Not curable

Q: Kidney diseases are spreading in Sri Lanka. What do you estimate to be the increase in the next 10-20 years?

A: No proper consensus has yet been done for the whole island. However, the incidence appears to be increasing. It may affect 10 to 15% of the adult population in the country within the next 10 years.

A: It is probably due to the screening programmes conducted in most hospitals, and more vulnerable individuals coming for these tests due to awareness raising. Other possible reasons are the rapid spread of diabetes mellitus, wide usage of agrochemicals and fertilizer as well as certain unidentified factors.

A Kidney disease can affect any person. But the causes seems vary depending on the cause. For example diabetic kidney failure occurs after 5 to 10 years of poor blood sugar control. Therefore, it is commoner among diabetic patients after 5 to 10 years of the disease. Majority of kidney patients world over and in Sri Lanka are victims of diabetes. Other causes include hypertension, glomerulonephritis, polycystic kidney disease, kidney stones, infections and drug induced kidney damage. There is a group of patients who do not have any identifiable cause and these patients are found only in certain geographical regions. The latter group of patients are labelled as kidney disease of uncertain aetiology (CKD-u).

Q: Are there different forms of kidney diseases? What are the types that are most prevalent in Sri Lanka?

A: Mainly there are two forms. Short term (acute kidney injury) and long term (chronic kidney disease). Acute kidney injury is potentially reversible if treated early and appropriately. Main causes of acute kidney injury include dehydration, toxins such as snake venom and blockage to urine flow. Minority of acute patients can go in to chronic form of the disease. Chronic kidney injury is a slow and irreversible kidney damage. This occurs over months to years and usually happens without symptoms.

Kidney diseases have leaped in numbers both globally and in Sri Lanka, and likely to increase in the next decade or so. The increasing prevalence of diabetes mellitus, wide use of agro chemicals and fertiliser, and more individuals attending screening programmes are all contributory factors. In addition, there is also kidney disease of uncertain aetiology CKD-u, diagnosed in persons who don't have identifiable causes. To find out more about these diseases and their causes Sunday Observer spoke to Consultant Nephrologist Sri Jayawardenepura Hospital, Dr Chintana Galahitiyawa

A: North Central Province, as it has highest incidence of CKDu patients in addition to patients with usual causes.

A: Yes. The chronic form of the disease manifests over the years. Therefore it can remain unnoticed and without symptoms till late stages. The development of symptoms is also slowly progressive and mostly non specific.

A: No significant symptoms occur till later stages. Symptoms are mainly due to accumulation of toxic metabolites in the body. Example loss of appetite, generalized body itch, sleeplessness, nausea, vomiting and generalized body weakness.

They can have anaemia, reduced urine production and swelling of the body, breathlessness due to water congestion in lungs and increased acidity in blood, electrolyte imbalances such as high potassium levels and calcium deficiency.

A: generally patients become very weak. Cardiac rhythm complications due to electrolyte imbalances, renal bone disease and bone marrow suppression due to high toxin levels. Chronic kidney disease patients are more vulnerable for coronary artery disease (heart attacks) and heart failure. Advanced kidney disease patients become dark in complexion due to pigmentation changes.

A: Yes. Majority of advanced kidney disease patients die of heart attacks. Other causes include severe lung congestion, heat rhythm irregularities and brain malfunction due to high toxin levels.

A: Chronic kidney disease is not curable. But it is preventable. Usually early detection of kidney damage and proper treatment might prevent or retard the progression and prevent or delay the kidney failure. Patients can live on regular haemodialysis (blood purification treatment) or suitable patients can have a kidney transplant. Technically speaking transplanted patients can be called 'cured' as they have a functioning kidney.

A: Treatment depends on the cause of kidney disease. Some diseases are treated with medicines. Certain patients where the disease is due to surgical reasons such as blockage to urine flow can be treated with surgery.

Transplant is the ultimate cure for the kidney failure as it gives a well functioning kidney and most of the symptoms and complications of kidney failure are reversed. More importantly patients get more freedom to enjoy their normal life without restrictions on water intake and food. Finding matching donors is the problem.

Q: A great deal of attention is now being given to Chronic Kidney Disease of Unknown Aetiology ( CKDu) which has now been re-named Chronic Kidney Disease of multi -factorial origin. Is this because the pattern of the disease has changed? Is it a new disease?

A: CKDu is not similar to any of the recognized diseases to date. It has its own features and appears both biochemically and histologically a different entity. There are similar disease patters observed in other parts of the world; i.e Some areas in India, Balkan area in Europe.

A: Highest prevalence is reported in Anuradhapura and Polonnaruwa district. CKDu in Sri Lanka has shown clustering of cases in some parts of the North central province but it has been recognized in other areas as well, e.g. Uva province, Wayamba province and some parts of southern province.

The damage mainly occurs in the supporting structure of the kidney tissue initially and later it spreads throughout. Protein leakage is not marked and high blood pressure is not commonly seen among this group of patients. Progression is slow and some studies have shown preponderance in middle aged males. Most of the patients reported are farmers. Their symptoms are quite late and they present at advanced stages of the disease.

Q: There has been a mixed response to the reasons given for this spread in these districts in the report. Some scientists and medical personnel say it is due to contaminated drinking water, high fertiliser use or the unhealthy life styles. Others say that hard metals in the water, like phosphate, iron etc is the only cause. What is your opinion?

A: Finding a cause for this illness is both important and challenging. My opinion is we should minimize exposing our bodies to all these toxic compounds till scientists come up with the confirmatory evidence.

Q: What is the treatment given to patients with CKDu? Does it vary from patient to patient? On the severity of the disease?

A: Yes, each individual patient needs specific regimen of treatment depending on their age, disease stage and the degree of complications exist.

There is no specific treatment available for CKDu. The current management plan is to educate the patient and the family and to give supportive treatments to minimize the progression of the disease.

A: Patients have dialysis therapy when they reach end stage kidney disease. . Ideally this treatment should be offered as a bridge to kidney transplant for the suitable patients. For patients who do not qualify for transplant can go on lifelong peritoneal or haemo (blood) dialysis.

Q: Are there enough dialysis machines to meet the requirements of all those needing them?

A: Although dialysis facility has improved immensely in recent years, we still don't have enough machines and trained staff to serve all our patients who need them. We need to increase the number of working machines especially in the areas of high disease burden. At Sri Jayewardenepura hospital we have 10 machines working in three shifts. We serve for 50 to 60 regular dialysis patients and a large number of crash landers and acute patients.

Q: Is providing good quality drinking water and controlling environmental pollution a key solution to bringing down deaths and morbidity due to CKDu?

A: Although these are basic requirements for healthy life, as we still don't know the exact causative factor is difficult to say that this will stop the CKDu.

Q: Recently the National Poisons Information Centre stated agro chemicals was a leading cause for suicides in Sri Lanka . As a Nephrologost , describe the impacts of ingesting agro chemicals on the human body. Does it lead to liver failure?

A: There are certain agrochemicals which are highly lethal at very small quantities Ex Parquet. Chronic exposure to these chemicals can lead to slowly progressive organ damage. Certain chemicals re toxic to liver cells and ingestion of these by accident or in attempted suicide can lead to liver failure. We need to educate the general public and improve their awareness on these poisons.

Q: Any new technological advances on curing kidney disease 1) in general 2) CKDu?

A.: There is a lot of research in developed countries to harvest kidney cells and to grow them on a supporting structure to develop functioning kidney tissue to cure patients with kidney failure. But there are no new technological advances at present.

A: There are a few things I want to mention. We should consume adequate volumes of safe drinking water to ensure a good urine output. I recommend 2 to 2.5 litres of water for young healthy individuals on a daily basis.

Cutting down salt in our diet is helpful in minimizing kidney damage and controlling high blood pressure. Proper control of diabetes and hypertension is very important as they are the leading causes of kidney failure world over.

Further, patients with diabetes, high blood pressure, kidney stones, urine flow blocks and people with family history of kidney disease should undergo regular kidney checkups to detect any damage early in the disease.