CKD cases data collection and statistics

2. Done by CRRIs – SINDHUJA S , SOMESH B L , SREEDEVI
ARAVINDAN , SRIRAMKUMAR S , SUBITSA S , DHINESH S
Under the guidance of DR. GRACY PAULIN , Assistant
Professor , Department of Community Medicine

3. ABSTRACT
• BACKGROUND: The clinical course of chronic kidney disease( CKD ) is typically a progressive loss
of nephron function, ultimately leading to unemployment and end stage renal
disease(ESRD) requiring some form of renal replacement therapy. As this puts a
significant burden on patients family as well as national resources , planning for
prevention of CKD by early identification of kidney damage by identifying and
screening high risk individuals is the most practical solution.
• AIM: To study the clinical and socioepidemiological profile of chronic kidney disease
patients in a tertiary care hospital, Thoothukudi and to establish the relationship
between the risk factors and CKD.
• METHODS: This study was conducted in 50 patients admitted in nephrology and
general medicine wards between Feb 20 - March 20, 2019 at the government
Thoothukudi medical college hospital using questionnaire and patients medical
records
• RESULTS: Of the total 50 patients included in the study , 35 (70% ) were males and 15
(30%) were females . Majority of the patients(48%) were between age group 41-60. 33
patients (66%) were from rural area and 78% belong to lower middle class. 40%, 16%,
36% belong to CKD stage 3,4,5 respectively . Most common presenting complaints
were symptoms of fluid overload and cardiovascular disturbance such as pedal edema
(38%),breathlessness (28%),generalised edema (10%),oliguria (14%). In our study,
hypertension is the etiological factor (66%),diabetes (22%),intake of excess salt
containing food (32%),over usage of analgesics (22%) and family history (4%)
,smoking (36%)the statistical correlation between anaemia(76%) and stage of CKD
was discussed in this study
• . CONCLUSION: Over prescription and usage of over the counter analgesics should
be considered as a serious issue.CKD screening should be included in NPCDCS
programme in NCD clinic at all health care levels. More dialysis units should be
launched.
• KEYWORDS: CHRONIC KIDNEY DISEASE ( CKD), END STAGE RENAL DISEASE (ESRD),CLINICAL
AND EPIDEMIOLOGICAL PROFILE,ETIOLOGY OF CKD,RISK FACTORS OF CKD.

4. • Chronic kidney disease is defined as abnormal kidney structure or
function present for more than 3 months with implications for
health. Kidney damage refers to a broad range of abnormalities
observed during clinical assessment which may be insensitive and
non specific for cause of disease but may precede reduction in
kidney function.
• The clinical courses typically the progressive loss of nephron function
ultimately leading to end stage renal disease characterised by
hypertension,anaemia,renal bone disease, nutritional impairment
,impaired quality of life, reduced life expectancy, ultimately leading
to some form of renal replacement therapy. This puts a substantial
burden on global health resources as all modalities of treatment are
expensive.[1]
• According to the study done in 2017, Tamil Nadu has 2024
hemodialysis machines compared to 1,25,307 patients in Tamil Nadu
with end stage renal disease, we are lacking the machines by 4,214
machines and the projected shortfall is around 68%.[3].

5. STAGE DEFINITION DESCRIPTION CLINICAL C/O
1 Kidney damage with
normal GFR
MILD CKD Asymptomatic
2 GFR 60-89 Asymptomatic
3A GFR 45-59 MODERATE CKD Asymptomatic
3B GFR 30-44 ANEMIA in some
patients.Non
progressive/slow
progressing
4 GFR 15-29 SEVERE CKD First symptom at
GFR<20. Electrolyte
problems likely as GFR
falls
5 GFR <15 /on dialysis Kidney failure Significant symptoms
and complications
usually present.

6. • It is established that in India diabetes and hypertension
are responsible for more than 40 to 60% CKD and
various primary ,secondary and tertiary preventive
measures for prevention of ckd is prescribed.[1].
• The lack of community based screening programmes
and failure to ensure optimal control of hypertension
and diabetes mellitus has lead to patients being
detected with CKD at an advanced stage that should
be reversed.
• Hence planning for prevention of ckd based on
screening and identification of population at risk is the
only practical solution possible for India.
• The study was taken up to highlight the
epidemiological characteristics ,clinical presentation
,aetiology ,complications and outcome of patients who
presented with ckd in a government tertiary care
hospital.

7. • AIMS AND OBJECTIVES:
1. To study the clinical and epidemiological
profile of ckd patients in tertiary care
hospital in Thoothukudi,Tamil Nadu.
2. To determine the relation of possible
associated risk factors of CKD
(hypertension, diabetes mellitus , over the
counter drugs ,excessive intake of salt
containing food items).

8. MATERIALS AND METHODOLOGY
• STUDY SETTING : Department Of Nephrology
And Department Of General Medicine,
GTKMCH
• STUDY DESIGN : Descriptive study
• STUDY POPULATION : Patients with CKD
admitted in Nephrology and General Medicine
wards
• SAMPLE SIZE : we had enrolled all the patients
admitted in the nephrology and general
medicine wards during the study period
• STUDY PERIOD : Feb 20,2019 to March 20, 2019

9. • STUDY TOOL : Questionnaire and Patient’s medical records.
Blood pressure was measured using a manual mercury
sphygmomanometer twice 20 mins apart.Questionnaire was
prepared in view of obtaining details in sociodemographic
,clinical , etiological, complication profiles. Informed consent
was obtained from all the patients who are participated in this
study.
• SAMPLING TECHNIQUE : Convenient sampling
• DATA ANALYSIS: Datas collected were entered in MS Excel
and analysis done.
• INCLUSION CRITERIA : The chronic kidney disease patients
admitted in nephrology and general medicine wards
• EXCLUSION CRITERIA: Patients with uraemic encephalopathy
,pregnant women with CKD, patients who are not willing for
the study

10. • 54 patients were admitted in our study
period . Among them, 2 were pregnant
and 1 was terminally ill and one another
was not willing for the study. So, we had
collected and analysed data from 50
patients

11. 70% MALE
(35)
30% FEMALE
(15)
MALE
FEMALE
n=50

12. 8%
(4)
22%(11)
52%
(26)
18%
(9)
0%
10%
20%
30%
40%
50%
60%
<20 21-40 41-60 61-80
FIG 1.2 : AGE WISE DISTRIBUTION CKD
n=50

13. FIG 1.3 EMPLOYMENT STATUS
OF CKD PATIENTS
8%
(4)
92%
UNEMPLO
YED(46)
EMPLOYED
UNEMPLOYED
FIG 1.4 PERIOD OF
UNEMPLOYMENT
32%
(15)
68%
(31)
LESS THAN
1 YEAR
MORE
THAN 1
YEAR

14. 2%
18%
(9)MIDDLE CLASS
78%LOWER MIDDLE
CLASS(39)
2%
UPPER
UPPER MIDDLE
MIDDLE
LOWER MIDDLE
LOWER

15. 66%
RURAL(33)
34%URBAN(17)
RURAL
URBAN

16. 0%
8%
40%
16%
36%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
stage 1 stage 2 stage 3 stage 4 stage 5
n=50

17. 38% PEDAL EDEMA
28%
BREATHLESSNESS
10%
14%
10%
PEDAL EDEMA
BREATHLESSNESS
GENERALISED EDEMA
OLIGURIA
OTHERS

18. 4%
22%
11%
32%
0%
10%
20%
30%
40%
50%
60%
70%
FAMILY HISTORY DIABETES MELLITUS HYPERTENSION OVER THE COUNTER
DRUGS
INTAKE OF EXCESS
SALT CONTENT
66%

19. STAGE 1 STAGE 2 STAGE 3 STAGE 4 STAGE 5
DM - 1(25%) 4(20%) 3(37%) 3(16%)
HT - 2(50%) 11(55%) 5(62%) 15(83%)
BOTH - 0 1(5%) 2(25%) 2(11%)
83% of ckd patients had history of hypertension

20. 0
25%
20%
37%
16%
0
50%
55%
62%
83%
0 0
5%
25%
11%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
stage 1 stage 2 stage 3 stage 4 stage 5
diabetes
hypertension
both

21. TABLE 3.2PERCENTAGE OF PATIENTS WITH
UNCONTROLLED DIABETES AND HYPERTENSION
• These patients are found to be in advanced
stages of CKD.
• Among these 7 patients with uncontrolled hypertension,
4 were found to be at stage I hypertension( systole 140-
159 mm/hg & diastole 90-99 mm/hg) and 3 were at
stage II ( systole 160 -179 & diastole 100-109).
DISEASE NO.OF PATIENTS NOT UNDER
CONTROL WITH TREATMENT
PERCENTAGE
DIABETES MELLITUS 2 18%
HYPERTENSION 7 21%

22. TREATMENT PROFILE:
FIG 4.1 PERCENTAGE OF CKD PATIENTS UNDER
MEDICAL AND RENAL REPLACEMENT THERAPY:
42% RENAL
REPLACEMENT
THERAPY(21)
58%ONLY
MEDICAL
MANAGEMENT
(29)

23. 80%
(17)
5%
(1)
15%
(3)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
HEMODIALYSIS PERITONEAL DIALYSIS BOTH

24. 76%
(38)
18%(9)
22%
(11)
4%
(2)
14%
0%
10%
20%
30%
40%
50%
60%
70%
80%
ANAEMIA CARDIOVASCULAR
COMPLICATIONS
URAEMIC GASTRITIS HEPATITS B,HCV NO COMPLICATIONS
.
COMPLICATION PROFILE:
FIG 5.1 PERCENTAGE OF CKD PATIENTS WITH VARIOUS COMPLICATIONS:

25. In our study we found that majority of patients
presented with complications such as anaemia,
cardiovascular complications,uraemic gastritis
HEP B, HCV accounting for 76%,18%,22% and 4%
respectively.
Among them 36% of ckd patients had more than
one complications and they were found to be in
advanced stages of ckd which makes them
difficult for management. 14% of patients had no
complications and they belonged to earlier
stages which accounts for it

26. Complications Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Nil _ 2(50%) 1(5%) 3(38%) 2(11%)
Single _ 2(50%) 11(55%) 4(50%) 7(39%)
multiple _ _ 8(40%) 1(12%) 9(50%)
Stages No. of patients No. of patients
with anaemia
Percentage
Stage 2 4 1 25%
Stage 3 20 17 85%
Stage 4 8 5 62%
Stage 5 18 17 94%
TABLE 5.2 SHOWING PATIENTS WITH ANAEMIA ACCORDING TO
SEVERITY OF CKD

27. • Majority of patients in stage 3 and 5 were
found to be anaemic.
25%
85%
62%
94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
STAGE 2 STAGE 3 STAGE 4 STAGE 5

29. SOCIODEMOGRAPHIC PROFILE
Male gender has been recognised as an
important factor in the development of CKD.In our study
70% were males which was concordant with CKD
registry of India Report where males constituted 68% of
the total CKD patients and CMC Vellore study where 62%
were males probably reflects the faster decline in GFR in
males as compared to females due to hormonal
influence because estrogens may attenuate ckd
progression by lowering the cardiovascular stress
response to adrenergic stimuli.
The prevalence of ckd increases with age
because of the documented age related decline in GFR.
In our study majority of patients were in the age group
of 41 to 60 years which was concordant with the CKD
registry of INDIA REPORT was 48.3 +_ 16.6 years and
CMC Vellore study was 38.2+_14.4 years.

30. A large majority of patients in our study
belongs to lower middle class according to
MODIFIED BG PRASAD’S socioeconomic
classification with the family income of less than
1971.
As said earlier among 50 patients, 92 % of ckd
patients are unemployed and among that 68% are
unemployed for more than 1 year which accounts
for the economic burden and decreased quality of
lifestyle for the patient and the family.
In our study prevalence of CKD is common
among rural areas due to lack of awareness
among people especially in
OTTAPIDARAM,PUDHUKOTTAI&THIRUCHENDUR.

31. CLINICAL PROFILE
Most of patients (90%) diagnosed to have CKD in
advanced stages of 3, 4 & 5 in which preparations for
transplantation and dialysis are required. Late referral of patients
with renal failure to nephrologists compromises the preparation for
dialysis and subsequent survival of those patients. Even patients
unsuitable for dialysis will benefit from the management of their
anaemia and bone disease.
Uremia leads to disturbance in the function of
virtually every organ system . Various clinical features and symptoms
of fluid and electrolyte disturbance, haematological disturbance,
cardiovascular & gastrointestinal disturbance were considered for
our study.

32. • Out of 50 patients, 90%of patients were
presented with fluid overload symptoms and
cardiovascular symptoms such as pedal
edema , breathlessness, oliguria, generalised
edema& ascites. others presented with
gastrointestinal symptoms like loose stools &
vomiting . hence patients presenting with
above said cardiovascular symptom for the
first time should be screened for CKD.

33. ETIOLOGICAL PROFILE
In our study ,relationship between various
etiological factors studied which showed that life
style diseases such as hypertension(66%) and
diabetes(22%) tops among the causes of ckd.
Over the counter drugs accounts for 11%
and intake of excess salt containing food accounts
for 32 % of ckd.
Meticulous control of blood glucose has
been shown to reduce the development of CKD by
35% among the diabetic patients. In our study,
18 % of diabetic patients were not under glycemic
control as per the FBS,PPBS values.

34. The CKD registry of india report 73% had hypertension. Hypertension
is the most common cause of ESRD and also the commonest
complication.[1] Angiotensin converting enzyme inhibitors and non
dihydropyridine calcium channel blockers are effective in slowing
progression of renal insufficiency. In our study 21% hypertensive
patients were not under control . Majority of them were in advanced
stages
At the time of examination about 79% of hypertensive
patients under regular treatment were found to have normal blood
pressure of range (systolic <140 & diastolic <90mm/hg).21% of
hypertensive patients were with uncontrolled hypertension( stage 1
& 2). When kidney disease progresses CKD patients become
hypertensive, also have acquired combined hyperlipidemia
&hyperhomocystinemia ,increased oxidative stress , decreased
physical activity & psychosocial stress. If patient chose to smoke
additive risk is profound.

35. 36% of patients are smokers which shows the strong association
between smoking and CKD. Among males,51% of them have the habit of
smoking. Among smokers 55% have 5 pack years.(no.of pack years=no.of
packs of cigarette smoked per day* no .of years of smoking).[6]
About 22% patients had history of over consumption of analgesics like
NSAIDS .Inhibition of renal prostaglandins which reduces renal plasma flow
by inhibiting vasodilatation.
32% of patients had history of increased consumption of excessive salt
containing food like dry salted fish,pappad,pickles etc which alters the
sodium balance which causes the kidneys to have reduced function and
remove less water resulting in high blood pressure. Among these patients
36% of them had hypertension which shows the strong relationship.
10% of the patients had history of both diabetes and hypertension.
Above discussed etiologicals factors are all modifiable which shows that CKD
is a preventable disease.
Dyslipidemia ,hyperuricemia,obesity are the modifiable risk factors of
CKD which are not included in our study due to lack of laboratory facilities
and in the view of not disturbing the patients.
Only 4% of patients had family history of CKD which shows a genetic
predisposition for the development of the disease.

36. COMPLICATIONS
76% of patients developed anaemia as a
complication of CKD. 50% of them had haemoglobin
concentration less than 7gm/dl. Among them 45% of
patients were in stage 3 and 45% were in stage 5 of
CKD which is in accordance with the CKD registry of
India report. anaemia is due to decreased production of
erythropoietin by the failing kidney. Anaemia is an
independent predictor og mortality and associated with
increased morbidity in CKD. Crrection of anaemia
improves the quality of life,reduces the frequency of
heart failure and hospitalization among patients
receiving dialysis.
12% of patients developed cardiovascular
disease such as cardiac failure,CAD,left ventricular
hypertrophy. In our study 3 patients already suffered
from coronary artery disease and were under regular
treatment before developing CKD. This is a preventable
and potentially treatable co morbidity of CKD.

37. 23% of anaemic patients found to have cardiovascular
complication also. All the patients with cardiovascular complication
found to be anaemic which makes their management difficult.
22% of patients developed gastritis as a complication of CKD
. This is due to the increased serum urea level which causes
gastrooesophageal dysmotility and mucosal lesions causing
unpleasant symptoms.
4% of patients developed hepatitis B and HCV infection as a
result of transmission of viruses during repeated blood transfusions
and dialysis.In another study the prevalence of chronic hep c
determined by anti hcv testing ranges from 6 %-38% [14].
We did not come across other rare complications of CKD such as
uremic dermatitis,renal osteodystrophy in our study period. We
came across a patient with uremic encephalopathy but as the
patient was terminally ill he was excluded from the study.

38. TREATMENT PROFILE
58%patients were managed conservatively by
advising salt and fluid restriction and medically and
42% patients was under renal replacement therapy. In
CKD registry study,76% were managed conservatively.
As said earlier ,in our study , 92% of patients belong to
ckd stage 3 or more who needs renal replacement
therapy. But the data shows that only 42% of the
patients actually get renal replacement therapy.
Hemodialysis is adequate only when it is done
for 4 hrs 3 times per week[6].For PD ,4 exchanges per
day is required each taking 30-60 mins.[6]. But in
government set up frequency for dialysis is less
comparatively.
In India there is a shortage of nephrologist as
well as hemodialysis units and the cost of treatment
makes it unaccessible for the most. The centre where
this study was conducted has no live kidney donor
transplant programme .

39. • The study period was 1 month which is not
sufficient for the study of progression of CKD.
• Many factors like
obesity,hyperlipidemia,hyperuricemia, serum
phosphate level could not be included in the
study.
• The study population was only 50 which is
not an accurate representation of all ckd
patients.
• Out patients with CKD were not included in
the study .

40.  Primordial prevention of ckd can be done by preventing risk factors like diabetes and
hypertension , creating awareness programme regarding over the counter usage of
drugs and its ill effects.
 Primary prevention of ckd by screening of renal functional tests for all diabetes and
hypertensive patients under NPCDCS programme at all ncd clinics.
 Secondary prevention by conducting CMES for health care professionals to diagnose
and to refer the ckd patients to the nephrologists at the earliest.
 Tertiary prevention-Like RNTCP, schemes for providing funds for financial support of
patients family.
 To provide counselling for all ckd patients and their families to overcome depression and
for regular treatment and followup.
 Government should create more dialysis units and kidney donor transplant programmes
to improve the quality of life of ckd patients at advanced stages at free of cost without
any insurance scheme restrictions.
 We recommend that further research in ckd patients to establish the iatrogenic cause of
hep b hcv in dialysis patients.
 More Nephrologists can be recruited in our hospital.
 As ther are few limitations of e GFR better staging methods for ckd could be
discovered.
Further studies can be done to prove whether early initiation of rrt improves outcome.

41. CONCLUSION
To execute a change in the management of patients
with CKD, medical students, health care professionals and
physicians need to be educated about the prevalence and
complications of CKD and the importance of early referral to
nephrologists , screening of high risk individuals –those with
hypertension, diabetes, cardiovascular and other risk factors. Life
style modification , physical exercise , abstinence from smoking
will retard the progression to ESRD .
Over prescription and usage of analgesics should be
considered as a serious issue and steps to reduce the same
should be undertaken as early as possible.
All these will help in bringing down the huge burden due
to mismatch between demand and availability of resources for
renal replacement therapy in developing countries like India
especially for patients belonging to lower socio economic group.
.

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