Nischala’s Blog-o-Rendezvous with Dr.RENUKA
About Dr Renuka S
Dr. Renuka is a consulting Nephrologist (M.B.B.S, MD (Nephro)) who currently practices in Bangalore, India
I first met Dr. Renuka way back in 2006. It was a meeting that changed my life in more ways than one. Today (In 2012) looking back at our association, I can definitely say that she’s been one of the “nicest and kindest” doctors I’ve ever met or known in my life. The combination of her medical experience in nephrology coupled with her kindness, positivity, objectivity, presence of mind, sensible and practical ways in dealing with all kinds of medical and non-medical situations makes her a very unique doctor – One who stands out in today’s day and age. And hence, she will always be remembered by many who have interacted with her.
Over the past few years, Dr. Renuka has been a mentor, friend, philosopher, guide and confidant through the many highs and lows of my own life. Hence, I was very happy when she agreed to do this rendezvous with me.
NOTE: The primary aim of this discussion was to create awareness about the importance of kidneys in the human body.
Nischala: Good Afternoon Dr Renuka. Thank you so much for your time
Dr Renuka: Good Afternoon..
Nischala: As discussed when we met last, I’d like to have this discussion with the intent of creating an awareness of the kidney function in the human body and a high level understanding of the problems associated with kidney failure. So to begin, let’s start with the basics – What are the key functions of the kidneys in the human body?
Dr Renuka: Sure. There are 3 basic functions of the kidneys in the human body. One is the excretory function, i.e., to excrete waste from the human body like urea, creatinine, etc. Second is the homeostatic function, i.e. to maintain the acid and base levels within the body to ensure the correct salt and water balance. This ensures the regulation of the Blood Pressure (BP) within the human body. Third is related to the hormonal function of the body. The human kidney secretes important hormones – Calcitriol (which is Vitamin D in active form) & Erthyrpoietin (an essential hormone that controls red cell production. The haemoglobin is a good reflection of this measure) and also the enzyme renin
Nischala: OK. So my next logical question is what are the most common kidney related problems?
Dr Renuka: Today, there are many problems related to the kidney functions:
1) Asymptomatic kidney disease in which there is a leakage of protein urea but no visibile symotions for the patient
2) Nephritic Syndrome which is usually characterized by pedal edema, i.e., swelling of the feet and ankles due to fluid accumulation. Of course there are other symptoms which can be diagnosed with medical investigations like blood and urine tests
3) Nephrotic Syndrome in which there is usually swelling all over the body due to fluids accumulation in the body. Of course there are other symptoms which can be diagnosed with medical investigations like blood and urine tests
4) Rapidly progressive renal failure in which there is rapid worsening of the renal function in a matter of few days – So for example you’re creatinine level is 2 today and in a span of few day it reaches to very high level (say 10 and above)
5) Acute kidney injury in which the kidney does not work temporarily. And over a period of time the kidney function is regained
6) Chronic Renal Failure in which there is a permanent loss of kidney function and this happens gradually over a period of time. In most cases, this is chronic and needs timely diagnosis and medical treatment
Nischala: OK. So can you please elaborate on Chronic Renal Failure? What are the stages for this?
Dr Renuka: Chronic Renal Failure is a condition in which there is permanent loss of kidney function. It is usually a slow and progressive illness. The National American Kidney Foundation has defined the 5 stages in the Chronic Renal Failure based on GFR Rate (Glomerular Filtration Rate).
A note of GFR : Your GFR tells how much kidney function you have. It may be estimated from your blood level of creatinine. If your GFR falls below 30 you will need to see a kidney disease specialist.[ Src: http://www.kidney.org/kidneydisease/understandinglabvalues.cfm ]
Stage 1 – GFR is greater than 90 Ml / min
Stage 2 – GFR is between 60 to 89 Ml / min
Stage 3 – GFR is between 30 – 59 Ml / min
Stage 4 – GFR is between 15 – 29 Ml / min
Stage 5 – GFR is less than 15 Ml / min
At Stage 2, most doctors typically start counselling individuals and families on long term treatment options. The most important aspect is to mentally prepare people to the treatment. Also early detection and timely initiation of medication can prove to be very effective in the delay of the onset of the Stage 5. So for example if it takes someone 1 – 1.5 years to transition from Stage 2 to Stage 5, if you begin medication early, you will possibly end with at Stage 5 in 5-6 years. This makes a huge difference in the lives of many patients
Nischala: What are the key causes for Kidney Failure?
Dr Renuka: There are many causes for Kidney Failure, the key ones are below:
1) Diabetis – The primary cause of in about 95% of the cases
3) Glomerular disease
4) Interstitial disease – which really means due to the lifestyle changes in today’s day and age. So for e.g.: Our day to day diet. A lot of people consume aerated drinks on a regular basis. These drinks have a very high percentage of phosphate which can lead to kidney problems. Another cause is the large consumption of medicines that we consume on a regular basis without being aware of the chemical composition and the way they can adversely affect out body internally
5) Familial or Hereditary – So if it runs in the family, there is a chance that you end up with kidney failure and very little can be done to prevent this.
Nischala: What are the trends with respect to Kidney Failure? In terms of age, gender, nationality, etc? Are there any global trends as well? Is there any research and published data available?
Dr Renuka: Yes. The US Renal Data System (USRDS) regularly publishes statistics on kidney related information. The last one was published in 2010. According to this report, 38 million Americans (which is about 10% of the total population) have kidney related disorders and about 55000 people are on dialysis. A few thousands have undergone kidney transplantation. And 88600 die of kidney failure. Also, the cost of maintaining these patients / year on dialysis is 59.4 Billion $
In India till 2005 there was no CKD (Chronic Kidney Disease) registry. Indian Society of Nephrology created a registry database to collect statistics across India. However, many hospitals have not yet registered and hence the data is not updated, as of date. While efforts are underway to bridge this gap, as of 2012 following is the published statistics – 52273 of adult patients have chronic kidney failure. In terms of trends, 70% are male and 30% are female. Average age is about 50. And diabetes is the most common cause
Nischala: Thanks for sharing this. So, what can anyone do to prevent Kidney Failure?
Dr Renuka: As I mentioned earlier, the main reasons for the cause of CRF is diabetes, a sedentary lifestyle and consumption of wrong food on a regular basis (junk foods especially those with high fat / sugar content). So one way is obviously through an active lifestyle with adequate exercise and physical activity and of course a balanced diet.
On a larger scale, Dr Mani from Apollo Hospital Chennai has pioneered an initiative to prevent kidney disease, rather to screen early the probability of occurrence of a kidney problem and to start preventive medical treatments. One of the most important ways that he has done this is through regular and periodic screening of key medical parameters (for e.g.: blood and urine tests, BP) which indicate potential kidney disease. So for example, he observed that about 30% of those who were screened had urine abnormality, i.e High levels of sugar and protein in the urine OR high BP. You can read more on his work here. So when these leading indicators are detected, immediate treatment is provided based on the medical evaluation and assessment.
But coming back to your question, diet and lifestyle changes need to be made. Specifically in terms of diet, it is recommended to avoid alcohol and smoking. Also, one should keep a regular check on sugar levels and blood pressure. Constant monitoring of one’s diet is also essential – so one should eat when hungry or at fixed times – And especially not cultivate the habit of eating throughout the day. Also, it is important to ensure a balanced diet which has a combination of all food types like carbohydrates, proteins, vitamins, minerals and fats. Another key point is to avoid aerated drinks – They have a very high phosphorous content.
In addition, regular exercise is an absolute MUST – Even a brisk morning walk everyday goes a long way in controlling hypertension and preventing or controlling diabetes. If you cannot find time to walk exclusively, fit it into your routine as a part of your everyday activities, but do make sure it is an integral part of your life!
Another important aspect is to regularly monitor your urine protein, constantly monitor sugar levels and BP (Blood Pressure). In case of a family history of kidney related diseases, then early screening is recommended. The sooner a problem is detected, the earlier medical treatment can be initiated and this proves to be very effective is preventing further degradation of the kidney related disorders.
Nischala: What are the suggested medical treatments to deal with kidney failure?
Dr Renuka: So it depends completely on the stage at which this is detected, the patient’s age and overall health – especially if the patient already has pre-existing ailments like heart problems and / or diabetes. But broadly, kidney failure can be treated either with medical management, dialysis (haemodialysis or peritoneal dialysis) or kidney transplantation.
Nischala: What is dialysis? Can you please elaborate on Haemodialysis and Peritoneal Dialysis?
Dr Renuka: Dialysis is the artificial replacement of kidney functions in the body. It is a process for removal of excess water (as urine) and waste from the body with the help of the artificial kidney.
There are 2 types of dialysis:
1) Haemodialysis – This is a process in which the excess water and waste is removed from circulating blood through an external filter / artificial kidney (which usually has a dialysate), purified and is returned to the body. Due to the impaired kidney function, the blood has a high concentrate of blood urea and creatinine. The dialysate in the artificial kidney removes the waste from the blood through the process of diffusion. This waste goes into the drain and purified blood is re-circulated into the body
2) Peritoneal dialysis – This is a process in which the peritoneal membrane which lines your abdomen facilitates the process of dialysis. The peritoneum is rich in blood supply and it’s like a bag holding your internal organs. To do peritoneal dialysis, this bag is filled up with a special fluid, called dialysate. Wastes and extra fluid in the blood slowly flow into the dialysate.
After a few hours, all the waste from the body accumulates in the dialysate. Then the used dialysate is drained out and clean fluid is put in. This process needs to repeat several times a day.
During dialysis, blood and dialysate are kept apart by a membrane. Wastes and fluid flow out through tiny holes in the membrane. Blood cells and protein, which the body needs to keep, are too big to pass through, and stay in the blood
Nischala : Ok Thanks. Is there any online link where one can read (as a layman) to understand this better
Dr Renuka: You can check the link at Kidney School
Nischala: I will go through this. Thanks again. So moving on, what are the pros and cons of Haemodialysis?
Dr Renuka: In haemodialysis, you have to come to the dialysis centre which is usually in a hospital as the procedure is done by specialists at the centre. So the disadvantage is that you have to commute to the dialysis centre on a regular basis and usually someone should accompany you. Each sitting lasts for several hours and you have to plan your work and schedule around this. By the end of the procedure, most patients are pretty exhausted since the procedure in itself can be quite intensive and tiring. Also, there is strict diet and fluid restrictions which mean you cannot eat and drink all foods. Many patients find this toughest, especially if you don’t have self-control!
In the long term, there are chances of blood borne viral infections since the blood is being removed from the body for purification. Also, there is a possibility of Hepatitis C infection – for which there is no vaccination. Sometimes there can also be bleeding from the nose and mouth as well.
On the plus side, it is extremely useful in acute emergency and can help cleanse the waste from the body instantly and effectively. Also, since the procedure is administered by trained medical experts, you can relax (patients and family) when the procedure is being done – Of course there is stress and emotions to deal with, but physically you will be idle!
Nischala: What are the pros and cons of Peritoneal Dialysis?
Dr Renuka: There are many positives – One, peritoneal dialysis can be done at home, so there is no need to come to a dialysis centre. Two, since the process in internal to the body, there is no blood loss. Thirdly, it is continuous process. Also, there is limited diet restriction and so there is more flexibility on your diet intake. And if health permits, you can self-administer the procedure.
However, the peritoneal fluid has a high sugar concentration of sugar, so that is a disadvantage in case you already have diabetes. Another disadvantage is that you need to strictly follow the procedural guidelines while doing the procedure. So you need to wash your hands really well, sterilize the equipment and procedure area and also follow the steps for doing the peritoneal dialysis very accurately. Because if you don’t, there is a high risk of infection – This is called peritonitis. This usually requires hospitalization and a dosage of antibiotics to control the infection.
In India, a decade back awareness of peritoneal dialysis was very low and also the cost was very high – i.e., Peritoneal dialysis was almost 50% more than haemodialysis. However today, the cost differential is about 10% – so peritoneal dialysis is more than haemodialysis by only 10%; and hence is being preferred by many patients if they can afford it!
Nischala: Coming to Kidney transplantation, what are the current trends in terms of numbers and acceptance?
Dr Renuka: So the best form of renal replacement therapy is kidney transplantation. It improves the quality of life, work and day-to-day activities. The key challenge is to find the right match of kidney donors. According to The kidney transplantation act of 1994, a kidney from a living person could be considered only from the immediate family with a matching blood group – And immediate family means parents (mother / father), siblings(brother / sister), children(son / daughter), spouse (husband / wife)– who are more than 20 years and less than 60 years of age.
In 2009, this act was amended to include kidney transplantation from “near-relatives” – So as of date, as long as you are medically fit you can be considered for a kidney transplant by virtue of the following relationships – first cousins, maternal / paternal uncles / aunty and grandparents. Also, not-so-close relatives who have stayed with the patient can donate organs, provided there is no commercial dealing.
Irrespective of the relationship between the kidney donor and kidney recipient, it is now mandatory to appear before the Ethical Committee to get an Ethical Committee Clearance. And this is governed by the Health Ministry of State.
Last option for transplantation is cadavers / diseased donor transplant – For e.g.: people who are brain dead or on ventilator. The family is usually counselled for transplant. If they are willing, then the process of kidney transplantation is initiated. In most cases, family agrees because they feel that in some way they can help another human being and that their loved ones “live” through someone else. These are really heart-warming moments because one needs to make a life-changing decision about someone they love and care about, at probably one of the most vulnerable moments of life! So the role of counselling is very important in such cases!
In terms of the operational modalities, there is a centralized list of patients awaiting kidney transplantation created region-wise. In Bangalore, there is an independent body in Nimhans called the Zonal Kidney Coordinator Cell which manages this list. If anyone is keen on kidney transplantation, they need to register with this cell. Upon confirmation of registration, they are added to the waiting list. When a donor kidney is identified for a transplant, the first 10 registered patients are activated and notified on a first come first served basis. It is a totally impartial and neutral way. Once a patient is ready for the transplantation, the hospital is informed. The hospital then arranges the next steps in terms of scheduling the procedure, informing the surgeon, arranging OT (Operation Theatre), co-ordinating with blood bank, etc.
Nischala: Hmm.. So What are the challenges with respect to kidney transplantation?
Dr Renuka: The first challenge is that kidney diseases are increasing and there is an acute shortage of kidney donors. Due to the ever increasing waiting list, there is an increase in the cadaver transplant. Hospitals are also considering marginal donors, i.e., older people above the age of 60 years old if they are medically fine, or people with some malignancies which cannot spread.
Also the good news is that the success rates of kidney transplantation has increased year on year. So the first year kidney rejection has come down significantly (Chronic Allograft Nephropathy). On the flip side, many patients don’t come for follow-ups and become irregular in their medication after 1 year – which leads to different kinds of medical complications with time. So it is important to be regular with medication, with prescribed medical investigations periodically and doctor visits.
Nischala: So any specific case that you remember and would like to share?
Dr Renuka: Yes. There is one case of an employee in Central Silk Board (Bangalore) who was a 40 year old diabetic when he was diagnosed with chronic renal failure. It changed his and his family’s life completely. He had to be absent from work for a long time to start off dialysis. It affected his family because he was the key earning member in the house and there was a loss of income and increased medical expenditure due to his kidney treatment. Luckily in 1998 he got a cadaver kidney. The transplantation was successful. After that, he was very religious in following a strict diet, taking medicines and also leading a healthy lifestyle. Today in 2012 almost 14 years later – he is still doing very well. His family is all well settled and children are also doing well for themselves.
See kidney failure is not just about the patient. It is the whole family who suffers and endures the day to day hardships. The patient definitely undergoes physical pain, mental stress and agony, emotional highs and lows and also most patients experience a huge sense of GUILT that they are a burden of their family – That is the hardest! Also, many times the family finds is hard to come to terms with the situation. So the first reaction is obviously shock! And then denial – most people don’t accept the results and diagnosis and keep running between hospitals for alternate medical opinions. Many even explore alternate medicine and healing – but they don’t work! Usually it takes about 1-1.5 years to accept and reconcile to the situation. And usually in this time more damage is done internally – to the kidney, heart and other organs as well.
Nischala : Any other message you’d like to share as a part of this rendezvous?
Dr Renuka: With the advancement of technology and innovations in the medical field, there is now a lot of research on a durable artificial kidney. In 2010 Decemeber, a miniature computer was designed to function as a dialysis machine – So you can put it in a belt on your waist and re-charge with a battery – It is called DAK (Durable Artificial Kidney). The good news is that human trials have been successful and as per latest data this should be available in the US market in 2-3 years’ time. It will be expensive when it is launched. Also it will take time to come to India. But yes! It was make a transformational difference in the life of kidney patients!
Also the point I want to emphasize again is that delaying treatment can be detrimental to patients especially in young people. Usually, we come across 2 kinds of situations – One in which there are no financial constraints – so either the patients have an insurance cover or adequate financial security. In this case, they usually go for the best treatment. What really makes a difference here is the self-discipline and quality of lifestyle they maintain after they undergo the treatment. For those who have financial constraints, it is an everyday struggle. In some cases families have to make a tough choice between basic every day needs like food 3 times a day and going in for renal treatment – These are the really touching cases! And those who make the tough decisions go through a lifetime of guilt because of their choices or because they took short-cuts.
The challenge is that there is no government hospital which provides haemodialysis at subsidized costs. And dialysis in private hospitals is not affordable for everyone. There are however a few philanthropic organizations and initiatives which aim to provide affordable or subsidized treatments in rural areas or to those who cannot afford it.
Also many of our affluent old patients and families have a huge sense of gratitude for their fresh lease of life after dialysis or transplantation– and hence send us voluntary donations so that we can help those who cannot afford it. In some instances, we also have cases of individuals and families who sponsor the education of those children whose parents cannot afford it because they are currently spending all funds on renal treatment. In fact, a group of doctors in our network also sponsor the education of 1 child every year. So we all contribute between 6000 Rs to 8000 Rs.
So as doctors, we do our bit and best to contribute and help those in need in more than one ways!
Nischala: Thanks so much for your time and sharing your views
Dr Renuka: Sure. I hope people read this and it benefits them in some way
How did you like this Rendezvous? Leave a comment to let me know…