Clinicodemographic Profile of Kidney Diseases in a Tertiary Hospital of Central Nepal, Chitwan: A Descriptive Cross-sectional Study

ABSTRACT Introduction: Spectrum of kidney diseases differs significantly in developing and developed countries. However, there is no central registry regarding the nature of such diseases in Nepal and our center either. The study aims to know the clinicodemographic spectrum of kidney disease patients admitted to our hospital. Methods: This study was a descriptive cross sectional study done in the department of Nephrology, College of Medical Sciences Teaching Hospital from May 2018 to April 219. Convenient sampling was done and all the consecutive kidney disease patients irrespective of their age, sex, and renal diagnosis were included in the study. Ethical approval was taken from the Institutional Review Committee of the college (reference number. 2016/COMSTH/IRC/049). Clinicodemographic profile of kidney diseases were studied using statistical package for the social sciences version 20 and were represented as mean, standard deviation, number, percentage and ratio. Results: Out of a total of 829 patients, the commonest clinical syndrome and the histological patterns were end-stage renal disease 248 (29.9%) and IgA nephropathy 18 (20.7%) respectively. The mean age was 51.4±18.6 years. The commonest reason for hospitalization was sepsis 372 (44.8%). Males were 486 (58.6%) and females were 343 (41.4%). Conclusions: The commonest clinical presentation and the reason for admissions were end-stage renal disease and sepsis syndrome respectively.


INTRODUCTION
The spectrum of kidney diseases includes various aspects of renal disorders and differs significantly in developing and developed countries. If left untreated they may lead to renal failure that may require renal replacement therapy, which is extremely expensive and places a severe burden on the healthcare system of the country. 1 Kidney diseases have become a major public health problem globally and in Nepal too. [2][3][4][5] and the estimated prevalence of chronic kidney disease (CKD) is around 10.6% but is expected to be higher. 4,5 In a recent metaanalysis of AKI, the incidence of AKI was found to be 7.5% in Southern Asia and 31.0% in South-eastern Asia; 6,7 However there are no such data from Nepal. data regarding the nature of such patients in our center. We, therefore, thought of doing a study to know the clinicodemographic spectrum of kidney disease patients admitted to our hospital.

METHODS
This study was a descriptive cross sectional study carried out in the department of Nephrology over one year, from May 2018 to April 2019. The ethical clearance for conducting the study was taken from the Institutional review committee of the hospital with the Ref no. 2016/ COMSTH/IRC/049. Convenient sampling was done and all the consecutive kidney disease patients, who were admitted in the department of Nephrology, irrespective of their age, sex, and renal diagnosis, were included in the study. The clinical diagnosis of renal diseases was made by a nephrologist with an experience of > 5 years in clinical Nephrology and all the diagnoses were supported by relevant biochemistry, radiology, and pathology reports. The prevalence of chronic kidney disease (CKD) is around (p) is 10.6% 4 , taking 95 % CI and 2.5% margin of error then sample size was calculated by using formula, n= Z 2 x p x q / e 2 = (1.96) 2 x (0.106) x (1-0.106) / (0.025) 2

=582
By taking 10% non-response error the actual sample size of this research was 642 but this research was conducted among 829 patients.
The standard definitions were used to define the renal diagnosis as per the updated kidney disease improving global outcome (KDIGO) equivalent criteria, wherever applicable. Written informed consent was taken from all the patients.. The patient's demographic profile, clinical diagnosis, comorbidities, the reason for hospital admissions, length of hospital stay, and the number of repeat admissions were noted in the proforma. The data were then entered in the MS XP sheet and were transferred to statistical package for social sciences version 20 (Chicago, IL, USA) program for analysis. The data were analyzed using mean, standard deviation, number, percentage and ratio.

RESULTS
A total of 829 patients were admitted within a period of one year from April 2018 to May 2019. The commonest clinical syndrome and the histological patterns were end-stage renal disease 248 (29.9%) and IgA nephropathy 18 (20.7%) respectively. The commonest reason for hospitalization was sepsis 372 (44.8%). Out of them, males were 486 (58.6%) and the females were 343 (41.4%). The mean age of the patient was 51.4±18.6 years. The minimum age was 9 years and the maximum age was 93 years (Table 1). Of 829 patients, 246 (29.7%) were of age <40 years and 583 (70.3%) were of age ≥ 40 years. Further age distributions were as shown in the table below.  Most of the histological patterns of the kidney biopsies were of IgA nephropathy 18 (20.7%) followed by lupus nephritis 11 (12.6%), minimal change disease 9 (10.3%), membranous glomerulonephropathy 7 (8.0%) ( Table 3).

DISCUSSION
In Nepal, there are limited numbers of nephrologists and only a few dedicated nephron centers to provide the nephrology service to kidney patients. Our study was the first of its kind from Chitwan to know the nature of kidney diseases prevailing in this region. Of the 829 patients, the majority of the patients were males 486 (58.3%), with the male to female ratio of 1.4. Similar observations of male preponderance were seen in other studies from India. 8,9 This dominance of males over the female may reflect the socio-dynamic influence of our society, where a treatment privilege goes to males or it may be because the males were inherently predisposed to develop kidney diseases. This area of research needs multicentric genetic studies.  10 projecting CKD/ESRD to be the commonest clinical presentation in different parts of the world including ours. The high burden of ESRD could be explained by the silent and asymptomatic nature of the disease, lack of population awareness about the disease, poorly equipped health care system, and high cost of treatment. 1,11 Sixty-six (7.9%) patients were diagnosed ESRD for the first time in our study, making the incident ESRD a significant problem in our center. Similar to our study Sakhuja,et al. 12 also reported about two-thirds of their patients to be new ESRD at the time of the first consultation.
The overall CKD patients including the patients from ESRD group, acute on CKD group, and CKD3-5 group were 527 (63.6%), which projects CKD as the dominant clinical syndrome. The observation of CKD being the dominant clinical syndrome in our study might be explained by the global increase in the prevalence of diabetes and chronic glomerulonephritis. Similar observations of CKD being the dominant presentation were also seen in Indian studies from North India (PGI, 13 AIIMS, 14 and SGPGI). 15 The commonest cause of ESRD in our study was T2DM 94 (37.9%) followed by CGN 75 (30.2%) and HTN 63 (25.4%) highlighting the fact that T2DM is the number one cause of ESRD in our region and also globally. 16,17 However, there seems to a considerable heterogeneity in the causes of CKD/ESRD within and across the country. Few studies from Nepal and India, found CGN to be the commonest cause of CKD.ESRD. 11

CONCLUSIONS
This study has helped us understand the nature and spectrum of kidney diseases prevailing in our region and can help formulate appropriate programmes and plans to tackle the common prevailing problems. However we need a multicentric study to understand the true nature and prevalence of the kidney diseases in the country.