| Abstract|| |
The exact prevalence of chronic kidney disease in India is not clear in the absence of regular national registry data and provided only by small observational series or rely on reports from personal experience, but the quality of data is quiet uneven. There are only three population based studies in India commenting on the magnitude of chronic kidney disease. In a prevention program started at community level in Chennai, the reported prevalence is 0.86% in the project population and 1.39% in the control region. The second study is based on Delhi involving 4972 urban patients. The prevalence of chronic renal failure (defined as serum creatinine more than 1.8 mg/dL) to be 0.79 % or 7852 per million/population. The third study perhaps the only longitudinal study to identify the incidence of end stage renal disease is based on 572,029 subjects residing in city of Bhopal suggests that the average crude and age adjusted incidence rates of end stage renal disease were 151 and 232 per million population respectively. The resources and skill for taking care of this large case load, both in terms of personal and health care infrastructure do not exist currently and would need to be created. To tackle the problem of limited access to renal replacement therapy, an important method would be to try and reduce the incidence of end stage renal disease and the need of renal replacement therapy by preventive measures. It is clear that treatment of chronic kidney disease and its advanced stage end stage renal disease is expensive and beyond the reach of average Indian. Thus it is crucial that prevention of chronic kidney disease has to be the goal of medical fraternity, government of India and the general public. This article suggests a series of primary, secondary and tertiary preventive measures for prevention of chronic kidney disease. Clearly there are already many effective and attractive interventions for the treatment and prevention of chronic kidney disease exist and many more surely be developed.
Keywords: Epidemiolgy, CKD, India
|How to cite this article:|
Prabahar MR, Chandrasekaran V, Soundararajan P. Epidemic of Chronic Kidney Disease in India -What Can Be Done?. Saudi J Kidney Dis Transpl 2008;19:847-53
|How to cite this URL:|
Prabahar MR, Chandrasekaran V, Soundararajan P. Epidemic of Chronic Kidney Disease in India -What Can Be Done?. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2013 May 23];19:847-53. Available from: http://www.sjkdt.org/text.asp?2008/19/5/847/42478
| Introduction|| |
Contemporary societies are in the midst of an epidemic of chronic non communicable diseases including that of chronic kidney disease (CKD). India is no exception to this rule. Many parts of India are undergoing rapid epidemiological transition as a consequence of economic and social changes.  The increase in non communicable diseases is real and not simply due to better diagnosis. This epidemiologic transition is partially attributable to better nutrition, control of infectious disease and gain in life expectancy. An untoward consequence of this extension of life is the emergence of chronic diseases as leading causes of death. 
CKD is a world wide health problem. According to World Health organization (WHO) Global Burden of Disease project, diseases of the kidney and urinary tract contribute to global burden with approximately 850,000 deaths every year and 115,010,107 disability adjusted life years. CKD 12 th leading cause of death and 17 th cause of disability.  This global prevalence, however, may be grossly underestimated for a number of reasons. Patients with CKD are at high risk for cardiovascular disease (CVD) and cerebro vascular disease (CBVD), and they are more likely to die of CVD than to develop end-stage renal failure. Moreover, patients with CVD often develop CKD during the course of their disease, which may go unrecognized. Therefore, an unknown proportion of people whose death and disability attributed to CVD have kidney disease as well. 
Moreover, most epidemiological data (prevalence, incidence, patient demography, morbidity, and mortality) on CKD are derived from renal registries. However, most registries record data of patients who are at late stage of kidney disease. Much less is known about the prevalence of the earlier stages of the CKD. Indeed, it has been acknowledged that the majority of the individuals at early stages of CKD have gone undiagnosed and under treated. 
| The Indian Scenario|| |
The population of India exceeds one billion and is projected to become the major reservoir of chronic diseases like diabetes and hypertension. Since 25–40% of these subjects may develop CKD, the endstage renal disease (ESRD) burden will rise and the health care system would need to take care of them.
India is experiencing a rapid health transition with large and rising burdens of chronic diseases, which are estimated to account for 53% of all deaths and 44% of disability adjusted life years lost in 2005.  Even in rural India, chronic non-communicable diseases are emerging as the leading cause of death.  India leads the world with the largest number of diabetics earning the term of "diabetes capital of the world". According to the Diabetes Atlas More Details 2006 published by the International Diabetes Federation, the number of diabetics in India currently around 40.9 million is expected to rise to 69.9 million by 2025 unless urgent preventive measures are practiced.  Changes in lifestyle and urbanization resulted in obesity, hypertension and diabetes, which are associated with increased risk of CKD. The exact prevalence of CKD in India is not clear in the absence of regular national registry data and provided only by small observational studies or personal experiences, and the quality of data is quiet uneven.
For a long time, it has been presumed that nearly 100,000 new patients with ESRD in India require renal replacement therapy every year based on data from tertiary referral centers.  There are only three population based studies in India that reported on the magnitude of CKD. ,, In a prevention program started at community level in Chennai, the reported prevalence of CKD was 0.86% in the study population and 1.39% in the control region. This study was limited since it studied only the rural population around Chennai in the state of Tamil Nadu and only those with urinary abnormalities or a positive response to a questionnaire were subjected to blood testing, with a potential to underestimate the true prevalence of CKD, which was defined as estimated glomerular filtration rate (GFR) less than 80 ml/min by MDRD (Modification of diet in renal diseases) formula. 
The second study is involved 4972 urban patients from Delhi. The prevalence of CKD defined as serum creatinine more than 1.8 mg/dL was 0.79 % or 7852 per million/ population. The third United States NHANES (National Health and Nutrition Examination Survey) stated that there were 12 times more CKD than ESRD. Extrapolating this information to the above mentioned data, the prevalence of ESRD appears to be 785 per million population in India. The limitations of this study included lack of information on exact prevalence of ESRD and the reliance on serum creatinine to define CKD. 
The third study, the only longitudinal study of the incidence of ESRD, is based on 572,029 subjects residing in city of Bhopal. It suggested that the average crude and age adjusted incidence rates of ESRD ranged from 151 to 232 per million population respectively. Furthermore, diabetic nephropathy was the commonest cause of ESRD (44%). The limitation of this study was the lack of information regarding earlier stages of CKD and the predominant urban nature of the study. Assuming the uniform incidence all over the country, approximately 152,000 new ESRD patients would require renal replacement therapy (RRT) every year in India.  The resources and skill for taking care of this large case load are currently inadequate.
On basis of the recent survey of the ICMR (Indian Council of Medical Research), it is estimated that prevalence of diabetes in adults is 3.8% and 11.8% in rural and urban areas, respectively.  Moreover, prevalence of hypertension has been reported to range from 20– 40% and 12–17% in urban and rural adults, respectively. 
| Etiology of CKD in India|| |
Some data are available on the pattern of ESRD in India. Glomerulonephritis and interstitial nephritis were reported to be the predominant causes previously,  however, recent data highlight the emergence of diabetic nephropathy as the major cause of ESRD in India. This finding is consistent with the world wide trend of steady rise in contribution of diabetes to ESRD. According to the first annual report published by the CKD registry of India involving 13,151 patients, diabetes and hypertension were major causes of CKD in India accounting for 28.5% and 16.2% respectively, as in other parts of the world. However, unlike the other registry data, although its prevalence is declining compared to previous years, chronic glomerulonephritis remains the second common cause of CKD and accounts for 16.2%.  Registry data may be inaccurate, as it is not based on biopsy diagnosis but based on physician's interpretation of patient's history of duration of hypertension and laboratory findings, which can overlap. In the other community based study, diabetes, hypertension and chronic glomerulonephritis accounted for 41%, 22%, and 16% of cases of CKD, respectively.  We did not present data of tertiary care hospital based studies, since they may not represent the causes of CKD in the general population.
| Facilities for RRT in India|| |
The availability of RRT is limited in India, which has approximately 400 dialysis units with 1000 dialysis stations with the majority being in the private sector. The government sector cannot afford to provide maintenance dialysis, and it runs only pre transplant dialysis units. CAPD is not practiced widely because of its exorbitant cost and reluctance of patients to perform it at home.  Regarding renal transplantation, India has approximately 100 approved centers, most of which are in the private sector. With the absence of a national organ sharing program, living donor transplant is the only option for most patients. Renal transplantation costs US $8,000 and $2000 in the private and public sectors, respectively, therefore, only a fraction of Indians can afford it, (Unpublished observations).
| Cost of treatment of CKD in India|| |
The management of ESRD in India is largely guided by economic considerations. Not only the magnitude of CKD but also the cost of RRT is enormous in India. Treatment of ESRD in India is a low priority for cost strapped public hospitals and in the absence of health insurance plans, less than 10% of all patients receive any kind of renal replacement therapy.  India is a poor country with per capita income of $460/yr. Only 2.2% earn above $1000/year, and 23% of our population exists below poverty line earning less than $100/year. Our government is just poor and spends only $9 per capita on health.  The cost of HD (Hemodialysis) session in India ranges from $20 to $40 including the cost of disposables. The cost of arterio venous fistula surgery is $150 and of erythropoietin $400/month. As a result only 30% HD patients receive erythropoietin therapy. The monthly cost of HD is $300, whereas CAPD costs $600. The cost of transplant is $8900 in the first year, which declines later to $3000 annually cost. Among the three RRT options, renal transplant is the preferred choice as it is cost effective and offers better quality of life.  Cyclosporine, azathioprine, and prednisolone continue to be the back bone of post-transplant immunosuppression in India despite the advent of newer drugs. In significant proportions of cases, low dose cyclosporine with ketaconazole or cyclosporine withdrawal after one year has been practiced to minimize the costs.  Financial considerations often preclude appropriate treatment of cytomegalovirus infection and steroid resistant rejection that result in additional morbidity and mortality.
| The Social Implications of ESRD|| |
ESRD is a devastating medical, social and economic problem for patients and their families. The availability and quality of dialysis programmes largely depend on the prevailing economic conditions and social support. In one study, it was concluded that 63% of patients were supported by their employer or charity, 26% received loans and 34% sold assets or pooled their family resources.  In spite of all these options, only 3–5% got some form of RRT. Data from the CKD registry disclose that 66.1% of 19–60 years males, who are the economically productive age group, formed 69.9% of the most commonly affected groups.  Therefore, patients with ESRD must finance their enormous direct treatment cost in addition to loss of job.
| What can be done?|| |
To tackle the problem of limited access to RRT, an important method would be to try and reduce the incidence of ESRD and the need of RRT by preventive measures, which can be primary, secondary, and tertiary.
| Primary prevention measures|| |
Public health education is the cornerstone of this preventive approach. Public perception of CKD is poor and knowledge among both general public and general practitioners about kidney diseases is poor in India. In our own unpublished observations, less than 20% of our primary care physicians knew the exact definition of CKD and 12% were aware of MDRD formula to calculate estimated GFR. Such knowledge deficit should be addressed seriously. Public awareness of the link between lifestyle and health is poor in India. Education on diet, increased physical activity and decreased tobacco usage should begin in schools during childhood. All adults more than 40 years of age should be advised to have regular checkups with measurement of blood pressure, blood sugar and serum cholesterol levels. Such screening should be made mandatory during pre employment screening. In a recent study, 73.7% of diabetics in rural areas and 56.9% in urban areas were unaware of their diagnosis. 
It has been suggested that intrauterine malnutrition and decreased birth weight is associated with a decrease of the number of nephrons and increase the risk of CKD in adults. If such observations are confirmed, primary prevention of CKD will also require great attention to women's health and nutrition during pregnancy.  At the present time, it is estimated that over 50% of pregnant women in India suffer from anemia and malnutrition and low birth weight is observed in more than 30% of live births in India. 
These challenges call for new social and administrative policies and infrastructure models from the government of India. Obviously, this also requires increased health care spending by government of India. Indian government spent just $5 per capita on healthcare. The percentage gross domestic product (GDP) allocated to health care dropped to1.4% in contrast to 5% of GDP suggested by WHO. 
| Secondary prevention measures|| |
When CKD is diagnosed early and managed aggressively, its progression can be slowed or halted. The obvious task ahead for health authorities in the developing world is to detect and treat kidney disease at the earliest possible stage. Many of such therapeutic interventions have been discussed in detail elsewhere. 
Screening the high risk individuals should be the priority as population screening might be too costly and not cost effective. The high risk groups include diabetics, hypertensive patients, the elderly, relatives of patients with CKD, and patients with autoimmune diseases that are likely to involve the kidney. Screening should consist of dipstick testing for proteinuria with confirmatory retesting within three months. Persistent abnormalities would then be validated by an estimation of spot urine albumin creatinine ratio (ACR). A raised ACR would justify further functional, radiologic and or histological investigations.  Use of single daily pill (poly pill) containing generic angiotensin converting enzyme inhibitors, statins, aspirin and folic acid in order to simultaneous control of diabetes, hypertension, dyslipidemia may be a viable option. 
Recently, in a rural population in southern India, The Kidney Help Trust of Chennai developed a program to prevent kidney failure by active screening of the entire population of a village and provided the least expensive available drugs for management of diabetes and hypertension. During follow-up, the prevalence of CKD was 8.6 per 1000 population, whereas in the neighboring village which did not obtain such a program, the prevalence of CKD was 13.9 per 1000 population, thereby, preventing 5.3 subjects per 1000 population from developing ESRD.  The cost of this program was less than $0.25 per participant. Such efforts can and should be reproduced across the country through the existing primary health center (PHCs) that cover a population of around 25,000 spread over an area of 50 sq km. Nongovernmental agencies working in this area can also be roped in to emulate this model.
There is definite lack of information available on prevalence, incidence and outcome of CKD in India. Such information is vital to design large scale prevention programs. One such effort is creation of CKD registry by Indian Society of Nephrology (ISN) whose first annual report is readily accessible in the internet. Unfortunately, only 7.8% of members of ISN regularly contribute to the database. 
Having established the need for screening for CKD to initiate primary and secondary preventive measures, the question that remains is of funding and infrastructural support for such programs. Logically, governmental agencies should take the lead. Since India is simultaneously experiencing several disease burdens due to old and new infections, nutritional deficiencies and chronic diseases, individual interventions for clinical care are unlikely to be affordable on large scale. Hence, it might be necessary to recruit the support of non-governmental organizations, charities and the pharmaceutical industry to offer financial assistance for such projects. There is a common perception that prevention and treatment of chronic conditions are much more expensive than prevention and treatment of infectious disease. On the contrary, initiatives like the one from the Kidney Help Trust in Chennai prove that preventive measures can be possible at a low cost. 
A number of concerns about non-communicable diseases may render them less compelling targets for funding. One such concern is that chronic diseases affect only rich countries. However, the data from WHO reveals that the non-communicable chronic diseases have a substantial impact on low income countries.  Moreover, the need for prolonged treatment may diminish their appeal to donors. However, the chronic nature of non-communicable diseases magnifies the effect on families, since expensive long-term treatment consumes savings and often requires a family member to leave employment to become a caregiver. 
| Tertiary prevention measures|| |
There are no state-funded programs for CKD patients in India unlike many other countries, and patients must pay for their RRT. Private health insurance covers many ESRD patients. High treatment cost limits access to RRT for most Indians. With incidence of CKD projected to rise further, facilities should be developed to take care of the increasing number of incident ESRD cases. Regarding improvement of facilities for RRT is concerned; the Tamilnadu Government model is worth exploration throughout India. The government of Tamilnadu has initiated hemodialysis centers in all district headquarters hospitals staffed with trained personnel, and has provided free immunosuppressive drugs for patients who undergo live related kidney transplantation in governmental hospitals to encourage related kidney donation. Reducing the cost of ESRD treatment can be achieved by imposing tax exemption to medications, similar to those regulated for anti-retroviral drugs. Widespread use of generic drugs and setting of subsidized dialysis units is another option, although the standard for medical care provided by them needs to be drastically improved. Use of local equipment and manufacturing can also be attempted to reduce their cost.
Despite the passage of national human organ transplant act in 1994, deceased donor kidney transplantation is infrequent in this country. Marked shortage of donor kidneys, lack of good deceased program, absence of legal restrictions, and large scale poverty resulted in trafficking of organs. The enactment of legislation to regulate renal transplantation in India has not been able to prevent unrelated (paid) donor transplants, which constitute 60–70% of transplantation practice. The ethical aspects of commercial living kidney donation have been widely debated in the media and transplant community in India. Living related donor transplants constitute 30–40% of all transplants in India, but there is a conspicuous gender bias with female donors donating kidneys to their male relatives. Deceased transplantation has yet to increase since it currently accounts for less than 2% of transplants. Government policies and guidelines similar to those proposed by M K Mani et al should be considered to develop a good deceased transplantation program. 
We conclude that CKD has become one of the most important chronic non communicable disease epidemics in the world including India. It is clear that treatment of CKD and its advanced stage ESRD is expensive and beyond the reach of the average Indian citizen. Therefore, prevention of CKD should be the goal of medical community, government of India, and the general public. Clearly there are already many effective and attractive interventions for the treatment and prevention of CKD exist and many more surely can be developed.
| References|| |
|1.||Joshi R, Magnolia C, Srinivas I, et al. Chronic diseases now leading cause of death in rural India-mortality data from the Andhra Pradesh rural health initiative. Int J Epidemiol 2006;35 (6):1522-9. |
|2.||McClellam WM. The Epidemic of renal disease: What drives it and what can be done Nephrol Dial Transplant 2006;21(6):1461-4. |
|3.||World Health Organisation -Burden of disease project available at: http://www.3.who_int/whosis/menu.cfm?path= evidence,burden & language accessed on September 2006. |
|4.||Schieppati A, Giuseppe R. Chronic renal diseases as a public health problem: Epidemiology, Social and economic implications. Kidney Int 2005;68(supp 98):s7-10. |
|5.||Srinath Reddy K, Bhah B, Verghese C, Ramadoss A. Responding to threat of chronic diseases in India. Lancet 2005;366(9498): 1746-51. |
|6.||Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125 (3):217-30. |
|7.||Kher V. ESRD in developing countries Nephrology forum. Kidney Int 2002;62(1):350-62. |
|8.||Mani MK. Experience with a program for prevention of chronic renal failure in India. Kidney Int 2005;67(supp 94):75-8. |
|9.||Agarwal SK, Dash SC, Irshad M, Raju S, Singh R, Pandey RM. Prevalence of chronic renal failure in adults in Delhi, India Nephrol Dial Transplant 2005;20(8):1638-42. |
|10.||Modi GK, Jha V. The incidence of end stage renal disease in India, a population based study Kidney Int 2006;70(12):2131-3. |
|11.||Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18(2):73-8. |
|12.||Mittal S, Kher V, Gulati S, Agarwal LK, Arora P. Chronic renal failure in India. Renal Failure 1997;19(6):763-70. |
|13.||First annual report of Indian CKD registry accessed at - on March 15, 2007. |
|14.||Agarwal SK. Chronic Kidney disease and its prevention in India. Kidney Int 2005;68(Supp 98):S42-5. |
|15.||Keshaviah P. Resource limitations and strategies for the treatment of uremia. Blood Purif 2001;19(1):44-52. |
|16.||Sakhiya V, Sud K. End stage renal disease in India and Pakistan: Burden of diseases and management issues. Kidney Int 2003;63 (supp83):115-8. |
|17.||Sadikot SM, Nigam A, Das S, et al. Diabetes India, The burden of diabetes and impaired glucose tolerance in India using the WHO 1999 criteria: Prevalence of diabetes in India study (PODIS). Diabetes Res Clin Pract 2004; 66(3):301-7. |
|18.||Nelson RG. Intrauterine determinants of diabetes kidney disease in disadvantaged population. Kidney Int 2003;63(supp83):S3-16. |
|19.||Ramachandran A, Snehalatha C, Vijay V, King H. Impact of poverty on the prevalence of diabetes and its complications in urban southern India. Diabetes Med 2002;19(2):130-5. |
|20.||Political neglect of India's health. Lancet 2004;363(9421):1565. |
|21.||Brenner BM. Retarding the progression of renal disease. Kidney Int 2003;64(1):370-8. |
|22.||Barsoum R. Chronic kidney disease in the developing world. N Engl J Med 2006;354 (10):997-9. |
|23.||Anderson GE, Chu E. Expanding priorities- confronting chronic diseases in countries with low income. N Eng J Med 2007;356(3):209-11. |
|24.||Mani MK. Development of cadaver renal transplantation in India. Nephrology 2002;7: 177-82. |
Murugesan Ram Prabahar
Department of Nephrology, Sri Ramachandra University, No. 1, Ramachandra Nagar, Porur, Chennai-600116, Tamilnadu