A 54-year-old Indian tricycle rickshaw puller, the sole breadwinner of a family of five, was diagnosed with hypertension during routine evaluation for easy fatigability. On further investigations, he was found to have anaemia, a serum creatinine concentration of 4.6 mg/dl, blood urea nitrogen of 80 mg/dl, an estimated glomerular filtration rate (GFR) of 19 ml/min/1.73 m² of body-surface area and bilateral shrunken kidneys, with loss of corticomedullary differentiation. The patient was advised long-term dialysis or transplantation, for which neither the patient nor the relatives were willing to proceed because of economic constraints, and got the patient discharged against medical advice. This situation clearly epitomises the situation of patients with chronic kidney disease (CKD) in India.

The attention being paid globally to CKD is attributable to five factors: the rapid increase in its prevalence, the enormous cost of treatment, recent data indicating that overt disease is the tip of an iceberg of covert disease, an appreciation of its major role in increasing the risk of cardiovascular disease and the discovery of effective measures to prevent its progression. These factors render CKD an important focus of healthcare planning even in the developed world, but the problems they delineate in the developing world are far more challenging. There are no concrete data on the true incidence and prevalence of chronic renal failure in the developing world. Delayed diagnosis and failure of institution of measures to slow progression of renal failure result in a predominantly young population with end-stage renal disease (ESRD). Some 85% of the world’s population live in low-income or middle-income countries, where the clinical, epidemiological and socioeconomic effects of the disease are expected to be the greatest. Data from the US suggest that, for every patient with ESRD, there are >200 patients with …