Kidney Problems in Rural Areas
“Nephrology = Dialysis” is like a pneumonic now – but not true. As the scope of a nephrologist is very much at every step of your life. Right from the antenatal study of the fetus, pediatric renal problems to the last stage of every patient lying on a ventilator – the Nephrologist is always the part of the team!
Scope of the Nephrologist:
Pediatric Urinary issues - Enuresis, Stones, Proteinuria, Hypertension
Diabetic Kidney Disease
Acute/Chronic kidney injuries secondary to Urological issues
Acid base balance - HPP, RTA
Cardiac & Radiological issues
Urinary problems - Chronic dysuria, Genito Urinary Koch’s
Chronic geriatric care with renal issues
Permanent / Long term Hemodialysis Catheter insertion
Renal Pregnancy issues – HUS, TTP, PIH, Septicemia/DIC
Malignancy & Kidney – RCC, Cervical malignancies, Myeloma
Late diagnosis or Late referral or both! Usually the time of referral to a Nephrologist is very late, already when the creatinine is very high. So early referrals have good chances of easy/early recoverability from renal damage. However, suspecting a renal problem even prior it overtly manifests is of prime importance.
So the important question - When to suspect a renal disorder in daily OPD?
· Diabetic patient developing new onset HTN, even if Creatinine is Normal, is itself a warning sign.
· Every Proteinuria should be evaluated as chronic protein loss also leads to Chronic Kidney Disease whatever the primary cause of proteinuria.
“A good urine examination is like a poor man’s renal biopsy.” So finding atypical findings on the Urine routine should raise suspicion like casts, RBCs, protein in every case, Urine Sugar in non diabetic patients.
DON’T RELY ONLY ON CREATININE VALUE in other words Normal creatinine doesn’t mean 100% normal renal function, it’s as saying a normal ECG doesn’t rule out a coronary block!
· Creatinine depends on muscle mass, exercise, non veg diet
· Starts to rise after 50% of renal function deteriorates
· In sepsis rise in creatinine is late
The Indian Renal Scenario: The estimated 2019 population of India is 1,362,255,678, a huge number in which - 800 people per 10 lac have renal problems – looks quite a small amount of population. However one lac patients per year enter renal replacement therapy every year either hemo / peritoneal dialysis or renal transplant.
What effects your kidney? The basic problems in rural areas is lack of knowledge of urinary hygiene in females, high TDS water intake leading to stones, heavy consumption of painkillers (NSAIDs) for joint aches, use of “home remedies” for curing daily ailments, quack consultation & late consultation with a proper doctor. All these contribute to a huge amount of neglect, late presentation of disorders & delay in proper management & diagnosis, leading to higher chances of chronicity & irreversibility (permanent damage).
Drugs affecting kidney: All drugs affect renal function, so moderate use of drugs is the key, prevention is always better than cure.
NSAIDs: 13% of them cause renal failure/injury, this injury is not dose related i.e. it can also occur to a person who is already taking it for years long & on the other hand also to a person who has taken it for the first time, mainly it remains hidden in history & hence goes unnoticed. All NSAIDs are known for this effect & there is NO “SAFE” NSAID.
Aminoglycosides, Amphotercin B, AKT – all require Renal dosing & can cause a substantial damage to the kidneys.
Nutrition in CKD:
Renal nutrition is a vast topic, it depends on the stage of CKD. Grossly the protein intake & water intake are targeted. Higher the stage of CKD lower the protein intake, exception is for dialysis patient where higher amounts of protein is advised. Water restriction/liberation depends on many factors like the patients cardiac function, residual renal function, urine output, etc.
Anemia in CKD: Anemia correction is of prime importance, it helps in overall improvement, immunity, cardiac function of the patient. Regular dietary changes for anemia do not help CKD patients gain rise in Hb. Basic problem lies in Erythropoietin deficiency. So EPO injections as advised along with Iron & B complex is crucial in maintaining Hb level.
Hypertension Control: Reduces the risk of Caridac (Chronic & Acute) & Neurological complications.
Regular dialysis: Thrice a week dialysis in all patients is much more natural, helps in avoiding chronic uremic complications, reduces bone disorders, cardiac complications, etc.
CKD Stage V – “Is it the end of life?”
Why people don’t want dialysis- “Gets Habitual to dialysis” – usually heard every time, but is a misnomer – now a days the quality of dialysis, hygiene, technology – has great longevity on dialysis dependent patient as long as 13-15 years in patients who take dialysis as advised.
Longevity on dialysis: Patients taking dialysis as advised have a longevity of almost 12-15 years of good life span, this is contributed by regular use of Erythropoetin, Iron-B complex, Nutrition, High protein, Early AV Fistula or Permanent Dialysis Access has shown to improve life span in dialysis patients.
The Author: Dr. S N Devdikar, is a practicing Nephrologist, has expertise of over 20,000 dialysis since 2014 at Devdikar Medical Centre which is an ISO 9001:2015 Certified Centre, 35 bedded hospital facility inclusive of Dialysis (12 bedded), Intensive Care Unit (10 bedded), equipped with Operation theatre & Ultrasonography center in service since 1982, attached with fully operational Laboratory services & Medical store with Nephrology, Urology, Obstetric-Gynecology, Critical Care & General Medicine specialties along with MJPJAY National Insurance.
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