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Letter to the Editor
ARTICLE IN PRESS
doi:
10.25259/IJN_165_2024

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

Department of Nephrology, Osmania Medical College and Hospital, Afzalgunj, Hyderabad, India
Corresponding author: Manisha Sahay, Department of Nephrology, Osmania Medical College and Hospital, Afzalgunj, Hyderabad, India. E-mail: drmanishasahay@gmail.com
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How to cite this article: Sahay M. Hub and Spoke Model for Kidney Care – From Prevention to Treatment. Indian J Nephrol. doi: 10.25259/IJN_165_2024

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.

Table 1: Hub and spoke model with Osmania Medical College and Hospital hub center
Name of district Name of the facility Distance from Hub in kilometers Total number of functional dialysis machines Number of new patients registered (March 2024) Number of dialysis sessions held (March 2024) Total patients who came for dialysis (March 2024) Cumulative number of dialysis sessions held
Bodhan Bodhan 205 5 1 497 46 4345
Hyderabad Nampally 5 5 3 338 30 2590
Golconda 11 5 1 265 26 2096
Malakpet 5 10 997 82 7506
Osmania 0 18 20 2318 247 20063
Kamareddy Bichkunda 170 5 1 189 17 3817
Yellareddy 158 5 309 26 2771
Banswada 167 10 1 472 37 4419
Kamareddy 113.6 9 560 54 5246
Medchal Ghatkeshar 28 5 2 646 55 5850
Nalgonda Nagarjuna Sagar 156 5 1 260 24 2606
Devarakonda 107 5 452 37 5295
Miryalaguda 145 5 1 611 71 5413
Nalgonda 102 10 5 1145 109 10144
Nizamabad Armoor 206 5 1 462 43 6490
Dichpally 220 5 1 175 15 625
Nizamabad 216 15 976 84 6381
Suryapet Kodad 182 5 3 472 47 4592
Huzurnagar 191 5 1 523 51 4811
Suryapet 139 5 1 515 53 4662
Yadadri Bhongir Choutuppal 50 5 424 41 5943
Bhongir 80 5 1 551 46 6289
155 46 13331 1259 124715

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.

Hub and spoke model of kidney disease prevention and kidney replacement therapy (KRT).
Figure 1:
Hub and spoke model of kidney disease prevention and kidney replacement therapy (KRT).

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.

Conflicts of interest

There are no conflicts of interest.

References

  1. Available from https://pmndp.mohfw.gov.in/en [Last accessed 2024 April 01].
  2. , , . Hemodialysis at Doorstep – “Hub-and-spoke” model of dialysis in a developing country. Saudi J Kidney Dis Transpl. 2020;31:840-9.
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  3. . KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2022;102:S1-S127.
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  4. , , , . EMPA-KIDNEY: Expanding the range of kidney protection by SGLT2 inhibitors. Clin Kidney J. 2023;16:1187-98.
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  5. , , , , , . Equity and quality of global CKD care – what are we waiting for? Am J Nephrol 2023 doi: 10.1159/000535864
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