Chronic Kidney Disease (CKD) is increasing in India by epidemic proportions. Globally, one in every ten individuals is affected by CKD. The 2016 Global Burden of Disease reports an 87 per cent rise in the global burden of CKD and a doubling of CKD deaths between 1990 and 2016.
CKD is a condition characterised by chronic (> 3 months) urinary abnormality (protein or blood loss) or chronic reduction in kidney function (< 60 per cent). Diabetes and hypertension are the major reasons for developing this condition. Other causes include autoimmune diseases, hereditary kidney diseases like polycystic kidney disease, kidney stones and abuse of painkillers called non-steroidal anti-inflammatory drugs.
Rising incidence in youngsters
The urban population is more affected by CKD owing to the rise in lifestyle diseases. A recent survey conducted to analyse factors contributing to CKD in the urban population found that 40 per cent of the CKD cases were due to diabetes, 20 per cent due to hypertension and the rest owing to other causes mentioned above. In about 25 per cent of the cases, the causes are unknown. Youngsters today have a fast-paced lifestyle, as a result of which the age a person can develop CKD has become 40-50 years instead of the earlier 50-60 years.
Management of CKD includes treatment of the primary cause, if known, and treatment of complications associated with CKD, which include hypertension, abnormalities in volume and composition of body water and anaemia (low haemoglobin). Diet modification is also important and should be initiated at an early stage. The most common dietary modification is protein restriction, as the kidney's main function is to eliminate waste products of protein breakdown. It must be stressed that treatment including dietary modification must be individualised as complications of CKD vary from case to case. When kidney function is significantly reduced (<5 to 10 per cent), renal replacement therapy becomes mandatory. This stage is called end stage kidney disease (ESKD).
Treatment options for ESKD
There are three options: haemodialysis, peritoneal dialysis and kidney transplant.
In haemodialysis, blood is pumped out of the patient’s body to an artificial kidney to clean out the impurities. Patients will have to undergo the procedure thrice a week, with each session lasting three to four hours. It can be taxing for patients owing to the constant visits to the haemodialysis centre. It is worse for people in remote areas, with limited access to such centres. In peritoneal dialysis, a synthetic tube is placed in the peritoneal cavity of the abdomen. A cleansing fluid called dialysate is introduced through the synthetic tube and allowed to remain in the peritoneal cavity for six to eight hours. During this period, waste products and excess water from the blood diffuse into the dialysate, which is then drained out and fresh dialysate is introduced. This procedure is carried out three to four times daily. Peritoneal dialysis is simpler as it can be done at home or office and, therefore, involves limited lifestyle interruptions. It can even be done overnight, while the patient is asleep, with the help of a machine.
Kidney transplant provides better quality of life, longer survival and is more cost-effective in the long run. However, getting a suitable donor (living or deceased) is a challenge. Less than 5 per cent of patients developing ESKD are able to undergo kidney transplant.
Peritoneal dialysis: a boon for CKD patients
The outcomes of patients who receive haemodialysis or peritoneal dialysis are very similar, although some patients may be better suited for one modality compared to the other. For example, peritoneal dialysis has various advantages like no haemodynamic instability. Further, as there is no blood loss, haemoglobin is better maintained. The diet is more liberal, as this is a daily process and patients can perform this in the comfort of their home. This is a more suitable option for patients with high blood pressure and heart ailments as it allows removal of excess fluid in a gentle manner, thereby reducing stress on the heart. Moreover, peritoneal dialysis is very helpful for patients living in remote areas with limited access to haemodialysis facilities. Cost of peritoneal dialysis is similar to haemodialysis. With the Insurance Regulatory and Development Authority recommendation to insurance firms to include peritoneal dialysis in their policy, we see a scope for more patients being able to avail of peritoneal dialysis facilities in the future.
Challenges in managing CKD
The real challenge with managing CKD is the availability of treatment. On an average, only 20 per cent of the urban population and less than 5 per cent of the rural population get treatment facilities for CKD. Haemodialysis is availed of by only 8 to 9 per cent of the population and peritoneal dialysis only by 2 to 4 per cent. Less than 5 per cent people can avail of transplant as a treatment option. This brings to the fore the need to address the gap in treatment. Health is a state subject, and states like Andhra Pradesh and Telangana have a Jeevandayee scheme for addressing the needs of CKD patients. India should be more preventive than curative and address the looming epidemic of diabetes and hypertension to curb the growing incidences of CKD affecting India’s young population.
Shah is a nephrologist at Global Hospitals, Mumbai.