|Year : 2019 | Volume
| Issue : 4 | Page : 795-802
|Chronic Kidney Disease among Middle-Aged and Elderly Population: A cross-sectional screening in a Hospital Camp in Varanasi, India
Pradeep Kumar Rai1, Punam Rai2, Rasika Ganpathi Bhat3, Sonam Bedi4
1 Department of Nephrology, Opal Hospital, Varanasi, Uttar Pradesh, India
2 Department of Clinical Physiology, Opal Hospital, Varanasi, Uttar Pradesh, India
3 Department of Medical Genetics, College of Nursing, Bombay Hospital and Research Center, Mumbai, Maharashtra, India
4 Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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|Date of Submission||27-Mar-2018|
|Date of Decision||11-May-2018|
|Date of Acceptance||02-Jul-2018|
|Date of Web Publication||27-Aug-2019|
| Abstract|| |
Chronic kidney disease (CKD) is no longer considered just a health burden, but a major health priority owing to its high treatment costs and poor outcome. The lack of community-based screening programs has led to the detection of CKD patients at advanced stages. This study aims to estimate the prevalence of CKD and patterns of known risk factors among the general population (middle-aged and elderly) attending a screening camp in a community-based setting. The study participants constituted a part of the general population of Varanasi (aged ≥45 years) who volunteered in a screening camp that was organized as part of the World Kidney Day Initiative at Opal Hospital. Information on age, sex, height, weight, smoking and drug history, history of diabetes, hypertension, and family history of kidney disease was extensively interrogated, while laboratory investigations such as urinalysis and serum creatinine levels were recorded. More than three-fifths of the participants were middle-aged adults (i.e., 45–64 years) and the remaining 34.8% were elderly population, i.e., ≥65 years. The overall prevalence of CKD in the 198 studied participants was 29.3%. Higher number of participants (40.6%) of elderly population had CKD (P = 0.011). The serum creatinine, albuminuria, and estimated glomerular filtration rate levels were strongly associated with CKD (P <0.05). Our study suggests that elderly individuals are at risk with higher serum creatinine levels and would benefit from early detection of CKD to prevent disease progression and associated morbidity and mortality.
|How to cite this article:|
Rai PK, Rai P, Bhat RG, Bedi S. Chronic Kidney Disease among Middle-Aged and Elderly Population: A cross-sectional screening in a Hospital Camp in Varanasi, India. Saudi J Kidney Dis Transpl 2019;30:795-802
|How to cite this URL:|
Rai PK, Rai P, Bhat RG, Bedi S. Chronic Kidney Disease among Middle-Aged and Elderly Population: A cross-sectional screening in a Hospital Camp in Varanasi, India. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Nov 17];30:795-802. Available from: http://www.sjkdt.org/text.asp?2019/30/4/795/265454
| Introduction|| |
Chronic kidney disease (CKD) is no longer considered just a health burden today but a major health priority due to its high treatment costs and poor outcome., One reason is the rapid increase in the incidence of diabetes mel-litus (DM) and hypertension (HTN), worldwide. Even early stages of CKD are known to be associated with increased risk of cardiovascular morbidity, premature mortality, and decreased quality of life. Due to its asymptomatic nature, CKD is generally detected only at advanced stages, resulting in delayed diagnosis. Progression of CKD to renal failure and other adverse outcomes can be prevented or delayed through early detection and treatment.
In 2002, the Kidney Disease Outcomes Quality Initiative (KDOQI) of the National Kidney Foundation (NKF) developed a practice guideline for CKD, recommending routine testing for the detection of kidney disease during general health check-up for individuals at risk.
The estimated age-adjusted incidence of end-stage renal disease (ESRD) is 229 per million population whereas more than one lakh new patients enter renal replacement programs annually in India. However, because of scarce resources, only 10% of these ESRD patients receive any form of renal replacement therapy., The lack of community-based screening programs for CKD results in patient detection at advanced stages.,, Hence, this study aimed to estimate the prevalence patterns of some known risk factors of CKD in the general population (middle-aged and elderly) attending the screening camp on the World Kidney Day (March 12, 2015) at Opal Hospital in Varanasi.
| Subjects and Methods|| |
The study subjects constituted general population of Varanasi who were screened as part of the World Kidney Day Initiative at Opal Hospital on March 12, 2015. In total, 198 volunteers aged ≥45 years and who provided informed consent were included in the analysis. We excluded any subject with signs and symptoms, suggestive of acute kidney injury (e.g., history of vomiting, diarrhea, and fever) in the recent past. Information on socio-demographic profile and personal characteristics such as age, sex, height, weight, smoking and drug history, history of DM and HTN, and family history of kidney disease was extensively interrogated, while clinical investigations such as urinalysis and serum creatinine levels were recorded on a pre-structured questionnaire. Systolic and diastolic blood pressure (BP) was measured only on one occasion, i.e., on the day of screening.
Some of the variables were converted into categories for appropriate clinical interpretation. Age was divided into two categories, e.g., <65 and ≥65 years. Gender was classified as male and female. Body mass index (BMI) was calculated using height and weight of individuals. Any individual with BMI ≥30 was considered as obese. Diabetes was defined as the use of glucose lowering medicine, fasting plasma glucose ≥126 mg/dL, or hemoglobin A1c ≥6.5%. HTN was defined as the use of antihypertensive medication, systolic BP ≥140 mm Hg, or diastolic BP ≥9 0 mm Hg.
Smoking status, obesity, DM, HTN, family history of renal disease, and albuminuria were dichotomized as: yes (present) and no (absent). Serum creatinine level (mg/dL) was divided into two groups: <1.30 and ≥1.30 mg/dL. A urine dipstick (Medi-Test Combi 9-Macherey Nagel, Duren, Germany) was performed for each participant. Two milliliters of the blood sample was collected from each participant through venipuncture to investigate for serum creatinine level. All individuals with a positive CKD test result for kidney dysfunction or damage in the screening were referred to the nephrologists; they were not followed up. The disease outcome considered was the presence of CKD, and furthermore, its stages were considered based on the estimated glomerular filtration rate (eGFR) levels and albuminuria. The eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Reduced renal function was defined as an eGFR <60 mL/min/1.73 m2. CKD was defined based on reduced renal function, or presence of albuminuria. Albuminuria was regarded as significant if it was 1+ and above. CKD stages were defined as: stage 1 if eGFR was ≥90 mL/min/1.73 m2 and albuminuria was present; stage 2 if eGFR = 60–89 mL/min/1.73 m2 and albuminuria was present; stage 3 if eGFR = 30–59 mL/min/1.73 m2; stage 4 if eGFR = 15–29 mL/min/1.73 m2; and stage 5 if eGFR <15 mL/min/1.73 m2.
Among the studied subjects, eGFR could be obtained in only 136 subjects (68.7%); hence, further analysis was confined to 136 subjects only. The association of each variable with the disease outcome, CKD, was analyzed separately using Pearson’s Chi-square test. Statistical significance was fixed at P = 0.05. All the analysis was performed on Statistical Package for the Social Sciences (SPSS) version 16.0 (SPSS Inc., Chicago IL., USA).
| Results|| |
The overall prevalence of CKD in 198 studied subjects was 29.3%, of which 24.1% were in stage 1, 17.2% in stage 2, and 58.6% in stage 3. No subjects belonged to stages 4 and 5 of CKD. The profile of individuals who participated in the study is presented in [Table 1] and [Figure 1]. The profile indicated that more than three-fifth (65.2%) of the participants belonged to the middle-aged adult group (i.e., 45–64 years) and the remaining 34.8% were the elderly population, i.e., ≥65 years. Among participants aged 45–64 years, 23.3% had CKD; a significantly larger number of participants (40.6%) of population ≥65 years had CKD (P = 0.011). There was a preponderance of males in the studied population (62.6%).
|Figure 1: Prevalence of chronic kidney disease in population with different characteristics.|
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More than a quarter of males (27.4%) and little more (32.4%) females were found to have CKD; however, no statistical association was seen between CKD and gender (P = 0.453). Although only a small fraction of subjects (5.6%) were currently smokers, 36.4% of them had CKD, which was almost the same (28.6%) among nonsmokers (P = 0.733). Around 12% of the participants were obese and had a CKD prevalence of 17.4%, while in the subjects with normal BMI (88%), the prevalence of CKD was much higher (30.2%), although statistical difference was insignificant (P = 0.203).
Family history of renal disease was found in 5.1% of the subjects; the prevalence of CKD was almost same (i.e., around 30%) in participants, irrespective of the presence or absence of family history (P >0.05). Co-morbidities such as DM and HTN were found in 13.6% and 22.2% of the individuals; among them, the prevalence of CKD was seen in more than two-fifth of the participants (44.4% with DM and 40.9% in HTN). Although the prevalence of CKD among the nondiabetic and normo-tensive participants was apparently much less (only in around quarter of participants), no statistical evidence of associations of CKD with these comorbidities was seen (P >0.05). The serum creatinine level of nearly 12.6% of the participants was ≥1.30 mg/dL, of which almost 58.3% had CKD; the level of serum creatinine was strongly associated with CKD (P = 0.001). About 50% of the participants had eGFR levels between 60 and 89, and 25% each had either higher (>90) or lower (30–59) groups of eGFR. About 41% of the participants had CKD in spite of higher eGFR (≥90), while 14.7% of middle eGFR (60–89) and all (100%) of lower (30–59) eGFR had CKD. The eGFR being a function of serum creatinine showed very high association with CKD pre-valence (P <0.0001). Albuminuria was found to be positive in nearly 30% and was strongly associated with CKD (P <0.0001).
About 34% and 39% of obese participants had DM and HTN (P = 0.005 and P = 0.040, respectively). Nearly all obese individuals (91.3%) were of middle age (P = 0.007); obesity was also strongly associated with the presence of family history of renal disease (P = 0.020). Family history of renal disease was commonly seen in the female population (0.042). The eGFR was strongly associated with age-group of the subjects (P <0.0001); higher eGFR was seen in middle-aged adults compared to lower eGFR levels in the elderly population. Comorbidities such as DM and HTN were strongly associated with each other (P <0.0001). Very few hypertensive subjects had family history of renal disease (P = 0.045). The eGFR being a function of serum creatinine was inversely associated with it (P <0.0001). Of the 136 participants calculated for eGFR, 42.6% had CKD. The distribution of CKD subjects based on eGFR is shown in [Table 2]. Some of the characteristics of participating subjects were not recorded, due to the obvious problems faced during collection of primary data; hence, valid percentages are reported in [Table 1].
| Discussion|| |
Delayed recognition and treatment of CKD may predispose patients to adverse future outcomes. Some of the more important negative outcomes include rapid onset of end-stage renal disease, progression of comorbid conditions such as anemia and cardiovascular disease (CVD), suboptimal vascular access at initiation of dialysis, increased use of hemo-dialysis facilities, increased hospitalization, increased cost, and worse survival. Early detection of disease via screening programs is widely recommended.,,, The objective of the present study was to describe the prevalence patterns and association with some known risk factors of CKD among general population (middle aged and elderly) at screening levels in a hospital-based camp in Varanasi.
The most important disparity between the present study and other recent studies mainly lays in the choice of study subjects, which, in our case was limited to the general population (not the kidney patients) who attended the hospital-based screening camp on the World Kidney Day. In addition to this, the subjects (specifically aged ≥45 years) who volunteered to participate in their own in this screening camp were healthy. It provided better insight into the asymptomatic disease in society. Similar hospital- and community-based studies have been organized to assess the prevalence of CKD in elderly populations.,,, Annual CKD screening is recommended by the American Diabetes Association, by the National Kidney Foundation for patients at risk, by the Joint National Committee on HTN for patients with diabetes and HTN, and by the American Heart Association for patients with cardiovascular disease.
Indian researchers seem to follow varied diagnostic criteria for CKD. Agarwal et al studied south Delhi urban adult population and reported a prevalence of 0.79% in that group. The serum creatinine cutoff of over 1.8 mg/dL, on two occasions approximately 12 weeks apart, was taken as the defining criteria for CKD. However, subjects with positive protei-nuria (assessed by dipstick test) were excluded in their definition of CKD., Contradictorily, various studies have demonstrated that proteinuria and high serum creatinine levels are the two valuable predictive determinants for ESRD.,
In the present study, urinary protein excretion and serum creatinine levels were utilized for screening of the population at risk for CKD. A high serum creatinine level (≥1.30 mg/dL) was demonstrated in 18.5% elderly and 9.6% middle-aged adults. Increasing age was significantly related to CKD.
More than one-third of obese participants had DM and HTN. This ongoing increase in obesity due to lifestyle changes is a prelude to multiple obesity-associated health problems including DM, HTN, CVD, and CKD; often, these diseases occur together., Obesity, DM, and HTN are the main preventable risk factors for ESRD, CVD, disability and increased healthcare costs. The overall prevalence of CKD in our study, comprising 198 subjects based on eGFR and albuminuria levels, was 29.3% of which 24.1% were of stage 1, 17.2% of stage 2, and 58.6% of stage 3. Albuminuria was found to be positive in nearly one-third of the individuals (30.8%). The strong association of albuminuria with CKD is consistent with the observation that albuminuria is used as an important marker for CKD detection. eGFR was strongly associated with the age group of the individuals. Conco-mitantly, CKD in the elderly population was higher than those compared to their younger counterparts which clearly depict that aging is a factor strongly associated with the occurrence of CKD.,, Age itself is the biggest nonmodifiable risk factor for most of the chronic diseases. There always remains a question about the distinction between early CKD and normal age-related decline in renal function. Reduction in renal blood flow and mass, as well as increased glomerulosclerosis, is part of the normal aging process, with eGFR falling about 0.75 mL/min/1.73 m2 per year from the age of 40 years. In the present study, subjects were of age ≥45 years and therefore vulnerable to the age-related glome-rulosclerosis and decline in kidney function. In many studies, CKD patients aged over 60 years might not even have significant albumi-nuria. It is therefore, difficult to differentiate between age-related loss of kidney function and renal diseases. The role of the aging process has long been recognized for other organ systems and diseases as well. Co-morbidities coherent with aging process such as DM and HTN are also common in CKD patients. In the UK, almost 64% patients over 65 years and having CKD had four or more additional comorbidities. Further work is required to determine whether renal impairment in elderly patients is associated with, or causes other conditions.
DM and HTN were strongly associated with one another (P <0.0001). Increased prevalence of CKD could be partly explained by the high prevalence of risk factors such as DM and HTN in the screened population (13.6% and 22.2%, respectively). The prevalence of DM and HTN in India varied widely in many studies and ranged from 6% to 20% and 13% to 58%, respectively. In Western countries, DM and HTN account for over 65% of the cases of CKD. In India too, DM and HTN account for 40%–60% cases of CKD. Among the CKD group, 20.7% had DM and 31% had HTN. Very few hypertensive subjects had family history of renal disease (P = 0.045). India is observing fast demographic transition and proportion of elderly population is on the rise; moreover, the lifestyle, e.g., food habits are changing unfavorably and physical activity is reducing. Thus, the situation of asymptomatic CKD subjects along with DM and HTN are growing up. Under such conditions, the findings of the present study cannot be generalized but gives the signal to screen elderly population at mass level for CKD to avoid the adverse outcomes in future lives. Since DM and HTN also ultimately lead to CKD and other complications, early screening for CKD along with DM and HTN will reduce the load of healthcare delivery system that is involved in renal transplant and treatment of CVDs.
| Conclusion|| |
With old age, concomitant diabetes and HTN are rising which are the probable risk factors for developing CKD with the fast-changing lifestyle of people. Hence, a regular screening process is required in such high-risk groups before one reaches to a stage of irreversible adverse outcome. This early detection would benefit in preventing disease progression and associated morbidity and mortality.
Conflict of interest: None declared.
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Pradeep Kumar Rai
Department of Nephrology, Opal Hospital, Varanasi - 221 005, Uttar Pradesh
[Table 1], [Table 2]
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