World Kidney Day is a global campaign aimed at raising awareness of the importance of kidneys and understanding kidney diseases, their prevention and treatments. World Kidney Day comes back every year and is celebrated on the second Thursday of every March. All across the globe, WKD deals in hundreds of events that take place like public screenings in Argentina, Zumba marathons in Malaysia, and this year in India a virtual summit was done. World Kidney Day is a joint initiative of the International Society of Nephrology (ISN) and the International Federation of Kidney Foundations (IFKF). It deals in awareness about preventive behaviors, awareness about risk factors, and awareness about how to live with a kidney disease.
World Kidney Day started in 2006 and has not stopped growing ever since. Every year, the campaign highlights a particular theme.
- 2022 Kidney Health for All – Bridge the gap to better kidney care
- 2021 Kidney Health for Everyone Everywhere – Living Well with Kidney Disease
- 2020 Kidney Health for Everyone Everywhere – from Prevention to Detection and Equitable Access to Care
- 2019 Kidney Health for Everyone, Everywhere
- 2018 Kidneys & Women’s Health. Include, Value, Empower
- 2017 Kidney Disease & Obesity – Healthy Lifestyle for Healthy Kidneys
- 2016 Kidney Disease & Children – Act Early to Prevent It!
- 2015 Kidney Health for All
- 2014 Chronic Kidney Disease (CKD) and aging
- 2013 Kidneys for Life – Stop Kidney Attack!
- 2012 Donate – Kidneys for Life – Receive
- 2011 Protect your kidneys: Save your heart
- 2010 Protect your kidneys: Control diabetes
- 2009 Protect your kidneys: Keep your pressure down
- 2008 Your amazing kidneys!
- 2007 CKD: Common, harmful and treatable
- 2006 Are your kidneys OK?
In retrospect, scoping in on the Indian subcontinent, NephroPlus, one of India’s largest dialysis care network, for the occasion of World Kidney Day, convened a first-of-its-kind virtual summit on 6th March 2022, bringing together more than 700 proponents for Kidney Health & Dialysis Care in partnership with leading nephrologists, industry experts, mental health advocates, and clinical nutritionists to provide valuable data and experiential knowledge-sharing for the renal community. The burden of Chronic Kidney Disease (CKD) and risk factors like hypertension and diabetes are substantial and provide a solid rationale to share knowledge, inspire action and empower dialysis patients, their families, and care professionals. This was followed by another virtual Summit yesterday, 9th March 2022.
The summit focused on the importance of kidney health literacy and quality improvement initiatives in renal care by implementing practices to retard the progression of Chronic Kidney Disease (CKD). The rich, engaging discussions addressed some of the areas of improvement in CKD care such as patient education, CKD management, and quality improvement, in addition to the significance of proper diet and nutrition, mental health and therapy, as well as emotional and social support from families, care partners and the community for better patient health outcomes.
The panelists for the summit were Dr. Vivekanand Jha, Chairman of the Scientific Advisory Board at NephroPlus and immediate past President of the International Society of Nephrology, Dr. Sundar Sankaran, Scientific Chairperson at the Summit & Head – International Transplant Services and Adjunct Prof. of Nephrology at Manipal Hospitals, Bengaluru, Dr. Suresh Sankar, NephroPlus Senior Vice President, Clinical Affairs, and Kamal D Shah, Co-Founder of NephroPlus.
Dr. Jha highlighted the concept of interdisciplinary care in kidney disease. This patient-centric approach has been associated with improved health outcomes and enlightened the attendees with the hopeful message that “although kidney diseases are common and harmful, they are treatable.” His message heralded a high-level conversation among the best clinical minds in the industry on meaningful ways to improve morbidity and mortality for patients with CKD. Dr. Jha also apprised the audience on the evolving “Chronic Care Model,” a multi-level framework that focuses on improving care for patients with chronic diseases. It provides a holistic approach in identifying facilitators of better outcomes for individuals with chronic conditions in primary care settings and also provides substantial support to End-Stage Renal Disease (ESRD) patients. Another finding revealed at the summit was that there are 2.2 lakh, new patients of ESRD, every year, creating an annual demand for 3.4 Crore dialysis as the available 4,950 centers and infrastructure struggle to keep up with increasing demand. Speakers like Dr. Shankar Prasad N, Professor, and Head of the Department of Nephrology, Kasturba Medical College, Manipal advocated a third option separate from dialysis and kidney transplant.
“Conservative Kidney Management (CKM) is something that many can consider as a third option. Dialysis has limitations and adverse effects, while kidney replacement is costly. With CKM, you can provide much-needed care to large populations. This is not for everyone, though, but patients who have a low tolerance to dialysis, aged people and those whose death occurs in one year won’t be a surprise. To family members can be placed on CKM. It doesn’t include dialysis and is a patient-centric approach that aims at improving the quality of life of patients with chronic kidney disease,” he said.
The topic of vascular access was covered by Dr. Sankaran, who said: “As a method, a good vascular access enables effective removal of chemicals and fluid from the bloodstream.” He chaired two lectures around vascular access through which knowledge on how accesses can be improved was elaborately discussed.
On his part, Dr. Sankar attempted a demystification of the role of social media in renal care. “We must do more to teach people how to separate facts from fiction. Social media can be a useful tool if we take advantage of it. Still, we must also be careful to check the massive misinformation by unscrupulous people on the subject,” he said.
Shah, who participated in the introductory discussion as part of an interdisciplinary team, was vocal about the management of ESKD and how changes to conventional approaches can bring about better results. “ESKD is becoming increasingly prevalent, and as professionals, we must rise to the occasion by developing cost-effective, sustainable, and accessible solutions to help dialysis patients,” he stressed.
The summit was a restatement of NephroPlus’ commitment to showing how renal patients can be better cared for based on their peculiar situations.
The summit iterated the problem of Chronic Kidney Diseases that have a global prevalence of 13.4%, statistics showed that CKD is 5th highest cause of death globally, and it is 3rd fastest-growing disease in the globe. Hence the 2022 theme of World Kidney Day, that is celebrated today, 10th March, was “Bridge the knowledge gap to better kidney care.”
In the summit it was stressed that although kidney disease is common and harmful, it is treatable, and the theme for getting the summit together to bring in more health-workers, policymakers, care givers, and educators was “Stronger together”, which brings in an array of approaches such as
- Use of a multidisciplinary care team in preventing
- Kidney disease by a team promotes a holistic approach
- Physician, nurse, dietician, pharmacist, and social worker
- Shared decision-making
- Considers the values and cultural aspects of the patients
- Takes care of the patients’ information needs without compromising the quality of life
- Kidney replacement therapy is a continuum of care and is not a standalone treatment
- Conservative Care
- Kidney Transplant
- Peritoneal Dialysis
- Hemodialysis
The summit reiterated what had been said in the March 6th coming together: Kidney organizations have a responsibility to improve focus patient-centred care, create a supportive environment for care partners and to improve health outcomes, hence, decrease global societal burden of kidney health and the seriousness of renal diseases, importantly, Chronic Kidney Diseases.
Chronic Kidney Disease (CKD) refers to an irreversible deterioration
in renal function. For operational purposes, CKD is defined as the
presence, for at least three months, of evidence of kidney damage with
an abnormal glomerular filtration rate (GFR) or, alternatively, by a
2
GFR below 60ml/min/1.73 m body surface area. A cut off of
2
60ml/min/1.73 m body surface area is selected because it represents a
decrement to approximately half of normal renal function and because
its use avoids the classification of many older individuals who may
[1]
have mild reductions in their GFR.
CKD a major epidemic of this century, has become a major public
health problem both in terms of patient number and treatment cost,
with most patients either referred to one of many renal replacement
therapies such as haemodialysis, peritoneal dialysis and renal
transplantation or death supervenes as a result of cardiovascular
disease.
India, which is the diabetic capital of the world, now heading towards
the same in hypertension, and with increasing life expectancy of the
population, CKD needs to be considered in their management, as all
[2]
are directly related to it. In India the incidence rate of end-stage renal
disease (ESRD) is 232 per million population and with an annual
growth of 10-20% of the dialysis population.
Th us , stu dy was ca rr ied ou t to d eline at e the cl in ical a nd
epidemiological profile of patients on haemodialysis seen in this
region.
Methods
A hospital based cross sectional study was carried out in the
department of General Medicine, at a teaching hospital in Sikkim after
taking approval from the institutional ethical committee. A total of 50
CKD patients undergoing haemodialysis who gave written informed
consent were recruited. Data was collected by direct interview and
from the medical records of the patient using a predesigned, pretested
proforma meeting the objectives of the study. Data was analysed usin
Chronic Kidney Disease (CKD) refers to an irreversible deterioration in renal function. For operational purposes, CKD is defined as the presence, for at least three months, of evidence of kidney damage with an abnormal glomerular filtration rate (GFR) or, alternatively, by a 2 GFR below 60ml/min/1.73 m body surface area. A cut off of 2 60ml/min/1.73 m body surface area is selected because it represents a decrement to approximately half of normal renal function and because its use avoids the classification of many older individuals who may have mild reductions in their GFR. CKD a major epidemic of this century, has become a major public health problem both in terms of patient number and treatment cost, with most patients either referred to one of many renal replacement therapies such as haemodialysis, peritoneal dialysis and renal transplantation or death supervenes as a result of cardiovascular disease. India, which is the diabetic capital of the world, now heading towards the same in hypertension, and with increasing life expectancy of the population, CKD needs to be considered in their management, as all are directly related to it. In India the incidence rate of end-stage renal disease (ESRD) is 232 per million populations and with an annual growth of 10-20% of the dialysis population.
(Jain, Amit & Khatri, Dheeraj & Theengh, Diki & Nandy, Parvati. (2018). Clinico-epidemiological profile of haemodialysis patients in a teaching hospital in North Eastern India. International Journal of Scientific Research. 7. 15-8. )
Through thorough research it as found that (Cite the above research gate link here):
A total of 50 CKD patients undergoing haemodialysis at a teaching hospital in East Sikkim, were included in the study. A majority (54%) of these patients were between the age of 40 to 60 years with the mean age of 50 ± 12. Among these 33 were male and 17 were female with most being of Nepali ethnicity (54%), Hindu (52%) and married (76%). Most of the patients belonged to East Sikkim (62%) and communicated to the dialysis centre in public transport (60%). Majority had done there middle schooling (56%), with most being exemployed (44%) with a monthly income of most being >20,000 (42%) and on reimbursement (64%) especially from the Government as source of fund for their health care cost. Most patients were on haemodialysis, for less than five years (86%) with 46% of them for less than one year. Most patients had received blood transfusion (78%) during haemodialysis with A(42%) being the most common blood group followed by O (32%). Most of them consumed a mixed diet (98%), not following the recommended diet (54%). Only 6% of the patient had a positive serology, all for hepatitis C. 86% had being vaccinated against hepatitis B while only 48% had being vaccinated against Influenza and pneumococcal. Muscle cramps (58%), dizziness (58%) and infection (52%) were the most common complication while on haemodialysis, with most being oliguric (96%). Most had history of addiction to alcohol (48%) and tobacco (36%) and did not have any family history of any kidney disease (76%). Hypertensive nephrosclerosis (32%) and diabetic nephropathy (30%) were the most common aetiology. Most patients had spent less than one month on conservative care (58%) with biopsy done on only 14% of the patients. Temporary central venous catheter was the mode of vascular access in all the patients for their first haemodialysis. Majority were aware about renal transplantation but were not on any waiting list for the same (56%), with 42% of the patients having no perspectives of renal transplantation with 84% having no likely kidney donors.
Speaking about Sikkim, there haven’t been many researches to provide concrete data but a study by PubMed Central (PMC), a free full-text archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health’s National Library of Medicine (NIH/NLM), Shijo John Joseph, Samrat Singh Bhandari, and Sanjiba Dutta, shows “Cognitive Impairment and its Correlates in Chronic Kidney Disease Patients Undergoing Haemodialysis.”
In this study the method used was a hospital based cross-sectional study and the participants were the patients attending HD in Sikkim Manipal Institute of Medical Sciences (SMIMS) and Sir Thodup Namgyal Memorial (STNM) Hospital in Gangtok, Sikkim. The study was conducted from March 2016 to March 2017. The study was approved by the Institutional Ethical Committee (IEC, Reg.no. 360/15–083) of SMIMS. A total of 50 patients who attended the dialysis units of SMIMS AND STNM hospitals and who were willing to participate in the study were included after a written consent was obtained from them. It was decided that all patients undergoing HD and meeting the inclusion criteria and providing informed consent during the one-year period would be taken up for this study. Letter of consent was presented in Nepali and English. In this study 50 patients suffering from CKD, undergoing HD from state of Sikkim in India were investigated. Minimum and maximum ages of the patients undergoing HD were 24 years and 70 years respectively with a mean of 50.32 years and SD of 12.4 years. Duration of dialysis for the patients had a mean of 18.8 months with SD of 15.11 months. The prevalence of depression in the patients was 42%.
Severity of Depression amongst CKD Patients Undergoing Haemodialysis, (NCBI/NLM/NIH)
The study found out that there is convincingly an unfavourable impact of HD on CKD patients. The high prevalence of CI in these patients leads to poor QoL and increase in mortality.24 Identifying CI early in the course of illness would help the treating team to make patient precise treatment decisions.10 The finding in our study unquestionably leads us to the understanding of high prevalence of CI in these patients. More research of this kind in diverse sociodemographic profiles would help us in better understanding of cognitive impairment and depression of such patients.
The findings are shocking, as Sikkim has an already alarming rate of mental health diseases, and culturally the state is well known for an affiliation to alchohol, one of the biggest culprits behind CKD, the study shows that the correlation between the two, in people who suffer from CKD is ghastly. With the shcoking facts stated in the second table, it is well in the territory of reason to state that many people have lost their life savings trying to battle renal diseases.
Dr Shankaran shares a despondent anecdote, “There has been a case in the pediatric CKD cases I’ve seen where people have contemplated and made up their minds in losing a child rather than coming to the roads while trying to battle CKD, which sounds really sad but looking objectively, they said it was easier to have another child and let this one go than to come to the roads trying to bear exoenses that would deplete in due time, which would ultimately cause losing the child.”
As dismal as it may sound, there have been cases in India where people have lost everything trying to battle CKD. However there has been silver linings to the dark clouds. The Pradhan Mantri National Dialysis Program (NDP), which was introduced in 2016 has helped many in India, and in Sikkim availing free dialysis. The eligibility for availing NDP was for poverty Line and below poverty line patients who could apply for free dialysis scheme. To avail NDP the annual income of the person must be less than 1 lac per annum. All kidney patients in the district who are not either government employees or draw a pension of less than 3 lakhs INR per year can be included in this scheme. The patients can avail this service at free of cost. The hospitals cannot levy any additional charges on the patients. Government takes care of their treatment.
In Sikkim, strides have been evident since 2020 when Chief Minister Prem Singh Tamang shared a seraphic message that came as a blessing for people battling CKD.
“The people from South and West Sikkim will now have easy access to such facilities in their own District Hospitals which will save their time and money spent on travelling. In the last 18 months, we have focused on improving the health sector in the State and have taken decisions accordingly. We have introduced dialysis centres in Geyzing and Namchi hospital along with STNM, we have also provided health insurance to the economically weaker section of our society and are regularly lending our support for medical treatments and other purposes” Tamang shared a message from his official page in 2020.
To top that off, amid the pandemic STNM Hospital in September 2020 administered dialysis treatment or Renal Recovery Therapy on a COVID positive patient inside the COVID-19 section’s Central ICU at the hospital in Gangtok.
Sikkim has started policies in tandem with the NDP, that gives access to free dialysis and has seen numerous in-state dialysis centres used for the same.
The availability of application, as per the free dialysis scheme goes as follows:
- The person requesting for free dialysis can avail the service under Pradhan Mantri National Dialysis Program (PM – NDP).
- Kindly refer to the eligibility criteria section to know the criteria for availing this scheme.
- The person must approach the nearby government multispecialty hospital in his/her district.
- The requestor must get an appointment at the hospital to consult a qualified nephrologist.
- Once patient is examined by the nephrologist, the nephrologist writes down the diagnostic tests (Urea, Creatinine, Sodium, Potassium, complete bio-chemistry & haematology profile) to be done before dialysis.
- These tests should be done through the free diagnostic program or governments own laboratory.
- Based on the test results the nephrologist refers the patient for dialysis in district hospitals which offer free dialysis to patients under (PM – NDP) scheme.
- SMS based appointment system for all patients enrolled for services. The patient gets the appointment time/date through text message from the hospital.
- The Service Provider shall not be entitled to levy any charge on the patients. The services shall be provided completely cashless to all patients referred by district/sub-district hospitals.
Chronic Kidney Disease (CKD) refers to an irreversible deterioration in renal function. For operational purposes, CKD is defined as the presence, for at least three months, of evidence of kidney damage with an abnormal glomerular filtration rate (GFR) or, alternatively, by a 2 GFR below 60ml/min/1.73 m body surface area. A cut off of 2 60ml/min/1.73 m body surface area is selected because it represents a decrement to approximately half of normal renal function and because its use avoids the classification of many older individuals who may have mild reductions in their GFR. CKD a major epidemic of this century, has become a major public health problem both in terms of patient number and treatment cost, with most patients either referred to one of many renal replacement therapies such as haemodialysis, peritoneal dialysis and renal transplantation or death supervenes as a result of cardiovascular disease. India, which is the diabetic capital of the world, now heading towards the same in hypertension, and with increasing life expectancy of the population, CKD needs to be considered in their management, as all are directly related to it. In India the incidence rate of end-stage renal disease (ESRD) is 232 per million populations and with an annual growth of 10-20% of the dialysis population.
(Jain, Amit & Khatri, Dheeraj & Theengh, Diki & Nandy, Parvati. (2018). Clinico-epidemiological profile of haemodialysis patients in a teaching hospital in North Eastern India. International Journal of Scientific Research. 7. 15-8. )
A total of 50 CKD patients undergoing haemodialysis at a teaching hospital in East Sikkim, were included in the study. A majority (54%) of these patients were between the age of 40 to 60 years with the mean age of 50 ± 12. Among these 33 were male and 17 were female with most being of Nepali ethnicity (54%), Hindu (52%) and married (76%). Most of the patients belonged to East Sikkim (62%) and communicated to the dialysis centre in public transport (60%). Majority had done there middle schooling (56%), with most being exemployed (44%) with a monthly income of most being >20,000 (42%) and on reimbursement (64%) especially from the Government as source of fund for their health care cost. Most patients were on haemodialysis, for less than five years (86%) with 46% of them for less than one year. Most patients had received blood transfusion (78%) during haemodialysis with A(42%) being the most common blood group followed by O (32%). Most of them consumed a mixed diet (98%), not following the recommended diet (54%). Only 6% of the patient had a positive serology, all for hepatitis C. 86% had being vaccinated against hepatitis B while only 48% had being vaccinated against Influenza and pneumococcal. Muscle cramps (58%), dizziness (58%) and infection (52%) were the most common complication while on haemodialysis, with most being oliguric (96%). Most had history of addiction to alcohol (48%) and tobacco (36%) and did not have any family history of any kidney disease (76%). Hypertensive nephrosclerosis (32%) and diabetic nephropathy (30%) were the most common aetiology. Most patients had spent less than one month on conservative care (58%) with biopsy done on only 14% of the patients. Temporary central venous catheter was the mode of vascular access in all the patients for their first haemodialysis. Majority were aware about renal transplantation but were not on any waiting list for the same (56%), with 42% of the patients having no perspectives of renal transplantation with 84% having no likely kidney donors.
Speaking about Sikkim, there haven’t been many researches to provide concrete data but a study by PubMed Central (PMC), a free full-text archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health’s National Library of Medicine (NIH/NLM), Shijo John Joseph, Samrat Singh Bhandari, and Sanjiba Dutta, shows “Cognitive Impairment and its Correlates in Chronic Kidney Disease Patients Undergoing Haemodialysis.”
In this study the method used was a hospital based cross-sectional study and the participants were the patients attending HD in Sikkim Manipal Institute of Medical Sciences (SMIMS) and Sir Thodup Namgyal Memorial (STNM) Hospital in Gangtok, Sikkim. The study was conducted from March 2016 to March 2017. The study was approved by the Institutional Ethical Committee (IEC, Reg.no. 360/15–083) of SMIMS. A total of 50 patients who attended the dialysis units of SMIMS AND STNM hospitals and who were willing to participate in the study were included after a written consent was obtained from them. It was decided that all patients undergoing HD and meeting the inclusion criteria and providing informed consent during the one-year period would be taken up for this study. Letter of consent was presented in Nepali and English. In this study, 50 patients suffering from CKD, undergoing HD from state of Sikkim in India were investigated. Minimum and maximum ages of the patients undergoing HD were 24 years and 70 years respectively, with a mean of 50.32 years and SD of 12.4 years. Duration of dialysis for the patients had a mean of 18.8 months, with SD of 15.11 months. The prevalence of depression in the patients was 42%.
Severity of Depression amongst CKD Patients Undergoing Haemodialysis, (NCBI/NLM/NIH)
The study found out that there is convincingly an unfavourable impact of HD on CKD patients. The high prevalence of CI in these patients leads to poor QoL and increase in mortality.24 Identifying CI early in the course of illness would help the treating team to make patient precise treatment decisions.10 The finding in our study unquestionably leads us to the understanding of high prevalence of CI in these patients. More research of this kind in diverse sociodemographic profiles would help us in better understanding of cognitive impairment and depression of such patients.
The findings are shocking, as Sikkim has an already alarming rate of mental health diseases, and culturally the state is well known for an affiliation to alchohol, one of the biggest culprits behind CKD, the study shows that the correlation between the two, in people who suffer from CKD is ghastly. With the shcoking facts stated in the second table, it is well in the territory of reason to state that many people have lost their life savings trying to battle renal diseases.
Dr Shankaran shares a despondent anecdote, “There has been a case in the pediatric CKD cases I’ve seen where people have contemplated and made up their minds in losing a child rather than coming to the roads while trying to battle CKD, which sounds really sad but looking objectively, they said it was easier to have another child and let this one go than to come to the roads trying to bear exoenses that would deplete in due time, which would ultimately cause losing the child.”
As dismal as it may sound, there have been cases in India where people have lost everything trying to battle CKD. However there has been silver linings to the dark clouds. The Pradhan Mantri National Dialysis Program (NDP), which was introduced in 2016 has helped many in India, and in Sikkim availing free dialysis. The eligibility for availing NDP was for poverty Line and below poverty line patients who could apply for free dialysis scheme. To avail NDP the annual income of the person must be less than 1 lac per annum. All kidney patients in the district who are not either government employees or draw a pension of less than 3 lakhs INR per year can be included in this scheme. The patients can avail this service at free of cost. The hospitals cannot levy any additional charges on the patients. Government takes care of their treatment.
In Sikkim, strides have been evident since 2020 when Chief Minister Prem Singh Tamang shared a seraphic message that came as a blessing for people battling CKD.
“The people from South and West Sikkim will now have easy access to such facilities in their own District Hospitals which will save their time and money spent on travelling. In the last 18 months, we have focused on improving the health sector in the State and have taken decisions accordingly. We have introduced dialysis centres in Geyzing and Namchi hospital along with STNM, we have also provided health insurance to the economically weaker section of our society and are regularly lending our support for medical treatments and other purposes” Tamang shared a message from his official page in 2020.
To top that off, amid the pandemic STNM Hospital in September 2020 administered dialysis treatment or Renal Recovery Therapy on a COVID positive patient inside the COVID-19 section’s Central ICU at the hospital in Gangtok.
Sikkim has started policies, in tandem with the NDP, that gives access to free dialysis and has seen numerous in-state dialysis centres used for the same.
The availability of application, as per the free dialysis scheme, goes as follows:
The person requesting for free dialysis can avail the service under Pradhan Mantri National Dialysis Program (PM – NDP).
Kindly refer to the eligibility criteria section to know the criteria for availing this scheme.
The person must approach the nearby government multispecialty hospital in his/her district.
The requestor must get an appointment at the hospital to consult a qualified nephrologists.
Once the patient is examined by the nephrologists, the nephrologist writes down the diagnostic tests (Urea, Creatinine, Sodium, Potassium, complete bio-chemistry & hematology profile) to be done before dialysis.
These tests should be done through the free diagnostic program or governments own laboratory.
Based on the test results the nephrologists refers the patient for dialysis in district hospitals which offer free dialysis to patients under (PM – NDP) scheme.
SMS based appointment system for all patients enrolled for services. The patient gets the appointment time/date through text message from the hospital.
The Service Provider shall not be entitled to levy any charge on the patients. The services shall be provided completely cashless to all patients referred by district/sub-district hospitals.
The required documents for the same are:
Identity proof, Ration Car, Aadhaar card, Applicant passport size photograph, Below poverty Line ( BPL) certificate, Residential Proof, Referral documents from government hospital, Test Reports
