The prevention of Chronic Renal Failure at the community level.
The rural programme of the Kidney Help Trust.
Dr. M.K. Mani, Chief Nephrologist, Apollo Hospital, Chennai.
For the past 14 years, the Kidney Help Trust of Chennai has run a programme to prevent chronic renal failure by regular screening initially of an entire population of 21,000, and treatment of diabetes and hypertension with the cheapest available drugs. The total cost amounts to just Rs. 21.75 (45 US cents) per capita of the population per year. After 10 years, the programme was expanded to cover the adjacent area with a population of 21,500. Both the original population and the new population were surveyed, and the kidney function was measured. There are 28 persons with kidney function below normal per 1000 of the new population, while the population covered by the project has only 11 per thousand. Around 60% of chronic renal failure has been prevented with extremely small expense. The new population has also been provided the same coverage, so the Trust protects 42,500 people now.
The function of the kidneys and the effects of kidney failure
The kidneys play a vital role in the purification of the blood, and in the regulation of many aspects of the function of the body: the blood pressure, the formation of red blood cells, and the formation and maintenance of healthy bone being the most important of these. Most human beings are born with two kidneys, and their importance can be judged by the fact that together they weigh just 0.4% of the weight of the body, yet receive 25% of the blood pumped by the heart to the body, and consume 10% of the oxygen. The extremely high blood flow makes the kidney vulnerable to injury, since noxious substances carried in the blood reach the kidney in large quantities. Further, diseases that damage the blood vessels, like diabetes and high blood pressure, affect the kidneys, since they are full of blood vessels. When the kidneys fail, toxins accumulate in the blood and the patient is gradually poisoned. His blood pressure rises, he becomes anaemic and weak, and the bones become brittle and painful. He gradually succumbs to a miserable death.
How can we treat kidney failure?
With a few exceptions, most parts of our country now have numerous hospitals with facilities for dialysis (the purification of the blood) and kidney transplantation (the insertion of a healthy kidney from a living donor or a cadaver into the patient), and these procedures are carried out with very good results. Unfortunately, the cost is extremely high. Dialysis costs between Rs. 15,000/- and Rs. 20,000/- (US $ 300/- to 400/-) 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/- (US $ 6,000/- to 7,000/-), and requires medicines costing between Rs. 10,000/- and Rs. 1,00,000/- (US $ 200/- to 2,000/-) per year to prevent rejection of the transplant and to sustain life. Our per capita income is around Rs. 32,000/- (US $ 650/-) a year. The expenditure of the State and Central Governments on health works out to around Rs. 800/- (US $ 17/-) 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 3% 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.
The prevention of chronic renal failure
Diabetes accounts for around 30% of all the chronic renal failure in India and hypertension for another 10%. 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. If other renal diseases are detected and treated early, it may 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.
The plan of action
We started with a rural area since 70% of India’s population is in the villages, and these are less well served medically. Our initial population consisted of around 21,000 people in 26 villages in Sriperumbudur Taluk. The main workers are girls from the area who have completed their schooling.
We train them to perform the simple tasks we require in a few days, and closely monitor their work for the first few weeks till we are confident of their reliability. The demographics of the entire area has been mapped out, and we have a card for each habitation.
- Screening of every person in the area once in 18 months: our workers ask each one a simple set of questions: have you ever had swelling of the feet, difficulty in breathing, pain on passing urine, blood in the urine, the need to pass urine frequently (more than twice in an hour) or to get up from sleep at night to pass urine, or pain in the back over the kidneys. A sample of urine is examined at the site for sugar and for protein. Most diabetics will be detected by finding sugar in the urine, and protein leaks into the urine in around 80% of kidney disease. The blood pressure is recorded for all individuals over the age of 5.
- Verification by the doctor: all 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 Kidney Help Trust who makes regular visits to each village.
- Initial investigation: the Apollo Hospital of Chennai has been kind enough to do some simple tests for us free of charge. All subjects verified by the doctor have blood urea, serum creatinine, blood glucose and glycated haemoglobin (a test which gives the average of the blood sugar over the preceding three months) done. Those who already have evidence of kidney disease are invited to go to Apollo Hospital where they are investigated and treated free. However, very few of these patients agree to visit the hospital.
- Treatment: diabetes is treated with glibenclamide and metformin, hypertension with reserpine, hydralazine and hydrochlorothiazide, all drugs of low cost yet of proven efficacy. Medicines are provided free by the Kidney Help Trust. Enalapril is used only in selected patients as it is more expensive. We have recently received a generous donation of Enalapril tablets from the Balaji Trust (Sapiens Health Foundation), and are able to give this drug to some of our patients. However, possible side effects of this drug necessitate more frequent blood tests that add to the expenses, and therefore we have to restrict the use. Monitoring of blood pressure is done at weekly intervals by the health workers, and diabetes is monitored with glycated haemoglobin done every three months. The dose of medicines is adjusted to achieve good control.
- Implementation: the health workers go to each village in turn, and establish themselves at the designated centre, which may be the verandah of the school or panchayat office, or sometimes the shade of a convenient tree. The population is invited to come there for the check, but those who do not come are visited at their homes to ensure as near complete coverage as possible.
- The response: 90% of the populace co-operated for the survey. The figure of 21,000 mentioned earlier is that 90%. Only 30% of the patients picked up had been aware of their disease earlier. This fact underlines the importance of screening every single member of the community. One recognised method of screening populations is to run a camp in an area, where doctors are available for the public to consult and technicians to do investigations. Only those who suspect they have a problem would attend, and 70% of patients would be missed. We would lose the opportunity of treating patients from the very earliest stage of the disease. After diagnosis, 25% of the patients preferred to take treatment with their own doctors. Of the remainder, 79% co-operated for treatment.
- The results: among those who co-operated with us for treatment, blood pressure was controlled to ideal levels (less than 140/90) in 96%, glycated haemoglobin to normal in 52% and significantly improved though not to completely normal in another 25%.
- The efficacy of the project: this was assessed after the project had been running for 10 years, by extending the project to an adjacent area of around 21,500. The screening was done in both areas in the same year, and the findings of the two areas were compared. A test was made of the kidney function on this occasion, using a formula in each individual that gives a numerical value for the kidney function (the glomerular filtration rate or GFR). The normal value of the GFR in Indians is between 80 and 110 ml/minute. All those who were picked up by screening and were then verified by the doctor had this estimation done. GFR was found to be below 80 ml/minute in 28 per thousand in the new area that had not had the benefit of the project over the last ten years, and just 11 per thousand in the area covered by our project. It appears that we have prevented 17 patients from developing kidney failure per 1000 of the population, around 60% of those who would have gone into kidney failure without our intervention.
- The cost of the project: funding has come from a number of individual and corporate donors. Donations to the Trust have been exempted from income tax under Section 80 G of the Income Tax Act. The total cost of the project, including salaries of the workers and the doctors, transport of the doctors from Chennai to the project area, chemicals for the simple urine tests and all the medicines used, have come to just Rs. 21.75 (45 US cents) per capita of the population per year. This does not take into account the tests done at the Apollo Hospital, whose support is gratefully acknowledged.
For further details please contact:
Kidney Help Trust,
1, Kasturirangan Road,
Chennai 600 018,
Telephone: + 91-44-2499-1537.