When the Kidneys Fail

Published in Panorama


28 year old Saleh visited his physician for a pretty minor problem. As a matter of routine test, the General Practitioner checked his blood pressure. It was abnormally high. He immediately ordered blood and kidney function test. The result was as suspected: everything was deranged in the kidneys and Saleh was diagnosed as having renal failure!

Yes, by far this is the most common presentation of renal or kidney failure – a symptom-less, innocuous state. The kidney has such an amazing reserve of functions, so by the time patients get to perceive symptoms, there is already a fairly significant amount of damage to it, reveals Dr.Babu Shersad, Consultant Physician and Nephrologist, Welcare Hospital, Dubai.

Renal failure may be acute or chronic and occurs when the kidneys stop working. While it is a gradual process many a time, it can also happen suddenly when it takes an acute form, explains Dr.Shersad. “The cause for each, acute and chronic is different. When the kidneys fail acutely over a short period of time, it may be infection-related, drug-induced, when the patient suffers low blood pressure because of bleeding internally or externally, anywhere in the body, or after a crush following a road accident.”

The most important causes of chronic renal failure are diabetes and hypertension, emphasizes Dr.Shersad. “Both conditions can bring on renal failure and if they co-exist in an individual, the effects are multiplied and the damage is faster and more severe. Drug abuse is another leading cause of renal failure and this is brought by prolonged use even of pain-killers and analgesics, like the drugs belonging to the brufen family. One of the most important cause of kidney damage, now identified, is herbs and herbal remedies. There’s substantial data to show a direct correlation between the use of certain herbs and kidney damage.”

Another major category of patients experiencing kidney damage are those with obstructions and outflow problems in the urinary tract, says Dr.Shersad. “An enlarged prostate, kidney stone, bleeding, tumours in the urinary tract can cause damage to the kidneys. Any mechanical problem causing obstruction to the passage of urine can bring on the condition. But it is very important to identify this because many of these conditions are reversible if treated appropriately, and kidney damage can be reversed.”

Speaking on some of the rarer causes of kidney failure, Dr.Shersad reveals, “Malaria and other tropical infections can bring on renal failure. This can be due to the infection per se; sometimes it’s a delayed response to the antigen, it’s an immune process; sometimes it’s just the medication involved in the treatment. All these factors put together can cause renal failure.

Is it possible for children to have renal failure? The answer is in the affirmative. “But the causes are a little different,” explains Dr.Shersad. “Many of them have immune related problems involving the kidneys. Very young children, because of anatomical defects can have blockage in the passage of urine. This can happen even with newborns. These children will have to be evaluated and treated surgically. One of the commonest things for renal failure in children, is the innocuous things like diarrhoea and dysentery. If they are not treated appropriately and if you don’t correct the dehydration in time, they can develop renal failure which can be very severe.”

Is there a genetic or heredity factor involved in renal failure? “Some of these immune diseases can be genetically mediated. If there are other things like diabetes, polycystic kidney disease which runs in families and gets passed on from one generation to the other, it can cause renal failure in adults,” clarifies Dr.Shersad.

How long does it take for a chronic renal failure to build up? “It’s totally individualistic,” emphasizes Dr.Shersad. “While some progress rapidly within months, in others it may take from some months to a few years.”

What are the symptoms of a renal failure? Many a times patients don’t have any symptoms; only on lab testing do we find that the patient is having renal failure. In the initial stages, it can be very much silent, without any manifestations, agrees Dr.Shersad. “Most of the times this is so. The manifestations are simply protean. They can have neurological problems also with a sensation of pins and needles in the legs. There may be loss of appetite and a metallic taste in the mouth.”

“One of the earliest symptoms is fatigue, lassitude, lethargy, malaise, disinclination to work or play. There is excess fluid in the body, swelling of various parts, fluid in the lungs and there can be a variety of electrolyte problems. As the creatinine clearance declines, patients have other symptoms like aversion to a certain type of food, especially non-veg good, swelling in the legs and hands, nausea, vomiting, decreased urine output and volume. Later, when there is associated gastritis and the patients have stomach ulcers, they may even vomit blood. There could also be involvement of the heart which might be rhythm related with slow, irregular heart beats, fluid collection around the heart and chest pain not related to the heart attack.”

What happens if the kidneys fail? The main culprit on such occasions could be the high levels of potassium. It can actually kill if it is very high, reveals Dr.Sherzad. “It’s requirement for the body is so minute that even if it exceeds this normal by a decimal amount, it can play havoc. It can stop the heart from functioning. Normally, any potassium in excess of the body requirement is excreted by the kidneys. So when the kidneys stop working, potassium builds up and remains in the body, creating other problems.”

The importance of the kidneys cannot be ever-emphasized in the scheme of things. “The kidney is very important for sustaining life because it does a whole variety of tasks,” explains Dr.Shersad. “It is involved in the metabolism of the body, it excretes waste products, produces hormones which are necessary to maintain blood pressure and blood counts, to maintain healthy bones. And if it stops functioning, all these processes will be in disarray!”

What are the diagnostic measures involved before treatment can be started for renal failure? It’s like solving a math problem. You have to assess the degree of damage, see how much of it is reversible, how much of it is treatable and then you have to see if there are any co-existing or precipitating factors. If you don’t take care of all these things, then you miss the bus,” cautions Dr.Shersad.

“So the tests are directed at solving each of these problems,” continues Dr.Shersad. You start of by assessing the blood and urine, looking for certain parameters like blood count, urea, creatinine, calcium, phosphorus. You have to get an ultra sound of the kidney or further imaging studies to know exactly where the problem is located in the kidney. By doing the ultra sound, scan, MRI, we actually look at the kidney size, the blood flow to it, whether there is any obstruction.

Once diagnosis of renal failure is confirmed, what is the treatment course? “Treatment is multi-pronged,” declares Dr.Shersad. “You have to essentially support whatever function is lost for the kidney. This involves patients being on multiple medications – drugs and injections. In addition blood count may needed to be boosted. If there are infections they require to be treated. Block in the urinary passage, stones, will have to be taken care of, possibly through surgery depending upon the health status of the patient. If potassium levels are very high, they need to be brought down.”

When does dialysis enter the picture? “Each patient is individually assessed before going in for dialysis,” explains Dr.Shersad. “Once the kidney is damaged beyond a certain level, it may necessitate dialysis. The rough thumb rule is when the creatinine level for a diabetic is less than 15, and for non-diabetics, less than 10, we initiate Renal Replacement Therapy, that is, dialysis or kidney transplant.”

Elaborating further on dialysis, Dr.Shersad says, “When we take recourse to dialysis, we are essentially supporting renal function through external means. This may be either through haemo-dialysis or through peritoneal dialysis. In peritoneal dialysis, the membranes in the body act as filters to expel the waste products out of the body.”

Are both forms of dialysis equally applicable to all prospective dialysis candidates? “This depends again on individual cases,” explains Dr.Shersad. “Peritoneal dialysis is the preferred modality in diabetics and children. In diabetics, it gives them means to control the sugar if they are on insulin since they can add it to the dialysis bags. Also, many diabetics have very poor blood vessels which makes access a problem and for haemo dialysis you need good blood vessels. Similarly in kids, accessing blood vessels is a problem.”

Is dialysis possible only in a hospital setup? “Peritoneal dialysis can be done at home too,” opines Dr.Shersad. “Nowadays the trend is to go for automatic machines and it requires a fairly motivated patient, good home environment, family support and very clean surroundings. Haemo dialysis is usually done in hospitals though it can also be done at home.”

How long does the dialysis process take? It’s again age and body-size dependent. However, on an average, it should take four hours, says the doctor.

What precautions do these patients with renal failure need to take? Diet requires to be tailor made with the help of a dietician, to suit individual conditions. Foods high in potassium and phosphates should to avoided. Salt intake should be reduced to the extent possible.

What is the prognosis for dialysis patients? “If everything is done the right way, they can continue dialysis for several years – 20-25 years or more,” assures Dr.Shersad.

Is it possible to prevent renal failure? Lifestyle modifications to cut down the risk of diabetes, hypertension, overweight and obesity, is the need of the hour says Dr.Shersad. Cutting down on salt, eating wisely and judiciously and exercise sufficiently on routine basis would be the key acts of prevention, according to the Specialist.


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