|Year : 2023 | Volume
| Issue : 1 | Page : 1-2
The management of chronic kidney disease in India: Where are we going wrong?
Muthu Krishna Mani
Retired Nephrologist, Chennai, Tamil Nadu, India
|Date of Submission||25-Feb-2023|
|Date of Acceptance||01-Mar-2023|
|Date of Web Publication||26-Apr-2023|
Dr. Muthu Krishna Mani
1, Kasturirangan Road, Chennai - 600018, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mani MK. The management of chronic kidney disease in India: Where are we going wrong?. J Med Evid 2023;4:1-2
Life has never been better for some Indians with end-stage renal disease than it is today. The Governments of the southern states, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu and Telangana maintain dialysis programmes, and they are supplemented by the Pradhan Mantri National Dialysis Programme (I am not well acquainted with the fate of renal patients in the other states). Their website claims that 15.8 lakh dialyses had been supported till September 2022. I am afraid no further details are provided. We need a detailed audit of the entire programme, both of the expenses incurred and the benefits to the patients. Shaikh et al. analysed the long-term dialysis programme in the old composite Andhra Pradesh (before bifurcation) under the Rajiv Aarogyasri scheme. Nearly 17% of the patients died. A more sinister statistic is that 63.5% of them dropped out of the programme. Why would anyone abandon a life-saving treatment that cost him nothing? The authors were not able to find out the reasons for patients preferring to die. It would suggest that the quality of life was poor, or that dialysis was inadequate and the patients just died at home.
It is estimated that 2.2 lakhs of Indians enter the end stage of chronic renal disease each year, and will die if they do not receive regular dialysis or a renal transplant. The estimated expense called for is Rs. 3 to 4 lakhs annually per patient. Please remember that a well-dialysed patient should survive several years, which means that he remains on the programme while more patients are added each year. We need to rehabilitate these patients so that they remain productive members of society. It is not worthwhile to just keep someone alive at such a huge expense if he is not contributing to the welfare of his family and the community in some way.
Government supports eight dialyses a month per patient, or 96 dialyses per year. That means the 15.8 lakh dialyses supported by the Government so far would have provided 16,458 patients with a year's dialysis, an insignificant number compared with the additional 2.2 lakhs who need dialysis every year.
I have visited long-term dialysis facilities in a number of countries. I have not been to Scandinavia, but amongst the other countries of Europe, Australia, the USA and Japan, I believe the best running long-term dialysis programmes are in Japan. Japanese patients on long-term dialysis are well rehabilitated and are able to live near-normal lives. Yet, the authors of a recent review state, 'the total cost of haemodialysis therapy currently accounts for 5% of the total medical expenditure in Japan. Thus, it is mandatory for Japanese society to find a solution to these issues for sustainability'. When that is the opinion in wealthy Japan, it is foolish for us to attempt to provide long-term dialysis to all our patients. Japan's per capita Government expenditure on health in 2019 was US $ 4587 in 2019, and ours was US $ 63.75 in the same year (World Bank Data from the internet). Long-term dialysis would be a crippling proportion of health costs compared to theirs. It simply cannot be done and should not be attempted. The token efforts that are being made by both the Central and the various State governments are clearly aimed at short-term political gain.
Uncontrolled diabetes mellitus accounts for 35% of the patients with chronic renal failure in India. Uncontrolled hypertension by itself destroys the kidneys in 15%, and in addition accelerates the decline of renal function in patients with renal failure of any cause. Mark the word 'uncontrolled'. Sustained high blood glucose and sustained high blood pressure (BP) damage blood vessels all over the body and lead to the complications of these two diseases. If the patient controls diabetes and hypertension from day 1, there will be no complications whatsoever. There lies the rub. Neither disease by itself causes any major symptoms, so no patient will realise that he has the disease unless he looks for it. If he waits for symptoms to develop, several years would have elapsed in most patients, and by then, significant damage would have been done. This means we have to look for these diseases, diagnose them as soon as they start and control them well.
Fortunately, this is easily done. The Kidney Help Trust used a simple questionnaire, recorded the BP and tested the urine for glucose and albumin in every person in our study population. The major objection that has been raised is that screening for diabetes with urine sugar will miss too many diabetics. Applying the methods of the Kidney Help Trust to 1000 patients who underwent fasting and postprandial blood glucose estimation during Apollo Hospital's Master Health Check showed that we missed only 13.8% of people with diabetes. In the village, we would send a team of 2 workers to collect samples for tests. It would take at least five minutes to collect a blood sample from each subject, and no working person would be prepared to stay fasting for the few hours it would take our workers to cover all the dwellings in a village, or to take their meals at a specified time so that we could collect a post prandial sample. Therefore it would be impossible to use fasting or post prandial blood glucose levels in a community survey. Further, blood glucose measurements for an entire population would be far more costly than urine sugar. It would certainly be more reliable to use glycated haemoglobin (HbA1c) as the screening method, but the cost would clearly be beyond reach, and please remember that it should be repeated every year. If someone does not have diabetes or hypertension today, he or she could certainly develop either disease tomorrow. Daily screening of the entire population is clearly not feasible, but annual screening can and should be done. If we miss any diabetic during a survey, the chances are that we will pick her or him up the next year, and not much damage would have been done.
The Kidney Help Trust has demonstrated (in a population of around 43,000) that it is possible to screen the entire population and then achieve excellent control of hypertension (96% of hypertensives brought to a BP of <140/90) and good control of diabetes (52% of people with diabetes to HbA1c of <7%, a further 25% with their original HbA1c reduced by 10% or more) at a total cost of Rs. 31.26 per capita of population per year. This was associated with a reduction of chronic renal failure from 28 per 1000 of population in a similar group of people who had only standard Government Primary Health Centre coverage without the benefit of our intervention to 11 per 1000 of our population. Added beneficial outcomes were reduction in strokes from 10 per 1000 to 1.8 per 1000 and 'heart attacks' from 9.1 per thousand to 2.8 per thousand.
The Kidney Help Trust ran this programme for 25 years. I tried desperately to get Government, either in Tamil Nadu or at the Centre, interested. I spoke or wrote to many ministers and secretaries. While some gave me verbal encouragement, not one has proceeded to do anything about it. I must say that when Mr. Keshav Desiraju was a Secretary in the Central Health Department, he was interested and sent one of the Deputy Directors of Health to see me, with a view to taking up the project. Sadly, he was transferred from the Health Department soon after, and whatever plans he might have had disappeared with him.
Our administrators and politicians need to do a little arithmetic. They will not be able to afford long-term dialysis for our population in the foreseeable future. They can afford to prevent renal failure and other vascular complications in our diabetic and hypertensive people and are duty bound to initiate the programme immediately.
| References|| |
Shaikh M, Woodward M, John O, Bassi A, Jan S, Sahay M, et al.
Utilization, costs, and outcomes for patients receiving publicly funded hemodialysis in India. Kidney Int 2018;94:440-5.
Hanafusa N, Fukagawa M. Global dialysis perspective: Japan. Kidney360 2020;1:416-9.
Mani MK. What we should do for chronic renal failure in India. J Mahatma Gandhi Inst Med Sci 2017;22:73-7. [Full text]