Kidney disease is preventable with early detection

By Carol Aloysius

The rising number of patients with chronic kidney problems as well as those affected by chronic kidney disease of unknown origins ( CKdu) has become a serious health issue in our country. Since the largest number of patients kidney have been reported from the North Central Provinces, the Sunday Observer spoke to Consultant Nephrologist Dr CHINTANA GALAHITIYAWA of the Anuradhapura Teaching Hospital to get a better insight into the causes of this widely prevalent disease, how it could be prevented, the treatment procedures, as well as the immediate needs of the hospital.

Question: What causes kidney diseases?

Answer: Kidney diseases are mainly of two types. Acute (new onset disease of days to weeks which usually be cured if diagnosed in time and properly treated).

Causes include infections (ex-Leptospirosis and severe infections), Low blood pressure of any cause 2. Chronic (long standing slowly progressing kidney damage which usually is irreversible) Causes - ex-long standing Diabetes, High blood pressure 3. Chronic kidney disease of unknown origin (CKDu) is the term used for north central province kidney disease which is classified as interstitial nephritis histologically.

Q. Are there different types of kidney disease - e.g. stage one, stage 2 and end stage etc?

A: Chronic kidney disease is divided in to 5 stages according to EGFR (Estimated Glomerular Filtration Rate)

Normal EGFR 90 to 125

Stage 1 - 90 with Asymptomatic urinary abnormalities
Stage 2 - 60 to 89
Stage 3 - 30 to 59
Stage 4 - 15 to 29

Q. How prevalent is it in Sri Lanka?
A. No recent studies have been done in Sri Lanka to determine the prevalence.

Q. What are the symptoms?
A. No specific symptoms and the majority are asymptomatic till they reach advanced stages.

Common symptoms include general weakness, loss of appetite, swelling of the body, body itch and shortness of breath.

Q. Can they be detected early before going on to stage 2?

A. Yes, in some fortunate patients diagnosed early in routine medical checkups. At present many early stage patients are detected in the North Central Province (NCP) in the community based screening programs.

Q. Is it hereditary? Can a parent pass it on to a child?
A. There are rare hereditary kidney diseases. Ex-Alport’s disease, Familial FSGS

Q. Who are the most vulnerable groups to get this?
A. NCP kidney disease is commonly seen among the farming community. Usually affects the adults and rare among teenagers.

Q. How can it be prevented?
A. The current belief is that NCP kidney disease is caused by the toxins contained in agrochemicals and fertiliser such as Arsenic and Cadmium. Long term exposure to these toxins and accumulation of these in the kidneys over years cause progressive kidney damage. Minimising exposure with safe handling of agrochemicals and consumption of safe water might prevent this disease.

Q. What are the adverse effects of kidney disease on the body?

A. Kidney is the principal metabolic regulatory organ of the body. Kidney failure cause metabolic derangement (electrolyte imbalances such as high potassium and phosphate.

Calcium levels will drop.) Patients become anaemic (low haemoglobin). They also fail to maintain water balance of the body and patients urine output drops and develop swelling of the body. Other impacts include, failure to maintain acid-base balance and acidity of blood goes up. Blood pressure also usually rises and patients tend to develop coronary artery disease (heart attacks.)

Q. Do they last a life time or are they temporary?

A. To treat these problems, we need to replace the functions of the kidneys artificially. This is called renal replacement therapy, such as dialysis or renal transplant.

Unless the patient gets renal replacement therapy, the adverse effects will gradually get worse and become life threatening.

Q. Does having a kidney stone make you vulnerable to the disease?

A. There is no evidence to say that they are more vulnerable to develop CKD-u. But patients with stones are more prone to develop kidney infections and they can obstruct the urine drainage. These can subsequently cause chronic kidney disease.

Q. What role do NCD’s such as diabetes, hypertension and cholesterol play as contributory factors?

A. Long standing poorly controlled diabetes and/or hypertension can cause chronic kidney disease. Diabetes is the commonest cause for CKD worldwide.

Therefore, these can aggravate the severity and expedite the development of ESRD in NCP kidney disease patients.

Q. Any new breakthroughs in treatment worldwide and in Sri Lanka?

A. Haemodialysis and renal transplant is the only treatment available for ESRD. With the advancement of immuno-suppressive therapy during past decade has markedly improved the success in renal transplants and their life span. New dialysis regimens and new equipment have improved the effectiveness and patients quality of life.

Q. Are there separate wards for patients with kidney problems?

A. There are separate Nephrology wards, at Maligawatte in Colombo, Sri Jayewardenepura Hospital and Anuradhapura hospital.

Q. How is kidney disease treated? With Drugs? Surgery? Dialysis?

A. Treatment depends on the CKD stage. Stage 1 to 5 patients are treated with drugs only. When they reach End stage, they need to have renal replacement therapy to live. Usual initial step is starting regular dialysis. Dialysis is of two types.

1. Hemo-dialysis - cleaning of patients’ blood and remove excess water through a complex machine and return to patients over a short period of 2.5 to 4 hours twice or thrice a week.

2. Peritoneal dialysis - removes patients’ toxins and excess water by a special fluid instilled into the peritoneal cavity through a catheter inserted into the abdominal wall. It’s a continuous procedure and the fluid instilled in the abdomen is periodically exchanged.

It’s done daily and gives more freedom to the patient. Unfortunately this is less popular in Sri Lanka.

Patients who are medically fit enough to have surgery and who have a matching donor are offered renal transplantation.

Q. How do babies get kidney disease?

A. The causes are different from adults. Congenital causes are the main factors causing CKD in babies.

Q. Is there a separate ward for them?

A. Paediatric nephrology is a developing field in Sri Lanka. At present they are treated in the paediatric wards and there aren’t any paediatric nephrology wards. But, adults have separate Nephrology wards.

At Colombo Maligawatte, Sri Jayewardenepura and Anuradhapura hospitals have dedicated adult wards.

Q. What role does diet play?

A. Diet is an important factor in management of kidney disease. Patients should get adequate nutrition and at the same time they should avoid certain items that contain harmful substances such as potassium and phosphates.

Patients should limit their fluid intake to recommended amounts when they reach ESRD and on RRT.

Q. When does one need dialysis?

A. When a CKD patient reaches ESRD and when they have medically uncontrolled metabolic derangements leading to poor quality of life or toxin levels reaching life threatening quantities.

Q. What is dialysis? Explain the procedure.

A. Hemo-dialysis - cleaning of patients’ blood and remove excess water through a complex machine and return to patients over a short period of 2.5 to four hours twice or thrice a week.

The hemo dialysis machine has a part resembling an artificial kidney. It has a semipermeable membrane which separates patient’s blood and special dialysate fluid flowing on opposite directions. During this procedure toxins are exchanged into dialysate fluid long with excess water.

Q. What is CKDu which is now spreading in the North Central province.

A. It’s a slowly progressive chronic kidney disease which is mainly seen in North Central Province and some parts of Uva Province. It mainly affects middle aged and adult population. Likely causes are toxins contained in agrochemicals and fertiliser such as arsenic and cadmium.

Classical areas observed are areas which have the combination of hard water and high agrochemical/fertiliser usage. This kidney disease is irreversible and no effective treatment available to date.

Q. As a Teaching hospital serving over a thousand patients, does your hospital have adequate facilities to meet the increased number of kidney patients?

A. At present we have adequate infrastructure at Anuradhapura unit and we will be getting more medical and nursing staff towards the latter part of this year.

The Minister of Health is closely liaising with the NCP renal unit to fulfill these requirements. As the number of patients increases day by day the current facilities need to be improved with time and the plan is to improve the facilities in peripheral units such as Padaviya, Kebithigollewa and Medawachchiya. The first satellite dialysis unit will be opened soon at Padaviya.

Q. Your message to the public on preventing kidney disease?

A. As the cause in not clear at present for the CKDu it is better to take all the precautions to avoid all potential causes such as;

1. Clean water (bottled, filtered)
2. Safe handling of agrochemicals and fertiliser
3. Minimise the adding of agrochemicals and fertiliser to the environment

Basic screening for hypertension, diabetes and proteinuria Screening for kidney impairment for early diagnosis especially for relatives of diagnosed patients and people from the same village.

Hope for Lankan autism sufferers

Autism is a disorder of neural development characterised by impaired social interaction and verbal and non-verbal communication and by restricted, repetitive or stereotyped behaviour. Autism spectrum disorder (ASD) and autism are both general terms for a group of complex disorders of brain development.

The diagnostic criteria require that symptoms become apparent before a child is three years old.

Autism affects information processing in the brain by altering how nerve cells and their synapses connect and organise; how this occurs is not well understood.[3] It is one of three recognised disorders in the autism spectrum (ASDs), the other two being Asperger syndrome, which lacks delays in cognitive development and language, and pervasive developmental disorder, not otherwise specified (commonly abbreviated as PDD-NOS), which is diagnosed when the full set of criteria for autism or Asperger syndrome are not met. Autism has a strong genetic basis, although the genetics of autism are complex and it is unclear whether ASD is explained more by rare mutations, or by rare combinations of common genetic variants.

In rare cases, autism is strongly associated with agents that cause birth defects.[6] Controversies surround other proposed environmental causes, such as heavy metals, pesticides or childhood vaccines; the vaccine hypotheses are biologically implausible and lack convincing scientific evidence.[8]

The prevalence of autism is about 1–2 per 1,000 people worldwide, and the Centres for Disease Control and Prevention (CDC) report 20 per 1,000 children in the United States are diagnosed with ASD as of 2012 (up from 11 per 1,000 in 2008).

The number of people diagnosed with autism has been increasing dramatically since the 1980s, partly due to changes in diagnostic practice and government-subsidized financial incentives for named diagnoses; the question of whether actual prevalence has increased is unresolved.

Parents usually notice signs in the first two years of their child's life.[12] The signs usually develop gradually, but some autistic children first develop more normally and then regress.

Not many children with autism live independently after reaching adulthood, though some become successful.

An autistic culture has developed, with some individuals seeking a cure and others believing autism should be accepted as a difference and not treated as a disorder.

There are over 40,000 suffering with autism in Sri Lanka.

Many struggle without access to public services in education, health, specialist speech therapy and respite care.

There are only a handful of schools who can offer only a few places for children with autism in Sri Lanka.

The vast majority have no access to education many are kept at home due to reasons of culture.

A reputed team now offers group therapies and day care facilities for Autism and special need children in Sri Lanka. More details about the special program conducted at Dehiwala could be obtained from 077-6019172

Autism, the experts suggest, is a brain disorder characterised by impaired social interaction and communication skills and limited activities and interests is the most characteristic and best studied PDD.

Other types of PDD are Asperger's syndrome, Rett's Syndrome,childhood dis-integrative disorders and others.

Breast-feeding babies improve their chance of climbing social ladder

Breastfeeding improves a child’s chance of climbing the social ladder and becoming a successful adult, according to a long-term study.

The analysis of more than 34,000 people born in the 1950s and 1970s found that those who had been breastfed as a baby were 24 percent more likely to be upwardly mobile - and 20 per cent less likely to drop down the social ladder.

The health benefits of breastfeeding are well known, but the study is among the first to identify tangible benefits later in life.

Two groups of people - born in 1958 and in 1970 - were categorised by the job their father did when they were 10 or 11, and the job they themselves had when they were 33 or 34.

Social class was divided into four categories based on job type - from unskilled and semi-skilled manual work to professional or managerial work. The authors of the study, published in Archives of Disease in Childhood, said that it provided evidence of long-term health, developmental and behavioural advantages to children, which crucially persist into adulthood. Breastfeeding enhances brain development, which boosts intellect, which in turn increases upward social mobility, they said.

“There are few studies that look at the long-term outcomes of breastfeeding, but this study shows its long-lasting positive effect,” said Professor Amanda Sacker, one of the report’s authors.

The NHS recommends breastfeeding to new mothers for the first six months of a baby’s life. Breast milk protects children from infections, and breastfed babies are also less likely to become obese or develop eczema.

The report’s authors said that breastfeeding also helped to generate a strong emotional bond between mother and baby.

“Perhaps the combination of physical contact and the most appropriate nutrients required for growth and brain development is implicated in the better neurocognitive and adult outcomes of breastfed infants,” they said.

Professor Sacker said that mothers who could not breastfeed could still aid their baby’s emotional and cognitive development with cuddling and close skin-to-skin contact with their baby while feeding. The study comes in the wake of figures that revealed the number of women breastfeeding their babies in England has dropped for the first time in a decade.

Numbers have been increasing in recent years, following a long-term decline associated with more women working and the increasing use of baby formula.

- The Independent