Prevention of chronic renal failure at the community level.

Renal transplantation in India costs about US$5000 ($1=Rupees 48.25), azathioprine costs $200 a year and cyclosporine costs $2000. Against this the average per capita income is $279 (Rs. 12989) per year; 36% of the population earn less than $105, and only 2.2% earn more than $1000. The country cannot afford to treat end-stage renal disease. Thirty percent of chronic renal failure is due to diabetic nephropathy, and 10% each to hypertensive nephropathy and chronic pyelonephritis. Social and preventive health workers of the Kidney Help Trust administered a questionnaire at the homes of a study population of 25,000, examined the urine of every individual for albumin and reducing substances, and checked the blood pressure of every person aged over 5; 90% of the population cooperated. Six percent were hypertensive and four percent had diabetes. Eight percent of them subsequently took regular treatment. Using only reserpine, hydrallazine and hydrochlorothiazide for hypertension, and glibenclamide and metformin for diabetes (as these are the cheapest agents available), we were able to control the blood pressure to 140/90 or less in 96% of cases, and to reduce HbAIC by 10% or more of the original reading in 77%. An HbA1C of 7% was achieved in 50% of the diabetic subjects. The total cost amounts to 27 US cents for one year per capita of the study population. The Indian Government now spends $7.67 per capita on health each year, but expects patients to attend its Primary Health Centers. The patients do not attend because in doing so they lose a day's wages. We believe that domiciliary treatment is the solution for these diseases, and expect to see a fall in the incidence of chronic renal failure if this is instituted in the future.