Why kidney failure is far from a death sentence

A common misconception about a kidney failure diagnosis is that it translates to a death sentence for the patient. 

Resident physician Chemai Kirwa, based at the Karen Hospital in Nairobi, says this perception is wrong and misleading. 

He said advancements in medical care have changed the narrative. Treatment for kidney failure (dialysis) is now easily accessible anywhere.  

"I have seen patients stay on dialysis for up to 20 years and continue living their normal life," he said. 

The kidney is one of the most vital organs in the body as it cleans the blood by filtering out waste from it. 

Everyone has two kidneys. They are bean-shaped and around the size of a fist.

"Kidney failure comes about when the kidney can no longer perform its function of cleaning one's blood," Kirwa said. 

There are two types of kidney failure: acute kidney failure and chronic kidney failure. 

He said acute kidney failures are mostly reversible. 

"Let us say, somebody is acutely dehydrated. Once you hydrate them, the kidneys come back and work normally," he said. 

"If there is a drug that is hurting the kidney, when we withdraw it, the patient recovers."

Over time, if the insult caused by acute kidney failure is persistent for more than three months, it becomes chronic kidney disease. 

"In chronic kidney disease, in most cases it is not reversible, and what we try to as doctors is maintain its progression towards the end stage," he said. 

The chronic kidney disease stages are grouped into five based on the percentage functionality of the kidneys. 

"From stage one, which is mild, to the end stage, where the kidney is working less than 15 per cent," Kirwa said.

"When they are working on less than 15 per cent, that is when we say the patient has approached the end-stage."  

When the kidney is at end stage with only 15 per cent functionality, the doctor then recommends dialysis. 

THE CAUSES

Kirwa said there are pre-renal factors that cause kidney failure. He said these include the mass of a person, their hydration levels and infections such as sepsis. 

Low blood pressure is also a pre-renal factor as it causes kidneys not to be well perfused (get enough blood supply). 

Some factors affect the kidneys directly and are referred to as intra-renal factors. 

Post-renal factors, on the other hand, refers to anything that can hurt the kidney from its ends towards the ureter and the bladder. 

"Anything that affects the end of the kidneys towards the bladder can hurt the kidney," Kirwa said. 

The most common risk factors of kidney disease are hypertension and diabetes. 

Being overweight or obese is also a risk factor. So is alcohol consumption, smoking and living a sedentary lifestyle. 

Additionally, those with family who have autosomal dominant polycystic kidney disease (ADPKD) are at risk of developing kidney diseases. 

Kirwa said ADPKD is the most common monogenic kidney disease among the population 

It is characterised by relentless development of kidney cysts, hypertension, and eventually end-stage renal disease (ESRD).

"If you have a relative with ADPKD disease, then that also puts you at risk. Go get checked frequently," he said. 

Further, he said that though most drugs are metabolised by the liver, some are excreted through the kidneys. 

He said most Kenyans like self-medicating, particularly when it comes to painkillers. 

"Painkillers like Diclofenac, long-term use, especially when not prescribed by a doctor, tends to hurt the kidney," he said. 

"And that is why we are seeing an increase in kidney-related issues just because of the NSAIDs painkillers."

Kirwa said this group of painkillers has been proven to hurt the kidneys. 

SYMPTOMS AND TREATMENT

Kidney failure does not have symptoms till it is at its end stage. 

In the early stages, so long as most parts of one's kidney's are working, one will not get any symptoms. 

"So most times, patients come in when it is at the end stage after they start noticing the symptoms," Kirwa said. 

These include nausea, vomiting, lack of appetite, trouble sleeping, confusion, swelling of limbs and dry and itchy skin. 

He said people should go for checkups often to ensure their kidneys are functioning well. 

Particularly those predisposed to the disease, such as diabetes as well as hypertension patients. 

When kidney failure is first recognised, it is difficult to say whether it is at the acute or chronic stage. 

This is because one has to be put under observation for more than three months before the kidney disease is declared chronic or acute. 

Kirwa said once a patient walks into the hospital with kidney failure-related symptoms, three tests are conducted. 

"We usually do something called urea and electrolyte test," he said. 

"Retinin is a waste product of metabolism and is usually filtered by the kidneys. If your kidneys are healthy, then your levels of retinin ought to be low.

"If your kidneys have started being weak, it means the filtration capacity has been affected. Thus the retinin will start to accumulate, and that is how I will tell your kidneys are getting weak." 

Most times, a urinalysis is done. From the urine features, the doctor can tell if the kidney is hurting. 

If the urinalysis shows the presence of proteins, which are heavy components of the blood that are not filtered by the kidneys, it is a sign of kidney failure. 

"If I find proteins in your urine, it means there is a defect in the filtering system," he said. 

Another test a possible kidney patient will have is an ultrasound to check the structure  and size of the kidneys. 

"Based on the results, that is when I can tell whether your kidneys are hurting or healthy. At this point, I still can't tell whether it is acute or chronic," he said. 

"But let us say you did the test five months ago, which showed you have weak kidneys. And we do the test now to find you still have weak kidneys. At that point, we can say you have chronic kidney failure." 

Kirwa said if the test is done and it shows one's kidney function became elevated over the period, it is categorised as acute kidney disease. 

He said treatment for an acute kidney injury, which can be cured, is by looking for the cause. 

Thereafter, one undergoes checkups to ensure it does not progress to become chronic. 

A healthy kidney ought to have at least 60 per cent functionality.

Kirwa said kidney functionality is calculated using the Glomeruli Filtration Rate based on one's gender and size. 

He said there are five stages of kidney failures, graded 1 to 5. 

"At stage 1, the GFR is at 90 or higher, which means the kidneys are working well," he said. 

The stages progress till stage 5, where kidney functionality is at 15 per cent or less, and the patient is diagnosed with kidney failure. 

He said before the patient gets to stage 5, they are introduced to hemodialysis or a kidney transplant. 

MACHINES FOR KIDNEYS

In hemodialysis, blood is cleaned by machines outside the body. Doctors get an access point to your blood, either through the neck or groin, using a catheter. 

"The catheter placed by the nephrologist enables you to be connected to the dialysis machine. So we pump blood out, filter it and pump it back in," Kirwa said. 

He said due to the sedentary lifestyle most people are living, the number of kidney patients who get to the end stage and are in need of dialysis has increased. 

However, due to the increase in dialysis machines as well, Kirwa said the treatment outcomes have also seen great improvement over the years. 

A patient has two to three dialysis sessions a week, depending on the remaining functionality of the kidneys. 

A dialysis session usually runs for about four hours and is treated as outpatient.

"Luckily nowadays, dialysis is also covered by NHIF, which eases the burden on the patient," he said. 

Another treatment for chronic kidney disease is a transplant, whereby the patient is given a good functioning kidney. 

A transplant is the definitive management for end-stage kidney disease. 

"With a transplant, the patient no longer needs to go for dialysis," Kirwa said. 

After a transplant, however, the patient is monitored closely to ensure their body does not reject the new organ. 

Based on studies, Kirwa said a transplant has been shown to have better outcomes as well as giving the patient a quality life compared to dialysis. 

"Survival rates for transplant are higher compared to dialysis," he said. 

Moreover, there are more transplant centres coming up in the country. 

DIET RESTRICTIONS

The restrictions in terms of diet are more for a dialysis patient than a transplant patient. 

What really hinders many people from getting transplants is the high cost and poor sensitisation about kidney disease, Kirwa said. 

"Current laws and regulations in the country say that only a relative can be your donor. That is first-degree relatives. That is your parent or siblings,"  he said. 

Kirwa said there are families where no one is willing to donate for the patient.

He said although people have two kidneys, one can continue living a healthy life even after donating one kidney. 

Kirwa said one does not develop kidney disease because they donated one of their kidneys. 

Patients with kidney disease are urged to reduce their protein intake because when broken down, proteins form a lot of waste product. 

They are also to eat a well-balanced diet. 

Those with advanced kidney disease are advised to avoid foods rich in potassium, especially the patients in dialysis. 

"They have to avoid oranges, bananas, coconut water and avocados. Even when preparing their foods, especially greens, they have to boil it first and pour that water to wash away the potassium," he said. 

He said the diet restrictions are more for a dialysis patient than a transplant patient. 

PATIENT'S AGONY

At the Karen Hospital renal unit, we met Pr Alice Nderitu, who was taking care of her husband, Rev Peter Kihara, preachers at First Love Pentecostal church on Ngong road. 

Kihara has been going for dialysis for five years now.

He said though the process is not painful, it is very much uncomfortable.

"It comes with nausea and vomiting in the morning, lack of appetite," Kihara said.  

At night, he cannot sleep horizontally due to discomfort as well. 

"I have to be in a raised position to sleep," he said.  

Kihara said the problem began five years ago with a swelling in his legs.

"When the kidneys fail, there is water that is not filtered out. It is this water that looks for places to settle, thus the swelling on the body," he said. 

Earlier on, he was diabetic, which is a risk factor. With the swelling, he could not even put on closed shoes. 

The preacher still goes to the office every so often. His wife said since July 2018, their lives changed as she had to stop so much to look after him. 

"It is very expensive to manage a kidney patient. His diet is completely different from what we take," Nderitu said. 

"I have to make sure that he avoids any type of stress." 

Initially, they hoped that their son would be the donor to allow Kihara to get a transplant. 

Unfortunately, because the reverend had a low heart rate, the transplant was put on hold. 

They are in the hospital nine times a month — twice each week for dialysis, and one clinic visit. 

Nderitu praised the government for catering for part of the dialysis through NHIF, and hoped that the same will continue with SHIF.