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World Kidney Day: A Doctor Educates On “Living Well With The Kidney Disease”

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About 850 million people worldwide are afflicted with some form of kidney disease.

With an annual incidence of approximately 100 per million population, Pakistan is likely to have 22,000 new “Endstage” kidney disease patients, requiring dialysis or transplantation in 2021.

The theme of the World Kidney day 2021 is: “Living well with kidney disease”. It aims to raise awareness about those afflictions that harm kidneys.

Pakistan is spending only 1 percent of its GDP on healthcare. With diabetes and its sequelae assuming epidemic proportions, including Chronic kidney disease in nearly 30-35 percent of diabetics, it is imperative for our government to take a pro active role. Addressing Kidney disease as a national emergency is needed.

The key strategies may be dealt with at primordial, primary, secondary, tertiary and quarternary care levels.

At the primordial and primary care level, health education in the form of awareness campaigns utilizing print and electronic media, health education booklets and early detection of symptoms is vital. These signs include increased urine frequency during the night, as a result of failure to concentrate urine, puffiness under the eyes on waking up, and protein in urine analysis and/or blood in urine . In addition, the elevated serum creatinine – above the expected Pakistan national average (0.8 mg/dl in males or 0.6 to 0.7 mg/dl in females) – should be investigated.

At the primary to secondary care levels,  blood pressure control less than 130/80 mm Hg and optimal diabetic control with 3 monthly HbA1c levels close to 6 % is vital. It can be done with the use of ACE inhibitors or AR2 Receptor blockers and SGLT2 inhibitors, particularly in proteinuric kidney disease. Additionally, dietary protein restriction is vital for slowing progression of chronic kidney disease; defined as Glomerular filtration rate/ GFR less than 60 ml/minute for at least 3 months.

There is staging of chronic kidney disease as per KDIGO standards; Stage 1 as structural changes in kidneys with or without protein in urine, when GFR is more than 90 ml/min and Stage 11 (GFR 60 to 89); Stagè 111A (GFR 45 to 59); Stage 111B (GFR 30 to 44); Stage 1V (GFR 15 to 29); Stage V (GFR Less than 15); Stage VD (Dialysis patients) and Stage VT (Transplant patients)

At the tertiary care level, experts in Kidney disease management (Nephrologists) should be managing chronic kidney disease, Stage 111 onwards, as other electrolyte, mineral and bone disease management and anemia of chronic kidney disease requires specialized care.

At Stage IV, future possibilities of pre-emptive kidney transplantation, Hemodialysis or Peritoneal dialysis should be considered. Preparation for creating vascular access for Hemodialysis, if chosen as a modality, should be underway in Stage IV as GFR approaches 20 ml/minute. The vascular access takes 2 to 3 months for maturity (if an Arteriovenous fistula is created).

At the tertiary to quarternary care levels, dialysis needs to be initiated and transplant candidates are to be identified early. Patients should be transplanted with full ethical and safety considerations at HOTA authorized specialized facilities.

Since the entire spectrum of chronic kidney disease is accelerated and worsened by acute kidney injury and failure to treat reversible Glomerular and tubulointerstitial diseases of the kidneys, it is imperative to avoid casual treatments. Over the counter drugs, Non Steroidal anti inflammatory drugs, pain killers, and nephrotoxic drugs  including “kushtay” prescribed by Hakeems should be avoided. Kidney biopsies at early stages of Glomerular disease are essential in determining the combination of medications required to reverse often treatable causes of kidney disease.

It may be obvious that chronic kidney disease and its sequelae of dialysis and transplantation may span decades.

Thus, it is important to discuss strategies for living well with kidney disease with your care providers. These include full awareness of signs, symptoms and complications as well as attention to diet, regular exercise such as 20 to 30 minutes daily walks, smoking cessation and weight loss for overweight patients .

Additional adjustments are required on dialysis in terms of weight gains between dialysis, dietary potassium and phosphorus control and adequate protein intake, depending on modality of dialysis. A college or work schedule adjustment around dialysis schedule should allow participation in all activities of interest with minimum dependance on others. Family support nonetheless is important for full social, physical and emotional well being.

Once transplantation is done, a diligent management and adherence to transplant medications and prevention of infections is the key to healthy living along with prevention of cardiovascular disease with healthy dietary habits and exercise.

All kidney disease patients should ideally get annual flu shots, 5 yearly Pneumococcal vaccines and vaccination for Covid. Covid 19 vaccines may not have been tested in clinical trials on dialysis or transplant patients but the consequences of Covid in these patients with immunocompromised states can be more serious. Therefore, there is a general consensus to vaccinate the population among the Nephrology community.

A major burden for patients and families with dialysis and transplantation are the prohibitive costs of long term treatment. Pakistan needs a National insurance program specifically geared to Stage V dialysis and transplant patients. majority of Pakistanis cannot economically sustain long term costs of these treatments without governmental help. Perhaps, all big corporations, pharmaceuticals, businesses and entrepreneurs can also come forward. Under ‘corporate social responsibility’, they can help reviving the Pakistan Dialysis support coupons based program, and add Transplant services to this project.

We must remember that these chronic kidney disease afflictions do not choose between presidents and paupers, young and the old.

The Nephrology community will do its part and be a willing partner and stakeholder in the Kidney Disease National program.

Together we can !

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Naya Daur