CKD: Disease Burden And Impact On Health Care From A Public Health Perspective — Dr Ghazali Ahmad

Public health needs and disease burden should be tackled and managed at the community level by public health experts and practitioners.

The prevalence of chronic kidney disease (CKD) is increasing in most countries, especially in the Asia-Pacific region, due to the increased incidence and prevalence of various non-communicable diseases (NCDs), especially hypertension, diabetes mellitus, and obesity, plus the prevalence of ageing populations.

While many patients with advanced CKD will succumb to cardiovascular events well before they need the first renal replacement therapy, the increased awareness and availability of renal replacement therapy (RRT), together with general increased expectations from the public for such treatments to be made available in public health facilities, have resulted in an increased number of patients at Stage 5 CKD being placed on regular expensive dialysis programmes.

Treatment of various types of CKD, particularly various forms of RRT for end-stage kidney disease (ESKD) is resource-intensive, requiring specialised and highly trained technicians, nurses, and clinicians, expensive medications, consumables, and hardware.

Coupled with the compromised quality of life, limited degree of rehabilitation, high complication rates either due to treatment or underlying disease, and generally reduced survival, the long-term strategy of building more dialysis units and providing more RRT including kidney transplants for ESKD patients will progressively drain the already limited health care resources, demand disproportionately higher funding compared to other treatment programmes, and is obviously non-sustainable financially in the long term.

A serious and properly planned national health programme is needed to mitigate the explosive rise of CKD by selectively targeting key NCDs for prevention, early detection and optimising care to reduce or slow down complications resulting from hypertension, diabetes mellitus, obesity, and smoking. 

As this is a major public health issue, we have to shake, reshape, and reinforce the primary health care services and system, working together with other national health and non-health agencies to tackle this lifestyle-related public health menace.  

The gaps between what have been decided as official policy by the health authorities, and what has actually been implemented and achieved with regard to prevention, detection, and management of diabetes, hypertension, and other NCDs at various levels of healthcare services, including the management of numerous multi-system complications of diabetes, will need to be addressed.

The lopsided financial and human resources and service incentives accorded to the secondary, tertiary, and specialised health services will need a major overhaul.  We need to attract the best and committed professionals to serve in the more important preventive aspects of health care to protect a proportionately larger number of the population to keep them healthy and productive.

This is a more worthwhile health system investment in the long run, rather than providing maximum resources for repeated and multiple heroic clinical procedures and funding firefighting activities for the management of complex and highly expensive treatment procedures.

These were carried out at the expense of cheaper and potentially more useful and effective health and wellness maintenance for the general population.  

As for optimising the management of those already afflicted with various NCDs, including CKD, even with the best intentions and planning, implementing any strategy or programme (including the implementation of various published clinical practice guidelines) to tackle them in the long term, can be very challenging. It will require cross-sectoral participation and support of many stakeholders, including the private health care sector, civil society, and the public.

Public health needs and disease burden should correctly be tackled and managed at the community level by public health experts and practitioners. The sooner we can get to agree on this, strengthening them with the necessary support and resources, the earlier we can get down to serious business of tackling the CKD and other NCDs effectively.

Dr Ghazali Ahmad is a consultant nephrologist at Institut Jantung Negara (IJN).

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