Portal de Periódicos da CAPES

Chronic kidney disease and its prevention in India

2005; Elsevier BV; Volume: 68; Linguagem: Inglês

10.1111/j.1523-1755.2005.09808.x

1523-1755

Sanjay Kumar Agarwal,

Healthcare Systems and Reforms

Chronic kidney disease and its prevention in India. Chronic kidney disease (CKD) is an important, chronic, noncommunicable disease epidemic that affects the world, including India. Because of the absence of a renal registry in India, the true magnitude of CKD/end-stage renal disease (ESRD) is unknown. Two community-based studies, although methodologically different, have shown a prevalence of chronic renal failure of 0.16% and 0.79%. The cost of maintenance hemodialysis for a single session varies between US $10 to 40 between government-run and private hospitals. The average cost of erythropoetin is approximately US $150 to 200 per month. The cost of chronic ambulatory peritoneal dialysis with "Y" set at 3 exchanges per week, which most patients in India do, is US $400 per month. The cost of a renal transplant (RT) procedure is approximately US $700 to 800 in the government sector and US $6000 in the private sector. The cost of immunosuppression with basic triple immunosuppression drugs (cyclosporine, steroid, and azathioprin) is US $250 per month. There are hardly any state-funded medical treatment and medical insurance facilities for CKD and ESRD patients in India. India has nearly 700 nephrologists and approximately 400 dialysis units with 1000 dialysis stations, with the majority being in the private sector. A maximum of 2% of patients can be subjected to maintenance hemodialysis. Until now, approximately 3000 patients have been initiated on chronic ambulatory peritoneal dialysis. India has approximately 100 RT centers, mostly in private setup, and not more than 3000 to 4000 RTs are performed annually. Thus, only 3% to 5% of all patients with ESRD in India get some form of renal replacement therapy. Thus, planning for prevention of CKD on a long-term basis is the only practical solution for India.abstrsactIt appears that even in India, diabetes and hypertension are responsible for 40% to 50% of all cases of chronic renal failure. Screening for these 2 diseases and CKD is simple and easy to perform. The best approach will be to start screening for CKD in a high-risk group, like first-degree relatives of patients with diabetes, hypertension, and CKD, and simultaneously making a platform to run the program through the existing health care system of the country. The key issue of funding the program needs to be explored. Initial funding may come from international agencies like the World Health Organization, World Bank, and International Society of Nephrology, along with support from the country itself. Ultimately, funding has to be sustained from our own existing health care system. Chronic kidney disease and its prevention in India. Chronic kidney disease (CKD) is an important, chronic, noncommunicable disease epidemic that affects the world, including India. Because of the absence of a renal registry in India, the true magnitude of CKD/end-stage renal disease (ESRD) is unknown. Two community-based studies, although methodologically different, have shown a prevalence of chronic renal failure of 0.16% and 0.79%. The cost of maintenance hemodialysis for a single session varies between US $10 to 40 between government-run and private hospitals. The average cost of erythropoetin is approximately US $150 to 200 per month. The cost of chronic ambulatory peritoneal dialysis with "Y" set at 3 exchanges per week, which most patients in India do, is US $400 per month. The cost of a renal transplant (RT) procedure is approximately US $700 to 800 in the government sector and US $6000 in the private sector. The cost of immunosuppression with basic triple immunosuppression drugs (cyclosporine, steroid, and azathioprin) is US $250 per month. There are hardly any state-funded medical treatment and medical insurance facilities for CKD and ESRD patients in India. India has nearly 700 nephrologists and approximately 400 dialysis units with 1000 dialysis stations, with the majority being in the private sector. A maximum of 2% of patients can be subjected to maintenance hemodialysis. Until now, approximately 3000 patients have been initiated on chronic ambulatory peritoneal dialysis. India has approximately 100 RT centers, mostly in private setup, and not more than 3000 to 4000 RTs are performed annually. Thus, only 3% to 5% of all patients with ESRD in India get some form of renal replacement therapy. Thus, planning for prevention of CKD on a long-term basis is the only practical solution for India. It appears that even in India, diabetes and hypertension are responsible for 40% to 50% of all cases of chronic renal failure. Screening for these 2 diseases and CKD is simple and easy to perform. The best approach will be to start screening for CKD in a high-risk group, like first-degree relatives of patients with diabetes, hypertension, and CKD, and simultaneously making a platform to run the program through the existing health care system of the country. The key issue of funding the program needs to be explored. Initial funding may come from international agencies like the World Health Organization, World Bank, and International Society of Nephrology, along with support from the country itself. Ultimately, funding has to be sustained from our own existing health care system. Chronic kidney disease (CKD) has become one of the most important, chronic, noncommunicable disease epidemics in the world, including India. It is clear that treatment of CKD and its advanced stage, that is, end-stage renal disease (ESRD), is consuming a huge proportion of health resources in most of the country, and in India it is beyond the reach of the average Indian. Thus, it is crucial that prevention of CKD become an important goal of the medical fraternity, government, and public at large in any country, including India. For a long time it was presumed that nearly 100,000 new patients with ESRD required renal replacement therapy (RRT) every year. In the absence of a renal registry in India, the true magnitude of CKD/ESRD is not known. Most of the data related to CKD are hospital-based, from few tertiary care centers, which document the spectrum of etiology for CKD rather than the magnitude of the problem. There are only 2 population-based studies in India commenting on the magnitude of CKD. Mani [1.Mani M.K. Prevention of chronic renal failure at the community level.Kidney Int. 2003; 63: S86-S89Abstract Full Text Full Text PDF Scopus (77) Google Scholar] from Chennai in south India, while, in general, initiating a prevention program (more so for diabetes and hypertension at the community level in a rural area with a total population 25,000), reported a prevalence of chronic renal failure (CRF) of 0.16% and other renal diseases (short of CRF) in 0.7% of patients. In this study, a preventive and social health worker traveled from house to house, where each family member was asked to fill out a brief questionnaire related to renal illness. Urine was examined for albumin and reducing substance with sulphosalicylic acid and benedict solution, respectively. However, all patients were not evaluated with blood tests for urea/creatinine, and only those who had some abnormality in the urine test/blood pressure and/or a positive response to a questionnaire were subjected to a blood test for urea/creatinine. The second study, which has been accepted for publication and is currently in press [2.Agarwal S.K. Dash S.C. Irshad M. et al.Prevalence of chronic renal failure in adults in Delhi, India Nephrol Dial Transplant in press.in press. 2000; Google Scholar], was done by our group. Four thousand nine hundred and seventy-two patients in urban communities in Delhi were screened for blood urea and creatinine estimation with a specific aim to find out the prevalence of CRF. In addition, other information related to kidney disease, diabetes, and hypertension was also collected. A thorough history and a detailed physical examination, including blood pressure measurement as per our questionnaire, were obtained from each patient in the family that was 16 years of age and older. After this, a fresh mid-stream urine sample was examined for albumin and sugar with a dipstick. Of the 4972 patients evaluated, prevalence of CRF, defined as serum creatinine >1.8 mg% (upper limit of our laboratory) persistent for more than 3 months in the absence of any reversible factor, was found to be 0.79% or 7852 per million population. This figure is much higher than the figure in the study from Mani [1.Mani M.K. Prevention of chronic renal failure at the community level.Kidney Int. 2003; 63: S86-S89Abstract Full Text Full Text PDF Scopus (77) Google Scholar]. In the absence of a registry related to renal diseases, these are the only 2 community-based data available from India. A 1998 report from the Third National Health and Nutrition Examination Survey, conducted from 1988 to 1994 in the United States, estimated that if we take serum creatinine >1.7 mg% as the cutoff for CRF—a value close to 1.8 mg%, which is what we have taken as the cutoff for defining CRF in the present study—then during the same period, there were 12 times more CRF cases than ESRD cases [3.Chronic kidney disease as a public health problem.Am J Kidney Dis. 2002; 39: S37-S45Google Scholar]. Extrapolating this information, if we take patients with ESRD to be 10% of patients with CKD, from our own study, the prevalence of ESRD comes out to be 785 per million population in India. Not only is the magnitude of the CKD/ESRD problem high in India, but the cost of RRT is also exuberant. With India's gross national product being US $470 and the average expanse of various state and central government on health cost being approximately US $7, the government expects that the cost of RRT should be borne by the individual himself. However, there is some support from the government to a small number of patients, and the cost of therapy in this government setup is significantly subsidized. Cost of maintenance hemodialysis (MHD) for a single session varies between US $10 to 40 between government-run and private hospitals. This excludes the cost of erythropoetin, which is approximately US $150 to 200 per month (the majority of patients receives 4000 to 6000 units of erythropoetin every week). The cost of continuous ambulatory peritoneal dialysis (CAPD) with "Y" set at 3 exchanges per week, which most patients in India do, is US $400 per month. The cost of erythropoietin is similar to MHD. The cost of renal transplant (RT) varies between the government sector and the private sector. The cost of an RT procedure is US $700 to 800 in the government sector and US $6000 in the private sector. The cost of immunosuppression with basic triple immunosuppression drugs (cyclosporine, steroid, and azathioprin) is US $250 per month; this figure may go down if cyclosporine is withdrawn and the patient is only given steroids and azathioprin. Thus, on a long-term basis, RT still remains a cheaper modality of treatment for ESRD in India compared with both MHD and CAPD. With competition, local manufacturing of CAPD bags and immunosuppressive medications, and a decrease in the import duties on various items, the cost of RRT is coming down and may go down further. However, with the availability of an automated cycler for night peritoneal dialysis and newer immunosuppressive medications like mycophenolate mofetil, rapamycin, interleukin-2 reception antibodies, and so forth, the cost of therapy can increase also. In the absence of state-funded medical treatment and medical insurance facilities for patients with CKD/ESRD, there are various sources from which patients get money for treatment. In one study, it was concluded that 63% had help from their employer or charity, 26% took loans, and 34% sold assets or pooled their family resources. Obviously, many have more than one source [4.Bapat U. A study of psychologic aspects of chronic renal failure. A project report for the MA degree in social work. Tata Institute of Social Sciences, India1984Google Scholar]. In spite of all these options, only 3% to 5% of all patients with ESRD in India get some form of renal replacement therapy (RRT). It is not at all difficult to imagine what happens to the rest of them. In all major studies of ESRD from different parts of India (mostly hospital-based studies), men in their 30s were the most common group affected by the disease [5.Agarwal S.K. Dash S.C. Spectrum of renal diseases in India in adults.J Assoc Physicians India. 2000; 48: 594-600PubMed Google Scholar, 6.Mani M.K. Chronic renal failure in India.Nephrol Dial Transplant. 1993; 8: 684-689Crossref PubMed Scopus (54) Google Scholar, 7.Mittal S. Kher V. Gulati S. et al.Chronic renal failure in India.Ren Fail. 1997; 19: 753-770Crossref Scopus (50) Google Scholar, 8.Sakhuja V. Jha V. Ghosh A.K. et al.Chronic renal failure in India.Nephrol Dial Transplant. 1994; 9: 871-872PubMed Google Scholar]. Thus, an employed patient with ESRD must search for finances for his treatment, not only for direct treatment cost but also for the indirect cost of a loss of job/working days, which is enormous. Thus, many calling CRF a "chronic revenue failure" is not inappropriate, especially in the Indian context. Aside from the cost of RRT, availability of RRT is also an issue in India. India has nearly 700 nephrologists and approximately 400 dialysis units with 1000 dialysis stations [9.Keshaviah P. Resource limitations and strategies for the treatment of uremia.Blood Purif. 2001; 19: 44-52Crossref PubMed Scopus (9) Google Scholar], with the majority being in the private sector. The government sector cannot afford to provide MHD, and thus only runs RT-oriented dialysis. The majority of hospitals do 2 shifts of dialysis. Even though we take all stations doing MHD, a maximum of 2% of patients can be subjected to MHD. Although the first patient on CAPD in India was initiated in 1990, until now only approximately 3000 patients have been initiated on this modality of therapy [10.Abraham G. Mathew M. Hinduja A. Padma G. Continuous ambulatory peritoneal dialysis: Indian scenario.J Indian Med Assoc. 2002; 100: 184-187Google Scholar]. Thus, although CAPD is becoming popular and is being used more frequently, it still has a long way to go. Generally, CAPD is used as a last resort as RRT in India. Regarding RT, India has approximately 100 RT centers, most of which are in private setup. No more than 3000 to 4000 RTs are done annually [11.Kher V. End stage renal disease in India.Kidney Int. 2002; 62: 350-362Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar]. In the absence of a well-organized cadaver program, living donors constitute the major donor source in India and, unfortunately, a large number of them are unrelated. In spite of an organ transplant bill being passed in 1994, until now only approximately 550 cadaver RTs have been performed in India. Thus, taking altogether (3000 RT + maximum 5000 MHD + maximum 300 CAPD per year), approximately 3.5% of patients with ESRD get any sort of RRT. Therefore, it is clear that considering the magnitude of the problem of CKD/ESRD in India and the availability of RRT and its cost implications, India cannot afford to provide care for the majority of its patients with CKD/ESRD. Thus, planning for the prevention of CKD on a long-term basis is the only practical solution for India, just as it would be for any other country. Before any preventive program for a chronic illness (like CKD) on community basis is planned, a few other issues need to be addressed [1.Mani M.K. Prevention of chronic renal failure at the community level.Kidney Int. 2003; 63: S86-S89Abstract Full Text Full Text PDF Scopus (77) Google Scholar]: (1) Is the disease easy to detect? (2) Can the disease be easily prevented? (3) Is the cost of prevention less than the treatment? (4) Can the preventable program be sustainable? Because CKD is a clinical syndrome, one has to understand its etiology if one wishes to plan a preventive program at the community level. As discussed prevIously, there are only 2 community-based data on CRF in India. Dr. Mani's study has not published, in detail, the etiology of CRF in 0.16% of his patients with CRF in the community. Our own unpublished study, although not planned to study the etiology of CRF, showed that of the 0.79% patients with CRF, 41% were due to diabetes, 22% to hypertension, and 16% to chronic glomerulonephritis. Thus, diabetes and hypertension constituted 63% of all cases of CRF in our study. One may argue that the etiology of hypertension as a cause of CRF is controversial, and many other diseases causing CRF may be attributed to hypertension, because hypertension is a common early manifestation in many other diseases causing CRF. If we compare other hospital-based studies from India regarding the etiology of CRF/ESRD [5.Agarwal S.K. Dash S.C. Spectrum of renal diseases in India in adults.J Assoc Physicians India. 2000; 48: 594-600PubMed Google Scholar, 6.Mani M.K. Chronic renal failure in India.Nephrol Dial Transplant. 1993; 8: 684-689Crossref PubMed Scopus (54) Google Scholar, 8.Sakhuja V. Jha V. Ghosh A.K. et al.Chronic renal failure in India.Nephrol Dial Transplant. 1994; 9: 871-872PubMed Google Scholar], the data are variable Figure 1. Nearly 25% of all patients with ESRD in these studies had diabetes and 6% to 13% had hypertension. However, we must realize that these are tertiary-care, hospital-based studies and do not represent the community. For example, in all of these studies, the mean age of patients was early 40s, whereas in our community-based study, the mean age of patients with CRF was 59 years. There may be a bias in favor of younger persons attending hospitals. This can cause differences in the etiology of patients with CRF attending hospitals compared with patients in the community. Further, if we see that patients with CRF caused by diabetes and hypertension only in one of these studies [8.Sakhuja V. Jha V. Ghosh A.K. et al.Chronic renal failure in India.Nephrol Dial Transplant. 1994; 9: 871-872PubMed Google Scholar], the mean age of patients was nearly 50 years. Also, in the same study, in patients over 40 years of age, diabetes and hypertension comprised more than 55% of cases of CRF, a pattern similar to what is seen in our community-based study. All of this suggests that even in India, diabetes and hypertension are responsible for at least nearly 50% of all cases of CRF. With the increasing problem of diabetes in India, the absolute number of diabetic patients with CKD/ESRD is likely to be enormous. Thus, if we concentrate on these 2 diseases only on a community basis for a prevention program for CKD, we may be able to prevent a large number of CKD cases. It is obvious that clinical examination for blood pressure, urine examination for protein and sugar, spot urine for albumin/creatinine, and blood test for sugar and creatinine are simple tests to perform, and these are the tests required for the diagnosis and basic management of CKD and its 2 major etiologies—diabetes and hypertension. Further, it is also established that if we diagnose CKD early, its progression to ESRD can be retarded significantly by nonmedical and medical therapy, quality of life can be improved, and, once the patient reaches ESRD, its outcome of therapy is better. From western data, it is also known that, economically, prevention is cheaper than the therapy for CKD/ESRD. Implementation is the most difficult issue in a CKD prevention program in any country, more so in a large country like India. Programs like those in the Aboriginal communities in Australia led by Hoy [12.Hoy W.E. Wang Z. Baker P.R.A. Kelly A.M. Reduction in natural death and renal failure from a systematic screening and treatment program in an Australian Aboriginal community.Kidney Int. 2003; 63: S66-S73Abstract Full Text Full Text PDF Scopus (67) Google Scholar] are not applicable in India, because there is no such small community that has a very high risk of CKD that can be targeted. Programs like those being done by Ramirez [13.Ramirez S.P.B. Hsu S.I.H. Mcclellan W. Taking the public health approach to the prevention of end stage renal disease: The NKF Singapore program.Kidney Int. 2003; 63: S61-S65Abstract Full Text Full Text PDF Scopus (34) Google Scholar] in a small country like Singapore, in which the whole country is approached, will also not be applicable in India because of obvious logistics of population size. Something in between needs to be started in India, where a program has yet to begin. Mani's program [1.Mani M.K. Prevention of chronic renal failure at the community level.Kidney Int. 2003; 63: S86-S89Abstract Full Text Full Text PDF Scopus (77) Google Scholar] looks quite encouraging, but adopting this for the whole country is still far away and also needs to be accepted by health care policy makers. At the individual level, it may not be possible. Until that happens, the best approach will be to start screening for CKD in high-risk groups, like first-degree relatives of patients with diabetes and hypertension and patients with CKD. There are some studies, which have demonstrated that first-degree relatives of these high-risk groups have a higher chance of having CKD. In a recent study, the long-term risk of developing overt nephropathy in type 1 diabetes mellitus was found to be 72% in diabetic relatives of nephropathy patients, compared with 25% among diabetic patients whose relatives lacked kidney disease [14.Quinn M. Angelico M.C. Warram J.H. Krolewski A.S. Familial factors determine the development of diabetic nephropathy in patients with IDDM.Diabetologia. 1996; 39: 940-945Crossref PubMed Scopus (400) Google Scholar]. It is increasingly clear that ESRD clusters in families. This familial aggregation is pronounced in nephropathies associated with hypertension [15.Freedman B.I. Tuttle A.B. Spray B.J. Familial predisposition to nephropathy in African-Americans with non-insulin-dependent diabetes mellitus.Am J Kidney Dis. 1995; 25: 710-713Abstract Full Text PDF PubMed Scopus (176) Google Scholar] and types 1 and 2 diabetes mellitus [16.Freedman B.I. Wilson C.H. Spray B.J. et al.Familial clustering of end-stage renal disease in blacks with lupus nephritis.Am J Kidney Dis. 1997; 29: 729-732Abstract Full Text PDF PubMed Scopus (73) Google Scholar, 17.Freedman B.I. Soucie J.M. Stone S.M. Pegram S. Familial clustering of end stage renal disease in blacks with HIV-associated nephropathy.Am J Kidney Dis. 1999; 34: 254-258Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar]. This clustering occurs in excess of that expected from the prevalence of hypertension and diabetes mellitus within families [18.Simon D.B. Farhi A. Mahnensmith R. Lifton R.P. Inherited susceptibility to HIV nephropathy in African Americans [abstract].J Am Soc Nephrol. 1996; 7: 1343Google Scholar]. Another study in 4365 incident ESRD patients in the southeastern United States revealed that 14% of white patients and 23% of black patients had first- or second-degree relatives with ESRD [17.Freedman B.I. Soucie J.M. Stone S.M. Pegram S. Familial clustering of end stage renal disease in blacks with HIV-associated nephropathy.Am J Kidney Dis. 1999; 34: 254-258Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar]. The prevalence of subclinical nephropathy in these families is likely to be far greater. We are aware of 2 important prevention programs, which have demonstrated the importance of screening CKD in families of high-risk groups: the Kidney Early Evaluation Program (KEEP) [19.Brown W.W. Peters R.M. Ohmit S.E. et al.Early detection of kidney disease in community setting. The Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2003; 42: 22-35Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar], sponsored by the National Kidney Foundation, and the Family History of ESRD program by the Southeastern Kidney Council/ESRD Network in the United States [20.Freedman B.I. Soucie J.M. Mcclellan W.M. Family history of end stage renal disease among incident dialysis patients.J Am Soc Nephrol. 1997; 8: 1942-1945PubMed Google Scholar]. While starting a prevention program from a high-risk group, we should also simultaneously use other strategies that are relevant from a point of prevention of CKD on a long-term basis. In my opinion, the following simultaneous strategies currently need to be adopted for starting this program: (1) Starting awareness of CKD in the medical community and among policy makers and the community at large through the print media, electronic media, radio, and pamphlet distribution at appropriate forums like hospitals, schools, banks, shopping malls, and so forth. (2) Planning multicentric studies for finding the prevalence of CKD and its causes in 4 corners of the country. (3) Starting the screening of first-degree relatives of patients with CKD, diabetes, and hypertension in an organized manner, possibly starting in the urban area of the country through a network with a central database. (4) Implementing regular screening for CKD in patients with diabetes mellitus and hypertension. (5) Referring patients with CKD to an appropriate setup for planning management. (6) Educating medical personnel about the algorithmic approach for the management of patients with CKD at the community health center level, particularly the appropriate use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. With this approach, we are likely to fulfill the following short-term objectives of: making people aware of CKD and its importance; finding the prevalence of CKD and its major causes in India in community-based studies; showing the impact of screening high-risk individuals to the community and policy makers. Once the short-term objectives have been met, it will then be easy to convince policy makers to implement a prevention program using a wider network of the existing health care structure of the country. In India, there is an existing health care system both for the rural as well as for the urban community. However, it is better established for the rural population than the urban population Table 1 [21.Bulletin on "Rural Health Statistics in India" issued by Infrastructure Division, Department of Family Welfare, Ministry of Health and Family Welfare Government of India New Delhi.India. March 2002; Google Scholar]. In urban areas, in addition to central government health services, there are other organizations like railways, the Municipal Corporation, and so forth, which are running their own dispensaries and hospitals as per the need of their own organizations. We have to redeem such an existing health care system in a better way for prevention programs like one for CKD. For the first time in India, the National Health Policy 2002, in addition to other objectives, made one of its objectives to "establish a baseline estimate for non-communicable diseases," which was never an issue in previous health policies [21.Bulletin on "Rural Health Statistics in India" issued by Infrastructure Division, Department of Family Welfare, Ministry of Health and Family Welfare Government of India New Delhi.India. March 2002; Google Scholar].Table 1Existing Indian health care setup in a rural areaSubcenterPrimary health centerCommunity health centerNumbers137,31122,8423043Population covered540032,842240,000Villages covered4.527.8201Bed strengthNo4-630Personnel1 MPW (male)1 MO4 MO1 MPW (female)14 paramedics Other staff7 nurses Pharmacist Lab technician Radiographer Other staffAbbreviations are: MPW, multipurpose worker; MO, medical officer. Open table in a new tab Abbreviations are: MPW, multipurpose worker; MO, medical officer. Finally, the key issue of funding the program needs to be explored. Mani [1.Mani M.K. Prevention of chronic renal failure at the community level.Kidney Int. 2003; 63: S86-S89Abstract Full Text Full Text PDF Scopus (77) Google Scholar], in his community-based program, has shown that by using cheaper medicines for controlling blood pressure and diabetes, blood pressure can be less than 140/90 mm Hg in 96% cases and can bring glycated hemoglobin levels to 7% or less in 50% of patients. By using local health care workers, the annual cost of the treatment program was US $.27 cents per capita. Overall, it looks quite encouraging. But whether the same program can be organized and sustained in the whole country is questionable. This requires, in addition to commitment of physician fraternity, a political will for prevention of CKD, which, in my opinion, is significantly lacking at present. Currently in India, CKD is not a priority for the government at all, and initial funding has to come from international agencies like the World Health Organization, World Bank, and International Society of Nephrology (just as in the case of acquired immune deficiency syndrome and noncommunicable diseases like cardiovascular diseases, polio eradication, and so forth). The concept of a "global fund" for CKD, an idea that Schieppati et al have discussed, is still to be accepted [22.Schieppati A. Perico N. Remuzzi G. Preventing end stage renal disease: The potential impact of screening and intervention in developing countries.Kidney Int. 2003; 63: 1948-1950Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Further, once the prevention program has started and established to some degree, the existing system of health care needs to be used for the prevention program for CKD also. To conclude, CKD/ESRD is a major problem for India, and with increasing diabetes burden, it is going to increase further. Managing the whole population of these patients will be impossible for India, where many other issues are of more priority than CKD. However, money invested now in establishing a prevention program for CKD in India is certainly going to give results in years to come and, ultimately, in the long-run will still be cost effective. Then the saved money can be used for other health care programs. But, in my opinion, this idea will not be easy to impress on current policy makers and the political system of this country. Our study for determining the prevalence of CRF in Delhi, India, was funded by the Indian Council of Medical Research, New Delhi, India.