MYTHS AND FACTS ABOUT KIDNEY DISEASE

Myth : All kidney diseases are serious and incurable

Fact : Most kidney diseases are treatable. Some are self-limiting and occur only once in a lifetime. Some progress towards renal failure but this progression can be slowed down if the disease is detected early. Even in late cases, treatment may help in reversing or slowing down the loss of kidney function.

Myth : only one kidney is affected by kidney diseases.

Fact : All medical diseases (high BP, diabetes, glomerulonephritis, nephrotic syndrome, poisonings, infections of urinary tract etc) affect both kidneys.

Some structural diseases like tumours, stones, abscesses, renal artery or vein clots, ureteral narrowings, may affect only one kidney.

Myth : I am passing enough urine. Hence my kidneys are not obstructed.

Facts : Most obstructions of the bladder and partial obstructions of the ureter  (stones or accidental ligation during surgery) cause more urine to be formed and passed. Only bilateral total obstruction or obstruction below bladder neck cause reduced urine output.

Myth : I am passing enough urine. Hence my kidneys are healthy and I do not require treatment or dialysis.

Fact : Some kidney disease cause decreased urine output or oliguria (< 400 ml urine/day). Most, however, are nonoliguric or Polyuric (urine output > 3000 ml/day). Even with normal or large urine production, waste material like acids, potassium, urea, creatinine and many more may not be excreted. A person then may require treatment at times dialysis as well.

Myth : Drinking more water will keep my kidneys healthy. This is the treatment for kidney diseases.

Fact : Usual water intake is well managed by thirst in healthy people. Drinking 2-3 litres of fluid may avoid some stone formations and urinary tract infections. Continuing to drink fluids when kidneys are failing or have failed may cause fluid in the lungs (pulmonary edema) or poor control of hypertension. The consequences may be deadly. Follow your doctors’ advice.

Myth : Dialysis once started is required life long.

Fact : In temporary or reversible renal failure, dialysis is required till kidney recovers. In CKD or ESRD with no reversibility, dialysis is required for emergency treatment of high potassium or fluid in the lungs. Maintainance dialysis for uremic symptoms, neuropathy, encephalopathy, pericarditis etc usually means either lifelong dialysis or renal transplant.

Water Balance

Water Balance

Life on earth began in water. Water is the largest molecular constituent of the body. It makes up for about 60% of the total body weight in males and 55% in females.

It provides a medium for metabolic functions in the body. Enzymatic reactions occur in aqueous media. It maintains the form of cells, tissues and organs, helps in digestion, evacuation of body wastes, maintenance of body temperature, lubrication in joints, prevention of infections and many more such functions.

Water Distribution in the body

Of the total body water, 2/3 is in the cells and 1/3 is extracellular. Of the extracellular water, 2/3 is outside the vascular system and 1/3 is in blood.

Regulation of water balance

The osmolality( a measure of solute concentration in water) is held in a very narrow limit in the human body. This typically is 280 to 295 mosm/kg. If the osmolality increases in the body fluids, a hormone called ADH is produced at the base of the brain. This hormone increases thirst and decreases water excretion in the urine thus restoring osmolality.

If excess water is taken, in healthy humans, it is promptly excreted in urine. Even an intake of 8-10 liters in healthy persons may be tolerated.

Water quantities for balance in the body

Body losses of  water

Water is required for cooling down of the body by formation and evaporation of sweat. About 1 ml of sweat is required for losing .58 ml kcal of body heat. Thus about 400-500 ml of water is used in this way depending on environmental temperature, wind velocity, dryness of air etc. 100 -200 ml may be lost in the formation of stools. Small amounts are also lost in vapour form during breathing.

Kidneys excrete about 800 mosm of daily solutes in salt and electrolytes, urea etc. Since maximum urine concentration in healthy adults is about 1200 mosm, 2/3 litre of water is lost in this way daily.

Gains of water from outside

Apart from water ingested directly in fluids and beverages, water is also contained in food. Some fruits may have almost 100% water while most will have 50 to 60% water content. Thus 500 ml to 600 ml of water is ingested in foods. Water in similar quantity is produced by metabolism of proteins and carbohydrates in the body.

Thus to maintain a balance a minimum of about 600-800 ml of water is required to be ingested in the liquid form. An intake of 1.5 to 3 l is sufficient for most cases for healthy living. In old people a litre more water results in better function of the kidney and bladder.

Kidney Biopsy

Kidney Biopsy

Kidney Biopsy is a procedure in which a very tiny piece of the kidney is removed for examination under a microscope for diagnosis of the kidney disease. It may also inform us about prognosis (future course ) of the disease, severity of disease and suggest ways of treatment. The information given below is relevant for cases of native kidney biopsy.

Indications for kidney biopsy:

When urine shows high levels of protein, RBCs or other abnormalities like casts.

Unexplained acute kidney injury

Some cases of chronic kidney disease

renal transplant dysfunction

The procedure of kidney biopsy:

Patients consent is taken.

Blood group is checked.

Tests are done to see that the bleeding and clotting is normal

Ultrasonography to confirm that both kidneys are

present ,

normal or large,

more or less symmetrical,

there is no stone disease, tumour or cyst etc.

The person is made to lie down on his abdomen with the back facing up. After cleaning the area with antiseptics, the site of biopsy is injected with local anesthetic drugs. After a few minutes, a biopsy needle is gradually inserted till it is lying very close to the cortex of the kidney and the site is confirmed by  USG. Then the trigger is pressed. This inserts the needle for a distance of 10-15 mm in the kidney and a piece of tissue (16 to 18 gauge in core diameter ) is trapped in the needle. The needle is then withdrawn and the site dressed in clean sterile gauze. It is pressed for a few minutes with compression of about 1to 2 kgs and patient then turned to lie on his back. His USG is checked for any bleeding after biopsy and shifted to the ward.

He is kept under observation for 24 hrs (sometimes only 6 hrs) for any complications. If none, he or she is discharged and called to attend the hospital with biopsy report.

Processing and transport of biopsy:

The tissue is sent in formalin/ glutaraldehyde or cold saline for different tests. It is usually seen by light microscope and immunofluorescent staining and if available, electron microscopy.

Risks of kidney biopsy:

The common risk is bleeding. It occurs in most cases but usually is insignificant. If a large amount of blood is lost, patient may require blood transfusion and rarely if bleeding is not controlled, the kidney may have to even be removed. Nowadays such occurrences are rare.

The biopsy site or kidney may get infected, lacerated and even deaths after biopsy have been reported. The risk of death is about 1in 1000 to 1 in 10000 at various centers.

Our Kidneys

Our Kidneys

Common Questions

  • Are both my kidneys affected?

Ans. Most diseases involve both kidney diseases simultaneously. Exceptions are obstructions in one kidney or ureter, the tumor of one kidney, injury to one kidney or ureter, infections confined to one kidney etc.

However, some people may be born with only one kidney!

  • Have both my kidneys failed?

Ans. If the urea and creatinine are high, it means both kidneys are functioning less. If one kidney function is normal, urea and creatinine are usually not elevated.

  • Will the kidney function recover with dialysis?

Ans:     Dialysis does not improve kidney function. It is a substitute for some of the kidney functions. In acute kidney injuries, dialysis may buy time and allow the kidneys to start functioning again. In Chronic kidney disease, unless there are some reversible elements, the kidney function will not only not recover but the residual function will also decrease with time.

  • Do kidney donors lead a normal life? Can they do heavy work?

Ans:     After the nephrectomy operation, recovery takes about 2 to 3 months. Once the muscle scars have healed well, the donors can lead a normal life.

Pain Killers and Kidney

Pain Killers and Kidney

Analgesics (pain killers) are one of the most important causes of permanent kidney damage. These drugs are grouped as NSAIDs or Non-steroidal anti-inflammatory drugs.

In European countries these form one of the commonest cause of CKD in countries like Belgium, Sweden, Australia and US. With greater awareness of this problem, the incidence is decreasing in the western world while more and more cases are being diagnosed in India.

The vultures, hawks, and raptors, crows and similar birds are on the verge of extinction. A theory postulating the cause of this decline in their numbers is consumption of carcass of dead animals fed analgesics for fattening and milk productions. The analgesics remaining in the dead tissue causes kidney failure in these birds resulting in their premature death.

The commonest drug implicated is phenacetin in combination with aspirin and codeine. Combination drugs are more likely to cause kidney damage. Ingestion of 1000 to 5000 tab is sufficient to cause permanent renal damage.

Most countries have banned phenacetin while in many analgesics are not sold without a prescription.

The disease is more common in a woman suffering from a headache, arthritis or a backache. Psychological dependence and abuse of analgesics is a common problem. This causes further abuse of the drugs and often denial of the same. Underestimation of analgesic abuse is common.

These drugs may also cause edema of feet, high blood pressure, atherosclerosis of blood vessels and damage to the stomach and intestines. These have also caused urinary bladder tumours of malignant variety.

The kidney damage starts in the tip of filtering system called papilla. These are may become thick, calcified and may break off (papillary necrosis). This is a result of less blood supply to this area of the kidney.

Additionally, NSAIDs may also cause AKI (acute kidney injury) by a mechanism akin to allergy.

These diseases can be prevented by limiting analgesic usage to only situations where medically needed while keeping a watch on dosage and regular monitoring of kidney function.

Immunosuppression after Kidney Transplant

Immunosuppression after Kidney Transplant

The drugs are always taken on the advice of a physician experienced in dealing with transplants. Patients should never change doses on their own. Stopping of drugs may result in acute rejection and damage to or loss of the kidney. Usually three drugs are given. These are required to be taken lifelong.

The medicines may be Tacrolimus/ cyclosporine.

Older patients of functioning transplants may be on cyclosporine. These drugs are similar and called Calcineurin inhibitors. These drugs have a no of interactions with other drugs. Simultaneous intake of other drugs may increase or decrease the levels of these drugs.

Some common side efftects of CNI inhibitors are tremors, high BP, increase in urea and creatinine( due to kidney dysfunction) , swelling of the feet and high blood sugars. These also increase chances of infections.

Cyclosporine can also increase body hair, facial hair, or hair from the ears. This is called hirsutism and may be very unpleasant side effect in ladies. The dosage of these drugs are based on their blood levels which need to be checked periodically.

Azathioprine or mycophenolate.

These drugs are the other commonly used immunosuppressives. They may decrease blood cell formation (WBCs or RBCs or platelets or all three togather. They can also increase infections in the transplant recipient. Mycophenolate may cause abdominal cramps, diarrhoea or constipation.

These are expensive drugs and the blood levels are not easily available.

The interactions are fewer with other drugs.

Steroids

This is an important component of the immunosuppressive regime.

These drugs are started at very high levels in the 1st few days and rapidly reduced.

Though very effective in its action, these drugs are full of side effects. These drugs may cause weight gain, high sugars, high BP, dyslipidemias, behavioral disorders, hirsutism, rounding of the face, muscle weakness and sleeplessness. They can also cause bone weakness and increase chances of infections as do the other transplant medicines.

The drugs are always taken under medical supervision and sudden changes or stoppage of the drug may be catastrophic.