March 13 is World Kidney Day:

Kidney transplant offers longer life to CKD patients

Transplant success rate over 90 percent in Sri Lanka:

By Carol Aloysius

With kidney disease now rampant in the island, the surge in the number of patients who have reached stage 5 level of the disease has raised serious concerns among kidney specialists.

For these patients dialysis treatment is the main option. Chronic kidney disease (CKD) patients on dialysis requires a minimum of twice a week treatment to survive. The treatment is not only costly and a hassle to patients making that bi-weekly trek to the hospital, it prevents them from leading a quality life.

So what is the other option they have?

Kidney transplants will definitely give them a longer quality life says an expert in the field, who cites global studies on the subject to prove his argument. He says that unlike dialysis treatment which is hampered by the limited facilities in our hospitals, there are plenty of kidneys to go around, if the kidneys from brain dead patients admitted to hospitals could be donated to these critically ill dying patients. A kidney transplant will give them a new lease of life and save lives. The need of the hour is more donors of live kidneys”, says Sri Jayawardenepura hospital Consultant Nephrologist Dr Chinthana Galahitiyawa who explains why kidney transplants are a better option for chronic kidney patients in this interview with the Sunday Observer.

Excerpts...

Q. As kidney disease is widely prevalent, what are the most common kidney diseases one finds in our country?

A. Diabetic kidney disease, Hypertensive kidney disease, Chronic kidney disease of Unknown aetiology, Glomerulonephritis, and Polycystic kidney disease.

Q. What are the most severe health risks they carry?

A. Kidneys are the main controller of body water content, electrolyte concentration (ex Potassium, Sodium, chloride) Acid Base\balance. Kidneys are responsible for clearing up nitrogenous waste products from the body. Kidneys also mediate blood pressure control, and secrete a hormone called Erythropoetin to stimulate bone marrow to produce red blood cells. Additionally, they contribute in vitamin D production.

Q. What happens when there is kidney failure?

A. Complete or partial malfunction of the kidney functions is called kidney failure.

In kidney failure all above mentioned functions will get disturbed. This results in failure to control the water content and patients developing swelling (Oedema) of the body.

Wet lungs might lead to shortness of breath. Electrolyte imbalance is a major issue and it can be lethal. Specially high potassium levels can cause cardiac arrest in a short time period. Rising body acidity is detrimental to all cellular functions.

Q. What are the main symptoms? How are they caused?

A. Accumulation of waste products such as ammonia, urea and creatinine in the body is the main reason for the so called “uraemic” symptoms in kidney patients. These include loss of appetite, nausea, hiccups, vomiting, lack of sleep, itching of the body, lack of energy, change in skin colour and drowsiness. Blood pressure rises and becomes uncontrollable. Red blood cell production reduces and patient might develop anaemia. Kidney disease population in general is calcium and vitamin D deficient.

When all these problems derange the body composition it becomes life threatening. Apart from these direct problems in kidney failure, it puts the patient at a higher risk for ischemic heart disease (coronary artery disease).

The majority of the chronic kidney disease patients will die of heart attacks than from the end stage kidney failure.

Q. Is it irreversible?

A. Yes, it's irreversible. Chronic kidney disease is a slow progressive loss of kidney functions over the months to years.

Q. How does treatment help?

A. It will help to slow down the progression of the disease and to minimize the metabolic derangements. Treatments are helpful to alleviate the symptoms and improve the quality of life.

Q. How do you treat it?

A. Control the underlying disease ex-Diabetes, Blood Pressure. Avoid further damages ex- avoiding kidney damaging medicines such as strong pain killers in the class of NSAID, certain antibiotics and radio contrast dies used in angiography and CT scans.

Proper measured fluid intake to avoid dehydration and regular medical follow ups and good quality water consumption are also important here.

Q. What is end-stage renal disease? How do you treat patients who have reached this stage?

A. Kidney functions are classified according to Estimated Glomerular Filtration rate (EGFR). This is calculated using patients creatinine level, age, gender and body weight.

Normal EGFR is 90 to 110. CKD is classified in to 5 stages according to the EGFR value. End stage is EGFR is less than 15 and the patient has symptoms and signs of “uraemia”, where he needs renal replacement therapy for the survival.

This includes blood or peritoneal dialysis or kidney transplant.The usual pattern is to educate the patient and the family well before they reach the end stage. There the patient is prepared for a renal replacement therapy (RRT) or continued with conservative care.

Those who wish to have haemodialysis needs a arteriole-venous fistula (AVF) created to get the needle access for dialysis. For patients planning to have peritoneal dialysis can get a peritoneal dialysis catheter inserted to their abdomen.

Once these measures are done the patient can wait till they actually need RRT and have the treatment when it is needed. Patients need replacement of calcium and stimulation for red cell production by erythropoietin injections regularly. Further they need regular diabetic and blood pressure control medications.

Q. You mentioned that patients with stage 5 kidney disease had two options: dialysis or kidney transplant. Which is the better option and why?

A. Dialysis is the process where another mechanism purifies patient's blood in place of his/her own kidneys.

This is mainly of two types. Haemodiadialysis where actually the blood is sent in to a machine for cleaning and send back to the patient. In peritoneal dialysis a special fluid is instilled in to the peritoneal cavity and that removes the toxins and extra water from the body.

Once these dialysis processes purify the patients uraemic toxins and controls the water content regularly, patients can live a reasonably good quality life. But they will require dialysis for the rest of their lives.

They will need to have regular well organized and monitored dialysis program. The only option to stop this is by having a transplanted kidney.

Q. Compared to dialysis, are kidney transplants better for the patients?

A. World wide data confirms that the patients live longer with kidney transplants than with dialysis. Their quality of life and fertility is much better with transplants. Further, patients have much more freedom with transplants as they are less restricted in diet and also they don't spend time bound to dialysis machines. Cost-wise too it is advantageous.

Q. Drugs after a transplant-are they also given free to patients in state hospitals?

A. In Sri Lanka all transplant medicines are given freely from the government hospitals.

They need to continue these immune suppressants indefinitely. But with time this may be cut down to a minimum.

Regular maintenance haemodialysis however is not freely available to all the patients due to the heavy demand at the public sector hospitals. Therefore many patients have to bear the cost of dialysis at private sector.

Q. Once a person gets a new kidney, how long will it remain in his body if it doesn't reject it?

A. It will remain for longer periods and the usual Sri Lankan life span or a renal allograft is more than ten years.

Q. Does the age of the patient or the donor have any significance in the success of a transplant?

A. Yes, we usually take kidneys from age compatible donors. Young kidneys work better!

Q. Are there side-effects after a transplant? What are they?

A. Many patients gain weight and some can develop diabetes.

They are more prone to catch infections than the general population. They should be on a normal calorie diet with less salt.

The best option is to meet a qualified dietitian to get a suitable individualized diet devised. Regular exercises are advisable for all the patients to keep their sugar, blood pressure and weight at optimum levels.

Q. Since kidney transplants are a better option, do we have enough spare kidneys to round?

A. Unfortunately no. Most of the patient's family members are also suffering from similar diseases such as diabetes, high blood pressure and polycystic kidney disease.

Further their blood groups are not always compatible. Because of these reasons we have a huge deficit of live donor kidneys.

At Sri Jayawardenepura Hospital alone, we have more than twenty patients who are in need of a kidney transplant but without suitable donors at the moment.

We also have roughly 3,000 kidney patients visiting our OPDs, many of them might need a kidney transplants in the future.

Q. What is the success rate of these transplants?

A. Sri Lankan transplant rates are compatible with those of the western countries. It is about 90 percent successful in the first year.

Q. Will kidney transplants be the future approach to treating end stage chronic kidney failure patients?

A. It has already established its place as the preferred modality in end stage kidney disease.

In Sri Lanka we have the skills and equipment to do these transplants successfully, but we need more donor kidneys, which is our main obstacle. We also need to develop more transplant centres to cater to the rising numbers of patients.

Q. Any message to the public regarding this issue?

A. We have planned to establish a national cadaveric kidney donation program to fill the deficit in the future.

We hope to conduct island wide awareness programs to motivate people sign up necessary documents to donate their organs in case of sudden deaths to be utilised for the benefit of these long suffering patients.

A special program to raise awareness on this subject will be held at Maligawatte Nephrology Dialysis Centre On March 13 from 8 a.m. to 12 noon.

Protect your kidneys

by Dr. Nadeeka K. Rathnamalala

The kidneys are amazing organs that do many essential tasks to keep us healthy. Each kidney is roughly the size of your fist and is situated deep in the abdomen. The kidney consists of about a million tiny functional units called the nephrons. The main job of the kidneys is to remove toxins and excess water from blood. Kidneys also help control your blood pressure, to produce red blood cells and to keep bones healthy.

Kidneys control the level of minerals in the blood such as sodium and potassium and also help maintain the acidity in the blood. Although only about 1.5 litres of urine is produced a day, the kidneys filter nearly 180 litres of blood daily.

Chronic Kidney Disease (CKD)

When there is progressive loss of function of kidney over months to years it is known as Chronic Kidney Disease.

Many of the tests that are available detect this at a fairly advanced stage as some of these tests may still be in the normal range until 50 % of the combined function of the kidneys is lost. When the tiny filters or the nephrons are damaged they shut down.

Initially when it is only a few nephrons, the others are able to take on a greater work load and compensate for it. It is when this compensation can no longer take place that the effects are seen.

Serum creatinine is the most widely used test that uses blood to estimate the kidney function.

As this marker starts to go above the normal range only after 50 percent of kidney function is lost we now combine it with a calculation known as the estimated glomerular filtration rate (eGFR). Testing your urine for the presence of abnormal amounts of proteins is another way of detecting kidney problems.

This is especially useful if you are diabetic in which the presence of albumin (a protein component in blood) in urine is the earliest sign of kidney damage.

Stages of CKD

As kidney disease progresses slowly, it has been categorised in to five stages with stage five named End Stage Renal Failure (ESRF).Not everyone progresses from stage 1 to 5 as in some the progression will be very slow and they may never reach ESRF.

Burden of CKD

About 1 in 10 people have some degree of CKD. It can develop at any age and various conditions can lead to CKD. Kidney disease can affect people of all ages and races. African Americans, Hispanics, American Indians and people of South Asian origin (those from India, Bangladesh, Sri Lanka or Pakistan) have a higher risk of CKD. This risk is due in part to high rates of diabetes and high blood pressure in our part of the world.

CKD can occur at any age, but it becomes more common with increasing age and is more common in women. Although about half of people aged 75 or more have some degree of CKD, many of these people do not actually have diseases of their kidneys; they have normal ageing of their kidneys. Simple blood and urine tests can detect CKD and simple, low cost treatments can slow the progression of the disease, reduce the risk of associated heart attacks and strokes and improve quality of life.

According to the Global Burden of Disease study, in 1992, CKD ranked 27thin the list of causes for deaths in the world while in 2010 it ranked 18th. This degree of movement was second only to that of HIV and AIDS. As the prevalence of this disease is increasing dramatically, it poses an enormous financial burden on health systems worldwide. According to recent reports the National Health Service in United Kingdom spends more on kidney disease than breast, lung, colon and skin cancer combined. In Australia, the cost of treating all current and new cases of End Stage Renal Failure (ESRF) is estimated at $12 billion. In China, the economy will lose US$558 billion over the next decade due to effects on death and disability attributable to chronic cardiovascular and renal disease.

High blood pressure and diabetes are the leading causes of CKD. High blood pressure causes over a quarter of all cases of kidney failure. Diabetes has been established as the cause of around one-third of all cases.

Other less common conditions include inflammation (glomerulonephritis) or infections (pyelonephritis). Sometimes CKD is inherited (such as polycystic disease) or the result of long-standing blockage to the urinary system (such as enlarged prostate or kidney stones).

Some drugs can cause CKD, especially some pain-killing drugs (analgesics) if taken over a long time. There are situations where the cause for the CKD cannot be determined like in the case of the kidney disease in the North central Province in Sri Lanka.

Treating CKD

There is no cure for CKD however, treatment can slow the progression and prevent certain complications.

The main treatments are modification of diet and medications in early stages which would help maintain the balance normally maintained by the kidneys. When one reaches ESRF the options available are dialysis and transplantation.

Dialysis is an artificial method of achieving the balance maintained by the kidneys by excreting unwanted products and excess water. However this lacks some of the other functions maintained by the kidney such as the role in production of red blood cells, maintenance of mineral balance in bones and blood pressure regulation. There are two main forms of dialysis.

Hemodialysis is widely used in Sri Lanka where the patient is connected through bloodlines to a machine through which the blood is cleaned and put back in to the body. To maintain a balance to have an acceptable quality of life at least 12 hours on the machine is needed distributed through the week. As the patient needs to come in to a dialysis centre to receive this form of dialysis and each session usually spans over four hours, the patient comes in three times a week.

The other form of dialysis which is still not widely available in Sri Lanka is known as Continuous Ambulatory Peritoneal Dialysis (CAPD). In this method the lining of the abdominal cavity which is called the peritoneum acts as a sieve that gets the waste products out of the body. The patient fills the abdomen with a fluid through a tube that is placed in the abdominal cavity, after which an exchange takes place between the blood vessels supplying the wall and the fluid. The fluid is removed once it is saturated with the waste products from the blood. This is a home based therapy and the patient can even walk around and carry out his day to day activities while having fluid in the abdomen. Both these forms of dialysis do not cure kidney disease, instead they help maintain an acceptable quality of life.

Kidney transplantation

Kidney transplantation is considered the best treatment option for most people with kidney disease as the quality of life and survival is better than those on dialysis. It is an operation where a healthy kidney is placed in a person with poorly functioning kidneys. A kidney can come from a living relative, a living unrelated person, or from a person who has died (deceased or cadaver donor); only one kidney is required to survive. In general, organs from living donors function better and for longer periods of time than those from donors who are deceased.

Overall, transplant success rates are very good. Transplants from deceased donors have an 85 to 90 percent success rate for the first year.

Preventing CKD

Early diagnosis of CKD enables certain preventive measures to be taken which have been proven successful through substantive research. Testing for kidney disease if you have high blood pressure, diabetes, a family history of kidney disease or overweight can help prevent or delay kidney disease. Key preventive measures that have been defined are

· Controlling blood pressure - tighter the control within the normal range lesser the decline in kidney function

· Specific medications - e.g. ACE inhibitors

· Reducing salt intake

to lower blood pressure

·Control of sugar

and lipids

·Cessation of smoking

·Control of weight

·Increasing physical

activity

The writer is Senior Registrar in Nephrology, National Hospital of Sri Lanka