Hypertension and kidney disease in Asia

PURPOSE OF REVIEW: Communicable diseases were traditionally the major cause of public health concern in Asian countries, most of which were less developed. With industrialization and associated lifestyle changes during the past few decades, however, noncommunicable diseases similar to those that affect Western societies have emerged in Asian countries. The purpose of the review was to examine recent evidence about the burden and factors associated with hypertension and chronic kidney disease (CKD) in Asian countries.RECENT FINDINGS: Hypertension has become one of the leading causes of mortality in Asia. Although its prevalence continues to rise, it remains under-diagnosed and under-treated. CKD is becoming increasingly common mainly due to an increase in risk factors such as high blood pressure, diabetes, and obesity. Treatment of advanced CKD is overwhelmingly burdensome in a resource poor environment. Barriers to early detection of CKD in Asians include the fact that equations to estimate the glomerular filtration rate have not been validated in this population, and the uncertainty about appropriate glomerular filtration rate cutoff values to define CKD.SUMMARY: Concerted efforts are needed to develop and implement cost-effective strategies for prevention and treatment of hypertension and CKD in Asian countries. More research is needed on these conditions in these populations

Serum creatinine as marker of kidney function in South Asians: a study of reduced GFR in adults in Pakistan

Migrant populations of South Asian origin have a higher risk for chronic kidney disease than the native whites. Several formulas have been developed to estimate kidney function from serum creatinine concentration. However, none of these has been validated in the South Asian population, which generally has different muscle mass composition than whites. A population-based cross-sectional study was performed on 262 individuals who were aged \u3e or = 40 yr in Karachi, Pakistan. Reduced GFR was defined as creatinine clearance (Ccr) measured in 24-h urine collection of /min per 1.73 m2. Creatinine excretion was compared with age- and gender-matched white individuals by comparison of observed versus expected results on the basis of a formula using t test. The agreement among Cockcroft Gault (CG) Ccr and Modification of Diet in Renal Disease (MDRD) Study GFR equations was assessed by regression analyses, and the degree of accuracy of estimated versus measured GFR was determined. Mean (95% confidence interval) creatinine excretion was 1.7 (1.0 to 2.4) mg/kg per d lower than expected for age- and gender-matched white individuals (P \u3c 0.001). The coefficient of determination for measured Ccr on the logarithmic scale was 66.7 and 55.6% for the CG and MDRD Study equations, respectively. The proportion of estimates within 20, 30, and 50% of measured Ccr values was 47.7 versus 32.8% (P \u3c 0.001), 64.9 versus 49.6% (P \u3c 0.001), and 79.4 versus 72.9 (P = 0.07) for CG versus MDRD Study equations, respectively. Lower mean creatinine excretion in these individuals may explain, in part, suboptimal agreement between estimated versus measured GFR. Inclusion of terms for ethnic and racial groups other than white and black might improve the performance of GFR estimating equations

Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial.

BACKGROUND: Evidence on economically efficient strategies to lower blood pressure (BP) from low- and middle-income countries remains scarce. The Control of Blood Pressure and Risk Attenuation (COBRA) trial randomized 1341 hypertensive subjects in 12 randomly selected communities in Karachi, Pakistan, to 3 intervention programs: (1) combined home health education (HHE) plus trained general practitioner (GP); (2) HHE only; and (3) trained GP only. The comparator was no intervention (or usual care). The reduction in BP was most pronounced in the combined group. The present study examined the cost-effectiveness of these strategies. METHODS AND RESULTS: Total costs were assessed at baseline and 2 years to estimate incremental cost-effectiveness ratios based on (1) intervention cost; (2) cost of physician consultation, medications, diagnostics, changes in lifestyle, and productivity loss; and (3) change in systolic BP. Precision of the incremental cost-effectiveness ratio estimates was assessed by 1000 bootstrapping replications. Bayesian probabilistic sensitivity analysis was also performed. The annual costs per participant associated with the combined HHE plus trained GP, HHE alone, and trained GP alone were $3.99,$3.34, and $0.65, respectively. HHE plus trained GP was the most cost-effective intervention, with an incremental cost-effectiveness ratio of$23 (95 confidence interval, 6-99) per mm Hg reduction in systolic BP compared with usual care, and remained so in 97.7 of 1000 bootstrapped replications. CONCLUSIONS: The combined intervention of HHE plus trained GP is potentially affordable and more cost-effective for BP control than usual care or either strategy alone in some communities in Pakistan, and possibly other countries in Indochina with similar healthcare infrastructure

Dietary Patterns and their Association with Hypertension Among Pakistani Urban Adults

Hypertension is one of the most common chronic diseases affecting more than 25% of adults worldwide. In Pakistan, 33% of the adult population suffers from hypertension. Numerous epidemiological studies have demonstrated the critical role of dietary patterns in the causation, prevention and management of hypertension. There’s a dearth of evidence from South Asia in this regard. The present study aimed to identify the association between dietary patterns and hypertension among 4304 low income urban adults who participated in the Control of Blood Pressure and Risk Attenuation (COBRA) study in Karachi, Pakistan. Dietary information was collected by a 33- item food frequency questionnaire and 3 unique dietary patterns namely; fat and sweet, fruit and vegetable, and seafood and yogurt patterns were derived using principal component factor analyses. We used univariate and multivariable logistic regression to examine the association between dietary patterns and hypertension. Men were more likely to have hypertension, while increase in age, and body mass index were also associated with hypertension (p\u3c0.001). After adjusting for age, gender, education, marital status, body mass index, and tobacco use; the seafood and yogurt pattern was less likely (OR=0.78: 95% CI: 0.63, 0.98; p-value 0.03) to be associated with hypertension, whereas no significant associations were seen for other two dietary patterns. These findings suggest that certain dietary patterns may be associated with hypertension among Pakistani low income urban adults

Do Dietary Patterns Explain High Prevalence of Cardiovascular Risk Factors Among Pakistani Urban Adults? A Cross-Sectional Study

Background The prevalence of cardiovascular disease (CVD) in South Asia is higher than in any other developing countries. The diversity of diets in populations among developing countries may be one explanation for the differences in CVD. This study was carried out to explore the association between dietary patterns and the presence of cardiovascular risk factors among Pakistani low income urban adults. Methods Socio demographic, physical activity and dietary information was collected from 1546 Pakistani subjects aged ≥40 years from the Control of Hypertension and Risk Attenuation (COBRA) study. Anthropometric, clinical and biomarker measures were assessed. Cluster analysis was used to identify dietary patterns from a food frequency questionnaire (FFQ) and multinomial regression was employed to investigate the association between dietary clusters and cardiovascular risk factors, using one of the dietary clusters as a reference category. Results The most prevalent CVD risk factors among participants were elevated low density lipoprotein- cholesterol (LDL-C) (69.8 %) and systolic blood pressure (SBP) (68.2 %), followed by central obesity (57.1 %), low levels of high density lipoprotein-Cholesterol (HDL-C) (56.3 %), overall obesity (46.0 %), high total cholesterol (32.3 %), and elevated fasting blood sugar (FBS) (34.9 %). The cluster analysis generated 3 non-overlapping diet patterns. Cluster 1(Traditional Pakistani Diet), was dominated by fruits, vegetables, milk products and chicken, included participants with high mean body mass index (BMI), waist circumference (WC), HDL-C and low mean SBP. Cluster 2 (Moderate Diet) reflected a moderate intake of most food items and included participants with significantly higher mean SBP. Cluster 3 (Fatty Diet) was characterized by high intake of beef, whole milk, paratha and lentils and those following this cluster had a low mean HDL-C and high SBP. In analyses controlling for age, gender, tobacco use and physical activity, participants in the Traditional diet cluster were more likely to be overweight (OR 1.39, 95 % CI 1.08 to 1.78) and high central adiposity (1.33, 95 % CI 1.04 to 1.71) than participants in the Moderate diet cluster, though less likely to have elevated SBP (OR 0.67, 95 % CI 0.51 to 0.86). LDL-C levels were higher in both the traditional Pakistani diet and Fatty diet cluster compared to the Moderate diet cluster. Low HDL-C was also more prevalent among the Traditional Pakistani diet cluster. Conclusion Among Pakistani population discernable diet patterns can be derived using clusters analysis. CVD risk factors prevalence differed by cluster membership, though relations for specific CVD risk are not consistent across clusters

Diabetes, cardiovascular disease, and chronic kidney disease in South Asia: current status and future directions

No abstract available

Chronic kidney disease

Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients

Prevalence of microalbuminuria and associated electrocardiographic abnormalities in an Indo-Asian population

Background. Microalbuminuria (MA) is a known predictor of cardiovascular disease (CVD) in European origin populations, but such data are lacking in native Indo-Asian populations, where CVD risks are high. Major electrocardiographic (ECG) changes are predictive of cardiovascular mortality. We determined the association of MA with major ECG changes in the general population of Pakistan