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• W2044528696 abstract "Chronic kidney disease (CKD) is increasingly acknowledged as a major public health challenge in South Asia.1Levey A.S. Coresh J. Chronic kidney disease.Lancet. 2011; 379: 165-180Abstract Full Text Full Text PDF PubMed Scopus (1330) Google Scholar, 2Jafar T.H. The growing burden of chronic kidney disease in Pakistan.N Engl J Med. 2006; 354: 995-997Crossref PubMed Scopus (69) Google Scholar The adverse outcomes associated with CKD, including kidney failure, accelerated cardiovascular disease (CVD), and premature mortality, have a more profound impact on the national economies of lower and middle-income nations, including India, Pakistan, Bangladesh, and Sri Lanka.3Abegunde D.O. Mathers C.D. Adam T. Ortegon M. Strong K. The burden and costs of chronic diseases in low-income and middle-income countries.Lancet. 2007; 370: 1929-1938Abstract Full Text Full Text PDF PubMed Scopus (1028) Google Scholar Fortunately, CKD progression can be slowed with early detection and initiation of pharmacologic and behavioral interventions.4Jafar T.H. Stark P.C. Schmid C.H. et al.Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis.Ann Intern Med. 2003; 139: 244-252Crossref PubMed Scopus (968) Google Scholar However, the effectiveness of these interventions at a public health level is also related to the political, economic, and social determinants of CKD.5Powe N.R. Melamed M.L. Racial disparities in the optimal delivery of chronic kidney disease care.Med Clin North Am. 2005; 89: 475-488Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar In 2002, the US National Kidney Foundation sponsored the development and dissemination of the KDOQI (Kidney Disease Outcomes Quality Initiative) clinical practice guidelines for CKD.6National Kidney FoundationK/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: evaluation, classification, and stratification.Am J Kidney Dis. 2002; 39: S1-S266PubMed Google Scholar The overall goal of the guidelines was to improve detection of early stages of CKD, quality of care, and outcomes of patients with CKD worldwide. In this editorial, we discuss the impact of the KDOQI CKD guidelines from a public health perspective in South Asia. According to successive estimates from the World Health Organization's (WHO) Global Burden of Disease Study, countries in South Asia are experiencing a steep increase in chronic noncommunicable diseases and associated risk factors, including those for CKD.7Lopez A.D. Mathers C.D. Ezzati M. Jamison D.T. Murray C.J. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data.Lancet. 2006; 367: 1747-1757Abstract Full Text Full Text PDF PubMed Scopus (4184) Google Scholar Much of this is a consequence of suboptimally regulated industrialization and unbalanced trade policies, resulting in increased exposure of children and adults, already susceptible to chronic disease, to unhealthy diets and physical inactivity.8Finucane M.M. Stevens G.A. Cowan M.J. et al.National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants.Lancet. 2011; 377: 557-567Abstract Full Text Full Text PDF PubMed Scopus (3162) Google Scholar The number of people with diabetes in South Asia reached 70 million in 2010 and is expected to surpass 100 million by 2030.9Wild S. Roglic G. Green A. Sicree R. King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030.Diabetes Care. 2004; 27: 1047-1053Crossref PubMed Scopus (12052) Google Scholar In addition, 1 in 3 adults 40 years and older has hypertension, and risks of hypertension and diabetes are high even during childhood in both urban and rural areas.10Jafar T.H. Islam M. Poulter N. et al.Children in South Asia have higher body mass-adjusted blood pressure levels than white children in the United States: a comparative study.Circulation. 2005; 111: 1291-1297Crossref PubMed Scopus (138) Google Scholar Although nationally representative estimates are not available, evidence from low-income communities indicates a high crude prevalence of CKD (up to 15% despite a young population age structure).11Jafar T.H. Schmid C.H. Levey A.S. Serum creatinine as marker of kidney function in South Asians: a study of reduced GFR in adults in Pakistan.J Am Soc Nephrol. 2005; 16: 1413-1419Crossref PubMed Scopus (102) Google Scholar, 12Singh N.P. Ingle G.K. Saini V.K. et al.Prevalence of low glomerular filtration rate, proteinuria and associated risk factors in North India using Cockcroft-Gault and Modification of Diet in Renal Disease equation: an observational, cross-sectional study.BMC Nephrol. 2009; 10: 4Crossref PubMed Scopus (80) Google Scholar This is not surprising because low birth weight and prematurity, in part due to maternal malnutrition, are common in this population and may be associated with enhanced susceptibility to insulin resistance and CKD.13Bhargava S.K. Sachdev H.S. Fall C.H. et al.Relation of serial changes in childhood body-mass index to impaired glucose tolerance in young adulthood.N Engl J Med. 2004; 350: 865-875Crossref PubMed Scopus (832) Google Scholar, 14Thrift A.G. Srikanth V. Fitzgerald S.M. et al.Potential roles of high salt intake and maternal malnutrition in the development of hypertension in disadvantaged populations.Clin Exp Pharmacol Physiol. 2010; 37: e78-e90Crossref PubMed Scopus (23) Google Scholar Furthermore, the rate of progression of CKD has been shown to be faster in people of South Asian origin than in other populations.15Chandie Shaw P.K. Baboe F. van Es L.A. et al.South-Asian type 2 diabetic patients have higher incidence and faster progression of renal disease compared with Dutch-European diabetic patients.Diabetes Care. 2006; 29: 1383-1385Crossref PubMed Scopus (96) Google Scholar The implications of a high burden of CKD are sobering in the face of major infrastructural constraints compromising quality health care in South Asia, where scarce resources have to compete with many other national priorities. Thus, the socially disadvantaged are the worst affected. Table 1 shows the demographic profile, deaths from noncommunicable diseases, and health systems capacity in South Asia to prevent noncommunicable diseases. According to the World Bank in 2011, ∼40% of the 1.4 billion people in South Asia live under conditions of extreme poverty (<US $1.25/d purchase power parity).16Engeagau M. El-Saharty S. Kudesia P. Rajan V. Rosenhouse S. Okamoto K. Capitalizing on the Demographic Transition: Tackling Noncommunicable Diseases in South Asia. The World Bank, Washington, DC2011Google Scholar Therefore, treatment for chronic kidney failure is not an affordable option and <10% of patients with chronic kidney failure (most of whom are referred late) are able to receive any form of dialysis or transplant.17Parameswaran S. Geda S.B. Rathi M. et al.Referral pattern of patients with end-stage renal disease at a public sector hospital and its impact on outcome.Natl Med J India. 2011; 24: 208-213PubMed Google Scholar In addition, earlier age CVD mortality is already high in South Asians and may be exaggerated further by a multiplier effect of CKD.18Patel V. Chatterji S. Chisholm D. et al.Chronic diseases and injuries in India.Lancet. 2011; 377: 413-428Abstract Full Text Full Text PDF PubMed Scopus (271) Google Scholar Thus, prevention of CKD should be a high priority for South Asia.Table 1Public Health–Related Statistics for Selected South Asian CountriesSource: 2011 World Bank report.16Engeagau M. El-Saharty S. Kudesia P. Rajan V. Rosenhouse S. Okamoto K. Capitalizing on the Demographic Transition: Tackling Noncommunicable Diseases in South Asia. The World Bank, Washington, DC2011Google ScholarBangladeshIndiaNepalPakistanSri LankaPopulation (million)160.01,140.028.9166.120.2Percentage rural7371836485Life expectancy (y)6664676774Economic indicators GNI per capita Unadjusted (US$)3701,0404009501,780 PPP adjusted (US$)1,1002,9301,1102,5904,460 Percentage in extreme povertyaLess than US $1.25 purchasing power parity.49.641.655.122.614.0Health indicators Health expenditures Percentage of GDP3.54.04.92.94.0 Per capita total expenditure on health (US$)1743202481 Age-standardized deaths from NCDsbNCD death rates are from World Health Organization Global Burden of Disease 2004.59.359.056.95954Capacity and planning Overarching NCD policyHNocThere has been progress in this during the last year since World Bank capacity evaluation in 2010.NoMH National NCD targetsNoNoNoNoNo Quality of care assessmentNoNoNoNoNo Impact evaluationNoLNoNoNoAbbreviations: GDP, gross domestic product; GNI, gross national income; H, high level of activity; L, low level of activity; M, medium level of activity; NCD, noncommunicable disease; PPP, purchasing power parity.a Less than US $1.25 purchasing power parity.b NCD death rates are from World Health Organization Global Burden of Disease 2004.c There has been progress in this during the last year since World Bank capacity evaluation in 2010. Open table in a new tab Abbreviations: GDP, gross domestic product; GNI, gross national income; H, high level of activity; L, low level of activity; M, medium level of activity; NCD, noncommunicable disease; PPP, purchasing power parity. Unfortunately, CKD remains grossly underdetected. Even the WHO Global Burden of Disease Study recognized only “nephritis” or “nephrosis.”7Lopez A.D. Mathers C.D. Ezzati M. Jamison D.T. Murray C.J. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data.Lancet. 2006; 367: 1747-1757Abstract Full Text Full Text PDF PubMed Scopus (4184) Google Scholar Thus, the magnitude of the burden of CKD has been underappreciated in South Asia at both the clinical practice and public health policy levels,19Agarwal S.K. Srivastava R.K. Chronic kidney disease in India: challenges and solutions.Nephron Clin Pract. 2009; 111 (discussion c203): c197-c203Crossref PubMed Scopus (121) Google Scholar with the latter influencing national budgetary allocation and international donor assistance to disease control programs in developing countries. The 2002 KDOQI CKD guidelines classified CKD into stages (1-5) based on risk of complications and emphasized the importance of standardized care, especially during early stages, to improve outcomes.6National Kidney FoundationK/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: evaluation, classification, and stratification.Am J Kidney Dis. 2002; 39: S1-S266PubMed Google Scholar The risk of associated complications is present in worldwide populations, with a recent meta-analysis of general and high-risk cohorts, including from South Asia, confirming the marked and graded risk of CVD and kidney failure associated with early stages of CKD independent of traditional cardiovascular risk factors.20Matsushita K. van der Velde M. Astor B.C. et al.Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis.Lancet. 2011; 375: 2073-2081Google Scholar Application of the KDOQI CKD definition and staging in epidemiologic studies led to awareness that the prevalence of CKD in South Asia is substantially greater than previously perceived, thereby alerting physicians and policymakers that CKD needs to be addressed at a public health level.21Bhowmik D. Pandav C.S. Tiwari S.C. Public health strategies to stem the tide of chronic kidney disease in India.Indian J Public Health. 2008; 52: 224-229PubMed Google Scholar This is clearly the first step for planning health services that will lead to improved clinical practices and patient outcomes, particularly in resource-challenged South Asian countries. In India, CKD has been included as one of the components in the proposed noncommunicable diseases program of Prevention and Control of Diabetes, Cardiovascular Disease and Stroke.22Bhawan V. New Delhi Call for Action On Combating Noncommunicable Diseases in India.http://www.world-heart-federation.org/fileadmin/user_upload/documents/Advocacy/Resources/Articles__Series__Reports/NewDelhi_NCDs_CallforAction.pdfGoogle Scholar Further, major funding agencies for medical research in India, such as the Indian Council of Medical Research and Department of Biotechnology, have identified CKD as a thematic area for research funding. There have been additional gains. A number of recommendations by the KDOQI CKD guidelines, such as staging of CKD by estimated glomerular filtration rate (eGFR) level and action plans regarding management and treatment, have been endorsed by the national nephrology societies (eg, Indian Society of Nephrology and Pakistan Society of Nephrology).23Guidelines for the management of CKD.Indian J Nephrol. 2005; 15: S1-S6Google Scholar, 24Tamizuddin S. Ahmed W. Knowledge, attitude and practices regarding chronic kidney disease and estimated GFR in a tertiary care hospital in Pakistan.J Pak Med Assoc. 2010; 60: 342-346PubMed Google Scholar However, implementation of key recommendations, including screening for CKD, may be limited to selected high-risk groups due to economic considerations. For example, even the laboratories in urban cities in South Asia do not routinely perform automated reporting of eGFR, and screening for proteinuria (or albuminuria) in high-risk individuals is sporadic. It is important to emphasize that both albuminuria and eGFR screening have been shown to be cost-effective in persons with diabetes in high-income countries.25Atthobari J. Asselbergs F.W. Boersma C. et al.Cost-effectiveness of screening for albuminuria with subsequent fosinopril treatment to prevent cardiovascular events: a pharmacoeconomic analysis linked to the Prevention of Renal and Vascular Endstage Disease (PREVEND) Study and the Prevention of Renal and Vascular Endstage Disease Intervention Trial (PREVEND IT).Clin Ther. 2006; 28: 432-444Abstract Full Text PDF PubMed Scopus (117) Google Scholar These strategies need evaluation in South Asia, preferably using innovative low-cost technologies that would enhance their economic efficiency in resource-scarce settings and outreach in rural settings. These efforts must be coupled with training of general practitioners and nonphysician health workers on the early detection, prevention, and management of CKD for improved patient outcomes. Although the successes of models of hypertension control programs through similar models of organized health care delivery and diabetes prevention through lifestyle modification in the South Asian settings are particularly encouraging,26Jafar T.H. Islam M. Bux R. et al.Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial.Circulation. 2011; 124: 1615-1625Crossref PubMed Scopus (55) Google Scholar, 27Ramachandran A. Snehalatha C. Yamuna A. Mary S. Ping Z. Cost-effectiveness of the interventions in the primary prevention of diabetes among Asian Indians: within-trial results of the Indian Diabetes Prevention Programme (IDPP).Diabetes Care. 2007; 30: 2548-2552Crossref PubMed Scopus (129) Google Scholar it is vital to demonstrate an affordable CKD prevention program integrated within the chronic noncommunicable disease framework. Finally, efforts to address the underlying common risk factors for hypertension, diabetes, CVD, and CKD—through both regulatory policies for a healthy environment and public awareness regarding life style changes—are required for a comprehensive approach.28Beaglehole R. Bonita R. Horton R. et al.Priority actions for the non-communicable disease crisis.Lancet. 2011; 377: 1438-1447Abstract Full Text Full Text PDF PubMed Scopus (1214) Google Scholar The national renal societies in South Asia and other stakeholders (governments, WHO, World Bank, academia, nongovernmental organizations, and the private sector, including industry) can have a significant role in moving the CKD prevention agenda forward. The recent United Nations High Level Meeting on Prevention and Control of Non-communicable Diseases held in New York on September 11, 2011, is a clear signal of increasing global attention to concerted action on noncommunicable diseases through multisectoral cooperation. Clearly, the time is right to focus on CKD prevention in South Asia. Financial Disclosure: The authors declare that they have no relevant financial interests." @default.
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• W2044528696 title "A Decade After the KDOQI CKD Guidelines: A Perspective From South Asia" @default.
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