A Senior Consultant Nephrologist at India’s premier All India Institute of Medical Sciences AIIMS, Dr Sandeep Mahajan sees somewhere between 180-200 patients in different stages of kidney failure in the out patients department of the hospital every week. That is beside hundreds of admitted and post-operative follow-up patients in the hospital which gives him a fair idea of the extent of the kidney diseases in the country and the various options to cope with them. A strong believer in the concept of prevention is better than cure, Dr. Mahajan strongly believes that possibly the only way to fight kidney disease is to diagnose it early. Excerpts from an Interview:
Q. What is the extent of kidney problems in people of Indian Origin?
A. The exact prevalence of kidney diseases in our population is not well established because obviously it requires a lot of initial monitoring and diagnosis. Kidney problems as such don’t have any symptoms, and usually they are detected very late. Rough estimate would be there are one lakh new patients of end-stage renal disease per year. For every one lakh end-stage renal disease patients, there would be 15-20 % more patients suffering from early stages of kidney diseases. So that practically makes up for 20 Lakh new kidney patients each year. If you take average survival of these patients as 3-5 years, then you can very well imagine the extent of the disease in our country. And these are just conservative estimates.
Q. The kidney diseases is an asymptomatic disease in the sense that its existence is not known till very late and the patient does not even know that he is suffering from the disease… How long –in terms of number of years it takes from this asymptomatic stage to the stage where the kidneys are totally useless?
A. That is a tough question to answer… That would depend on the underlying disease, which has affected the kidney. For a susceptible diabetic patient who has poorly controlled sugars, it would take approximately 15 years to develop kidney failure and say ten years to develop early renal disease. But unfortunately in most of the disease the exact start and the total course of the disease is not known. It would depend on the kind of kidney disease and how it has been controlled. Some 20% of the patients having primary renal problem may require dialysis while 70-75 % of the patients who are diabetic or hypertensive with a track record of poorly controlled or uncontrolled disease would have significant renal failure.
Q. What are the consequences of this?
A. Well…let’s understand the functions of the kidney. We all know that kidney acts as an intelligent filter excreting the accumulated waste toxins while retaining useful compounds. They also are important in maintaining blood pressure, fluid balance, bone strength and hemoglobin in the blood. Early symptoms that are though mild and are often overlooked by the patients include; swelling of feet & face, feeling of weakness, fall in appetite, sudden worsening of BP & anemia. Severe kidney disease results in reversible as well as permanent damage to a lot of organs and if left untreated can present with life-threatening complications.
Q. What are the options for a patient having end-stage renal failure?
A. End stage renal failure, is a stage where the kidney is permanently compromised to work less than 10-15% of normal. Once a patient reaches this stage, he has two options, one to go for dialysis or transplantation. Especially in our country kidney transplants are the ideal and cheapest option. In terms of quality of life, it is probably the best. However for a transplant you have to have a related donor – either a blood relative or a spouse or children who are willing to donate their kidney. Secondly you should be fit enough to undergo transplantation. Thirdly you need medication to prevent the graft kidney from getting rejected… It has its set of complications like chance of getting infections. Fourthly you should be financially sound enough to afford the cost of medicines that is around Rs 8,000-10,000 per month. Among the dialysis, we have two options…
Q. Sorry to interrupt… but in some kidney transplant cases–a related donor is not available. Also, the medication given to suppress the immune system makes the patient catch so many other infections? What do you say to that?
A. Of the two I think the first one is a major problem…i.e. getting a related donor, especially with the increase in the incidence of diabetic related renal diseases in the country. By the age, you develop diabetes and diabetic renal disease – especially when most of the patients are that of type II diabetes – they are already 50-60-year-old. So the parents are out… chances are that the rest of the brothers, sisters and siblings would again have diabetes because it runs in the family…Children obviously we can’t say because they have at least 50% chances of developing diabetes later in the life. So we are just left with one possible donor that is the spouse. It is very difficult to get a related donor for a diabetic patient where the incidence of diabetes and diabetes-related complications are high. The second main problem comes with regards to the finances. It is still not easy spending Rs 8,000- 10,000 lifelong for a good majority of our patients. Second you may develop complications like infections that may require medications and subsequently increase the cost.
Q. Is it true that the success rate of a transplanted kidney is 8-10 years?
A. Yes, on an average only 50% of the transplanted kidneys are working at the end of eight years. In this, you may have a spectrum of patients in whom the kidneys are working for 10-15 years.
Q. It seems from this that Kidney transplant is not a permanent solution to the problem?
A. Well, transplant is not a 100% therapy because it is influenced by so many factors which are beyond medical control… You can have infections…you can have diabetes subsequent to transplant…you can have a rejection of the graft… the functioning of the graft to a certain extent is not entirely controlled by us. That is why there is a huge gap… for some patients the transplanted kidney works for 20 years and in some it does not work even for ten years. So the other option for those patients who do not have donors is dialysis. Among the dialysis, there are two options – either to go for peritoneal dialysis or hemodialysis. Medically speaking both are identical in terms of efficacy. Predominantly it is up to the patient to choose whether he wants peritoneal or hemodialysis. Both of the options have their plus points …. To a certain set of patients Peritoneal dialysis might look very lucrative as you can do it at home, and you don’t need to rush to the hospital. The quality of dialysis is ensured because you are doing it yourself. Plus the kidney functions tend to stabilize for a longer time on peritoneal dialysis than Hemodialysis. But not all patients are keen to do the therapy themselves. They are simply lazy, ignorant or too afraid to do the therapy themselves. So these are the kind of patients who would opt for Hemodialysis. Another factor that is important is how far is the dialysis unit from your home? Because you have to go to that hospital twice or thrice in a week which adds on to the cost of therapy. Besides the cost of transportation, at least two people who go to the patient loose their livelihood. HD as such has its benefits obviously its center oriented therapy with minimal burden on the patients. Another concern is the high rate of Hepatitis-C infection in most of the centers.
Q. Maybe that is because the patients have to maintain certain hygienic measures in their homes for doing the peritoneal dialysis themselves?
A. Well it is not operation theater like environment that you have to create for doing peritoneal dialysis at home. You just have to keep it neat. Normal dusting and cleaning every day or twice a day is sufficient, so the concept that hygiene is very difficult to maintain, is wrong. Just simple precautions like restricting people entry in the room, ensuring that furniture is minimum in the room, and while doing that procedure you have to switch off your ACs or the fans is all that matters. It’s the very safe procedure; if you do it properly then the risk of the infection is practically negligible. We have patients who have survived eight years ten years without a single episode of infection.. If you are meticulous enough to do the procedure yourself or cleaning the room properly, there is no reason you should have the infection.
Q. What is your view on CAPD?
A. If the patient does not have a prospect of transplant & is opting for a long-term dialysis, I would tend to keep motivated, patients on PD which has the benefit of a longer preservation of the residual renal function; which is not possible with HD.
Q. In terms of where the does APD figure into this?
A. Well, APD is a big addition to the CAPD prescription because it frees most of the patients from bothersome day-time exchanges. Medically speaking there are only a few indications where we prescribe APD like in situations where the patient has hernia or ultra-filtration problems. It is very costly but for those who can afford it is tremendously beneficial and easily adjusts to the patient’s lifestyle. He does not have to go to the hospital; he is not tied up to do the exchange daily. He is free the whole day, he can move around, he can work and can socialize.
Q. Who makes this choice as to what therapy to use in what case?
Mostly it is the patient. We just tell them about the modalities for say; a transplant. If he doesn’t want to go for a transplant, then we tell them about HD or PD. Our job is just to help them decide between HD, as well as PD. But the final choice has to come from the patient and if the patient is well-educated about the various dialysis modalities, what choice he makes would be the best choice for him. Left to the physician, he would be wrong rather than right because the factors he might consider important might not be that important for the patient. So, it’s best that the patient makes the choice of the dialysis.
Q. What kind of role do you see for a doctor in terms of managing an end stage renal disease patient?
A. Well, the doctor has obviously an important role to perform. Prior to starting the therapy he has to be a friend, he has to guide the patient… Subsequently there can be recurrent medical issues that need to be taken care of. So you have to be vigilant for all this. If you have a good cordial relations with the patients…they can have a good quality of life and good duration of life.
Q. Can kidney diseases be prevented?
A. Kidney diseases can be prevented if we can detect it early enough. However once significant damage has occurred you can’t entirely stop the disease from occurring but we can slow the progression and prevent related complications. As I said earlier most of the patients are those who have some other problems as well. Like diabetes, if we are vigilant enough to detect the kidney problem early, it can still be reversed. At an early stage, it can be prevented to a very great extent. So it is very important that the kidney diseases are detected early because once you reach the downward momentum it is very difficult to pull you back.
Q. How do you define the cutoff point from where the downward stage starts? And what symptoms would you want people to watch out?
A. In the early symptoms of a kidney disease, the symptoms are easily overlooked. The high-risk patients – who are diabetic, hypertensive or have a history of kidney disease in the family – they should get a regular urine protein and kidney function test done once in six months. The symptoms one should look out for include lethargy, swelling of the feet or face, getting up frequently in the night to pass urine—these are the early symptoms that can occur in a patient. But as you see most of these symptoms can be due to something else, so they are very difficult to pinpoint. Even doctors tend to overlook these symptoms, so the best is to get regular checkups. Even for a healthy person it is nice to know your kidneys, nice to know your Glomerular Filtration Rate GFR say once in a year or two years. And in patients who are high risk, hypertensive, diabetic… regular tests every six months, regular doctor visits every six months is the only way to detect these patients and to treat them.
— DATELINE INDIA SYNDICATE