Cost-effective protocol reduces renal disease in Chennai

G Sankaranarayanan - Chennai

A cost-effective protocol developed by the Chennai-based Kidney Help Trust (KHT) for the early detection and prevention of kidney failures has dramatically reduced the incidence of renal diseases in around 26 villages near Chennai.

The results of KHT’s eight-year-old rural programme on early detection of renal diseases, proved that only eight per 1000 villagers were found to have a glomerular filtration rate (GFR) of below 80 ml/minute indicating the necessity for treatment. When KHT conducted a study with the population of adjacent villages that were not covered by the programme, there were 33 people per 1000 found to have renal diseases.

“It appears we have prevented 25 patients from developing kidney failure per 1000 of the population,” said Dr M K Mani, managing trustee of KHT, who is also the chief nephrologist of the Apollo Hospital, Chennai. The programme run regular screening of the entire population of 23,000 who belong to 26 villages. “This could mean that around 75 percent of chronic renal failure has been prevented with extremely small expense.”

The total cost of the programme, designed by KHT, a voluntary organisation dedicated to the prevention and cure of renal diseases, works out to an unbelievable Rs 14.23 per capita of the population per year.

The entire programme does not involve CT scan or MRI or other costly test equipment or procedures. KHT deploys simple survey methodologies, cost-effective urine and blood tests, and most-effective but less expensive drugs - including ayurvedic - for the programme. It enrolls and trains volunteers - girls, who have completed their schoolings - on conducting the surveys and tests that are reviewed by the qualified doctors who visit the villages every month.

The whole concept was based on the fact that “you cannot detect the renal disease at early stage by looking at the candidates head or heart but urine and blood.” The girls could test the sugar and protein content of the urine with the KHT methodologies.

“Diabetes accounts for around 30 percent of all the chronic renal failure in India and hypertension for another 10 per cent. It has been amply demonstrated all over the world that tight control of these two conditions from the outset will protect against damage to the blood vessels and therefore to the kidneys. In addition, hypertension accelerates the decline in kidney function in all other renal diseases, and good control will give patients many more years of useful and healthy life,” said Dr Mani.

He added that if other renal diseases are detected and treated early, it might be possible to cure some of them. “We started with the premise that we should be able to prevent half the cases of kidney failure in the country,” Dr Mani said and adding, “Among our patients, blood pressure was controlled to ideal levels - less than 140/90 - in 96 percent, glycated haemoglobin to normal in 52 per cent and significantly improved though not to complete normal in another 25 per cent.”

Explaining the methodology, Mani said that KHT workers ask each villager a simple set of questions: “Have you ever had swelling of the feet? Difficulty in breathing? Pain on passing using? Blood in the urine?, etc.

The health workers then take collect a sample of urine which is examined at the site itself for sugar and for protein. Most diabetics will be detected by finding sugar in the urine, and protein leaks into the using in around 80 percent of kidney disease. The blood pressure is recorded for all individuals over the age of five.

The patients who test positive by answering any of the questions in the affirmative, who have a high blood pressure - over 140/90, or who have sugar or protein in the urine, are examined by a doctor of the Trust. The initial investigation to the patients is done free of cost by Apollo Hospitals. The subjects - who are verified by the doctors - have blood urea, serum creatinine, blood glucose and glycated haemoglobin (a test that gives the average of the blood sugar over the preceding three months) done.

The diabetes is treated with glibenclamide and metformin, hypertension with reserpine, hydralazine and hydrochlorothiazide, all drugs of low cost yet of proven efficacy. Enalapril is used in selected patients as it is more expensive. Monitoring of blood pressure is done at weekly intervals by the health workers, and diabetes is monitored with the glycated haemoglobin done every three months. The dose of medicine is adjusted to achieve good control.

“In typical health camps, only those who think they are ill come forward to undertake the checkups and tests. In our programmes, we go to each and every home,” Dr Mani says and points out that though 30 percent of the patient-population knew their disease condition already, the rest simply believed that they were healthy. “These are the people, who wouldn’t have gone for the testing done at health camps.”

Dr Mani says that 90 per cent of the populace cooperated for the survey. After the diagnosis, 25 per cent of the patients preferred to take treatment with their own doctors. Of the remaining, 79 per cent cooperated for KHT treatment.

Dr Mani believes that KHT has established and validated an effective protocol for the prevention of a large proportion of kidney failure at a very low cost. “We have not measured the impact on the incidence of stroke and heart disease, which would probably be even greater than the benefits of the kidneys,” he said.

According to him, the kidney programme can easily be replicated by small groups all over the country. It could even be taken up by members of the community themselves - on a self help group basis - with a little help from doctors and laboratories. The programme could also be easily incorporated into government health programmes using existing staff.

Highlighting the healthcare cost and infrastructure for renal care in India, Dr Mani said that though there are hospitals with facilities for dialysis - the purification of the blood, and kidney transplantation, unfortunately the cost of these treatments are extremely high. Dialysis costs between Rs 15,000 to Rs 20,000 per month and will have to be continued as long as the patient lives.

Renal transplantation costs between Rs 3,00,000 and Rs 3,50,000 and requires medicines costing between Rs 10,000 and Rs 1,00,000 per year to prevent rejection of the transplant and to sustain life.

“Our per capita income is around Rs 21,000 a year. The expenditure of the state and central governments on health works out to just around Rs. 400 per capita per year. It does not take a mathematical genius to realise that India and Indians cannot afford to treat chronic renal failure. In fact, it is estimated that just three percent of patients with chronic renal failure are now being treated. The only feasible option is to prevent it, if that can be done at a lower cost,” Dr Mani said.

Addressing a press conference recently Dr Jan J Weening, professor of Pathology at the University of Amsterdam, who is also the president of the International Society of Nephrology said he visited the KHT adopted villages and based on his assessment the prevention programme is a pioneering and result oriented initiative that could be replicated across the globe. Dr John Dirks, a senior fellow of Massey College and Professor Emeritus of Medicine at the University of Toronto, who was also present in the press conference hailed the features of the programme.

KHT is planning to impart training for NGOs and self help groups to spread its cost-effective preventive programme throughout the rural and urban centres across the country.