In many developing countries in the South Asian region, screening for chronic diseases in the community has shown a widely varying prevalence. However, certain geographical regions have shown a high prevalence of chronic kidney disease (CKD) of unknown etiology. This predominantly affects the young and middle-aged population with a lower socioeconomic status. Here, we describe the hotspots of CKD of undiagnosed etiology in South Asian countries including the North, Central and Eastern provinces of Sri Lanka and the coastal region of the state of Andhra Pradesh in India. Screening of these populations has revealed cases of CKD in various stages. Race has also been shown to be a factor, with a much lower prevalence of CKD in whites compared to Asians, which could be related to the known influence of ethnicity on CKD development as well as environmental factors. The difference between developed and developing nations is most stark in the realm of healthcare, which translates into CKD hotspots in many regions of South Asian countries. Additionally, the burden of CKD stage G5 remains unknown due to the lack of registry reports, poor access to healthcare and lack of an organized chronic disease management program. The population receiving various forms of renal replacement therapy has dramatically increased in the last decade due to better access to point of care, despite the disproportionate increase in nephrology manpower. In this article we will discuss the nephrology care provided in various countries in South Asia, including India, Bangladesh, Pakistan, Nepal, Bhutan, Sri Lanka and Afghanistan.

Kidney disease attributable deaths and disability-adjusted life years have risen rapidly in South Asia. Diabetes is the commonest cause of kidney disease, but a substantial burden of disease is due to unmeasured risk-factors. Supported by governments, dialysis is growing but needs better oversight. The paper describes current service, training and research needs in the region.

Background: End stage renal disease patients are treated with dialysis in Nepal. But there is no renal registry to indicate the burden of disease in the country. Objectives: The objective of this study is to find out the incidence of ESRD on renal replacement therapy and their out come. Materials and methods: It is a retrospective analysis (audit) of all ESRD patients who had received dialysis inside Nepal and had under gone transplantation from 1990 to 1999. The haemodialysis (HD) registry, HD patients file, intermittent peritoneal dialysis (IPD) registry of Bir Hospital, Shree Birendra Hospital, Tribhuwan University Teaching hospital and National Kidney Center were reviewed. Acute renal failure and acute on chronic renal failure were excluded and the demographic profile, dialysis session, dialysis duration and outcome of all ESRD patients were computed. One patient was counted only once in spite of attending more than one center for dialysis. SPSS package was used for analysis. Results: Total number of 1393 ESRD patients received renal replacement therapy (RRT) in the decade. Mean age of patients were 46.7 ± 16.7 with 70% of ESRD were between 20-60 years age with male: female ratio of 1.8:1. Initial mode of RRT was IPD in 58.2%, HD in 41.7% and pre-emptive transplantation in 0.1% patients. Records of 189 patients could not be found and out of remaining 1208 patients, 85.8% received dialysis for < 3 months, 6% received dialysis for more than a year and 9.5% had undergone kidney transplantation. The incidence of ESRD had increased gradually with 3.4 per million populations (pmp) in 1990 to 11.89 pmp in 1999 with an average annual incidence of 6 pmp and only 0.31% of expected ESRD patients received RRT. Conclusion: The incidence of ESRD is increasing but majority discontinue or die within 3 months. Dialysis centers needs to be expanded to different parts of country and prospective studies have to be carried out to find out of cause of ESRD and to institute preventive measures.Key words: End stage renal disease; Renal replacement therapy; Haemodialysis; Intermittent peritoneal dialysis; Incidence of end stage renal disease; Nepal. DOI: 10.3126/kumj.v7i3.2742 Kathmandu University Medical Journal (2009) Vol.7, No.3 Issue 27, 302-305

Discuss this article AbstractEffective learning of physical examination skills (PES) requires Introduction: suitable teaching and learning techniques and assessment methods. The Tribhuvan University (Nepal) curriculum recommends involving the departments of Medicine and Surgery in PES training (PEST) for second year students as a part of early clinical exposure. The project was developed to make teaching/learning of PES structured, involving eight clinical sciences departments and using appropriate methods for teaching and assessment in KIST Medical College, Nepal.Irby's three stages of clinical teaching model (Preparation, Teaching, Methods: Reflection), was applied for teaching. Skill acquisition was based on Millers' learning pyramid at "show how level" and Dreyfus' competency model at "competent level". Teaching/learning was conducted in small groups. A tutorial, demonstration and practice (TDS) model was developed for teaching/learning techniques based on a simple five-step method for teaching clinical skills. Assessment of effectiveness of training was done at "reaction level" as per Kirkpatrick's model based on students' feedback, "shows how level" as per Miller's pyramid of learning by OSCE and "competent level" as per Dreyfus' model using retro-pre questionnaire.The analysis of retro-pre questionnaire based on the Dreyfus model Results: found the average skill score (max score 184), before the introduction of the project module as 15.9 (median = 13.5) and after as 116.5 (median = 116). A paired t-test showed the difference to be statistically significant (100. ). The average overall feedback score for the students on PES training based on seven items on a five point Likert scale was found to be 4.30. The mean total objective structured clinical examination (OSCE) score was 3.77 (SD+/-0.33) out of 5; 80% of students scored more than 70%.Students learned most of the skills with the implementation of the Conclusion: structured PES module and did well in the OSCE. Students and faculty were satisfied with the training and assessment.

Background: Renal biopsy is an invaluable tool which provides histopathological description of renal disease in terms of severity of lesion and helps in formulating the long term plan. However such studies with histopathological description of renal biopsy among Nepalese children are scarce.Material and Methods: This was a retrospective study conducted among all children aged less than 18 years who underwent renal biopsy at two tertiary centers in Nepal between July 2015 and December 2017.Results: All 72 renal biopsies were done with Bard 18G spring loaded gun. Nephrotic syndrome and mixed nephritic-nephrotic features were the commonest indications for renal biopsy. IgA nephropathy was the most frequent histopathological diagnosis (20.8%) which was mainly observed in children of age group 11-18 years followed by minimal change disease (16.7%) and diffuse proliferative glomerulonephritis (16.7%). Majority of children with recurrent gross hematuria (6/7) or mixed nephritic-nephrotic features (6/8) had IgA nephropathy. Focal segmental glomerulosclerosis (6/8) was commonest in children with steroid resistant nephrotic syndrome and nephrotic syndrome with atypical features. Majority of children (10/12) with diffuse proliferative glomerulonephritis had features of poststreptococcal glomerulonephritis and 6/12 had crescents in glomeruli. Lupus nephritis (13.9%) was the commonest secondary cause of glomerular pathology and was observed predominantly in 11-18 years age.Conclusion: Renal biopsy is safe and not associated with clinically significant complications. Nephrotic syndrome was the commonest indication for renal biopsy and minimal change disease predominated. IgA nephropathy was the commonest histological diagnosis overall, as well as in children who presented with recurrent gross hematuria or mixed nephritic-nephrotic features.