India has a staggering burden of chronic kidney disease (CKD). Unfortunately for the vast majority of patients who progress to the end stage, the consequence is fatal renal failure. There is a strong case rapidly to scale up facilities for free or highly-subsidised dialysis because this therapy can cost a prohibitive Rs. 300,000 a year. Access to dialysis is crucial, since kidney transplants are available only to a small minority who can find a legal donor and afford the costs. But the major challenge lies at the public health policy level. Can governments prevent people with early CKD from developing renal failure? The good news is that they can — at relatively low cost. Fresh evidence indicates that a simple medical protocol can prevent most patients with compromised kidney function from developing end-stage disease early. Distinguished nephrologist M. Krishna Mani reports in his paper titled “Treating Renal Disease in India's Poor: The Art of the Possible” published by Seminars in Nephrology, January 2010, that a 15-year study of patients with chronic kidney disease from 1993 shows the potential for a remarkable extension of lifespan using the protocol. Compared with patients who were not part of the regimen, the treatment extended life by even 17 years. At the heart of the protocol is the reduction of the rate of decline in renal function using drugs classified as Angiotensin Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers.
The data from Dr. Mani's unit strengthen the trend of positive outcomes achieved in pilot programmes of the International Society of Nephrology Commission for the Global Advancement of Nephrology that followed the same strategy. These interventions provide key pointers for public health policy. The most important is obviously the need for a population-level programme of annual testing to detect diabetes and hypertension. Treating both conditions with lifestyle modification (such as dietary controls and exercise) and medication is essential to prevent kidney damage (and related cardiovascular disease). For those who have impaired renal function — measured by the presence of protein in urine and a threshold value for the kidney's filtration capacity — the treatment protocol must follow. Affordable generic drugs reduce further damage to kidney filters from elevated blood pressure and protein loss. The value of such prevention is inestimable, because only about one per cent of patients with end-stage renal disease in India can afford treatment. Moreover, there is just one nephrologist for every 1.6 million Indians. The kidney is a silent organ, but ignoring it can lead to disastrous consequences.