Deaths from renal failure among Indian adults now outstrip deaths from HIV/AIDS, signalling a major shift in causes of mortality in the country over the past decade — away from infectious disease causes to non-communicable disease causes. These are the results of a study published recently in The Lancet.
As per a National AIDS Control Organization (NACO) annual report 2015-16, in 2015, an estimated 67,600 people died of AIDS-related causes nationally. In the same year, renal failure accounted for an estimated three per cent of all premature deaths in India. The proportion of renal failure deaths has been steadily rising from 2.1 per cent in 2001-03 to 2.9 per cent in 2010-13. Compared with 86,000 renal failure deaths in 2003, the number has increased to 136,000 in 2015.
“What is more important than the absolute change in the number of deaths (which will reflect the increasing population and changing population structure in India over the past decade) is the changing age-standardised rates of renal failure death, which have significantly increased over the study time period, especially for the age group 45-69 years,” Prof. Prabhat Jha from the University of Toronto, Canada, and the corresponding author of the paper, tells me.
Renal failure is a growing cause of premature deaths in southern and eastern States in India.The rate of deaths due to renal failure at ages 15-69 years was 13 per 100,000 in 2001-03 but has since increased to 17 per 100,000 in 2010-13. Among 45 to 69 year olds, the rate has shot up from 30 per 100,000 in 2001-03 to 40 per 100,000 in 2010-13.
While the total number of deaths was more in rural areas, the death rate was higher in urban areas; the increase in deaths in urban areas increased from 27 per cent in 2001-03 to 32 per cent in 2010-13. And for reasons not known, the southern and eastern States recorded the highest number of premature renal failure deaths.
In the east (Assam, West Bengal, Odisha and Jharkhand), the death rate doubled to 50 per 100,000 population between the two time periods. In the south, Tamil Nadu had the highest death rate and it increased more than Kerala, Andhra Pradesh and Karnataka. In contrast to south and east India, the renal death rate in both north and west India remained nearly static during this time period.
“We are not able to definitely explain the reasons for the different rates of renal failure deaths in the south and east in this study. It seems likely it is due to differences in risk factors such as diabetes, including the prevalence of diabetes, how early it is diagnosed and how well controlled it is. These factors will all influence the progression of diabetes complications including renal failure,” Prof. Jha says.
While hypertension and cardiovascular disease are significantly associated with increased risk of renal failure deaths, diabetes is the leading risk factor for Indians. “Most people” with diabetes in India have poor glycaemic control.
Pointer to diagnosis
“Untreated or poorly controlled diabetes is well recognised to cause kidney complications, including progression to end-stage renal failure and death from renal failure,” he says. “Renal failure is usually a late complication of diabetes, developing many years after the onset of the disease, but among Indian adults with diabetes, we saw a substantial number of deaths in people in their fourth and fifth decade of life. This suggests that diabetes in Indian adults has been going under-diagnosed or under-treated, resulting in [an] acceleration of renal failure complications.”
Besides causing death due to renal failure, chronic kidney disease can also significantly increase the risk of premature cardiovascular death. So the total number of deaths caused by kidney disease will be much higher than those attributed to renal failure alone.