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NephroAsia: National Kidney Foundation of Singapore. June 2001.
The Prevention of Chronic Renal Failure at the Community Level
Part Two of Two
M. K. Mani, M.D.
Chief Nephrologist, Apollo Hospital, Madras, India.
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The benifits of controling hypertension
I think it is pretty clear that controlling high blood pressure will lower the risk of stroke, will lower the risk of cardiac disease and also is associated with a lower risk of end-stage renal disease. This again is WHO data.
The benfits of controling hypertension(cont..)
Lowering stroke and heart disease is not my goal, but I do not have an objection. If it is going to be lowered, I do not mind. I will give that as a bonus to these others.
We are not able to get tight control of diabetes. We do not get really good control of diabetes. I am encouraged by the data from the DCCT that says if you produce a 10 percent reduction in the hemoglobin A1c, you will get a 40 percent reduction in the vascular complications. We are certainly able to achieve this in some.
Blood pressure and its effects on renal failure
Our own hospital data shows that if you control the blood pressure in somebody who is already going into renal failure, you can slow down progression. That is something we can aim for in this population.
I do not know why we gave up using Reserpine. Reserpine is an Indian drug. It was developed in India. We gave up using it. Why? Maybe people said it will make somebody commit suicide. If somebody is born in India with an income of less than 5,000 rupees a year and he has not committed suicide yet, he is not going to commit suicide because I give him a tablet. So I do not have a worry about that. I am not the only person who says that Reserpine is a good drug. So I picked out these two papers from Hypertension 1997 and the American Journal of Hypertension 1996 just to give me a boost. This is something which can be used. Slowing diabetic nephropathy when we achieve it with Reserpine, data from Kidney International would suggest... but they are not done with Reserpine... they have used metoprolol... that you do not necessarily have to use an ACE inhibitor. You can get improvement even with other agents.
So what do we do with these patients once they are picked up? The social worker monitors them once a week and adjusts the dose of antihypertensives within limits; diabetes we monitor with glycated hemoglobin. Adjustments are done only by the doctors, and the doctors see the patients once a month; we have been able to get very good control of blood pressure; diabetes not so good.
The annual cost of the Kidney Help Trust rural program
What is the cost of our program? Materials, transport--we pay for the doctor to go from the city, all the materials, the Benedict's, things like that. All of that costs about 100,000 rupees. Salary is about 100,000 rupees. Medicine is about 100,000 rupees. We have a target of 370 rupees per capita per year, which is what the government spends. I do not really think that by establishing this thing in a population of 25,000 I am going to make any difference to 1 billion Indians. What I am hoping is that this is a project which I can sell, which other people can take up and do. Our cost is 13 rupees per capita, which is quite within the budget and seems to be working pretty well. I remind you again about the cost of the transplant. Even if you do not use cyclosporin and you use only azathioprine, it is going to cost you 10,000 rupees per year to maintain that transplant.
The results of the rural program
What did we achieve? About 90 percent cooperated with the survey. When we go house-to-house and ask people, it's about 90 percent. Ten percent tell us to go to hell. No, they do not tell us to go to hell in those words, but I can assure you that in Tamil we have very choice expressions which convey that meaning very well. Only 30 percent of those people we picked up knew earlier that they had a disease, only 30 percent. The rest had diabetes and hypertension and they did not know. They did not know that there was anything wrong with them. After we made the diagnosis, about 25 percent said, "We will go to our doctor. We will go and do something." Well and good.
We do not try to encroach on the general practitioners of the area. In fact, therefore, we have good support from them. We feed cases to them. Eighty percent also cooperate for treatment. Twenty percent, in spite of knowing that they have a disease and we want to help them, do not want our help. I do not know what you can do about those people. If we could get a law which would make it compulsory for them to take it, I would gladly support that law. We have achieved control... of those who cooperated, we achieved control to a blood pressure of 140/90 in 96 percent. Reserpine, hydralazine, hydrochlorothiazide. We have achieved a reduction of 10 percent in the Hb A1c in 77 percent of the population with just these drugs, which are affordable.
In the population we are doing an annual survey. Our goal is to do it every year. We actually succeeded in doing it once in 1.5 years. We are picking up at the rate of 0.3 percent of the population new diabetics and .55 percent new hypertensives every year.
Is prevention worth it?
When would any preventive program be worthwhile? If the disease is prevalent in the community--I think I have shown you that the disease is prevalent in the community. If the effects are serious enough to warrant the effort--diabetes, hypertension, chronic renal failure--obviously very worthwhile. Easy to detect--yes. Obviously we miss a few if their blood sugar goes up, but we are doing it every year. We are checking everybody every year. So if we miss them one year, we will catch them the next year with that. Can it be easily prevented? We cannot prevent the disease. We are hoping to see that with control we will be able to at least reduce the number of patients with end-stage renal disease. Is the cost of screening and prevention affordable? Thirteen rupees per capita per year? Yes, it is affordable even for India. Is it cheaper than treating the established disease? Obviously. There is no question of that at all.
So let me end with this message. Before the National Kidney Foundation of Singapore starts throwing stones at me, let me say that I am not against doing transplantation, dialysis and all the rest. If you can afford it, provide it. In India we have a large number of youngsters whom we have trained and who are doing transplantation and running dialysis programs. I myself have one of the largest dialysis and transplant programs in the country. Dr. Levin especially told me not to say what I had mentioned when I spoke at his center, and I'm not saying it. We cannot afford to treat end-stage renal disease.
I have a suspicion that even the U.S. and Japan cannot. And if Mr. Durai will forgive me, I have a suspicion that even Singapore cannot really afford to treat all the end-stage renal disease. You do your dialysis well. Next year you will want more patients because survival is better. The next year, you have still more patients. Somewhere or the other, you will not be able to serve them all. The solution is obviously going to be in prevention.
With limited resources, what can provide the greatest good for the greatest number? I think I have the plan. I have to show that this will work. What I need to do is 10 years down the line I will take the adjacent area of 25,000, and that will serve as my control. I do not think it would be ethical for me... certainly my program will not work if I diagnose hypertension and then at random I say, "Okay, you have treatment; you just watch." That is not going to work. In this population I am treating everyone. Later I will extend to the next population of 25,000 and use the initial survey as a control.
What I hope to do is to get more and more people to do it. I find it so simple. I don't see why it can't be done everywhere. Even rich countries can do the same thing, go house to house, pick up people, identify disease and treat it. It is very easy. It has worked extremely well with us. But, unfortunately so far, I have not been able to sell the idea. Even within India, I have not been able to convince even one other group to take up and do this. It is working very well. It does not take a lot of my time. I continue to run one of the busiest renal units in the country. I am able to do that quite well.
1. Kronig B, Pittrow DB, Kirch W, Welzel D, Weidinger G. Different concepts in first-line treatment of essential hypertension. Comparison of a low-dose reserpine-thiazide combination with nitrendipine monotherapy. German Reserpine in Hypertension Study Group. Hypertension. 1997 Feb;29(2):651-8.
2. No authors listed. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86.
3. No authors listed. 1999 World Health organization-International Society of Hypertension Guidelines for the Management of Hypertension. World Health Organization
4. Dr. Gro Harlem Brundtland. Removing Obstacles to Healthy Development World Health Organization