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      Public health interventions for chronic diseases: cost–benefit modelizations for eradicating chronic kidney disease of multifactorial origin (CKDmfo/ CKDu) from tropical countries

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          Abstract

          Background

          In the mid-1970s, an unusual chronic kidney disease of multifactorial origin (CKDmfo), also known as CKD of unknown aetiology (CKDu), began to manifest in several economically poor, tropical, agricultural countries. This preventable, environmentally induced, occupational disease affects several peri-equatorial countries; it first manifested in Sri Lanka in the mid-1990s. The study goal was to estimate the costs of eradicating CKDmfo and the resulting cost savings, using CKDmfo in Sri Lanka as an example. This chronic disease model is applicable to CKDu and few other chronic diseases in other countries.

          Methodology

          Eight cost-effective, key interventions were identified that are essential to eradicate CKDmfo. A systematic assessment was performed on these interventions (including providing clean water, behavioural and lifestyle changes, alleviating malnutrition, reducing irresponsible and overuse of agrochemicals, and cost-effective treatment options), the cost of prevention, and the resultant cost savings. A cost–benefit analysis was based on the data collected during the past 20 years of work in Sri Lanka.

          Findings

          The yearly cost required to eradicate the disease was approximately one-tenth of the current annual operating and opportunity costs due to CKDmfo. Analysis indicates that implementation of a focussed chronic disease-prevention plan using essential multiple interventions, CKDmfo can be eradicated within 15 years. This includes provision of potable water; real-time disease surveillance program; public and professional education; prevention of environmental pollution; alleviation of poverty and associated malnutrition; sustainable self-sufficiency in food, clean water, energy, and security; diversification of economy and job opportunities; sustainable economic development; regionwide programs of effective screening, early diagnosis and intervention to reverse the disease progression at earliest possible; and effective treatment of CKDmfo.

          Interpretation

          This analysis is based on multiple population-level, chronic disease-eradication strategies that include an interdisciplinary, geographic information system (GIS)-based, regionwide, long-term research and intervention program; economic diversification; and environmental, socioeconomic, and behavioural improvements. Such an approach will facilitate identification of root causes and key risk factors, enabling implementation of cost-effective longer-term interventions to eradicate chronic diseases, applicable to other countries as well.

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          Most cited references35

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          Reverse osmosis desalination: water sources, technology, and today's challenges.

          Reverse osmosis membrane technology has developed over the past 40 years to a 44% share in world desalting production capacity, and an 80% share in the total number of desalination plants installed worldwide. The use of membrane desalination has increased as materials have improved and costs have decreased. Today, reverse osmosis membranes are the leading technology for new desalination installations, and they are applied to a variety of salt water resources using tailored pretreatment and membrane system design. Two distinct branches of reverse osmosis desalination have emerged: seawater reverse osmosis and brackish water reverse osmosis. Differences between the two water sources, including foulants, salinity, waste brine (concentrate) disposal options, and plant location, have created significant differences in process development, implementation, and key technical problems. Pretreatment options are similar for both types of reverse osmosis and depend on the specific components of the water source. Both brackish water and seawater reverse osmosis (RO) will continue to be used worldwide; new technology in energy recovery and renewable energy, as well as innovative plant design, will allow greater use of desalination for inland and rural communities, while providing more affordable water for large coastal cities. A wide variety of research and general information on RO desalination is available; however, a direct comparison of seawater and brackish water RO systems is necessary to highlight similarities and differences in process development. This article brings to light key parameters of an RO process and process modifications due to feed water characteristics.
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            What do we know about chronic kidney disease in India: first report of the Indian CKD registry

            Background There are no national data on the magnitude and pattern of chronic kidney disease (CKD) in India. The Indian CKD Registry documents the demographics, etiological spectrum, practice patterns, variations and special characteristics. Methods Data was collected for this cross-sectional study in a standardized format according to predetermined criteria. Of the 52,273 adult patients, 35.5%, 27.9%, 25.6% and 11% patients came from South, North, West and East zones respectively. Results The mean age was 50.1 ± 14.6 years, with M:F ratio of 70:30. Patients from North Zone were younger and those from the East Zone older. Diabetic nephropathy was the commonest cause (31%), followed by CKD of undetermined etiology (16%), chronic glomerulonephritis (14%) and hypertensive nephrosclerosis (13%). About 48% cases presented in Stage V; they were younger than those in Stages III-IV. Diabetic nephropathy patients were older, more likely to present in earlier stages of CKD and had a higher frequency of males; whereas those with CKD of unexplained etiology were younger, had more females and more frequently presented in Stage V. Patients in lower income groups had more advanced CKD at presentation. Patients presenting to public sector hospitals were poorer, younger, and more frequently had CKD of unknown etiology. Conclusions This report confirms the emergence of diabetic nephropathy as the pre-eminent cause in India. Patients with CKD of unknown etiology are younger, poorer and more likely to present with advanced CKD. There were some geographic variations.
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              Chronic kidney disease of uncertain aetiology: prevalence and causative factors in a developing country

              Background This study describes chronic kidney disease of uncertain aetiology (CKDu), which cannot be attributed to diabetes, hypertension or other known aetiologies, that has emerged in the North Central region of Sri Lanka. Methods A cross-sectional study was conducted, to determine the prevalence of and risk factors for CKDu. Arsenic, cadmium, lead, selenium, pesticides and other elements were analysed in biological samples from individuals with CKDu and compared with age- and sex-matched controls in the endemic and non-endemic areas. Food, water, soil and agrochemicals from both areas were analysed for heavy metals. Results The age-standardised prevalence of CKDu was 12.9% (95% confidence interval [CI] = 11.5% to 14.4%) in males and 16.9% (95% CI = 15.5% to 18.3%) in females. Severe stages of CKDu were more frequent in males (stage 3: males versus females = 23.2% versus 7.4%; stage 4: males versus females = 22.0% versus 7.3%; P  39 years and those who farmed (chena cultivation) (OR [odds ratio] = 1.926, 95% CI = 1.561 to 2.376 and OR = 1.195, 95% CI = 1.007 to 1.418 respectively, P < 0.05). The risk was reduced in individuals who were male or who engaged in paddy cultivation (OR = 0.745, 95% CI = 0.562 to 0.988 and OR = 0.732, 95% CI = 0.542 to 0.988 respectively, P < 0.05). The mean concentration of cadmium in urine was significantly higher in those with CKDu (1.039 μg/g) compared with controls in the endemic and non-endemic areas (0.646 μg/g, P < 0.001 and 0.345 μg/g, P < 0.05) respectively. Urine cadmium sensitivity and specificity were 70% and 68.3% respectively (area under the receiver operating characteristic curve = 0.682, 95% CI = 0.61 to 0.75, cut-off value ≥0.397 μg/g). A significant dose–effect relationship was seen between urine cadmium concentration and CKDu stage (P < 0.05). Urine cadmium and arsenic concentrations in individuals with CKDu were at levels known to cause kidney damage. Food items from the endemic area contained cadmium and lead above reference levels. Serum selenium was <90 μg/l in 63% of those with CKDu and pesticides residues were above reference levels in 31.6% of those with CKDu. Conclusions These results indicate chronic exposure of people in the endemic area to low levels of cadmium through the food chain and also to pesticides. Significantly higher urinary excretion of cadmium in individuals with CKDu, and the dose–effect relationship between urine cadmium concentration and CKDu stages suggest that cadmium exposure is a risk factor for the pathogensis of CKDu. Deficiency of selenium and genetic susceptibility seen in individuals with CKDu suggest that they may be predisposing factors for the development of CKDu.
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                Author and article information

                Contributors
                Journal
                Heliyon
                Heliyon
                Heliyon
                Elsevier
                2405-8440
                01 November 2019
                October 2019
                01 November 2019
                : 5
                : 10
                : e02309
                Affiliations
                [1]Professor of Medicine, Endocrinology & Nutrition, Cardio-Metabolic & Endocrine Institute, New Jersy, U.S.A.
                Author notes
                []Corresponding author. suniljw@ 123456hotmail.com
                Article
                S2405-8440(19)35969-9 e02309
                10.1016/j.heliyon.2019.e02309
                6838989
                31720441
                47110648-94a2-4246-84d6-a68a274b3790
                © 2019 Published by Elsevier Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 4 October 2018
                : 29 March 2019
                : 12 August 2019
                Categories
                Article

                economics,health profession,epidemiology,internal medicine,pathology,physiology,public health,economic analysis,pollution,sri lanka,ckdu,socioeconomic,soil,agriculture,premature deaths,ckdmfo,cost-effective

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