ABSTRACT

INTRODUCTION
Chronic Kidney Disease (CKD) is a global public health concern, affecting
over 10% of the world's population. It is commonly associated with comorbidities
such as diabetes, hypertension, anemia, and bone disorders. The rising prevalence
of CKD, particularly in low- and middle-income countries, poses significant
challenges in healthcare management. Early detection and appropriate management
strategies are crucial for improving patient outcomes and reducing disease
progression.
OBJECTIVE
This study aims to investigate the prevalence of common comorbidities
(diabetes, hypertension, anemia, and bone diseases) among CKD patients. Explore
the association between CKD stages and the prevalence of comorbidities. Identify
demographic and clinical characteristics associated with comorbidities in CKD
patients. Evaluate the impact of comorbidities on CKD progression and patient
outcomes. <<Use past tense in abstract/objectives>>
METHODOLOGY
A cross-sectional study was conducted across three dialysis centers in
Mirpur, Bhimber, and Kotli, AJK. A structured questionnaire was used to collect
data from 350 CKD patients. The study employed a convenient sampling method,
and data were analyzed using SPSS version 20. Ethical approval was obtained from
relevant institutional authorities.
RESULT
The study revealed that 90.3% of CKD patients had at least one
comorbidity. Hypertension (70.6%) was the most common, followed by anemia
(55.7%), diabetes (34.9%), and bone disease (26.9%). Stage 5 CKD was
predominant (92.3%), indicating a high burden of advanced disease. Comorbidities
were significantly associated with older age and male gender. Regular use of
NSAIDs (61.7%) was noted, potentially exacerbating CKD progression.
CONCLUSION
The high prevalence of comorbidities among CKD patients highlights the
need for early screening and comprehensive management strategies. Targeted

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interventions for hypertension, anemia, and diabetes could help slow CKD
progression and improve patient outcomes. Future research should focus on
multidisciplinary approaches to optimize CKD care and reduce healthcare burden.

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 CHAPTER NO.01 <<Chapter title should be centered and bold>>
INTRODUCTION
1.1CHRONIC KIDNEY DISEASE (CKD) <<Add space after heading number>>

CKD has become a leading cause of death globally and is one of the few non-
communicable diseases whose death toll has increased over the past two decades
(Kovesdy et al., 2011). <<Paragraph should be justified>>
The number of people in the United States with kidney failure requiring
dialysis or transplantation more than doubled between 2000 and 2019, reaching
nearly 800,000, with diabetes being the primary cause in 47% of cases (Tuttle et
al., 2022).
Chronic kidney disease (CKD) is a progressive condition that affects over
10% of the global population, impacting more than 800 million people worldwide.
Particularly among older adults, women, racial minorities, and individuals with
diabetes or hypertension. The burden of CKD is particularly heavy in low- and
middle-income countries, where health care systems are often the least equipped to
manage its consequences (Kovesdy et al., 2011).
Chronic kidney disease refers to a range of diverse conditions that impact
the structure and function of the kidneys. The 2002 guidelines for defining and
classifying the disease marked a significant shift, recognizing it as a global public
health issue. The guideline emphasized the need for management by general
internists (Levey, Coresh et al., 2012).
Chronic kidney disease is categorized into stages based on disease severity,
which is evaluated using glomerular filtration rate (GFR), albuminuria levels, and
clinical diagnosis (including cause and pathology). The disease can be identified
through routine lab tests, and certain treatments can prevent its progression, slow
the decline in GFR, reduce complications such as cardiovascular risk, and enhance
both survival and quality of life (Levey, Coresh et al., 2012).
1.2 KDIGO CKD CLASSIFICATION
Chronic kidney disease (CKD) is defined by kidney damage or an estimated
glomerular filtration rate (eGFR) below 60 mL/min/1.73 m² that lasts for three
months or longer, regardless of the underlying cause. CKD involves a gradual
decline in kidney function, which may eventually require renal replacement

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therapy, such as dialysis or a kidney transplant. Kidney damage is indicated by
pathological abnormalities seen on imaging or renal biopsy, irregularities in urinary
sediment, or elevated urinary albumin excretion levels (Inker et al., 2014).
The 2012 Kidney Disease Improving Global Outcomes (KDIGO)
guidelines recommend identifying the underlying cause of and classifying the
disease into six stages based on glomerular filtration rate (GFR), ranging from G1
to G5, with G3 further divided into G3a and G3b. Additionally, the classification
incorporates three stages of albuminuria (A1, A2, and A3), which are determined
by the urinary albumin-creatinine ratio (ACR; mg/g or mg/mmol) from an early
morning "spot" urine sample.
The 6 categories include:

 G1: GFR 90 ml/min per 1.73 m2 and above

 G2: GFR 60 to 89 ml/min per 1.73 m2

 G3a: GFR 45 to 59 ml/min per 1.73 m2

 G3b: GFR 30 to 44 ml/min per 1.73 m2

 G4: GFR 15 to 29 ml/min per 1.73 m2

 G5: GFR less than 15 ml/min per 1.73 m2 or treatment by dialysis

The three levels of albuminuria include an albumin-creatinine ratio (ACR).

 A1: ACR less than 30 mg/gm (less than 3.4 mg/mmol)

 A2: ACR 30 to 299 mg/gm (3.4 to 34 mg/mmol)

 A3: ACR greater than 300 mg/gm (greater than 34 mg/mmol).

The enhanced classification of CKD has been helpful in identifying

prognostic markers linked to declining kidney function and elevated albuminuria.
However, a potential drawback of these classification systems is the risk of over
diagnosing CKD, particularly in older adults (Inker et al., 2014).
1.3 STAGING
The rationale for staging asymptomatic individuals with chronic kidney
disease (CKD) is that early detection enables timely therapeutic interventions,

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reduces exposure to nephrotoxic agents, and can slow the progression of CKD to
end-stage renal disease. Additionally, early CKD detection identifies a significant
risk factor for cardiovascular disease. Another advantage of early diagnosis is the
ability to adjust medication doses and prepare for renal replacement therapy if
necessary.
Screening for CKD in adults is recommended for individuals with the
following risk factors: history of diabetes, hypertension, cardiovascular disease
(CVD), HIV or hepatitis C infection, malignancy, autoimmune diseases, kidney
stones, or recurrent urinary tract infections. Family history of kidney disease.
Patients selected for CKD screening should undergo serum creatinine measurement
and GFR estimation using mathematical formulas. Albuminuria testing, preferably
by measuring the albumin-to-creatinine ratio from a spot urine sample due to its
convenience and strong correlation with 24-hour urine excretion. Imaging studies,
particularly kidney and urinary tract ultrasounds (Ammirati et al., 2020).
Key considerations for CKD detection include GFR estimation, provides a
more accurate assessment of kidney function than serum creatinine alone. Recent
studies indicate that the EPI-CKD (Chronic Kidney Disease Epidemiology
Collaboration) equation offers a more accurate prediction of kidney outcomes and
less bias compared to the MDRD formula. The albumin-to-creatinine ratio from a
spot urine sample is a more sensitive and specific marker of CKD than the protein-
to-creatinine ratio (Ammirati et al., 2020).
1.4 CAUSES OF CKD
The primary causes of chronic kidney disease (CKD) include diabetes, high
blood pressure (hypertension), chronic glomerulonephritis, chronic pyelonephritis,
long-term use of anti-inflammatory medications, autoimmune disorders, polycystic
kidney disease, AL port syndrome, congenital malformations, and extended
episodes of acute kidney injury (Ammirati et al., 2020).
The causes of chronic kidney disease (CKD) vary worldwide, with the most
common underlying conditions leading to CKD and eventually end-stage renal
disease (ESRD) being type 2 diabetes (30%-50%), type 1 diabetes (3.9%),
hypertension (27.2%), primary glomerulonephritis (8.2%), chronic tubulointerstitial
nephritis (3.6%), hereditary or cystic diseases (3.1%), secondary

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glomerulonephritis or vacuities (2.1%), plasma cell dyscrasias or neoplasms
(2.1%), sickle cell nephropathy, which accounts for less than 1% of ESRD cases in
the U.S.
CKD can arise from conditions that affect one of three areas: prerenal (reduced
blood flow to the kidneys), intrinsic renal (issues with the blood vessels, glomeruli,
or tubules), or postrenal (obstructions affecting urine flow) (Webster, Nagler et al.,
2017).
1.5 RISK FACTORS
The risk factors associated with chronic kidney disease are following: genetic
component, family history, gender, ethnicity, age, low birth weight, obesity,
socioeconomic status, smoking, nephrotoxins, acute kidney injury, diabetes
mellitus, and hypertension (Kazancioğlu, 2013).

1.6 COMORBIDITIES ASSOCIATED WITH CKD

1.6.1 Chronic Kidney Disease (CKD) Associated Anemia
Anemia is characterized by a reduction in one or more key red blood cell
parameters, including hemoglobin concentration, hematocrit, or red blood cell
count. According to the World Health Organization (WHO), anemia is defined as a
hemoglobin level of less than 13 g/dL in men and postmenopausal women and less
than 12 g/dL in premenopausal women (Organization, 1968)
The National Kidney Foundation (NKF) defines anemia as a hemoglobin
level below 13.5 g/dL in men and less than 12.0 g/dL in women (Thomas et al.,
2008).
CKD typically presents with a normochromic, normocytic anemia as it
progresses (Besarab et al., 2000).
Approximately one-quarter of patients with stage 1 CKD, half of those with
stages 2, 3, and 4 CKD, and three-quarters of patients starting dialysis suffer from
anemia. As a result, primary care providers play a crucial role in diagnosing and
managing anemia in CKD patients.
While anemia in CKD can arise from various mechanisms such as iron,
folate, or vitamin B12 deficiencies, gastrointestinal bleeding, severe
hyperparathyroidism, systemic inflammation, and reduced red blood cell survival,
the most significant and specific cause is decreased erythropoietin production.

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Erythropoietin, a glycoprotein produced by interstitial fibroblasts in the kidneys, is
essential for the growth and differentiation of red blood cells in the bone marrow.
In CKD, tubular atrophy leads to tubulointerstitial fibrosis, which impairs the
kidneys' ability to produce erythropoietin, resulting in anemia (Ruggenenti,
Schieppati et al., 2001).
1.6.2 CKD Associated Mineral and Bone Disorders
CKD-associated mineral and bone disorders encompass abnormalities in
bone and mineral metabolism, as well as extra skeletal calcification, caused by the
pathophysiology of chronic kidney disease (CKD) (Thomas et al., 2008).
Renal osteodystrophy refers to the range of histological changes in bone
structure that occur in CKD patients. The kidneys play a crucial role in phosphate
excretion and the 1-alpha-hydroxylation of vitamin D. In CKD, hypophosphatemia
develops due to insufficient levels of 1, 25-dihydroxy vitamin D, a consequence of
reduced synthesis from kidney scarring. Additionally, the kidney's ability to excrete
phosphate is diminished, leading to a drop in serum calcium levels and an increase
in parathyroid hormone (secondary hyperparathyroidism) (Thomas et al., 2008).
Parathyroid hormone promotes phosphate excretion and increases calcium
levels by enhancing bone resorption and stimulating 1-alpha-hydroxylation of 25-
hydroxy vitamin D produced by the liver, although this effect is limited due to
kidney damage. Elevated phosphorus levels are commonly seen in patients with
stage 3 CKD. However, secondary hyperparathyroidism often begins to affect bone
structure earlier, before abnormal serum phosphorus levels are detected. As a
result, phosphate binder therapy should be initiated when estimated glomerular
filtration rates (eGFR) fall below 50 mL/min per 1.73 m² (Thomas et al., 2008).
1.6.3 Hypertension
The mechanisms contributing to hypertension in CKD include volume
overload, increased sympathetic activity, salt retention, endothelial dysfunction,
and disruptions in hormonal systems that regulate blood pressure (BP). Poorly
controlled hypertension also increases the risk of cardiovascular (CV) morbidity
and mortality (Ku, Lee et al., 2019).

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1.6.4 Diabetes
The mechanisms driving kidney disease in diabetes include hyper filtration
injury, advanced glycation end products, and reactive oxygen species. At the
molecular level, various cytokines, growth factors, and hormones, such as
transforming growth factor-beta and angiotensin II, contribute to the pathological
changes seen in diabetic nephropathy (Kazancioglu et al., 2013).
1.7 METHODS OF ESTIMATING GFR
1.7.1 Serum Creatinine as an Index of Kidney Function and Its Inherent
Limitation
Traditionally, a single plasma creatinine measurement has been used to
assess glomerular function and, by extension, diagnose and stage chronic kidney
disease (CKD). In individuals, plasma creatinine levels are typically consistent
around a homeostatic set point, with an intra-individual variation of 5.3%. As a
result, a person might experience a significant rise in plasma creatinine due to
declining kidney function, yet still have values within the reference range.
Moreover, plasma creatinine levels can be influenced by factors such as muscle
mass, diet, gender, age, and ethnicity. For example, an elderly, lean woman with
kidney impairment may have a ‘normal’ plasma creatinine level despite a reduced
GFR, while a very muscular person might have an ‘abnormal’ creatinine despite
having a normal GFR. These limitations have shifted attention toward more direct
methods of measuring GFR (Florkowski, Chew et al., 2011).
1.7.2 GFR and Creatinine Clearance
The ideal filtration marker should not be protein-bound, must be freely filtered
by the glomerulus, have no tubular secretion, be unaffected by kidney metabolism,
and be physiologically inert. Very few substances meet these criteria. The gold
standard is inulin, a plant polysaccharide that is an exogenous substance requiring
injection and a complex collection process. Other alternatives include the use of
radionuclides like 125I-iothalamate, 51Cr-EDTA, or 99mTc-DTPA, but these
procedures are labor-intensive and too expensive for routine use, making them
unsuitable for screening chronic kidney disease (CKD).
In the past, a 24-hour urine creatinine clearance value was considered a more
sensitive method for detecting kidney failure than a single plasma creatinine

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measurement. However, issues such as the inconvenience of timed urine collection,
incomplete specimen collection, and significant within-subject variability (11%)
limit its effectiveness. Additionally, since creatinine undergoes some tubular
secretion, healthy individuals can have creatinine clearance values exceeding inulin
clearance by 10 to 40%, leading to an overestimation of GFR and potentially
masking early renal impairment (Perrone, Madias et al., 1992).
1.8 CKD PREVENTION AND MANAGEMENT
1.8.1 Dietary Modification
To address the global CKD crisis, it is crucial to focus on diet and lifestyle
changes, as well as rigorous management of diabetes and hypertension.
Additionally, there should be increased attention and urgency given to policies that
ensure access to highly effective medications for patients, rather than restricting
those (Bello et al., 2005).
Growing evidence suggests that lifestyle changes, such as weight loss,
exercise, and dietary adjustments, can be both effective and protective. Several
studies have demonstrated that such modifications, whether involving weight loss
alone or in combination with regular exercise, can significantly lower the risk of
developing type 2 diabetes in overweight individuals with impaired glucose
tolerance (Lindström et al., 2003).
Dietary strategies to lower blood pressure, including reducing salt intake
and consuming diets high in fruits and vegetables while low in saturated fats, have
been shown to be effective. This was investigated in the Dietary Approaches to
Stop Hypertension-Sodium Trial (Appel et al., 2003).
Improving population health through weight reduction, regular exercise,
and dietary changes will likely decrease the number of individuals with diabetes
and hypertension over time. This, in turn, is expected to significantly reduce the
incidence of chronic kidney disease (CKD) and related cardiovascular diseases
(CVD) (Obarzanek et al., 2003). <<Use past tense in abstract/objectives>>
Smoking has been associated with the onset of micro albuminuria in both
diabetic and non-diabetic individuals (Orth et al., 2002).
Quitting smoking will likely benefit those at risk of renal disease and
cardiovascular disease (CVD). Additionally, alcohol consumption has been linked

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to the development of end-stage renal failure (ESRF) and may also elevate
cardiovascular risks by affecting systemic blood pressure (Eckardt et al., 1981).
<<Use past tense in abstract/objectives>>
1.8.2 Pharmacologic Approaches
Controlling hypertension is the most crucial intervention to reduce
albuminuria/proteinuria and prevent the development of chronic kidney disease in
both diabetic and non-diabetic individuals (Adamczak, Zeier et al., 2002).
Early detection of prehypertensive conditions, aiming for lower blood
pressure levels across the general population and more aggressive management in
patients with hypertension and underlying CKD, is essential (Initiative, 2004).
Elevated systolic blood pressure above 115 mm Hg is associated with
doubled cardiovascular disease (CVD) risk. For patients with CKD, target blood
pressure should be less than 130/80 mm Hg without diabetes or proteinuria and less
than 125/75 mm Hg for those with diabetes or proteinuria exceeding 1 g/24 h
(Levey et al., 1999).
Glycemic control is a key factor in preventing and managing diabetic
nephropathy, with target glycosylated hemoglobin levels recommended around 7%,
though levels consistently below 8% are generally protective without significant
risk of hypoglycemic complications (Parving et al., 2001).
Managing albuminuria/proteinuria is also critical for slowing CKD
progression. Antihypertensive therapies, such as ACE inhibitors or angiotensin
receptor blockers, are widely recommended for their proteinuria-lowering effects
and potential additional renoprotective benefits through reduced renal inflammation
and fibrosis. These agents also offer cardiovascular protection, helping to minimize
CKD-related cardiovascular complications (Rossing, Hommel et al., 1994).
Dyslipidemia contributes to CKD progression, and lipid reduction with
statins has been shown to be protective, potentially enhancing outcomes when
combined with renin-angiotensin-aldosterone system inhibitors. Evidence from
lipid-lowering trials suggests that statins can slow CKD progression and provide
cardiovascular benefits (Zoja et al., 2002).
A meta-analysis of over 750 trials involving around 400,000 participants
has highlighted that a combination of medications, including an ACE inhibitor, a

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statin, and other cardio protective agents like aspirin and vitamins, can reduce CVD
events by up to 80% (Fried, Orchard et al., 2001).
This multi-drug approach could be beneficial for managing progressive
CKD and preventing associated cardiovascular issues. Implementing such
strategies could be a cost-effective way to address the global burden of renal and
cardiovascular diseases. Screening programs to identify at-risk individuals and
applying early, systematic preventive treatments would be crucial for this approach
(Aminu et al., 2005).
1.9 RATIONALE OF THE STUDY
Low health literacy, lack of access to healthcare professionals, comorbidities
can significantly impact the quality of life for CKD patients. Comorbidities can
impact treatment decisions, medication management, and overall patient care. The
high burden of CKD, increased healthcare costs, and high risk of hospitalization
and mortality. While managing the CKD patient with comorbidities requires
multiple medications, which leads to an increased risk of drug interactions and
adverse reactions.
All these factors lead to various challenges in the management of CKD
patients. The strong association between CKD and comorbidities provided an idea
to conduct research to understand their prevalence and impact on patient outcomes.
The study will help to optimize resource allocation in a healthcare setting. <<Use
past tense in abstract/objectives>>
1.10 SIGNIFICANCE OF THE STUDY
The study will help to understand comorbidities in CKD patients to provide
high-quality, patient-centered care and improve health outcomes. The study
findings could be used to educate patients about the risks and management of
comorbidities, promoting better self-management. <<Use past tense in
abstract/objectives>>
Health care settings can allocate resources more efficiently when they know
which comorbidities are most prevalent. Healthcare settings could use the data
from the study to start quality improvement programs for reducing the burden of
comorbidities in CKD patients, which will lead to better health outcomes and lower
healthcare costs. <<Use past tense in abstract/objectives>>

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1.11 OBJECTIVES OF THE STUDY
 To investigate the prevalence of common comorbidities (diabetes,
hypertension, anemia, and bone diseases) among CKD patients.
 To identify the demographic and clinical characteristics that contributing as
comorbidities.
 To evaluate the effect of comorbidities on the progression of CKD and the
outcomes of patients with CKD.

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 CHAPTER NO.02 <<Chapter title should be centered and bold>>

LITERATURE REVIEW
2.1 BACKGROUND
Chronic kidney disease (CKD) is increasingly recognized as a global health
concern, impacting approximately 10% of adults worldwide, double the prevalence
of diabetes (Hill et al., 2016). This serious condition affects various organ systems
and significantly raises the risk of cardiovascular issues and mortality. The 2016
Global Burden of Disease study noted that CKD moved from the 30th leading
cause of death in 1990 to the 22nd in 2016 (Vanholder et al., 2005).
Current management strategies emphasize raising awareness among
patients, caregivers, and healthcare providers, adhering to guideline
recommendations to reduce complications and slow disease progression, and
promoting self-management techniques. Although these approaches have
demonstrated benefits, significant challenges remain (Stevens et al., 2013).
Multimorbidity, characterized by the presence of two or more chronic
conditions in an individual, is an increasing concern in the care of CKD patients
(Fraser & Taal et al., 2016). However, the relationship between comorbidities and
renal outcomes in CKD patients is not fully understood. This study aimed to
evaluate how comorbidities influence renal outcomes in individuals with stage 3–5
CKD (Lee et al., 2018).
2.2 LITERATURE STUDIES
The global burden of chronic kidney disease (CKD) is substantial, with a
prevalence of 13.4% worldwide. This translates to a significant number of patients,
between 4.9 and 7.1 million, requiring renal replacement therapy due to end-stage
kidney disease (ESKD). A cross-sectional study was conducted in the medical
department of Lady Reading Hospital, Peshawar, over a six-month period, from
July to December 2015. A total of 327 CKD patients were analyzed, revealing an

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anemia prevalence of 48.62%. The patients had a history of diabetes, hypertension,
and glomerulonephritis (A. M. Khan et al., 2018).
A descriptive study was conducted on 300 subjects across five clinical
setups in Hyderabad, Pakistan, from March to December 2019. A specialized
Performa was developed for data collection, and the glomerular filtration rate was
estimated using the Kidney Disease Epidemiology Collaboration equation. The
study found a strong relationship between kidney disease, hyperglycemia, and
hypertension, with 73.1% of the patients diagnosed with diabetes (Ali, 2021).
A systematic review and meta-analysis of population-level prevalence
studies in South Asia was performed up to October 28, 2020. Searches were
performed across three databases: PubMed, Scopus, and Web of Science. A
random-effects model was applied, revealing a prevalence of chronic kidney
disease (CKD) in adults with hypertension at 27%, diabetes at 31%, and 14% in
obese patients (Shrestha et al., 2021).
A cross-sectional study was carried out in four medical units and the
nephrology ward of Jinnah Hospital, Lahore, including the nephrology outpatient
department, from April to May 2016. Non-random purposive sampling was
employed. The results showed a hypertension prevalence of 68.3% among chronic
kidney disease (CKD) patients, with 46% having diabetes. The male population
accounted for 56%, and 53% had a history of using traditional alternative
medicines (IMRAN, FAROOQ et al.,2016).
A cross-sectional study was conducted at a tertiary care hospital in Karachi,
Pakistan, from May 2019 to October 2019. Patients' medical records were also
reviewed. The hematological profile, creatinine levels, and serum blood urea
nitrogen were documented using a predesigned Performa. The study revealed that
anemia was a predominant manifestation in patients with chronic kidney disease
(CKD), along with elevated ESR and thrombocytopenia (Asghar et al., 2021).
A cross-sectional study was carried out in Karachi, Pakistan, from January
2014 to May 2015. Data were collected through screening tests, and the Chronic
Kidney Disease Collaboration equation was used to estimate the glomerular
filtration rate. The study found a strong association between chronic kidney disease
(CKD), hypertension, and diabetes (Khurram et al., 2015).

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 A cross-sectional study was conducted at the Baluchistan Institute of
Nephrology-Urology Quetta (BINUQ), Pakistan, using a specially developed data
collection form to gather patients' socio-demographic, clinical, and laboratory data.
In the multivariate analysis, only CKD stage 5 showed a statistically significant
association with the presence of anemia (OR=4.521, P=0.001). Among the 177
anemic patients, only 75.7% received anti-anemic treatment. Of those treated,
98.5% received blood transfusions, 6.7% were given folic acid, 2.9% received iron
supplements, and 2.2% were administered vitamin B12 (Rajput, Ahmad et al.,
2020).
A cross-sectional descriptive study was undertaken at the Diabetes Clinic of
Fauji Foundation Hospital in Rawalpindi from January to August 2006. Patients
were categorized based on the presence of one to five metabolic syndrome traits. A
progressive increase in these traits was compared with a decline in creatinine
clearance. The Pearson correlation test and multiple logistic regressions were
utilized to assess correlations, with significance set at ‘r’ and ‘p’ < 0.05. Among the
104 evaluated patients, 70% had hypertension, ischemic heart disease, or a family
history of diabetes. While 20% had normal creatinine clearance, 37% had levels
between 60-90 ml/min, 19% fell within 30-59 ml/min, 18% had levels below 30
ml/min, and 10% were already in stage 5 chronic kidney disease (Moin et al.,
2008).
A study was performed in Ayub Teaching Hospital from September 15 to
December 20, 2019. The significant level was set at p < 0.05. Out of the 176
diabetic samples, 32 had abnormally high serum creatinine and 66 had abnormal
serum urea. Hence, it was concluded that serum urea and creatinine are important
parameters to assess kidney function in diabetes mellitus (Ullah et al., 2023).
2.3 PREVALENCE
2.3.1 Global Prevalence
Chronic kidney disease is a non-communicable disease, with diabetes and
hypertension being the leading causes. Cardiovascular disease played a significant
role in early mortality and morbidity experienced by patients with CKD (Webster et
al., 2017).

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 A cross-sectional study was conducted in primary care in five provinces
across Canada from 2010 through 2015. Data were analyzed by geographic (urban
or rural residence), sociodemographic (age, sex, deprivation index), and clinical
(medications prescribed, comorbid conditions) factors, using data from CPCSSN
and the Canadian Deprivation Index. The highest prevalence was found in rural
settings compared with urban settings. CKD was highly prevalent among
individuals with 3 or more other chronic diseases (Aminu K Bello et al., 2019).
A study was carried out in the Canadian province of Manitoba from April
1996 to March 2012. Prevalence was estimated using three methods: a) all CKD
cases in administrative and laboratory databases; b) all CKD cases captured only
through the laboratory data; and c) and the capture-recapture method. The CKD
prevalence was 5.6% using the standard definition, 10.6% using only people
captured by the laboratory data, and 10.6% using the capture-recapture method. Of
the identified cases, 46% were at high risk of progression to end-stage kidney
disease (ESKD), 41% were at low risk, and 13% were not, classified due to
unavailable laboratory data. High-risk cases had a higher burden of comorbid
conditions (Chartier et al., 2018).
A repeated cross-sectional study was performed at NHANES (National
Health and Nutrition Examination Survey) from 1988 to 1994 and every 2 year
from 1999 to 2012. The unadjusted prevalence of stage 3 and 4 CKD increased
from the late 1990s to the early 2000s. The study concludes that there is no
appreciable increase in the prevalence of CKD in the U.S. population overall
during the most recent decades (Murphy et al., 2016).
A cross-sectional study was undertaken over a 24-month period lasting
from January 2021 to December 2022 GPs in Styria (Austria). The prevalence of
previously undetected CKD was estimated at 20.1%. In a multivariate analysis, age,
diabetes, and obesity were independent predictors of CKD (Siebenhofer et al.,
2024).
A descriptive cross-sectional analysis was conducted by Adelphi Real
World (Macclesfield, UK) between June and September 2012 in France, Germany,
Italy, Spain, and the UK. Patients completed PSC questionnaires requesting
information CKD history, healthcare resource utilization, work productivity, and

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HRQoL. Patients independently completed PSC questionnaires that requested
complementary information on their CKD history, healthcare resource utilization,
work productivity, and HRQoL (Eriksson et al., 2016).
A prospective observational cohort study was carried out in Germany from
2010 to 2012. The patients were examined by certified study nurses in the regional
GCKD centers or in the nephrology practices of the participating nephrologists. It
concluded that blood pressure control of CKD patients remains challenging even in
the setting of nephrology specialist care, despite high rates of awareness and
medication use (Schneider et al., 2018).
A cross-sectional, multicenter, non-interventional study was performed in
seven of the 26 Swiss cantons, including all five Swiss cantons with university
affiliated medical faculties (i.e., Basel, Bern, Geneva, Vaud, and Zurich), the
largest canton in central Switzerland (Lucerne), and the Italian-speaking canton of
Ticino. Socio-demographic variables, clinical status, and co-morbidities were
reported on a questionnaire. CKD prevalence in a primary care population is
therefore high, and preventive interventions may be advisable, in particular as CKD
prevalence is likely to rise over the next decades (Tomonaga et al., 2013).
A study was undertaken that involved a search from PubMed, Scopus, and
African Journals Online from database inception to 31 March 2020 to identify all
studies published on the prevalence, associated factors, etiology, comorbidities,
treatment, cost, and mortality of CKD in Cameroon. The study demonstrates that
patients with hypertension, diabetes mellitus, and human immunodeficiency virus
bear the greatest burden of CKD in Cameroon. Advanced age, hypertension,
diabetes mellitus, and obesity are major factors associated with CKD (Aseneh et
al., 2020).
A prospective observational cohort study was conducted in Germany. DM
was present in 1842 patients (35%) and the median HbA1C was 7.0% (Busch et al.,
2016).
The CKD-EPI-HUN study was a retrospective, population-based
epidemiological study using data collection. The study was carried out in the
subpopulation of healthcare-utilizing residents living in Southern Hungary, in
County Baranya within the catchment area of the University of Pecs, which is one

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of the largest healthcare providers in Hungary. The comorbidities of patients for the
entire group of CKD patients identified by both eGFR and albuminuria (N =
13,596) were recorded; of these, 41.5% had known diabetes, 70.2% had
hypertension, 20.5% had heart failure, 9.4% had myocardial infarction, and 10.5%
had a stroke (Zemplényi et al., 2023).
The study was spearheaded in 8 South Asian countries (Dec 1955-April
2017) using the PRISMA checklist and found that the prevalence of CKD ranged
from 10.6% in Nepal to 23.3% in Pakistan using the MDRD equation (Hasan et al.,
2018).
A cross-sectional survey was carried out in a nationally representative
sample of 12,109 Nepalese adults from 2016 to 2018 on selected chronic non-
communicable diseases. Multistage cluster sampling with a mix of probability
proportionate to size and systematic random sampling was used for the selection of
individuals aged 20 years and above. The overall prevalence of CKD in Nepal was
6.0%.Factors independently associated with CKD included older age, diabetes,
hypertension, and raised total cholesterol (Poudyal et al., 2022).
A cross-sectional study was undertaken among diabetic outpatients of a
tertiary hospital in Nepal. A valid questionnaire was used to collect data. The study
concludes that the prevalence of CKD in T2DM was 86.6%. Advancing age,
concomitant hypertension, increasing duration of T2DM, and presence of anemia
were found to be important risk factors of CKD (Joshi et al., 2023).
A cross-sectional analysis was carried out in Bangladesh from July 2013 to
December 2013.The overall prevalence of CKD among patients with T2D was
21.3%. Almost one in five people with T2D in urban Bangladesh had CKD, which
was almost twice more common in females as in males. The key finding of our
study is that household income and the duration of hypertension were significantly
associated with CKD in our study population (Islam et al., 2021).
This cross-sectional study was done at the Department of Physiology,
Mymensingh Medical College, Bangladesh, for one year from January to
December 2016. Hypertension and diabetes were more prevalent in CKD than in
non-CKD individuals, which were statistically significant. This study revealed that

18
the prevalence of HTN and DM is common in all stages of CKD patients in
Mymensingh, Bangladesh (Yousuf et al., 2023).
A cross-sectional study was conducted in slum areas in Mirpur, Dhaka,
among slum dwellers. The study period was from June 2004 to December 2005. A
multi-staged cluster procedure was followed using a simple random sampling
method. The association between age and CKD risk-factors like diabetes and
hypertension was found to be significantly higher among the >40 years of age
group compared to the individuals < 40 years of age group (Alam et al., 2010).
A prospective study was conducted on patients getting admitted to the
Medicine Department of a tertiary care center, Indore, from September 2013 to
September 2015.A 66.3% diabetic nephropathy patients and 51.9% type 2 diabetics
without nephropathy were found. The hypertensive study found that hypertension
was an independent risk factor for the Diabetic Kidney Disease (DKD). Along with
this, a proportional increase in the level of serum creatinine and eGFR was seen
with an incidence of hypertension in diabetic nephropathy (Verma et al., 2016).
A hospital-based cross-sectional study was conducted from April 2 to July
31, 2018. Using convenience sampling, data on patient’s sociodemographic
information, clinical characteristics, and laboratory parameters were collected using
patient interviews and reviews of medical records. The prevalence of CKD in
patients with diabetes is high and comparable with previous studies from low- and
middle-income countries. Pre-existing hypertension, current systolic blood
pressure >140 mm Hg, duration of diabetes >10 years, and presence
of retinopathy were significantly associated with CKD (Alemu, Hailu, et al., 2020).
A cross-sectional study was conducted that used a comprehensive direct
questionnaire to collect data on CKD prevalence and risk factors in the ASIR
region of Saudi Arabia. Factors such as sex, history of acute kidney disease,
obstructive sleep apnea, family history, smoking, diabetes, hypertension, peptic
ulcer, hyperlipidemia, multi-comorbidity, and use of NSAIDs were all associated
with an increased risk of CKD. The prevalence of CKD in this study was
comparatively lower when compared to other regions in Saudi Arabia (Alshahrani
et al., 2024).

19
 A cross-sectional study was conducted from December 2022 to January
2023, at Al-Sadr Teaching Hospital in Basra City. Data collected through a
structured questionnaire, patient interviews, and a review of medical records.
Hypertension was also found to be associated with 95% of the sample. Anemia
appears to be associated with CKD (Abed et al., 2023).
A study was undertaken at Al-Watani governmental hospital and medical
center, the largest non-surgical medical center in north Palestine, with in-and out-
patient community medical services from August 1, 2006, to August 1,
2007. Patient medical records were used. The study concludes that patients with
reduced renal function were elderly, had a higher number of chronic diseases, and
had a longer duration of diabetes and hypertension than those with CrCl≥ 60ml/
min. Men had a higher prevalence of reduced renal function than women (Sweileh
et al., 2009).
2.3.2 Prevalence in Pakistan
In Pakistan, only a few hospital-based studies have been conducted in the
past, indicating that diabetes and hypertension were the primary causes of chronic
kidney disease in urban areas, while glomerulonephritis and kidney stones were
more common in rural regions (Rizvi et al., 2002).
The epidemiology of chronic kidney disease (CKD) and its risk factors are
not well understood in Pakistan, with only a limited number of hospital-based
studies conducted in the past. These studies have indicated that diabetes mellitus
(DM) and hypertension (HTN) are the primary causes of CKD in urban areas,
while cases of CKD of unknown etiology, glomerulonephritis, and kidney stones
are more prevalent in rural regions. The incidence of DM is also rising in this area
for various reasons discussed in the literature. This increased prevalence of DM is
reflected in the growing number of diabetic patients visiting nephrology clinics
with nondiabetic kidney disease. In a biopsy series involving 212 diabetic patients,
91 (42.9%) were found to have nondiabetic kidney disease, while 45 (21.2%)
exhibited non-diabetic lesions alongside diabetic kidney disease. Another study
from the same city revealed that in a renal biopsy series of 62 diabetic patients, 34
(52%) had non-diabetic kidney disease (Imtiaz et al., 2018).

20
 A cross-sectional study was performed in Karachi, Pakistan. The overall
prevalence of CKD was 12.5%. About 267 adults were found to have hypertension
(Jessani et al., 2014).
A cross-sectional study was conducted at the Balochistan Institute of
Nephrology-Urology Quetta (BINUQ), Pakistan, using a specially developed data
collection form to gather patients' socio-demographic, clinical, and laboratory data.
In the multivariate analysis, only CKD stage 5 showed a statistically significant
association with the presence of anemia (OR=4.521, P=0.001). Among the 177
anemic patients, 75.7% of them received anti-anemic treatment. Of those treated,
98.5% received blood transfusions, 6.7% were given folic acid, 2.9% received iron
supplements, and 2.2% were administered vitamin B12 (Rajput et al., 2020).
A cross-sectional study was carried out on patients with CKD at a tertiary
care hospital in Karachi, Pakistan, from May 2019 to October 2019. A prevalidated
questionnaire was used to collect data from the patient. The results of the study
demonstrate that anemia is a predominant clinical laboratory manifestation in
patients with CKD along with elevated ESR, thrombocytopenia, leukocytosis, and
eosinophilia. A statistically significant correlation was observed between
hematological abnormalities in patients with ESRD and age, sex, DM, smoking
status, and duration of ESRD (Ahmed et al., 2021).
A comparative cross-sectional study was conducted at the Department of
Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, in
collaboration with the department of Nephrology, Armed Forces Institute of
Urology, Rawalpindi, from Sep 2018 to Oct 2019. This study revealed a high
frequency of iron deficiency anemia in non-dialysis chronic kidney disease
patients. Hypocalcaemia, hypophosphatemia, and hypomagnesaemia were found to
have a strong association with the presence of iron deficiency anemia in non-
dialysis-dependent chronic kidney disease patients (Kanwal et al., 2021).
An analytical cross-sectional study was done at Pak Emirates Military
Hospital Rawalpindi from Jul 2017 to Dec 2017. The study concludes that after
applying the logistic regression, we found that age, gender, dialysis vintage, and
other socio-demographic factors had no significant association with the CKD-MBD
subtypes (Butt et al., 2021).

21
 A study was conducted to observe the pattern of anemia and mineral bone
disorders (MBD) in patients with end-stage renal disease (ESRD) on maintenance
hemodialysis (MHD) at the Nephrology Department, Mayo Hospital, and Shalamar
Hospital, Lahore. In this study, most of the patients were anemic, most probably
due to a low dose of EPO and inadequate dialysis. High turnover and mixed bone
disorders were present in the majority of the patients (Anees et al., 2020).
A cross-sectional observational study was done at The Kidney Centre,
Postgraduate Training Institute Karachi, Pakistan, from Jan to June 2020. There is a
high prevalence of RLS in ESRD patients as compared to the general population.
Serum phosphorus levels need to be observed and corrected along with
maintenance of calcium and PTH levels to improve symptoms of RLS in these
patients (Sultan et al., 2022).
A cross-sectional study was performed over one year, from January 1,
2022, to December 31, 2022, in randomly selected urban towns of Lahore. The
study revealed that CKD was prevalent in about one-fourth of the participants from
the high-risk population of Lahore, indicating a high prevalence of the disease
within society. Moreover, hypertension, diabetes, family history of CKD, heart
disease, painkillers, and the use of herbal medicines were all significantly linked to
CKD in the surveyed sample population (A. Khan et al., 2024).
A multicenter follow-up study was carried out in six public and two private
dialysis centers in Pakistan. The quality of life of these patients was assessed using
the EQ-5D-5L questionnaire. HTN with coexisting CKD in hemodialysis patients
severely affected HRQoL (Aslam et al., 2022).
A cross-sectional study was undertaken in the Ali Fatima Hospital Lahore
for six months, from March 2022 to August 2022. The participants who were
selected by sampling technique were interviewed in the Khyber Teaching Hospital
Peshawar. The participants who suffered to maintain hemodialysis for > 3 months
the majority have low levels of Hb, which cause anemia, low PTH, which
associated with the mineral bone diseases, and also reduced serum Ca, P, K, Na,
and albumin levels (Riaz et al., 2023).
The observational, cross-sectional study was conducted at the Department
of Nephrology, The Kidney Centre Post-Graduate Training Institute, Karachi, from

22
April 27 to October 26, 2018, and comprised adult patients of either gender
diagnosed with anemia and estimated glomerular filtration rate. Iron deficiency
anemia was found to be highly prevalent and should be screened routinely and
managed appropriately. Iron deficiency anemia was found to be highly prevalent
and should be screened routinely and managed appropriately (Kamil et al., 2022).

CHAPTER No.03 <<Chapter title should be centered and bold>>

METHODOLOGY
3.1 STUDY DESIGN
A descriptive cross-sectional study design was used.
3.2 STUDY SETTINGS
The study was conducted at the following dialysis centers:
 District Health Quarter (DHQ) Hospital Mirpur, AJK.
 District Health Quarter (DHQ) Hospital Bhimber, AJK.
 District Health Quarter (DHQ) Hospital Kotli, AJK.
3.3 STUDY DURATION
Study duration was from April 2024 to February 2025.
3.4 STUDY POPULATION
This study included all the confirmed cases of chronic kidney disease at
DHQ Hospital Mirpur, AJK, DHQ Hospital Bhimber, AJK, and DHQ Hospital
Kotli, AJK.
3.5 SAMPLING METHOD
A convenient method of sampling had been used where all the cases that
meet inclusion criteria were selected.
3.6 SAMPLE SIZE
Sample size was calculated using the Raosoft sample size calculator, with a
95% confidence interval and 5% margin of error, N=385.
3.7 DATA COLLECTION METHOD

23
 A questionnaire composed of different questions or items used to gather
data from patients and caregivers. Questions comprising different variables,
including patients’ demographic characteristics, history of kidney disease,
treatment modalities, and complications of disease, were designed to collect the
data from the study population.
3.8 STATISTICAL ANALYSIS
Data were analyzed by using Statistical Package for Social Sciences (SPSS)
version 20. Statistical analysis was used to present the analyzed data for definite
measures such as tables or graphs.

3.9 ETHICAL CONSIDERATION

This study was conducted with the permission of the respective institute,
Akson College of Pharmacy, in joint venture with Mirpur University of Science
and Technology (MUST) Mirpur, AJK, bearing reference number 567/09/ACP/20.
The ethical permission for conducting the study was taken from the head of the
Hospital.

24
 CHAPTER NO.04 <<Chapter title should be centered and bold>>
RESULTS
4.1 DEMOGRAPHIC CHARACTERISTICS
The present study comprised a total of 350 respondents. The majority of
patients, 189 (54.0%), were over 50 years old.100 (28.6%) were in the 30–40 years
range. A smaller proportion, 43 (12.3%), was aged 20–30 years. Only 18 (5.1%)
were below 20 years. Males constituted 204 (58.3%) of the population, while
females accounted for 146 (41.7%). A detailed description is given in table 4.1
below:
Table 4.1: Demographic Characteristics
Frequency Percentage
Demographic variables
(n) (%)
Male 204 58.3
Gender
Female 146 41.7

<20years 18 5.1

20-30years 43 12.3
Age
30-40 years. 100 28.6

Over 50 years. 189 54.0

25
 Frequency
Percentage
250

204
200
Frequency & Percentage
146
150

100
58.3
50 41.7

0
Male Female

Gender

Fig. 4.1.1

Frequency Percentage
200 189
180
160
140
Frequency & Percentage

120
100
100
80
60 54
43
40 28.6
18 12.3
20 5.1
0
< 20 Years 20-30 Years 30-40 Years Over 50 Years

Age

Fig. 4.1.2

4.2 KIDNEY DISEASE

26
 A significant majority, 324 (92.6%), reported having been told they had
kidney disease, while 26 (7.4%) denied this. Most patients had been diagnosed for
1–3 years (126, 36.0%).Other durations included Less than 1 year (88, 25.1%). 5–
10 years: (84, 24.0%). 3–5 years: (47, 13.4%) and over 10 years: (5, 1.4%).Stage 5
predominated 323 (92.3%), suggesting a significant number of patients were at
advanced stages. Stage 4 accounted for 26 (6.0%), while earlier stages (1–3) had
minimal representation (combined 1.8%). A detailed description is given in the
table below;
Table 4.2: Kidney Diseases

Kidney Disease Variables Percentag

Frequency
e
(n)
(%)
324 92.6
Yes
Have you ever been told you have
kidney disease? No 26 7.4

<1 year 88 25.1

1-3 years 126 36.0

How long has it been since you
3-5 years 47 13.4
were first diagnosed?
5-10 years 84 24.0

>10yrs 5 1.4

Stage 1 2 .6

Stage 2 1 .3
Which stage of chronic kidney
Stage 3 3 .9
disease have you been diagnosed
with?
Stage 4 21 6.0

Stage 5 323 92.3

27
 Frequency
Percentage
350
Frequency & Percentage 323
300
250
200
150
92.3
100
50 21
2 0.6 1 0.3 3 0.9 6
0
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Stage of chronic kidney disease
Fig. 4.2.1
4.3MEDICATIONS
216 (61.7%) regularly used NSAIDs, while 134 (38.3%) did not. Frequency of
NSAID Use: 79 (22.6%) used them three times per week. Other frequencies
include Daily 32 (9.1%), Weekly 63 (18.0%), and Monthly 41 (11.7%). Use of
Herbal Supplements: Only 16.6% used herbal supplements, while the vast majority
(83.4%) did not. A detailed description is given in the table below;
Table 4.3 Medications
Percentag
Frequency
Medication variables e
(n)
(%)
Yes 216 61.7
Do you use regularly pain or any anti-
inflammatory medicine or NSAIDS?
No 134 38.3
At
least 32 9.1
daily
How often?
3
times
79 22.6
per
week
Once 63 18.0
a
week

28
 Once
a 41 11.7
month
None 135 38.6

Yes 58 16.6
Do you use herbal supplements?
No 292 83.4

Frequency
Percentage
250
216
Frequency & Percentage

200

150 134

100
61.7
50 38.3

0
Yes No
Anti-inflamatory drugs

Fig. 4.3.1

Frequency
Percentage
350
Frequency & Percentage

300 292

250
200
150
100 83.4
58
50 16.6
0
Yes No
Herbal Supplements
Fig. 4.3.2

29
4.4COMORBIDITIES
The patient of 316 (90.3%) reported having comorbidities, while 34 (9.7%) did
not. The number of comorbidities in most patients (195, 55.7%) had 2–3
comorbidities and other counts. No comorbid condition in 36 (10.3%), and one in
86 (24.6%), and four to six in 33 (9.4%).The specific comorbidities were
hypertension, which was present in 247 ( 70.6%); diabetes was present in 122
( 34.9%); anemia was present in 195 ( 55.7%); and bone Disease which was present
in 94 (26.9%). A detailed description is given in the table below;
Table 4.4: Comorbidities
Frequency
Comorbidities variables Percentage (%)
(n)
Yes 316 90.3
Presence of comorbidities
No 34 9.7

0 36 10.3

1 86 24.6
Total number of
comorbidities 2-3 195 55.7

4-6 33 9.4

Which of the following Yes 247 70.6

comorbidity is present?
A)Hypertension No 103 29.4

Yes 122 34.9

B) Diabetes
No 228 65.1

Yes 195 55.7

C) Anemia
No 155 44.3

Yes 94 26.9
D) Bone Disease
No 255 72.9

30
 Frequency
Percentage
350
316
300

Frequency & Percent-

250
200
150
100 90.3
age

50 34
9.7
0
Yes No
Comorbidities
Fig. 4.4.1

Frequency
Percentage
250
Frequency & Percentage

195
200

150

100 86
55.7
50 36 33
24.6
10.3 9.4
0
0 1 2_3 4_6
No.of Comorbidities

Fig. 4.4.2
4.5 HYPERTENSION
A total of 70.0% (245 individuals) reported having high blood pressure,
while 30.0% (105 individuals) did not. Among respondents, 68.0% (238
individuals) had taken medication for high blood pressure, while 2.0% (7
individuals) had not. The question was not applicable for 30.0% (105 individuals).
High blood pressure had been diagnosed less than a year ago for 6.9% (24

31
individuals), 1-3 years ago for 13.1% (46 individuals), 3-5 years ago for 9.4% (33
individuals), 5-10 years ago for 17.1% (60 individuals), and more than 10 years ago
for 23.4% (82 individuals). This was not applicable for 30.0% (105
individuals).Blood pressure monitoring at home was practiced by 67.1% (235
individuals), while 2.6% (9 individuals) did not check their blood pressure. The
question was not applicable for 30.3% (106 individuals). Among those who
checked their blood pressure, 24.0% (84 individuals) did so daily, 37.1% (130
individuals) several times a week, 4.9% (17 individuals) once a week and 3.4% (12
individuals) once a month. This was not applicable for 30.6% (107 individuals).
Blood pressure greater than 140/90 had been reported most of the time by 28.0%
(98 individuals), occasionally by 38.6% (135 individuals), and never by 3.1% (11
individuals). The question was not applicable for 30.3% (106 individuals). Exercise
had been performed daily by 27.1% (95 individuals), three times per week by 2.3%
(8 individuals), once a week by 11.4% (40 individuals), and once a month by 2.0%
(7 individuals). A significant 57.1% (200 individuals) reported no exercise. High
blood pressure had led to hospitalization for 23.4% (82 individuals), while 46.6%
(163 individuals) had not been hospitalized. This was not applicable for 30.0%
(105 individuals). A stroke had been experienced by 3.4% (12 individuals), while
66.9% (234 individuals) had not. This was not applicable for 29.7% (104
individuals). Heart attacks had occurred in 5.4% (19 individuals), whereas 64.9%
(227 individuals) had not experienced one. The question was not applicable for
29.7% (104 individuals). Surgery for arteries supplying blood had been reported by
5.1% (18 individuals), while 65.1% (228 individuals) had not undergone such
surgery. This was not applicable for 29.7% (104 individuals). A detailed
description is given in the table below;
Table 4.5: Hypertension
Frequenc
Percentage
Hypertension variables y
(%)
(n)
Yes 245 70.0
Do you have a high blood
pressure? No 105 30.0
Do you take medicine for high Yes 238 68.0
blood pressure?

32
 No 7 2.0
Not
105 30.0
applicable
< 1 years 24 6.9

1-3 years 46 13.1

3-5 years 33 9.4

How long ago were first
diagnosed?
5-10 years 60 17.1

> 10 years 82 23.4

Not
105 30.0
applicable
Yes 235 67.1
Do you check your blood
No 9 2.6
pressure at home?
Not
106 30.3
applicable
Daily 84 24.0
Several
time per 130 37.1
week
How often? Once a
17 4.9
week
Once a
12 3.4
month
Not
107 30.6
applicable
Most of the
98 28.0
time
Occasionall
135 38.6
How often is your blood y
pressure greater than 140/90?
Never 11 3.1
Not
106 30.3
applicable
At least
If you exercise, how often? 95 27.1
daily

33
 3 times per
8 2.3
week
Once a
40 11.4
week
Once a
7 2.0
month
No 200 57.1

Yes 82 23.4
Have you ever been
hospitalized for high blood No 163 46.6
pressure?
Not
105 30.0
applicable
Yes 12 3.4
Have you had a stroke?
No 234 66.9
Not
104 29.7
applicable
Yes 19 5.4

Have you had a heart attack? No 227 64.9

Not
104 29.7
applicable
Yes 18 5.1
Have you had a surgery for
arteries No 228 65.1
Supplying the blood?
Not
104 29.7
applicable

34
 Frequency
Percentage
300

Frequency & Percentage

247
250

200

150
103
100 70.6
50 29.4
0
Yes No
Hypertension

Fig. 4.5.1

Frequency
Percentage
160
135
Frequency & Percentage

140
120 106
98
100
80
60
38.6
40 28 30.3
20 11
3.1
0
Most of time Ocassionally Never Not applicable
How often is your blood pressure > 140/90

Fig. 4.5.2
4.6 DIABETES
Diabetes or pre-diabetes had been diagnosed in 34.3% (120 individuals),
while 65.7% (230 individuals) had not been diagnosed. Among those diagnosed,
1.4% (5 individuals) had been diagnosed within a year, 4.0% (14 individuals) 1-3
years ago, 4.3% (15 individuals) 3-5 years ago, 14.3% (50 individuals); 5-10 years
ago; and 10.3% (36 individuals) more than 10 years ago. This was not applicable
for 65.7% (230 individuals).Pills for diabetes had been taken by 28.3% (99

35
individuals), while 6.0% (21 individuals) had not. This was not applicable for
65.7% (230 individuals).Pills had been taken for less than a year by 4.6% (16
individuals), 1-5 years by 12.9% (45 individuals), 5-10 years by 4.0% (14
individuals), and more than 10 years by 6.9% (24 individuals). This was not
applicable for 71.7% (251 individuals).Among those who stopped taking
medication, 9.1% (32 individuals) had stopped within the past year, 2.6% (9
individuals) within 1-5 years, and 2.3% (8 individuals) within 5-10 years. A total of
82.6% (289 individuals) reported not discontinuing medication. Insulin had been
used by 21.1% (74 individuals), while 12.9% (45 individuals) had not. This was not
applicable for 66.0% (231 individuals). Insulin had been used for less than a year
by 4.6% (16 individuals), 1-5 years by 5.1% (18 individuals), 5-10 years by 5.1%
(18 individuals), and more than 10 years by 6.9% (24 individuals). This was not
applicable for 78.3% (274 individuals).Among respondents, 0.6% (2 individuals)
had blood sugar levels below 100, 15.4% (54 individuals) between 100-150, 9.7%
(34 individuals) between 150-200, and 4.9% (17 individuals) above 200. A total of
4.0% (14 individuals) did not monitor their blood sugar levels, while this was not
applicable for 65.4% (229 individuals).Eye disease caused by diabetes had been
reported by 16.9% (59 individuals), while 17.7% (62 individuals) had not
experienced it. This was not applicable for 65.4% (229 individuals).Numb feet had
been experienced by 18.9% (66 individuals), while 15.7% (55 individuals) had not.
This was not applicable for 65.4% (229 individuals). A detailed description is given
in the table below;
Table 4.6: Diabetes
Frequency Percentage
Diabetes variables
(n) (%)
Yes 120 34.3
Have you ever been told you
have diabetes or pre-diabetes?
No 230 65.7

1 years 5 1.4
How long ago you were first
1-3yrs 14 4.0
diagnosed?
3-5 yrs. 15 4.3

36
 5-10 yrs. 50 14.3

>10 yrs. 36 10.3

Not
230 65.7
applicable
Yes 99 28.3
Do you take or have you ever
No 21 6.0
taken pills for diabetes?
Not
230 65.7
applicable
1 yrs. 16 4.6

1-5yrs 45 12.9
How many years did you take
5-10 yrs. 14 4.0
it?
>10 yrs. 24 6.9
Not
251 71.7
applicable
<1 yrs. 32 9.1

1-5 9 2.6

How long ago did you stop? 5-10 8 2.3

>10 yrs. 12 3.4

No 289 82.6

Yes 74 21.1
Do you take or have you ever
No 45 12.9
taken insulin?
Not
231 66.0
applicable
<1 yrs. 16 4.6
How many years did you take
it? 1-5 18 5.1

5-10 18 5.1

37
 >10 yrs. 24 6.9
Not
274 78.3
applicable
<1 yrs. 11 3.1
If you have stopped taking,
how long ago did you stop? 1-5 4 1.1

None 335 95.7

< 100 2 .6
100-150 54 15.4

150-200 34 9.7
How well have your blood
sugars been controlled? >200 17 4.9
I don't
14 4.0
check them
Not
229 65.4
applicable
Yes 59 16.9
Do you have eye disease from
No 62 17.7
diabetes?
Not
229 65.4
applicable
Yes 66 18.9

Do you have numb feet? No 55 15.7

Not
229 65.4
applicable

38
 Frequency
Percentage
250 228

Frequency & Percentage

200

150
122
100
65.1
50 34.9

0
Yes No
Diabetes

Fig. 4.6.1
4.7: Anemia
Respondents had been informed about anemia, low blood, or hemoglobin
levels in 55.7% of cases (195 individuals), while 43.7% (153 individuals) had not
been informed. Among those diagnosed, 17.7% (62 individuals) had been
diagnosed within the last year, 20.0% (70 individuals) within 1-3 years, 8.0% (28
individuals) within 3-5 years, and 8.3% (29 individuals) between 5-10 years ago.
Only 2.0% (7 individuals) reported being diagnosed over 10 years ago, while
43.7% (153 individuals) stated this question was not applicable to them. A
majority, 54.9% (192 individuals), reported taking medication to prevent anemia,
while 0.9% (3 individuals) did not. For 44.3% (155 individuals), the question was
not applicable. Among those who took medication, 5.7% (20 individuals) used
folate or folic acid, 21.72% (76 individuals) took iron (pills or injections), 5.7% (20
individuals) used vitamin B12, and 20.6% (72 individuals) used Epogen.A
minority, 2.3% (8 individuals), did not use any medication, and the question was
not applicable for 44.0% (154 individuals).Black stools had been experienced by
8.9% (31 individuals), while 46.9% (164 individuals) had not. This question was
not applicable for 44.3% (155 individuals).Bright red blood in stools had been
reported by 6.6% (23 individuals), whereas 49.1% (172 individuals) had not. For
44.3% (155 individuals), this was not applicable. Among females, 12.0% (42
individuals) reported menstruating, while 15.7% (55 individuals) did not. The

39
question was not applicable for 72.3% (253 individuals).A family history of anemia
had been reported by 4.9% (17 individuals), while 50.6% (177 individuals) did not
have such a history. This was not applicable for 44.6% (156 individuals).
Diagnoses included lymphoma 0.6% (2 individuals), leukemia 0.6% (2
individuals), vomiting blood 3.7% (13 individuals), and stomach ulcers 24.9% (87
individuals). However, 70.3% (246 individuals) had not experienced any of these
conditions. A detailed description is given in the table below;
Table 4.7: Anemia
Frequenc Percentag
Anemia variables
y e
(n) (%)
Have you ever been told you were Yes
195 55.7
anemic, had a low blood or
haemoglobin count?
No 153 43.7

1 year 62 17.7

1-3years 70 20.0

3-5years 28 8.0

How long ago you were first 5-10years 29 8.3

diagnosed?
>10 years 7 2.0
Not
153 43.7
applicable
Yes 192 54.9
Do you take medication to prevent
No 3 .9
anemia?
Not
155 44.3
applicable
Folate or
20 5.7
folic acid
Iron(pills
or 76 21.72
What type? injections)
Vitamin
20 5.7
b12
Epogen 72 20.6

40
 None 8 2.3
Not
154 44.0
applicable
Yes 31 8.9

Do you have any black stools? No 164 46.9

Not
155 44.3
applicable
Yes 23 6.6
Do you have any bright red blood in
No 172 49.1
your stool?
Not
155 44.3
applicable
Yes 42 12.0

If female, do you still menstruate? No

55 15.7
Not
253 72.3
applicable
Yes 17 4.9
Do you have family history of
No 177 50.6
anemia?
Not
156 44.6
applicable
Lymphom
2 .6
a
Leukemia 2 .6
Have you ever diagnosed with the Vomiting
13 3.7
following? blood
Stomach
87 24.9
ulcer
No 246 70.3

41
 Frequency
Percentage
250

Frequency & Percentage

195
200
155
150

100
55.7
50 44.3

0
Yes No

Anemia

Fig. 4.7.1
4.8: Bone Disease
Respondents had been informed about having osteoporosis, osteopenia,
brittle, thin, or weak bones in 27.4% (96 individuals), while 72.6% (254
individuals) had not. Among those diagnosed, 11.7% (41 individuals) had been
diagnosed within the past year, 8.9% (31 individuals) within 1-3 years, and 3.1%
(11 individuals) both in 3-5 years and over 10 years ago. The question was not
applicable for 73.1% (256 individuals).Bone scans accounted for 12.3% (43
individuals) of diagnoses, and broken bones accounted for 5.7% (20 individuals).
For 9.1% (32 individuals), no specific method had been used, while this question
was not applicable for 72.9% (255 individuals).A quarter, 25.4% (89 individuals),
took medication for bone disease, while 1.4% (5 individuals) did not. This was not
applicable for 73.1% (256 individuals).Among medication users, 4.6% (16
individuals) took calcium, 4.3% (15 individuals) used vitamin D, and 16.0% (56
individuals) used a combination of calcium and vitamin D. The question was not
applicable for 75.1% (263 individuals).The specific use of bisphosphonates was not
applicable for all respondents (100% of 350 individuals). A detailed description is
given in the table below;

42
Table 4.8: Bone Disease
Percentag
Frequency
Bone disease variables e
(n)
(%)
Yes 96 27.4
Have you ever been told you
had osteoporosis, osteopenia, No 254 72.6
brittle, thin or weak bone?
1 year 41 11.7

1-3 years 31 8.9

When were you told you had
osteoporosis, osteopenia, brittle, 3-5 years 11 3.1
thin or weak bone?
>10 years 11 3.1
Not
256 73.1
applicable
Bone scans 43 12.3

Broken bones 20 5.7

How was it diagnosed?
None 32 9.1
Not
255 72.9
applicable
Yes 89 25.4
Do you take any medicine for
No 5 1.4
bone disease?
Not
256 73.1
applicable
Calcium 16 4.6

Vitamin d 15 4.3

What type? Calcium +

vitamin d 56 16.0
combination
Not
263 75.1
applicable
If bisphosphonates which Not
medication? 350
applicable

43
 Frequency
Percentage
300
255

Frequency & Percentage

250

200

150
94
100 72.9
50 26.9
0
Yes No
Bone Disease

Fig. 4.8.1
4.9 CROSS-TABULATION
4.9.1Gender versus Comorbidities <<Add space after heading number>>
147 males had hypertension while 57 did not. In females 100 had
hypertension, while 46 did not. Hypertension was more prevalent in males (147)
compared to females (100).The ratio of male to female with hypertension was
roughly 3:2. In males, 78 had diabetes while 126 did not. In females, 44 had
diabetes while 102 did not. Diabetes was less common in both genders, but it was
still more prevalent in males (78) than in females (44). In males, 103 had anemia
while 101 did not. In females, 92 had anemia while 54 did not. The prevalence of
anemia was fairly balanced among genders but slightly higher in males (103)
compared to females (92).In males, 48 had bone disease while 155 did not. In
females, 46 had bone disease while 100 did not. Bone disease affected both genders
almost equally in numbers, but the total proportion was higher in males due to a
larger sample size. A detailed description is given in the table below;
Table: 4.9.1Gender versus Comorbidities

Variables Gender
P-Value
Female
Male
Yes
Hypertension 147 100 0.470

44
 No
57 46
Yes
78 44
Diabetes 0.117
No
126 102
Yes
103 92
0.20
Anemia No
101 54
Yes 48 46
Bone Disease
0.102
100
No 155

4.9.2 Age versus Comorbidities

Hypertension most prevalent in the over 50-year age group (141
individuals).Rare in the less than 20 years age group (3 individuals).Hypertension
risk increases significantly with age. Diabetes is most common in the over 50 years
age group (84 individuals).Minimal cases in the <20 years age group (1
individual).Like hypertension, diabetes prevalence grew with advancing age.
Anemia is highest in the over 50 years age group(109 individuals).Lower in
younger age groups, with only 6 cases in <20 years. Anemia was more frequent in
older populations, potentially due to underlying chronic disease. Bone disease is
highest in the over 50 years age group (52 Individuals).Lowest in the<20 years age
group (3 individuals).Bone disease, like other comorbidities, was age-dependent
with increased prevalence in older groups. Comorbidities like hypertension,
diabetes, and anemia, and bone disease have a significant positive correlation with
age, especially after 50 years. A detailed description is given in the table below;
Table: 4.9.2 Age versus Comorbidities
Age (yrs.)
Variables P-Value
Over 50
<20 20-30 30-40
Yes 3 26 77 141
Hypertension 0.01
No 15 17 23 48

45
 Yes
1 5 32 84 0.01
Diabetes No 17 38 68 105
Yes
6 23 57 109 0.251
Anemia
No 12 20 43 80
Yes
3 11 28 52 0.223
Bone Disease
No 15 32 71 137

4.10 Chi-Square Analysis

4.10.1 Comorbidities with Duration since CKD Diagnosis
Hypertension was most common in patients diagnosed with CKD for 1-3
years (91 cases) and remained high in the 5-10 year group (64 cases). A significant
association suggested that hypertension was prevalent in CKD patients and might
have increased over time (p=0.042).Diabetes peaked at 1-3 years (63 cases) and
then decreased over time. The highly significant association indicated that diabetes
was strongly linked with CKD and might have influenced disease progression (p
=0.000).Anemia was highest in the 1-3 year group (67 cases) and in the 5-10 year
group (58 cases). The significant p-value suggested that anemia was a common
complication of CKD and persisted across different durations (p=0.037).Bone
disease did not show a strong correlation with CKD duration. Although it was
present across all timeframes, the p-value indicated no statistically significant
relationship (p=0.085).The total number of comorbidities increased as the duration
of CKD lengthened. Patients diagnosed with CKD for longer durations had a higher
number of comorbidities, with the 5-10 year group having the most cases with
multiple comorbidities (4-6 conditions). A significant association suggested that
patients with CKD tended to accumulate more comorbidities over time (p=0.009).

46
Table: 4.10.1 Comorbidities with Duration since CKD Diagnosis
P-value
Variables Duration

<1 1-3 3-5 5-10 >10

year years years years years
Hypertension 51 91 37 64 4 0.042

Diabetes 25 63 14 20 0 0.01

Anemia 40 67 27 58 3 0.037

Bone Disease 20 29 11 32 2 0.085

Total 15 11 5 4 0 0.009
Comorbidities

4.10.2 NSAID Use and Gender

The chi-square test assessing the relationship between NSAID use and
gender revealed a statistically significant association (p = 0.027). The results
showed that males were more likely to have used NSAIDs regularly (116 males)
compared to females (100 females). This suggested that men may have experienced
or reported pain more frequently or might have had different healthcare-seeking
behaviors compared to women. This finding highlighted the need to explore
gender-specific factors influencing NSAID use, particularly considering the
potential nephrotoxic effects of prolonged NSAID consumption, which could have
exacerbated CKD progression.
4.10.3 NSAID Use and Age
The relationship between NSAID use and age also yielded a significant chi-
square value (p = 0.034). Older participants, particularly those over 50 years,
showed higher regular NSAID use (124 users) compared to younger groups, such
as those under 20 years (6 users). This trend reflected the age-related increase in
chronic pain or inflammatory conditions like arthritis, which may have necessitated
NSAID use. However, the findings underlined the importance of careful
monitoring and alternative pain management strategies for older adults, as
excessive NSAID use could have had detrimental effects on kidney function.

47
4.10.4 Presence of Comorbidities and Age
The chi-square test examining the relationship between comorbidities and
age revealed a highly significant association (p < 0.001). The results showed that
the prevalence of comorbidities increased substantially with age, with 178
participants over 50 years reporting comorbid conditions compared to only 11
participants less than 20 years. This finding emphasized the compounded health
risks faced by older CKD patients due to the coexistence of multiple chronic
conditions, such as hypertension and diabetes, which were known to worsen kidney
outcomes. These results stressed the importance of integrated care approaches for
older populations to manage both CKD and its associated comorbidities.
4.10.5 Hypertension and Age
A significant chi-square value (p < 0.001) was observed for the association
between hypertension and age. Hypertension was more prevalent among older
participants, with 141 individuals over 50 years diagnosed with the condition
compared to only 3 individuals less than 20 years. This finding was critical, as
hypertension was a leading cause of CKD progression. The results suggested that
age-specific strategies were essential for hypertension management, particularly in
older adults, to prevent further deterioration of kidney function.
4.10.6 Diabetes and Age
The analysis of diabetes prevalence across age groups showed a significant
association (p < 0.001). Diabetes was more common in participants over 50 years
(84 cases) compared to younger groups, where it was nearly absent (1 case under
20 years). This strong relationship underscored the need for targeted screening and
intervention for diabetes in older adults with CKD, as poorly controlled diabetes
was a major contributor to CKD progression and associated complications. These
chi-square analyses collectively highlighted critical patterns of health disparities
influenced by age and gender, providing a foundation for tailored interventions in
CKD management.

48
 CHAPTER NO: 05 <<Chapter title should be centered and bold>>
DISCUSSION, CONCLUSION, RECOMMENDATIONS
5.1 DISCUSSION
The study was carried out to explore the prevalence of CKD and associated
comorbidities in three districts (Mirpur, Bhimber, and Kotli) of Azad Jammu and
Kashmir.
We conducted a cross-sectional, questionnaire based study and asked
questions of the caregivers and patients to achieve the objectives of this study. The
results of the study highlight the substantial burden of CKD and its associated
comorbidities, particularly among older adults.
Chronic kidney disease (CKD) is increasingly recognized as a significant
global public health issue. The worldwide prevalence of CKD is estimated at
13.4% (ranging from 11.7% to 15.1%), and the number of individuals with end-
stage kidney disease (ESKD) requiring renal replacement therapy is projected to be
between 4.902 million and 7.083 million (Lv & Zhang, 2019).
The present study has revealed the chronic kidney disease and its associated
comorbidities demonstrate significant demographic patterns and risk factors. CKD
predominantly affected individuals over 50 years of age (54.0%), consistent with
global findings that older age and male gender are critical risk factors for CKD
development and progression. A similar study conducted in Mirpur, Bangladesh,
showed that the association between age and CKD risk factors like diabetes and
hypertension was found to be significantly higher among those>40 years of age
compared to individuals< 40 years of age (Alam et al., 2010). But the recent study
showed that this study is in coherence with other studies performed in many
countries, such as Pakistan and Palestine (Ahmed et al., 2021) (Sweileh et al.,
2009).
In the present study, the majority of patients (92.3%) were in Stage 5 CKD,
which indicates a severe disease burden and aligns with research showing that late-
stage CKD is prevalent in populations with limited early detection measures. This
stage of CKD is associated with significant morbidity and high healthcare costs,
underscoring the need for early intervention to delay progression. However, in
contrast to our study, the other investigation has shown that the highest percentage

49
of patients with diagnosed CKD belong to the 3 rd stage of the disease (Krzanowski
et al., 2015).
In the present study, a substantial proportion (90.3%) of patients reported
comorbidities, with hypertension (70.6%) and anemia (55.7%) being the most
common. While a cross-sectional study was conducted at Al-Sadr Teaching
Hospital in Basra City. Hypertension was found to be associated with 95% of the
sample. Anemia appears to be associated with CKD (Abed et al., 2023).
The present study reveals that hypertension was more prevalent in males
and in individuals over 50 years old, reflecting its well-established role as both a
cause and consequence of CKD. This study's findings on the prevalence of
hypertension (HTN) and diabetes mellitus (DM) in individuals with chronic kidney
disease (CKD) are consistent with similar studies conducted in various regions,
particularly in Mymensingh, Bangladesh. Both studies consistently demonstrate
that hypertension and diabetes are significantly more prevalent among individuals
with CKD than in the general population without kidney disease. In both studies,
the Mymensingh study, a statistical association was found between the presence of
these comorbidities and the increased risk of CKD. The findings align with well-
established literature that indicates HTN and DM are primary risk factors for
kidney dysfunction and progression to end-stage renal disease (ESRD) (Yousuf et
al., 2023).
The findings of the present study show that diabetes prevalence increases
with age, which aligns with a similar study conducted among diabetic outpatients in
Nepal. Both studies highlight the strong connection between metabolic disorders,
aging, and chronic kidney disease (CKD) (Joshi et al., 2023).
Our study found a high use of NSAIDs (61.7%), particularly among older
adults, which raised concerns due to their potential to damage the kidneys and
contribute to the progression of chronic kidney disease (CKD). This finding is
similar to a study conducted in Lahore, which also highlighted a significant
association between painkiller use and CKD. Both studies emphasize the need for
careful management of pain relief medications, especially in older adults, given
their increased vulnerability to kidney damage. The similarities between our
findings and the study conducted in Lahore emphasize the critical need for more

50
awareness about safe medication practices and age-appropriate pain management,
particularly in older adults. Both studies suggest that the use of NSAIDs and other
painkillers is a significant risk factor for CKD and that managing these risks can
help reduce the burden of kidney disease in high-risk populations (A. Khan et al.,
2024).
Our study found that bone disease (26.9%) and anemia were more prevalent
among older patients with chronic kidney disease (CKD). These complications are
common in CKD patients and significantly affect their quality of life, requiring
careful management. The findings of our study are consistent with two important
studies conducted in Pakistan at The Kidney Centre, Karachi, and Ali Fatima
Hospital, Lahore, which also reported a high prevalence of anemia and mineral
bone disorders among CKD patients (Kamil et al., 2022) (Riaz et al., 2023).
The chi-square analyses revealed significant correlations between age and
key factors, such as comorbidities, hypertension, and diabetes. Older individuals,
particularly those over 50 years, faced an increased prevalence of these conditions,
emphasizing the compounded health risks in elderly CKD populations.
5.2 CONCLUSION
The results of this study showed that diabetes and total comorbidities had
the strongest association with CKD duration, indicating that they were common
complications as CKD progressed. Hypertension and anemia also demonstrated
significant associations, suggesting that they frequently coexisted with CKD. In
contrast, bone disease did not exhibit a strong statistical relationship with CKD
duration. These findings emphasized the importance of early screening and
management of comorbidities in CKD patients, as their prevalence tended to
increase over time.
The study highlights the substantial burden of CKD and its associated
comorbidities, particularly among older adults, consistent with global trends. The
findings stress the importance of early diagnosis and integrated management
strategies to address CKD and its comorbidities like hypertension, diabetes, and
anemia. The significant usage of NSAIDs observed warrants patient education and
exploration of alternative treatment strategies to mitigate renal damage.

51
 Overall, the results advocate for targeted public health interventions that
emphasize early screening, lifestyle modifications, and age-specific management to
delay CKD progression and improve outcomes. This study contributes valuable
evidence for improving healthcare strategies for managing CKD in high-risk
populations.
5.3 RECOMMENDATIONS
Regular CKD screening should be prioritized for high-risk groups,
particularly individuals over 50 years of age and those with hypertension, diabetes,
or a family history of CKD. Implementing routine checks for eGFR, urine protein
levels, and blood pressure can facilitate early diagnosis.
Community-based health awareness programs should be launched to
educate the public on the importance of early detection and the risks of late-stage
CKD. Hypertension and diabetes should be tightly managed using evidence-based
guidelines to reduce their progression to CKD. This includes lifestyle
modifications, pharmacological interventions, and regular monitoring.
Address anemia and bone diseases with appropriate therapies such as
erythropoietin-stimulating agents, iron supplements, and vitamin D/calcium
combinations. Health professionals should counsel patients, particularly the elderly,
on the risks of prolonged NSAID use and explore safer pain management
alternatives, such as acetaminophen or non-pharmacological approaches like
physical therapy.
Implement strict prescription monitoring for NSAIDs and include
educational materials on their nephrotoxic effects. Dietary interventions specific to
CKD including reduced sodium, potassium, and phosphate intake, tailored to
individual disease stages.
Encourage regular physical activity and weight management to improve
overall health outcomes and control comorbid conditions. Develop targeted
interventions for older adults to manage comorbidities effectively, including
specialized CKD care programs that address the complexities of aging. Include
geriatric assessment tools in routine evaluations to consider frailty, polypharmacy,
and other age-related concerns in CKD care.

52
 By implementing these recommendations, healthcare systems can improve
CKD outcomes, reduce disease progression, and enhance the quality of life for
affected individuals.

53
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