Sunday, October 8, 2000		Keeping fit

EVERY now and then there is a new item in the Press or an appeal to help a patient who is suffering from kidney failure. It appears that sufficient information is not available to the lay public about this disease. It has very serious medical and financial implications for the patient, the family and the community at large. It is worthwhile having a look at this fairly common disease and discussing its various aspects.

The body has two kidneys which are bean-shaped, and located deep in the hollow of the abdomen tucked into the sides of the lumbar spine. In one out of 10,000 persons one kidney may be absent from birth. On the average, kidney size is about 11x6x3 cms in three dimensions and the two kidneys together weight about 250-300 gm in a 70 kgs man. From the kidneys two long tubes, known as the ureters take the urine to the urinary bladder in the pelvis. When 200-300 cc urine in the bladder is collected, urine is voided. This is controlled by a very fine neural mechanism along with psychosocial conditioning. Kidney is one of the most complex organ and is one of the biochemical wonders of the nature. Its physiological importance can be understood by the fact that whereas it hardly forms 0.5 per cent of the body weight, it receives nearly 15-20 per cent of the blood pumped out by the heart. Each kidney consists of about 1 million filtering unite known as nephron from which the tern nephrology is derived. The enormous blood received by the kidneys is meant for various physiological and metabolic functions. Kidney excretes the waste products of the body particularly the end result of protein metabolism which is measured by the blood level of urea and creatinine as an index of the renal function.

In addition to its excretory function, the kidney performs very important functions of (i) regulating fluid and water balance in the body, (ii) regulation of blood pressure, (iii) regulation of calcium metabolism by processing the final step of vitamin in the body for the absorption of calcium in the intestine and its deposition in the bones and (iv) production of eryerhophohien, which stimulates the formation of blood in the bone marrow. Another function of the kidney is to regulate the acid and alkali balance in the body along with the lungs so that the biochemical environment of the body is kept within a very narrow range in which various enzymatic and metabolic functions can be performed. Kidneys thus play a vital role in maintaining the normal internal body environment called "millieu interior" by the French Physiologist Claud Bernard.

If we consider the above major functions of the kidney, it can be easily understood what the consequences of kidney failure would be. As long as one kidney functions or even half of the normal kidney is left in the body, it can take care of the function of the body. Therefore, when we use the word renal failure it means the overall kidney functions of both the kidneys have declined considerably. Usually the renal failure is not apparent upto 30 per cent functions of the kidney and only when it goes below 10 per cent the patient needs some form of help to sustain life.

Symptoms of renal failure include loss of appetite, nausea, vomiting, swelling of the body, derangement of blood pressure, difficulty in breathing due collection of fluid in the lungs or to excessive acid in the body, general sense of fatigue and virtually all vital organs of the body like heart, brain, lungs, liver, nerves and various metabolic functions of the body including protein, fat, carbohydrate, uric acid and calcium are affected.

It is good to know that although urine volume is the best evidence of kidney function, urine formation may not always be decreased in some patients till the very end. This is one of the reasons that for a long time both the patient and the physician may be misled about the possibility of renal failure. The kidney failure can occur due to a large number of diseases. In general nephrologists divide renal failure into two types: (a) Acute renal failure — it comes rather quickly and is potentially reversible, (b) Chronic renal failure — it develops slowly over several months and sometimes years and is not reversible except partially is some reversible factors are present.

Treating acute renal failure is one of the most satisfying experience for the treating nephrologists and the physicians, as a nearly fatal disease is fully cured. There are a large number of causes of this kind of kidney failure which mainly constitute loss of blood or fluid or fall in blood pressure due to any cause. Diarrhoea, vomitting, haemorrhage, trauma, burns and heat stroke are common causes of this kind of kidney failure. Infections of all kind can directly or indirectly produce acute renal failure. Infection by leptospirosis is a common cause of acute renal failure in the states of Kerala and Tamil Nadu. Toxins of all kinds, including snake-bite, in our country can produce acute renal failure. Intrinsic diseases of the kidney and obstruction to the flow of urine can also produce acute renal failure. Lysis of red blood cells, known as bloods hemolysis, due to various causes can produce renal failure. Poisoning by copper sulphate used to be a common cause of this in North India, but the declined now.

The important thing to remember in this kind of renal failure is the problem of the basic cause. The patient should be handled in a competent way with provision of replacement of fluid, blood and other causes which may precipitate the renal failure as mentioned above. This form of renal failure may be reversed by the measures directed towards its cause. But they often need the dialysis therapy (described below) if it goes beyond a certain time and degree. The vast majority of these patients can be saved with he help of dialysis therapy provided the basic cause of kidney failure itself does not prove fatal.

Much more problematic, however, is the chronic renal failure, which requires much more medical skill, organisation, financial resources and vast network in the country to handle the problem. Here the kidneys have gradually come to less than 10 per cent of their function and the person is often very sick with the symptoms described above. It is estimated on the basis of statistics that nearly over 1-2 lakh patients of chronic renal failure occur annually in our country. The common cause of chronic renal failure, as analysed in the PGI over the last many years, as well as in glomrulonephritis, diabetes mellitus, high blood pressure, systemic immunological diseases, chronic infections of the kidney, prolonged use of pain killers and congenital abnormality of the kidney like polycystic diseases of the kidney.

Diseases of the blood vessels of the kidney and untreated obstruction of the kidney like bilateral stones and prostrate enlargement are the other causes.

Once the chronic renal failure is recognised and a firm diagnosis made by a competent physician/ nephrologist, treatment should be planned by discussion between the physician and the patient and his family. For sometime the patient can be treated by what is known as the conservative treatment of chronic renal failure which implies that no form of substitution therapy or replacement therapy in the form of dialysis or transplantation is given to these patients in early stages or because of financial of medical reasons. In this form of therapy an attempt is made to keep the patient free from various symptoms by limiting his protein intake, by giving him replacement of various nutrients like iron, folic acid, calcium, vit.D, water soluble vitamins, treating the hypertension, infections or any other apparent cause which may be reversible. The success is partial and alleviate the symptoms to prolong the life for a limited period.

The renal replacement therapy in the form of dialysis and kidney transplantation is a revolutionary improvement during the last 50 years or so and has completely changed the scene. Dialysis, is basically a process by which toxic substances normally excreted by the kidney are removed from the kidney by exchange between the blood and a specially prepared fluid across a semipermeable membrane. It is done either by utilising patient’s own membrance lining the abdominal cavity by putting 2 litres of fluid in it and draining it after variable periods. This form of dialysis is known as peritoneal dialysis. It is easy to use in acute renal failure but is costly in the chronic form because of the cost involved and some risk of infections. The ambulatory form of peritoneal dialysis is now available in our country in which the patient can go on changing the fluid himself few times a day. The other form of dialysis is known as hemodialysis. This is done with the help of a machine by passing the patient’s blood and the fluid in opposite directions. This takes four-five hours and needs to be done two or three times a week. It is fairly costly (Rs 1000-1500 per dialysis) and that is the major barrier to its utilisation by an average patient. The government-run hospitals can’t provide it and the corporate hospitals are unaffordable public and insurance funding may be the solution in the long run.

The real answer to this problem is our country, however, is kidney transplantation which has the advantage of being more efficient, more physiological and can more or less restore the kidney functions to normal. This operation is being performed in many centres in the country for the last over 40 years and in the PGI Chandigarh itself over 900 renal transplant operations have been performed. Kidney for transplantation can be taken from a closely related relative — known as living related donor or a person who is brain dead but whose heart is still beating (Cadaver donor). Even in cadaver transplantation matching of blood group and, if possible, other immunological parameters are done.

This operation is now regulated by the Organ Transplant Act of 1994 which was passed by the Parliament to prevent the exploitation of poor donors who were paid a pittance and most of the money was siphoned off by the middle man. The donation of kidney by an unrelated person is now sanctioned by an authorisation committee which makes sure that the person is not under pressure or coercion of any kind. Possibility of some mischief remains but has reduced considerably.

Since there is always a limitation of living donors in the family, the real solution to this problem is that more and more individual and families should come forward to donate their kidneys in case of an unfortunate mishap like an accident or an illness.

Another problem is the cost of the procedure. Operation of both the donor and the recipient costs nearly Rs 1 lakh and there is a continuous post-operative cost varying from Rs 10,000 per month in the beginning to Rs 3,00 to 4,000 subsequently. That is one source of frustration and hardship even when a donor is available. The family has to plan well in advance not only the logistics of surgery but also the long-term financial commitment. This is the source of those enotional appeals from the families in the lawns of PGI and other such institutes. This also brings out the yawning and painful gap between the available technology and its delivery to the masses.

A truly welfare society should bridge the gap between the two.