| Abstract|| |
The prevalence of chronic kidney disease (CKD) has increased substantially in India over the past two decades commensurate with the global trend and has currently emerged as a significant cause of mortality and morbidity. Use of complementary and alternative medicine (CAM), especially ayurvedic medication, is widespread in CKD although accurate data on the prevalence of use are lacking. A cross-sectional study was conducted from January to June 2017 in the nephrology outpatient clinic of a medical college hospital in Mangalore, South-West India. Adult patients (>18 years) with CKD (estimated glomerular filtration rate ≤60 mL/min) were considered potentially eligible and approached to participate in the survey. A 17-item semi-structured questionnaire adapted from the National Health Interview Survey Adult CAM Supplement was used for the study. A total of 278 patients (194 males and 84 females) with a mean age of 49.04 ± 12.06 years were included in the study; 67.3% were unemployed and married (83.8%), 35.6% had primary school education, more than 2/3rd of the patients had CKD Stage 5, and 110 patients were on renal replacement therapy with hemodialysis. Comorbidities such as hypertension were present in 46.8%, whereas 36.7% of the patients were diabetic. One hundred and eighty-four patients interviewed (66.3%) reported the use of one or more types of CAM therapy in the previous six months. Herbal and dietary supplements were used by 13 (7.1%); ayurvedic medication by 117 (63.6%); naturopathic, homeopathic, and Unani systems by 30 (16.3%), while spiritual/faith healing and acupuncture were used by 16 (8.7%) and eight (4.3%) of the patients, respectively. A multiple regression analysis between CAM users and non-users revealed that older age (P = 0.004), occupational status (P = 0.035), and income (P = 0.006) correlated strongly with CAM use. The present study highlights the high prevalence (66%) of use of alternative medication in patients with CKD.
|How to cite this article:|
Castelino LR, Nayak-Rao S, Shenoy M P. Prevalence of use of complementary and alternative medicine in chronic kidney disease: A cross-sectional single-center study from South India. Saudi J Kidney Dis Transpl 2019;30:185-93
|How to cite this URL:|
Castelino LR, Nayak-Rao S, Shenoy M P. Prevalence of use of complementary and alternative medicine in chronic kidney disease: A cross-sectional single-center study from South India. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Mar 23];30:185-93. Available from: http://www.sjkdt.org/text.asp?2019/30/1/185/252909
| Introduction|| |
The increasing burden of noncommunicable diseases (NCDs), which account for approximately 60% of all deaths worldwide, remains one of the important challenges that face the developed as well as the developing worlds. Among the NCDs, chronic kidney disease (CKD) now affects more than 500 million people worldwide, with 80% of those affected living in low- to middle-income countries. In most of these countries, traditional medications (TMs) are used by 75%–90% of people and may often form the principal form of health care. In India, the prevalence of CKD has increased substantially in the past two decades commensurate with the global trend and has currently emerged as a significant cause of mortality and morbidity with a significant decline in the overall patient's quality of life (QOL). Despite several medical advancements, survival of patients with end- stage renal disease (ESRD) remains drastically shorter than that of the general population.
Complementary and alternative medicine (CAM) may provide new therapeutic options for patients with ESRD and may mitigate symptoms and improve health-related QOL, which conventional therapies such as drugs and dialysis may not achieve. However, the short-term as well as possible long-term complications attributed to their use are presently unknown. CAM, as defined by the National Center for Complementary and Alternative Medicine, is a group of diverse mediated and health-care systems, practices, and products that are not generally considered to be a part of conventional medicine. The CAM modalities are classified as follows:
- Alternative medical systems (acupuncture, homeopathy, Ayurveda, siddha, and unani)
- Mind–body interventions (relaxation techniques, spiritual healing/prayer, hypnosis, meditation, and yoga)
- Biologically based therapies [herbal and dietary supplements (HDS)]
- Manipulative and body-based methods (massage therapy, exercise, chiropathy, or osteopathy)
- Energy therapies (energy healing, Reiki, and magnetic healing).
There is a widespread use of HDS, particularly in Asian countries. Even in developed countries such as the United States, herbal and supplemental products account for $100 billion in revenue annually. India has a long and well-documented history of traditional forms of health care such as Ayurveda, unani, siddha, and yoga, all of which are officially recognized by the national government. Among these alternative systems of medicine, Ayurveda, which has origins in the Vedic times from 3000 years ago, is the most widespread and used by about one billion people, although it has broad popularity and its usage extends well beyond Indian shores. However, none of these alternative therapies are regulated and subject to quality controls, thereby increasing their potential risk. CAM use, especially ayurvedic medication use, is widespread in noncommunicable chronic diseases such as hypertension, diabetes, and asthma, although accurate data on the prevalence of use in CKD are lacking. These medications being naturally sourced are believed to be safer and free from undesirable side effects. This may be the reason that most patients do not usually disclose this information to their treating physician unless specifically asked for. Although patients with CKD turn to CAM for controlling symptoms and coping with the disease, data on the use of CAM among nondialysis CKD patients remain insufficient.,, Most often, the reasons for this may be the usage of CAM modalities by CKD patients without the knowledge and approval of the health-care team. We believe that the usage of these alternative forms of medicine may be far greater in Asian countries, particularly in India, given that a large proportion of them have originated here. Given the concerns about alternative medication use in CKD patients and the presumed higher prevalence of use in Asian countries, it is important to establish the extent and patterns of use among CKD patients so that health-care providers can be better informed and advise patients accordingly.
| Materials and Methods|| |
A cross-sectional study was conducted from January to June 2017 in the adult nephrology outpatient clinic of a medical college hospital in Mangalore, South-West India. The hospital predominantly caters to a semi-urban patient population of two adjoining states of Kerala and Karnataka. Adult patients (>18 years) with diagnosed CKD (estimated GFR ≤60 mL/min) were considered potentially eligible and approached to participate in the survey. Patients who had undergone kidney transplantation were excluded from the study. Willing patients gave verbal and written con-sent to participate, and the study was approved by the Institutional Ethics Committee.
A 17-item semi-structured questionnaire adapted from the National Health Interview Survey Adult CAM Supplement was used for the study and administered directly by the principal investigator (LRC). Items were selected based on the prevalence of CAM use during the preceding six months, frequency of use, reasons why patients opted for alternative medication use, adverse effects if any experienced, and reasons for discontinuation of use, if relevant. In addition to the survey, data on demographics including age, gender, comorbid illnesses, CKD stage as per estimated glomerular filtration rate (eGFR), religion, marital status, educational level, employment status, and household income/monthly income were collected. CAM categories included the following:
- Herbal supplements
- Ayurvedic medication use
- Other naturopathic, homeopathic, unani, and acupuncture use
- Yoga and meditation
- Others such as spiritual healing, Reiki, and faith healing.
| Statistical Analysis|| |
Data were analyzed using descriptive statistics for CAM use by demographics including age, gender, cause of CKD, employment status, and educational level. All CAM therapies were combined as a single category, and Chi-square test was performed to determine factors related to CAM use. Multiple logistic regression analysis was undertaken to determine associations between CAM use and demographic characteristics. Tests were two sided, and P <0.05 was considered statistically significant. The study was approved by the Institutional Ethics Committee of the university.
| Results|| |
A total of 278 patients (194 males and 84 females) with a mean age of 49.04 ± 12.06 years receiving outpatient treatment at the university hospital nephrology clinic were recruited in the study. The sociodemographic data of the study participants are listed in [Table 1]. The majority of the respondents were unemployed (67.3%) at the time of the interview and married (83.8%). Nearly 35.6% of them had completed primary school education, whereas about 30% had completed secondary school education. Almost 42.4% of the patients belonged to the lower middle class category with a monthly income of <Rs. 5000 (75 USD) and more than 60% lived in a rural setting. More than 2/3rd of the patients had CKD-Stage 5 by eGFR, and 110 patients were on renal replacement therapy with hemodialysis (HD). Comorbidities such as hypertension were present in 46.8%, whereas 36.7% of the patients were diabetic. CKD was attributable to unknown causes in 6.5% of our patients.
|Table 1: Comparison of characteristics between complementary and alternative medicine users and nonusers.|
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One hundred and eighty-four of the patients interviewed (66.3%) reported the use of one or more types of CAM therapy in the previous six months. The types of CAM used by the patients are shown in [Table 2]. HDS were used by 13 (7.1%); ayurvedic medication by 117 (63.6%); naturopathic, homeopathic, and Unani systems by 30 (16.3%) patients, while spiritual/faith healing and acupuncture were used by 16 (8.7%) and eight (4.3%) patients, respectively. Out of the 184 patients who reported CAM use, about 50 (27.2%) reported using them infrequently (less than once/week), frequent use (greater than two–three times/week) was seen in 69 (37.5%), while 65 (35.3%) reported daily usage. Fifty-seven (31%) patients continued to use CAM at the time of the study period, whereas the remaining 127 (69%) had discontinued their use. The reasons for CAM use are depicted in [Table 3]. Most patients (62%) had used CAM based on recommendation from family members and friends. A multiple regression analysis between CAM users and nonusers revealed that older age (P = 0.004), occupational status (P = 0.035), and income (P = 0.006) correlated strongly with CAM use. CAM users were more likely to being in the age category of 40–60 years and were largely unemployed. Gender, educational status, and marital status as well as CKD stage did not have any statistical impact on CAM usage. Since the majority of our patients were users of herbal and/or ayurvedic medications, we did a subgroup analysis of this group. We divided CAM users into Category 1 which included herbal and ayurvedic medication users and Category 2 which included other CAM users. The results are shown in [Table 4], and Category 1 users were more likely to be male, in the age group of 40–60 years, belonging to the Hindu religion. They were also more likely to be of lower education status and largely unemployed with low socioeconomic status. Thirty-seven (20.1%) CAM users had experienced side effects of therapy. Out of the 127 patients who had previously used and subsequently discontinued the use of CAM, 81 (44%) said that they stopped using due to the perceived lack of benefits of their kidney disease, whereas 39 (21.2%) had been advised to stop them by the treating physician.
|Table 2: Types of complementary and alternative medicine used in the study (n = 184).|
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| Discussion|| |
The present cross-sectional study included 278 patients diagnosed with CKD undergoing treatment in an outpatient nephrology center in a university hospital. Participants were considered representative of patients with CKD in South India. Of the 278 patients included, the prevalence of CAM use was fairly high at 66.1%. Of these patients, about 31.0% of patients were ongoing CAM users. The use of CAM has been reported among HD patients at a global level;,,,,,, however, the use of CAM among nondialysis CKD patients is limited and to the best of our knowledge, this is the first study to be reported from South India. More than 2/3rd of the patients in our study repor-ted the usage of herbal and alternative medications. This number is far greater than other studies which have reported the prevalence of use ranging from 26%–45%., Grabe et al in the USA found 29% of patients with CKD using HDS, whereas Spanner et al, in Canada reported a usage of 45%. In the only Indian study performed by Arjuna Rao et al, the prevalence of CAM use in HD patients was 26%. The majority of patients identified as CAM users were in the age group of 40–60 years, and this finding is similar to other reports by Birdee et al and Arjuna Rao et al, which showed that usage of CAM was more among middle-aged patients compared to other age groups. This correlates with the prevalence of CKD being higher in this age group due to higher incidence of chronic diseases such as diabetes and hypertension. The use of CAM also varies by gender, geographic region, socioeconomic status, etc. In our study, we analyzed the usage of CAM according to age, gender, educational status, occupation, place of living, marital status, and stage of CKD. We found that income, occupational status, and age were found to significantly influence CAM usage, whereas educational and marital status was not relevant. Our study identified Ayurveda as the most commonly used CAM therapy (63.6%) followed by other traditional systems of medicine practiced in India such as naturo-pathy, unani, and homeopathic medicine (16.3%). We, therefore, conducted a post hoc subgroup analysis of patients who had taken herbal and ayurvedic medication versus other forms of CAM. We found that these patients were more likely to be poorly educated, belonging to the Hindu religion, and were of lower socioeconomic status. We postulate that most of this group patients switch to alternative medication use instead of conven-tional nephrology therapy which they found inaccessible or unaffordable as a desperate attempt at a possible cure, and that they perceived them to be safe.
In India, there is a paucity of data on the usage of CAM among CKD patients. As many as 200 million people may be living with CKD, the majority of whom live in rural settings, and have limited access to conventional health care. It is in this context that the traditional systems of medicine function often as the principal form of health care. Individuals not only take CAM specifically for the treatment of their kidney disease, but also for the treatment of comorbid conditions such as diabetes and hypertension. Ayurveda is a complex system of medicine using various potent herbs and plant products, and sometimes also using minis-cule amounts of amalgamation of certain heavy meals and in the context of biomedicine, these treatments promote diuresis, erythropoiesis, and cause glucose lowering and anti-inflammation. Some traditional medicines have also been proven to reduce proteinuria in patients with diabetic nephropathy. It is also known that the use of some TMs may adversely affect renal function, and this has led to concerns about the detrimental effect of long-term CAM use in patients with CKD. Furthermore, the contamination with and use of small doses of heavy metals are also part of the Indian system of medicine, and heavy metal toxicity with repeated and prolonged use in patients with limited renal function, with the potential for long-term irreversible damage, is of grave concern. Despite the widespread use of ayurvedic medication among patients with CKD, evidence of their safety and efficacy remains limited. In our study, 37 (20.1%) patients had experienced side effects of CAM therapy, whereas seven (3.8%) had stopped the-rapy due to toxicity. However, we could not look into the exact details of the side effects experienced by the patients. Since the study patients were not followed up over a longer period, long-term toxicities associated with CAM usage could not be assessed. Renal failure affects the pharmacokinetics of various medi-cations including TM. In addition, regular and prolonged consumption of TM can increase the potential risks of heavy metal toxicity with rapid decline in kidney function. Hemodynamic, hypoglycemic, electrolyte, and coagulation abnormalities and unpredictable effects on blood pressure have been observed. The risk of undesirable side effects of the use of CAM could also be due to the fact that most patients do not inform health-care professsionals of their use of CAM. It has been reported in one study that 72% of respondents did not inform their doctor about the use of HDS. This study also found a signifycant association between the use of HDS and poor adherence to conventional medication. Treating physicians should be well informed about the possible side effects of herbal treatments. Our study patients were also highly influenced by CAM use by family and close friends. This influence has also been supported by other studies in Asian population,, in patients with chronic illnesses.
The current study provides information about the high prevalence of use of CAM, the different types of CAM used by CKD patients, and reasons for their use. This study is possibly the first of its kind addressing this important issue with a reasonable sample size. The study has some limitations which include its cross-sectional design and the results being subject to recall bias regarding CAM use. Another limitation was that the study only assessed patients' responses and not those of the treating physicians toward CAM use. We were also not able to systematically look into the details and exact nature of the herbs the patients were taking, and this information will need a chemical analysis of the drug specimen, which was beyond the scope of this study.
| Conclusions|| |
The present study highlights the high prevalence (66%) of use of alternative medication use in patients with CKD. Ayurvedic therapy was the most commonly used mode with higher prevalence of use in the middle-aged and lower socioeconomic status patients. The health-care team should play an active role in inquiring about the use of such alternative therapy in all patients and be aware of possible drug interactions and complications that may arise. Better communication and education by health-care providers on the potential risks and benefits of CAM use in this vulnerable group of patients is needed to provide more holistic care.
| Research involving humans/animals|| |
The study is a cross-sectional survey of patients with CKD, and written informed consent from the patients had been taken.
| Acknowledgments|| |
The authors would like to thank Dr. Valerie Luyckx, Independent Consultant, University of Zurich, for her help and suggestions with the article.
Conflict of interest:
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[Table 1], [Table 2], [Table 3], [Table 4]