Pattern of End Stage Renal Disease in a Tertiary Care

Introduction: End Stage renal disease (ESRD) is a major public health problem across the world and it is rising. The incidence prevalence and causes of ESRD is not known in Nepal. With a population of 27 million people the estimated incidence of ESRD is around 2700/year if we take 100/million population at par with India and Pakistan. However majority of patients do not reach hospitals with dialysis facilities. The aim of the present study was to analyze the clinico-epidemiological profi le of ESRD in the Nepalese context.


INTRODUCTION
Chronic Kidney Disease (CKD) is a public health problem across the world and it is rising.According to United States Renal Data System (USRDS) the incidence of end stage renal disease (ESRD) has gone up in US from 249/ million population in 1992 to 337/million population in 2003. 1 The estimated incidence of ESRD in India and Pakistan is 100/million population/year. 2 However, recent population-based study in India showed it to be around 232/million population. 3he prevalence of ESRD increases as the economy of the country grows with more people seeking renal replacement therapy.Prevalence is highest in Japan at 2000/ million and only 100/ million in India. 4The incidence and prevalence of ESRD has not been studied in Nepal.The objective of the present study is to fi nd out the clinical and epidemiological profi le and problems of ESRD management in the Nepalese context.

METHODS
A retrospective cross sectional study of all ESRD patients (creatinine clearance <15 ml/min) admitted in Bir hospital from April 2001-April 2006 were done.Ethical approval and hospital permission was taken.The hospital records were reviewed.Acute and acute on chronic renal failure were excluded by the history, physical examination with exclusion of reversible factors like infection, dehydration, nephrotoxic drugs, investigations including ultra sonogram of abdomen (USG) showing normal kidneys and hydronephrosis without thinning of cortex, reversibility on treatment and follow up.Each patient was counted only once as a new ERSD despite of several admission for different problems.Different etiological diagnosis was reached from history, examination, investigations including urine analysis, haematological tests, biochemical parameters, radiological investigations including USG abdomen, X ray chest and X ray KUB.Creatinine clearance was calculated by Cockroft and Gault formula.Electrocardiogram (ECG) was done in all cases and echocardiography was done in selected cases.Doppler USG and angiogram was done in cases with ischemic renal disease.Mode of treatment and outcome was computed.Population on maintenance haemodialysis (MHD) in Bir hospital and other centers were followed up.Statistical analysis was done by statistical package for social science version 13 for windows.

RESULTS
Total number of ESRD patients during the period was 802 of which 510 were male and 292 were female with male to female ratio of 1.7:1.The mean age of patients was 46 years (range 2-96 years) with 66.3% patients in the age group 20-59 years.Annual number and age group of ESRD patients during study period is given in Table 1.On an average 13 new ESRD patients are enrolled monthly.Chronic glomerulonephritis is the leading cause of ESRD followed by diabetic nephropathy and hypertensive nephrosclerosis (Table 2).Uncommon causes were chronic tubulointerstitial nephritis, ischaemic renal disease and chronic allograft nephropathy.In 18.1% patients the cause of ESRD could not be ascertained.The major cause of obstructive uropathy was nephrolithiasis (53.1%) followed by neurogenic bladder (15.6%), posterior urethral valve (6.2%), stricture urethra (3.1%), phimosis (3.1%), benign enlargement of prostate (3.1%) and causes unidentifi ed (15.6%).Three out of the fi ve cases of neurogenic bladder were due to spinal injury.Ischaemic renal disease was due to atherosclerosis in one case and Takayasu's arteritis in another.
The mean age varied with different diseases being low in chronic glomerulonephritis and chronic pyelonephritis and higher in diabetic nephropathy, hypertensive nephrosclerosis and ADPKD (Figure1).Chronic glomerulonephritis was the commonest cause of ESRD in all age groups below 60 years while diabetic nephropathy was the commonest cause in age group 60-79 years (Table 2).
Biochemical investigations revealed blood urea 190 + 67 mg %, serum creatinine 10.6 + 8.7 mg%, serum sodium 134.7 + 11 meq /L and serum K 5.0 + 3.0 meq/L, serum calcium 8.1+ 1.2mg % and serum phosphorous 6.6 + 2.8 mg%.Mean Hb was 7.3 + 1.7 gm/dl.Intermittent peritoneal dialysis (IPD) was the initial mode of therapy in 68% which was followed by haemodialysis in 9.6% cases.Out of the patients receiving peritoneal dialysis 86.1% received only one session, 10.3% received 2 sessions, 3.6% received more than 2 sessions.Haemodialysis was the initial mode of treatment in 14% cases.Only conservative treatment was received by 17.6% cases, some of whom were in stage V CKD with severe anaemia and others refused dialysis due to fi nancial reasons.Continuous ambulatory peritoneal dialysis was least popular due to its high cost and received by only two cases (0.24%).Out of 23.6 % cases receiving haemodialysis, 5.1 % had only few sessions, 5.2% had dialysis for less than three months and only 13.3% cases could continue MHD for more than three months.Kidney transplant which was not available in the country was done in neighboring country in only 3.8% of cases.
Blood transfusion for anemia was the mode of therapy in 93 % cases and only 3.4% could afford erythropoietin.Hypertension was present in 83.6%, which was controlled on one drug in 39.8%, two drugs in 30.6%, three drugs in 12.1% and four drugs in 1.1%patients.14.7% patients expired during hospital admission.

DISCUSSION
The cause of end stage renal disease varies in different part of the world with diabetic nephropathy being the leading cause worldwide.The number of diabetic ESRD population is increasing 5 as diabetes is on the rise and people with diabetes are living longer.Diabetic nephropathy now accounts for 44% of all new ESRD in US. 1 CGN is a leading cause of ESRD in developing countries like India, Pakistan and Bangladesh 2,6,7 although recent population based study in India 3 had shown diabetic nephropathy as the leading cause of ESRD.Present study also has shown CGN as the commonest cause of ESRD followed by diabetic nephropathy and hypertension.Most of our patients presented very late in the disease and hence the cause could not be ascertained in 18% cases.Chronic pyelonephritis that constituted 2.5% of our cases was probably under diagnosed.The mean age of the patients with ESRD was younger with two third of all cases in 20-60 age group compared to developed countries where the elderly ESRD population is increasing. 8Most patients could not afford the cost of erythropoietin and hence blood transfusion was the mode of therapy.Intermittent peritoneal dialysis, which has largely been replaced by CAPD in most developed countries, is still being practiced for treatment of ESRD in some developing countries. 9It remained the initial mode of therapy in majority of cases because it was easily accessible and haemodialysis machines were few in number.Most patients could afford only one or two sessions of IPD and succumbed to death.Some patients had repeated IPD whenever they became symptomatic.Those who could continue dialysis went for maintenance haemodialysis.Hardly few could continue MHD because of the high cost of dialysis.Acceptance to renal replacement therapy has been low in developing countries like Bangladesh where one third abandon treatment within the fi rst three months and out of the remaining patients 10% go for renal transplant. 7Similarly review article by Sakhuja et al has shown that less than 10% of all patients in India and Pakistan receive any kind of renal replacement therapy as majority of patients starting dialysis stop treatment within the fi rst three months due to fi nancial constraints and only 5% go for renal transplant. 2 High dropout rate of 57% after few sessions of haemodialysis has been reported at B.P. Koirala Institute of Health Sciences in eastern Nepal. 10phrology service is limited to Kathmandu valley and a few other centers outside valley.The cost of twice weekly dialysis is $160 per month in Government hospital and $320 per month in non-government sector.Government hospital cannot provide dialysis for all and there is long waiting list for dialysis.Even in the government hospitals only service is provided at a nominal cost and patients have to buy the consumable items for dialysis.There is as yet no insurance policy for health services.Nepal being a country with a poor socioeconomic status with per capita income of $270 per year most Nepalese cannot afford to have maintenance dialysis.Only a handful could go to neighboring country like India for renal transplantation.

CONCLUSIONS
CGN is the leading cause of ESRD in our context followed by diabetic nephropathy and hypertensive nephrosclerosis.It affects younger age group people in their productive life.Most of the disease could have been prevented through screening programme.ESRD treatment is costly, not available in most parts of the country and unaffordable by most Nepalese people.This highlights the need for health education for prevention and early detection of chronic kidney disease.There should be health insurance policy and easy accessibility to dialysis facilities at subsidized cost.Renal transplantation would cut down the cost on dialysis and improve quality of life.

Figure 1 .
Figure 1.Mean age (years) of patients with different diseases