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Jafar Tazeen
Journal of Hypertension: September 2016
doi: 10.1097/01.hjh.0000499880.98439.10

Chronic kidney disease (CKD) defined as reduced estimated glomerular filtration rate (eGFR) or presence of albuminuria, progresses to end stage renal disease (ESRD), needing dialysis or kidney transplant to sustain life, and is associated with increased risks of premature cardiovascular disease (CVD) and mortality. CKD ranked 18th leading (and most rapidly rising cause of mortality by the Global Burden of Disease Study 2010. The social and economic consequences of CKD are far worse in low and middle income countries (LMICs) including India, Pakistan, Bangladesh, and Sri Lanka.

Accoriding to successive estimates of the World Health Organization, countries in South Asia have been experiencing a progressive rise in the burden of non-communicable diseases (NCD) one facet of which is CKD. About 1 in 5 adults older aged 30 years suffer from CKD South Asia. Although national level estimates are not available, a recent meta-analysis indicated prevalence of CKD is 7.7% in South Asia based on eGFR <60 ml/min/1.73 m2. However, evidence to inform CKD prevention and management programs is scarce.

Hypertension and diabetes are the most important risk factors for CKD in South Asia: 1 in 3 adults has hypertension. In addition, more than 70 million people had diabetes in 2010, and this number is expected to rise to 100 million by 2030. Both high blood pressure and diabetes are common even during chilldhood. The age of onset of CKD is also younger in South Asians than noted in studies in Western populations. This is unsurprising as low birth weight and prematurity, both in part due to maternal malnutrition are common in India, and predispose to insulin resistance and CKD. Rates of progression of CKD to ESRD have been shown to be faster in people of South Asian origin than white counterparts. However, less than 10% with ESRD are able to afford RRT (annual cost US $5000) in India. The impact of lives lost due to ESRD or premature CVD are far more grave in India where majority of the population lives in conditions of poverty (Fortunately, adverse complications of CKD can be prevented by prompt detection and early institution of therapy. Healthy lifestyle (maintaining ideal body weight, physical activity, healthy diet, and smoking cessation) and pharmaceutical interventions including maintaining blood pressure control preferably with blockers of renin angiotensin system (RAS) to reduce proteinuria, and glycemic control, and reduce the risk of atherosclerotic events with lipid lowering are important for prevention of CVD and delaying progression to ESRD. However, despite the publication of evidence-based guidelines on management of CKD, serious deficiencies in provider knowledge and practices regarding management of hypertension and CKD have been identified. Thus, CKD awareness rates are abysmally poor (6 and 10%) in the general and high risk population with CKD, respectively, in South Asia. Moreover, evidence of effective community based program to prevent and manage CKD has been lacking.

The Control of Blood Pressure and Risk Attenuation Trial assessed the effects of a combined public health intervention on the kidney health of hypertensive adults in Pakistan's general population. The intervention included training of community health workers on aspects of a healthy lifestyle (such as improving diet, stopping smoking, increasing physical activity, and taking prescribed blood pressure–lowering medications) and training of community general practitioners (GP) on the updated guidelines related to managing hypertension.

The combined home health education (HHE) plus trained GP intervention was beneficial in preserving kidney function over 7 years among adults with hypertension in communities in Karachi. These findings highlight the importance of scaling-up simple strategies for renal risk reduction in LMICs. Efforts are needed for integrate CKD prevention and management program within the broader NCD policy framework in South Asia.

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