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SK Agarwal

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 First medical school in merit for years of survey Single center with max. no of medical publications

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SK Agarwal

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

  2. 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 Kidney+Pancreas 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

  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. 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

  11. 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 & 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 (HbA1c<7%) 50 % • Overall persons required help 7.5% • New diabetes 0.32% • New Hypertension 0.55% Kidney Int 63(Suppl 83);S86-689, 2003

  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. Material & Methods • DesignPopulation based cross sectional survey • Setting Persons in the community • DurationThree years • InclusionAll persons > 14 years of age • ExclusionNot willing to take part in study

  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. 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

  18. 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

  19. 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

  20. 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 Normal < 140 < 90 Stage 1 140-159 90-99 Stage 2 > 160 > 99 • Diabetes Known diabetes on drug Random sugar > 200 mg% + +ve urine

  21. 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

  22. Other Important Observations • Total Hypertension22.82 % • 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 %

  23. 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 > 11.16 Mohan V et al IJMR 2001;116:121-132

  24. 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%)

  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 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

  27. Extrapolation of ESRD • Prevalence of CRF in adult 7852 / pmp • NHANES III USA 88-94, Scr > 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 • < 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

  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 • 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

  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 • 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

  33. 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

  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 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

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