Hub and Spoke Model for Kidney Care – From Prevention to Treatment

Dear Editor,

India adds 200,000 new end-stage kidney disease (ESKD) patients to the existing pool annually. The country has seen a revolution in dialysis with 1452 dialysis centers in 748 out of 806 districts with 9902 machines under the Pradhan Mantri National Dialysis Program (PMNDP) model.¹ There are approximately 2500 nephrologists, with the majority practicing in urban areas. To address the shortage of nephrologists in rural peripheral districts, the state of Telangana has started a hub and spoke model of dialysis where the hub center, usually a teaching hospital in the city, monitors the spoke dialysis centers in the surrounding districts within a radius of 200–250 km [Table 1]. A local medical officer trained at a hub center is responsible for managing each spoke center under the guidance of the hub nephrologist.² This has markedly improved the quality of dialysis. Telemonitoring facilities have been initiated between the hub and spoke centers in some states, which is commendable.

However, kidney replacement therapy (KRT), that is, dialysis or transplant, cannot match the ever-increasing burden of ESKD. KRT imposes a huge burden on the country’s economy. The key should be prevention of CKD and/or its progression using renin angiotensin system inhibitors, sodium glucose transporter inhibitors, GLP1Ra, and finerenone.³ Empagliflozin delays kidney failure, and the need for KRT from 1.9 years, if it is initiated at eGFR 20 mL/min/1.73 m², to 26.6 years, if initiated when eGFR is 85 mL/min/1.73 m².⁴ This can happen if CKD is identified early by screening.⁵ A practical solution for screening at grassroots level could be utilizing the already existing infrastructure of dialysis units in each district as “Kidney Care Centers” [Figure 1]. This does not need any infrastructure, and a medical worker at the dialysis center can be in charge of these. A starting point could involve screening the relatives of all patients who come for dialysis. Later, these centers can be made beacons for running community screening program in that district. MBBS students at the district medical colleges can be posted on rotation at these centers and can be tasked with door-to-door screening for CKD in that district. This will help inculcate interest in research in the young students.

Close

Figure 1:

Hub and spoke model of kidney disease prevention and kidney replacement therapy (KRT).

Export to PPT

The hub and spoke model for KRT as well as primary care can address the problem of shortage of nephrologists in peripheral centers and provide an opportunity for implementing early kidney disease detection programs in the community.