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Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 55-59

To identify newer probable risk factors of chronic kidney disease in the indian population: A case–control study

1 Department of Medicine, SBKS MIRC, Sumandeep Vidyapeeth University, Piparia, Vadodara, Gujarat, India
2 Department of Pharmacy, Sumandeep Vidyapeeth University, Piparia, Vadodara, Gujarat, India

Date of Submission11-Apr-2019
Date of Acceptance25-Jul-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Saurabh Mamtani
C-320 Anand Baug Society, Vadodara, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_14_19

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Introduction: This study was conducted to identify unknown factors which may have been contributing to the increasing incidence of chronic kidney disease (CKD) in the Indian population. Materials and Methods: We performed a population-based observational case–control study on patients having CKD as cases and their age- and sex-matched disease-free controls for 6 months. Detailed information on demographic, socioeconomic, behavioral, dietary, and medical history was collected using validated self-structured questionnaire, and the data were statistically analyzed to find out the association between various dietary, environmental, and behavioral factors and CKD. Results: The mean age of patients having CKD was 49.6 ± 14.59 years, with male-to-female ratio of 1.94:1. The history of consumption of nonsteroidal anti-inflammatory drugs, insomnia, obstructive sleep apnea, antibiotics, and smoking was present in 66%, 65%, 54%, 30%, and 27%, respectively. Anemia and malaria were present in 11.3% each. 17% gave a history of low water intake. People living in the rural area with no or limited medical facilities were more prone to CKD (55%). Conclusions: Although some of our observations may have been influenced by confounding and we cannot confirm these as causative associations, we were able to identify the unknown factors which may be contributory. This study at least opens up new areas of research to find causative factors for CKD and target health policies toward them to constraint the rapidly increasing prevalence and burden of the disease.

Keywords: Chronic kidney disease, chronic kidney disease a global burden, chronic kidney disease Indian population, new risk factor of chronic kidney disease, risk-factors of chronic kidney disease

How to cite this article:
Muley A, Mamtani S, Mistry M, Kantharia H, Chandrakar VR. To identify newer probable risk factors of chronic kidney disease in the indian population: A case–control study. Curr Med Issues 2019;17:55-9

How to cite this URL:
Muley A, Mamtani S, Mistry M, Kantharia H, Chandrakar VR. To identify newer probable risk factors of chronic kidney disease in the indian population: A case–control study. Curr Med Issues [serial online] 2019 [cited 2023 Feb 2];17:55-9. Available from: https://www.cmijournal.org/text.asp?2019/17/3/55/267902

  Introduction Top

Noncommunicable diseases (NCDs) have replaced communicable diseases as the most common cause of morbidity and premature mortality worldwide. Chronic kidney disease (CKD) is a key determinant of the poor health outcomes of major NCDs. Accordingly, many people are meeting their dooms worldwide by the affliction of this disease. An estimated 80% of the burden is in low- or middle-income countries, and 25% is in people younger than 60 years.[1] It is miserably factual that patients barely perceive any symptom till they reach an advanced stage.[2] CKD is associated with an 8–10-fold increase in cardiovascular mortality and is a risk multiplier in patients with diabetes and hypertension.[1],[3]

According to the National Kidney Foundation (NKF) guidelines, CKD is defined as either kidney damage or glomerular filtration rate (GFR) <60 ml/min/1.73 m2 for 3 or more months with or without evidence of kidney damage, irrespective of the cause.[3],[4] Considering the high prevalence of CKD risk factors, it has long been presumed that CKD represents a major public health problem in our country.[3],[5]

One way to reduce the global and national burden of CKD would be early intervention to prevent. To achieve this, the risk factors associated with CKD in our region should be identified, and then, policies should be aimed to make people aware of the risk factors.

Considering our country which hosts a number of ethnicities, widely divergent socioeconomic strata, rural–urban divide, different food habits, and varying pattern of infections, the spectrum of CKD may not be uniform in terms of etiologies, patient demographics, and clinical presentation. There is a paucity of data considering CKD in the Indian scenario; thus, there is a need of a comprehensive study to understand various aspects of CKD, especially risk factors. In this study, we tried to rediscover the traditional already existing risk factors according to the Indian scenario as well as to expose some camouflaged risk factors contributing secretly in worsening of renal diseases.

  Materials and Methods Top

This was an observational case–control study. It was conducted in the General Medicine Ward, Nephrology Ward and Dialysis Center of Dhiraj General Hospital, Piparia and Ramkrishna Paramhansa Dialysis Center, Kalali in Vadodara, Gujarat, India. The study was conducted for 6 months after getting approval from the Institutional Ethics Committee.

All patients between 18 and 80 years diagnosed with CKD according to the NKF criteria (kidney damage on ultrasonography or GFR <60 ml/min/1.73 m2 for 3 or more months with or without evidence of kidney damage) were included as cases. Patients of renal transplantation, cognitive impairment, unresponsive patients, and those with any other severe or chronic condition, for example, severe sepsis, snake bite, and malaria which may lead to renal failure were excluded from the study. Controls were randomly selected from the study base. Age- and sex-matched non-CKD participants having normal levels for the tested parameters and who complied with all the exclusion criteria of CKD patients were selected as controls.

After taking the voluntary informed consent, information regarding the history of illness, environment, and physical behavior was collected based on various prevalidated questionnaires (The WHO STEPwise approach to chronic disease risk factor Surveillance (STEPS) questionnaire for NCDs, dietary questionnaire, environmental/occupational questionnaire, and patient history questionnaire) in a face-to-face interview with participants and their family members. During the interview of dietary questionnaire, people consuming whole grains and vegetables for more than three times/week were considered as yes and below that were considered as no. Liquid consumption was considered less when the consumption was <1000 ml/day. Nonsteroidal anti-inflammatory drug (NSAID) consumption was considered to be positive if there was a history of consumption of NSAIDs at least twice a week for 1 month. We did not calculate cumulative dose as proper details regarding the compound used, and the dose taken was not available most of the times. Moreover, many of them used to consume NSAIDs on a whenever required basis. In all the other questionnaires, the yes and no patterns were self-explanatory. Antibiotic consumption was confirmed from prescription or bills whichever was available. All the data collected were transcribed into Microsoft Excel sheet for analysis. The presence of individual risk factors was determined as percentage in the CKD and non-CKD populations to find out if CKD occurs more often in individuals having some particular risk factors. A value of P with 95% confidence interval (CI) was calculated to assess the significance of difference observed between cases and controls. P < 0.05 was considered as statistically significant. Odds ratio (OR) was calculated to find the association of those risk factors with CKD.

  Results Top

A total of 142 patients were included in the study. Seventy-one were cases and 71 were controls. The mean age of the patients having CKD was 49.6 ± 14.59 years, and male-to-female ratio was 1.94:1. Nearly 9.8% of the total cases had a history of acute kidney injury. We studied many foods and environmental factors, of which we here report only those which we found to have a significant association with CKD.

Nearly 34% of cases had low household income, whereas only 4.2% of the controls had low household income, and the difference was statistically significant (OR 11.57; 95% CI, 3.29–40.66). Similarly, the number of homemakers, rural population, and industrial workers was also significantly more in cases as compared to the controls (OR 4.55, 95% CI, 1.70–12.11; OR 2.65, 95% CI, 1.36–5.39 and OR 19.14, CI, 1.08–338.33, respectively) [Table 1].
Table 1: Socioeconomic factors significantly associated with chronic kidney disease

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Habits of smoking and chewing tobacco were seen in controls and cases respectively; the data were statistically significantly more when compared to controls (OR 4.82; 95% CI, 2.3977–18.9485 and OR 73.75; 95% CI, 4.3791–1242.3031 for smoking and chewing tobacco, respectively). A significant number of cases (50.7%) had a sedentary lifestyle, while on the other hand, only 4.2% of controls had a sedentary lifestyle (OR 23.31; 95% CI, 6.7038–81.0820) [Table 2].
Table 2: Behavioral factors significantly associated with chronic kidney disease

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Significantly, large number of cases (42.3%) reported a medical history of hypertension compared to the controls (9.9%). The difference was statistically significant (OR 6.68; 95% CI, 2.6892–16.6425). Similar pattern was observed in the case of Type 2 diabetes mellitus (OR 9.11; 95% CI, 3.2704–25.4004), obstructive sleep apnea (OSA) (OR 10.52; 95% CI, 4.2420–26.1299), insomnia (OR 30.82; 95% CI, 7.3246–66.1649), anemia (OR 19.14; 95% CI, 1.0830–338.3376), and malaria (OR 8.8889; 95% CI, 1.0814–73.0670). Nearly 66.2% of cases had a history of NSAID consumption, while only 19.7% of controls reported the same. The history of use of antibiotics was also seen in approximately 30% cases and only 5.6% controls. Thus, NSAID and antibiotic consumption was also statistically significantly more in cases as compared to the controls (OR 7.035; 95% CI, 2.2719–21.7838 and OR 7.97; 95% CI, 3.7142–17.1162, respectively) [Table 3].
Table 3: Past medical history factors significantly associated with chronic kidney disease

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We observed that consumption of green mustards was significantly higher in cases as compared to the controls (OR 6.4615; 95% CI, 2.7027–15.4482). Similarly, consumption of some other foods was also found to be significantly higher in cases as compared to the controls such as millet or bajra (OR 4.0213; 95% CI, 1.6599–9.7421), drumstick (OR 2.8933; 95% CI, 1.2180–6.8731), mint (OR 3.744; 95% CI, 1.5970–8.7775), raw banana (OR 3.485; 95% CI, 1.7316–7.0137), colocasia roots or arbi (OR 5.6019; 95% CI, 2.6874–11.6771), eggplant (OR 3.84; 95% CI, 1.3224–11.510), garlic (OR 15.6897; 95% CI, 1.9926–123.5379), ivy or tinde (OR 9.0682; 95% CI, 4.1935–19.6095), jackfruit (OR 3.0286; 95% CI, 1.4908–6.1526), cowpea or lobia (OR 2.0143; 95% CI, 1.0236–3.9639), pumpkin (OR 5.7117; 95% CI, 2.7711–11.7727), and turnip (OR 3.086; 95% CI, 1.4331–6.6221). Consumption pattern of cooking oil revealed that practice of switching the oils/month was significantly high in 35% cases compared to 1.4% controls (OR 38.0435; 95% CI 4.9808–290.5772). Others which also showed a statistically significant difference in consumption among cases and controls were cotton oil (OR 3.6003; 95% CI 1.8036–7.1990), chocolate (OR 4.4866; 95% CI 1.4084–14.2925), sweet halwa (OR 31.7027; 95% CI, 7.2097–139.4043), and consumption of sugarcane juice (OR 5.544; 95% CI, 1.9551–15.7206) [Table 4].
Table 4: Dietary components found in significantly more proportion with CKD

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When inquired about the essential ingredients and daily necessity consumption, only two factors came out to be statistically significant, i.e., low water intake of 1–2 l in a day (OR 3.4068; 95% CI, 1.0422–11.1367) and consumption of uniodized salt (OR 6.325; 95% CI, 1.3480–29.6775) [Table 4].

  Discussion Top

Over the past decade, CKD has been recognized as a major global public health problem.[6] India does not have established program to manage CKD patients or even to collect the data. Thus, there is a paucity of data about CKD in the Indian population.[7] A comprehensive study to understand various aspects of CKD, especially risk factors, is a need of time. In this study, our main aim was to expose some camouflaged risk factors which might be contributing secretly in worsening of renal diseases.

Of all the 71 cases interviewed, 28% of the samples were from 51 to 60 years' age group, 20% of the samples were from 31 to 40 years' age group, 18% from 61 to 70 years' age group, 15% from 41 to 50 years' age group, 13% were <30 years of age, and 6% were >70 years of age. Thus, a number of patients were the highest in the 51–60 years' age group which is in accordance to the observation by the NKF Kidney Disease Outcomes Quality Initiative that renal function decreases with age in both men and women.[4]

We found that odds of finding agricultural workers and industrial workers in patients with CKD were significantly greater than that in controls. This is in accordance with a Sri Lankan study which reported that male paddy farmers of poor socioeconomic status present with progressive nonproteinuric renal failure.[8] This may be because of exposure to environmental or industrial toxins such as residual pesticides, fluoride, aluminum, cadmium, and cyanobacteria in drinking water.

We observed that a significantly greater number of patients on maintenance hemodialysis came from the low-income background and rural areas. In a similar study, Jha suggested that shortage in the number of publically funded specialized hospitals might have resulted in patients being forced to seek care in the expensive private hospitals. However, a vast majority do not have access to health insurance and hence have to self-fund treatment.[9] Due to the lack of resources, patients from the rural background and low-income status cannot afford the treatment at an initial stage of the disease due to which CKD transforms into end-stage renal disease much rapidly. As it is suggested in the observation of our study.

Two forms of tobacco use showed a significant association with CKD in this study. First, smoking was excessively found in cases as compared to the controls. Similarly, the habit of chewing tobacco was significantly more prevalent in cases as compared to the controls. A similar finding with a pathological significance was presented by Bleyer et al. who reported that more the consumption of cigarretes or tobacco/day higher the rise in serum creatinine values.[10]

Interestingly, in this study, we found that vigorous-intensity exercise and vigorous-intensity sports were associated with CKD. There is a probability that those who drank less water in proportion to their vigorous intensity exercise developed CKD. People with sedentary lifestyle also made a significant proportion of CKD group. Kwakernaak et al. in their study showed that sedentary behaviour had a direct effect on increase of waist-to-hip ratio which was correlated with unfavorable renal hemodynamic profile.[11]

The report based on registry published by Rajapurkar et al. stated that diabetic nephropathy is the preeminent cause of CKD in India.[12] In this study, consumption of antibiotics and NSAIDs has emerged and surpassed diabetic nephropathy as the preeminent cause of CKD. A large proportion of these were over-the-counter (OTC) consumptions without professional advice. These observations indicate the dire need for strict policy and regulations against OTC painkillers and antibiotics and also community awareness of their usage.

We also found that OSA, insomnia, and malaria also showed a significant association with CKD. To the best of our knowledge, this association has not been reported earlier. Although we cannot claim a causative association based on our findings, these observations generate hypothesis for a new area of research on their pathological connection with CKD.

Some dietary components such as green mustard, colocasia roots, ivy, pumpkin, and Indian sweet items also showed a significant association with CKD. However, since we did not collect data of quantity of consumption of the dietary components in this study; therefore, we cannot specifically comment on the association of these dietary factors with CKD as there can be confounding variables present contributing to exaggerated results. However, suggestive etiology for some dietary products can be related to the adulteration of the products, for example, in the case of green mustard, argemone is the common adulterate which can be a toxic element, leading to deterioration of the kidney function. More profound research is required in the aspect of dietary factors to develop a pathological correlation between these dietary products and CKD to confirm the association and assess the strength of association to guide future dietary policies.

Hence, in this study, we were able to identify many environmental, behavioral, and dietary factors which might have association with the risk of development of CKD. Although we could not establish causation, this study gives supportive evidence for lesser known risk factors for CKD such as OSA, insomnia, vigorous-intensity exercise and sports, cigarette or tobacco consumption, agricultural and industrial workers due to dehydration, and exposure to certain toxins. Studies conducted to find out the causative association of these risk factors with CKD will help in planning preventive strategies for this crippling disease. We also plan to extend the study and include questions on quantity of consumption on factors found significantly associated with CKD in this study to assess causative relation also. This study also serves as a suggestion for professional society, public health organizations, and policymakers to deal with certain issues at an early age.

  Conclusion Top

Based on the study results, we suggest some unknown factors which might be associated with CKD. Although some of these observations may have been influenced by confounding and we cannot confirm these as causative associations, we were able to identify the unknown factors which may be contributory. This study at least opens up new areas of research to find causative factors for CKD and target health policies toward them to constraint the rapidly increasing prevalence and burden of the disease.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int 2011;80:1258-70.  Back to cited text no. 1
Huda MN, Alam KS, Rashid HU. Prevalence of chronic kidney disease and its association with risk factors in disadvantageous population. Int J Nephrol 2012;2012:267329.  Back to cited text no. 2
Sathya GR. Prevalence of Risk factors for chronic kidney disease in a coastal area of Tamil Nadu, South India. IOSR Journal of Dental and Medical Sciences 2012;2:29-33.  Back to cited text no. 3
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1-266.  Back to cited text no. 4
Kazancioǧlu R. Risk factors for chronic kidney disease: An update. Kidney Int Suppl (2011) 2013;3:368-71.  Back to cited text no. 5
Schoolwerth AC, Engelgau MM, Hostetter TH, Rufo KH, Chianchiano D, McClellan WM, et al. Chronic kidney disease: A public health problem that needs a public health action plan. Prev Chronic Dis 2006;3:A57.  Back to cited text no. 6
Agarwal SK, Srivastava RK. Chronic kidney disease in India: Challenges and solutions. Nephron Clin Pract 2009;111:c197-203.  Back to cited text no. 7
Bandara JM, Senevirathna DM, Dasanayake DM, Herath V, Bandara JM, Abeysekara T, et al. Chronic renal failure among farm families in cascade irrigation systems in Sri Lanka associated with elevated dietary cadmium levels in rice and freshwater fish (Tilapia). Environ Geochem Health 2008;30:465-78.  Back to cited text no. 8
Jha V. Herbal medicines and chronic kidney disease. Nephrology (Carlton) 2010;15 Suppl 2:10-7.  Back to cited text no. 9
Bleyer AJ, Shemanski LR, Burke GL, Hansen KJ, Appel RG. Tobacco, hypertension, and vascular disease: Risk factors for renal functional decline in an older population. Kidney Int 2000;57:2072-9.  Back to cited text no. 10
Kwakernaak AJ, Zelle DM, Bakker SJ, Navis G. Central body fat distribution associates with unfavorable renal hemodynamics independent of body mass index. J Am Soc Nephrol 2013;24:987-94.  Back to cited text no. 11
Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India:First report of the Indian CKD registry. BMC Nephrol 2012;13:10.  Back to cited text no. 12


  [Table 1], [Table 2], [Table 3], [Table 4]


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