Chronic Kidney Disease in a Tertiary Care Hospital in Nepal

Abstract

Introduction: Chronic kidney disease (CKD) is an increasingly recognized major public health problem globally and in Nepal. It has a high prevalence in the population and is associated with high morbidity, mortality and health care costs. Here, we aimed to study the socio-demographic profiles, etiologies of CKD and associated co-morbidities in patients attending a referral hospital.

Methods: We conducted a hospital based, descriptive, observational, cross-sectional study among adult patients with CKD attending Tribhuvan University Teaching Hospital (TUTH), Kathmandu. Patients younger than 16 years and renal allograft recipients were excluded from the study. A diagnosis of CKD was established by the treating nephrologist based on KDIGO 2012 clinical practice guideline. Prior informed consent was taken. Data was collected on clinical features, socio-demographic profiles, major co-morbidities, presumed etiology of CKD and hematological and biochemical parameters of the
patients. SPSS version 24 (Chicago, IL, USA) was used for the analysis of data. The study protocol was approved by the Institutional Review Board (IRB) of Institute of Medicine (IOM).

Results: A total of 401 patients with CKD were included in the study. The mean age of the patient was 50.92 years (SD=17.98), male to female ratio was 1.8:1. Among these patients, 86% were Hindu, 24.4% were farmers, 57% were from the Hilly region of Nepal, 51% were active smokers, and 51.6% were alcohol consumers. Chronic glomerulonephritis (CGN) (36.2%; n= 145), diabetes mellitus (31.9%; n= 128) and hypertension (21.7%; n=87) were the three most common identified causes of CKD. Among the biopsy proven CGN patients, IgA nephropathy was the most common cause. In a large proportion of patients (68.3%) cause of CGN was not known. Most of the patients were in CKD stage 5 (27%), and stage 5D (55.8%). Coronary artery disease (CAD) (in 7% patients), heart failure (in 2.7%) and stroke (in 2.2%) were the most common comorbidities. Anemia was prevalent in CKD from stage 3 onwards, the severity increased with increasing stage (p <0.001). Hemodialysis was the predominant mode of renal
replacement therapy (RRT) used by 98.2% of CKD 5D patients.

Conclusion: Nepalese patients of CKD are younger; males are more affected than females. CGN, diabetes and hypertension are three most common causes of CKD; IgA nephropathy is the most common cause of biopsy proven CGN leading to CKD. Anemia is common from CKD stage 3 onwards. The most common associated co-morbidity is CAD.

Key words: Chronic kidney disease, CKD; Chronic glomerulonephritis, CGN; Diabetes mellitus, DM; Hypertension; Nepal

Full text

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104
Original Article
Chronic Kidney Disease in a Tertiary Care Hospital in Nepal
Sigdel MR, Pradhan RR
Department of Nephrology, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
Correspondence to: Dr Mahesh Raj Sigdel
Email: maheshsigdel@hotmail.com
Abstract
Introduction: Chronic kidney disease (CKD) is an increasingly recognized major public health problem
globally and in Nepal. It has a high prevalence in the population and is associated with high morbidity,
mortality and health care costs. Here, we aimed to study the socio-demographic proles, etiologies of
CKD and associated co-morbidities in patients attending a referral hospital.
Methods: We conducted a hospital based, descriptive, observational, cross-sectional study among adult
patients with CKD attending Tribhuvan University Teaching Hospital (TUTH), Kathmandu. Patients
younger than 16 years and renal allograft recipients were excluded from the study. A diagnosis of
CKD was established by the treating nephrologist based on KDIGO 2012 clinical practice guideline.
Prior informed consent was taken. Data was collected on clinical features, socio-demographic proles,
major co-morbidities, presumed etiology of CKD and hematological and biochemical parameters of the
patients. SPSS version 24 (Chicago, IL, USA) was used for the analysis of data. The study protocol was
approved by the Institutional Review Board (IRB) of Institute of Medicine (IOM).
Results: A total of 401 patients with CKD were included in the study. The mean age of the patient was
50.92 years (SD=17.98), male to female ratio was 1.8:1. Among these patients, 86% were Hindu, 24.4%
were farmers, 57% were from the Hilly region of Nepal, 51% were active smokers, and 51.6% were
alcohol consumers. Chronic glomerulonephritis (CGN) (36.2%; n= 145), diabetes mellitus (31.9%; n=
128) and hypertension (21.7%; n=87) were the three most common identied causes of CKD. Among
the biopsy proven CGN patients, IgA nephropathy was the most common cause. In a large proportion of
patients (68.3%) cause of CGN was not known. Most of the patients were in CKD stage 5 (27%), and
stage 5D (55.8%). Coronary artery disease (CAD) (in 7% patients), heart failure (in 2.7%) and stroke (in
2.2%) were the most common comorbidities. Anemia was prevalent in CKD from stage 3 onwards, the
severity increased with increasing stage (p <0.001). Hemodialysis was the predominant mode of renal
replacement therapy (RRT) used by 98.2% of CKD 5D patients.
Conclusion: Nepalese patients of CKD are younger; males are more affected than females. CGN,
diabetes and hypertension are three most common causes of CKD; IgA nephropathy is the most common
cause of biopsy proven CGN leading to CKD. Anemia is common from CKD stage 3 onwards. The most
common associated co-morbidity is CAD.
Key words: Chronic kidney disease, CKD; Chronic glomerulonephritis, CGN; Diabetes mellitus, DM;
Hypertension; Nepal
Introduction
The term chronic kidney disease (CKD) refers to any
disorder that affects the structure and or function of
kidney, has been present for at least three months and
has implications for health.1,2 CKD is a major public
health problem worldwide and is associated with
considerable morbidity and mortality.3 CKD is a newly
recognized public health problem in Nepal as well. 4
The estimated prevalence of CKD is around 10.6%
in urban areas of Nepal.5 A study by International
Society of Nephrology’s Kidney Disease Data Center
(ISN-KDDC) in 12 low and middle income countries
reported yet higher prevalence of CKD in the cohorts
from Nepal.6 The overall prevalence of CKD was 20.1
%, the prevalence of estimated glomerular ltration rate
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105
104-111
(eGFR) < 60 ml/min/1.73 m2 was 16.2% and that of
albumin creatinine ratio (ACR) > 30 mg/gm was 5.8%.
The awareness level was also low in both general and
high risk populations (6 % versus 10%).6 In another
study, the number needed to screen to detect a new case
with eGFR < 60ml/min/1.73 m2 was 2.6.7
The epidemiology of CKD is expected to differ between
developed and developing countries. In addition to
non-communicable diseases, communicable diseases
especially infections and toxic exposures are thought
to be common causes of CKD in developing countries.8
In Nepal, data on different aspects of CKD are still
few and inadequate. Information about the population
affected, their causes / risk factors and co-morbidities
should considerably help the health care providers,
planners, and policy makers to identify key strategies
for prevention and management of CKD. In the present
study, we aimed to study the epidemiology, socio-
demographic proles, etiology, and associated co-
morbidities of CKD patients at a tertiary care hospital
in Nepal.
Methods
This study was a hospital based observational,
descriptive, cross-sectional study, conducted at
Tribhuwan University Teaching Hospital (TUTH) in
Nepal over a period of 12 months from June 2017 to
May 2018. TUTH is a 700 bedded tertiary care hospital
located in Kathmandu and provides multi-specialty
health care services to patients from all 77 districts
of Nepal. A prior approval was obtained from the
Institutional review board (IRB) of Institute of Medicine
(IOM). Written informed consent was taken from all
the participants (or their primary caretakers wherever
applicable).
CKD was dened based on KDIGO 2012 clinical
practice guideline 2 for the evaluation and management
of chronic kidney disease as either of the following
present for ≥ three months: (a) Markers of kidney
damage (one or more): albuminuria (AER >30 mg/24
hours; ACR >30 mg/g [ >3 mg/mmol]), urine sediment
abnormalities, electrolyte and other abnormalities due to
tubular disorders, abnormalities detected by histology,
structural abnormalities detected by imaging, history of
kidney transplantation or (b) Decreased GFR <60 ml/
min/1.73 m2 (GFR categories G3a–G5). Consecutive
patients attending the nephrology outpatient department
or admitted to the Nephrology or Internal Medicine wards
of TUTH who met the criteria for CKD were considered
for enrollment. Glomerular ltration rate (GFR) was
calculated using CKD-EPI (Chronic Kidney Disease
Epidemiology Collaboration) equation for eGFR,9 then
categorized into different stages. We included a total of
401 patients aged 16 years and above, with CKD stages
3, 4, 5, and 5D (patients under dialysis) by a method
of non-probability sampling. Patients were excluded if
they denied consent, were younger than 16 years or were
renal transplant recipients. Data were collected on the
socio-demographic proles, presumed etiology of CKD,
major associated co-morbidities, and hematological and
biochemical parameters and lled in the predesigned
proforma. In the data analysis, continuous variables
were expressed as mean ± standard deviation (SD) and
categorical variables were expressed as frequency and
percentage. Analysis of normal variance (ANOVA)
test was employed to compare the mean laboratory
parameters amongst different stages of CKD. A p-value
< 0.05 was considered statistically signicant. The data
entry and all statistical analysis were performed using
SPSS version 24 (Chicago, IL, USA).
Results
Demographic characteristics of the patients
A total of 401 patients were included in the study. The
demographic characteristic of the study population is
presented in Table 1. The mean age of the patient in
the study was 50.92 years (SD=17.98). On subgroup
analysis based on stages of CKD, it was observed that
the mean age of patient in CKD stage 3, 4, 5, and 5D were
51 years, 58 years, 58 years, and 46 years respectively.
There were 260 (64.8%) male and 141 (35.2%) female
patients; the male to female ratio being 1.8:1. Gender
distribution of patients in different stages of CKD were,
CKD stage 3 (n=18): male 67% and female 33%; CKD
stage 4 (n=51): male 63% and female 37%; CKD stage
5 (n=108): male 56 % and female 44 %; and CKD
stage 5D (n=224): male 69 % and female 31 %. Gender
distribution of patient in different stages of CKD is
represented in Figure 1.
Figure 1: Gender of patients in different stages of
CKD (n=401)
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106
Among 401 patients, 86% were Hindu, 24.4% were farmers, 57.1% were from Hilly region of Nepal, 35% were
illiterate, 51% were current smoker, and 51.6% were consuming alcohol, and 81% were married. Most of the
patients (39.6%) were Brahmin or Chhetri caste under the traditional caste system. Annual family income was less
than 500,000 NPR (1 $ is equivalent to around 110 NPR) in the majority of the patients (72.5%).
Table 1: Demographic characteristics of the study population (n=401)
Characteristics Frequency Percentage
Sex Male 260 64.8
Female 141 35.2
Religion
Hindu 345 86
Buddhist 48 12
Muslim 4 1
Christian 4 1
Occupation
Farmer 98 24.4
Housewife 89 22.2
Businessman 45 11.2
Government employee 28 7
Dependent 81 20.2
Migrant worker 26 6.5
Carpenter 6 1.5
Student 20 5
Driver 7 1.7
Teacher 1 0.2
Address
Terai 130 32.4
Hilly 229 57.1
Himalayan 42 10.5
Ethnicity
Brahmin and Chhetri 159 39.6
Madhesi 40 10
Dalit 30 7.5
Newar 70 17.5
Janjati 102 25.4
Education
Illiterate 140 35
Primary level 129 30
Secondary level 100 25
Higher secondary or university 40 10
Family income per annum
Less than 1 lakh 120 30
1 to 5 lakh 171 42.5
5 to 10 lakh 60 15
More than 10 lakh 50 12.5
Marital status
Married 325 81
Unmarried 48 12
Divorced 16 4
Widow or widower 12 3
Smoking Yes 204 51
No 197 49
Alcohol consumption Yes 207 51.6
No 194 48.4
Sigdel MR, Pradhan RR
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107Chronic Kidney Disease in a Tertiary Care Hospital in Nepal
Etiology of CKD
We found that the three most common causes of CKD in
the studied population were chronic glomerulonephritis
(36.2%), diabetes mellitus (31.9%), and hypertension
(21.7%) followed by other causes (Table 2).
Table 2: Etiology of CKD in study population
(n=401)
Etiology Frequency Percentage
Chronic glomerulonephritis 145 36.2
Diabetes mellitus 128 31.9
Hypertension 87 21.7
Obstructive nephropathy 23 5.7
NSAIDS 3 0.7
Renal amyloidosis 2 0.5
ADPKD 8 2
Multiple myeloma 1 0.2
Recurrent UTI 1 0.2
Others 3 0.7
Total 401 100
NSAIDS, Non-steroidal anti-inammatory drugs;
ADPKD, Autosomal dominant polycystic kidney
disease; UTI, Urinary tract infection
Only 31.7% patients with presumed diagnosis of chronic
glomerulonephritis (CGN) had biopsy proven diagnosis.
In the majority of patients with presumed diagnosis of
CGN (68.3%), the original disease that led to CKD was
not known. Among the biopsy proven CGN patients, IgA
nephropathy was the most common cause, followed by
ANCA (anti neutrophil cytoplasmic antibody) associated
vasculitis and lupus nephritis (Table 3).
Table 3: Etiology of chronic glomerulonephritis
(CGN) in study population (n=145)
Etiology Frequency Percentage
Unknown 99 68.3
IgA nephropathy 19 13.1
Lupus nephritis 8 5.5
Focal segmental
glomerulosclerosis (FSGS) 2 1.4
Membranoproliferative
glomerulonephritis (MPGN) 1 0.7
Minimal change disease
(MCD) 1 0.7
Anti GBM disease 2 1.4
ANCA associated vasculitis 9 6.2
Non proliferative
glomerulonephritis 1 0.7
Systemic sclerosis 1 0.7
Membranous nephropathy 2 1.4
Total 145 100.0
Migrant workers and CKD
We observed that, out of 401 CKD patients, 26
(6.5%) patients were migrant workers who had been
to foreign countries for work and returned home, the
foreign countries were mostly Gulf countries. Most of
the patients were male (male, 96.2%; female, 3.8%).
The mean age in this group of patients was 36.5 years
(SD=12). Out of 26 patients, 18 (69.2%) had presumed
diagnosis of CGN as the cause of CKD; however, only
27.8 % of the presumed CGN cases (8 out of 26) had
biopsy proven diagnosis, in which IgA nephropathy was
the most common (3 out of 8). The etiology of CKD in
migrant worker is shown in Table 4.
Table 4: Etiology of CKD in migrant worker (n=26)
Etiology Frequency Percentage
Chronic glomerulonephritis 18 69.2
Hypertension 5 19.2
Diabetes 2 7.7
ADPKD 1 3.8
Total 26 100
ADPKD, Autosomal dominant polycystic kidney
disease
Distribution of patients based on stages of CKD
Table 5 shows the distribution of patients based on
stages of CKD. Most of the patients were in CKD stage
5 (108, 27%), and stage 5D (224, 55.8%). Amongst the
patients under maintenance dialysis, 98.2% (n=220)
were under maintenance hemodialysis (MHD) and
1.8% (n=4) were under peritoneal dialysis (PD). Among
the patients who were under MHD, 78.8% (n=172)
patients were under MHD for less than 6 month, 10.5%
(n=23) patients were under MHD for 6 to 12 month and
11.4% (n=25) patients were under MHD for more than
12 month. For these patients (n=220), 94.1% (n=207),
4.5% (n=10) and 1.4% (n=3) were under MHD two,
three and one session per week respectively.
Table 5: Distribution of patients based on stages of
CKD (n=401)
CKD stage Frequency Percentage
Stage 3 18 4.5
Stage 4 51 12.7
Stage 5 108 27
Stage 5D 224 55.8
Total 401 100
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CKD and co-morbidities
The various co-morbidities associated with CKD were
coronary artery disease (CAD) in 28 patients (7%),
heart failure in 11 (2.7%), stroke in 9 (2.2%), chronic
obstructive pulmonary disease in 8 (2%) and chronic
liver disease in 5 patients (1.2%).
Analysis of laboratory parameters
We noted that anemia was present throughout CKD
stages 3, 4, 5, and 5D. The severity of anemia increased
signicantly (p < 0.05) with increasing CKD stage. We
also observed that, intact parathyroid hormone (iPTH)
and phosphorus increased signicantly (p <0.05) with
increasing CKD stage. Though corrected calcium, and
vitamin D levels decreased with increasing CKD stage,
the difference did not reach statistical signicance (p
> 0.05). The mean vitamin D value was in insufcient
range in CKD stages 4, 5 and 5 D (Table 6).
Table 6: Comparison of laboratory parameters of
the study population (n=401)
Parameters CKD stage Mean SD p-value
Hemoglobin
Stage 3 9.98 2.00
< 0.001
Stage 4 8.97 2.24
Stage 5 8.79 2.10
Stage 5D 8.23 1.72
iPTH
Stage 3 98.47 63.68
0.002
Stage 4 223.05 355.42
Stage 5 330.61 372.36
Stage 5D 356.98 324.81
Albumin
Stage 3 29.55 7.58
0.005
Stage 4 31.56 7.07
Stage 5 33.70 5.73
Stage 5D 33.61 5.33
Corrected
calcium
Stage 3 2.00 0.23
0.358
Stage 4 1.98 0.21
Stage 5 1.92 0.30
Stage 5D 1.90 0.29
Phosphorus
Stage 3 3.14 0.77
< 0.001
Stage 4 3.82 1.39
Stage 5 4.89 1.82
Stage 5D 4.82 1.96
Vitamin D
Stage 3 30.98 14.85
0.876
Stage 4 27.41 12.79
Stage 5 27.83 16.74
Stage 5D 27.86 16.83
Discussion
CKD, with its associated morbidity and mortality, has
now been recognized as a major public health problem
globally.3 However, the demography and causes of CKD
differ between different countries.8 We found that the
affected population was young (mean age, 50.9 years;
SD, 17.98 years). Similar results were found in studies
from Africa10, India11,12, and Saudi Arabia.13 However,
studies from developed countries showed patients of
CKD were relatively older and the average age was
above 60 years.14 The discrepancy could be explained by
the fact that in Western countries there is greater access
to health care, preventive means, early detection &
management of patients at risk of developing CKD and
better longevity. It is likely that diseases like diabetes
and hypertension are earlier detected and better managed
in the West along with timely detection and treatment of
diseases like glomerulonephritis. We observed that male
were affected more compared to female irrespective of
stages of CKD (Table 1), the overall male to female
ratio being 1.8:1, and this nding was consistent with
other studies.11,14 It was surprising that the difference
in male versus female was more marked in CKD 3 and
CKD 5D; we hypothesize that this difference is due
to paternalistic and male dominated Nepalese society
where female patients seek health care relatively later
and signicantly fewer female patients have access to
renal replacement therapy.15 We observed that more
than 50% of the patients were coming from the Hilly
regions of Nepal and only 10% were Madhesis. This
underrepresentation of Nepalese Madhesis could be
because of their poor access to health care as well as
the vicinity to Northern India where many of them
traditionally seek health care.
In the present study, we found that 51% of the individuals
were current smoker, and 51.6% of the individuals were
consuming alcohol on regular basis. This nding of the
study is collaborated by study of Haroun et al.16, who
reported that current cigarette smoking was signicantly
associated with risk of CKD in both men and women
(hazard ratio in women 2.9 [1.7 to 5.0] and in men 2.4
[1.5 to 4.0]). Menon et al.17 illustrated that 52% of CKD
patients had history of excessive alcohol consumption,
which is consistent with our study. Campaigns on
smoking cessation and promotion of healthy lifestyles
could help in curbing the increasing epidemics of non
communicable diseases including CKD.
Sigdel MR, Pradhan RR
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We observed that the majority of the patients were
involved in agriculture (24.4%), were housewives
(22.2%) or dependent (20.2%); only a quarter of the
studied patients were in some active professions. This
is reective of employment pattern in contemporary
Nepalese society. We also discovered that 6.5% of
CKD patients had been migrant workers in foreign
countries. This group of patients was relatively young
(mean age, 36.5 years; SD, 12 years), and in the vast
majority of them the cause of CKD was presumed
chronic glomerulonephritis (69.2%). This could be
because the migrant workers have poor access to the
health care services in foreign country, lack health
related awareness, and have repeated chronic untreated
infections; the role of yet unidentied environmental
factors leading to CKD in workers in the Gulf countries
remains to be investigated.
Data regarding the nancial impact of CKD on patients
in Nepal are limited. In a study done at National Kidney
Center (NKC), Nepal, it was shown that about 37%
of CKD stage 5 patients had to sell their property for
the treatment.18 On an average, one patient spent Rs.
2,40,000 per year (1 $ = 110 NPR) in dialysis. Similarly,
medication cost was Rs.1,80,000 per annum and the
cost of transplantation was Rs.5,00,000 to 10,00,000.18
However, recently, the dialysis service has been
provided free of cost by Government of Nepal in the
government recognized health care institutions across
the country.19 In our study we found that, the majority
of the patients (72.5%) had annual family income less
than 500,000 NPR (1 $ is equivalent to around 108
NPR), and 35% were illiterate. This highlights the
challenges and economic burden imposed by CKD to
the patients, society and nation as a whole. Poverty,
lack of regular health check up, and health awareness
could be contributing factors for CKD.11
In our study, we discovered that the most common
etiology of CKD was CGN (36.2%). Only 31.7%
patients with presumed diagnosis of CGN had biopsy
proven diagnosis. Among the biopsy proven CGN
patients, IgA nephropathy appeared to be most common,
present in 13.1% patients. In a large proportion of
patient (68.3%) cause of CGN was not known. This
nding is in contrast with study conducted in developed
nations where diabetes mellitus is the commonest cause
of CKD. 20 The high prevalence of CKD secondary to
CGN in developing countries could be explained by
repeated infections leading to chronic inammation.
The health seeking behavior of Nepalese patients, poor
socioeconomic status, absence of health insurance and
poor access to reliable health care could have all led to
late presentation of treatable diseases and missed window
of opportunity to prevent CKD. Diabetes mellitus and
hypertension were the second and third most common
causes of CKD in our study population, this reects the
increasing impact of these non communicable diseases
in developing country like Nepal as well.
Most of the patients were in CKD stage 5 (27%), and
stage 5D (55.8%). Out of 224 patients who were under
maintenance dialysis, 98.2% (n=220) were under
Maintenance Hemodialysis (MHD) and 1.8% (n=4)
were under peritoneal dialysis (PD). This limited use of
PD as the modality of renal replacement therapy could
be multi-factorial, namely inadequate time given by
health professionals in counseling on PD, emergency
start of HD and continuation of the same, poor hygienic
practices of many patients, lack of home support for
PD, poor access to clean water, the additional costs of
PD uid (though this is provided free of cost of late)
etc.21,22 If PD could be made more popular,this could
address the issue to need to travel long distances or
migrate just to get HD.
End-stage kidney disease substantially increases the
risks of death, and cardiovascular disease.23 In our
study, we found out of 401 patients, 28 patients (7%)
had CAD, and 11 patients (2.7%) had heart failure.
This relatively lower prevalence of cardiovascular co-
morbidities could be explained by younger age of the
patients and CGN being the most common cause rather
than diabetes mellitus.
Early stages of CKD are usually asymptomatic
and symptoms are observed in late stages due to
complications of decreased kidney function. Major
complications are related to cardiovascular disease,
anemia, infections, neuropathy and abnormalities of
mineral and bone metabolism.24 We found that anemia
was universal to CKD stage 3, 4, 5, and 5D. The
severity of anemia increased signicantly (p <0.05)
with increasing CKD stage. Presence of anemia in CKD
stage 3 could be reective of the population prevalence
of anemia in Nepal and the poor nutrition of Nepalese
in general,25-27 rather than any CKD specic factors.
We also observed that, iPTH and phosphorus increased
signicantly (p <0.05) with increasing CKD stage
(Table 6).This nding is consistent with several other
observations and is explained by CKD physiology.28
Though corrected calcium, and vitamin D decreased
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with increasing CKD stage, these parameters didn’t
reach statistical signicance.
We recognize that being a relatively small, observational,
cross sectional hospital based study, our ndings
may not be generalizable to the whole CKD patients
from Nepal. However, we believe that the inferences
drawn from meticulous interpretation of data from this
nationally representative cohort in a referral hospital
would partially ll the gaps in data on CKD in Nepal
and help health care providers and policy makers in
identifying priority intervention areas. The ndings of
this study need to be validated from large scale multi-
center and population based studies.
Conclusion
The mean age of the Nepalese patients with CKD is
younger compared to their Western counterparts. Males
are almost twice as affected as females, at least in
hospital based study. CGN is still the most common
cause of CKD in Nepal, followed by diabetes and
hypertension. IgA nephropathy is the most common
biopsy proven cause of CGN leading to CKD. Anemia
is more common in Nepalese CKD patients and is
prevalent from stage 3 onwards. Hemodialyis is the
predominant mode of renal replacement therapy for end
stage kidney disease in Nepal.
Conict of interest: None declared.
References
Levey AS, Coresh J. Chronic kidney disease. Lancet. 1.
2012; 379: 165-80.
National Guideline C. KDIGO 2012 clinical practice 2.
guideline for the evaluation and management of chronic
kidney disease. 2013.
Schoolwerth AC, Engelgau MM, Hostetter TH, et al. 3.
Chronic kidney disease: a public health problem that
needs a public health action plan. Prev Chronic Dis.
2006; 3: A57.
Sharma SK, Dhakal S, Thapa L, et al. Community-based 4.
screening for chronic kidney disease, hypertension and
diabetes in Dharan. JNMA. 2013; 52: 205-12.
Sharma SK, Karki P, Baral N, Perico N, Perna A, Remuzzi 5.
G, et al. A community screening for chronic kidney
disease, hypertension, diabetes and their management in
Dharan, Nepal. World Congress of Nephrology. 2007;
52 (189): 205-12.
Ene-Iordache B, Perico N, Bikbov B, Carminati S, 6.
Remuzzi A, Perna A, et al. Chronic Kidney Disease and
cardiovascular risk in six regions of the world (ISN-
KDDC): A Cross sectional study. Lancet Glob Heal.
2016; 4(5): e307-19.
Sharma SK, Zou H, Togtokh A, Ene-Iordache B, Carminati 7.
S, Remuzzi A, et al. Burden of CKD, Proteinuria and
Cardiovascular Risk Among Chinese, Mongolian and
Nepalese Participants in the International Society Of
Nephrology Screening Programs. Am J Kidney Dis.
2016; 56(5): 915-27.
Wanigasuriya K. Update on uncertain etiology of chronic 8.
kidney disease in Sri Lanka’s north-central dry zone.
MEDICC Review. 2014; 16: 61-5.
Levey A. Chronic kidney disease epidemiology 9.
collaboration. Using standardized serum creatinine
values in the modication of diet in renal disease study
equation for estimating glomerular ltration rate. Ann
Intern Med. 2006; 145: 247-54.
Hamat I, Abderraman GM, Tondi ZMgM, et al. 10.
Epidemiological Prole of Chronic Kidney Disease at the
General Hospital of National Reference of Ni¯Djamena
(Chad). Open Journal of Nephrology. 2016; 6: 8.
Singh AK, Farag YMK, Mittal BV, et al. Epidemiology 11.
and risk factors of chronic kidney disease in India –
results from the SEEK (Screening and Early Evaluation
of Kidney Disease) study. BMC Nephrology. 2013; 14:
114.
Rajapurkar MM, John GT, Kirpalani AL, et al. What 12.
do we know about chronic kidney disease in India: rst
report of the Indian CKD registry. BMC Nephrology.
2012; 13: 10.
Alsuwaida A, Farag Y, Al Sayyari A, et al. Epidemiology 13.
of chronic kidney disease in the Kingdom of Saudi
Arabia (SEEK-Saudi investigators) - A pilot study. Saudi
Journal of Kidney Diseases and Transplantation. 2010;
21: 1066-72.
Jiwa M, Chakera A, Dadich A, Meng X, Kanjo E. The 14.
prole of patients with chronic kidney disease who
regularly present at an Australian general practice.
Current medical research and opinion. 2016; 32: 183-9.
Shah DS, Shrestha S, Kae MP. Renal transplantation 15.
in Nepal: Beginning of a new era!. Nephrology. 2013;
18: 369-75.
Haroun MK, Jaar BG, Hoffman SC, Comstock GW, 16.
Klag MJ, Coresh J. Risk factors for chronic kidney
disease: a prospective study of 23,534 men and women
in Washington County, Maryland. J Am Soc Nephrol.
2003; 14: 2934-41.
Sigdel MR, Pradhan RR
104-111

Journal of Institute of Medicine, August, 2018, 40:2
www.jiom.com.np
111
Menon V, Katz R, Mukamal K, et al. Alcohol consumption 17.
and kidney function decline in the elderlyAlcohol and
Kidney Disease. Nephrology Dialysis Transplantation.
2010; 25: 3301-7.
Mishra D, Koirala P. Status of Chronic Kidney Disease 18.
Patients Registered in National Kidney Center,
Banasthali, Kathmandu. 2015; 1: 5.
McGee J, Pandey B, Maskey A, Frazer T, Mackinney T. 19.
Free dialysis in Nepal: Logistical challenges explored.
Hemodialysis international International Symposium on
Home Hemodialysis. 2018.
Koye DN, Magliano DJ, Nelson RG, Pavkov ME. The 20.
Global Epidemiology of Diabetes and Kidney Disease.
Advances in chronic kidney disease. 2018; 25: 121-32.
Brown EA. How to address barriers to peritoneal dialysis 21.
in the elderly. Peritoneal Dialysis International. 2011;
31: S83-S5.
Oliver MJ, Garg AX, Blake PG, et al. Impact of 22.
contraindications, barriers to self-care and support on
incident peritoneal dialysis utilization. Nephrology
Dialysis Transplantation. 2010; 25: 2737-44.
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu 23.
CY. Chronic kidney disease and the risks of death,
cardiovascular events, and hospitalization. NEJM. 2004;
351: 1296-305.
Nigwekar SU, Tamez H, Thadhani RI. Vitamin D and 24.
chronic kidney disease-mineral bone disease (CKD-
MBD). BoneKEy reports. 2014; 3: 498.
Zimmermann MB, Hurrell RF. Nutritional iron 25.
deciency. Lancet. 2007; 370: 511-20.
Chandyo R, Strand T, Ulvik R, et al. Prevalence of 26.
iron deciency and anemia among healthy women of
reproductive age in Bhaktapur, Nepal. Europ J of clinical
nutrition. 2007; 61: 262.
Baral K, Onta S. Prevalence of anemia amongst 27.
adolescents in Nepal: a community based study in rural
and urban areas of Morang District. Nepal Med Coll J.
2009; 11: 179-82.
Levin A, Bakris G, Molitch M, et al. Prevalence 28.
of abnormal serum vitamin D, PTH, calcium, and
phosphorus in patients with chronic kidney disease:
results of the study to evaluate early kidney disease.
Kidney international. 2007; 71: 31-8.
Chronic Kidney Disease in a Tertiary Care Hospital in Nepal
104-111