1. SK Agarwal The Case for Prevention of CKD in India

2. 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

3. 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

4. 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

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/DOQI Stages of Chronic Kidney Disease StagesDescriptionGFR 1Kidney Damage with N/  GFR> 90 2Mild  GFR60-89 3Moderate  GFR30-59 4Severe  GFR15-29 5Kidney Failure< 15 or Dialysis

8. 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. 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

11. 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

12. 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

13. Screening & management of kidney disease Results: Kidney Int 63(Suppl 83);S86-689, 2003  Hypertension 5.26 %  Diabetes3.6 %  Kidney Diseases (Not CRF)0.7 %  Chronic Renal Failure0.16 %  BP control achieved96 %  Diabetes controlled (HbA1c<7%)50 %  Overall persons required help7.5%  New diabetes0.32%  New Hypertension0.55%

14. 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.  DesignPopulation based cross sectional survey  SettingPersons in the community  Duration Three years  Inclusion All persons > 14 years of age  ExclusionNot willing to take part in study Material & Methods

16. 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

17. 4 x p x q / d 2 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 / year1,00,000  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.)

18.  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.)

19.  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.)

20. Definitions  CRFRenal failure persisting for > 3 month in absence of reversible factor  Renal failureSerum creatinine > 1.8 mg%  HypertensionJNC VII criteria Normal< 140< 90 Stage 1140-15990-99 Stage 2> 160> 99  DiabetesKnown diabetes on drug Random sugar > 200 mg% + +ve urine Material & Methods (cont.)

21.  Subjects evaluated4972  Subjects gave blood sample 4712 (94.7%)  Mean age of subjects 42.38  12.54 years  Males56.16 %  No of cases with CRF37  Prevalence of CRF in adults0.79 %  Prevalence per million population7852 Results

22.  Total Hypertension22.82 % Known Hypertension15.48 % New Hypertension7.34 %  Total Diabetes> 11.16 % Known diabetes8.17 % New Diabetes2.99 %  Renal Stone Disease> 3.07 %  Recurrent UTI> 1.93 % Other Important Observations

23. Increasing Prevalence of Diabetes in India YearPlace AuthorsPrevalence (%) 1979ICMR Ahuja et al2.1(2.3/1.5) 1988Kudermukh Ramachandran5.0 1997Chennai Ramachandran11.6 2000Thiruvananthpuram Kutty et al12.4 2000Kashmir Zargar et al6.1 2001Dombivilli Lyeret al7.5 2001New Delhi Misra et al10.3 2001Chennai (CUSP) Mohan et al12 2001Chennai Ramachandrar12.1 2003 Delhi Agarwal et al> 11.16 Mohan V et al IJMR 2001;116:121-132

24.  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

25. Conclusions Prevalence of CRF in adult 7825 / pmp Diabetes and Ht constitute 63% of cases

26. Diabetes & Ht as cause of CRF Diabetes and Ht constitute 63% of cases Mean age of CRF Pts59 yrs Males48% 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%

27. 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 adults785 / pmp  Incidence of ESRD in India 785/3 = 261 / pmp  NHANES III USA 88-94, Scr > 1.7 ESRD 1/12 of CRF

28. 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

29. Incidence of ESRD in Indo-Asian in UK No / pmp / 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)

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

31. ESRD in Asians in USA USRDS 2002

32. ESRD in Singapore IncidencePrevalence Overall ESRD158 646 Chinese216 923 Malay262 953 Indian148 492 Data of 1997 Singapore renal Registry Data is pmp Personal communication Sylvia Ramirez

33. Incidence of ESRD in Indians Data sourceNo/pmp UK Indians220 USRDS 2000393 Singapore148 Our Study260

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

36. 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

37. 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

38. 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

41. 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

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

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

45. Current Status of Cadaver RT in India: State wise 1994-2003 (June) Chennai Delhi Mumbai Ahmedabad Pune Vellore Coimbatore Banglore Hyderabad Others

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 PatientGraft 1 Yr 9590 5 Yr 7570 10 yr 55

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

49. US $ / month Economics of Renal Transplant in India 800 6000 2500 200 3000 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 > 1027 x 10 6  Per Capita Income =$ 460 / Yr  Tax Payer (> $1,000/yr) =2.2 %  Below Poverty Line (<100$/yr) =30%  Government Spends =8$ / capita /yr

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