Muhammad Ashraf, a Faisalabad-born tailor, the sole breadwinner for a family of eight, had received diagnoses of type 2 diabetes and hypertension at 31 years of age. For the next 15 years, although he felt well and visited his primary care practitioner twice a year, his conditions were poorly controlled.
When he was 40, he began to notice fatigue and loss of appetite. After several weeks of the gradual progression of these symptoms, the man sought medical attention with the kind co-operation of country's noted nephrologist Tahir Shafi of Sheikh Zayed Medical Hospital and Research Centre, and was found to have a serum creatinine concentration of 5.2 mg per decilitre.
Twice-a-week sessions of haemodialysis were initiated, but the patient had to take out a loan to pay for them and soon was unable to afford to continue treatment. He has been lost to follow-up ever since.
Given pressing medical concerns such as infectious diseases and malnutrition faced by developing countries, why should we even talk about chronic kidney disease in such places?
The fact is that many developing countries are facing a silent epidemic of chronic kidney disease one facet of the health transition associated with industrialisation. Moreover, by virtue of its progression to kidney failure and its association with accelerated cardiovascular disease, chronic kidney disease has profound effects on morbidity, mortality, and health care costs, as well as important social implications, observed well-known urologist Professor, Farrukh Khan.
Urologists are of the view that approximately 15 to 20 percent of persons 40 years of age or older have a reduced estimated urological problems in West. Although GFR estimation equations have not been validated in Asian populations, such a burden is consistent with the high prevalence of diabetes and hypertension, the two main risk factors for chronic kidney disease.
Dr Jaffar an imminent urologist of Agha Khan Hospital said that evidence indicates that chronic kidney disease develops in about a third of patients with diabetes. The burden of hypertension is even higher affecting about one third of Pakistanis 45 years of age or older, according to the 1990-1994 National Health Survey of Pakistan.
These troubling rates are fuelled in part by diets high in partially hydrogenated vegetable oil and low in fresh produce, as well as by increases in sedentary lifestyles in low-income communities, where children spend an average of four to six hours per day watching television.
Moreover, Pakistani children have higher blood-pressure levels, adjusted for body-mass index, than white children in the United States and childhood levels have been shown elsewhere to predict levels in adulthood.
Moreover, populations in which low birth weight and malnutrition are common may be predisposed to chronic diseases associated with weight gain. Dr Jaffar said despite these predisposing conditions, screening for an early detection of chronic kidney disease, particularly in high-risk patients with hypertension and diabetes, remain grossly inadequate.
In part, this failure may be attributed to the fact that the health care systems in developing countries are geared toward providing short-term, symptomatic treatment. But perhaps an even greater problem is that these high-risk patients remain largely unidentified. Although the average Pakistani adult visits a primary care physician four to five times each year, 64 percent of adults have never had their blood pressure measured, and 70 percent of patients with hypertension and 50 percent of patients with diabetes are unaware of their condition.
Compounding the problem of under-detection are gaps in the knowledge of some Pakistani physicians about the management of hypertension and diabetes, which lead to under treatment and a lack of preventive measures against chronic kidney disease. Against this backdrop of poor medical practices, patients with kidney failure are faced with the high cost of renal-replacement therapy.
Kidney transplantation costs about $5,000, and post-transplantation medications cost $2,000 annually. Thus, treating kidney failure is an un-affordable proposition for public health systems that receive 0.8 to 4 percent of the gross national product (as compared with 10 to 15 percent in developed countries).
These hard facts, coupled with the general lack of third-party health insurance, mean that less than 10 percent of patients with kidney failure receive any kind of renal-replacement therapy.
Although the number of haemodialysis centres is increasing in many regions of Pakistan, most patients who begin to receive dialysis die or stop treatment within the first three months because of cost constraints. Kidney transplantation is the cheaper option, but only about 5 percent of patients with kidney failure receive a transplant. The shortage of donors is a universal problem, and paid organ donation accounts for 70 percent of all transplantation in Pakistan.
Clearly, programmes to prevent chronic kidney disease and to treat it in the earliest stages must be designed and integrated into the existing health care infrastructure.
The World Health Organisation's Innovative Care for Chronic Conditions Framework provides a model for redesigning health care systems in accordance with local resources.
The framework emphasises a well-defined care plan, self-care, scheduled follow-up appointments, monitoring of outcomes, adherence, and stepwise treatment protocols delivered mainly by primaryy care practitioners. However, increased referrals from such programmes, even if limited to patients with advanced disease, may place excessive demands on existing nephology services.
At present, there are only about 80 formally trained nephrologists in Pakistan for a population of about 160 million (the United States has more than 5000 nephrologists for a population of about 300 million). Capacity-building efforts are therefore needed to train physicians in this speciality.
Until the public health services in Pakistan are developed further, private primary care practitioners will continue to be the frontline care givers in Pakistan.
These physicians should be required perhaps even as a prerequisite for the renewal of licensure to participate in continuing medical education programmes regarding the management of hypertension, diabetes, and chronic kidney disease.
Ideally, developing countries would have access to ample resources to set up large-scale, integrated programmes for the prevention and treatment of chronic diseases, as well as dialysis and transplantation units for patients with kidney failure.
But in reality, such resources are unlikely to be found. Low-income countries must therefore shift their emphasis from renal-replacement therapy to more cost-effective preventive services, recognising that questions of social justice and equity will inevitably arise.
Since Pakistan's resources are currently being directed toward the rehabilitation of survivors of October's earthquake, it is unlikely that more resources will be allocated for the treatment or prevention of chronic kidney disease anytime soon.
International agencies must therefore recognise that without urgent attention to the problem, the adverse consequences of hypertension, diabetes, and chronic kidney disease will bring untold misery to the next generation of inhabitants of the subcontinent who represent one sixth of the world's population.
Every cloud has a silver-lining, one should not be disappointed of grim situation, present government has taken number of drastic measures to improve the plight aimed at overcoming kidney problem in the country.
In this behalf, the Punjab government headed by the Punjab Chief Minister Chaudhry Pervaiz Elahi directed the health authorities to establish more and more hospitals for treating kidney patients beside activating Punjab Baitul Maal and other non-governmental organisations (NGO's) to come forward to help the dying community where tailor like Muhammad Ashraf will be treated in the formatic stage and will be saved instead of bidding adieu for good.