Dr. D.K.AGARWAL, SENIOR NEPHROLOGIST APOLLO HOSPITALS, NEW DELHI.

Do you know that in our country there are approximately 5 lakh people suffering from total kidney failure and every year approximately 1 lakh people are added to this growing list. It means that out of every 2000 family, 1 family is suffering from this disease. Out of these only 6000-8000 people get treatment, which constitutes only 1-2% of the people suffering from this disease.

Now the question arises why do so less people get treatment ?

Although there are many reasons, the main ones are:

1. The common person does not have sufficient information about kidney related ailments.
2. There are very few fully equipped hospitals in our country to treat these types of patients.
3. People are not able to gather enough finances to get the treatment done.

Now lets study in detail about kidney and its related ailments so that everyone can undertake precautions.

What is kidney?

- Kidney is that organ of our body, which helps in purification of blood and also removes toxic
  materials from our body through urine.

- Each human being has two kidneys, which are connected to the urinary bladder through the
  ureter.

Where are the kidneys located?

- Kidneys are located on both sides of the spinal cord, above the waist and behind the stomach.   Each kidney is fist-sized.

- Each kidney is10-12 cm long, 5-6 cm wide and 3-4 cm thick and weigh approximately 150 gm.

Functions of kidney:

Our kidneys purify around 1500 litre of blood and convert it into approximately 1.5-litre urine per day. 1200ml of blood flows through both the kidneys per minute and out of it 1 ml of urine is formed per minute.

Formation of urine:

1000-1200 ml /minute                    Blood goes into kidneys.
100-120 ml /minute                       Filterate (after being filtered goes into tubules).
1-1.2 ml /minute                           Urine comes out of the body, rest is absorbed in
                                                   blood via tubules.

- Through the filtration of blood, dirty and harmful substances such as urea, creatinine etc are   thrown out of the body.
- Kidneys regulate the amount of water in our body. Therefore when the kidney fails, the entire   body starts to swell.
- Regulates the blood pressure and keeps the BP within normal range.
- They convert vitamin-D from 25-Dihydroxy cholecalciferol to 1:25 Dihydroxy cholecalciferol,   which absorbs calcium from intestine and makes our bones strong.
- Kidneys also help in formation of the red blood cells (which are formed in bone marrow) by   releasing erythropoietin hormone.

Now the question arises how do such trivial organs perform such heavy-duty work.

- Our kidney constitutes lacs of filters and 140-mile long tubules in approximation. The main   functional unit of kidney is nephron. Each kidney comprises approximately 10 lac nephrons.
- Filters filter the blood and the filtered blood is sent to the tubules.
- The tubules reabsorb useful substances such as sodium, potassium, calcium etc from the   liquid and approximately 1.5 litre urine comes out from the body.

How do kidneys get damaged?

There are many reasons for kidney failure but the prominent ones are the following:

1. Diabetes Mellitus.
2. High Blood Pressure.
3. Some medicines such as taken for reliving pain(pain killers) and other unnecessary     medicines.
4. Dehydration that is less amount of blood and water in the body due to vomiting, cholera and     diarrhoea etc.
5. Inflamation of filters of the kidney due to which proteins are lost in urine and this process is     called Glomerulonephritis. Healthy kidney does not allow proteins go in urine.
6. Formation of stones in kidney and urinary system.
7. Obstruction in the flow of urine.

Types of Kidney Failure

There are three main types of kidney failure
1. Acute Renal Failure - This can be treated and cured as the kidney is in diseased state for a short time, which results in reversible damage. Its causes include reduction in level of water in body (dehydration) due to cholera, excessive diarrhoea and vomiting, low blood pressure, side effects of medicine and infection etc.

2. Chronic renal failure - This can be treated but cannot be cured as the kidney is in diseased state for a long period, which results in irreversible damage. Its causes are diseases like long duration of uncontrolled diabetes, high blood pressure, swelling of membrane etc. It requires life-long dialysis or kidney transplantation.

3. Nephrotic Syndrome - Proteins are lost from the kidney in urine, which leads to swelling up of body and eventually results in kidney failure.

What are the symptom of Kidney Failure?

- Even if one kidney is removed from a person, the person can still lead his life with the other   healthy kidney.
- Symptoms of kidney failure develop when both the kidneys are damaged. The following can be   some of the symptoms:
1. Swelling of the body.
2. Decrease in appetite.
3. Recurring vomiting or nausea.
4. Reduction in blood haemoglobin level (anaemia).
5. Weakening of bones (osteoporosis).
6. Fatigue/ weakness.
7. High blood pressure.
8. Reduction in urine formation.
9. Breathlessness.

How to prevent a healthy kidney from being damaged?

- Increase in intake of water / take plenty of oral fluids.
- Control diabetes and high blood pressure if you are suffering from them.
- Take pain relieving medicines only when absolutely necessary and not more than the    prescribed limit.
- Don't take medicines, which are not required /avoid unnecessary medication.
- If you feel you have symptoms of kidney failure, consult a nephrologist immediately because   kidney ailments can be cured only if treatment is done at the earliest.
- Delay in getting the treatment increases the chances of the kidneys lending in irreversible   damage.

Cure and treatment for kidney ailments

1. Nephrotic Syndrome- If the amount of protein going into the urine has increased but the kidneys haven't been damaged then it can be cured with the help of medicines and putting proper restrictions on the diet as advised by a kidney specialist. To prevent the disease from further spreading, one should undergo kidney biopsy so that the correct disease can be detected and treated and the kidneys can henceforth be spared from getting damaged.

2. Acute renal failure - If the person is suffering from acute kidney failure caused by cholera, infection etc then the chances of recovery are quite good and the patient becomes as fit as before.

3. Chronic renal failure - It is treated in the following ways

(A) By taking proper care of the diet as advised by a kidney specialist.
(B) By preparing an alternative for kidney

Haemodialysis- At least two to three times in a week
                                    or
CAPD- Continuous Ambulatory Peritoneal Dialysis.
                                     or
Kidney Transplantation

Precautions in diet

1. Take less of salt and take liquids including milk, tea, and water according to the amount of     urine.
2. Avoid fruits that are juicy, take fruits that have pulp like apple, papaya, and guava only in     small quantity.
3. Take leafy and green vegetables only after draining the water in which they are boiled.
4. Take fewer amounts of proteins. Pulses, milk etc should not be taken in excesses.(If protein     consumption of patient is high).
5. Take one teaspoonful of oil or ghee in a day.

Haemodialysis
1. The blood is purified by an artificial kidney through a machine
2. In this two needles are used which are inserted in the swollen veins in the same way as a     glucose bottle needle is inserted.
3. Prior to this a small operation is done to join the vein and artery which prepares the veins to swell. Then the swollen veins are ready for needle insertion and this process is called Arterio-
     venous fistula. Maturation pf veins usually tales 2-4 weeks
4. From one needle, the impure blood goes out of body through one tube into the machine and
    the artificial kidney and from the other needle the purified blood comes back into the body
    through another tube.
5. A person gets dialysis done approximately two - three times in a week and each session
    takes about four hours.

Advantages and disadvantages of haemodialysis

Advantages	Disadvantage
1.Each week only 2-3 times haemodialysis has to be done for four hours rest of the days of the week are to work. 2.There is no need of a machine or gadget at home 3.Doctor and paramedical staff attend to the patient	1.Patient has to go to a haemodialysis centre. 2.There is certain restrictions on food and liquid intake. 3.Every time two injections has to be injected in the vein. 4.Sometimes people who have heart problem, diabetes etc and many children are also not able to tolerate haemodialysis well.

CAPD (Continuous Ambulatory Peritoneal Dialysis)

- This type of dialysis is done at home only whether it is a city or a village.
- In this the peritoneum of the abdomen acts as a filter.
- In this procedure, a tube called catheter is embedded on the wall of the abdomen.
- A blood purifying solution is flowed via catheter into the peritoneum.
- The solution absorbs all the toxic and dirty substances.
- This procedure has to be done 3-4 times in a day and the solution also has to be continuously   replaced. It takes approximately half an hour each time.

Automated Peritoneal Dialysis (APD) ·

- This is just like CAPD as described above but it is done through a special machine. This   machine alone costs approximately Rs.1.5 lac.
- In this, solutions and catheter are fitted with the machine at night with a fixed programme. This   machine cleans blood whole night and you can have sound sleep at night.
- There is no need to replace the solution in the daytime.

Advantage and disadvantage of CAPD

Advantages	Disadvantage
1.Patient himself can do dialysis. 2.There is no need to insert needle as in haemodialysis. 3.This type of dialysis is good for patients who have heart disease, diabetes and in small children who are not tolerating haemodialysis. 4.Patient has freedom to go to any place to live or to work. 5.There is relatively less restrictions generally in contrast to other method of dialysis.	1.The dialysis solutions has to be replaced 3-4 times in a day by patient himself. 2.There is more chances of contracting infection and getting peritonitis. Patients who cannot tolerate haemodialysis can opt for CAPD. 3.A catheter is left fixed to abdominal wall permanently,donot like at all. 4.All the medicines, solution and equipments has to be kept stored and ready at home.

KIDNEY TRANSPLANTATION
- In kidney transplantation a healthy kidney is fixed deep below the skin of abdomen infront of hipbone. A donor who is patients near and dear donates the healthy kidney.
- In kidney transplantation matching of blood group between the donor and recipient is must as given below:

If patient's blood group is	Donor's blood group should be
A or O B or O A or B or AB or O O	A B AB O

Matching of Rh factor is not necessary (+ or -) ?

- A healthy kidney can be obtained from two sources:
        1. Live donor-From family members.
        2. Cadaver- From persons who donate their kidney after brain death.
- After kidney transplant the patient is hospitalized for 10 days where as the donor is discharged
  from hospital within 3-10 days.
- After donating a kidney the donor is as healthy as before and lives a normal life.
- After kidney transplant the patient lives a normal life too and can go to his work or run his
   business as before after 2-3 months.
- The expenditure of kidney transplant is approximately 3-4 lac. After the operation medicines
   has to be taken regularly.

KIDNEY TRANSPLANTATION -Advantages and Disadvantages

Advantages	Disadvantage
1.1.Life becomes as normal as it was before kidney failure. 2.No need for dialysis. 3.Patient becomes self-dependent. 4.Patient can take normal diet. 5.Life'routine is as normal as any other man.	1.As there are remote chances of rejecion of transplanted kidney, patient has some tension. 2.Regular medication is required life long. 3.Body's power of defending infection is decreased therefore there is chances of infection particularly in first few months. 4.There can be side effects of medicines rarely.

What are your choices after total kidney failure?

Choices has to be made keeping in mind the following facts:

1. Life style of patient: If patient has field jobs, tour jobs - Kidney transplant is the best choice for him because facility of haemodialysis is not available everywhere.

2. Family condition: Kidney transplantation is the better option even if there is any financial problem because in long term there is less expenditure in comparision to dialysis and CAPD. If one of the family members is capable and dedicated enough for taking care of the patient then CAPD and haemodialysis can be one of better option, in case we are not opting for kidney transplantation.

3. Distance and location of dialysis centre from patient: When dialysis centre is very far then Kidney transplantation or CAPD is the better choice.

4. Home condition: Hygienic home condition is must for CAPD or else there is great chance of contracting infection.

5. Availability of kidney donor: For kidney transplantation, a suitable donor, live or cadaver is must.

6. Is the patient whole and sole earning member in the family? Kidney transplantation is the best option. He can earn his livelihood and look after his family.

7. Doctor's opinion: A kidney specialist helps the patient to choose the best option as he takes in consideration all the problem and diseases the patient is having. For example some patients of diabetes, heart diseases and some children may not tolerate haemodialysis. In these cases kidney transplantation or CAPD is prefered.

8. The emotional status, understanding and attachment of family members with patient: If patient is on CAPD or haemodialysis (2-3 times a week), the family members should be capable and dedicated enough for taking care of the patient. They should have true emotional attachment with the patient. Similarly the kidney donor can donate one of his kidneys to the patient only when donor is having true emotional attachment with the patient.
9. Overall, considering all the pros and cons, kidney taansplant is the best choice untill unless medically unfit followed by heamodialysis and then peritoneal dialysis in some.