The increasing burden of chronic kidney diseases (CKDs) is worrying experts. Lack of awareness among masses about CKDs, inadequate infrastructural and manpower issues, including facilities such as shortage of nephrologists, lack of availability of dialysis facilities, shortage in availability of organs and transplants, absence of screening programmes, widening treatment gap and economic burden on the affected families pose major challenges.

Drug Today Medical Times Correspondent Rohit Shishodia spoke to Prof (Dr) Sanjay K Agarwal about various aspects about CKDs including its prevalence, its prevention, overall burden in India and ways to over this major problem in the country.

Prof Dr Sanjay K. Agarwal is a faculty in the department of Nephrology at AIIMS since 1991 and Professor and Head, since 2009. For years he is continuing to provide intellectual ferment and promote scientific temper, besides generating excellence and social relevance in medical education and research in the field of nephrology in India.

Dr Agarwal has chaired expert groups like Global Burden of Disease: India CKD Group, CKD Task Force Group of International Society of Nephrology for CKD advocacy, WHO and MOHFW expert group for making Guidelines for Management of CKD at primary health care level in India and MOHFW expert group for making Guidelines for Prevention of Kidney Diseases in India.

Serving as technical expert in various regulatory bodies in India like DCGI, MCI, NBE and NOTTO, Dr Agarwal has played a key role establishing National Organ and Tissue Transplant Registry.

DTMT: Can you tell our readers about Chronic Kidney Disease (CKD)?

Prof Agarwal: Broadly, kidney diseases can be classified into two types, namely, acute kidney disease (AKD) and Chronic Kidney Disease (CKD). During AKD kidney gets affected for a shorter period, and in most cases, it is reversible. It means that a patient’s kidney can regain its normal functions. However, some patients with AKD may progress to CKD.

Conversely, CKD means that a patient has developed kidney disease for more than three months, which is usually irreversible. In place of regaining the ability to function normally the condition of the affected kidney progresses with time and will go from a mild degree to a severe degree of CKD.

Severe extreme stage of CKD is also called end-stage kidney disease, which means kidneys are damaged completely when the patient needs dialysis and transplant as the patient’s health cannot be managed through medical treatment.

CKD is much more important as it cannot be cured and the patient requires dialysis and a transplant at a later stage.

DTMT: What is the overall burden of CKDs in India?

Prof Agarwal: Around 10% of the adult population in India suffers from some degree of CKDs. We need to understand that kidney disease has various degrees of severity. CKD can be classified into five stages.

The glomerular filtration (GFR) rate is usually used to assess the overall kidney function, which is 100ml per minute in a healthy person and this decreases as the kidney gets progressively damaged.

In stage one of CKD, if the estimated value of GFR is more than 90, it is considered normal but still, the patient is labelled as a CKD patient as this means the patient’s kidney has been damaged somewhat.

If the level of creatinine in blood and protein in urine is high, then it is an indication of kidney damage. So if there is an access protein in the urine, then even though GFR is more than 90 still the patient will be labelled as a stage one CKD patient.

In stage two CKD, the GFR ranges between 60 and 90, while in stage three it is 30 to 60 and in stage four 15 to 30, while in stage five CKD, also called end-stage kidney disease GFR value is less than 15.

While 90-95 out of 100 CKD patients can be labelled as stages one, two and three, the rest five CKD patients will be at stages four and five.

Patients suffering from the first three stages of CKD, who comprise 95% of CKD patients usually remain asymptomatic or show very mild symptoms and are most likely not to seek medical help, thereby remaining at risk of missing a diagnosis at earlier stages, which is essential for increasing the chances of recovery.

We cannot screen even 10% of the population of the country, given the size of India’s population because logistically it is not possible.

So what we recommend is that there is a specific high-risk group of kidney diseases, including those suffering from diabetes, high blood pressure, elderly over 60 years of age, and those with a history of kidney disease in the family should be screened, so that we can make an early diagnosis of stage one, two and three and can start the treatment.

With treatment initiated at earlier stages, we can delay the progression of the disease to stage 4 or 5 after four and five years, when the requirement for dialysis and transplant arises, which may otherwise be reached in two years for some people. So, we are delaying the need for dialysis and transplant.

So that is why early diagnosis of a high-risk group of patients with kidney disease should be screened.

DTMT: Are there any regional variations of kidney diseases in India?

Prof Agarwal: Yes, in India we have done a study, funded by the Indian Council of Medical Research from the seven cities of the country and tried to find out the magnitude of CKD in India, which found that magnitude of CKD is not uniformly the same across India. There is variation in North, South, East and West.

Another study, known as Global Burden of Disease, which studied the burden of various diseases from 1990 and 2017 also estimated CKD prevalence in India. These findings,  found that there was regional variation between 1990 and 2017, which significantly increased during the period.

Compared to North and West India, CKD is more often found in the Southern and Eastern parts of the country. Although in percentage terms the difference is around just a couple of per cent, in absolute numbers it will be quite significant.

DTMT: What are the minor signs and early indications of kidney disease?

Prof Agarwal: First thing which people should not ignore is blood pressure. On the one side, high blood pressure is the cause of kidney disease but on the other side, CKD can also trigger blood pressure. Therefore, anybody who has got blood pressure should be investigated for CKD and anybody who has got swelling over the body usually in the limb then he must also be investigated for CKD.

Another sign is loss of appetite. If there is loss of appetite persists for weeks and months, then the person should be investigated for CKD.

Then anyone suffering from an unexplained fall in haemoglobin that persists for more than a few weeks they should be screened for ruling out CKD as adequate haemoglobin levels in the blood are essential for kidneys to function normally.

People who fracture their bones or suffer from bone pains even after encountering minor trauma should also be investigated for kidney diseases as normal kidney function is necessary for maintaining bone strength. So if the kidney is damaged, then even a minor trauma can cause bone pain and fracture.

Other than these symptoms, any person complaining of symptoms of kidney disease as complains of blood or pus in the urine, acute pain in the abdomen in the kidney area (renal colic), difficulty in passing urine or requiring to pass urine frequently, then they must be investigated for possible kidney disease.

What people must realise is that screening tests for kidney diseases are not at all expensive and relatively simple tests like serum creatinine and tests for protein in urine can indicate kidney issues. These coupled with regular monitoring of blood pressure and blood sugar can pick up 90% of the kidney damage in early stages.

DTMT: How much kidney disease has increased in the past 10 years and has it increased in the young age group?

Prof Agarwal: In the absence of a registry of kidney disease in our country, we cannot authentically say to what extent kidney diseases have increased, but real-time experience of nephrologists also substantiated by Global Burden of Disease indicates that CKD cases are showing an upward trend.

Hence, we can say that in the last fifteen and twenty years, kidney diseases have been increasing in India and if we take western data as they have scientifically published data to show that CKDs are rising with time.

DTMT: Can you elaborate a little more on blood creatinine level?

Prof Agarwal: Blood or serum creatinine is a little complex issue because creatinine being a by-product of muscle metabolism, gets excreted through the gut as well as the kidneys.

So what we see in the blood (serum creatinine) is affected by a combination of multiple factors and the same creatinine reading may not be normal for everybody.

For example, if we take forty-kilogram elderly female and her serum creatinine level is 1.3 then she will be labelled as stage three of CKD but if we take the eighty-year-old muscular man and he is having serum creatinine of 1.3 he may be diagnosed as having stage one CKD and even a normal serum creatinine level.

In  other words, how much creatinine is generated in the body and how much is excreted decides how much remains in the blood. So that is why nowadays instead of serum creatinine value, we estimate GFR by calculating serum creatinine with a formula that gives us an idea as to how much creatinine is generated and how much is excreted, called estimated GFR.

So instead of depending on a single absolute value of serum creatinine we estimate GFR and take that as criteria for defining whether a person is having a normal renal function or not.

DTMT: What steps can be taken to treat kidney diseases at the primary healthcare level?

Prof Agarwal: Government has integrated the CKD programme into the national program of prevention of non-communicable diseases, including cardiovascular disease, diabetes, hypertension, stroke and cancer recently. Under this programme, as envisaged by the Hon’ble PM, people in these high-risk groups will be screened for CKD by measuring serum creatinine and estimated GFR methods at wellness centres annually.

In case of any abnormality being detected, they will be given appropriate treatments either at the PHC or wellness centres or may be asked to go to community health centres for getting treated and if that is unable to resolve the issue, then the patient will be referred to district hospitals for treatment.

So it will be the severity of the CKD stage that will determine where the patient will get treatment. We are aiming to manage CKD at its early stages itself to prevent the disease from progressing to a stage where they require dialysis and kidney transplants.

 DTMT: Apart from diabetes and hypertension, what are other risk factors for kidney diseases?

Prof Agarwal: Renal stones certain genetic diseases, including polycystic kidney diseases, as well as a broad group of diseases, called glomerulonephritis can also cause CKD.

DTMT: What are the treatment options to manage CKD?

Prof Agarwal: It is important to understand that CKDs cannot be cured, but modern medicine has advanced to the point where we can delay or prevent further deterioration.

Second, we provide symptomatic CKD treatment to patients so that they can live normal life.

Aside from these, there are different treatments for CKD depending on the cause. For example, if diabetes is the cause, we must also treat diabetes, and if a stone is the cause of CKD, we must treat the kidney stone. So one is the specific treatment for the underlying cause of CKD, while the other is the non-specific treatment to delay progression from the early to late stages.