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Current Status of Chronic Kidney Disease Care in Southeast Asia Vivekanand Jha, MD, DM Summary: Chronic kidney disease (CKD) is a major health problem for the underdeveloped countries of southeast Asia, home to more than 2 billion people. The true incidence and prevalence in the region is not known, but estimates suggest that the prevalence may be more than that reported in Western societies. The majority of affected individuals are young and in the most productive years of their lives. The looming epidemic of diabetes and hypertension is likely to further add to the disease burden. A high prevalence has been reported from some regions, suggesting the presence of unique etiologic factors. A large proportion of patients present late, with advanced kidney failure and multiple complications. Management is hampered by the lack of health care services, especially in the rural areas. The health care expenditure by the governments in these countries is very low, and there are no regional or national policies for chronic disease management including CKD. There is a major shortage of trained nephrologists. In absence of any government or private reimbursement, most patients cannot afford the high treatment cost. Renal replacement therapy is available only to a minority. The practice of dialysis in the region is not standardized and a large number of patients develop complications. There is an urgent need to develop CKD detection and prevention programs. Investigations are required to characterize the unique etiologic factors in different geographic regions so that prevention programs can be targeted appropriately. Cost-cutting strategies would make renal replacement therapy accessible to the general population. According sufficient prominence to CKD in education programs would help increase awareness. Semin Nephrol 29:487-496 © 2009 Elsevier Inc. All rights reserved. Keywords: Chronic kidney disease, end-stage kidney disease, health care costs, dialysis, kidney transplantation, southeast Asia
outheast Asia, home to more than one third of the world’s population, can be divided into 2 main regions. The southern Asian region comprises India, Pakistan and Bangla Desh, Sri Lanka, Nepal, Bhutan, and Maldives, whose populations share common ethnic origins, cultural heritages, and are approximately at the same stage of economic development. The eastern Asian countries, namely Indonesia, Malaysia, Myanmar, Philippines, Thailand, Laos, and Vietnam, are more heterogeneous in terms of ethnicity and economic development, with Malaysia being more prosperous than the rest. Table 1 gives
S
Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Address reprints requests to Vivekanand Jha, MD, DM, Additional Professor of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India. E-mail:
[email protected] 0270-9295/09/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.semnephrol.2009.06.005
the economic and development indicators of the major southern and eastern Asian nations. Overall, the population in these countries is relatively young, about two-thirds live in rural areas and the economy is mostly farm-based. Despite recent economic growth, economic disparities continue to be evident within the societies. The number of affluent individuals has grown, but a large proportion living in rural areas and urban slums remain desperately poor. The slum-dweller population is growing rapidly as the rural poor come to cities in search of work. About 1.4 billion people in these countries live on less than $2 (US$) per day.1 In general, these countries perform poorly on most global human development, economic, and health care indices. Common to these countries are the challenges in providing health care to its people including to those with chronic kidney disease
Seminars in Nephrology, Vol 29, No 5, September 2009, pp 487-496
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Table 1. Economic and Development Indicators of Major Southern Asian Nations Indicator HDI rank Population, millions Urban population, % Life expectancy at birth Adult literacy rate, % Undernourished population, % Population living on ⬍$2/day, % Median age, y Population ⬍15 y, % Population aged ⱖ65 y, % GDP per capita PPP, US$ Share of income or consumption in the poorest 20%, % Share of income or consumption in the richest 20%, % Employment in agriculture, % Health expenditure per capita, US$ Public expenditure on health, % GDP Private expenditure on health, % GDP Physicians per 100,000 people Population using improved sanitation in 2004, % Infant mortality rate per /1,000 live births
Sri Bangladesh Cambodia India Indonesia Malaysia Nepal Pakistan Philippines Lanka Thailand Vietnam 140 153.3 25.1
131 14 19.7
128 1,134 28.7
107 226.1 48.1
63 25.7 67.3
142 27.1 15.8
136 158.1 34.9
63.1
58
63.7
69.7
73.7
62.6
47.5
73.6
61
90.4
88.7
30
33
20
6
84
77.7
80.4
22.8 35.2
21.7 37.6
3.5
3.1
2,053
2,727
90 84.6 62.7
99 19.1 15.1
78 63 32.3
105 85 26.4
64.6
71
71.6
69.6
73.7
48.6
49.9
92.6
90.7
92.6
90.3
3
17
24
18
22
22
16
52.4
9.3
68.5
73.6
43
41.6
25.2
..
25.1 33
27.2 28.4
24.6 31.4
20.7 39
20.5 37.2
22.3 36.2
30.4 24.2
32.8 21.7
26.9 29.6
5
5.5
4.4
3.7
3.9
3.8
6.5
7.8
5.6
3,452
3,843
10,882
1,550
2,370
5,137
4,595
8,677 6.3
3,071
8.6
6.8
8.1
8.4
4.4
6
9.3
5.4
7
9
42.7
49.6
45.3
43.3
54.3
54.6
40.3
50.6
48
49
44.3
52
70
67
44
15
79
42
37
34
43
58
64
140
91
118
402
71
48
203
163
293
184
0.9
1.7
0.9
1
2.2
1.5
0.4
1.4
2
2.3
1.5
2.2
5
4.1
1.8
1.6
4.1
1.8
2
2.3
1.2
4
26
16
60
13
70
21
74
58
55
37
53
39
17
33
55
94
35
59
72
91
99
61
54
98
56
28
10
56
79
25
12
18
16
Abbreviations: HDI, human development index; GDP, gross domestic product; PPP, purchasing power parity. Data from the United Nations Development Program1 and The World Factbook.38
(CKD). CKD comes to attention in these parts most frequently as end-stage renal disease (ESRD), a devastating medical, social, and economic problem for patients and their families. In contrast to the rest of the world where the stress is on improving quality of life and longterm survival through effective renal replacement therapy (RRT), limited accessibility and high treatment cost limit the continuation of treatment in these countries.2
CKD INCIDENCE AND PREVALENCE Lack of registries preclude an accurate estimation of the number of patients with CKD, including those needing RRT. Most of the reported data are hospital-based or rough estimates based on individual experience. Hospitals equipped to treat CKD patients are located almost exclusively in major cities. Patients living in remote rural areas have to
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travel long distances to such hospitals, sometimes to different countries. Indeed, many patients never come to medical attention because local care is not available and patients lack the resources to travel to specialized centers.3 A large gap therefore exists between the need and availability of RRT. Registry reports that enroll only those receiving RRT are likely to be significant underestimates. Malaysia, the only country in the region with a national Registry, has shown a progressive increase in ESRD treatment acceptance rates from 61 per million population (pmp) in 1998 to 139 pmp in 2006. The incidence has been estimated at 101 to 304 pmp in Thailand.4 A hospital set up by the order of the Supreme Court of India to provide free medical care to approximately 570,000 individuals potentially exposed to a toxic gas as a result of an industrial accident provided an opportunity to determine the incidence of ESRD in India. The crude and age-adjusted ESRD incidence rates between 2000 and 2004 were found to be 151 and 232 pmp, respectively.5 Even fewer studies have estimated the prevalence of CKD. The Malaysian National Registry estimated the 2007 ESRD prevalence at 680 pmp. In a recent study, the prevalence of stage III and IV CKD in Thailand was estimated at 13.6% and 21% using Modification of Diet in Renal Disease (MDRD) and Cockcroft and Gault equations, respectively.4 A longitudinal cohort study among employees of Electric Authority in Thailand showed an increase in the prevalence of CKD (glomerular filtration rate [GFR], ⬍60 mL/min by MDRD equation) from 1.7% in 1985 to 6.8% in 1998.6 Data from Vietnam estimate the prevalence of stage III to V CKD at 3.1% and 3.6% using the Cockcroft and Gault equation and the MDRD formula adjusted by the Japanese racial coefficient, respectively.7 These figures indicate a staggering load of CKD and present a major public health problem for the health care planners of these countries. In India, Mani8 reported a prevalence of chronic renal failure of 0.16% and other renal diseases (short of chronic renal failure) in 0.7% among a rural population of 25,000 who are served through a prevention program. Agarwal et al9 screened more than 4,900 individuals in
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urban communities and found a 0.79%-point prevalence of individuals with a serum creatinine level greater than 1.8 mg/dL. These figures must be interpreted with caution because of the wide variations in the definition of CKD, methodology, and sampled population. Commonly used formulae for estimation of GFR such as the MDRD equation have not been validated in southeastern Asian populations. Differences in body habitus and dietary habits make it likely that these formulae will require revalidation and possibly correction factors for accurate assessment of GFR, as shown in the Chinese and Japanese populations. Finally, a couple of recent studies10,11 showed the mean measured GFR values in healthy Indian adults (kidney donors) to be only 81 mL/min, substantially lower than that reported from the West, and raises the question whether these individuals should be classified as having CKD, or should the thresholds used to define CKD be modified? DEMOGRAPHICS OF ESRD Until about 10 years ago, glomerulonephritis and interstitial diseases were thought to be the most common causes of ESRD in southern Asia.12 The high prevalence of glomerular diseases was linked to the prevalent infections, and the interstitial nephritis was linked to environmental toxins. The etiologic spectrum, however, has changed in the past decade (Table 2). Differences in etiologies have been noted according to the geography, socioeconomic status, stage at which the patients present, and the available diagnostic tools. Certain diseases have been shown to predominate in specified geographic locations. Obstructive nephropathy caused by urolithiasis is common in Pakistan, Thailand,13,14 and parts of India known as stone belts. A large proportion of Indian ESRD patients present with a relatively short history, advanced renal failure, little or no edema, mild hypertension, and small smooth kidneys. This makes the task of guessing the primary disease difficult. Of 1,530 consecutive patients seen at our Institution over a 6-month period, the etiology could not be determined in 36%. A similar presentation has been described among southern Asians living in the United Kingdom.15
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Table 2. Causes of CKD in India and Pakistan
Diabetic nephropathy Chronic glomerulonephritis Chronic interstitial nephritis (including nephrolithiasis) Hypertension Autosomal-dominant polycystic kidney disease Unknown and others
India (n ⴝ 34,039)*
Pakistan (n ⴝ 4,392)†
31 14 11
37 14 6
14 2 20
33 2 7
*Data from the Indian CKD registry.19 †Data from the Dialysis Registry of Pakistan.28
Reports of CKD of uncertain etiology have emerged recently from the north-central provinces of Sri Lanka. Most of the affected individuals are male paddy farmers of poor socioeconomic status.16-18 Presentation is with progressive nonproteinuric renal failure. Early investigations revealed a tubulointerstitial nephritis with minimum inflammation and extensive fibrosis. The disease bears a strong resemblance to Balkan nephropathy and Chinese herbal nephropathy. It has been suggested that this could be a result of exposure to environmental toxins; residual pesticides, fluoride, aluminum, and cadmium that contaminate drinking water, rice, and edible fish are among the suggested culprit compounds. A recent Thai study4 showed an inverse relationship between the prevalence of CKD and the developmental status; the prevalence increased progressively from urban areas to urban slums to rural areas, again suggesting the presence of unique risk factors in rural population. Such observations argue against the usual assumption that CKD is a lifestyle-related disease and hence more likely to be encountered in the affluent urban population. Diabetic nephropathy, restricted earlier to the high-income group and older individuals, has emerged as the most important cause of CKD in large parts of southern Asia. According to the recently established Indian CKD registry, which has information on more than 35,000 patients, diabetes was listed as the primary diagnosis in 31% of cases.19 The frequency increased to 40% in incident ESRD cases.5 This has paralleled the increase in the prevalence of type II diabetes in the general population, especially in the areas undergoing rapid urbaniza-
tion.20,21 The projected increase in the prevalence of diabetes in the region suggests that these numbers are set to go up further in the next decade. The role of intrauterine origin of chronic disease in adults, particularly systemic arterial hypertension and CKD, has come to the fore recently and could explain the link between poverty and malnutrition in the mother and subsequent development of CKD in the offspring. Low birth weight and early malnutrition followed by overnutrition in adult life were shown to be associated with the development of metabolic syndrome, diabetes, and diabetic nephropathy in an Indian cohort.22 Whether nephrogenesis is influenced by intrauterine malnutrition and/or any adverse intrauterine environment is a matter of speculation. The finding of a high prevalence of proteinuria and blood pressure in southern Asian children could be part of this jigsaw puzzle.23,24 Also not investigated is the role of dietary habits and indigenous medicines. A significant proportion of the population in this region consumes exotic tropical herbs and fruits. Whether any of these have an adverse impact on kidney function remains unknown. Compared with the rest of the world, the mean age of CKD patients including those requiring RRT in southeastern Asian countries is much lower.5,12 This likely is related to unique environmental exposures at a younger age and poor availability of health care, which delays diagnosis and leads to a loss of opportunities to institute timely preventive measures. This culminates in faster progression to ESRD.
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DELIVERY OF ESRD CARE Delivery of CKD care in this region is linked intimately with the level of economic development. Although countries in the region are welfare states, health care does not figure highly in the list of priorities for the governments. As shown in Table 1, the annual per capita expenditure on health ranges from $38 (US$) in Myanmar to $408 (US$) in Malaysia. Health comes under the purview of the state (provincial) governments. Significant differences are noted in the selection of priorities and budgeting, leading to a lack of uniformity in the final delivery of care to the people. The public sector expenditure on health care is woefully small, forming only about 0.3% to 2.2% of the gross domestic product. The resulting shortage of services forces patients to take recourse to private hospitals. Private sector health care expenditure exceeds that by the governments in all countries of the region except Malaysia. The ratio is most lopsided in India, with private sector spending being almost 4.5 times that of the public sector (Table 1). With more than 90% of the working-class population having informal or unorganized status, there are few possibilities of ensuring that employers bear any part of the costs. This results in the need for out-of-pocket payments for health care. According to recent data, health now accounts for nearly 7% of total consumption expenditure in Indian households. These figures contrast sharply with the mean per capita health expenditure in the Organisation for Economic Co-operation and Development (OECD) countries ($2,759 [US$]; 9% of GDP); the share of public spending varies from around half in the United States to more than 80% in some countries of the European Union.25 Even in the rest of the developing world, the ratio of public to private health expenditures is 2:1. The public sector health care is organized in the shape of a pyramid: primary health centers are the basic units, followed by block and district-level hospitals, with tertiary care referral institutions forming the top. ESRD care is available only at the highest-tier hospitals. Because of the lack of a formal system of referrals, patients have the freedom to go to any hospital
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throughout the country. Hospitals are funded through a fixed annual budget, and it is up to each hospital to divide the funds for different programs. The scope of services also is limited. Patients are not charged for physician advice, hospitalization, investigations, or surgical procedures. The budget, however, often is not enough to provide drugs or disposables and the patients have to pay for these out of their own funds. The insufficient number of major hospitals results in overcrowding and long wait times (often stretching to several months) for specialized procedures such as dialysis or kidney transplantation. Patients have to travel long distances, often in excess of 1,000 km, to reach government-subsidized hospitals. Except for Malaysia, most countries do not have a national policy for treatment of CKD patients. In India, certain state governments have formulated policies for reimbursement of ESRD care, but its implementation is limited by the nonavailability of funds and ignorance of large sections of the society. A few hospitals are run by charitable organizations with some assistance from the government. They charge less than the private hospitals, and some provide free treatment, including drugs for a limited period. The Sind Institute of Urology and Transplantation in the city of Karachi (Pakistan), which receives about 65% of its funding through donations and the rest from the government, provided free medical care to more than 570,000 patients in 2007, which included 195 transplants and more than 130,000 hemodialysis sessions,26,27 and is a shining example of community participation in providing health care. Lack of trained manpower hampers health care delivery. Figure 1 shows the ratio of nephrologists to the population in different countries in the region. Some countries, such as Cambodia and Laos, do not have even one nephrologist. The number of nephrology training centers has increased recently, but a significant proportion of trained nephrologists leave to seek work in more affluent Western nations after qualifying. There are about 950 dialysis units in India located in 150 cities (the numbers are increasing constantly) with more than 3,500 dialysis
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Figure 1. Population (in millions) per nephrologist in southeastern Asia.
stations, and approximately 120 transplant centers. Less than 20% of the hospitals are in the public sector. A large number of dialysis units in the region are small physician-owned, minimalcare facilities with less than 5 dialysis stations. Pakistan had 140 dialysis centers in 2004, which increased to 195 in 2005. They are spread over 53 cities; about 30% are government funded, and 45% are under private management. The rest are run by community support or charitable agencies. About 10% to 15%, however, are nonfunctional.28 Many units are looked after by non-nephrologists or even technicians. Even within a country, indices of CKD care such as the number of dialysis facilities or ESRD treatment rates are related to the level of economic development (Fig. 2). FINANCIAL AND REIMBURSEMENT ISSUES CKD treatment presents an interesting study in medical cost effectiveness. Financing remains the major hurdle for development of RRT facilities in southeastern Asia, and is compounded by the lack of a government policy for the treatment of emerging chronic diseases. The exact cost of RRT in developing countries is hard to estimate, and varies with the prescription and the way a unit is set up. The subsidy provided by government hospitals is
difficult to calculate.29 The expenses incurred in setting up and maintaining the units and the staff salaries come out of the global hospital budget. This amount can vary widely depending on the size and location of the hospital, number of dialysis machines in the unit, and university or local affiliation. The overall treatment cost, although less in dollar terms than that in the developed countries because of the lower staff salaries and the low cost of drugs, is still several times higher than the per capita gross national product, and remains out of reach for the majority of the population. The additional cost of drugs such as erythropoietin, vitamin D analogues, or posttransplant immunosuppression increases the RRT costs by more than 100%. Economic growth has allowed an increase in treatment rates across the region; data from the Malaysian registry shows an increase in dialysis incidence from less than 20 pmp in 1990 to about 120 pmp in 2005. The ratio of the cost of hemodialysis to income came down from 1.86 in 1990 to 0.65 in 2005.30 The cost also is impacted by late presentation, with resulting poor clinical status that necessitates frequent and often long-term hospitalizations. More than 75% of ESRD patients in our hospital present with advanced uremia that
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Figure 2. (A) Graph showing the relationship between the per capita gross national product (GNP) and the number of dialysis units in different Indian states. (B) Chart showing the dialysis treatment rates in different states of Malaysia in 1997 and 2004 according to their level of economic development.30
requires initiation of dialysis within 48 hours of arrival. Poor hygiene, hot and humid climate, and overcrowding predispose to a variety of life-threatening infections. It is estimated that 12% to 18% of all dialysis and transplant patients develop tuberculosis.3 As mentioned earlier, patients usually have to bear the costs of RRT out of their own funds.29 Charitable organizations and government administered relief funds provide limited assistance to poor patients. One Indian study (quoted by Mani8) estimated that about two thirds of patients took help from employees or accepted charity, one-third sold property or family valuables such as jewelry, and a quarter took loans to cover the cost of RRT. Many patients raised funds in more than one way. Only 4% were able to cover the cost from within their family resources. Costs to the society are even harder to calculate. As mentioned earlier, the ESRD population is composed of young individuals, in the most productive years of their lives, and often are the sole wage earners of families with multiple dependents. The need to travel long distance to seek treatment forces families to relocate, leading to loss of livelihood of the other family members and impacting children’s education.31 Finally, the need to raise funds for treatment often erodes the accumulated assets of the family and forces some to even borrow
large sums from local moneylenders. The combined effect of this on the families and society is devastating. RRTs Mass-based hemodialysis (HD) programs are virtually sparse in most countries of the region.3 Many ESRD patients receive short-term HD, but only the affluent are known to be on HD for long periods. The decision on the frequency and duration of dialysis rests on patient symptomatology and financial considerations. The prevalent practice is to provide one to two 4-hour sessions every week.3,14 Dialyzer re-use is practically universal and often performed manually. It is not uncommon for patients to reduce the dialysis frequency as financial resources dwindle, leading ultimately to discontinuation of dialysis or death.2 In a cohort of more than 1,200 consecutive ESRD patients referred to our (public sector) hospital, the mean HD duration was less than 1 month. About 10% of patients died in the hospital and another 60% left the program and were lost to follow-up evaluation. Only 2% were on HD for more than 6 months. According to the Indian CKD registry,19 about 57% of ESRD patients were not on any replacement therapy. The absence of regulations by the government or professional societies has prevented
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standardization of dialysis procedure including minimum standards for dialysis machines, quality of water used for dialysis, type of dialyzers, and re-use policies. Peritoneal dialysis (PD) is underused because of delayed presentation, and nephrologists’ bias, especially from those who have their own HD units. Also, average PD costs are higher than that of HD in the region, probably because the out-of-pocket expenses for consumables are higher.14,32 Concerns often are raised on the grounds that poorly educated patients are likely to be noncompliant and the specter of infection owing to the hot, humid climate and poor hygienic conditions. As a result, only patients with multiple comorbidities not suitable for HD are initiated on PD. This culminates in high initial drop-out rates. More than 4,100 patients were initiated on PD in 2006 in India, but about 2,350 stopped the therapy during the year. Almost 30% of all drop-outs occurred within 6 months of initiation; most of them died owing to comorbidities, indicating that the patient selection might have been suboptimal.32 Constraints in running an effective dialysis program leave renal transplantation as the main treatment option for ESRD patients. Transplantation activity, however, falls woefully short of demand, with finances, lack of an organized cadaver donor transplant program, and social and religious issues being the major stumbling blocks. Continuation of immunosuppression and management of complications present additional challenges. PUBLIC HEALTH PERSPECTIVE OF CKD Governments in the region have yet to realize that kidney diseases are taking a big toll on its young population and have yet to formulate strategies to provide care for patents with CKD. Moreover, ESRD treatment would consume a disproportionate piece of an already tiny health care budget pie. Early detection of CKD and institution of measures to slow down its progression is the most cost-effective way to reduce the burden of disease. According to the model suggested by Schoolwerth et al,33 CKD fulfils the criteria for being classified as a public health problem, and requires a public health approach. However, in the absence of any government policy, such programs have not been initiated.
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Institution and implementation of the prevention programs will require drugs, equipment, creation of research institutions, and education and training of health professionals.34 To date, the academic response to the challenge of noncommunicable diseases in this region has been muted; education institutions and teaching programs, even in medical schools, have paid scant attention to these issues because these are perceived as being unglamorous. Current-day medical graduates are ill-prepared for the vital roles they need to play in the changing health environment and deal with the increasing chronic disease burden. In addition to a pertinent medical education, awareness and public health education strategies must be introduced to prepare students and the general public about the growing burden of chronic disease, and to sensitize them about the need to tackle these conditions at an early stage. Nephrology communities in these countries have the added responsibility of continuing research to find out the etiologic factors behind the pockets of high prevalence of unexplained CKD. Such investigations require global coordination with colleagues in advanced nations. Until the public sector develops, individual practitioners will continue to be the frontline caregivers. These physicians should be required, perhaps even mandated, to participate in continuing medical education programs regarding the management of hypertension, diabetes, and CKD.35 The community can be empowered and recruited in this endeavor. An example is the surveillance and treatment program run in a rural area of approximately 25,000 people by the Kidney Help Trust. Health workers, drawn from the local population, are trained to administer a questionnaire, record blood pressure, and check blood glucose levels and protein in the urine by visiting people in their homes. Cheap drugs are provided for treatment. This approach was effective in controlling blood pressure in 96% of the hypertensive patients, and in reducing the glycated hemoglobin in 52% of the diabetic patients.36 Professional societies need to be engaged in developing early detection and intervention programs that suit the needs and organizational facilities of different regions and lobbying with
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governments for implementation. Events such as World Kidney Day help in propagation of the message of prevention. A group of Asian nephrologists have come together under the Asian Forum of CKD Initiative to champion the cause of increasing awareness and developing uniform CKD detection protocols, intervention practices, and evaluation framework using local resources.37 FUTURE PROSPECTS FOR RRT Without government support, ESRD treatment programs cannot reach the masses even in affluent nations. Innovative and affordable health insurance schemes that collect small regular contributions (in one instance, Rupees 5 or 10 cents per person every month) have been started in parts of India and can bring RRT nearer to the common citizen and remove the tag of it being an elite therapy. Even within the constraints imposed by the economy, a few measures can help expand the scope of dialysis. These include indigenous manufacture of dialysis machines, water treatment systems, dialyzers, PD fluid bags, and lowcost cyclers, and effective re-use of disposables. Timely preparation of the patient for RRT including counseling regarding choice of RRT, management of comorbid conditions, nutritional intervention, early creation of vascular access, insertion of a PD catheter, and preemptive transplantation would help in reducing patient morbidity and mortality. In view of the advantages in resource-poor settings, a PD-first policy with judicious shift of selected patients to HD holds a lot of attraction. The development of transplant programs in public sector hospitals should be encouraged because they are cost effective and hence accessible to the general population. Deceaseddonor transplants have to be promoted, but would require improvement in hospital infrastructure and imparting education to the public and providers. The predominance of living related transplants in the foreseeable future presents opportunities to find strategies to minimize immunosuppression in well-matched transplants. Another approach is the use of drugs that suppress the metabolism of costly immuno-
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suppressive drugs, allowing a reduction in the drug dose and leading to cost savings. The Indian government is in the process of developing a national ESRD treatment program. Dialysis will be provided through a network of stand-alone units set up in partnership with the private sector. A one-year program to train physicians to run dialysis units is being prepared. The National Organ Transplant Program will facilitate deceased organ donation through organized organ procurement and the distribution systems throughout the country. Care for the earlier stages of CKD could be channeled through the recently launched National Rural Health Mission, aimed to provide effective healthcare to the rural population. It is hoped that this program would be integrated with existing national chronic disease programs, i.e., those for diabetes, cardiovascular diseases and stroke, and will include measures for CKD detection and management. In conclusion, CKD is a major looming health problem for the countries of southeastern Asia. It takes a heavy toll on the societies because the majority of affected individuals are young and in the most productive years of their lives. A large proportion of patients present with advanced kidney failure of unexplained etiology. Management is affected by the lack of availability of health care services, especially in the rural areas, and poor government support. There is an urgent need to develop CKD detection and prevention strategies suited to the region, which can reduce the enormous burden of CKD. Investigations are required to characterize the unique etiologic factors in different geographic regions so that prevention programs can be targeted appropriately. Cost-cutting strategies would make RRT accessible to the general population. REFERENCES 1. United Nations Development Program. Human development indices: a statistical update 2008. [2009 January 5]. Available from: http://hdr.undp.org/en/ statistics/. 2. Chugh KS, Jha V. Differences in the care of ESRD patients worldwide: required resources and future outlook. Kidney Int Suppl. 1995;50:S7-13. 3. Jha V, Chugh KS. Dialysis in developing countries: priorities and obstacles. Nephrology (Carlton). 1996; 2:65-72.
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