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NephroAsia: National Kidney Foundation of Singapore. June 2001.
The Prevention of Chronic Renal Failure at the Community Level
Part One of Two
M. K. Mani, M.D.
Chief Nephrologist, Apollo Hospital, Madras, India.
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the podium to start the talk.
Moderator: (Dr. William Owen, Jr.)
Our first speaker is Professor Mani, who is the Chief Nephrologist at Apollo Hospital in Madras. The title of his presentation is "The Prevention of Chronic Renal Failure at the Community Level." Professor Mani.
Dr. Kurokawa, Dr. Owen, Ladies and Gentlemen. Dr. Ku, may I pay my respects to you on behalf of the nephrologists of India. You have not only been the father figure for nephrology in Singapore but also for many in India. You have been an example of what can be achieved by nephrologists working together. May I have my first slide? Is it something I have to do? Right. Self-help is the best help, they say.
The Indian economic situation
All of you are aware that India is a poor country. I am not sure if you are aware of just how poor it is. I need to give you an idea of that. We can do everything that is being done for chronic renal failure anywhere in the world, but it all comes at a price. We have transplant programs, we have CAPD, we have hemodialysis. I would like you to just look through briefly at the costs, the initial costs, the annual maintenance costs...all this is in rupees, but I would like you just to remember it because we will be talking about the Indian income in rupees.
This is where our problem arises--a huge population, a per capita income of under 13,000 rupees per year. To put it in perspective for some of you, this means under $500 Singapore per year, under $280 U.S. per year. This is the per capita income of our country. Only 2.2 percent of the population earn more than 50,000 rupees a year. The poverty line is drawn by our government purely on the basis of how many calories--2,400 calories a day would cost approximately 5,000 rupees per year. It varies from place to place. The poverty line in different states, cities, villages is drawn at a different level. Thirty-six percent of the population of India live below this poverty line.
We are talking about renal transplant, which is the least expensive mode of treatment of offering renal replacement therapy. That is 250,000 rupees per year. The poverty line, 5,000; 36 percent of the population below that.
Government health care
We cannot expect the government to do much because the government is a very poor government. The average of what the government spends, state and central government on health per capita is 370 rupees. The recurring theme, of course, is the cost of the renal transplant.
We do run transplant programs. How have they been paid for? Just 4.0 percent of the families had the money to pay for the transplant; the rest took loans, sold property, or took charity. It worries me very much because even when we do a successful transplant, it means that by and large we make the family poorer. They sell property. If they take a loan, the loan has to be repaid. The charity which comes could perhaps have been spent on something else because there are so many problems in the country.
Transplantation and the treatment of end-stage renal disease is a big highway which comes to us from the West. It is a multi-lane highway. We have multi-lane highways in India, too, but the form of traffic on Indian highways is a little bit different. We have to make our solutions according to the resources that we have and make it available. It seems to me pretty clear that we cannot afford to treat end-stage renal disease.
So what can we do about this? I have been having a running battle with Dr. Lau. Many of you may not be aware because he wants me all the time to stress on the burden of renal disease in India and I have constantly been telling him, "I have no figures." There are no figures of what is actually the burden of renal disease. We do not know the prevalence of renal disease in the community. We have to guess from individual hospitals. What I am going to give you now are the figures from my own unit.
Chronic renal failure at Apollo hospital
Of this number of patients whom we saw in the last 17 years, diabetic nephropathy, at about 30 percent, is the most common cause of chronic renal failure. This experience has been duplicated in a large number of different units.
What I put in white on this slide are conditions for which I think something can be done by way of preventing end-stage renal disease due to that condition. I have a few words to say about the chronic interstitial nephritis, which is very common in our country. Chronic glomerular nephritis, whatever can be done, is being done.
I do not think we can achieve much more. We can try to prevent arteriolar nephrosclerosis, and chronic pyelonephritis is usually due to neglected infections. The point is, we have such good antibiotics available now that every urinary tract infection gets treated and people do not look into the cause of the infection. Was there underlying disease? That is the problem. If you look into that, you may be able to do something to prevent that patient from going on to the end-stage.
Autosomal dominant polycystic is probably an eminently preventable disease if only people with the disease would refrain from having children. We can screen families with ultrasound available. That is a very difficult thing to do in India because we believe that our salvation depends upon our having children who will pray for us and perform the necessary rites to enable us to remain in heaven. Unfortunately that means that we will add to the population -- one of the reasons why we have so many millions of people in the country.
These 8 diseases constitute 96 percent of all ESRD. The ones in white I think we can do something about. They add up to more than 50 percent. So I think we can do something to prevent renal failure in this, 50 percent.
Chronic intersitial nephritis in India
Now some of this is to give you an idea. Why do we have so much chronic interstitial nephritis? We do not know. Not everybody accepts that there is so much of chronic interstitial nephritis. In fact, the group from Chandigarh claim that they do not see chronic interstitial nephritis at all. It is a very prestigious renal unit in the country. This is their data that they put in. It so happens that they also have autopsy data on chronic renal failure. There was a large amount of amyloid, other conditions which came in because of peculiar circumstances in that region. What I want you to note is that as far as these three conditions are concerned, the most common of them was diabetes and chronic interstitial was the next.
A series of renal biopsies on Asians in London these are Indians who settled in the United Kingdom, it also shows that there is a very high incidence of chronic interstitial nephritis. So we know that there is lot of chronic interstitial nephritis; but we do not know what causes it.
We have looked at a few things. We thought of lead--a lot of leaded gasoline, other pollution in the cities, but this is dominantly a disease of the rural areas. More of the rural population get it than urban population. We looked at Hanta-virus. It did not show anything in particular. We do not really know what it is. Recently we have some evidence that hydrocarbons may be involved in this, and we are looking at smoke from coal and firewood used in cooking, which is done in village huts. There is a small project going on in the city at the moment looking into the villages around the city. We are trying to find out from that. It was suggested it may be tuberculosis. We have a lot of tuberculosis in the country. We have looked at the tuberculosis patients, and we did not find that they have a higher incidence of chronic interstitial disease.
Chronic glomerular nephritides causing chronic renal failure
Among the chronic glomerular nephritides--this is just to give you an idea--I want to stress that IgA nephropathy is becoming more prevalent, membranoproliferative less so. At a meeting in Bali a few months ago, Dr. Couser said that membranoproliferative nephritis is going down in the world because hepatitis C is going down. That is not true in India. We have certainly seen a lot of hepatitis C. I do not think that the reduction in membranoproliferative nephritis is because of a reduction in hepatitis C as far as India is concerned. There is no doubt that we are seeing less and less, and we are seeing more and more of IgA nephropathy.
Incidence of IgA nephropathy
This is again from my own unit. I want you to see overall the incidence of IgA nephropathy. This is not including the hematuria group, the isolated hematuria. This is IgA as a cause of acute renal failure, nephrotic syndrome, chronic renal failure. You will find a steady rise in the incidence of IgA nephropathy that we see. I do not know the reasons for this, but the fact is very clear.
Rural health policy
Let me now get on to what I really want to talk about. I would like you to see the burden of ESRD in developing nations and possible solutions. So what I am trying to talk about now is a possible solution.
Government is the major provider of medical care in the country. What is government doing about it? Seventy percent of Indians live in the villages. Let's see now specifically what is being done in the villages. We have primary health centers with two doctors. They cover a population of 25,000. The primary centers vary in many states; my own state of Tamil Nadu is one of the best developed. We have very good centers. There is a paramedical staff available and all medical care is free. Everybody who goes there gets all the treatment that they have, free. The patient has to go to the primary health center to get his medicine.
If you have a population of 25,000 that is distributed in villages and hamlets, it means that people have to travel about 10 or 15 kilometers to get to the primary center. Now people in Singapore laugh about 10 or 15 kilometers. They will do it in a few minutes. In the United States, you will do it in a few minutes. If you do not have a road and if you have to walk the 15 kilometers or if you have got to go on a bullock cart across a dirt track, it takes a pretty long time. When you get to the primary center, there are a number of other people over there waiting for the medicines and you get in line.
So the net result is a person who goes there loses a day's wages. If he loses a day's wages, that day his family does not eat. So no chronic disease gets treated. People go to the primary center if they have some kind of an acute illness which prevents them from working on that day--high fever, severe pain--they go to the primary center and they take their treatment. They will not go every week to get a week's supply of medicines for treating hypertension or treating diabetes. So these conditions are not treated by primary health centers in the rural population in the country.
We have special programs for leprosy. The leprosy program has been extremely successful. We are talking about the eradication of leprosy from the country in the near future. Tuberculosis programs are there. They are not so successful, but they are there. There is no program in place for diabetes or hypertension.
Caused of death in developing countries
I will apologize for this slide, which I downloaded from the internet. It is a WHO slide. I downloaded it from the WHO Website and copied it here. The point I think you can see quite clearly. Developing countries... it is not only India, it is the whole developing world... you find the most common cause of death is infectious diseases. That is a big chunk here. It is hardly existent in the Western world. It is more or less taken care of over there. That is not what I want to stress. You see this, which is vascular diseases, largely a result of diabetes and hypertension. I want you to see that this slice of the pie is getting bigger in the developing world. If you look through some of the poster sessions, you will see here there definitely is an increase--it is not only India; I find it prevalent in other countries too. Diabetes is a very strong cause of illness and all the complications associated with it.
Why do we have so much of diabetes? Certainly the diabetes in India is all non-insulin dependent. Less than one percent of our diabetics are insulin-dependent diabetics. Why is this so? Maybe the thrifty gene hypothesis may play some part in this. There have been some studies associating this with low birth weight, some with low maternal weight. Maybe it is malnutrition in intra-uterine life which leads to the diabetes. I do not know the answers to that. We have a lot of non-insulin dependent diabetes in the country. In my own city of Chennai, population surveys show that 11 percent of the population, 11 percent of the unselected population, are diabetics. So obviously we are going to get a large number of people who have diabetic nephropathy in course of time.
Kidney Help Trust
So what are they doing about this? I belong to a trust called the Kidney Help Trust. We are a much more modest foundation than the National Kidney Foundation of Singapore, so I hesitate to speak about it in this forum. What we are doing is we have a pilot project and we hope to see that we can do something about this problem. We have taken a population of 25,000 because that is the government unit of the primary health center.
What we do is we take girls who finish their schooling, who are not going to proceed with their education, who are going to get married in a few years' time, they stay in their own houses, we train them for six months... there is a regular course called the Preventive Social Health Workers Course. We put them through this course. We pay them 2,500 a month. They go back to their own homes and they live there, so they do not have extra living expenses. We give them a cycle. We take it back when they get married and leave us. We do not give it as part of the dowry. The cycle belongs to us. They work two or three years, and then they get married, and then we pick up somebody else, and we go on. They get 2,500 rupees a month. A doctor goes from the city... doctors do not stay in the villages. They go from the city, and we pay for their transport, and we give them 500 rupees per visit.
Kidney health trust protocol
We have the demographics of this area completely. Every house population we know exactly who is there in the house. We have a card for each family. We have centers... what we call centers are the veranda of the school or a good convenient tree. We send a van around with a folding table and a few chairs. The doctor, the social worker go there. We spread the word through the village. We ask people to come. If they come, okay; but if they do not come, we go to their houses. That, I think, is the crucial part of this. They are all working in the day, so our workers go in the evening to their houses. Every individual is checked.
We have a questionnaire, so we ask those questions. We look at the urine for albumin by sulphosalicylic acid, glucose by Benedict's, and we record the blood pressure of everybody over the age of five. The other tests are done for everyone, urine whenever we are able to get the sample of urine from a little child, but otherwise for everybody. Blood pressure is recorded only over the age of five. We found it just too difficult to get it below that age. We use sulphosalicylic acid and Benedict's not because they are most convenient. The strips are obviously a little more convenient, but a strip costs 2 rupees. And this is infinitely cheaper.
What is the questionnaire? This questionnaire--you can all see it. We translate it into Tamil, laminate it, give it to each one of the workers who goes and asks mechanically. Everybody over there is asked to give the answers to this questionnaire.
The protocol (cont..)
Anybody who is positive for this, who has a blood pressure above 140/90, who has sugar in the urine or reducing substances in the urine I should say since they are using Benedict's, who has albumin in the urine, is then asked to come and see our doctor. They are seen by the doctor either at the center or if they do not come to the center, the doctor will go to the house. We estimate urea and sugar. Other investigations, thanks to my employer, the Apollo Hospital, we were able to get them done free of cost at present if required. We treat blood pressure with reserpine, hydralazine, hydrochlorothiazide only. Why? Cheapest. They are much cheaper than all the others. Diabetes--metformin, glibenclamide-- thankfully these are all non-insulin dependent diabetes and we can use these in these patients.
Results of the Kidney Help Trust project
What have we found? 5.25 percent of the population... after checking every member of the population, 5.25 percent, hypertensive; 3.5 percent, diabetes; renal disease not yet in chronic renal failure, .7 percent; chronic renal failure, .16; urological diseases, .25 percent. It adds up to more than 7.5 because some people have more than one of these. But 7.5 percent need some support from us.
Part Two of Two