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COMMENTARY
Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 375-377  

The pressing need for integrated nephrology services in Northeastern India


1 Senior Resident, Department of Nephrology, Nephrology Unit, GNRC Institute of Medical Sciences-A Unit of GNRC Ltd, North Guwahati, Assam, India
2 Senior Consultant and Head, Department of Nephrology, Nephrology Unit, GNRC Institute of Medical Sciences-A Unit of GNRC Ltd, North Guwahati, Assam, India

Date of Submission17-Feb-2022
Date of Decision04-Aug-2022
Date of Acceptance06-Aug-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Shobhana Nayak Rao
Nephrology Unit, GNRC Institute of Medical Sciences.A Unit of GNRC Ltd, Silagrant, Amingaon, North Guwahati - 781 031, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_246_22

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   Abstract 


Chronic kidney disease (CKD) is a major public health problem with an estimated prevalence ranging from 5% to 13% over South Asian region. CKD care and the need for provision of care for the management of end-stage renal disease are an increasingly growing need in India with rising rates of CKD, especially those attributable to uncertain etiologies in certain regions of India. There is a wide disparity between nephrology care services and availability between geographical regions of the kidney with the representation of nephrologists and nephrology care centers more in the Southern and Western regions than in the rest of the country. The Northeastern region of the country is poorly presented in terms of both availability as well as the accessibility of nephrology care services. Better integration and provision of care are the sole need of the hour.

Keywords: Accessibility, integrated service, nephrology care


How to cite this article:
Panchal A, Rao SN. The pressing need for integrated nephrology services in Northeastern India. Indian J Public Health 2022;66:375-7

How to cite this URL:
Panchal A, Rao SN. The pressing need for integrated nephrology services in Northeastern India. Indian J Public Health [serial online] 2022 [cited 2022 Sep 30];66:375-7. Available from: https://www.ijph.in/text.asp?2022/66/3/375/356606




   Introduction Top


Chronic kidney disease (CKD) is a major global health problem. According to the most recent estimates from the Global Burden of Disease Study, CKD has become the 12th leading cause of death, up from the 17th position approximately three decades ago.[1] The number of patients with kidney failure receiving kidney replacement therapy was estimated to be 2.62 million in 2010 and this figure is projected to double by 2030[2] affecting 5.44 million people. The number of CKD deaths increased 42% worldwide between 1997 and 2017. In South Asia, 9,459,473 disability –adjusted life years; 26% of all disability-adjusted life years worldwide were attributable of CKD in 2017.[2]

The prevalence of CKD in South Asia ranges from 5.01% (95% confidence interval [CI] 4.63–5.46) in Afghanistan to 13.24 (95% CI 12.26–14.31) in Sri Lanka. Findings from a population-based study have shown an age-adjusted incidence of kidney failure in India to be 226 pmp.[3] [Table 1] represents the delivery of nephrology services including dialysis centers as well as the nephrology workforce within the South Asian region including India and other neighboring countries.[4] As is evident from this [Table 1], the available workforce is quite inadequate to address the needs of a large number of patients in the region as evidenced by the low number of nephrologists (0.14–0.68 pmp), relative to developed countries (23.2 pmp).[5] There are also shortages of other personnel involved in kidney care such as dialysis nurses, technicians, vascular access coordinators, counselors, psychologists, and transplant coordinators. Country-level analysis often fails to account for the uneven distribution of the trained health-care workforce, particularly large deficiencies in rural areas.
Table 1: Representation of nephrology services in Southern Asia

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The eight states that comprise Northeastern India lack behind the rest of India in terms of development such as industry, infrastructure, employment as well as health indices. Among these states, Assam is the largest in terms of size and population wise in the region with an estimated population >300 million (2011 census), of which 86% live in rural settings. Despite the richness of natural endowment, the region is one of the most backward areas of the countries. Assam lacks behind the national average in terms of key indicators of health such as infant mortality rate, maternal mortality rate, and childhood malnutrition. A recent survey published by Assocham in 2021 also highlighted the increasing prevalence of noncommunicable diseases (NCDs) such as hypertension and heart problems.[6] This was stated to be at 22.3%; a prevalence much higher compared to the national average of 11.63%. Higher prevalence of kidney and respiratory disorders was also seen in comparison to the national average. The reasons for this could be the increased consumption of nonvegetarian food including red meat, lower consumption of fruits, and vegetables as well as lower levels of physical activity leading to a higher proportion of the population who are overweight. The survey also pointed out that about 40% of the people in the region sought medical advice for the treatment of NCD at a very critical stage of their illness as compared to the national average of 17%. This leads to a vast patient population that has comorbidities that go unrecognized and are living with them untreated at an earlier stage of the disease. Out-of-pocket expenditure for NCD treatment was also seen in 87% of people in the region.

These data show the increasing need for preventative care, early detection of NCD as well as optimization of specialist-based care such as nephrology. A retrospective single-center study from the regiondone by Sharma et al.[7] in a referral medical college hospital including a little >5000 CKD patients found that diabetes mellitus accounted for 42.2% of causes for CKD, followed by chronic glomerulonephritis in 21.4% and hypertension in 19.5%. Nearly, 2.7% of patients had CKD of unknown etiology. According to the Diabetes Atlas 2006, the number of patients with DM in India, currently, around 40.9 million is expected to rise to 70 million by 2025 unless urgent preventative measures are taken.

Every year in India about 2.2 lakh new patients with end-stage renal disease get added annually resulting in demand for 3.4 crore dialysis sessions every year. With approximately only 4950 dialysis centers largely in the private sector, the demand is less than half met with the current infrastructure. Northeast India comprising the seven sister states has a population of over 45 million comprising 3.76% of India's population. Overall population density of the region is 159 person/km2, though the state of Assam has a much higher population density at >300 persons/km2, while Arunachal Pradesh has the lowest density at 39 persons/km2. In the state of Assam, the majority of dialysis centers, nephrology care referral units, and the nephrology workforce including nephrologists are located in and around the major city Guwahati in lower Assam and in Dibrugarh, a major industrial hub in the upper Assam area. Patients needing care have only these two major cities for nephrology care and have to travel long distances for accessing them.

Guwahati city has the maximum number of practicing nephrologists of approximately around 10 and with an estimated population of 1.15 million (2021 census) has a nephrology ratio of 0.1pmp, one of the highest in the country. However, this ratio falls to 0.06 in rural areas. Satellite dialysis units funded by the Pradhan Mantri National Dialysis Program (PMNDP) under National Health Mission launched in 2016 and inaugurated in the state since 2019 are being currently operational in 20 public health Institutions across Assam and in few private health-care centers as well. PMNDP is currently available in almost all of the 59 districts belonging to all eight states. However, the geographical distribution of these centers is few and far between with patients having to travel long distances of around 30–150 km for maintenance hemodialysis; the additional burden that patients have to bear the out-of-pocket travel expense. These peripheral centers are staffed by only nurses and dialysis technicians and none of them have in-house nephrologists at the site. Predialysis care of CKD patients which is crucial for adequate prevention of disease progression of kidney disease is not covered under any health insurance scheme and > 90% of patients have to incur additional costs of medications, regular tests, etc., Nephrology care given the acute shortage of trained nephrologists is provided in the community by general physicians, endocrinologists, and practitioners of traditional systems of medicine.

It has been seen that referral to nephrologists occurs in more than 50% of patients only when the estimated glomerular filtration rate (eGFR) <15 ml/min/1.73 m2. Nephrology training programs do exist in most regions of the country; however, they are largely concentrated in the Southern and Western regions of the country. However, given the low number of trainees, it will take a long time before the population density of nephrologists comes anywhere close to that in the Western world.

The uneven distribution of trained nephrology workforce particularly the large deficiencies in rural areas demands that we need to have flexible approaches to managing CKD patients at earlier stages of the disease. As with the management of other NCD's such as diabetes and hypertension, care of patients with early stages of CKD can be provided by primary care physicians and nurse practitioners (like in the Western world) with the help of checklists and standardized algorithms. They can be involved in risk stratification, provide standard recommendations including dietary counseling, the follow-up to ensure nephrologist treatment adherence, and also make appropriate referrals when needed. Here, it is necessary to stress that nephrologist referral is mandatory for all patients when eGFR <30 ml/min/1.73 m2. However, more than 50% of patients in the Indian context are only seen in CKD-Stage 5 when eGFR <15 ml/min. This triaged system of care down to the primary health-care level will increase CKD awareness, as well as screening and better implementation of preventative measures.

Finally, a state-wise registry of CKD patient data documenting the incidence and prevalence of CKD patients documenting and outcomes is sorely needed; various region-wise nephrology groups have to work in coordination actively to make this a necessity. Registry outcomes need to be focused, organized, and fairly representative of patient population and need to be presented and published regularly at zonal and national nephrology conferences.

In conclusion, with this article focusing on the largest and most populated state in the North East, we would like to bring to attention to the fact that this region of India still remains a relatively underserved region of the country, especially in terms of specialized health infrastructure. Nephrology services are given the increasing prevalence of CKD overall in the country and more specifically in the region will require greater augmentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bibhov B, Purell CA, Levey AS, Smith M, Abdoli A, Abele M, et al. Global, regional and national burden of chronic kidney disease, 1990-2107: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2020;395:709-33.  Back to cited text no. 1
    
2.
Liyanaga T, Ninomiya T, Jha V, Neal M, Patrice HM, Okpechi I, et al. Worldwide access to treatment for end-stage kidney disease: A systematic review. Lancet 2015;385:1975-82.  Back to cited text no. 2
    
3.
Jha V, Ur-Rashid H, Agarwal SK, Akhtar SF, Kafle RK, Sheriff R, et al. The state of nephrology in South Asia. Kidney Int 2019;95:31-7.  Back to cited text no. 3
    
4.
Bello AK, Okpechi IG, Jha V, Harris DC, Levin A, Johnson DW. Understanding distribution and variability in care organization and services for the management of kidney care across world regions. Kidney Int Suppl 2021;11:e1-10.  Back to cited text no. 4
    
5.
Bello AK, Levin A, Lunney M, Osman MA, Ye F, Ashuntantang GE, et al. Status of care for end stage kidney disease in countries and regions worldwide: International cross sectional survey. BMJ 2019;367:l5873.  Back to cited text no. 5
    
6.
ASSOCHAM discussion on Healthy Heart. Available at https://www.assocham.org/press-release-page.php?release-name=assocham-discussion-on-healthy- heart- [Last accessed on 2022 Aug 02].  Back to cited text no. 6
    
7.
Sharma M, Doley P, Das HJ. Etiological profile of chronic kidney disease: A single-center retrospective hospital-based study. Saudi J Kidney Dis Transpl 2018;29:409-13.  Back to cited text no. 7
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