1. Saleem Jessani 1, Rasool Bux 1 and Tazeen H. Jafar 1,2. 1 Aga Khan University, Karachi, Pakistan 2 Duke-NUS Graduate Medical School, Singapore Socio-demographic CKD IN PAKISTAN Socio-demographic and Clinical Determinants

2. INTRODUCTION CKD is increasing being recognized as a global public health problem. CKD is associated with substantial morbidity and mortality. It affects about 5–7% of the world population and is more common in developing countries However, information on the prevalence and determinants of CKD and its management in the developing countries especially the South Asian region is lacking.

3. OBJECTIVES To determine the prevalence of CKD To determine socio-demographic and clinical factors associated with CKD To explore the existing management of patients with CKD with regards to  BP control  Use of antihypertensive medications

4. METHODS Study design - Study design - Population based cross-sectional study Study participants - Study participants - 2873 adults from the COBRA StudyPredictors  Socio-demographic: Age, Sex, Education, Tobacco use & Physical activity  Clinical: BMI, Hypertension, Diabetes, SBP, DBP, h/o CAD, h/o Stroke, Fasting Glucose, Triglycerides, Total Cholesterol, LDL, HDL,

5. METHODS (CONT…) Study outcome  CKD was defined as eGFR < 60 mL/min/1.73 m 2 (reduced eGFR) or Urine ACR ≥ 30 mg/g (albuminuria) based on the spot urine sample eGFR was estimated using the CKD-EPI Pakistan equation (0.686 × CKD-EPI 1.059 (Jessani et al. AJKD 2014.)

6. Rationale for using CKD-EPI Pakistan P 30 Accuracy = 68.0%P 30 Accuracy = 76.1%

7. Rationale for using CKD-EPI Pakistan P 30 Accuracy = 76.1%P 30 Accuracy = 81.6% Correction Factor: 0.686 × CKD-EPI 1.059

8. Prevalence of CKD and Reduced eGFR Age groups / Disease Prevalence, % (95% CI) Overall (n=2873)Men (N= 1374)Women (N=1499) Overall (n=2873) CKD Reduced eGFR 12.5 (11.3 – 13.8) 5.3 (4.5 – 6.2) 11.6 (9.9 – 13.4) 5.2 (4.1 – 6.5) 13.3 (11.7 – 15.2) 5.5 (4.4 – 6.7) 40 – 49 yrs (n=1429) CKD Reduced eGFR 5.9 (4.7 – 7.2) 1.3 (0.7 – 2.0) 6.2 (4.5 – 8.3) 1.6 (0.8 – 2.9) 5.6 (4.1 – 7.5) 0.9 (0.4 – 1.9) 50 – 59 yrs (n=755) CKD Reduced eGFR 14.2 (11.8 – 16.9) 5.3 (3.8 – 7.1) 11.5 (8.4 – 15.3) 4.9 (3.0 – 7.7) 16.6 (13.1 – 20.7) 5.6 (3.6 – 8.4) ≥ 60 yrs (n=689) CKD Reduced eGFR 24.4 (21.2 – 27.8) 13.8 (11.3 – 16.6) 22.6 (18.2 – 27.5) 12.7 (9.3 – 16.7) 26.1 (21. 6 – 30.9) 14.8 (11.3 – 19.0)

9. Socio-demographic and Clinical Characteristics of individuals with and without CKD CharacteristicsTotal (n=2873) CKD Status Negative 2514 (87.4) Positive 359 (12.5) Age in years, mean ± SD51.5 ± 10.750.5 ± 10.058.8 ± 12.3* Women, n (%)1499 (52.2)1299 (51.7)200 (55.7) Primary or higher Edu, n (%)1881 (65.5)1682 (66.9) 199 (55.4)* Current Tobacco users, n (%)1113 (38.7) 980 (39.0) 133 (37.0) Phy. Activity, METs < 840, n (%)1725 (60.0)1473 (58.6)252 (70.2)* Hypertension, n (%)1267 (44.9)1013 (41.0)254 (72.2)* Diabetes Mellitus, n (%)615 (21.4)465 (18.5)150 (41.8)* History of CHD, n (%)246 (8.6)203 (8.1)43 (12.0)* History of stroke, n (%)88 (3.1)59 (2.3)29 (8.1)* Body mass index, mean ± SD25.8 ± 5.5 25.7 ± 5.1 Systolic BP, mean ± SD137 ± 24135 ± 22153 ± 27* Diastolic BP, mean ± SD86 ±1385 ±1291 ± 15* Fasting glucose, mean ± SD115.8 ± 50.9112.5 ± 46.8138.9 ± 69.3* S. Cholesterol, mean ± SD188.0 ± 39.3187.0 ± 37.8194.8 ± 48.2* LDL, mean ± SD115.6 ± 30.9115.2 ± 29.8118.7 ± 37.1 HDL, mean ± SD40.2 ± 10.240.1 ± 9.941.0 ± 12.2 Triglycerides, mean ± SD159.3 ± 95.5156.4 ± 93.9179.3 ± 103.8*

10. Multivariable Regression Models for CKD Characteristics Model 1 Adj. OR (95% CI) Model 2 Adj. OR (95% CI) Age in years / For each 1 year increase1.06 (1.05 – 1.07) Physical Activity < 840 METs vs. ≥ 840 METs 1.35 (1.04 – 1.75) - Hypertension Hypertensive vs. Non-hypertensive NA 1.90 (1.40 – 2.57) Diabetes mellitus Diabetic vs. Non-diabetic NA 1.69 (1.18 – 2.43) History of stroke Positive vs. Negative NA 1.73 (1.03 – 2.92) Systolic BP / each 1 mmHg increase NA 1.014 (1.008 – 1.020) Fasting glucose / each 1 mg/dL increase NA 1.004 (1.001 – 1.007) Triglycerides / each 1 mg/dL increase NA 1.002 (1.00 – 1.003) Model1 = Socio-demographic determinants; Model 2 = Socio-demographic & clinical determinants

11. BP Control and Use of Antihypertensive medications among CKD Patients Characteristics Overall Urine ACR, mg/g, n (%, 95% CIs) <30.0≥ 30.0 n=267N=56N=211 BP ≤ 140/90 mm Hg, n (%) (95% CI) 51 (19.1) (14.6 – 24.3) 13 (23.2) (13.0 – 36.4) 38 (18.0) (13.1 – 23.9) BP ≤ 130/80 mm Hg, n (%) (95% CI) 17 (6.4) (3.8 – 10.0) 6 (10.7) (4.0 – 21.9) 11 (5.2) (2.6 – 9.1) Use of Antihypertensive meds, n (%) (95% CI) 130 (48.7) (42.6 – 54.9) 33 (58.9) (45.0 – 71.9) 97 (46.0) (39.1 – 52.9)

12. Use of Antihypertensive Medications by Class of Drugs among CKD Patients Antihypertensive medications Overall Urine ACR, mg/g, n (%, 95% CIs) <30.0≥ 30.0 n=267N=56N=211 ACEI/ARB 26 (9.7) (6.5 – 13.9) 7 (12.5) (5.2 – 24.1) 19 (9.0) (5.5 – 13.7) Beta blockers 43 (16.1) (11.9 – 21.1) 9 (16.1) (7.6 – 28.3) 34 (16.1) (11.4 – 21.8) Calcium channel blockers 18 (6.7) (4.0 – 10.4) 4 (7.1) (2.0 – 17.3) 14 (6.6) (3.7 – 10.9) Diuretics 3 (1.1) (0.2 – 3.2) 2 (3.6) (0.4 – 12.3) 1 (0.5) (0.0 – 2.6) Alpa-2 agonist /alpha blockers 4 (1.5) (0.4 – 3.8) 1 (1.8) (0.0 – 9.6) 3 (1.4) (0.3 – 4.1) Combinations† 36 (13.5) (9.6 – 18.2) 10 (17.9) (8.9 – 30.4) 26 (12.3) ( 8.2 – 17.5) †Combinations are based on various groups of above mentioned anti-hypertensive drugs.

13. CONCLUSIONS CKD is common among Pakistani adults. BP control among these patients is grossly sub-optimal. The socio-demographic and clinical factors associated with CKD highlight the need for integration of CKD prevention efforts along with other non-communicable diseases in Pakistan.

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