Have you or your loved ones been affected by Kidney Disease? Do you want to know more about this condition?
This guide talks about the basics of kidney disease and how it is categorised, as well as the causes, risk factors, complications, symptoms and tests needed to diagnose Kidney Disease in Sri Lanka. It also touches on how to make changes in your lifestyle, what you can do to look after your kidneys and the various treatment options available in Sri Lanka.

The basics – what do our kidneys do?

Our kidneys are two bean-shaped organs that are the size of a fist, located in the middle of your back on each side of the spine. They are situated above the waist and just below your rib cage, with the left kidney a little higher and larger than the right. When dealing with our kidneys, we often come across the terms ‘renal’ and ‘nephrology’; these are common medical terms associated with our kidneys.

Our kidneys play an important role in our body, with several functions that are essential to life. The kidney’s main job is to filter and clean our blood – it does this by removing wastes and extra water to make urine. Each kidney has one million tiny filtering units inside called nephrons, where all the cleaningof blood and production of urine occurs. Urine then flows from the kidney to the bladder, which is then passed out of the body.

In addition to cleaning our blood and producing urine, our kidneys help control blood pressure and make important substances that our body needs to stay healthy. The kidneys balance the amount of fluid content in the body, which in turn helps control pressure. They also produce the enzyme renin, which helps maintain proper blood pressure. The kidneys control the level of important minerals in our body such as sodium, phosphorus, calcium and potassium, which are useful to help our body systems work well. Finally, our kidneys produce the hormone erythropoietin to help make red blood cells, and help activate vitamin D to maintain healthy bones.

What is kidney disease?

Kidney disease occurs when our kidneys are unable to perform their functions properly. Our kidneys are no longer able to remove waste products and extra water from the blood, which ends up building up in the body, causing several complications. Kidney damage and decreased function that lasts longer than three months is called chronic kidney disease (CKD). This is a very serious condition, because patients may not have any symptoms until severe kidney damage, which is incurable, has occurred. With CKD, our kidneys do not usually fail at once – instead, CKD usually progresses slowly over a period of years. If CKD is caught early, medicines and lifestyle changes may help slow its progress.

There are five stages of CKD, with stage 1 being the mildest and stage 5 the most severe. These stages are defined by the National Kidney Foundation, and are accepted by nephrologists in Sri Lanka and across the world. This helps improve the quality of care for people with kidney disease, as each stage requires different tests and treatment.

StageDescriptionGFR (ml/min)
1Kidney damage with normal GFR; slight blood or protein in urine>90 (normal)
2Mild kidney damage with mild decrease in GFR60-89
3Moderate decrease in GFR30-59
4Severe reduction in GFR15-29
5End Stage Renal Disease<15

*GFR is a blood test which indicates kidney function; as chronic kidney disease progresses, your GFR number decreases.

What are the causes and risk factors of kidney disease?

Kidney disease affects several millions of people worldwide every year, including Sri Lanka. Approximately 1 in 10 people around the world have been diagnosed with chronic kidney disease, and even young people are susceptible to it. The main causes and risk factors of kidney disease are diabetes and high blood pressure (also known as hypertension).

Bacteria, allergies, kidney stones (build up of mineral deposits in nephrons), tumours and toxic chemicals are possible sources of kidney damage. Kidney inflammation (glomerulonephritis), diseases such as polycystic kidney disease (PKD), autoimmune diseases and birth defects can also cause kidney disease. Other factors that may increase the risk of CKD include aging (people over 65 years old have increased risk), heart disease, smoking, obesity, high cholesterol, genetic predisposition and family history of kidney disease.

What is CKDu in Sri Lanka?

In Sri Lanka, chronic kidney disease of unknown aetiology (CKDu) has become a major health issue over the past two decades. This is a different form of kidney disease, which is NOT associated with conventional risk factors such as diabetes and hypertension. The root cause of CKDu has not been definitively established yet – hence it is referred to as ‘CKD unknown/uncertain aetiology’. Initially affecting several rural communities around North Central and Uva Provinces of Sri Lanka, CKDu is now prevalent in North Western, Eastern, Southern and Central provinces, and parts of the Northern Province of the island.

According to the World Health Organization, approximately 15% of the population in Anuradhapura, Polonnaruwa and Badulla Districts between the age group 15-70 years are affected by CKDu. Although majority of those affected are male paddy farmers and agricultural labourers, there are now a growing number of women and children being affected by CKDu. The WHO believes that this unknown CKD is an environmental-exposure disease caused by multiple factors such as chronic exposure to kidney damaging pesticides, arsenic, lead, cadmium, poor diet and genetic susceptibility to kidney failure. It is also in Nicaragua, El Salvador & even India. It is now being increasingly recognised as chronic agrochemical related Kidney disease.

What happens in kidney failure?

In the first few stages of kidney disease, our kidneys are still able to regulate the balance of fluids, salts and waste products in the body. As kidney destruction continues, there is a reduction in kidney function, which leads to several problems and complications. Stage 5 CKD or End Stage Kidney Disease is essentially referred to as kidney failure. At this advanced stage, the kidneys lose nearly all their ability to do their job properly.

In most cases, kidney failure occurs after several years of having CKD, since this is a gradual process. In certain situations, acute renal failure can occur as denovo or top of CKD – this is when our kidneys fail suddenly, often due to a drug allergy or poison or Snakebite , or severe blood loss or trauma. Whichever the case may be, a person with kidney failure requires dialysis or a kidney transplant to stay alive.

What are the complications of kidney disease?

During kidney failure, several harmful effects occur throughout the body. Potential complications include:

Fluid build up (oedema): Fluids and salts build up in the body, which causes swollen arms and legs, high blood pressure and fluid in the lungs, which subsequently leads to heart failure.

Anaemia: Since the kidneys are unable to make the hormone erythropoietin, which is vital for red blood cell production, patients start to feel weak, have pale skin and easily become tired.

Heart and blood vessel disease (cardiovascular disease): CKD speeds up the hardening of arteries, which increases the risk of stroke, heart attack and heart failure. Heart disease is the most common cause of death in people with kidney failure. Also, a sudden rise in potassium levels could affect your heart’s ability to function.

Weak bones: Irregular levels of calcium, phosphate and vitamin D can lead to bone disease and an increased risk of bone fractures.

Toxic build up: Failure to remove waste products results in the build up of toxins in blood, which are poisonous if they reach high levels. This is referred to as uremic syndrome and affects many parts of the body including the nerves, intestines and heart. Patients experience tiredness, difficulty concentrating, nausea, vomiting, lack of appetite and insomnia due to this.

What are the symptoms of kidney disease?

In the first stages of chronic kidney disease, there are no obvious symptoms since the kidneys are able to compensate for lost function for several years. Many people in Sri Lanka who have kidney disease do not know it until they are already very sick and have sustained irreversible damage. Knowing symptoms associated with kidney disease can help people detect CKD as early as possible in order to get proper treatment.If kidney disease is found and treated early, this can help slow down the progression of kidney disease to later, incurable stages (4 or 5).

Symptoms include:

 

    • Changes in urine output, frequency and colour
    • Swelling of legs, ankles, feet, face or hands
    • Fatigue and exhaustion
    • Persistent itching, nausea, vomiting
    • Metallic taste in mouth
    • Shortness of breath and chest pain
    • Back of flank pain
    • Loss of appetite
    • Dizziness
    • Sleeping problemsIf you or someone you know has one or more of these symptoms of CKD, it is important to see a doctor for further blood and urine tests. Since the symptoms of kidney disease are not specific – they can also be caused by other illnesses – the only way to know the real cause of your symptoms is by seeing a doctor.

      How is kidney disease diagnosed?

      In Sri Lanka, three simple tests are used to help detect kidney disease – Glomerular filtration rate, blood pressure and urinalysis.Glomerular filtration rate (GFR): This is a useful method to determine kidney function; it tells us how well our kidneys work to remove waste products from the blood. The higher the GFR level the better; GFR lower than 60 mg/ml is an indicator of kidney disease. GFR is calculated based on the results of a blood test for serum creatinine and factors in gender and age. High blood levels of creatinine and urea suggest kidney disease. More Sophisticated test called Bio impedance is a useful follow up test to monitor progress.

      Blood pressure: High blood pressure is a cause, result and an indicator of kidney disease. A blood pressure of 140/90 mmHg or higher is referred to as high blood pressure.

      Urine tests: This test checks for the presence of protein, blood and other components in urine. Normally, protein and blood cells are not present in urine. Having protein in urine is one of the earliest signs of kidney disease. For those that have diabetes, microalbumin levels in urine should be determined.

      Based on these basic screening tests, if there are any signs of kidney disease, then patients are referred to a nephrologist – a kidney disease specialist. Special imaging tests or biopsies can be performed if necessary to help determine the cause of the kidney problem. The nephrologist will then evaluate and prescribe medications or lifestyle changes to help slow the progression of the disease.

      Is kidney disease contagious?

      No, you cannot catch kidney disease from someone who has it. Most kidney disease is caused by diabetes, or high blood pressure – which are conditions that run in families. If you have a family history of diabetes, high blood pressure or kidney disease, then it is important to have regular checkups to ensure that you are healthy. Diabetic Kidney Failure has a Familial tendency to occur.

      It is important to note that lifestyle also has an impact on diabetes and high blood pressure, and ultimately kidney disease. Factors such as smoking, drinking alcohol, lack of exercise, unhealthy eating and insufficient water intake cause harm to our kidneys; therefore care should be taken to follow a lifestyle that lessens the chance of sickness.

      How to prevent kidney disease?

      The best way to keep our kidneys healthy is to reduce our risk factors. Whilst certain risks cannot be avoided, such as aging, family history of diabetes/hypertension, or genetic propensity to kidney disease, other factors such as lifestyle choices will help keep our kidneys healthy. It is possible to reduce your risk of chronic kidney disease by:

      • Avoiding alcohol or drinking in moderation
      • Maintaining a healthy weight for your height by daily physical activity and reducing calories
      • Quitting smoking
      • Managing medical conditions such as diabetes, hypertension and unhealthy cholesterol levels which increase the risk of kidney disease
      • Getting regular kidney disease tests for patients who are at risk
      • Cutting down on salt, red meat, sugar sweetened drinks, processed foods and sugar
      • Avoiding excessive use of certain medicines such as aspirin and ibuprofen. Always follow instructions with over the counter medication especially long term pain killer use and take medications as prescribed by your doctor.
      • Eating fresh fruit and vegetables
      • Drinking 8 glasses of water a day


How is early kidney disease treated?

Kidney disease is usually a progressive disease – this means that damage in the kidneys tends to be permanent, and cannot be undone. Although there is no cure for chronic kidney disease, there are various treatment measures to help control symptoms, reduce complications and slow the progression of the disease. If kidney disease is found early, medication, dietary and lifestyle changes that are prescribed by your doctor can help slow down the progression of kidney disease and increase the life of your kidneys.Typical medicines include high blood pressure medications such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers to help lower pressure and preserve kidney function, diuretics (water pills) to help your body get rid of excess water and salt through urine, and statins to help lower cholesterol levels. In addition, medications to alleviate symptoms such as anaemia, swelling and weak bones are also given.

Dietary changes such as a low protein diet (vegetables, fruits, breads and cereals) are essential for patients suffering from kidney disease as it helps minimize waste products in the blood. Depending on your kidney function and overall health, your doctor may recommend that you avoid products with added salt and choose lower-potassium foods rather than high-potassium foods. Avoiding high protein foods such as lean meats, milk, cheese, eggs and beans and high-potassium foods such as bananas, spinach and potatoes is recommended.

Lifestyle changes such as exercising regularly and avoiding smoking and drinking alcohol are also part of treatment. If you already have diabetes and high blood pressure, then it is important to keep these conditions under control to stop them from causing further damage to your kidneys.

What are treatment options for kidney failure?

At the end stages of kidney disease (stage 4 and 5), your kidneys can no longer clear waste and fluid on their own. This is complete or near-complete kidney failure – at this point, dialysis or a kidney transplant is needed.

Dialysis is an artificial method to remove waste products and extra fluid from the blood. It uses a special solution(dialysate) that contains a mixture of pure water and chemicals to carefully remove waste, salt and excess fluid from the blood without removing important substances. This way, the level of certain chemicals in the bloodstream, such as potassium, can be kept at normal levels. In Sri Lanka, there are two types of dialysis available – hemodialysis and peritoneal dialysis.

What is hemodialysis?

In hemodialysis, blood is pumped out of the body by a special machine and is filtered through a dialyzer, which cleans out toxins that your kidneys can no longer remove. A dialyzer is often referred to as an artificial kidney, and consists of thousands of special filter tubes made of a semi-porous membrane. These filters are surrounded by dialysis solution, which is useful for filtration. Small waste products are pushed into the solution, whilst blood cells and important blood components remain in the blood. The clean filtered blood is then pumped back into the patient. To perform hemodialysis, an access point needs to be created to get blood from the body to the dialyzer and back to the body.

Depending on your doctor, schedule and budget, your dialysis treatment schedule in Sri Lanka can vary. Usually, hemodialysis at a dialysis centre during the day is conducted three times a week, with each treatment session lasting 3-4 hours. Dialysis can also be performed at home (home hemodialysis) or in a dialysis centre overnight while you sleep (in-centre nocturnal hemodialysis).

What is peritoneal dialysis?

In peritoneal dialysis, the cleaning of blood takes place inside the body in your abdomen (belly). A soft permanent tube, called a catheter, is placed in the abdomen by minor surgery. This enables you to easily connect to special tubing which allows dialysis solution to flow into your belly. The lining of the abdomen (the peritoneal membrane) acts as a natural filter, and it lets wastes and extra fluid in the blood pass through it into the dialysis solution. The lining also holds back important things that the body needs such as blood cells and nutrients.

The dialysis solution stays in the abdomen for two hours or more, after which it is drained from your body into an empty bag which is then discarded. This process is repeated a number of times during the day using fresh dialysis solution. This process is called continuous ambulatory peritoneal dialysis (CAPD). Although peritoneal dialysis does not need to be done at a medical centre, it is not as efficient at removing waste products as hemodialysis is. Also, there is a risk of infection due to the presence of a permanent tube in the abdomen.

What should dialysis patients know?

Although dialysis helps patients with kidney failure, it is not as efficient as a normal kidney. Patients on dialysis still need to be careful with their diet and fluid intake, and may also require medication to replace other functions of the kidney, such as maintaining blood pressure and prevention of anaemia.

It is important to discuss and decide the right dialysis option for you with your doctor, based on your lifestyle and medical needs. Dialysis treatment itself is painless. However some people may experience minor discomfort when they are being connected to the hemodialysis machine or at the end of CAPD drain cycle. It may take a few weeks to adjust to life on dialysis, but once you get used to the routine, then you will be able to feel much better physically and emotionally.

What is a kidney transplant?

For many patients with kidney failure, dialysis is only a temporary treatment which keeps the kidneys going until a suitable organ is identified for a kidney transplant. A kidney transplant is an operation where a healthy kidney from a donor is placed in your body. The new kidney takes over the work of your kidneys.Many people feel that a successful kidney transplant provides a better quality of life, as dialysis is no longer required – patients with kidney transplants have greater freedom, more energy and a less strict routine and diet.

During a kidney transplant, a surgeon will place the new kidney in your lower abdomen, and connects the blood vessels of the new kidney to your own vessels. Your blood will then flow through the new kidney, which will start to produce urine. The surgery usually takes 3-4 hours to complete in Sri Lanka.

Since a person only needs one kidney to survive, this means that living people can donate a kidney, and can usually live safely without complications with one remaining kidney. Therefore, transplant kidneys can come from both deceased and healthy living donors.Those that receive a kidney from a living related donor tend to do better than those who receive a kidney from a deceased donor.

Living donors can be related to the person receiving the transplant, such as a parent, brother or sister, or child; or unrelated, such as a friend or spouse, or a stranger who wishes to donate a kidney to anyone in need of a transplant.It is important that the donor and the person receiving the kidney (recipient) have similar tissue and blood group types, to ensure that the body does not reject the organ. People with kidney transplants will need to take medication for the rest of their lives, to keep your body from rejecting the new organ. A successful kidney transplant requires close follow-up with your doctor.

Kidney transplants in Sri Lanka

Sri Lanka has a well established kidney transplant programme that has been running for nearly three decades. The first successful kidney transplant in Sri Lanka was carried out by the Faculty of Medicine (University of Colombo) kidney transplant programme in 1985 – this pioneering team still continues to oversee transplants in Sri Lanka today. Several patients have undergone kidney transplants in both government and private sectors by several teams numbering over 4000

Performing a kidney transplant in Sri Lanka involves several processes: pre and post care and counselling, an excellent medical team, support services, lab services, and proper screening of donors and recipients to ensure legal, medical and social responsibility. Thousands of patients – adults and children – have undergone renal transplantation in both government and private sectors, under the purview of the Ministry of Health. Sri Lanka needs a comprehensive National Organ Donor Program, with leadership given by the ministry, University and interested groups. There is also a need to discourage commercial donations and work towards a national cadaveric donation program. There are early interested in starting liver, lung and heart transplant in the last two years.

 

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