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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2011  |  Volume : 22  |  Issue : 3  |  Page : 564-565
Life cycle of chronic kidney disease patients


1 Department of Nephrology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
2 Ministry of Health and Family Welfare, CGHS, New Delhi, India

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Date of Web Publication7-May-2011
 

How to cite this article:
Gupta A, Tiwari SC, Khaira A, Gupta P, Bhowmik DM, Mahajan S. Life cycle of chronic kidney disease patients. Saudi J Kidney Dis Transpl 2011;22:564-5

How to cite this URL:
Gupta A, Tiwari SC, Khaira A, Gupta P, Bhowmik DM, Mahajan S. Life cycle of chronic kidney disease patients. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Apr 25];22:564-5. Available from: http://www.sjkdt.org/text.asp?2011/22/3/564/80502
To the Editor ,

The usual life cycle of a chronic kidney disease (CKD) patient starts from diagnosis to conservative treatment, to placement of a vascular access, choosing a modality of renal replacement therapy, and finally renal transplantation.

In developing countries, there is not much of a government support for long-term dialysis care programs or renal transplantation. There are two major issues with renal transplant program. There is no organized deceased donation program and an overwhelming majority of transplants is performed using living donors. This has led to the malpractice of commercial transplantation. Secondly, most of the time we choose live related renal transplantation, but expose the patients again to risks of rejection due to poor compliance with medicines or infections as a result of poor hygiene and bad socioeconomic living conditions, all of which result in graft loss and eventual dialysis.

On the other hand, if we examine the two modalities of dialysis, the hemodialysis (HD) program in the majority of developing countries is started with a temporary vascular access because of late referrals to the nephrologist. [1] Furthermore, there is inadequate number of centers for dialysis. Renal replacement therapy (RRT) is a low-priority area for healthcare planners in our country. There is a direct relationship between the number of dialysis centers and per capita gross national income of developing nations. Shortage in the number of government-funded hospitals and lack of provision of maintenance dialysis centers by the government has fanned the growth of a large number of private hospitals offering RRT. The high cost of HD makes it within the reach of only very rich patients. The public hospitals, which have an adequate infrastructure, have long waiting lists of patients for dialysis and are able to provide support for a period of few months only. Therefore, priority is given to patients who have planned for a renal transplant. The entire family of the patient is usually involved to bear the economic burdens, with resulting loss of income of other family members too. The patients, who are on maintenance HD, remain under-dialyzed due to missing dialysis sessions, use of cheaper cellulose dialyzers, and dialyzer reuse. Most of the patients on dialysis cannot afford it thrice a week; therefore, compared to their western counterparts, the level of nutrition and sense of well-being is far less. Nephrologists around the world talk about KT/V, but may not be able to apply this numeric formula to this population.

The other modality is continuous ambulatory peritoneal dialysis (CAPD). The cost of this renal support is slightly more than HD and it has become a modality for majority of those who are rich, elderly or can have it reimbursed. However, then we still lack dedicated staff for a CAPD program.

For a good physical health, we have a big armamentarium in the form of diet, anti-hypertensive drugs, calcium and vitamin-D compounds, phosphate binders, iron and erythropoietin to support the disease, but lack of education and resources fail to impart appropriate compliance.

India has about 600 practicing nephrologists (0.6 parts per million), 400 dialysis units and 105 transplant centers and more than two-thirds of them are in the private sector. [2] The majority of the existing dialysis units are small with less than five stations, which is grossly inadequate. In addition, most of the units are in the cities and big towns, whereas more than two-thirds of our population resides in the rural areas.

The estimated number of patients requiring RRT in India is around 80-100/million population. [3],[4] A large proportion of our patients is from rural areas, who never seek a specialist advice due to ignorance and poverty and hence are not included in estimates. Out of those who get specialists' advice, only a minority can afford any definitive RRT. The vast majority of patients starting HD either die or stop treatment because of cost constraints within the first three months, and less than 2% patients are started on ambulatory peritoneal dialysis. Although renal transplantation is the least expensive option, only about 5% of all patients with end stage renal disease (ESRD) end up having a transplant. Living related donor transplants constitute 30-40% of all transplants in India, but there is a conspicuous gender bias with female donors donating kidneys for their male relatives. [5] Deceased donor transplantation accounts for less than 2% of all transplants. The final acceptance rate of patients for RRT turns out to be less than 5 pmp/year. [3],[4]

Unlike the western counterparts, the concept of health insurance and medical reimbursement is virtually nonexistent in India. The costs of RRT, therefore, have to be borne by the patients and their families from their own funds. Most organizations give a fixed amount/year as a part of medical reimbursement, which is inadequate to cover the costs incurred in RRT. Most reimburse the cost of hospitalization, but only a few cover expenses of out-patient treatment and thus neglect this aspect of the treatment. Charitable organizations and government providing relief funds are of limited assistance to poor patients and in general are able to cover only a few months of treatment costs. To cover such costs, it was found that 63% of our patients took help from employees or charity, 30% sold their property or family values, i.e., jewelry, and 26% took loans to cover the cost of RRT. Only 4% were able to bear the financial burden from within the family. [6] Family bonds are strong in our country, and quite often, extended family members temporarily sacrifice their earnings to help in treatment. However, at times, there is a split in a joint family or marriage, pushing the patient into further socioeconomic problems. We conclude that there is a marked contrast in the life cycle of CKD patients from the developing nations compared to their western counterparts.

 
   References Top

1.Tiwari SC, Bhowmik DM. Staging of CKD: Is a New Stage Needed? Am J Kidney Dis 2008;51:346.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Jha V. End-stage renal disease in developing countries. The India experience. Renal Fail 2004; 26:201-8.  Back to cited text no. 2
    
3.Chugh KS, Jha V. Differences in the care of ESRD patients worldwide: Required resources and future outlook. Kidney Int Suppl 2005;48:S7-13.  Back to cited text no. 3
    
4.Jha V, Chugh KS. Dialysis in developing countries: priorities and obstacles. Nephrology 1996;2:65-72.  Back to cited text no. 4
    
5.Sakhuja V, Sud K. End-stage renal disease in India and Pakistan: burden of disease and management issues. Kidney Int Suppl 2003;83:S115-8.  Back to cited text no. 5
[PUBMED]    
6.Mani MK. The management of end stage renal disease in India. Artif Organs 1998;22:182-6.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Ankur Gupta
Department of Nephrology, All India Institute of Medical Sciences (AIIMS), New Delhi
India
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