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Diabetes And Kidney Disease In India

Dr. Ajay K. Singh

The World Health Organization (WHO) has forecast that diabetes rates worldwide are growing in epidemic proportions. It is estimated that by 2025 over 100 million people will have diabetes in South Asia – in India alone 57 million will be affected. While in the developed world, the complications of diabetes are frequently treatable, in India this is far from true.

One of the most common complications of diabetes is kidney disease. Approximately 5 to 10 years after the onset of diabetes, the kidneys frequently become affected. If diabetes in its early phase goes undetected and uncontrolled the likelihood of getting kidney involvement is high. Over 30 to 40% of diabetics may eventually develop kidney disease. Once the kidneys become involved they start leaking protein and kidney function suffers. High blood pressure also develops. As kidney function worsens other complications of kidney disease ensure, including anemia and bone disease. Continuing to tightly control the blood sugars remains a key issue, but control of blood pressure and the use of kidney protective drugs is also paramount. The use of drugs such as angiotensin converting enzyme inhibitors (ACE inhibitors – for example, enalapril or lisinopril) or angiotensin receptor blockers (ARBs – for example, losartan or irbesartan) becomes critical.

The problem for the developing world is that there are few if any programs targeting early detection of diabetes and kidney disease. As well, medications for the treatment of blood pressure and for kidney protection are out of the economic reach of most of the population. Once kidney disease progresses to kidney failure the situation becomes dire. In India, relative to the average income, dialysis and kidney transplantation are expensive and not feasible. As well, most people either have no access to a dialysis facility or are unaware that these are treatment options. In over 90% of people developing kidney failure in India the outcome is death. In 2005, it is estimated that over 100,000 people died because of kidney failure.

The cost of dialysis in India is approximately 1000 rupees per treatment. At a minimum, kidney failure patients need dialysis 2 to 3 times each week – amounting to 2 to 3 thousand rupees in direct expenditure. Adding to this cost is the money that needs to be spent on medications such as epo (to maintain the blood count) and vitamin D (to maintain healthy bones). Most people in India cannot afford to pay this amount of money for treatment even on a short-term basis.

The case for early detection and prevention can be made on economic grounds alone. The human case is obvious and greatly tragic. If diabetes can be detected early then attempts to prevent kidney disease can be vigorously pursued. Once the earliest stages of kidney disease become apparent, preventing progression of kidney disease to kidney failure is important. Unfortunately, the public health care system is starved of resources and doctors can scarcely take care of the patients they already manage. What is urgently needed is a concerted effort involving leaders in India as well as those in the developed world to formulate a strategy to deal with this evolving crisis.

If we have learnt anything from the AIDS crisis in Africa it is that a multi-pronged international effort is needed. It needs to start now and it needs to focus on prevention. Recognizing that both governmental and non-governmental organizations (NGO’s) need to be involved is key. Like the AIDS crisis, both governmental funds and private donations will be required. At least one aspect of the response to this crisis needs to be an embrace of education targeted at increasing awareness among the population. There also needs to be a focus on developing inexpensive screening methods – their value evaluated through the prism of what is pragmatic in a developing country. Changing the medical and health curriculum towards chronic diseases such as diabetes and kidney disease also needs to be a goal because we need skilled doctors and nurses to take care of these patients.  As a start, we need to develop pilot programs that can test out strategies aimed at education and prevention. With the size of the impending diabetes and kidney failure epidemic there is no time to wait.

One such early detection program has begun in Saragur at the HD Kote Taluk near Mysore, Karnataka. The project is part of the “Screening and Early Evaluation of Kidney Disease” (SEEK) project. The SEEK project has 11 sites in India, including several academic centers who are participating. The project is coordinated out of the Brigham and Women’s Hospital in Boston. The Boston team comprises of Dr. Ajay K. Singh, Dr. Bharati Mittal, and Paula Hertello. The SEEK program is supported by the Indian Society of Nephrology and is funded by Janssen-Cilag, a member of the Johnson and Johnson global family.

The HD Kote project is being conduced under the aegis of the Swami Vivekananda Youth Movement (SVYM) -- a leading Indian NGO that has achieved many ground-breaking accomplishments in community health care. The plan is to embark on a kidney disease and diabetes screening program. The first screening was held this week and over 60 subjects were enrolled. Led by Dr. Sreedhara, a nephrologist at Apollo Hospital in Bangalore and Dr. Seetharam a pathologist at SVYM, the pilot program aims to understand the prevalence of diabetes and kidney failure in this rural population.

The progress that’s already been achieved by the SEEK project emphasizes that, for a country as vast and complex as India, more initiatives are needed. More people need to get involved: more private-public, national-international collaborations are essential. If we can recognize diabetes and kidney disease early and consequently prevent kidney failure we would have wisely learnt lessons from the AIDS crisis in the developing world: being pro-active and open to innovative ideas aimed at prevention may be able to prevent a huge human and economic calamity.

(Dr. Ajay K. Singh, is a kidney specialist in Boston, USA, and is on the Harvard Medical School faculty. He is leading a program termed “Screening and Early Evaluation of Kidney Disease (SEEK) based in India at 10 leading centers and targeted at screening and early detection of kidney disease. )

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