INTERNATIONAL ADVISORGeorgi Abraham

EDITOR IN CHIEFC. Zoccali, Italy

CKD in South Asia - An update

Georgi Abraham1, Santosh Varughese2, Thiagarajan Thandavan3, Arpana Iyengar4, Milly Mathew5, S. A. JaffarNaqvi6, Rezvi Sheriff7, Harun Ur-Rashid8, Natarajan Gopalakrishnan9, KL Gupta10, Amit Gupta11, IbrahimShiham12, Rishi Kumar Kafle13, Tashi Namgay14

1,5Madras Medical Mission & Pondicherry Institute of Medical Science, India, 2Christian Medical College, India,3Tides IHMS, India, 4St. Johns Medical College, India, 6The Kidney Foundation, Pakistan; 7University Of Colombo,Srilanka, 8Kidney Foundation Hospital and Research Institute, Bangladesh, 9Madras Medical College, India,10PGIMER, India, 11SGPGI, India, 12IGMH, Maldives, 13National Kidney Center, Nepal, 14Bhutan KidneyFoundation, Bhutan

AbstractIn the South Asian region, screening for chronic kidney disease (CKD) in the community has shown widely varyingprevalence. Hotspots of CKD of unknown etiology exist in certain geographical regions. This predominantly affectsthe young and middle-aged population with a lower socioeconomic status. The gross national product (GDP) percapita income has shown a steady increase in the developing countries, the highest being Maldives followed by SriLanka, Bhutan, India, Pakistan, Bangladesh, Nepal and Afghanistan. The burden of CKD G5 remains unknown dueto the lack of registry reports, poor access to healthcare and lack of an organized chronic disease managementprogram. The growth of pediatric nephrology as an independent subspecialty has been a major milestone in thelast decade in South India. The modality of renal replacement therapy (RRT) varies greatly in terms of prevalencebased on socioeconomic status, GPD per capita income, reimbursement policy, infrastructural facilities andavailability of skilled nephrologists and other healthcare personnel. Among the countries in the region, Indiaprovides the largest incidence of renal replacement therapy including both living and deceased donortransplantation. The proportion of nephrologists caring for the population remains the same as previouslyreported, one per million population (pmp). Both basic and clinical research is of low priority because of the lack ofinfrastructure and manpower. We discuss the nephrology care provided in various countries of South Asia: India,Bangladesh, Pakistan, Nepal, Bhutan, Sri Lanka, Afghanistan and Maldives.

INTRODUCTIONThis update on chronic kidney disease (CKD) in South Asia is a follow-up to the NDT newsletter published inDecember 2014. CKD is an important cause of increasing global morbidity and mortality, which constitutes aglobal public health priority. Globally, the number of CKD G5 patients receiving renal replacement therapy isestimated to be more than 1.4 million, with an annual growth rate of 8%. The burden is very high in thedeveloping countries of South Asia, Eastern Europe and Latin America. Diabetes mellitus, hypertension, lowersocioeconomic status, environmental factors and intrauterine growth retardation could all predispose to CKD inSouth Asian developing countries. The lack of sufficient infrastructure and personnel in many low and middleincome countries (LMICs) limits high-quality screening for early detection and prevention of CKD in developingcountries. In addition, there is a scarcity of data on pediatric patients with CKD.

However, for many LMICs and regions, data on CKD epidemiology are scarce or even absent due to the lack ofresources and adequate tools for data collection, and there is often no or insufficient awareness about theproblem. In the general population, CKD prevalence is 14.4%, with a difference between whites (7.4%) Asians(21.9%) and blacks (23%). Therefore, careful evaluation of CKD epidemiology is needed, especially among peopleliving in LMICs who cannot afford the high costs of renal replacement therapy. Most of the available hemodialysisfacilities are in the major metropolitan cities followed by two- and three-tier cities and are predominately privatelyrun, and to a lesser extent state government run. Here we discuss renal replacement therapy in South Asiancountries.

INDIA

In India, the ratio of doctors per population is 1/1674, which is far below World Health Organization (WHO)recommendations. Unless there is a strong engagement of non-nephrology doctors, including primary carephysicians, early detection and prevention programs will not reach the main stream. The nephrology workforce inSouth Asian countries is still 1/pmp, which is grossly inadequate. CKD in two coastal districts of Andhra Pradesh:

In the coastal regions of the Srikakulam district and Chimakurthy mandal (30–40 km from the coast) in thePrakasham district of Andhra Pradesh, India (known as the Udannam area), 60% of the local population wasfound to have CKD. Around 4000 villagers have died of CKD in the last decade, and almost a third of thepopulation in Uddanam suffers from CKD. Of the 1500 people from 13 villages in the Prakasham district evaluated,27% had serum creatinine levels >1.5 mg/dL. Medical experts and the local population suspect that contaminateddrinking water may hold the clue to the etiology. As the only source of drinking water for these two regions isgroundwater, major ions and trace elements were measured in different sources of water to identify the causativeelement(s), if any. Comparison of hydrochemical data has indicated that the groundwater in the Srikakulamcoastal region is less mineralized than in the Prakasham region, which may be due to geological, hydrological andclimatic conditions. However, the concentrations of various inorganic chemicals are within permissible limits, andthese inorganic chemicals are unlikely to be the causative factor for CKD. With suspicion continuing that kidneydamage could be due to contaminants in the drinking water, it is necessary to investigate whether other organicand inorganic chemicals are associated with kidney damage.

Malnutrition is widely prevalent in CKD ND and CKD D patients. There is an initiative by a few skilled dietitians toassess nutritional status and management of the diet. The cost of maintenance HD per session lies between 12and 60 US dollars in South Asian countries. The government-run hemodialysis (HD) and continuous ambulatoryperitoneal dialysis (CAPD) programs in the southern states of India provide free dialysis for the underprivilegedpopulation, although the number of dialysis treatments is restricted. The number of prevalent maintenance HDpatients per million population varies widely in the South Asian region depending upon the GDP per capita income,as shown in Figure 1. There are 110 000 prevalent maintenance HD patients in India of which over 94% undergotwice weekly, 4-hour sessions using bicarbonate buffer. The vast majority of patients receive arteriovenous (AV)fistula (90% prevalence) as vascular access, followed by temporary internal jugular access, tunneled catheter andAV graft. In developing South Asian countries, dialyzer reuse is widely practiced for economic reasons. Thedialyzer reprocessing is done either manually or by automated techniques, and dialyzers are used up to 15 times.

Figure 1: Prevalent hemodialysis patients (PMP) and current GDP in US Dollars

According to the Indian CKD registry, diabetic kidney failure is the major cause of CKD in India. Hemodialysis isthe main renal replacement therapy (RRT) modality for diabetic CKD 5. A multicenter retrospective analysis ofmaintenance hemodialysis patient survival of diabetic versus non-diabetic CKD 5 D patients according tosocioeconomic status was performed in five centers in South India. Among the 897 maintenance HD patients, 335were diabetic and 562 non-diabetic. The 5-year survival rate after censoring was 16.6% for diabetics and 28.6%for non-diabetics (P <0.001). Figure 2 shows a Kaplan Meier curve comparing survival rate. With the manufactureof dialyzer and blood tubing, which has been initiated in India, it is hoped that the cost of the dialysis can bereduced.

Figure 2: Survival of diabetics versus non-diabetics

CAPD and APD were initiated in India in 1991. However, the growth was slow in the initial years as a result of thenon-availability of dialysis fluid and catheters. The manufacture of dialysis fluid in India 15 years ago enabled thegrowth of peritoneal dialysis (PD). A once in a lifetime payment scheme and government support has expandedthe CAPD program to the remote corners of the country. Peritonitis remains the single major cause of dropout,and the incidence has declined dramatically in the last five years. Figure 3 and 4 show the growth of CAPD andAPD in India. Table 1 shows PD prevalence in Asia.

Figure 3: Number of PD Patients in India 1997-2014

Footnote: Despite the increase in numbers, PD utility remains limited in the South Asian countries, however, thefull and partial reimbursement by the respective government in Sri Lanka, Bangladesh, Nepal, India andAfghanistan is expected to increase PD prevalence.

Figure 4: APD Prevalence

Table 1: PD prevalence in Asia – 2014

India has emerged as the country with the third largest number of renal transplants worldwide, with over 6000renal transplantations performed yearly with the majority being living donor transplantations. The strict applicationof the THOA (Transplantation of Human Organs Act) has significantly reduced the number of commercial unrelatedtransplantations. Deceased donor transplantation has made significant strides in certain parts of India. Figure 5shows the details of deceased donor transplants in India. The Tamil Nadu program has been very successful. Thedeceased donor transplantation program in other South Asian countries is in the initial stages. The efforts made bythe leaders in nephrology and transplantation in other South Asian countries are sure to see benefits in the comingyears.

The transplant coordinators (who are non-physicians) have regular training programs which are conducted by theMOHAN (Multi-Organ Harvesting and Network) foundation that certifies them as grief counselors and advocates ofdeceased organ donation.

Figure 5: Number of deceased donor renal transplants performed in various states and unionterritories of India (2012-2014)

The Madras Medical Mission - Nephrology, Transplant and Research Center

The Madras Medical Mission Hospital is recognized by the International Society of Nephrology (ISN) andInternational Society of Peritoneal Dialysis (ISPD) for short-term and long-term fellowship training of traineesfrom South Asian countries, the Middle East and Africa. The Madras Medical Mission CKD program encompassesearly detection and prevention (Tanker Foundation), general nephrology, clinical microbiology andnephropathology with an electron microscopy facility and laparoscopic renal transplantation team.

Current research by the Madras Medical Mission and Tanker Foundation is investigating the rapid detection andidentification of bacterial pathogens in cases of PD peritonitis by the use of 16s rDNA polymerase chain reaction(PCR) in the diagnosis of culture- negative peritonitis. Studies of Klotho and fibroblast growth factor (FGF) 23 as amarker of bone mineral abnormalities in predicting survival in CKD 5D and CKD ND are ongoing. Nutritionalassessment and management of CKD patients using various tools and studies of polymorphism of the renalasegene in CKD are currently in progress.

Christian Medical College, VelloreFor over four decades, the Christian Medical College (CMC) Vellore has offered nephrology services that haveattracted patients from all across the country and its neighboring regions. A three-year post-doctoral specialtynephrology training (DM) is offered to four doctors annually. A three-year graduate program (BSc) in dialysistechnology is offered to 10 candidates annually. The institution is continuing to pursue new avenues of clinical andlaboratory-based research. Our current ongoing research includes the study of IgA nephropathy in Indians, sodiumset-point in hemodialysis, therapeutic drug monitoring of immunosuppressives, renal histopathology, proliferativeglomerulonephritides, peritoneal dialysis and access infections, chronic kidney disease, voluntary kidney donorfollow-up, polycystic kidney disease, transplant infections, hemodialysis access, community nephrology, etc. Ourlaboratory provides the opportunity for collaborative research with other disciplines--both intra- and extra-mural. An interventional nephrology fellowship is planned at CMC in the near future.

Department of Nephrology, Christian Medical College, Vellore

Pediatric Nephrology There are thirty million pregnancies every year in India. This increase in population has led to an increase in theneed for nephrologists, which has a skewed distribution. The growth of pediatric nephrology as an independentsubspecialty has been a major milestone in the last decade in South India. This growth has resulted in theestablishment of centers of excellence for pediatric renal care services, pioneering opportunities for training inpediatric nephrology, initiation of community outreach services and stepping up to the challenging field of researchin pediatric nephrology. The efforts of many individuals have led to this outstanding growth in the field. Leaders inthe field have provided the mission and vision for the path forward. This, coupled with the support of premierinstitutions, cooperation of the pediatric community and intensive care pediatric services, support from adultnephrologists, recognition by regional universities, financial support from non-governmental organizations andinternational collaborations under the umbrella of the International Society of Nephrology (ISN) and InternationalPediatric Nephrology Association (IPNA) has led to a phenomenal revolution in pediatric nephrology. Children areno longer viewed as miniature adults, but as individuals who require quality pediatric nephrology care. The major academic institutions in South India offering pediatric nephrology services are St John’s Medical CollegeHospital, Bangalore, Christian Medical College, Vellore, Osmania Institute of Medical Sciences, Hyderabad andGovernment Medical College Hospital, Trivandrum. In addition to these hospitals, there are many private hospitalsand a few government institutions in cities like Bangalore, Hyderabad and Chennai that offer renal care tochildren.

The Pediatric Nephrology team at St John’s Medical College Hospital

Clinical CareOur team is one of the few free-standing pediatric nephrology departments in India. Children with acute andchronic kidney disease, from the entire southern region as well as many other regions of India, are referred to us.We care for children with acute kidney injury (AKI), CKD, various glomerular diseases, tropical renal diseases aswell as the rarer inherited tubulopathies and polycystic kidney disease. We provide acute intermittent andcontinuous renal replacement therapies. Our outpatient service consists of general nephrology clinics anddedicated clinics for children with CKD, nephrorology and hypertension. Our department has a large chronicdialysis program including both CAPD and HD. We have a well-established renal transplant program and haveperformed nearly 80 transplants to date, including deceased organ transplantation. Despite being a tertiary carenephrology center, we provide care to patients from rural underserved areas with strong community outreachprograms and open communication with primary care physicians in the region.

Children who have undergone renal transplantation at our center, celebrating WKD in 2012

TrainingTraining and education has been our forte. Our department offers fellowship courses that are recognized by theregional universities and has been a pioneer in initiating the 3-year post-doctoral DM course in pediatricnephology in India. We have been recognized as a training center by the IPNA to train pediatricians from otherAsian countries. Most of the 35 pediatricians trained by us over the last decade have returned to their respectiveregions to establish pediatric nephrology services in underserved areas. The adult nephrology trainees can opt topartake in an observership at our center as a part of their course curriculum. Our team has assumed the leadingrole of implementing “competence- based pediatric nephrology training modules” for pediatricians in the state ofKarnataka. We have had tremendous support for upgrading education and faculty development under variousprograms supported by the ISN. A program of our Sister Renal Center was awarded with the “Schrier Award” atthe World Congress of Nephrology 2015, and we are the supporting the center in the establishment of pediatricnephrology services in Ethiopia, Africa under the ISN Sister Renal Center (SRC) Trio program. We have beengranted a Sister Transplant Center partnership with Rome, Italy this year rewarded by the ISN-TTS (TheTransplantation Society) initiative. Other institutions such as CMC Vellore and Mehta Children’s Hospital, Chennai are also recognized training centersin pediatric nephrology.

Regional profile of the trainees trained in pediatric nephrology at our center

Current ResearchOur group focuses on clinical, translational and basic science research which is directly supervised by the faculty ofpediatric nephrology with one postdoc and three PhD students. The key areas of research are i) the role ofvitamin A in renal development, ii) the molecular and genetic basis for nephrotic syndrome and iii) the clinical

utility of biomarkers in AKI. The clinical research includes tracking the kidney size of newborns, bone mineraldisease in CKD, qualitative research in CKD and assessment of volume status in nephrotic syndrome. The Vellorecenter has also been engaged in research in nephrotic syndrome and various aspects of chronic kidney disease.The centers are also part of a multicentric collaboration for research on the hemolytic uremic syndrome andnephrotic syndrome.We as a team are geared up to face challenges unique to developing nations, with regard to patient care, capacitybuilding, spreading awareness, providing sound financial support to patient care and encouraging researchopportunities. We have certainly come a long way, but have miles to go before we sleep.

NEPAL

Prof. Rishi Kafle

Nepal is a country with a population of 28 million, with currently 30 nephrologists in the country. Until 1980, therewere no facilities for renal replacement therapy in Nepal. In the early 1980s, intermittent peritoneal dialysis andrenal biopsies were initiated by the late Dr. Puskar Raj Satyal in Bir Hospital, Kathmandu. In 1986, with the help ofthe of the Indian government, the first hemodialysis unit was established in the same hospital, with twofunctioning hemodialysis machines. In 1996, the second dialysis unit was established in Tribhuvan UniversityTeaching Hospital, subsequently followed by a few other private hospitals and dialysis centers within KathmanduValley and outside the capital.Dr. Rishi Kafle, through the Nepal Kidney Foundation, which started on a small scale in 1997, has built up a hugedialysis unit providing free or subsidized dialysis to a large section of the Nepali CKD population. Dr. SanjibSarma’s outstanding work on early detection and prevention of kidney disease in Dharan in eastern Nepal wasrecognized by the ISN.The first successful renal transplantation was performed at Tribhuvan University Teaching Hospital in August 2008.The transplant surgeon, Dr. David Francis, was supported by Nepalese surgeon and nephrologist Dr. Dibya SinghShah. So far, more than 270 renal transplantations have been performed. Two more centers also perform renaltransplantation with a total of ~400 transplantations having been performed in the country to date.Continuous ambulatory peritoneal dialysis (CAPD) service has now also been initiated, and about 100 patients areon CAPD. There are ~1500 HD patients dialyzing in 41 hemodialysis centers with 252 hemodialysis machines. Thegovernment of Nepal now provides up to $1890 remuneration to renal transplant patients towards transplantsurgery and immunosuppressive drugs and up to $2460 to HD and CAPD patients.Still, the nephrology services are far from sufficient and must be expanded throughout the country, as so far onlythe largest cities have the facilities for optimum nephrology care. Nephrolgy services need to be made much moreaffordable and accessible to all. Our program offers strictly living-related donor renal transplantation, but it is timeto introduce a deceased donor transplantation program in Nepal. Finally, awareness, early detection and timelymanagement of kidney disease would help to decrease the burden of this disease in Nepal.A catastrophic earthquake of 7.8 magnitude rocked Nepal on April 25, 2015 killing 8800 and injuring more than22 000 people. The epicenter was approximately 80 km northwest of the capital Kathmandu. The quake occurredon a Saturday when most of the dialysis centers were closed, and only a few of the 16 service providers inKathmandu were able to open the next day. It took around 40 hours to resume operations at the National KidneyCenter (NKC) due to damage to the water treatment plant. By then, there was a significant buildup of patientsrequiring dialysis, and partial sessions were provided to try and accommodate as many patients as possible. Theservice gradually picked up and normal operations resumed about two weeks later. The powerful aftershock,measuring 7.3 in magnitude, which occurred on May 12, was a setback invoking safety and security concerns andalso forcing one service provider to close its doors due to extensive structural damage. During all this, there weresurprisingly only a few cases of acute kidney injury from trauma and crush injuries. It is estimated that around100 new patients were treated with 20 succumbing to their injuries and the rest recovering after receiving dialysisand supportive care.Fresenius Medical Care responded to NKC's request for help to cope with damages inflicted by the earthquake.Along with the support from the international nephrology community, they donated dialysis machines, withportable reverse osmosis (RO) systems and consumables, which were distributed to the various centers providingcare after the earthquake.

SRI LANKA

The rise in the incidence of diabetes and hypertension and its associated renal complications in recent years in SriLanka is part of the South Asian epidemic. In the major part of the country, CKD due to diabetes, hypertensionand stone disease shows a prevalence of 0.4/1000 population, but in areas where chronic kidney disease ofunknown origin (CKDu) is widespread, there is a CKD prevalence of 1.8/1000 population. The recent phenomenon of CKDu has been plaguing two of its nine provinces, viz. North Central Province andNorthwest Province. Much research has gone into determining the etiology of this disease without any definitiveanswers. It is thought to be an environmental toxic nephropathy which was found to be a chronic interstitialnephropathy. Heavy metal contamination with Cd, As and Pb, pesticide residues from agricultural practices,glyphosate, triple phosphates, fluoride, hard water and cyanogens from algae have all been incriminated byvarious researches. There is a strong consensus to rename this condition chronic agricultural nephropathy. Nearly 1.7 million of the 21 million population live in the affected areas, and 69 258 individuals are currentlyattending clinics (CKD1-5). Studies show that 31.8% of the patients have been diagnosed with CKD3, 40.0%

CKD4 and 24.5% CKD5. Contaminated surface water seems to be an important factor, as CKD prevalence is low (1.5%) in areas where thewater source is deep wells, natural springs and pipe-borne town water, whereas, prevalence is high (7.7%) inthose areas using shallow dug wells, stream water and tanks.

The government is now promoting the supply of clean portable water to households for drinking and cooking, aspublic health tap water systems are too expensive. While much attention is being paid to supplying clean water for drinking and cooking, farmers only reluctantlytake a few gallons of water to work. As they do extremely strenuous field work under the hot sun, they sufferfrom water loss due to sweating which ultimately leads to dehydration. In addition, they sweeten their tea withlarge quantities of sugar to provide higher energy levels. Attention is now being paid to these factors as well. Avulnerable kidney due to chronic toxic water exposure can be affected by recurrent dehydration and worsened byintermittent intake of sweetened drinks, which together may account for loss of kidney function. Dehydration andhigh sucrose levels in addition to contaminated water as a cause of AKI on CKD has been extensively studied inSouth America, and there has recently been growing support in favor of this theory. Side by side, tertiary care for CKD in the form of dialysis and transplantation has grown over the years (see Table2 below).

Table 2 – Availability of tertiary care facilities in Nepal in 2015

Western Hospital, which started services for dialysis and transplantation in 1985, was the first in the country,recently celebrating 30 years of service. The President of Sri Lanka, Hon. Maithreepala Sirisena, Minister ofHealth, Dr. Rajitha Senarathne and the Minister of Finance, Mr. Ravi Karunnayake attended the function. ProfessorGeorgi Abraham was the special guest. The photographs below were taken at the event.

The President of Sri Lanka. Hon. Maithreepala Sirisena with Prof. Rezvi Sherif

Over 1000 transplants and 100 000 hemodialysis sessions have taken place in Western Hospital. The hospital hasalso assisted the government through training programs and was awarded partial funding of dialysis andtransplantations through the President’s Fund.There are now many centers in Sri Lanka performing hemodialysis and kidney transplantations. Over 4000 living-donor kidney transplants and about 200 deceased-donor transplants have been performed to date, but fewer than10 liver transplants have been performed. In the private sector, there is a growing trend towards unrelated transplants. A state-sponsored request byBuddhist priests for altruistic organ donations is responsible for this trend, which has now spread to other citizens.Authorization by an ethical committee is required. An increasing number of foreign patients provide their owndonors (unrelated) from their own country, but they are subject to clearance by the hospital ethical committeesand the Ministry of Health Ethical Committee before permission is granted for transplantation. Organ traffickingand transplant tourism is prohibited.

The Chinese government recently pledged a donation of 100 million US dollars for a 500-bed renal hospital in theNCP town, Pollonnaruwa, in view of the CKDu epidemic. The hospital should be ready in two years. In themeantime, there is a need to train more personnel at all levels of nephrology.

BANGLADESH

In Bangladesh, there are 954 HD patients, the causes of CKD G5 among those patients on HD in 2012–2013 beingas follows: chronic glomerulonephritis, 251 (25.5%), diabetic nephropathy, 403 (41%) and hypertensive renaldisease, 324 (33%). In 1998, among all causes of CKD G5, the rate of chronic glomerulonephritis was 40%,diabetic nephropathy 31%, hypertension 15%, obstructive uropathy 8% and undetermined causes 10%. In 1994,the number of patients presenting with diabetic nephropathy was 24%, in 1998, 31% (an increase of 7%) and in2013 (41%) (a further 10% increase compared to 1998). The causes of primary glomerulonephritis could not bedetermined because the patients presented with CKD G5 with proteinuria and bilateral contracted kidneys.However, the causes of glomerulonephritis studied from 1990-2004 were (n = 1238) minimal change disease(10%), mesangial proliferative glomerulonephritis (32%), membranous nephropathy (21%),membranoproliferative glomerulonephritis (17%), IgA-nephropathy, (10%), focal segmental glomeruloschlerosis(11%), lupus nephritis (12%) and postinfectious glomerulonephritis (3.4%)22.

Manpower in nephrology:There are 120 nephrologists working in various hospitals in Bangladesh including 12 professors, 18 associateprofessors and 21 assistant professors working in various public and private institutes across the country. A totalof 28 doctors are undergoing resident training in four public institutes for postdoctorate degrees in nephrology asof 2013. Bangladesh College of Physicians and Surgeons also offers postdoctorat degrees in nephrology in additionto four other institutes.

Renal replacement therapy:Approximately 150-200 patients per million population (PMP) reach end-stage renal disease (ESRD) each year inBangladesh, according to a hospital-based survey. The total population in 2000 was 132 million, in 2005, 143million and in 2010, 151 million.17 A number of surveys were carried out in urban (n = 1200), rural (n = 2000)and disadvantaged populations (n = 1000) in 2005–2006. The data showed that 17-18 million of the adultpopulation suffered from CKD stages 1-5; of these, 11-12% were G3.18,19,20

Renal disease care, including dialysis, is provided by 11 of the 21 government-run medical college hospitals, onenephrology institute and one medical university. A transplant facility is available only in the postgraduate medicaluniversity. On the other hand, 86 private hospitals are providing care for renal dialysis patients, and 8 centers areperforming kidney transplantation.

There are 95 HD centers in Bangladesh; of these, 52 centers are in the capital city Dhaka, with a population of15.391 million. In Chittagong (population 5.2 million), there are 16 centers, in Sylhet (population 0.98 million) 10centers, in Khulna (population 1.78 million) 5 centers and in Rajshahi (population 0.932 million) 11 centers. Theage distribution in Bangladesh is 0-18 yrs (32%), 15-54 yrs (56.8%), 55 yrs and over (11%). The healthexpenditure is 3.7% of the GDP (2011 est.), physician population ratio 0.36 physicians per 1000 population andhospital bed ratio 0.6 beds per 1000 population21.

On 31 December 2013, the number of prevalent patients on RRT was 18 900 (119 pmp). Of these, 17 458 (113pmp) were on hospital HD, 43% on 8 hours of dialysis per week and 55% on 12 hours per week. The mean ageof the patients on RRT was 46 years (range 12-76 years). The mean age of patients on HD was 41 years, CAPD52 years and transplant, 34 years.

BHUTAN

Bhutan currently has a population of 708 241, with a per capita GDP of $2068.37 in 2014, which is equivalent to16%. For a small country with a large population, Bhutan is witnessing a rampant rise in the number of patientswith CKD, which has become the largest health burden and challenge in Bhutan, accounting for 62% of the totaldeaths due to disease. This has led to increased healthcare costs, as Bhutan must refer transplant treatmentsabroad. Additionally, the prevalence of non-communicable diseases (NCDs), such as hypertension and diabetes poses agreater threat, as they are the leading causes of CKD in the country. Records show that the incidence of diabeteshas increased from 2541 cases in 2008 to 4097 in 2012, while the incidence of hypertension has increased from 20 347 in 2008 to 27 023 in 2012.

This year, hospitals across the country have experienced a dramatic rise in the incidence of CKD, with about 12cases being diagnosed each month until June 2015. Today, there are 140 CKD patients undergoing dialysis inthree different hospitals. Jigme Dorji Wangchuck National Referral Hospital in the capital city of Thimphu has eightHD machines, Mongar Regional Referral Hospital in Eastern Bhutan three and Gelephu Regional Referral Hospital inSouthern Bhutan two. Government intervention and support

The government has maintained a system of completely free healthcare, not only for the Bhutanese citizens butalso for all those who reside within the country. The Ministry of Health is the central government institutionresponsible for ensuring the maintenance of good health for its citizens by providing a dynamic professionalhealthcare system. For every transplant, the Health Ministry allocates between $12 100 and $13 600 per patient,including donor expenditures. The government also grants each patient reimbursement for additional expenses.Her Royal Highness Gyaltsuen Jetsun Pema Wangchuck is the key person and driving force behind this provisionof healthcare for the citizens of Bhutan.

Wedding photo of Her Majesty the Gyaltsuen Jetsun Pema Wangchuck

Mr. Tashi Namgay, Founder/Executive Director of the Bhutan Kidney Foundation with membersand volunteers.

AFGHANISTAN

Currently, the population of the Islamic Republic of Afghanistan is estimated to be 33 million. AlthoughAfghanistan is a democracy, it is constantly plagued by strife and conflict which affects the provision of renalhealthcare in many parts of the country. Afghanistan has 10 nephrologists and 200 HD machines which areconcentrated in Kabul, Jalalbad and Mazar E Sharif. CKD is widely prevalent in Afghanistan. Patients travel to Peshwar in Northwest Pakistan and a few patients travelto New Delhi, India for advanced renal care such as CAPD and transplantation.

PAKISTAN

Prof. S.A. Jaffa Naqvi Prof. Dr. Adeeb Ul Hassan Rizvi

Pakistan is a country which does not spend more than 0.6% of its gross national product (GNP) on healthcare andonly 1.9% on education. Education is essential for proper healthcare in order to afford a better understanding ofthe appropriate measures necessary for disease prevention and treatment, especially in regard to the need forprolonged treatment, as in CKD. In the province of Sindh, with a population of 9800 inhabitants, 22 districts werescreened, and the resulting etiology is as follows: diabetes 715, hypertension 1911, stone diseases 343,congenital diseases 337 and unknown causes 305 (Table 3).

In Pakistan, disease awareness and education is communicated to the community through public lectures.Preventive measures are emphasized, such as cessation of smoking, adherence to a low-salt diet and weightreduction through dieting. According to the 2013 Renal Registry of Pakistan, there were 1159 HD machines and 7260 dialysis patients, of which 4841 had dialysis twice a week, 1537 three times a week and 882 at irregularintervals.

Table 3 – Causes of ESRD in Pakistan

Transplantation can be divided into ethical and non-ethical transplants. Non-ethical transplants involve thetransplantation of kidneys from unrelated “voluntary” kidney donors, often for monetary compensation. This isunregulated and illegal. Nearly 4000 ethical transplantations are being performed from living related donors withfull government and community support. These transplantations are performed free of cost. Dialysis receives 20%government support.

In Karachi Pakistan, the Sindh Institute of Urology and Transplantation (SIUT), under the leadership of ProfessorDr. Adeeb Ul Hassan Rizvi since its inception in 1970, nephrologists and urologists have performedtransplantations free of cost to the underprivileged people of Pakistan with the support of the federal government.The SIUT has advanced renal care in the region and is the single largest renal transplant center performing ethicaltransplantation.

MALDIVES

Dr. Ibrahim Shiham

The Maldives is an archipelago in the Indian Ocean located 600 km south of the Indian subcontinent. Itconsists of 1192 tiny coral islands of which a total of 187 islands are officially inhabited. The projected populationof Maldives in 2014 was 341 848.The healthcare delivery system of Maldives is organized into a four-tier referral system with the island level healthfacilities referring patients to higher level health facilities in the atolls, regions and central level depending uponneed and service availability. At the central level, the Indira Gandhi Memorial Hospital (IGMH), which wasestablished in 1994 by the government of India, is the only government-run tertiary hospital. It has over 275 bedsand an 8-bed ICU with eight ventilators, one hemodialysis machine and one CRRT machine.The crude death rate (CDR) of Maldives has steadily declined over the years, and it has stabilized between 3 and4 per 1000 population during the last decade. The life expectancy at birth has increased from 70.0 to 72.5 yearsfor males and 70.1 to 74.1 for females from the year 2000 to 2008, respectively. Cardiovascular diseases, chronicrespiratory diseases, accidents and injuries and cancer are the leading causes of death in the country. In terms ofdisability-adjusted life years (DALYs), NCDs (including injuries) account for 78% of the total disease burden. Only22% of the DALYs come from communicable diseases, maternal and child health issues and all nutritional issuescombined (NCD policy brief 2011, Maldives). Kidney disease was listed as the 11th most common cause ofmortality in 2012. In Maldives, there are no population-based surveys targeting diseases, including kidney disease.The ESRD population shows a high percentage of diabetes and hypertension patients. There is also a generaltrend toward increased kidney disease detection. Out of the three forms of renal replacement therapy, HD is the most prevalent. In recent years, especially afterthe social insurance scheme started supporting kidney transplantation, the number of transplantations has steadilyincreased, although the lack of voluntary donors remains a major problem.

Hemodialysis services were introduced in IGMH in 2003, under the guidance of a nephrologist from India, with fourdialysis machines. The nephrologists stayed on for 2 years, after which the unit was run by internists as part ofthe Department of Internal Medicine. For the first 10 years, the dialysis machines were run for five shifts everyday of the week. Therefore, patients were required to attend sessions even at inconvenient or difficult times. Themachines also required frequent repairs, and the lack of a dialysis-free day hindered regular servicing.The first Maldivian nephrologist joined the staff in April 2014, and a division of nephrology was established withone medical officer and nephrologist. Hemodialysis services have continued to grow, and we moved to a brandnew dialysis center in November 2014, which houses 20 machines which run four shifts 6 days a week. Currentlythere are more than 140 ESRD patients on regular maintenance hemodialysis at our center. All hemodialysissessions are free of cost to the recipient. There are scheduled monthly meetings with the hemodialysis staff andnephrology team in addition to monthly meetings with dialysis patients and their caretakers. There are also fouradditional hemodialysis centers in the country in different atolls, and the number of government-run dialysiscenters in the country is increasing.

Reference:

1. The 2nd annual report of the CKD registry of India 2007.www.ckdri.org2. Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden

of major noncommunicable diseases. Kidney Int. 2011 Dec;80(12):1258-70.3. Stanifer JW, Jing B et.al., The epidemiology of chronic kidney disease in sub-Saharan Africa: a systematic

review and meta-analysis. The Lancet Global Health 2014;2(3):e174-81.4. Georgi Abraham, Thiagarajan Thandavan, Santosh Varughese, Amit Gupta. CKD in South Asia.

http://www.era-edta.org/newsletter_ndt_southasia.html