The primary purpose of this proposal is to provide mentored guidance for Dr. Shuchi Anand as she becomes an independent clinician researcher. Dr. Anand is interested in kidney disease care in a global health context, particularly in highlighting the growing burden of chronic kidney disease (CKD) in low- and middle-income countries and in devising innovative strategies to manage CKD. Thus this proposal will study the epidemiology of CKD in South Asians and evaluate low-cost tools for its management in patients with diabetes. South Asians have recently been identified to be at high risk for insulin resistance in the form of diabetes and metabolic syndrome, with a four-fold higher prevalence and two-fold higher incidence of diabetes than U.S. whites. Yet limited data are available on one of the most important end-organ consequences, i.e., CKD. This proposal uses data from the Cardiometabolic Risk Reduction in South Asia (CARRS) study, a community-based cohort of adults living in New Delhi, Chennai, and Karachi to study the prevalence and incidence of CKD, with the hypothesis that insulin resistance will be the primary risk factor for CKD even among South Asians living in a resource-constrained setting. To evaluate the extent to which management of risk factors such as blood glucose and blood pressure plays a role in determining the burden of CKD, the study will compare CKD prevalence in CARRS with CKD prevalence in South Asians living in the U.S. (where risk factors are expected to be better managed). A pooled dataset will be created from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study and the Pan Asian Cohort (PAC) Research Database to perform this analysis. In addition the study will explore which markers of body size (waist-circumference, waist-to-hip ratio, or body mass index) and of insulin resistance (fasting glucose, hemoglobin a1c, or fasting insulin levels) best predict new onset CKD among South Asians.
The final aim of this proposal is to create a sub-study within an ongoing randomized control trial in five sites in rural India. The sub-study will evaluate a structured education intervention by a lay health worker in motivating patients with diabetes to seek care after undergoing a screening urine dipstick, which will be used as a tool to identify high risk (proteinuric) patients as well a to discuss the end-organ consequences of diabetes. A qualitative survey of patients and providers will also be performed to identify barriers to care. The overall goal is to report on the burden of CKD among South Asians and attempt to manage it with low-cost strategies. With this proposal, Dr. Anand will advance her epidemiology skills by working on analyses from the CARRS, MASALA, and PAC databases. She will obtain additional training in health services research via didactic coursework and on-the-ground project implementation. Throughout the process, she will receive training and guidance from experts in global health, nephrology, health policy, and biostatistics as she builds a strong foundation for a productive research career.
This project will generate important data about the burden and risk factors of chronic kidney disease among South Asians, who are a rapidly growing racial/ethnic group within the U.S. and are known to be at extremely high risk for diabetes (the primary cause of chronic kidney disease in most other racial/ethnic groups). We will study the mechanisms that link abdominal obesity, insulin resistance, and chronic kidney disease. It will also evaluate a low-cost strategy that relies on lay health workers to screen for kidney disease among patients with diabetes and to motivate them to seek care. The strategy will have applicability not only in low- and middle- income countries, but also in the U.S. where non-physician health care workers are increasingly becoming a part of the team caring for patients with chronic diseases.