| Abstract|| |
Bangladesh is one of the densely populated countries, a nation of 128 million people, 75% of whom lives in rural areas and the annual per capita gross national product (GNP) is US$ 380.00. The health care budget is 1.2% of GNP and the priority areas are population control, provision of clean drinking water and eradication of communicable diseases. The country has a small number of nephrologists and renal care is available in large cities only. The causes of renal diseases include glomerulonephritis, diabetes, hypertension, nephrolithiasis, obstructive uropathy and interstitial nephropathy. The incidence of end-stage renal disease is not known, but would be much higher than in developed countries because of high incidence of infection and environmental pollution. The treatment of ESRD has low priority in Bangladesh because of the government health policy and high cost of treatment. As a result, less than 10% of ESRD patients are able to maintain dialysis in private hospitals and governmental dialysis centers that are already overcrowded. The vast majority of patients who are started on dialysis die or stop treatment within the first three months. Renal transplantation is not as expensive as dialysis and is less costly in the university hospital than in private hospitals. Cyclosporine is usually replaced by azathioprine after six months of transplantation. Although organ act law is effective since 1998, cadaveric transplant has not picked up due to lack of infrastructure, facility and orientation regarding cadaveric transplantation. Preventive measures of renal disease can not be overemphasized.
Keywords: Renal Failure, Dialysis, Transplantation, Bangladesh.
|How to cite this article:|
Ur Rashid H. Health Delivery System for Renal Disease Care in Bangladesh. Saudi J Kidney Dis Transpl 2004;15:185-9
| Introduction|| |
Bangladesh is one of the most densely populated areas in the world. It is bordered by India and Burma. The total population, according to 2000 population census is 128 million; 64% is below 19 years of age and more than 75% lives in rural areas. Annual per capita gross national product (GNP) is 380 US dollars. The health care budget is 1.2% of the GNP and the priority areas of government spending on health are: population control, provision of clean drinking water, sanitation and control of communicable diseases.
The health care system is divided into primary in rural areas, secondary in cities and secondary and tertiary in divisional capitals. In addition, the larger cities provide medical care through medical college hospitals and postgraduate institutes. The governmental hospitals in villages and cities are overcrowded as treatment is provided free in them, whereas private hospitals are very costly and unaffordable by the majority. Renal disease care is available in 6 of 13 and dialysis in 4 of the 13 governmental and university hospitals. On the other hand, 10 private hospitals provide care and dialysis for renal patients. There is one kidney transplant center in the university hospital and another in the private sector.
| Patterns of renal diseases in Bangladesh|| |
Although national registries are not available, the data from different medical colleges and community based studies in this country suggest that glomerulonephritis, acute and chronic renal failure, urinary tract infection, renal stone diseases and obstructive uropathy are common renal problems.
Of the cases of glomerulonephritis, poststreptococcal acute glomerulonephritis is commoner in children than is minimal change nephrotic syndrome.  However in adults, minimal change disease comprises only 10% in our series. Other causes of glomerulonephritis are mesangial proliferative (29%), diffuse and focal sclerosis (20%), membranous nephropathy (17%) membranoproliferative (12%), and IgA nephropathy (6%). Of the secondary causes, lupus nephritis comprises less than 5% in our series. ,
The commonest cause of acute renal failure (ARF) both in children and adults is gastroenteritis (44%). Other medical causes in adults are severe infection (8%) and acute viral hepatitis (7%). The surgical causes of ARF account for 18% and the obstetrical complications for 11% of the total cases of ARF. 
| End-stage renal disease|| |
The exact incidence of end-stage renal disease (ESRD) is not known. The reported annual incidence from developing countries varies from 34 to 240 per million population (PMP);  this incidence is higher than that in the developed countries.  The increased incidence of ESRD in developing countries is probably due to high incidence of post-infectious glomerulonephritis, uncontrolled hypertension and untreated diabetes mellitus. Taking a conservative estimate of incidence of ESRD at 100/ million among the population of 128 million, an estimated 13000 new patients are likely to develop ESRD every year. The prevalence is much lower as most of the patients die due to lack of renal replacement therapy.
The causes of ESRD are shown in Table1. The commonest cause is glomerulonephritis (40%) followed by diabetes (31%) and hypertension (15%).  The incidence of glomerulonephritis decreased as compared to 1994, whereas the incidence of diabetes increased. This incidence is similar to that reported by other South Asian countries , The mean age of the patients with ESRD is 42 years, which is similar to India and Pakistan but much less than that of the developed countries (61 years). The lower mean age of the patients with ESRD could be explained in part by the delay in diagnosis and failure to institute appropriate therapy.
The majority of patients present late in the course of their disease. More than 80% of patients presenting with ESRD are usually unaware of their disease. Therefore, most of them either dialyze by temporary access like Jugular or femoral catheterization. Intermittent peritoneal dialysis (IPD) is done if hemodialysis is not available. The access to renal replacement therapy (RRT) is restricted to few governmental and private hospitals. Private dialysis clinics are largely situated in the main cities and few other larger cities outside Dhaka. Although governmental hospitals provide dialysis treatment free, they cover less than 20% of ESRD cases; 80% of ESRD patients dialyze in private centers. There is no health plan or charity organization to support this program. Kidney Foundation of Bangladesh has recently formed and has taken an ambitious plan for these patients.
| Renal Replacement Therapy (RRT)|| |
There are 14 dialysis centers, with 150 dialysis machines providing dialysis in three shifts in Bangladesh. The governmental hospitals and majority of the private sector dialysis units provide hemodialysis for 4 hours, twice a week using cellulose/polysulphone membrane. All dialysis units reuse the dialyzers after manual cleaning using 3% formaldehyde. Acetate buffer is used in more than 80% of the dialysis units. The average blood flow varies from 150-250ml and Kt/V is less than one, serum albumin 32 gm/L and hemoglobin 70-80 gm/l. Anemia is almost universal in dialysis patients and 85% patients on hemo dialysis need regular blood transfusion to correct anemia.
The survival rates for the patients on three times per week dialysis schedule were 77% and 57% at 3 and 5 years, whereas those on twice per week dialysis had survival rates of 55% and 40% at 3 and at 5 years, respectively. Moreover, the quality of life in our dialysis patients is not satisfactory. Only one third of the treated patients remain active at home or still employed.
Infection is common in patients on dialysis. The most common infections being hepatitis B, hepatitis C, and tuberculosis;  hepatitis B is prevalent in 5-10%, whereas hepatitis C is prevalent in 20-60% and tuberculosis in 7%.
The most important cause of death is irregular dialysis (33%), followed by cardiovascular and cerebrovascular causes. 
(b)Chronic Ambulatory Peritoneal Dialysis (CAPD)
CAPD is not a widely used modality of treatment in ESRD patients in Bangladesh. A total of 66 patients were on CAPD since 1998. Most of the patients were on three, two-liter exchanges per day and peritonitis was the most important complication. Moreover, the cost of CAPD is a factor that restricts the wider acceptability in our country.
(c) Renal Transplantation
Renal transplantation is the best form of treatment for patients with ESRD. Although organ act was passed by the parliament in 1998, only few live related renal transplants have been performed in Bangladesh. A total of 458 renal transplant patients were registered between 1981 and 2001.
All patients usually receive cyclosporine, azathioprine and prednisolone for 3-6 months then cyclosporine is withdrawn within 6 months to 1 year; due to financial reason. The graft survival in our patients is 90% & 80% at one and 5 years, respectively. , The mean age of transplant patients is 36 years, whereas the mean donors' age is 40 years. The donors include parents; especially mothers, siblings; usually sisters, spouses; mostly wives and 2nd degree relatives; uncles and aunts. Unrelated renal transplantation is not performed in Bangladesh.
| Cost of RRT|| |
Renal replacement therapy, either maintenance dialysis or transplantation are costly. The annual cost of hemodialysis at private hospitals can vary between 4000 United States dollars (US$) for twice weekly to 5500 US$ for thrice weekly dialysis. The cost of erythropoietin, 4000 IU/week raises the cost further. This cost is out of reach for 90% of hemodialysis patients.
Therefore one third of patients on dialysis abandon treatment within three months after the start of dialysis and die; of the remaining, 10% is treated with renal transplantation.
Less than one percent undergoes CAPD; the cost is similar to that of hemodialysis and the most important drawback is the high incidence of peritonitis.
Renal transplantation is not as expensive as hemodialysis. The cost of renal transplant in Bangladesh in a private hospital is approximately 3000 US$ including surgical fees, medications, and other important hospital charges for one month; the cost in governmental hospitals is 60% less. The cost of cyclosporine and azathioprine for the first six months after transplantation is approximately 1500 US$ that results in withdrawal of cyclosporine from almost all cases within 6 months to one year.
| Manpower and Training in Nephrology|| |
There are only 40 Nephrologists in the whole country. This means that one nephrologist is available to treat 2.5 million people. The postgraduate courses of Nephrology were started in 1986 in only one institute. At present, four other medical colleges have also started Nephrology training. Therefore, it is hoped that in the next three years 50 more nephrologists will be available to treat kidney patients.
| Future Plans|| |
Ideally every ESRD patient should have access to renal replacement therapy. The reality is that it is not possible due to lack of facilities, financial constraints and governmental policies for health care spending. Therefore, preventive strategies have to be implemented in order to delay the onset of ESRD. Early diagnosis and follow-up of chronic diseases such as diabetes and hypertension may delay ESRD in about 60% cases. This is possible by increasing the awareness about renal diseases in the medical community and the public at large.
Efforts should be made to further reduce the cost of dialysis therapy; effective reuse of dialyzers and blood lines may help. However, maintenance dialysis or CAPD are not likely to be viable option for treatment of ESRD in our country. Renal transplant including pre-emptive transplantation remains the best and least expensive option for RRT. Cadaveric kidney transplantation has to be encouraged, despite the lack of motivation of the public, religious belief, lack of infrastructure and high cost of immunosuppressive drugs.
Better allocation of government funding, introduction of medical insurance, non-government charity organizations all can help together to support the RRT program for ESRD patients.
| References|| |
|1.||Rashid HU: Post streptococcal acute glomerulonephritis in children in Bangladesh (ed) Sanjoy K. Agarwal (In) current topics in nephrology, urology and transplantation in SARRC countries AIIMS, New Delhi, 114, 1998. |
|2.||Rashid HU: Bangladesh renal registry report 1986-1996. Bang Renal J 2002;21(1): 25-8. |
|3.||Rashid HU, Khanam A, Ahmed J: IgA nephropathy in Bangladesh ; in Sitprija U, Chittinandana A, Vasuva Hakal S, Tung Sarga K (ed). The 9 th Asian Pacific Congress of nephrology, Monduzzi editore, 2003;95-98. |
|4.||Rashid HU, Hossain RM, Khanam A. Outcome of acute renal failure in adults in a teaching Hospital in Bangladesh. Ren Fail 1993;15(5):603-7. |
|5.||Chugh KS, Jha V, Chugh S. Economics of dialysis and renal transplantation in the developing world. Transplant Proc 1999;31: 3275-7. [PUBMED] [FULLTEXT]|
|6.||Chugh KS, Jha U. Differences in the care of ESRD patients worldwide: required resources and future outlook. Kidney Int Suppl 1995; 50:S7-13. |
|7.||Sakhuja V and Sud K. End stage renal disease in India and and Pakistan: burden of disease and management issues. Kidney Int Suppl 2002;83:S115-8. |
|8.||Rashid HU, Khanam A, Islam S, Wahab MA, Iqbal KM. Experience with living donor kidney transplantation in Bangladesh. Transplant Proc 1999;31:3112. [PUBMED] [FULLTEXT]|
|9.||Rahman H, Majumder AB, Iqbal M, et al. Cardiovasculer problems in patients on maintenance hemodialysis. Bang Renal J 1997;16(2):49-56. |
|10.||Rashid HU, Rahman M, Wahab MA, Kibria G, Rahman S, Jinnat S. Living related kidney transplantation using low-dose triple immunosupression. Transplant Proc 1994; 26(4):2089. |
Harun Ur Rashid
Department of Nephrology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
[Table - 1]