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Early detection and management of chronic kidney disease programs in Nepal
Sanjib Kumar Sharma MD, Department of Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal

Introduction
Nepal is a poor country that cannot afford renal replacement therapy for ESRD due to lack of resources. Diabetes mellitus, glomerulonephritis and hypertension are the most important causes of ESRD in Nepal. Therefore, the prevention programs are directed to early detection and management chronic kidney disease and their risk factors.

Methodology
Various programs to create public awareness on kidney disease and their risk factors were organized, which was followed by a door-to-door screening and intervention program conducted in 3218 people ｳ 20 years old in Dharan, Nepal. Lifestyle habit, physical examination and blood pressure were assessed. Spot urine was examined for proteins and glucose by dipstick. Fasting blood glucose and serum creatinine were measured in a subset of people. CKD was diagnosed based on dipstick proteinuria and/or GFR <60 ml/min/1.73 m2 (as MDRD - 4 variables). A cardiovascular risk factor score, 0 to 6, was determined. After 1 year of patient management, achievement of blood pressure and glycemic control and reduction of proteinuria was assessed.

Results
Mean age of screened subjects was 42.9 ｱ 14.48 years. History of CKD was documented in 0.5%. 23.5% were smokers and 52.9% had sedentary life style. Overweight, obesity, diabetes, hypertension and proteinuria were found in 25.3%, 5.3%, 7.5%, 38.6%, and 5.0% respectively. 47% hypertensives were newly detected during the screening. Only 25% of known diabetics were treated with adequate glycemic control. 51% of known hypertensive patients were on treatment but only 41% of them had adequate blood pressure control. CKD was detected in 10.6%. Two or more cardiovascular risk factors were present in 47.3%. Multivariate logistic regression analysis showed that age [OR 1.05 (1.03 to 1.06), p <0.0001] and presence of diabetes [OR 2.44 (1.11 to 5.32, p = 0.027)] were statistically significant predictors for CKD. 848 patients entered the management program. 15% dropped out during follow-up. Glycemic and blood pressure control was achieved in 60% and 72%, respectively. Regression or stabilization of proteinuria was reported in 52%.

Conclusion
Burden of CKD and cardiovascular risk factors are high. Although, identification of the subjects with or at high risk of developing chronic renal diseases and implementation of prevention program in retarding the progression to ESRD support of huge financial and human resources remains highly challenging.