Interventional nephrology and vascular access practice: A perspective from South and Southeast Asia.

South and Southeast Asia is the most populated, heterogeneous part of the world. The Association of Vascular Access and InTerventionAl Renal physicians (AVATAR Foundation), India, gathered trends on epidemiology and Interventional Nephrology (IN) for this region. The countries were divided as upper-middle- and higher-income countries as Group-1 and lower and lower-middle-income countries as Group-2. Forty-three percent and 70% patients in the Group 1 and 2 countries had unplanned hemodialysis (HD) initiation. Among the incident HD patients, the dominant Vascular Access (VA) was non-tunneled central catheter (non-TCC) in 70% of Group 2 and tunneled central catheter (TCC) in 32.5% in Group 1 countries. Arterio-Venous Fistula (AVF) in the incident HD patients was observed in 24.5% and 35% of patients in Group-2 and Group-1, respectively. Eight percent and 68.7% of the prevalent HD patients in Group-2 and Group-1 received HD through an AVF respectively. Nephrologists performing any IN procedure were 90% and 60% in Group-2 and Group 1, respectively. The common procedures performed by nephrologists include renal biopsy (93.3%), peritoneal dialysis (PD) catheter insertion (80%), TCC (66.7%) and non-TCC (100%). Constraints for IN include lack of time (73.3%), lack of back-up (40%), lack of training (73.3%), economic issues (33.3%), medico-legal problems (46.6%), no incentive (20%), other interests (46.6%) and institution not supportive (26%). Routine VA surveillance is performed in 12.5% and 83.3% of Group-2 and Group-1, respectively. To conclude, non-TCC and TCC are the most common vascular access in incident HD patients in Group-2 and Group-1, respectively. Lack of training, back-up support and economic constraints were main constraints for IN growth in Group-2 countries.

Peritoneal dialysis: Status report in South and South East Asia.

BACKGROUND: Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region. METHODS: The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups. RESULTS: Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization. CONCLUSION: Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

Aetiology, practice patterns and burden of end-stage kidney disease in South Asia and South-East Asia: A questionnaire-based survey.

AIM: There is paucity of data on the epidemiology of end-stage kidney disease (ESKD) from South Asia and South-East Asia. The objective of this study was to assess the aetiology, practice patterns and disease burden and growth of ESKD in the region comparing the economies. METHODS: The national nephrology societies of the region; responded to the 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 ESKD. Diabetes, hypertension and chronic glomerulonephritis were most common causes. The mean age in Group 2 was lower by a decade (Group 1 vs. Group 2-59.45 vs 47.7 years). CONCLUSION: Haemodialysis 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 haemodialysis and peritoneal dialysis.

Left ventricular hypertrophy among predialysis chronic kidney disease patients: Sindh institute of urology and transplantation experience.

Left ventricular hypertrophy (LVH) is an independent predictor of mortality and its prevention can decrease cardiovascular mortality among predialysis chronic kidney disease (CKD) patients. This cross-sectional study was conducted at the Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from March 2013 to October 2013 to determine the frequency of LVH and its risk factors in patients with CKD. A total of 135 outpatients with CKD duration longer than three months, were included in this study. All patients underwent laboratory investigations which included serum creatinine, blood counts, serum calcium, phosphate and uric acid, and parathormone. M-mode, two-dimensional echocardiogram in the left decubitus position was performed to document LVH. LVH was labeled when the left ventricular mass index was >131 g/m2 in men and >100 g/m2 in women on echocardiogram. LVH was found in 76 study patients (56.3%). The frequency of LVH was significantly high in patients with stage-4 CKD and those with duration of CKD above 12 months. Other risk factors included low hemoglobin, high serum calcium and phosphate levels, and decreasing estimated glomerular filtration rate. In conclusion, early detection of LVH and control of risk factors may help to achieve a decrease in cardiovascular morbidity and mortality in patients with CKD.

Accuracy of GFR estimation formula in determination of glomerular filtration rate in kidney donors: Comparison with 24 h urine creatinine clearance.

To determine the accuracy of estimated glomerular filtration rate (eGFR) using the modification of diet in renal disease (MDRD), Cockcroft-Gault (CG), and chronic kidney disease epidemiology (CKD-EPI) formulas in potential kidney donors compared with 24-h urine creatinine clearance, we studied 207 potential live kidney donors in our center. There were 126 (60.9%) males and 81 (39.1%) females. Male:female ratio was 1.6:1. The age of the donors ranged from 18-58 years, with mean age of 35.30 ± 9.23 years and most of the individuals were below 40 years of age. The body mass index (BMI) was calculated and venous blood samples were obtained for the measurement of serum creatinine and every study participant was instructed to collect 24-h urine. GFR was calculated based on 24-h urine creatinine clearance and the formulas. The accuracy of GFR estimation formula was taken as positive if the GFR calculated by the formulas and urine creatinine clearance fell between 90-120 mL/min/1.73 m(2). The accuracy of the MDRD formula was 48.8% and the CG formula was 41.5% whereas the accuracy of the CKD-EPI formula was 78.2%. The accuracy of the eGFR using the MDRD formula was significantly higher in males than females (57.9% vs. 33.3% P = 0.001), while there was no statistically significant difference in the eGFR between them in case of the use of the CG and the CKD-EPI formulas. BMI and obesity had no effect on the accuracy of eGFR by the use of the different formulas. The performance of GFR estimation formulas was sub optimal and these either underestimated and/or over-estimated the GFR in healthy subjects. CKD-EPI is closer to 24 -h urinary creatinine clearance in the calculation of eGFR. However, none of the eGFR formulas can be used in renal transplant donors because of their low accuracy, and 24-h urine creatinine clearance should be used for evaluation of the GFR in this population.

Dyslipidaemia among renal transplant recipients: cyclosporine versus tacrolimus.

OBJECTIVES: To compare new onset dyslipidaemia in live-related renal transplant recipients taking cyclosporine versus tacrolimus after 3 months of therapy. METHODS: The randomised controlled trial was conducted at the Sindh Institute of Urology and Transplantation (SIUT) Karachi, from September 2010 to April 2011, and included 182 End Stage Renal Disease patients on maintenance haemodialysis with pre-transplant normal lipid profile. The patients, who had live-related renal transplant, were randomly allocated to two equal groups using lottery. Group A received cyclosporine (3 mg/kg) and group B was treated with tacrolimus (0.1 mg/kg). All patients had pre-transplant fasting lipid profile checked when they were on maintenance haemodialysis and 3 months after renal transplantation. Serum fasting lipid profile was collected by taking 5 ml blood by venipuncture after an overnight fast of 9-12 hours. SPSS 10 was used for statistical analyses. RESULTS: Of the 182 patients, 144 (79.1%) were males and 38 (20.9%) were females. The overall mean age was 30.18 +/- 9.57 years, and the mean weight was 54.41 +/- 11.144 kg. Significant difference was not observed between the two groups regarding age and weight of the patients. Dyslipidaemia was found in 115(63.2%) subjects; 61(67%) in group A and 54 (59.3%) in group B. There was no statistical difference (p=0.28) when comparison was done after 3 months of therapy. CONCLUSIONS: The occurrence of new onset hyperlipidaemia is similar in renal transplant recipients receiving either cyclosporine or tacrolimus in first 3 months post-transplant, but there is room for more research in this field as dyslipidaemia following successful renal transplantation is a frequent and persistent complication.

A kidney transplantation model in a low-resource country: an experience from Pakistan.

Pakistan is a low-resource country with a population of 185 million where expenditure on health is 1.3% of the gross national product. The estimated incidence of end-stage renal disease (ESRD) is 100 per million of the population. The paucity and high costs of renal replacement therapy render more than 90% of the ESRD population disenfranchised from replacement therapy. Our center, which is a government sector organization, established as an integrated dialysis and living related renal transplant program in the 1980s, where all services were provided free of cost to all patients with life-long follow-up care including medications. The model was based on a concept of community/government partnership where the contributions to funds vary between 40% and 60% for each partner. The model has been self sustaining for 25 years, with an annual budget of $28 million in 2010. Presently, over 600 patients are dialyzed each day and each week, 7-10 patients have received live related transplants. The overall 1- and 5-year graft survival rate of 3150 transplants is 92% and 85%, respectively. Free dialysis and transplantation established our institute as a focus of transplantation in the country. This model therefore allowed the institute to have a vital role in the campaign against transplant tourism and in the promulgation of the transplant law. It shows that in low-resource countries, specialized centers in the government sector can, with community support, provide high-quality ESRD care to the disenfranchised population.