‘Kidney Health for All’ - Implications for India

On March 10, 2022, the world will celebrate the 16th World Kidney Day(WKD). It is a joint initiative of the International Society of Nephrology (ISN) and the International Federation of Kidney Foundations -World Kidney Alliance (IFKF-WKA) and is celebrated globally with the aim of improving kidney health and reducing the burden of kidney disease.[1] The theme for WKD 2022 is ‘Kidney Health for All’. It is important to remember that while kidney disease is common and harmful, it is usually preventable. It affects the lifestyle of the individual patient and also impacts the family and the society at large. By promoting ‘Kidney Health for All’, it is intended that the world recognises the deleterious socioeconomic impact of kidney diseases and employs kidney healthy practices which will go a long way in reducing the burden of kidney diseases in the community. In this article, an attempt is made to elucidate the challenges in the diagnosis and care of patients with Chronic Kidney Disease(CKD) in India. CKD is a common condition with the prevalence of 8-16% in the global population.[2] It affects approximately one in every ten individuals and much of the morbidity of CKD is due to the associated cardiovascular(CV) events such as myocardial infarction, heart failure, stroke and arrhythmias. There is also an increased risk of death from CV events and sudden cardiac death is particularly common. The prevalence of CKD is gradually rising and so also is the mortality. Globally, the all-age mortality from CKD increased 41.5% from 1990 to 2017 and the all-age prevalence increased 29.3%.[3] There is also a huge component of loss of Disability adjusted life years (DALY) due to CKD. The prevalence and the risk factors for CKD however tend to differ among the developed and the developing countries. While lifestyle diseases such as diabetes, hypertension and obesity predominate in the developed countries, the causes are much more varied and multidimensional in lower and low-middle income countries (LMICs).[4] Tropical infections such as leptospirosis, malaria cause acute kidney injury, as a sequelae of which there is persistence of kidney damage. Climate change with rising global ambient temperature, growing uses of agrochemicals are other postulated causes. Low birth weight, unclean water, lack of sanitation, malnutrition and lack of health literacy are other major drivers of the high prevalence of CKD. In addition, there is also the influence of poverty and illiteracy on healthcare accessibility and availability. The inequality of health care services and the ignorance drive people to presentation at an advanced stage of the disease and with complications. This in turn enhances the healthcare expenditure in the already poor people turning it into a vicious cycle. Healthcare in India and the burden of noncommunicable diseases: India is a vast country with a great variability in the people, landscapes, density of population, literacy rate and health care facilities across the country. While 70% of the Indian population is said to reside in the villages, the healthcare services are predominantly concentrated in the urban areas. There is a nationwide public health system organized at various levels that is almost entirely free to users. However, 82% of the outpatient services and 58% of inpatient services are provided by the private sector, which comes at a significant cost, ill afforded by the country’s poor.[5] Further there is a paucity of medical professionals working in the rural areas. It is estimated that 74% of the doctors work in urban areas. The infrastructure of existing hospitals in rural areas is also not adequate. Thus the people may have to resort to fraudulent healers, informal healthcare providers or sometimes, traditional healers for their health needs. India faces a huge burden of diseases which has now shifted from communicable diseases to noncommunicable diseases and they account for 60% of all deaths in recent times.[6] The age adjusted prevalence of diabetes is 9.6% with the prevalence being greater in urban areas. It is estimated that a staggering 53% have undiagnosed diabetes.[7] A recent meta-analysis reports an increase of prevalence in both rural and urban India from 2.4% and 3.3% in 1972 to 15.0% and 19.0% respectively in the years 2015-2019.[8] The prevalence of hypertension is about 30%[9] and the gap in prevalence between urban and rural India is slowly reducing. A study from rural areas near Shimoga, for example, reported an age -adjusted prevalence of 30%.[10] The Fourth District Level Household Survey reported hypertension in 25.3% with greater prevalence in men (27.4%) than women (20.0%). This translates into 207 million persons with hypertension in India.[11] With a huge population burden (estimated at 1.39 billion in 2021), it is imperative that the onus of the primary mode of control of diseases, including kidney disease, should be by focusing on preventive efforts. A national programme for control of NCDs called the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NCPDCS) was launched in 2010, but it did not include a policy for CKD, until recently. Population based screening for diabetes and hypertension is an integral part of the NPCDCS programme.[12] Hurdles in diagnosis and management of CKD in India The rising prevalence of CKD in India is a well-known phenomenon. The earlier studies reported a prevalence of 0.89%-1.39%, while the multi-centric SEEK study recorded a prevalence of 17.2%.[13] It is, however, difficult to objectively compare various figures available from various studies on the prevalence of CKD. The studies offer varied prevalence rates, depending on the time period in which the study was conducted and the different defining criteria employed for the diagnosis of CKD. In addition, there are regional differences with some areas showing a dramatic increase in cases of CKD compared to others. There are hotspots of CKD along the east coast of India, where the reported prevalence of CKD is very high, almost 18%.[14] The diagnosis of CKD, though simple, has its pitfalls too. Lack of standardization in methods of estimation of creatinine between laboratories and differences in equations estimating Glomerular filtration rate is another impediment for comparison of prevalence among regions.[13] There is no eGFR estimating equation validated for the Indian population. There is no national registry for documentation of CKD and its various socio-demographic characteristics with early efforts at such a cause quickly petering off. All these are hurdles to our understanding of the distribution of the disease in the country. At the primary level too, the practitioners who attend to the vast majority of the people with various ailments are less oriented to kidney disease and diagnose them late. Late referral to nephrologists, delay in diagnosis of kidney dysfunction in patients with long standing diabetes/hypertension and indiscriminate use of nephrotoxic medications are other factors that complicate kidney care. Challenges in the management of CKD in India There are currently very few qualified nephrologists (rough estimate is around 1850 nephrologists for a population of 1.3 billion) and mostly in the urban areas,[15] The delayed referral to nephrologists also adversely affects the care of patients. It is reported that only 20-30% patients achieve the recommended blood pressure and glycemic targets and reflects poor physician practices. The availability of renal replacement therapy (RRT) is also mainly concentrated in urban areas and many have to travel long distances to reach dialysis centers. It is estimated that only about 10% of patients with end stage kidney disease (ESKD) can afford to be on long term dialysis and discontinuation of therapy is common. Although many public hospitals now have haemodialysis units under the Pradhan Mantri National Dialysis Programme (PMNDP),[16] the rising numbers of ESKD can barely be accommodated in these centers. Reports suggest that peritoneal dialysis as the initial RRT option is cost-effective compared to haemodialysis, but this is yet to translate to routine clinical practice.[17] Renal transplantation is available in mostly private hospitals and the deceased donor transplantation program has only barely taken off at a few centers. Kidney Health for all - what can be done? This year’s WKD theme-‘Kidney Health for all’ is an all-inclusive goal to ensure that kidney health is equally accessible to all, overcoming the regional, national, racial and gender inequalities. It is essentially an adaptation of the 17 Sustainable Development Goals(SDGs) that had been formally adopted by all United Nations member countries in 2015.[18] Education is the cornerstone to ensure that everyone has a basic understanding of the need for evaluation and management of early kidney disease. Improved health in the family as a whole with more focus on the health of the mother and the child, improving health literacy and improving opportunities to build a better workforce are other strategies. Quality education is the key to reduce inequality and poverty. Improving the nutritional status, provision of clean water and better sanitation promotes health. Community health workers, auxiliary nurse midwives and Accredited Social Health Activists (ASHA) may be trained to screen for diabetes, hypertension and provide basic health education to rural population.[15] They could be taught to monitor the health status of patients with CKD. Promoting gender parity is important to ensure equal opportunities to access healthcare. Better antenatal care results in healthy babies with lower risk of CKD in later life.[19] Avoidance and better control of preeclampsia also reduces risk for later development of CKD for women. Regular screening at community level for diabetes and hypertension and ensuring adequate control goes a long way in prevention of CKD. Ensuring equitable distribution of RRT facilities with quality care that is accessible and affordable is a priority for countries and a suitable policy be drafted by policymakers in this regard. Conclusions: Health is a fundamental right of all individuals on this planet and the WKD serves to remind the practitioners of kidney care, their responsibilities in ensuring the deliverance of good quality kidney care to patients. Efforts at kidney awareness are made all over the world by conducting various activities which serve to gradually bring awareness to people and promote kidney health. Co-ordinated efforts among various stakeholders are important to ensure this goal. Source of funding: Nil Conflict of interest: None