Sixth International Congress of the Middle East Society For Organ Transplantation

Economics of dialysis and renal transplantation in the developing world

Renal disorders are a major cause of morbidity and mortality in the world particularly in the developing world. Increasing environmental insults, poor recognition of acute and chronic renal disease, undeveloped preventive strategies, delayed and limited access to renal care, and high cost of treatment are important features in tropical regions where about 40% of the world's poorest population live. Acute renal injury occurs mainly from diarrhoeal disorders in children of the tropics where preventive strategies are effective. Tropical infections are common precipitants of glomerulonephritis. The epidemiology of parasitic infections, protozoal disorders, vector-borne diseases, and drug resistance patterns are all changing; some of these are linked directly or indirectly with global environmental changes. Particulate matter (PM_2.5; ≤2.5 µm in aerodynamic diameter or smaller), ambient coarse PM (PM₁₀; ≤10 µm in aerodynamic diameter), NO₂ and CO in the atmosphere are present in large concentrations in most cities of the tropics and are inhaled to reach systemic circulation and may cause renal injury. In addition, a high incidence of chronic kidney disease is seen in regions of Sri Lanka, Latin America, and certain parts of India. The common threads to aetiology are dehydration, exposure to pesticides, and poor socioeconomic status among agricultural groups. As the economy improves with equitable distribution of benefits, and primary health is prioritized in these regions, renal health should also improve. The International Society of Nephrology has launched the 0by25 initiative in 2013 to eliminate preventable deaths from acute kidney injury (AKI) by 2025 with special emphasis on developing countries in Africa, Asia, and Latin America.

India and Pakistan are the two largest and most populous countries in South Asia. The burden of noncommunicable disease (NCD) has increased in recent years and it is estimated that over 40% of all deaths are due to NCD. The exact magnitude of the burden of chronic kidney disease or end-stage kidney disease is not known. A population-based study calculated the end-stage renal disease (ESRD) incidence at 152 per million population. Diabetic kidney disease is the commonest cause of ESRD in India. CKD of undertermined etiology forms a large proportion as well. Environmental factors have been postulated in its causation. The majority of nephrology-related services are concentrated in expensive private sector hospitals. Economic issues limit the availability of renal replacement therapy to large sections of the population. Hemodialysis and peritoneal dialysis are equally expensive. Dialysis prescriptions are not optimized. Renal transplant is the most suitable option for a majority of patients, but is dependent on living donors. The Indian government has included kidney disease as a priority area, and is setting up facilities to provide subsidized dialysis for the whole population. A national transplant program envisions the setting up of a nationwide organ procurement network.

Chronic kidney disease is defined as a reduced glomerular filtration rate, increased urinary albumin excretion, or both, and is an increasing public health issue. Prevalence is estimated to be 8–16% worldwide. Complications include increased all-cause and cardiovascular mortality, kidney-disease progression, acute kidney injury, cognitive decline, anaemia, mineral and bone disorders, and fractures. Worldwide, diabetes mellitus is the most common cause of chronic kidney disease, but in some regions other causes, such as herbal and environmental toxins, are more common. The poorest populations are at the highest risk. Screening and intervention can prevent chronic kidney disease, and where management strategies have been implemented the incidence of end-stage kidney disease has been reduced. Awareness of the disorder, however, remains low in many communities and among many physicians. Strategies to reduce burden and costs related to chronic kidney disease need to be included in national programmes for non-communicable diseases.

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.