Most of us are born with two kidneys that we hope will serve us all our lives.
When one kidney is damaged or no longer works, the other one can still cope, but if this “reserve” also malfunctions, then all hell can break loose.
According to the latest 2015 data from World Health Organization (WHO), chronic kidney disease (CKD) affects approximately 10% of the world’s population and is among the top 20 causes of death.
What is more frightening is that the number of patients whose kidneys have failed and are on dialysis has risen in leaps and bounds in Malaysia over the past decade.
The 24th Report of the Malaysian Dialysis and Transplant Registry in 2016 shows that the figures increased from 17,097 in 2007 to 39,711 in 2016.
Says Universiti Kebangsaan Malaysia internal medicine clinical lecturer Prof Emeritus Datin Dr Norella Kong: “Before, no one talked about anything other than the first 10 causes of mortality.
“It is only in the past decade or so that CKD’s impact has grown.
“Dialysis is a major means of treatment, which is very expensive, and once a patient is on it, he or she is being kept alive by a machine for umpteen years.
“This leaves a large economic impact on a country’s resources.”
Kidney or renal function is measured by the glomerular filtration rate and CKD is staged accordingly.
There are five stages of CKD, and the beginning stages (one to three) are often asymptomatic, i.e. do not show any symptoms.
Even if there are symptoms, these tend to be generic ones like loss of appetite and weight, nausea and vomiting, itchiness, fatigue, and swollen legs, which can be easily mistaken for other conditions.
By the time the patient reaches stages four and five, the objective is to maintain their remaining kidney function for as long as possible, rather than curing the disease, which is possible in the early stages of CKD.
By stage five, patients normally cannot survive without dialysis.
“Even if 1% of patients move on to end stage CKD, it is a big number,” says the retired consultant nephrologist and MAA Medicare Charitable Foundation Board of Trustees member – an NGO that currently cares for about 800 poor and underprivileged kidney patients at 12 charity dialysis centres nationwide.
Having been in the field for over 50 years, she says CKD was initially a problem among the aged, but with greater awareness over the years, it’s now being picked up at a younger age.
Not an ‘elderly’ disease
Primary kidney problems – those diagnosed in the womb and within the first few years of life – used to be fairly fatal a few centuries ago before advances in the medical field.
But now, the number of these kidney disease patients is actually quite low, as abnormalities in kidney function can now be detected early enough to prevent or delay the progression of disease.
Only 3% of end stage CKD are a result of primary kidney disease; the rest are from acquired causes.
“We have health screening programmes at various stages of life in place, so we have the services to pick up any abnormalities.
“At birth, babies are screened and vaccinated against hepatitis B (which can lead to CKD).
“We’ve also got programmes to vaccinate young girls for the human papillomavirus (HPV, which is a cause of cervical, vaginal, vulvar, penile, anal, and head and neck cancers in kidney transplant recipients), though now we’ve discovered that the males need to be vaccinated as well to stop the spread.
“However, it costs time and money to screen kids for urinary abnormalities, so we only do it when the child is about to enter university or get a scholarship.
“But if you leave school after Form Five or Six, then you are not screened until you get to the employment phase or are obtaining health insurance,” says Prof Emeritus Kong.
Although there are many opportunities for CKD to be picked up, the numbers are still increasing.
“Back then, if there was a small trace of protein in the urine, the medical officers will generally pass you by because they didn’t realise what may happen 20 years down the road in females when they get pregnant.
“These early abnormalities were not acted upon, but now, our guidelines say these individuals require follow up and they are referred to nephrologists (kidney specialists),” says Prof Emeritus Kong.
Sadly, the most common causes of CKD are a result of our modern lifestyle.
Diabetes currently contributes 65% of new dialysis patients with end-stage CKD, while hypertension or high blood pressure amounts to 20% of such cases.
Deaths from dialysis have more than doubled from 1,988 in 2007 to 5,366 in 2016.
New transplant recipient rates have reduced from 113 to 82 during the same period, possibly due to the lack of kidney donors.
At present, the average waiting time for a kidney transplant is also three times longer than 10 years ago.
Although women are more prone to developing kidney problems, there are more men on dialysis as women tend to take care of themselves better.
According to Prof Emeritus Kong, CKD patients on dialysis constitute 65% males and 35% females.
She says, “That’s because men have this •tidak apa• attitude or are in denial, whereas females tend to look after themselves better!”
However, females do have unique concerns when it comes to CKD.
Prof Emeritus Kong explains, “When females first have sex, they may be exposed to urinary tract infections (UTI) because of our shorter urethra.
“But not all UTIs will move on to CKD as it depends on how far (up the urinary system) the bacteria travels.
“In a small proportion of patients, especially if the tube connecting from the bladder to the kidney is dilated for any reason, allowing the reflux of urine back to the kidney, it will bring infection up to the kidney. That’s when you get pyelonephritis.”
The good news for many women is that pregnancy offers an opportunity for diagnosis of kidney disease through the standard antenatal tests.
The bad news is that pregnancy is also when both acute and chronic kidney disease may exhibit symptoms or signs for the first time.
If a woman has CKD when she gets pregnant, it can have a negative impact on both herself and the baby. The more advanced the mother’s CKD, the more risk she and her baby will face.
Pregnancy may also exacerbate previously-undiagnosed conditions in the mother, e.g. diabetes and hypertension, resulting in the development of pre-eclampsia after 20 weeks of pregnancy.
Pre-eclampsia is a complication of pregnancy characterised by high blood pressure and signs of damage to another organ system, most often the liver and kidneys, and can occur in women whose blood pressure was previously normal.
Pre-eclampsia increases the probability of hypertension and CKD in later years.
“By the time pre-eclampsia develops in a pregnant woman, it’s often too late. We cannot terminate the pregnancy.
“We have to monitor their blood pressure and foetal growth very carefully.
“The blood pressure can spiral out of control and they may have a fit, or even die. Sometimes, even when they get through the crisis, it leaves them brain-damaged.
“In real life, nothing is ideal, so we often encounter these latecomers, and sadly, we lose a few mothers and babies,” says Prof Emeritus Kong.
The other problem with pre-eclampsia is that the blood vessels in the placenta can spasm (resulting in constriction) and the baby may not get proper nutrition.
In these circumstances, the foetus is often small for its age (intrauterine growth retardation or restriction) or born prematurely.
She elaborates, “Pre-term babies have their own complications, even if they survive.
“To compensate for the underdevelopment as a foetus, it guzzles whatever it can and by the time the child is five or six years old, these children are heavier than their peers.”
This continues when they reach their teens as their brain is now wired to think their intake of excessive food is normal and will trigger hunger if they do not eat to this excessive level, which will make them obese.
Specific conditions like rheumatoid arthritis, systemic lupus and sclerosis, which affect the kidney, also afflict women more than men.
Prof Emeritus Kong says there is no reason why CKD cannot be detected early, or even cured.
However, most young adults think they are okay as they have no symptoms.
Females embark on pregnancy without pre-checking, especially in rural settings.
“But we tell them, hey, hold your horses! If you embark on a pregnancy unprepared and you have kidney disease, we have to counsel and advise you.
“Sometimes they don’t listen, then don’t come again due to guilt, and only return when complications occur.
“This happens even among relatively educated populations,” she says, sighing.
If the pregnant woman loses her kidney function during pregnancy, she might need to go on dialysis.
She may regain kidney function after delivering her baby, which will allow her to go off dialysis.
However, being on dialysis makes women less fertile.
Prof Emeritus Kong also warns of herbal and traditional medicines, which can cause permanent kidney damage.
“Herbal tea is fine once in a while, but be careful because I’ve seen patients with long term kidney damage resulting from herbal and traditional medicines e.g. jamu, which are taken by a lot of women to ‘tighten’ the vagina muscles,” she says.
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