Kidney Centre
Compiled by Dr. P.D.Gulati

KIDNEY CARE: Some commonly asked questions

GENERAL - BASICS IN KIDNEY DISEASE
 
1:1. What do we understand by kidneys and the urinary tract ?
•
The two kidneys are situated at the back of abdominal cavity
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Each kidney weighs 150 gm; contains one million filtering units called Nephrons' the filter is called 'glomerulus' which is attached to long coiledcollecting tube
•
Excess of water and waste substances are removed from the body in the urine, through the 'Ureter' 'bladder' which when filled causes a sensation to pass urine through the terminal tube called 'Urethra'.
2:0 What do the kidneys do ?
•
The kidneys (1). Control the amount of water in the body, (2) Remove the waste substances and excess of potassium, phosphates from the blood; (3) Play important role in the formation of red blood cell through production of hormone called 'Erythropoetin;' (4) Control blood pressure through hormone called renin; and (5) Keep the bones healthy through vitamin D3.

2:1 Kidney and Blood Pressure : Blood pressure implies the force of blood flow through the arteries and depends upon the size of arteries , force with which the heart pumps blood and the amount of water and salt in the body; kidney cells secrete a hormone called 'renin' which also plays an important role in regulation of blood pressure.
2:2 Kidney and Anemia : kidneys produce a hormone called 'Erythropoetin' - a substance that controls the rate at which bone marrow produces red blood cells; Besides kidney failure patients have lack of iron and vitamin B12 and folic acid due to decreased in fact of food.
2:3 Kidney and Bones
i)
when kidneys fail, phosphorus accumulates in the blood which causes calcium to be drawn out of the bones. In order to correct this, avoid eating phosphate containing foods such as meat, cheese, nuts, dried beans, soft drink etc.
ii)
Healthy kidneys change Vit D to a more active form (Vit D3) . When kidneys fail level of calcium in the blood and bones falls.
 
3:1 What is urine and its significance in kidney diseases?
Urine is composed of excreted water containing unwanted waste substances filtered from the blood by the kidneys Simple urine test provides enormous information to the doctor; leakage of sugar occurs in diabetes, bile in hepatitis, proteins in nephrits. Damage to the kidney filter leads to leakage of albumin through urine, protein of much smaller size called microalbumin, starts leaking early in the urine diabetes;


4:0 What are the diseases that affect the kidneys ?


4:1 Diabetes Mellitus : Kidney involvement occurs at a fast pace if control of both diabetes and blood pressure is poor; eye changes are usually present.


4:2 High Blood Pressure Sudden rise of BP can damage the kidneys in a relatively short period; whereas lesser grades of hypertension cause slow kidney damage our several years which may remain symptomatic;. Patient of high blood pressure should have the tests of kidney function done at 6 month interval, and get regular check up and medication so as to keep BP below 130/80 mmkg.


4:3 Nephritis and Nephrotic Syndrome is allergic inflammation of the kidneys, occurs usually in children after an episode of throat infections or skin boil, recovers fully; less than 5 percent children develop sustained hypertension and albumin and blood in urine) and may even develop kidney failure. a fair number of them develop hypertension and kidney failure . Nephritis is the commonest cause of kidney failure in adults .Nephrotic syndrome is a disease of children and adults both .Protein leakage in the urine occurs in large qualities; remission with medicine (steroid) is satisfactory in children relapses are frequent . In adults, high blood pressure occurs; a large number of their develop kidney failure.


4:4 Kidney Stones & Infections Stones in the kidney are quite common in North India (Stone belt); exact cause is not known; some elements in food and water or may be in the soil where vegetables are grown could possibly cause kidney stones; large stones cause blockage of the ureter, can cause irreversible damage to the kidney; if in both kidneys it may lead to high blood pressure and kidney failure recurrent. Infection in the kidneys may cause kidney damage and kidney failure.


4:5 Drugs & Kidneys Pain killers, antibiotics, Non-steroidal drugs (NSAIDS) like brufen etc may cause kidney damage if taken without proper medical advice; heavy metals used in several indigenous preparation have posed additional problem , few antibiotics like sulpha , penicillin cause alltergic type acute renal failure; which often recovers if detected and treated in time.


Kidney Failure
 
5:1 What is kidney failure and how does it occur
When the kidneys stop functioning; it leads to retension of water and waste (poisonous) substances in the circulation; condition is called 'Kidney Failure'. When stoppage occurs due to sudden blockage of blood supply to both kidneys or blockage by stones, sudden 'acute kidney failure', occurs. If the kidneys stop working gradually over weeks and months. It is called 'chronic kidney failure'; common causes are : diabetes mellitus, hypertension, chronic glomerulonephritis, bilateral kidney stones with chronic infection (chronic pylonephrits), prolonged exposure to pain killers/NSAIDS) antibiotics etc. When kidney function is reduced to 5 percent and the damage caused is permanent, end stage kidney disease (ESRD)/Occurs patient can survive only on regular dialysis or after kidney transplantation.


5:2 What happens when kidneys fail?
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Accumulation of water leads to swelling on face and legs, high BP; that of poisonous substances like urea and creatinine causes lack of appetite, nausea, vomiting, muscle weakness, pallor, anemia.
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Kidney manufactures hormone called 'erythopoetin' which stimulates bone marrow to produce red blood cells containing hemoglobin which is necessary for supplying oxygen to all parts of body; lack of oxygen in the blood causes lack of energy and tiredness.
•
Lack of vitamin D production by the kidneys leads to reduced calcium in the blood and bones; phosphate levels in the blood get elevated in kidney failure; this causes calcium be drawn out of the bones leading to osteo- malacia, ostoporosis, stiff cystic bones (osteodytophy) due to increase in the hormone called parathormone (PTH); such patients often complain of bone pains and backache.


5:3 How do you evaluate kidney failure ?
Besides the basic (1) Urine test of red colour urine (blood cells positive, protein test ++ glomerulonephritis ); sugar (diabetes); pus cells (cystitis, pfelonepnitis ) crytals (kidney stones) / elevated blood urea, creatinine, potassium and fall of hemoglobin occur.

(c)
Potassium kidney failure can cause disturbance in the heart rhythem which may prove fatal.
(d)
Hemoglobin levels fall (anaemia occurs) due to lack of erythropoetin production by the damaged kidneys.
(e)
Ultrasound, x-ray, CT-scan/often indicate structure defects and even kidney stones.
5:4 What are the various treatment options for 'end stage kidney failure'
When only 5 percent of kidney function is left, life can only be sustained either on regular maintenance dialysis or by kidney transplantation. Patients our 65 years, younger subjects with severe heart disease or those with primary kidney disease having high chances of recurrence in the transplanted kidney are advised to remain on dialysis; all younger patients are strongly advised to get kidney transplant done; diabetes is no longer a contraindication today.


DIALYSIS & TRANSPLANATION
6:1 What is dialysis ?
Dialysis is a procedure that performs the function of the failed kidneys; it removes waste nitrogenous substances like urea, creatinine and excess water from the blood.


6:2 What are the various dialysis options and How to choose?
There are two types of dialysis I) Hemodialysis (H.D) : Synthetic membrane (cellophone ) in the shape of thin tubes (capillary dialysis) is used; blood is passed through these into a dialysis machine at a slow speed for a period of 4 hours; glucose and salt solution (dialysate ) flows in opposite direction outside the tubes; blood thiner (anticoagulant - heparin) is used to avoid clotting of blood; hemodialysis is repeated twice or thrice a week. Average cost of hemodialysis comes to Rs. 12000/- to Rs. 16000/- per month besides, the cost of canulation 2000/- for groin; subclavianor jugular costs approximately Rs. 5000/- . For long term use, 'arteriovenous fistula' (AV Fistula) is used (II) Peritoneal dialysis (PD) : In this, peritoneum of the abdomen is used as membrane. The process lasts for 36 to 48 hours . sugar- salt and solution (exchange of 2 litres) pushed in the peritoneum; One hourly exchanges are used CAPD consists of 2 litre of sugar and salt solution, placed in the peronium for 4 hours under fully hygienic condition, 3 such exchange are done daily or patient could undertake 10 hours of night dialysis using an automatic cycler machine (costing about Rs. 3:5 lakhs). Cost of single 36 hour peritoneal dialysis Rs.2000/ to Rs. 2500/- CAPD works out about Rs. 15000/- to Rs. 20000/- per month. Peritoneal dialysis is preferred for patients having bleeding tendencies, heart disease especially diabetics; also .Hepatitis B positive patients waiting for a place in the isolation unit or transplantation. CAPD is perhaps the best home dialysis option for patients of End-stage renal disease.


6:3 When is dialysis indicated ?
It is a life saving procedure in 'acute kidney failure' 'Decision to start dialysis in patients of chronic kidney failure' is based more on patient's symptoms though serum creatinine levels of 10 mg% or more often indicates initiation of dialysis in; loss of appetite, nausea, vomiting, excessive water accumulation indicate early initation of dialysis. In the presence of infection, blood potassium level rises and blood PH falls (acidosis); these indicate urgent need of dialysis for their correction.


6:4 What are the risks of dialysis?
(i) Hemodialysis machine failure, blockage and/or infection of the vascular access, patient may experience vomiting, fever with chill, headache, breathlessness, itching, leg cramps, rarely chest pain.

(ii) Peritoneal dialysis or CAPD may patients develope catheter blockage and/ or infection at the catheter site which are easily treated; but serious infection like 'peritontis'; often need stopping CAPD and strong ant------------ for 2 to 3 weeks, when patient is put on machine didyris strict vigil by the attending nurse/doctor is needed to prevent.


6:5 What is ultra filtration and when is it required?
Healthy kidneys regulate the amount of water in the body. In fluid overload (overhydration), ankle/body swelling BP is high; neck veins become prominent, breath less due to lung congestion. Overload can be easily corrected by dialysis; increasing negative pressure of on hemodialysis called 'ultrafiltration' in order to prevent damage to heart by overload, dialysis patient is advised not to gain weight in between two dialysis sessions by restricting fluid intake.


6:6: What is continuous renal replacement (CRRT)?
This is commonly used in ICU in patient with low blood pressure with or without increased fluid retention using special more expensive polysulfone or poly venyl-nitrile filter.


6:7 What is the quality of life expected on dialysis?
Accepting long term dialysis is the key to success of this therapy; educating the patient and his attendants individually or in groups regarding the need for dialysis its various options, these benefits, including dietary relaxation, increased work of fluid fruits etc should be emphasised;


KIDNEY TRANSPLANATION
The best option for a patient with end-stage renal disease (ESRD) is to get kidney transplantation done.


7.1 What is meant by kidney transplantation?
A healthy kidney from a healthy person is placed by an operation into the abdomen of the patient of ESRD; the blood circulation and urinary drainage systems are connected to the body's natural parts; this new kidney functions with the help of medicines called immuno-suppressant's which do not allow the body's in built immune system to reject the new kidney.


7:2 what are the essential requirements of kidney transplantation?
(i)
Blood group of the donor (person giving the kidney) and the recipient (person receiving the kidney) should be the same; Rh factor may or may not be the same; the donor can also have 'o' group (universal donor); AB group patient is universal recipient
(ii)
'Issue type' called HLA system should also match; though it is not essential for blood related donor.


7:3 Who are the possible donors? What is the expected cost of medicines used and operation?
(i)
Living related donor real brother, sister, father, mother, son or daughter (age - 20 to 60 years) the spouse (husband or wife) Cost of transplantation 2.5 to 3.0 (in private), one lac in public hospitals.
(ii)
Living un- related donor The law allows a donor from this group only if financial gain of any nature has been thoroughly scrutinized and completely ruled out. Because of the possibility of commercialization in the category, it should be discouraged.
(iii)
Cadaver (dead body) donor Accident or stroke case-brain-dead- beating heart, with BP maintained on drugs liver, heart, and pancreas can also be utilised, prior consent must have been obtained. Only few centres in India are presently undertaking cadaver transplantation, there are associated social and legal problems; the law needs certain amendments.


7:4 Is the donor thoroughly screened for any hidden illness?
Diabetes, high blood pressure other serious system illness involving the kidney liver and heart; renal artery angiography to establish the patency and variation of the renal arteries; selected donor would have already had the HLA typing done.


7:5 What screening of the recipient is essential before transplant operation?
(i)
Detailed cardiac assessment to determine suitability for the major transplant surgery
(ii)
Corss match is the final check; In case, cross match is positive recipient's body will soon reject the donor kidney as such, this is unsuitable.


7:6 What are essential steps of transplant operation and follow up?
(i)
Dialysis so that blood urea and creatinc are brought down significantly.
(ii)
Operation is in twin theatre - one for removing the donor kidney and the other for recipient's surgery.
(iii)
Usually the donor's left kidney is removed and is placed in the right side lower abdomen of the recipient; generally the recipient's own kidney are not removed operation takes 2-3 hours.
(iv)
Patient needs to stay in specially created isolation ward with ICU arrangements to provide complete care and also for close monitoring the patient is usually shifted to single room in 2-3 days.
(v)
Transplanted kidney is expected to produce adequate urine in the first 24 hours most of the retained urea, occasional by creatinine and other substances are removed; adequate fluid replacement will be required. In a patient, transplanted kidneys responds slowly and may need few dialysis in the initial post operation period. Daily kidney function check is required in first week after operation.
(vi)
Regular follow up and blood tests are essential, more frequent in first 3 months; less frequent subsequently/life long.


7:7 Is there any risk to the kidney donor?
Healthy donor dose not develop any problem after a follow up of over 20 years; BP is marginally higher in Rarely, single kidney in the donor may develop hyper filtration leading to protein leakage and changes in the kidney;


7:8 Which complications are common after kidney transplantation?
Technical-ureteic obstruction, leak; medical; graft rejection, occurrence of opportunistic infections, toxic effects of antirjection drugs, risk of cancer rarely.


7:9 What are the average expected results of transplantation?
One year graft survival in over 90 percent (10 percent less in diabetic); 3 years survival is 80 percent and 5 year is about 70 percent. cadaver transplant 10-20% less than . living donor transplantation.


7:10 Can kidney transplantation be done again in the same person?
Yes, one of my patients had four (4) kidney transplants, fourth is functioning after seven years; total of nine (9) transplants in one person have been recorded in the world literature.


PREVENTION OF KIDNEY DISEASE
8:1 How can we prevent kidney disease?
Rapid escalation of the cost of medical care specially in patients of advanced kidney failure, has made it mandatory for the patient and health professional to promote preventive measures in early stages.
(i)
Nephritis proper attention to the public health measures e.g. environmental sanitation, personal hygiene and prompt treatment of throat infection.
(ii)
Early recognition of urethral value, meatal narrowing, congential/ defect causing backflow of urine - ' reflux'. Timely treatment of bladder reck obstruction by prostate enlargement in elderly males; repeated kidney for infection high fluid intake is useful.
(iii)
Control of diabetes fasting less than 100 mg' and post meal less than 130mg' BP less than 130/80 m and early use of protective drugs ACE inhibitor, usually postpone kidney failure.
(iv)
Indiscriminate use of antibiotics, pain killers, indigenous medicines herbal preparations, must be avoided.
(v)
Awareness about certain food items promoting stone formation such as increased intake of milk products (calcium-rich) spinach, tomatoes strawberry, chocolate (oxalate rich), red meat, (uric acid), soda bicarb 2 to4 gm day is useful antibiotics for infective stones.


Prevention of Kidney failure: prompt attention to hygenic conditions leading to diarrhoea, dysetery, cholera, other infections resulting in shock anti--mosquito measures; all these will help curtail the development of acute kidney failure.

In patients of 'chronic kidney failure' prompts correction of some of the reversiable factors like dehydration, infection, exposure to drugs and toxins, may be beneficial for retarding progression; In selected situation, ACE-inhibitor drug, antipleteleh drugs, cholesterol lowering medicines are beneficial; early reorganization in vital.