When the kidneys fail

With only one paediatric haemodialysis unit in the country, renal failure in children is a reality Sri Lanka is yet to wake up to...:

by Carol Aloysius

The incidence of children detected with kidney diseases that could lead to renal failure has increased island -wide. Yet facilities needed for their care and treatment falls far short of the demand, with only a very few hospitals having adequate equipment. In addition the country faces an acute shortage of qualified specialists in this field and trained nursing staff. Drug shortages are also not uncommon, depriving underprivileged children, who comprise the bulk of paediatric kidney patients, of life supporting drugs (given free in State hospitals).

The Teaching Hospital Peradeniya, which is the only hospital in the island to perform renal transplants, recently launched a special project to help children with kidney diseases and renal complications. Here Dr Shenal Thalgahagoda, Paediatric Nephrologist, Teaching Hospital, Peradeniya, shares his views on some of the complications of renal diseases in children, and gaps the hospital hopes to fill under the project.

Excerpts...

Q: The incidence of kidney diseases leading to renal failure has risen sharply in Sri Lanka in recent years. What is renal or kidney failure?

A: The main functions of the kidney are to clear out the body's waste products and to maintain fluid balance. It also secretes the hormone erythropoietin, which is involved in the formation of red blood cells. The kidney is also involved in bone metabolism through secretion of the active form of vitamin D. It also maintains acid - base balance in the body. In renal failure the above functions are deranged. The body cannot excrete waste products leading to their accumulation. Fluid can also accumulate leading to volume overload. Lack of erythropoietin leads to anaemia and altered vitamin D metabolism leads to deformed bones, especially in children. There is also build-up of acid levels in the body.

Q: What are the most common kidney diseases in Sri Lanka among young, and among the old?

A: Kidney diseases among the young and old vary quite a lot. While kidney damage secondary to diabetes is by far the commonest condition in adults worldwide, in children, congenital abnormalities are commonest. Nephritis and Nephrotic Syndrome are seen in both adults and children, but the causes of these two conditions vary greatly among adults and children. In Sri Lanka Chronic Kidney Disease of unknown origin (CKDu) has come into great prominence in the adult population but this is not the case in children.

Q: Do they all lead to renal failure? Or are there specific types that do so?

A: No. The vast majority of them don't lead to renal failure.

Q. Is there an increase in the number of children being diagnosed with kidney diseases that leads to renal failure?

A: The aetiology of renal failure in children is different to that in adults. Therefore, as conditions like diabetic nephropathy and CKDu are not common in children, the incidence does not show as significant an increase as in adults. It is perhaps becoming more prominent because people are becoming increasingly aware of the condition.

Q: Could a kidney disease be inherited from a parent? Is it genetic in some cases?

A: Yes. There are certain conditions like Alport syndrome and some tubular disorders that are inherited. A genetic basis is also being increasingly found in Nephrotic syndrome.

Q: What about snake bites? Can a bite from a poisonous snake cause renal failure in both adults and children?

A: Yes. Snake bite is an important cause of renal failure, especially in adults, who are more vulnerable, due to more frequent exposure.

Q: Water contaminated with heavy metals is said to be one of the main causes for the rise in kidney disease, including CKdu in the North Central, Eastern Province and Central Province. Your comments?

A: Heavy metals have been implicated, as has fertilizer. However nothing has been conclusively proven to be the cause.

Q. What are the main complications of having a kidney ailment, especially in children? What organs of the body does it impact on?

A: Renal failure can impact most organs in the body. It can cause anaemia and also dysfunction of the heart. Bone metabolism is affected leading to deformities of bones. Patients also have loss of appetite and generalized ill health. Advanced renal failure can lead to fits and an impaired level of consciousness.

Q. Nephritis is an illness affecting the kidneys and is more common in children. Your comments?

A: The term nephritis indicates inflammation of the kidneys. There are many causes for this, but in children the commonest is post infectious glomerulonephritis. Inflammation of the kidneys leads to dysfunction of the kidneys and a reduced urine output, swelling of the body due to volume overload and hypertension.

Q:Can nephritis be caused by bacteria from skin infections, scratches, insect bites, scabies etc?

A: Post infectious glomerulonephritis occurs secondary to infection by the bacterium Group A ß haemolytic streptococcus. This bacterium can cause skin infections. Thus skin infections can lead to nephritis. Similarly streptococcal infections of the throat can also lead to nephritis. Nephritis results from a host (patient) immune response to the bacterial antigens. This immune response leads to renal damage.

Symptoms

Q: What are the symptoms of the onset of a kidney disease?

A:The symptoms of renal failure are extremely variable. This can range from vague symptoms like lethargy and poor appetite to reduced urine output, hypertension and body swelling. Renal involvement is also being detected at screening programmes.

Watch out for these signs

Q: How will a parent know if his child is developing a kidney ailment?

A. In the early stages of chronic kidney disease children can be quite asymptomatic (symptom free). Failure to gain wait, short stature, deformities of bones, i.e. bowing of legs and knock knees and bed wetting are also important ways of presentation in children, apart from those mentioned above.

Stark realities and projections

Only one paediatric haemodialysis unit

"Advanced renal failure requires either dialysis or renal transplantation. At the Teaching Hospital, Peradeniya we presently can perform only peritoneal dialysis as we do not have haemodialysis facilities. For this we are dependent on the services of the adult nephrology team at the Kandy Teaching Hospital. However this is possible only for older children. Lady Ridgeway Hospital, Colombo possesses the only paediatric haemodialysis unit in the island.

We perform renal transplants at the Peradeniya General Hospital. Our hospital is the only hospital in the island which offers this service.

5 Paediatric nephrologists

There are only five paediatric nephrologists practicing at present in the country and two more in training. The need however is much greater.

100-150 admissions

We get about 100-150 new admissions per month and at any given time we have between 20-30 renal patients warded in our unit. We also see around 400-500 patients per month in our renal clinics. We have four cubicles in our ward for renal patients. We do not have a renal ICU at present but one of the cubicles serves as a high dependency unit cum peritoneal dialysis unit.

Drugs not available

Most medication is supplied by the governmn. But of late we have run in to problems of unavailability of drugs. This is extremely worrying as these patients' lives depend on regular medication. The drugs are very expensive and most patients can't afford to buy them from the private sector.

Most urgent needs

Improvement of paediatric haemodialysis facilities is an absolute necessity. We also need a constant supply of medication as these drugs are very expensive and most patients cannot afford to buy them from the private sector.

Future plans

We have embarked on a project to build a fully-fledged paediatric haemodialysis and high dependency unit at Teaching Hospital, Peradeniya. We are also in the process of converting a cubicle in the ward to a haemodialysis unit.

Funding

We are dependent on the government for most funding. We have also created a Fund which is dependent on donations from the generous public. It is also used to support needy patients when investigations need to be performed in the private sector. We have also utilized the public to sponsor poor patients with a monthly stipend.

On the horizon

To have quality nephrology care including dialysis and renal transplantation accessible to all. For this we need public assistance to sponsor individual patients.

Dr Shenal Thalgahagoda

Kidney failure in children

Q: How is kidney failure detected in children?

A: A blood sample to detect the level of creatinine is the easiest way to detect renal failure. An estimation of one's renal function can be made based on this simple blood test. A formal measurement of glomerular filtration rate (GFR) can also be done.

Q: What are the methods used to treat children with renal failure?

A: Children with renal failure require medication to support the functions of the failing kidney.

These involve treatment of anaemia with erythropoietin, correction of acidosis with bicarbonate, treatment of bone disease with vitamin D and phosphate binders etc.

These are available in the government sector to all patients free of charge.

Q: If a child gets a kidney disease or has renal failure, will it be for life? Is it reversible?

A: More advanced chronic kidney disease is an irreversible and relentlessly progressive condition.

It is incurable and will ultimately lead to renal failure. What medication does is to slow the progression.

Q: How do you prevent kidney diseases in children?

A: It depends on the aetiology .While in adults renal failure can be prevented through strict control of diabetes, in children the commonest cause is congenital abnormality, which cannot be prevented.

Q: Your message to parents with children having kidney disease?

A: Advice to parents would depend on the condition and other relevant details of each patient. In general, compliance with medication and regular follow up would be important to all renal patients, regularly.

(For more information contact Prof. Chandra Abeysekera, Prof. of Paediatrics, Faculty of Medicine, Peradeniya University.