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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2013  |  Volume : 24  |  Issue : 6  |  Page : 1285-1290
Kidney disease in the elderly: A Sri Lankan perspective

1 Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
2 University Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka

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Date of Web Publication13-Nov-2013


Renal disease in the elderly in Sri Lanka is a largely neglected area in the literature with hardly any publications. We carried out a hospital-based survey of elderly patients (elderly is defined in this article as patients aged 65 years or above) with renal disease. This prospective study included all patients aged 65 years or above admitted to the University Medical Unit, National Hospital of Sri Lanka, over a period of 1 year with a primary renal-related illness as the reason for hospitalization. This hospital-based survey is the first of its kind to look into the nephrological disease profile of elderly patients in Sri Lanka. Based on our findings, we have made several pertinent recommendations regarding the care of the elderly with renal disease in Sri Lanka that may be relevant to other developing nations as well.

How to cite this article:
Rodrigo C, Samarakoon L, Rajapakse S, Lanerolle R, Sheriff R. Kidney disease in the elderly: A Sri Lankan perspective. Saudi J Kidney Dis Transpl 2013;24:1285-90

How to cite this URL:
Rodrigo C, Samarakoon L, Rajapakse S, Lanerolle R, Sheriff R. Kidney disease in the elderly: A Sri Lankan perspective. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2021 Feb 26];24:1285-90. Available from: https://www.sjkdt.org/text.asp?2013/24/6/1285/121282

   Introduction Top

Sri Lanka's population is one of the fastest aging in the world. The percentage of the total population (20 million) above the age of 65 years was estimated to be 6.3% in 2000, and is projected to rise to 21.3% by 2050. [1],[2] The dependency ratio at old age will rise from 9.3% to 34.7% during this time period. [1] Faced with a fast aging population, the health-care infrastructure also needs to adapt accordingly. Current statistics indicate that proper planning is needed to tackle the health care demands in both preventive and curative sectors.

Renal disease in the elderly in Sri Lanka is a largely neglected area in the literature with hardly any publications. The disease burden due to chronic kidney disease (CKD) is on the rise in Sri Lanka. The North Central province of the country has been hit by a wave of newly diagnosed CKD patients reaching "epidemic" proportions. [3] It has become a factor that limits average life expectancy in these regions. The so-called "CKD of unknown origin" is still an enigma to the nephrologists and scientists regarding the etiology.

When the resources are limited (e.g., facilities for dialysis, expensive drugs), the priority of distribution is for the young. [4] The elderly are at risk of marginalization, with their needs unattended. However, with the changing population dynamics of an increasing elderly population, the order of prioritization might change in the future. We still do not have any published data on the nephrology-related disease burden among the elderly in Sri Lanka. The first step in attending to the needs of the elderly with renal disease is quantifying the problem and, therefore, assessing the renal disease burden in the elderly in Sri Lanka is a timely need.

   Methods Top

We carried out a hospital-based survey of elderly patients with renal disease (elderly is defined in this article as patients aged 65 years or above). This prospective study was carried out at the University Medical Unit, National Hospital of Sri Lanka, over a period of 1 year, and included all patients with a primary renal-related illness/cause as the reason for admission.

The data collection instrument was a pretested, interviewer-administered questionnaire containing items of basic demography, details of presenting complaints, past medical history, drug history as well as compliance and outcome of the current admission. Verbal consent was taken prior to enrolment.

Data were analyzed using the SPSS ® (version 15) statistical software package. Findings relevant to descriptive statistics were summarized into proportions and averages. Significance of associations was calculated using appropriate statistical tests such as the chi square test and Fisher's exact test. The study was approved by the Ethics Review Board of the National Hospital of Sri Lanka.

   Results Top


During the study period, 86 patients over 65 years of age (72 male and 14 female) were admitted with a primary renal disease and were included in the study. Repeated admissions by the same patient were not counted. The age range of the sample was from 65 to 84 years (mean 70.3 years; SD 5.8 years). Majority of the study patients were of Sinhalese ethnicity (75.87%). Most of them (72.84%) were married with a living spouse and 12 (14%) were widowed. A significant majority (56.65%) had completed at least 5 years of formal school education, while two (2%) had tertiary educational qualifications (a university degree). Fifty-eight percent of the sample had a monthly income of less than 5000 rupees (less than 50 USD), which was below the poverty line. Fifty-seven patients (66%) lived with their children, 27 (31%) lived with their spouse and two patients (2%) lived alone. The basic demographic characteristics of the study patients are depicted in [Table 1].
Table 1: Basic demographic characteristics of the study patients (n = 86).

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Forty-five patients (52%) had diabetes mellitus while 57 patients (66%) had hypertension. Ischemic heart disease had been diagnosed in 19 patients (22%) while hyperlipidemia was diagnosed in 16 patients (19%) at the time of admission. Other reported co-morbidities included asthma (two patients, 2%), cerebrovascular accidents (two patients, 2%) and heart failure (one patient, 1%).

Renal disease and management

Twenty-nine patients (34%) had acute kidney injury (AKI) while 72 (84%) had CKD. Fourteen patients (16%) had acute on chronic kidney failure. The majority of CKD patients (51. 71%) had end-stage renal disease (ESRD, CKD stage-V). Three patients (4%) presented in C-KD stage-I, two (2.7%) in CKD stage-II, seven (9.7%) in stage-III and eight (11%) in stage-IV.

The etiology of AKI in the study patients is summarized in [Table 2]. While a multitude of causes were identified as precipitants for AKI, the most common was hump-nosed viper bites (four, 14%). Of all AKI patients, 15 (52%) required hemodialysis (HD), two were managed with peritoneal dialysis while the remaining did not require dialysis.
Table 2: Etiology of acute kidney disease in the study patients (n = 29).

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Etiologically, diabetes and hypertension accounted for most cases of CKD. Collectively, 61% of the patients with CKD had their most attributable etiology as diabetes, hypertension or both. Of the patients with ESRD, 37 (63%) were initiated on HD. However, a majority of them were inadequately dialyzed. Twenty-eight patients were dialyzed only once a week and four had twice a week dialysis. State sector dialysis was provided for all patients with AKI needing HD. However, none of the patients with CKD received dialysis according to their requirements from the state sector due to the limited resources. Five patients (14%) with CKD were regularly dialyzed in the private sector hospitals at their own expense or supported by the government. Only one patient of the entire sample said that he could afford regular long-term private sector dialysis.

The number of medications these patients were taking varied from one to 13, with the majority (64, 74%) being on at least six drugs or more. The most commonly prescribed drugs were angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB), which were given to 54 patients (63%), while diuretics (62, 72%), phosphate binders (42, 48%), statins (54, 63%), alfa blockers (35, 40%) and calcium channel blockers (33, 38%) were also commonly prescribed. Of the patients with C-KD, 17 (24%) were on erythropoietin while 40 (56%) were on oral hematinics.

Of the total sample, eight patients (9.3%) died while being admitted in the hospital (four had AKI and the other four had CKD). The others were discharged and regular follow-up was arranged. However, the number of deaths during the study period in this sample may be more as some patients might have died at home from complications of their illness.

   Discussion Top

The duration of our study was 1 year and, in this period, the number of elderly patients within the age criteria selected (greater than 65 years of age), admitted with renal disease, was few. This was when re-admissions were not counted. However, on approximation, this was merely 1% of the total admissions to the ward per year. Although the prevalence of CKD is on the rise in Sri Lanka, the limited number of patients presenting in the above-65 years age category is worth exploring. One possibility is that given the scarcity of dialysis facilities compounded by non-affordability, many who are diagnosed with CKD do not survive till the age of 65 years.

It is also interesting that a large proportion of the sample was diagnosed to have diabetes mellitus and hypertension in addition to their renal ailment. In many patients, the most plausible etiology for CKD was diabetes, hypertension or both. It is a well-known fact that the morbidity and mortality statistics are shifting from infectious diseases to non-communicable diseases in many developing countries, including Sri Lanka. Using a nationally representative sample, Katulanda et al estimate that the prevalence of diabetes in adults over 20 years of age in Sri Lanka is 10.3% (males 9.8%, females 10.9%). [5] The prevalence is higher in the urban population when compared with the rural population, and is expected to rise to 13.9% by the year 2030. Likewise, complications of diabetes including nephropathy will also be on the rise, especially among the elderly, who would have been living with the disease for a longer time. Early identification and prevention of renal damage in hypertension and diabetes is a timely need in Sri Lanka.

The etiological factors for AKI in the study group were many. However, it is noteworthy that the most common cause was hump-nosed viper bites (Hypnale hypnale). Hump-nosed viper bites are common in the wet zone of Sri Lanka. These bites cause an intense local reaction in addition to AKI, causing significant morbidity. [6] Even if the victim survives the initial episode of AKI, there is a risk of developing subsequent CKD as well. The hump-nosed vipers are currently categorized as moderately venomous snakes. Those belonging to the highly venomous categories include cobra, Russell's viper, Ceylon krait, Indian krait and saw-scaled viper. [7] However, it must be noted that hardly any fatalities have been reported in the published literature with Ceylon krait and saw-scaled viper bites in Sri Lanka. On a comparative scale, the morbidity and mortality of hump-nosed viper bits may be more significant, and it has been inappropriately classified as a moderately venomous snake. [8]

In Sri Lanka, the health care facilities for its citizens are provided in both the government hospitals (free of charge) and the private sector hospitals. However, unfortunately, the social support systems such as health insurance are not very popular and there are no similar state-sponsored welfare programs. Therefore, the demand for HD in the government sector is huge and exceeds its capacity to deliver. [4] Currently, HD facilities are available in less than 10 government hospitals countrywide, and they do not have more than 10 dialysis machines at each hospital (many having one or two). Obviously, this results in a prioritization of patients based on urgency for dialysis, with priority being given to AKI patients and CKD patients with transplant plans. The chances of a long-term dialysis facility for an elderly patient with CKD without transplant plans are virtually non-existent in the government sector in Sri Lanka.

Therefore, except in life-threatening emergencies, the only option available for such patients is private sector dialysis. The average cost of a HD session in the private sector is about USD 60 (a regimen of twice-weekly dialysis for 1 month would cost around USD 480 at a minimum).

In our sample, for many, this was not affordable (67% of the patients needing dialysis had a total monthly income less than USD 50). Many patients who cannot maintain an adequate dialysis regimen at such a cost are inadequately dialyzed, resulting in reduced life expectancy. This may explain the relatively smaller numbers of CKD patients in the over-65 years age group.

Poly-pharmacy among the patients was another pertinent observation. The most commonly prescribed drugs were the anti-hypertensives, phosphate binders and statins. Three-quarters of the sample were on at least six drugs. Not only are the elderly susceptible to increased side-effects of drugs, they are also more sensitive to their effects.

Most of them had good family support, but complicated dosing regimens affected the compliance (some drugs to be taken thrice daily and some twice daily). None of the patients had been properly evaluated for symptoms of dementia or depression, which could affect drug compliance as well as the overall quality of life. Erythropoietin is an expensive drug and it is provided free of cost to patients with anemia and CKD in the clinics.

However, given the limited availability and costs, many who deserve it are maintained on oral hematinics alone. This fact is reflected in the sample as the number on hematinics is twice as that on erythropoietin.

   Conclusions Top

This hospital-based survey is the first of its kind to look into the nephrological disease profile of elderly patients in Sri Lanka. Based on the results and our interpretations, we would like to make the following recommendations for care of the elderly with renal disease:

  1. Designing community- and hospital-based studies to calculate survival of patients diagnosed with CKD in Sri Lanka
  2. Raising public awareness of primary, secondary and tertiary prevention of co-morbidities such as diabetes and hypertension
  3. Community-based studies on assessing the burden of renal disease associated with diabetes and hypertension in Sri Lanka
  4. AKI following hump-nosed viper bites being a problem of all age groups, we encourage re-thinking of its classification status as a moderately venomous snake
  5. A government-funded (or at least subsidized) health insurance scheme to enable senior citizens with CKD to have dialysis support
  6. Educating health care workers on simplifying drug regimens to increase compliance among patients and
  7. Assessment for symptoms of depression and dementia should be a part of the work-up of elderly patients with CKD.

   References Top

1.United Nations. World population ageing. New York; 2004.  Back to cited text no. 1
2.Ranasinghe CC, Rodrigo C, Premaratne S, Adhikari AM, Rajapakse S. An audit on care of patients with type 2 diabetes mellitus in a tertiary care medical clinic in Sri Lanka. Int J Diabetes Dev Ctries 2010;30:174.  Back to cited text no. 2
3.Nanayakkara S, Senevirathna ST, Karunaratne U, et al. Evidence of tubular damage in the very early stage of chronic kidney disease of uncertain etiology in the North Central Province of Sri Lanka: A cross-sectional study. Environ Health Prev Med 2012;17:109-17.  Back to cited text no. 3
4.Rodrigo C, Lanerolle R, Arambepola C. Adequacy of hemodialysis in patients with chronic kidney disease in Sri Lanka: A prospective study. Saudi J Kidney Dis Transpl 20-10;21: 1145-6.  Back to cited text no. 4
5.Katulanda P, Constantine GR, Mahesh JG, et al. Prevalence and projections of diabetes and prediabetes in adults in Sri Lanka--Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Diabet Med 2008;25:1062-9.  Back to cited text no. 5
6.Kularatne K, Budagoda S, Maduwage K, Naser K, Kumarasiri R, Kularatne S. Parallels between Russell's viper (Daboia russelii) and humpnosed viper (Hypnale species) bites in the central hills of Sri Lanka amidst the heavy burden of unidentified snake bites. Asian Pac J Trop Med 2011;4:564-7.   Back to cited text no. 6
7.Ariaratnam CA, Sheriff MH, Arambepola C, Theakston RD, Warrell DA. Syndromic approach to treatment of snake bite in Sri Lanka based on results of a prospective national hospital-based survey of patients envenomed by identified snakes. Am J Trop Med Hyg 2009;81:725-31.   Back to cited text no. 7
8.Joseph JK, Simpson ID, Menon NC, et al. First authenticated cases of life-threatening envenoming by the hump-nosed pit viper (Hypnale hypnale) in India. Trans R Soc Trop Med Hyg 2007;101:85-90.  Back to cited text no. 8

Correspondence Address:
Chaturaka Rodrigo
Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo
Sri Lanka
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DOI: 10.4103/1319-2442.121282

PMID: 24231505

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