Kidney disease (CKD) or chronic kidney disease, has surged to unacceptable levels in recent years, making it a major public health burden.
As most people are still unaware of the basic facts of the disease due to the many theories on how and why it is caused, The Sunday Observer . spoke to Consultant Nephrologist, Sri Jayewardenepura Teaching Hospital, Dr. Dilukshi Pilapitiya to share her hands-on knowledge as to how, and why CKD occurs and how it can be prevented.
Excerpts
Q. For the benefit of readers who still lack even basic knowledge about kidney disease what is the role kidneys play in maintaining a person’s well being?
 Dr. Dilukshi Pilapitiya |
A. Kidneys perform many functions in a person’s body. They remove body waste and toxins through urine, balance water, salt and many other ions like potassium, prodce a hormone called erythropoietin needed to produce red blood cells. They also produce the hormone ‘renin’ which regulates blood pressure. In addition, kidneys make the active form of vitamin D which is needed for bone health.
Q. What are the risk factors/conditions that drive this disease?
A. The risk factors and conditions that cause this disease are as follows:
1. Diabetes
2. Hypertension
3. Obstruction to urine flow causing reflux nephropathy
4. Heart disease
5. Protein/ blood losing conditions (glomerulonephritides)
6. Genetic diseases (Ex: polycystic kidney disease)
7. Renal stones
8. Chronic interstitial nephritis of agricultural communities
9. Snake bites, past leptospirosis, etc
Q. So what kind of adverse fallouts are likely to occur as a result of these negative conditions?
A. When kidneys are affected for prolonged periods they start to fail. When damages to the kidneys reach an irreversible state the kidneys fail progressively, and are unable to maintain and function properly. For example, when kidneys can’t balance water in the body, the patient starts to retain water in his body which will swell as he is unable to pass the excess water as urine. If undetected, they can become so swollen that they sometimes accumulate water in their lungs, making it difficult to breathe, and at times could even die from this.
Q. I understand Kidney diseases are mainly of two types; acute and chronic. Is this correct?
A. Yes. Some get acute kidney injury and recover fully while some with acute kidney injury will have some residual damage and hence reduction of their renal reserve due to a severe acute injury or repeated acute kidney injury insults. We say there is chronic kidney disease (CKD) when there is persistent renal damage beyond the first 3-months of the initial insult.
Q. Who are those most vulnerable to getting CKD?
A. Low health literacy people with unhealthy exposure to pesticides/drink from unclean water supplies, i.e. abandoned wells in areas of high pesticide usage are more vulnerable to get it.
Q. What are the symptoms to look out for in a person with suspicious signs of the disease?
A. Frothy urine/red-coloured urine which may denote losing proteins/blood with urine. If you have this, you need to get your urine checked. If you have swollen feet/swelling around eyes, this may indicate kidney disease. If you have pain in the loin which may or may not radiate to your groin, this may indicate renal stones and should get it checked. Apart from this if you have diabetes/hypertension, you should get kidney checkups at least annually, and screening frequency depends on duration of diabetes / hypertension.
Q. Can these symptoms be reversed if one seeks early treatment?
A. Yes, until a certain level. After kidneys have fully failed/irreversibly damaged, symptoms can only be supported by means of medication and renal replacement therapy modalities. If diagnosed early, we can give renal optimised advice/adjustments in order to preserve renal function as much as possible. In certain conditions like passing proteins/blood through kidneys due to various glomerulonephritides, if we detect early and treat accordingly, the whole disease process can be halted and even cured in certain occasions.
Q. Is diabetes and hypertension a cause?
A. Yes, diabetes is one of the leading causes of CKD worldwide. Long-standing hypertension may damage kidneys as well as the heart and the brain. This is called target organ damage due to hypertension. Long-term hypertension produces microscopic changes in blood vessels which damage kidneys. Over time these become irreversible, making kidneys shrunken in size.
Q. Give us some examples of the kind of foods we should eat, and ways to cook them healthily to minimise these risks
A. Choose whole grains (whole wheat, brown rice, oats, unprocessed products) and veggies. When eating meat/fish choose baking/broiling rather than frying. Choose foods with no added sugar, read labels (if you read labels of salad dressings you will not pour them over your salad because you must walk miles to get rid of those calories!). Slow down at snack time – choose healthy options during late-night work shifts/stressful periods like celery chops, carrot/guava cuts, low fat popcorn, peeled oranges, etc.
Q. It has been reported that in the past two decades, Chronic Kidney Disease of unknown etiology (CKDu) has emerged as a significant contributor to the burden of CKD in rural Sri Lanka, with prevalence of 15.1–22.9 percent for CKDu in some Sri Lankan districts. What is CKDu? Is this an emerging trend in kidney disease in Sri Lanka?
A. CKDu, (new-term CINAC) - which stands for chronic-interstitial-nephritis-of-agricultural-communities, is a form of kidney disease acquired by people living in certain endemic areas and is believed to be due to environmental exposures. Current thinking is this is due to exposure to heavy metals/toxins in pesticides which are trapped in the hard water in certain areas. This also has aggravating factors such as being exposed to high environmental temperatures during working hours and not having adequate hydration. CINAC is now becoming slightly less more prevalent in affected communities. This could mainly be due to better availability of clean water and more awareness of the disease making people more cautious and keener towards following good health habits.
Q. Are the symptoms similar to ordinary kidney disease?
A. Yes. Symptoms experienced due to kidney failure are similar.
Q. Do most patients with this condition invariably end up with renal failure?
A. Yes, although each individual may differ in their rates of kidney function decline.
Q. In the case of critically ill patients with kidney failure - how are they managed? Dialysis? Are there different types of dialysis? How often does a patient need to undergo dialysis treatment?
A. At least twice a week. In many developed countries, the minimum frequency of dialysis is thrice a week but unfortunately, we cannot do this in our set up due to lack of resources. Peritoneal dialysis is done via exchanges of a special fluid through your tummy. This is usually done six days a week, at home after training.
Q. What are the other options available to the patient? Is transplant surgery a good option for a badly damaged kidney? Why?
A. Having a kidney transplant changes a patients’ life forever. Patients on dialysis must reach their dialysis unit at least twice weekly and whenever they feel unwell with difficulty in breathing. This limits their ability to travel distances freely. In addition, they cannot drink water to quench their thirst as fluid limitation is ~500ml/day. After a successful transplant these limitations are overcome.
Q. What if the patient rejects it for some reason?
A. There are many treatment options available to manage rejection episodes like plasma exchange, rituximab injections.
Q. For how long will a new kidney last in one’s body?
A. Generally, a live-donor kidney will last for about 15-20 years and a deceased-donor kidney 10-15 years on average. But this may vary according to many factors, such as the correct match of the kidney, or the recipient having diabetes, or else the recipient developing an infection etc.
Q. So what precautions are taken to minimise these risks before surgery?
A. Patients must undergo an extensive array of investigations to rule out underlying diseases which may become worse post-transplant. For instance, if someone has a chronic infection or an underlying cancer, this may become uncontrollable after initiation of immune-suppression medication post-transplant. The heart too needs to be optimised before transplant, as kidney patients are more prone to get heart attacks. Donors are investigated extensively to make sure they are healthy prior to organ retrieval. They should also undergo an ethical clearance before the surgery.
Q. Is there an age limit for donors?
A. The age cut off for males is 25years and females 30 years. There is no universally accepted upper-limit for age, and we sometimes accept older donors as well, provided they are in good health and the age gap is reasonable.
Q. How soon does it usually take for a patient to recover?
A. A donor can resume light-work schedules in 2-4weeks post-surgery. If they are into hard work, 4-6weeks’ post-surgery or depending on the medical opinion on discharge. For kidney transplant recipients they need to be followed up closely during the first 3-months, then monthly thereafter. Kidney transplant recipients should make sure they avoid dirty/polluted environments plus places/people they could contract infections from.
Q. Does the patient have to continue to take drugs daily after surgery? If so, for how long?
A. After a kidney transplantation, medication which modifies their immunity should be taken lifelong. In addition, they should be reviewed in clinics to adjust doses according to changes in their physiology regularly.
Q. What are the side effects of these drugs?
A. There are many side-effects. They are on mandatory immune-suppression drugs, which reduce patients’ immunity, hence their ability to fight infections. These drugs can cause high blood-pressure and alter your blood sugar and thus these drugs need to be monitored regularly. They can show other side-effects such as elevated potassium levels, reduce white blood cells. We monitor blood levels of these drugs to keep them at optimum levels.
Q. If someone wants to donate a kidney who should she /he contact?
A. Currently there is no designated body in Sri Lanka which officially coordinates altruistic donations of live-organs via live-donor registries. If someone is interested in donating, they should look at newspaper articles of end stage renal failure patients who request kidneys in order to be transplanted.
Q. Have you a message to readers?
A. Prevention is the best method. Eat healthy foods. Maintain a healthy lifestyle. Try walking 10000 steps per day and not keep gaps as long as 72 hours in between your exercise schedules.
Aim for a healthy weight-have your target BMI less than 25. Stop smoking as it is fibrotic for kidneys, and you are calling cancers your way. Minimise alcohol intake. Learn to manage stress by engaging in stress reducing activities like listening to music, doing yoga/meditation/gardening regularly. Adhere to a healthy lifestyle always and don’t forget to screen for diabetes/hypertension regularly as early detection will help better control these diseases from early stages and mitigate their progression to CKD. Those with diabetes/hypertension should also try to get their blood sugar/blood pressure within targets with regular medical follow-up.