coimbatore
Banglore
Mumbai
Ahmedabad
Hyderabad
46
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

47
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

48
Economics of Dialysis in India
US / month
500
400
250
150
49
Economics of Renal Transplant in India
US / month
6000
3000
2500
800
200
600
50
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

51
Economic Facts Of India

• Population gt 1027 x 106
• Per Capita Income 460 / Yr
• Tax Payer (gt 1,000/yr) 2.2
• Below Poverty Line (lt100/yr) 30
• Government Spends 8 / capita /yr

52
Summary
Incidence of ESRD 260 / pmp
RT 3 / pmp
HD 2 / pmp
CAPD 1 / pmp
Govt. spend 8/capita/yr
RRT /person /yr 750-3000
What to rest 254 pmp ?
Death
Prevention is only solution