Etiology, Practice Patterns and Burden of End-Stage Kidney Disease in South Asia & South-East Asia: A Questionnaire Based Survey

Abstract

Aim

There is paucity of data on the epidemiology of end-stage kidney disease from South Asia and South-East Asia. The objective of this study was to assess the etiology, practice patterns & disease burden and growth of end stage kidney disease in the region comparing the economies.

Methods

The national nephrology societies of the region; responded to questionnaire; based on latest registries, acceptable community-based studies and society perceptions. The countries in the region were classified into Group-1 (High|higher-middle-income) and Group-2 (lower|lowermiddle income). Student –t test, Mann Whitney U test and Fisher’s exact test were used for comparison.

Results

Fifteen countries provided the data. The average incidence of ESKD was estimated at 226.7 per million population (pmp), (Group-1 vs. Group-2, 305.8 vs. 167.8 pmp) and average prevalence at 940.8 pmp (Group-1 vs. Group-2, 1306 vs. 321 pmp). Group-1 countries had a higher incidence and prevalence of end stage kidney disease. Diabetes, Hypertension and chronic glomerulonephritis were most common causes. The mean age in Group-2 was lower by a decade (Group-2 vs. Group-1 - 47.7vs. 59.45years).

Conclusion

Hemodialysis was the most common kidney replacement therapy in both groups and conservative management of ESKD was the second commonest available treatment option within group 2. The disease burden was expected to grow >20% in 50% of group 1 countries and 78% of group-2 countries along with the parallel growth in Hemodialysis & Peritoneal dialysis.

Introduction

The ‘Global Burden of Disease’ study reported chronic kidney disease (CKD) as a major public health problem worldwide, with a global prevalence of 8-10% and was found to be associated with high mortality.^1–2 Besides longer life expectancy, increase in non-communicable diseases such as diabetes mellitus (DM) and hypertension contributed significantly to the development of CKD and thus end-stage kidney disease (ESKD) adding to the financial burden of an individual and the society. The incidence of CKD was estimated to be 30-fold higher than that of ESKD.³

South Asia (SA) represents only 11.71% of the Asian continent geographically, but being densely populated, contains 40% of the Asian population and one-fourth of global population. South East Asia (SEA) covers 10.5% of Asia’s and 3% of global land, has 8.5 % of world’s population; this is third most populous region after SA & East Asia.

The epidemiology of CKD and ESKD in SA&SEA is largely not well understood. In recent years, the etiology of CKD had shifted from infections to non-communicable diseases (NCD) such as DM, hypertension and obesity. Aligned with the global trends, there is a surge in SEA region and management of the NCDs in this region is further worsened by high population density, limited healthcare resources and affordability. In addition, relatively younger patients are progressing to ESKD, which necessitates an aggressive preventive and treatment approach. Unlike the availability of accurate estimates of CKD burden in the developed countries, the lack of precise data has remained a major barrier to develop national healthcare policies and to implement mitigation programs in SA&SEA. The competing needs of improving sanitation, providing clean water and treating communicable diseases has often resulted in allocation of inadequate resources to manage NCDs. Hasan M et al.⁴ reported a high prevalence of CKD in SA, but the epidemiological data was insufficient as most of the studies were from India, Bangladesh, Pakistan and Nepal with conspicuously limited studies from Sri Lanka, and Afghanistan. Further, the data was skewed as majority of the patients included in the studies were from urban areas. The availability of CKD registry was limited in most countries from SA&SEA. In the countries that had a semblance of CKD registry, it was extrapolated either from a single center or regional cohorts’ data and was often incomplete. Hence, this multinational survey-based study was aimed to collect data on the clinical aspects of ESKD in terms of prevalence, common etiologies and patient demographics in this region.

Materials and Methods

Respective nominated representatives from national nephrology societies of SA&SEA countries were approached with a questionnaire designed by the Association of Vascular Access and intervenTionAl Renal physicians (AVATAR, www.AVATAR.net.in) Foundation based in India (Supplementary - appendix 1). The survey was planned to i) understand the extent of ESKD disease burden ii) identify the differences in practice pattern based on socioeconomic status iii) current status of Interventional Nephrology and iv) projected growth of ESKD, renal replacement therapy (RRT) and workforce over next 5-years within the region. A survey consisting of 39 questions was distributed to national nephrology societies of 15 countries and were categorized as Group 1 representing the high /upper-middle-income countries and Group 2 representing the low/lower-middle-income countries, based on the economic status classification by the World Bank. The Group 1 countries included - Singapore, Hong Kong, Taiwan, Malaysia, Thailand and Brunei and Group 2 countries included - India, Pakistan, Bangladesh, Sri Lanka, Indonesia, Nepal, Philippines, Myanmar (Burma), and Vietnam. The survey response from five countries Afghanistan, Bhutan, Cambodia, Maldives, Timor Leste and Laos was unavailable due to inability to reach their nephrology leadership.

The expert panel completing the survey comprised of the president or their designee representing individual national society. The responses were provided based on the data available from limited national disease registries, local or regional studies or an educated guesstimate of the problem. The Presidents or their designee from 15 countries presented the data at the 7th Annual AVATAR Meeting held in Delhi in July 2018. The clarifications and additional inputs were obtained by face-to-face discussions or by electronic communications. The data collected from the survey and discussions was compiled, grouped and analysed. The current manuscript represents – aetiology, practice pattern and ESKD burden in SA&SEA as shown in the schematic below (figure1).

Figure 1. Material & Methods - Schematic Description Of Data Collection.

Statistical Methods

Pooled data was transcribed into Microsoft Excel worksheets after editing for completeness. Continuous variables were presented as mean (±SD) and median (IQR) as appropriate. The comparison between Group 1 and Group 2 was done using student-t test if the variable followed normal distribution, otherwise the comparison was done using Mann Whitney U test. The categorical variables were compared using Fisher’s exact test. The P-value of 0.05 was considered as significant. Data was analyzed using SPSSv23.0.

Results

The data was available from 15 countries in this region.

Incidence and prevalence of ESKD

With a mean and median population of 162.5 and 53.7 million respectively; SA&SEA represented the most populous region; the mean population in Group 2 countries (255.5 million) was almost 11 times than that of Group 1 (23.0 million) (Table 1). There was a huge variation in the population and health expenditure amongst different countries in the region; Sri Lanka (21 million), Nepal (29 million) in Group 2 and Brunei (0.42 million), Singapore (5.8 million) in Group 1 were comparatively less densely populated countries. Taiwan (6.3% GDP) and Brunei (2.6% GDP) had the highest and lowest GDP percentage as health expenditure, respectively, among Group 1 countries. Health expenditure as percentage of GDP was greater in Vietnam (7.07%), Myanmar (5.9%) & Nepal (5.8%) and was least in Pakistan (2.8%) and Indonesia (3%) among group 2 countries (Table 2). The average incidence of ESKD in the region was 226.9 pmp; higher in Group 1 countries (Group 1 vs. Group 2, 305.8 vs. 167.75 pmp, respectively). There was a regional variation in incidence with highest incidence in Taiwan (455 pmp), and lowest in Nepal (100 pmp). Myanmar, which belongs to Group 2 had a higher incidence (250 pmp) compared to Hong Kong (171 pmp) belonging to Group 1. Similar data was not available from Vietnam.

Table 1. ESKD Statistics in SA&SEA Region.

Variables	Overall						Group 1						Group 2
	N	Mean	SD	Median	Min	Max	N	Mean	SD	Median	Min	Max	N	Mean	SD	Median	Min	Max
Total population (Millions)	15	162.5	338.8	53.7	0.43	1352.6	6	23	25.6	15.6	0.43	69.4	9	255.5	419.7	107	21.7	1352.6
GDP as Total National Health Expenditure (%)	15	4.5	1.4	4.2	2.6	7.1	6	4.6	1.3	4.6	2.6	6.3	9	4.5	1.5	4	2.8	7.1
GDP by PPP (Billions USD)	15	26624.9	30094.1	12284	2682	93905	6	55648	28849.8	56922	17871	93905	9	7276.1	3431.8	6775	2682	12811
Estimated Per Capita National Income (USD)	14	16953.4	24986.9	4782.5	292.8	83250	6	35657.6	29470.8	28128.5	5960	83250	8	2925.3	3788.5	1710.2	292.8	11970
ESKD Population (million)
Incidence/million	14	226.9	100.9	190.5	100	455	6	305.8	102.9	286.8	171	455	8	167.75	45	163	100	250
Prevalence/million	12	1053	855.1	940.8	172	3219	5	1778.6	837.1	1306	1268	3219	7	534.8	348.2	321	172	1046.5
Age of ESKD patient:
Male (years)	15	52.9	8.5	51.3	35	65	6	59.3	4.4	60	51.3	64.7	9	48.6	8	48	35	65
Female (years)	15	51.9	8.5	51.3	35	68.2	6	59.6	5.5	60	51.3	68.2	9	46.8	5.9	47	35	55

Group1 – High Income | Higher Middle Income countries, Group2 – Low Income | Lower Middle Income countries, GDP-Gross Domestic Product, PPP – Purchasing Power Parity, ESKD – End Stage Kidney Disease, ESKD – End Stage Kidney Disease, HD- Hemodialysis, PD- Peritoneal Dialys

Table 2. Country Wise Distribution of Demographics and RRT Choices.

Countries	Group As per economic status	World Bank Ranking 1 2017	National population2 (in million)	GDP as Total National Health Expenditure (%)3	Estimated Per Capita National Income (USD) 4	Mean Age (Years)		% Distribution of RRT Options in Prevalent Patients
								PD (%)	HD (%)	Renal Transplant (%)	Conservative Management(%)
						Male	Female
Singapore	Group 1 countries	3	5.639	4.9	56,957	61	61	10.1	71.6	18.3	-
Brunei		4	0.429	2.6	83,250	51.3	51.3	10	86	4	-
Hong Kong		9	7.451	5.5	32,927	59	57	46	15	39	-
Taiwan		15	23.726	6.3	23,330	64.7	68.2	8.8	87.1	4.1	<1
Malaysia		43	31.529	4.21	11,521.45	60	60	9.5	85.7	4.7	-
Thailand		71	69.429	4.1	5,960	60	60	30	60	10	-
Sri Lanka	Group 2 countries	94	21.67	3.5	11,970	48	44.5	7	62	21	10
Indonesia		95	267.663	3	3,605	50	50	3	94	3	-
Philippines		113	106.652	4.5	2989	65	55	3.4	94.1	2.5	-
India		120	1352.617	4	2,134	44.4	42.9	0.5	67.3	5	27.2
Vietnam		124	95.54	7.07	1770.3	50	50	10	40	10	40
Myanmar		127	53.708	5.9	1,299	35	35	2	36	0.8	61.2
Pakistan		132	212.215	2.8	1547.9	45	45	0.5	10	5	84.5
Bangladesh		138	161.356	3.5	1,650	53	52	5	70	5	20
Nepal		156	28.089	5.8	681	47	47	5	95	0	0

Based on the data provided by the National Societies; Group1 – High Income | Higher Middle Income countries, Group2 – Low Income | Lower Middle Income countries, GDP – Gross Domestic Product, HD- Hemodialysis, PD-Peritoneal Dialysis

¹Historical GDP by country/Statistics from the World Bank 1960-2018. Available from https://knoema.com/mhrzolg/historical-gdp-by-country-statistics-from-the-world-bank-1960-2018?country=Hong%20Kong%20SAR%2C%20China

²he Power of Choice. Reproductive rights and demographic transition. UNFPA. The state of World Population 2018. Available from https://www.unfpa.org/sites/default/files/pub-pdf/UNFPA_PUB_2018_EN_SWP.pdf

³World Bank data.Available from https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=SG-LK-BN-HK-PH-IN-ID-MY-MM-NP-VN-TH-PK-BD

⁴World development indicators. https://databank.worldbank.org/reports.aspx?source=2&type=metadata&series=NY.GDP.PCAP.CD.

The median disease prevalence in this region was 940.8 pmp (Group 1 vs. Group 2, 1306 vs. 321 pmp, respectively). The data on prevalence was unavailable from three countries including Singapore from Group 1 and Myanmar & Pakistan from group 2. Sri Lanka had a highest disease prevalence amongst Group 2 (1046.5 pmp) countries, which is lower than the lowest reported from Group 1 countries (Hong Kong, 1268 pmp) (Table 1&3).

Table 3. Country-Wise Economic Status, ESKD Incidence, Prevalence and Top 3 Etiologies in the Countries.

Countries	Group As per economic status	ESKD incidence/million	ESKD prevalence/million	Expected Growth Of ESKD Population in next 5 years (%)	Expected Growth Of HD units in next 5 years (%)	Expected Growth Of PD in next 5 years (%)	1st commonest aetiology of CKD	2nd commonest aetiology of CKD	3rd commonest aetiology of CKD
Singapore	GROUP 1 countries	256.5	DNA	> 20 %	> 20 %	10 -20%	Diabetes Mellitus	Glomerulonephritis	Hypertension
Brunei		387	1814	> 20 %	> 20 %	> 20 %	Diabetes Mellitus	Glomerulonephritis	Hypertension
Hong Kong		171	1268	10-20%	10 -20%	10 - 20%	Diabetes Mellitus	Glomerulonephritis	Hypertension
Taiwan		455	3219	< 10 %	< 10 %	< 10 %	Diabetes Mellitus	Glomerulonephritis	Hypertension
Malaysia		248	1286	> 20 %	10- 20%	> 20 %	Diabetes Mellitus	Hypertension	Unknown
Thailand		317	1306	10 -20%	10 - 20%	10 -20%	Diabetes Mellitus	Hypertension	Glomerulonephritis
Sri Lanka	GROUP 2 countries	195	1046.5	> 20 %	> 20 %	10 - 20%	Diabetes Mellitus	Hypertension	Unknown
Indonesia		135	319	< 10 %	NA	NA	Diabetes Mellitus	Hypertension	Glomerulonephritis
Philippines		186	321	10 -20%	< 10 %	< 10 %	Diabetes Mellitus	Hypertension	Glomerulonephritis
India		151	800	10 -20%	> 20 %	10 -20%	Diabetes Mellitus	Unknown	Glomerulonephritis
Vietnam		DNA	835	10 - 20%	< 10 %	< 10 %	Glomerulonephritis	Diabetes Mellitus	Urological disorders
Myanmar		250	DNA	10 -20%	10 - 20%	< 10 %	Diabetes Mellitus	Hypertension	Glomerulonephritis
Pakistan		150	DNA	10 - 20%	< 10 %	No Growth	Diabetes Mellitus	Hypertension	Glomerulonephritis
Bangladesh		175	250	< 10 %	10 -20%	10 - 20%	Diabetes Mellitus	Hypertension	Glomerulonephritis
Nepal		100	172	> 20 %	> 20 %	> 20 %	Diabetes Mellitus	Glomerulonephritis	Unknown

Based on the data provided by the National Societies

Group1 – High Income | Higher Middle Income countries, Group2 – Low Income | Lower Middle Income countries; DNA- Data Not Available, ESKD – End Stage Kidney Disease, HD- Hemodialysis, PD- Peritoneal Dialysis, CKD– Chronic Kidney Disease

Etiology

DM was the predominant etiology for ESKD followed by hypertension, Chronic Glomerulonephritis (CGN), unknown etiology and other urological diseases (Table 4).

Table 4. First Three Commonest Etiologies of ESKD in SA&SEA (Based on data from table 3).

Variables	Overall N=15 (%)	Economic Type
		Group 1	Group 2
		N (%)	N (%)
1st Commonest Etiology
Diabetes Mellitus	14 (93.3)	6 (100.0)	8 (88.9)
Glomerulonephritis	1 (6.7)	0 (0.0)	1 (11.1)
2nd Commonest Etiology
Diabetes Mellitus	1(6.7)	0 (0.0)	1 (11.1)
Glomerulonephritis	5 (33.3)	4 (66.7)	1 (11.1)
Hypertension	8 (53.3)	2 (33.3)	6 (66.7)
Unknown Etiologies	1 (6.7)	0 (0.0)	1 (11.1)
3rd Commonest Etiologies
Glomerulonephritis	7 (46.7)	1 (16.7)	6 (66.7)
Hypertension	4 (26.7)	4 (66.7)	0 (0.0)
Unknown Etiologies	3 (20.0)	1 (16.7)	2 (22.2)
Urological Diseases	1 (6.3)	0 (0.0)	1 (11.1)

Group1 – High Income | Higher Middle Income countries, Group2 – Low Income | Lower Middle Income countries N=number to total countries participated

Age

The ESKD population was younger by a decade in Group 2 countries compared to Group 1 (47.7± 6.95-years vs. 59.45±4.95-years, respectively; mean age 52.4±8.5 years). Philippines and Taiwan had reported the highest mean age for male and female prevalent ESKD patients i.e. 65 years and 68.2 years respectively, while Myanmar had the lowest mean age of ESKD in both genders i.e. 35years (Table 1 & 2).

Modality of Treatment

HD (64.9±28.1%) was the predominant treatment in entire SA & SEA countries than PD (10.1 ± 12.2 %) & Kidney Transplant (9.2±10 %). Utilization of PD in Hong Kong (46%) and Thailand (30%) is high since PD first policy is practiced here. None opted for conservative treatment in Group 1, except Taiwan (<1%) whereas 27±29.9% of ESKD patients opted for conservative treatment in Group 2.

Growth of ESKD population

The ESKD growth projection for next 5-years was calculated on the basis of estimates provided by respective nephrology societies. Three out of 6 countries in group 1 expected a growth of >20% in next 5-years. Taiwan expected the lowest growth (<10%) whereas it was between 10 and 20% in Thailand & Hong Kong. In Group 2, 78% (7/9) countries expected a growth of ≥20% in the ESKD population over next five years, wherein only for two countries i.e. Bangladesh & Indonesia this growth rate was <10 % (Table 3).

All countries in Group 1 (except Taiwan) foresee a growth of CAPD in the coming years, between 10% to > 20 %. Among Group 2 countries, the growth of CAPD was expected to parallel the growth of HD. A parallel progress in HD units and CAPD penetrance were expected to meet the demands of the disease burden. However, the CAPD penetration in Pakistan was reported extremely low and less likely to grow in near future (Table 3).

Discussion

SA&SEA represent heavily populated regions, located geographically close together but they differ significantly in cultural practices and economic status, Group 1 countries being economically better.

ESKD Incidence and Prevalence

In the year 2011 there were approximately two million ESKD patients were treated with renal replacement therapy worldwide. There is a huge difference in the incidence and prevalence of ESKD not only between Group 1 and Group 2 but also among the countries within each group. Major determinants such as Universal Health Coverage, efficient screening & detection of CKD in Group 1 countries contribute towards high and accurate disease burden assessment and resource allocation. On the other hand, factors such as lack of healthcare policies and health insurance leading to poor access to health care, lack of registry data along with popularity of alternative therapies and religious dogmas are likely responsible for the apparent low incidence and prevalence of CKD and ESKD in group 2.

The incidence and prevalence of ESKD in the United States of America (USA) was reported to be 400-500 pmp and 2700-3500 pmp, respectively, which is higher than that reported in Group 1.⁵ (Table 1). Though the disease burden in SA&SEA was comparatively lower than the developed countries like USA, projected growth over the next five years was high, cautioning the stakeholders to be prepared to face the challenge.

The decreased morbidity and mortality of the incident patients possibly had resulted in 3-fold higher prevalence of ESKD in Group 1 countries (1778.6 pmp in Group 1 vs. 621.6 pmp in Group 2). In addition, there was under-reporting of data of prevalent ESKD patients from Group 2 countries (India, Philippines, and Indonesia) due to high mortality, busy physician workforce and absence of national registries.

Etiology

Similar to the global trend, DM had remained the leading cause of kidney disease in SA&SEA region. Contrary to the popular belief, where glomerulonephritis (GN) was thought to be synonymous with underdevelopment; our study data showed GN as the second important cause of CKD in the Group 1 countries, whereas Group 2 countries reported hypertension as the second common etiology, with GN receding to the 3^rd position reflecting increasing prevalence of hypertension and lifestyle diseases in the latter. Inaccurate reporting of GN as hypertension in Group 2 countries due to late presentation was another reason for hypertension being the 2^nd leading cause. Data from Indian CKD registry with database of 52,273 patients reported DM, CKD of undetermined etiology and GN as three most common etiologies causing ESKD.⁶ In the past, DM was thought to be a disease of the affluent population and hence diabetic kidney disease (DKD) was common in the western world, while GN presumably due to infection and interstitial disease due to drugs or environmental toxins was thought to be the harbinger of CKD in the economically deprived regions. ⁶ Our study and recent data showed that DKD was a major cause of ESKD even in Group 2 countries. Improvement in access to health care and management of communicable disease with a parallel increase in sedentary life style and obesity have led to increase in incidence and prevalence of diabetic kidney disease. The high prevalence of maternal and intrauterine fetal malnutrition may also be contributing to the low birth weight causing DM and metabolic syndrome later in adulthood leading to CKD.

Pakistan registry reported DM (35.80%), hypertension (39.78%), GN (13.40%), calculus disease (3.22%) and autosomal dominant polycystic kidney disease (4.09%) as major diseases contributing to CKD.⁷DM (33.5%) and hypertension (16.5%) were reported as major contributors to CKD in Bangladesh.⁸ Indonesian National Health Survey 2013 reported hypertension (37%) and diabetes mellitus (27%) as main primary causative diseases for CKD.⁹

The published literature from Group 1 countries supported our study findings with DM and GN as two most common etiologies. Table 5 summarizes the etiologies for ESKD in this region reported by various studies.

Table 5. Etiology of ESKD in The Countries of SA&SEA.

Country	Diabetes Mellitus	Hypertension	Chronic glomerulonephritis	Obstructive Uropathy	Interstitial nephritis
Singapore 10	56%	6%	29%		-
Brunei 11	57.1%	24.1%	9.8%	-	-
Hong Kong 12 –13	49.6%	-	-	-	-
Taiwan 14	43.2%	8.3%	25.1%	-	2.8%
Malaysia 15	44.9%	24.2%	-	9.2 %	-
Sri Lanka16	44%	17%	12%	5.5%	-
Indonesia 17	28%	36%	10%	3%	-
Phillipines registry*	38%	20%	26%
India 6	31.3%	12.9%	13.8%	3.4%	7%
Vietnam	-	-	-	-	-
Myanmar 18	15%	55%	12%
Pakistan 19	33%	12%	33%	7%
Bangladesh 20	65.4 %	49.5%	6.54%	-	15%
Nepal 21	31.9%	21.7%	36.2%	5.7%	0.7%

^*Data from Phillipines registry developed along with Renal disease control project (REDCOP).

All references are at the end of manuscript

In Group 1 countries, relative increase in GN could be multifactorial, it could be related to obesity (due to focal segmental glomerulosclerosis), methicillin-resistant Staphylococcus aureus related and due to increase in biopsy/screening trends (IgA Nephropathy).

More recently, CKD of undetermined origin (CKDu) had emerged as separate entity, contributing significantly in some of the low- and middle-income countries, including El Salvador, Nicaragua, Egypt, Sri Lanka and India for the development of ESKD. Few reports were available from the North Central province of Sri Lanka and Udhanam of Srikakulam district in India. ²²

In addition, in the geographical region of stone belt covering large part of Pakistan, India and Thailand, obstructive uropathy was a significant contributor to the development of CKD.²² Indigenous medicines, descripted heat stress nephropathy, unexplored genetic causes, late diagnosed reflux nephropathy and high prevalence of post-partum renal failure were other significant contributors of CKD in Group 2 countries, which also faced a double jeopardy because of new emerging DKD over and above the inherent conventional etiologies. This changing disease profile would need a revision of strategic policies to cater to the increasing burden of ESKD.

Comparing the SA&SEA countries with the developed countries, it was seen that in the USA, the causes of ESKD were DM (38%) followed by hypertension (26%), glomerular disease (15%), and others (15%) as per the data available from the United States Renal Data System (USRDS). The causes of ESKD in the West were similar to the top three etiologies in Group 1 in the SA&SEA region.

Age

Our observation of younger population of ESKD by more than a decade in Group 2 countries was reported from the region by other studies as well.²³A study from South India (2018) showed that only 14.8% patients on dialysis were aged >60 yrs.²⁴Data from the Pakistan registry in 2014, revealed that the mean age group of 50% dialysis population was 51-70 years.⁷ The commonest age range of patients on dialysis in Pakistan was between 46- 60 years (48%).²⁵ The mean age of HD patients in Pakistan, in different studies was reported as 46 years, ²⁶ highest 58 years, ²⁷and lowest 33.5 years.²⁸The mean age of patients on HD in Bangladesh was 40±15 years.²⁹In Nepal, mean age of CKD patients was 46.7±16.7 years and 70% of ESKD were between 20-60 years age.³⁰

Available data from Group 1 countries indicates that the age of the patients initiating RRT and prevalent dialysis patients was higher. Relatively lesser transplantation rate coupled with low mortality contributed to this high prevalence.¹⁴According to the Singapore renal registry, the mean age of new CKD patients increased from 56.3 years in 1999 to about 64 years, 2009 onwards. ¹³According to the data from Brunei registry, the mean age of dialysis patients was 57±12.5 years and 45% of the patients were aged between 41 and 60 years.¹¹In Group 2 countries, the younger age of ESKD population could be attributed to the factors highlighted previously in addition to high prevalence of post-infectious CKD, obstetric CKD and CKDu.

A study from the United States of America reported that approximately 48% patients of ESKD starting dialysis were older than 65 years. This was similar to group 1 countries in SA&SEA region where ESKD occurs at a later age. Thus, more affluent populations had ESKD occurring at an older age due to more life style diseases i.e. DM, hypertension and relatively prolonged life span.

RRT Options in SA & SEA Region

There exists a wide variation in the treatment chosen by the patients. HD was the preferred treatment in Group 1 countries, with none opting for conservative treatment, except Taiwan, where conservative treatment was opted for by <1%. CAPD and renal transplant were the next preferred treatments. Similarly HD was preferred modality in Group 2 countries, however, a third of ESKD population opted for conservative treatment; CAPD and transplant were also opted for by less than 10% of ESKD patient population. HD remains the predominant mode of RRT in SA & SEA except in countries where PD first policy is mandatory (Thailand and Hong Kong). The difference in the treatment modality could be due to out-of-pocket expenses resulting in financial burden on the individual and family, limited resources, poor healthcare literacy, advanced disease stage at the time of presentation and some strange religious beliefs. Also, the choice of treatment modality is governed by the national policy, PD being the preferred treatment where it was mandated by national policy. As healthcare was provided under universal healthcare policy in majority of Group 1 countries; the rate of renal transplant was much higher as compared to Group 2. Interestingly, Sri Lanka in Group 2 had higher rate of renal transplantation than Singapore, a Group 1 country. Pakistan had a low rate of CAPD (0.5%), HD (10%), and renal transplant (5%) and 84.5% were managed conservatively either by choice or compulsion. In Nepal, HD was the preferred treatment as the expenses were borne by the government and no one opted for conservative treatment.

Growth of ESKD and RRT

Globally, there was an increasing trend in the disease burden, and the same is expected from this region as reflected in our projections. Group 1 countries have a well-established protocol for diagnosis and management, hence, growth of ESKD population along with growth of RRT facilities is expected. Aging population in Group 2 countries and occurrence of lifestyle diseases at a much younger age contribute to growth of ESKD population in these countries as well and necessitates introduction of robust interventions including early screening. There is a need for a shift in the focus from treatment to preventive strategies to curb the increasing incidence of ESKD. Stabilization of ESKD population, as reported in few developed countries has yet to happen in this region. Increasing ESKD patients at an alarming rate of >20% is a potential catastrophe for the health sector of this region.

Future epidemiological studies in large, diverse populations including paediatric, elderly and women in different reproductive age groups are needed. Collaborative approach among the nephrology associations and policy makers of Group 2 region is the need of the hour to handle the growing burden with effective policies.

Conclusion

DM was the most common etiology followed by hypertension in both the groups replacing the previously prevalent infection related glomerulonephritis, which indicated a shift from infectious cause to lifestyle related non-communicable diseases.

HD remained the most preferred treatment in both the groups, followed by non-dialysis medical treatment in group 2. A younger patient pool, increasing ESKD incidence and prevalence demands for a more aggressive treatment strategy. The burden of CKDu, CKD due to infections, toxin-mediated diseases in economically poor countries of SA&SEA added to the growth of ESKD population and merits special attention. Though facilities for management of ESKD have increased but the increase is disproportionate to the ESKD growth, thus need of hour is greater focus on prevention of ESKD to curb increasing incidence of ESKD in SA&SEA.

We emphasize on large collaborative epidemiological studies for better management strategies. One strange fact that this study highlighted was practice of conservative treatment in group 2, which varied from 0% in Nepal where state bore the cost of ESKD treatment, to 84.5% in Pakistan that had lowest healthcare GDP. Other group 2 countries too registered high numbers under conservative treatment like Myanmar (61.2%), VietNam (40.5%), India (27.2%), Bangladesh (20%) and Sri Lanka (10%). It seemed this was not an option by choice but a compulsion for subjects living in these countries; thus respective stakeholders need to strategize to minimise conservative treatment option which is different from voluntary palliative treatment.