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 

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  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/DOQI Stages of Chronic Kidney Disease StagesDescriptionGFR 1Kidney Damage with N/  GFR> 90 2Mild  GFR Moderate  GFR Severe  GFR 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 )

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

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 %  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%

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

 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

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 / 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.)

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

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

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

Increasing Prevalence of Diabetes in India YearPlace AuthorsPrevalence (%) 1979ICMR Ahuja et al2.1(2.3/1.5) 1988Kudermukh Ramachandran Chennai Ramachandran Thiruvananthpuram Kutty et al Kashmir Zargar et al Dombivilli Lyeret al New Delhi Misra et al Chennai (CUSP) Mohan et al Chennai Ramachandrar Delhi Agarwal et al> Mohan V et al IJMR 2001;116:

 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 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%

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

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 No / pmp / Yr Ball S. et al Q J Med 2001;94: RR of ESRD in Indo-Asian is 3.8 ( ) RR of ESRD adjusted for age is 6.6 ( )

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

ESRD in Asians in USA USRDS 2002

ESRD in Singapore IncidencePrevalence Overall ESRD Chinese Malay Indian Data of 1997 Singapore renal Registry Data is pmp Personal communication Sylvia Ramirez

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

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

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 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 (June) Total number

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

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 Yr yr 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

US $ / month Economics of Dialysis in India

US $ / month Economics of Renal Transplant in India

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 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

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