Current status of end-stage renal disease care in South Asia

Of the 1.5 million people of South Asia, a large number live in extreme poverty in rural urban areas and have limited access to health care. End-stage renal disease (ESRD) is a devastating medical, social, and economic problem. Lack of registries prevent an accurate assessment of the incidence or prevalence of ESRD, but a recent population-based study assessed the age-adjusted incidence at 232 cases per million population per year. ESRD treatment facilities are available only in major cities, requiring many patients to travel long distances to seek care. Many patients never come to medical attention. Until recently, infection-related glomerulonephritides were considered the most common cause of ESRD, but recent years have shown rapid emergence of diabetic nephropathy as the most frequent cause among new ESRD patients who are younger compared to their Western counterparts. A large number presents with a short history of ESRD of undetermined etiology and often require emergency dialysis. Non-availability of health insurance limits the ability of patients to afford costly ESRD care. The quality of chronic dialysis is dictated mostly by non-medical, financial factors. Maintenance hemodialysis (HD) facilities are scarce. Chronic peritoneal dialysis is not cheaper than HD; high cost and nephrologist bias have limited the growth of peritoneal dialysis in South Asia. Transplants using organs from a related donor is the only viable form of renal replacement therapy for the majority. Cost issues and lack of an effective deceased donor program have limited its availability. Improvement in ESRD care would require strong support from the government, awareness on the part of the medical community of the need of timely referral of these patients to the nephrologist, appropriate pre-dialysis education and development of a network of integrated ESRD treatment facilities for optimal utilization of all forms of renal replacement therapy so that the outcomes of these patients can be improved.