When the kidneys fail

by Carol Aloysius

Kidney failure is one of the most difficult challenges faced by local medical experts, battling to contain its spread, especially in the North Central Province.

Already, the government has invested millions of rupees to treat patients whose lives depend on renal replacement therapies such as dialysis or transplant. Yet, with an average of 350-400 new kidney patients reporting to hospitals in the North Central Province alone, where the numbers of already affected patients are staggering, the health budget is at bursting point.

What has caused this spread of kidney diseases in the country, especially in the NCP in recent years, to the extent it is now regarded as a national health problem by health authorities, compelling President Maithripala Sirisena to set up a Kidney Disease Control Task Force?

While opinions vary and new theories continue to emerge, ongoing research points strongly to two notable culprits: agro chemicals, which farmers in this largely agricultural region use to eradicate pests and weeds, toxic chemicals and hot metals from factory effluents . Both are pollutants and harmful to human health if ingested or used for cooking.

A severe dearth of trained staff and lack of adequate dialysis units and essential equipment has compounded the problems of the health authorities in the NCP.

Here Dr Joel Arudchelvam, one of the leading kidney transplant surgeons in the country, who has been responsible for 17 transplants in the Anuradhapura Hospital in the past year alone, and just recently led the first kidney transplant team at the Polonnaruwa General Hospital, explains to the Sunday Observer about a disease, few people still do not understand and why it causes our body organs to shut down.

Excerpts…

Q: Kidney disease is fast spreading in the island and is now a significant health problem. Yet not many people know the kidneys play a vital role in our body to the extent that their failure can cause it to shut down. Many are not even aware where the kidneys are located in the body. Tell us the functions of the kidney and where is it located in our body?

A: The kidneys are organs that filter the blood and get rid of many unwanted substances. There are two kidneys on each side at the back of the abdominal cavity, just above the level of the waist.

Each is bean shaped and the size of a fist. A tube called the ureter runs down from each kidney to the bladder. This is a muscular bag situated in the pelvic. From the bladder a single tube, the ureter, runs down the middle of the penis in the case of males and in females it opens just above the vaginal opening. The kidneys have a good blood supply and the blood gets filtered of waste products through the urine.

Q: So what makes them fail to function?

A: It could happen in recurrent and chronic infections of the urinary tract or in other diseases like diabetes, nephritis and kidney stones.

Q: How can the life of such a person be saved?

A: By attaching an artificial kidney (dialysis machine), which filters toxic materials from the blood, or by transplanting a new kidney.

Q: What is chronic kidney disease [CKD]?

A: CKD is a long term reduction in kidney function resulting from kidney damage from various causes.

This results in symptoms and signs in patient and abnormalities in blood tests.

Q: What is the most common kidney disease in Sri Lanka?

A: Causes for CKD varies depending on the age group. In children, it is following glomerulonephritis and urinary tract abnormalities, whereas in adults it is due to chronic glomerulonephritis and a special form of kidney disease (Chronic Kidney Disease of unknown etiology (CKDu)), which is prevalent in the North Central Province. Other causes for CKD includes diabetes mellitus and hypertension.

Q: What is CKDu?

A: CKDu is a form of chronic kidney disease not attributable to common causes mentioned above.

Q: Where do you find most patients with CKDu?

A: Most patients are found in certain parts of the North Central Province (Medawachchiya, Padaviya, Kebitigolawa, and Medirigiriya ), North Western Province (Nikawewa ),and parts of Uva Province

Q: What causes CKDu?

A: As mentioned above the exact cause for CKDu is unknown. But it is thought that water contamination with heavy metals like Arsenic (As), Cadmium (Cd), and Lead (Pb) from agrochemicals and pesticides is the cause. Genetically predisposed individuals are more affected.

Q: What is end stage renal failure (ESRF)?

A: This is a severe form of renal failure. Patients with ESRF needs Renal Replacement Therapy (RRT) - either dialysis or renal transplantation. Dialysis can clear some of the waste products from the body but most of the other functions of the kidney cannot be performed by dialysis. Besides, the patient also needs three sessions of dialysis per week, each lasting four hours, which would cause a great deal of inconvenience to him/her.

Q: So is renal transplantation a better option?

A: Transplantation basically means transferring tissues or organs from one individual to another. In kidney transplantation the kidney is taken from one individual (donor) and placed in a patient (recipient) with end stage renal failure. The donor may be a living individual (live donor) or a deceased individual (cadaveric donor). With a new kidney graft, all the functions of the body will improve, resulting in a better quality of life for the patient when compared to dialysis.

Q: How is this procedure carried out?

A: In live donor renal transplantation, the first surgery we perform is to remove the kidney (graft) from the donor (donor nephrectomy). This can be done both laparoscopically (keyhole) and by open surgery.

After taking out the donor kidney it is perfused with cold preservative solution (HTK solution) and kept in ice box. Then the recipient is taken. The kidney vessels are usually joined to iliac vessels of the recipient (Refer figure) the ureter of the donor kidney is connected to the recipient’s bladder.

Q: How many patients from the NCP where CKDu has the highest prevalence, undergone kidney transplants in recent years?

A: In the North Central Province, since 2012, transplants have been mainly done in the Teaching Hospital, Anuradhapura. Altogether 49 renal transplants have been done in the North Central Province so far most of them are at the Anuradhapura Teaching Hospital.

Q: How many patients with kidney disease are awaiting surgery in the NCP?

A: At present there are about 70 to 80 patients in the North Central Province who need kidney transplantation . Till then their only option is dialysis.

Q: How many dialysis units are there for the entire North Central Province?

A: There are dialysis units at Anuradhapura, Polonnaruwa and Padawiya Hospitals. However, the largest number of dialysis are done at Anuradhapura.

Q: What are the main obstacles you face when performing a kidney transplant operation?

A: One obstacle is the lack of trained staff. But the main obstacle is the lack of donor kidneys. Getting a kidney from a live donor, especially in an area where sometimes members of the same family could be suffering from CKDu, and even people in the same area , is a big problem.

Q: So what is your solution?

A: To solve this issue we should try to establish a deceased donor program. The Ministry is trying to establish this in the future.

Q: Islandwide, how many hospitals have facilities for transplant of kidneys? Are they adequate to serve the demand for this life saving surgery?

A: At present renal transplantation is done at the National Hospital Colombo, Maligawatte Hospital, Sri Jayawardenapura Hospital, Kandy Teaching Hospital, Peradeniya Hospital, Karapitiya Teaching Hospital, Anuradhapura Teaching Hospital, Polonnaruwa General Hospital, as well as certain private hospitals.

Q: You had very recently led the operating team that did the first ever kidney transplant at the Polonnaruwa General Hospital. Tell us about that trail blazing surgery, the teething problems you faced, and how you overcame them.

A: The patient, 35-year-old H.A. Lakshman Samankumara of Unagalawekera Settlement Scheme, was suffering from Chronic Kidney Disease of Unknown Aetiology (CKDu) . The donor was his 57-year -old mother.

CKDu is very common in the North Central Province. Many of the patients who were in an advanced stage of the disease required dialysis.

They go to the Anuradhapura Hospital until we decided to perform the first transplant surgery at the Polonnaruwa hospital.

Being our first kidney transplant there, we had a few obstacles. We didn’t have enough trained staff, so we had to borrow some of the experienced staff for this operation.

We also lacked some of the needed instruments like the Special Retraction for the recipient and vascular instruments. These too we borrowed from the Anuradhapura Hospital. But despite these initial hiccups, the operation itself has been a success and went off smoothly.

Q: Has the patient been discharged?

A: Yet both donor and recipient have been discharged. The recipient is in good health. The serum creatinine which indicates the clearing function of the kidney is normal. That means the creatinine is functioning well and the kidney is functioning well and no complications have developed..

Q:Will the patient need to be on medications?

A: It is natural the body will continue to try and reject the new replacement. So he will have to be on anti-rejection medications for life.

Q: Your message to patients?

A: If you live in a high risk area as in the NCP, and you develop any suspicious symptoms such as what I have mentioned earlier, get yourself checked out immediately by a qualified hospital practitioner without delay. The earlier the detection the easier to avoid complications.