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).
A renal biopsy being performed on a young patient by Dr
Shenal Thalgahagoda for a definite diagnosis of his
malfunctioning kidney. |
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. |