Prevalence of chronic kidney disease in Thai adults: a national health survey

<p>Abstract</p> <p>Background</p> <p>The prevalence of patients with end stage renal disease (ESRD) who need dialysis and/or transplantation has more than doubled in Thailand during the past two decades. It has been suggested that therapeutic strategies to reduce the risk of ESRD and other complications in CKD are now available, thus the early recognition and the institution of proven therapeutic strategies are important and beneficial. We, therefore, aimed to determine the prevalence of CKD in Thai adults from the National Health Examination Survey of 2004.</p> <p>Methods</p> <p>Data from a nationally representative sample of 3,117 individuals aged 15 years and older was collected using questionnaires, physical examination and blood samples. Serum creatinine was measured by Jaffé method. GFR was estimated using the Chinese modified Modification of Diet in Renal Disease Study equation. Chronic kidney Disease (CKD) stages were classified based on Kidney Disease Outcome Quality Initiative (K/DOQI).</p> <p>Results</p> <p>The prevalence of CKD in Thai adults weighted to the 2004 Thai population by stage was 8.1% for stage 3, 0.2% and 0.15% for stage 4 and 5 respectively. Compared to non-CKD, individuals with CKD were older, had a higher level of cholesterol, and higher blood pressure. Those with cardiovascular risk factors were more likely to have CKD (stage 3-5) than those without, including hypertension (OR 1.6, 95%CI 1.1, 3.4), diabetes (OR 1.87, 95%CI 1.0, 3.4). CKD was more common in northeast (OR 2.1, 95%CI 1.3, 3.3) compared to central region. Urinalysis was not performed, therefore, we could not have data on CKD stage 1 and 2. We have no specific GFR formula for Thai population.</p> <p>Conclusion</p> <p>The identification of CKD patients should be evaluated and monitored for appropriate intervention for progression to kidney disease from this screening.</p

Assessing the Cost-Effectiveness of Interventions for Cardiovascular Disease Prevention in Thailand

Background: Economic evaluation of interventions for disease prevention and treatment is increasingly popular worldwide due to the need to efficiently allocate limited health care resources. Cardiovascular disease (CVD) is a major health problem in Thailand. Aims: To provide the Thai healthcare system with information on ways to efficiently reduce CVD. Methods: The dissertation is composed of six parts. The first part involves literature search to convey an understanding of CVD epidemiology (incidence, prevalence, and mortality), and health and economic outcomes. General methods for assessing burden of disease and risk factors and economic evaluation are also presented. Although this thesis advocates the use of ‘absolute CVD risk assessment’ in favour of treatment by individual risk factors, the second chapter reports the joint prevalence, treatment and control, and factors associated with diagnosis, treatment and control of hypercholesterolemia and hypertension using data from a national health survey. This was done to gain an overview of both risk factors and their current treatment in Thailand before turning to the absolute risk approach. Chapter Three measures associations, in terms of relative risk (RR), of systolic blood pressure (SBP) and cholesterol (TC) with ischaemic heart disease (IHD) and stroke. RRs of IHD/stroke associated with 10 mmHg increase in SBP or 1 mmol/l increase in TC are assessed for 2,702 males and 797 females aged 35-54 at the start of study using Cox Proportional Hazards Models. The results are compared with those obtained elsewhere. Chapter Four presents the development of a tool for predicting CVD risks for Thai people. Framingham risk equations are recalibrated using contemporary cumulative risks of CVD. Using Thai population data, predictions of the recalibrated equations are compared with those generated with a published equation. Chapter Five assesses the cost-effectiveness of blood pressure (BP) and TC lowering drugs for CVD prevention in 6 population subgroups by sex and level of absolute CVD risk. A Markov model is developed with 4 explicit health states: alive without CVD, alive with IHD, alive with stroke and death. The comparator is doing nothing. Current practice is also assessed. Results: There is clear evidence for a causal link between CVD and several risk factors (such as suboptimal blood pressure (BP) and total cholesterol (TC), tobacco use, and diabetes mellitus), and a number of interventions have been proven effective against CVD. Reduction of TC and/or BP from any level is beneficial in reducing CVD incidence. The terms ‘hypertension’ or ‘hypercholesterolemia’ have become clinically less important than ‘absolute CVD risk’, which takes into account synergistic effects of multiple risk factors. Although the evidence comes mainly from developed countries, there is a trend towards greater risk factor exposure in many developing countries because of changes towards life styles with high fat consumption, low physical activity levels, and low vegetable and fruit consumption. Rises in CVD incidence in developing countries are likely (Chapter 1). In Thailand, 14% and 17% of men and women have hypercholesterolemia, 23% and 21% have hypertension, and 5% and 6% have both, respectively. A large proportion of individuals with these risk factors is not diagnosed nor treated, let alone adequately controlled (Chapter 2). Assessment of associations showed that each 1 mmol/L increase in TC is associated with a 5-fold increase in IHD risk in people aged 30-44. RRs of IHD/stroke per 10 mmHg increase in SBP are significant in all age groups. Increases in IHD and stroke risks associated with these 2 risk factors are comparable to those in the Asia Pacific and western populations (Chapter 3). In Chapter Four, average incidence of IHD in men and women aged 30+ is estimated at 480 and 500, and stroke, 840 and 720 per 100,000, respectively. Framingham equations before calibration overestimated IHD risks by 250% in men and 59% in women and stroke by 16% in men. Our equation produced similar predictions for CVD risks in Thai men over 8 years as the existing equation, but our equations can be used for predicting CVD risk at any time span and in both sexes. Assessment of the cost-effectiveness of BP and TC lowering drugs shows that the most cost-effective option for CVD prevention in people with 10-year risks of 5% and greater would be a generic ‘polypill’ (a theoretical tablet containing three BP lowering drugs (thiazide diuretics, calcium channel blockers, and angiotensin converting enzyme inhibitors) in half standard doses and a statin in standard dose) followed by a combination of the three generic BP drugs (in full doses). Current practice is much less cost-effective than these generic combinations. Conclusions: There is great scope for improved prevention of CVD in Thailand with regards to current levels and management of BP and TC and the use of effective generic drugs. Intensification of these interventions is strongly recommended. Cost-effectiveness of other population wide interventions such as the use of food condiments high in potassium and low in sodium and tobacco use cessation should be further investigated

Generalized cost-effectiveness analysis of pharmaceutical interventions for primary prevention of cardiovascular disease in Thailand

Objectives: To assess the cost-effectiveness of blood pressure (BP)-lowering and cholesterol-lowering drugs for cardiovascular disease (CVD) prevention. Methods:We constructed a Markov model in which the Thai population was classified by 10-year absolute CVD risk and modeled the use of BP- and cholesterol-lowering drugs, including a "--polypill" (three BP-lowering drugs and a statin). We applied "--do-nothing" as the comparator, a health sector perspective on lifetime cost-effectiveness, 3% discounting of costs and effects, and used probabilistic sensitivity analysis. Outcomes are expressed as average and incremental cost-effectiveness in Thai baht per disability-adjusted life-year averted. Results: The polypill would be a very cost-effective option for CVD prevention even in people at modest risk (10-year risk of 5%-9.9%). Use of the three most cost-effective BP drugs is also associated with a net cost saving and large health gain at risk levels greater than 5%. Adding a generic statin gives a price per disability-adjusted life-year of 0.5 (10-year risk at 20%+) to 1.5 (10-year risk at 5%-9.9%) times Thai per-capita gross domestic product using lowest available annual costs. However, at current average drug prices, adding a statin would be considered cost-effective only for those with a 10-year absolute CVD risk of 20% and more. Conclusions:Primary CVD prevention with the polypill or a combination of three generic BP-lowering drugs is very cost-effective in the Thai population

Blood pressure, cholesterol and cardiovascular disease in Thailand

Although associations between risk factors such as hypertension and hypercholesterolaemia, and cardiovascular disease (CVD) are well-established it is not known to what extent these associations are similar in people from different ethnicities or regions. This study aims to measure the contributions of systolic blood pressure (SBP) and total cholesterol (TC) to ischaemic heart disease (IHD) and stroke in the Thai population.Data from a Thai cohort study were used for analyses. Participants were 2702 males and 797 females aged between 35 and 54 years at the start of study in 1985. Cox Proportional Hazards Models were used to assess RRs of IHD or stroke associated with SBP or TC stratified by age at the time of an event of 30-44, 45-59, and 60-69 years. During the 17 years of follow-up, 96 IHD (40 non-fatal, 56 fatal), 69 strokes (32 non-fatal and 37 fatal) occurred. Each 1 mmol/l increase in TC was associated with a fivefold increase in IHD risk in people aged 30-44 years, but not with significant increase in stroke risk in any age group. The RRs (95% CIs) of IHD per 10 mm Hg increase in SBP were 1.31 (1.04 to 1.64) and 1.46 (1.15 to 1.87), and of stroke, 1.40 (1.10 to 1.79) and 1.85 (1.40 to 2.45) in people aged 45-59 and 60-69 years, respectively.Increases in IHD and stroke risks associated with these two risk factors observed in Thailand are comparable with those in the Asia Pacific and western populations