We are born with two kidneys and although we only need one to survive, chronic kidney disease (CKD) is a common ailment.
According to the Global Burden of Disease 2015 study, it is estimated that the 1.2 million deaths, 19 million disability-adjusted life-years and 18 million years of life lost from cardiovascular diseases are directly attributable to reduced glomerular filtration rates (GFR).
GFR is an estimate of how well the kidneys function to filter toxins.
Since 2002, kidney disease has been defined based on GFR and classified into stages 1 to 5, with stage 5 being the most severe, requiring renal replacement
CKD, as opposed to acute kidney failure, is a slow and gradually progressive disease.
Even if one kidney stops functioning, the other is sufficient to perform the kidney’s normal functions.
It is not usually until the disease is fairly well advanced and the condition has become severe, that signs and symptoms are noticeable. By this time, most of the damage is already irreversible.
Damaging the kidneys
The two most common causes of CKD are diabetes and high blood pressure (hypertension).
Too much glucose in your blood damages the kidney’s filters, and over time, they are not able to properly filter wastes and extra fluids from your blood.
Hypertension damages the blood vessels in the kidneys so that they don’t work as well as they should.
Extra fluid in the blood vessels may then raise your blood pressure even more, creating a dangerous cycle.
“Our local data shows that in 2017, we had about 40,000 patients on dialysis.
“We project that in 2040, this figure will rise to 100,000 due to obesity, which can lead to diabetes and hypertension.
“The kidneys will have a higher demand to clear the toxins and they will eventually tire out,” says consultant physician and nephrologist Dr Maisarah Jalalonmuhali.
Unlike your skin, the kidney cannot regenerate itself, thus it continues to slave away and deteriorates gradually.
We often don’t know that it has started to malfunction unless a blood and urine test is carried out.
Imaging procedures such as an ultrasound or an X-ray, may also be carried out if a kidney problem is suspected.
There is also no way of knowing which kidney is deteriorating first as the GFR is an estimate of both kidneys.
When a patient develops kidney problems, they’re not as “sick” as those with lung or liver failure.
Neither is there any pain unless the problem is due to a stone or urine reflux (backflow of urine).
“Your blood results may show normal readings, but you may experience symptoms such as water retention, leg swelling, nausea, vomiting, itchiness, etc.
“These are non-specific symptoms, that’s why we are unable to detect kidney disease earlier, unless it is due to nephrotic syndrome with protein or blood leaking into the urine.
“If there is no underlying problem, you can still get CKD from autoimmune disorders or polycystic kidney disease – an inherited disorder in which clusters of cysts develop within your kidneys, causing them to enlarge and lose function over time.
“The speed of deterioration depends on your risk factors, so we usually aim to slow down the progression.
“When the patient’s GFR estimate is between 15-20ml/min, we start preparing them for renal replacement therapy,” she explains.
Renal replacement therapy includes conservative care, dialysis or a kidney transplant.
Types of dialysis
Basically, there are two kinds of dialysis.
In haemodialysis, blood is pumped out of your body into an artificial kidney machine, which removes waste and extra fluid from the blood, and returned to your body by tubes that connect you to the machine.
This treatment is carried out three times a week, with every session lasting around four hours.
Peritoneal dialysis is a treatment that uses the lining of your abdomen called the peritoneum, and a cleaning solution called dialysate, to clean your blood.
Dialysate absorbs waste and fluid from your blood, using your peritoneum as a filter.
Peritoneal dialysis is done more frequently than haemodialysis, resulting in less accumulation of potassium, sodium and fluid in your body.
This allows you to have a more flexible diet than you could have on haemodialysis.
It’s done four times a day or once at night.
Says Dr Maisarah, “It takes roughly 20 to 40 minutes to do the peritoneal dialysis treatment.
“We place a Tenckhoff catheter in the abdominal area to extract the toxins from the body.
“There’s a lot more work with this dialysis, but the outcome is better.
“It’s not that difficult – it’s just like having four meals a day.”
Peritoneal dialysis patients are selected based on their lifestyle.
They are mostly active, working adults who are independent and can be trained to do the procedure themselves.
They also have to keep the area clean to prevent infections.
“When the patients reach CKD stage 5 and they are still symptomless, we won’t start dialysis until the GFR is about 7ml/min.
“Studies have proven that there is no benefit to starting dialysis earlier or later,” she notes.
While dialysis can keep patients alive, it comes with a set of problems.
Dialysis makes travelling difficult and some patients require a longer time to recover after a session.
“If the dialysis is not done properly, you can get infections.
“Toxins and fluids can accumulate and stop the heart from functioning. It can be fatal,” says Dr Maisarah.
Apart from fluid and toxin removal, the kidney produces the hormone erythropoietin, which plays a key role in the production of red blood cells that carry oxygen from the lungs to the rest of the body.
Hence, dialysis patients have a list of drugs to take, depending on their underlying diseases, as well as iron infusions or tablets for low haemoglobin levels.
They also have to adhere to food restrictions, e.g. a diet low in sodium, sugar, potassium and fluid.
Long-term haemodialysis treatments cause the blood vessels to become thick and rigid, and along with low haemoglobin levels, this causes the heart to start to fail.
The life expectancy for patients on dialysis is not that great, compared to receiving a kidney transplant.
Malaysian data shows a 55% survival at five years with dialysis, but for transplants, it’s about 90% for 10 years.
While the best treatment for CKD is getting a kidney transplant, the difficulty lies in both getting donors and the unfitness of some patients for the transplant procedure.
Malaysia’s number of deceased donors is small, despite our push to increase the number of organ donors, so most patients have to come with their own living donor, usually family members or their spouse.
Donors who are unrelated to the patient have to get approval from the Unrelated Transplant Approval Committee set up by the Health Ministry, but so far, there have been no applications.
“After death (of an organ donor), the organ harvesting team led by a surgeon will take out the kidney and put it in a solution.
“There is a cold ischaemic time (the time between the chilling of the organ after its blood supply has been reduced or cut off, and when it is warmed by having its blood supply restored).
“The kidney can be kept up to 36 hours, but the shorter the time, the better,” Dr Maisarah says.
Incompatible blood types
In the past, if your blood contained antibodies that reacted to your donor’s blood type, the antibody reaction would immediately cause you to reject your transplant. This would prevent a successful transplant.
Back then, the only option was to identify recipient-donor transplant pairs with compatible ABO blood types.
Over the years, advances in medicine made ABO incompatible kidney transplants possible between certain recipients and living donors.
The option of having a living donor with a different blood type reduced the time on a waiting list for some people, although in Malaysia, most patients still depend on deceased donors for their kidney.
With an ABO incompatible kidney transplant, the recipient receives medical treatment before and after the transplant to lower antibody levels in their blood and reduce the risk of antibodies rejecting the donor kidney.
“For the living donor, it is an elective operation. They get admitted a day before the operation.
“After surgery, they spend the next two days in an intensive care unit for us to monitor them, and by the fourth or fifth day, they are sent to the ward.
“Roughly, they spend a week to 10 days in hospital. They recover quite fast,” says Dr Maisarah.
Patients can have a transplant even a few years after being on dialysis, but the survival rate may not be as good, as the blood vessels would have hardened from calcium and phosphate deposits.
She points out, “There is no time frame on when you should transplant a patient.
“As long as they remain well, are ready with the donor and have all the necessary tests done, we can proceed.
“Our guidelines says anytime the GFR is less than 15, you can do the transplant.
”We can also do the transplant before symptoms occur so that they can bypass the dialysis and use the new kidney to function normally. This is called a preemptive transplant.”
Rejection any time
During the transplant, the patient’s own kidneys are not removed unless there is a need to do so.
This includes cases of polycystic kidney disease where the kidney is so huge that it bulges forward, so that there is not enough space to place the new kidney.
Removing a kidney is technically difficult as it puts the patients at risk of bleeding.
They may need a blood transfusion and may develop antibodies that can cause rejection of the donated kidney in the future.
The majority of kidney transplant recipients will only need to take up to three anti-rejection drugs for life, as opposed to the multiple drugs dialysis patients need to be on.
“This is not your native organ, so your body will try to protect itself against this foreign material.
“Even after a few years, it may realise that something is different and will attack it.
“How long it lasts depends on how well you take care of yourself.
“You cannot miss taking the drugs, not even for a day because it can become inflamed.
“Our median graft survival for kidney transplant is 15-18 years, but some can last up to 30 years.
“If the kidney fails, you can do another transplant. I’ve seen patients with four kidneys, then they go into dialysis,” says Dr Maisarah.
Her advice to take care of your kidneys: stop smoking, avoid sugary beverages and drink more plain water.
“Coffee and tea (not the three-in-one types) are fine, although it’s quite impossible to drink one litre of it a day – it’ll give you migraines and palpitations!
“Avoid supplements when you don’t know what the ingredients are.
“Some people claim their products are good, but remember that it takes more than 10 years to research and develop a medicine, while supplements enter the market very quickly.
“Some of these can cause side effects to the kidneys.
“Also reduce taking painkillers, as taking them for long periods – for example, when you have gout – can damage the kidneys,” she says.
On taking protein shakes to lose weight or to rebuild and recover after a workout, she says people should do so cautiously.
“I had a gym-going patient who had excessive protein in the urine due to drinking too much of these shakes.
“Once he stopped taking them, his protein levels returned to normal.
“Don’t assume that just because you’re exercising, you should take protein shakes.
“The intake depends on how hard you’re working and how many calories you’re burning a day.
“Generally, a high protein intake is above 1.3g per kg of body weight.
“Do check your urine and blood to ensure your protein levels are not over the limit, ” she says.
With CKD patients on the rise, do consider donating one of your healthy kidneys or become an organ donor so that your organs can help others upon your death.
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