Kidney Disease Prevention: A Necessity to Reduce the Cost Burden of the Society

In 2018, the World Health Organization (WHO) reported kidney disease to be the 9th leading cause of death in Bangladesh, but experts currently rank it at 7th and forecasts it to be the 5th leading cause by 2040. Bangladeshis, particularly Bangladeshi women have a higher prevalence of kidney disease compared to the global incidence. Data indicate that 26 to 30 million people in Bangladesh may have chronic kidney disease (CKD).¹

Worldwide 850 million people are suffering from kidney disease and an additional 1.3 million people develop sudden kidney failure every year. Sadly, 85% of it is in developing countries like Bangladesh.²

Although CKD is yet to be declared a major non-communicable disease, it is recognized as a global public health burden. The underlying risk factors include old age, presence of type 2 diabetes mellitus (T2DM), being a female, low socioeconomic status, excessive use of antibiotics, adulterated food, and chronic intake of non-steroidal anti-inflammatory drugs.³ Furthermore, the simultaneous rise in T2DM and hypertension raises the likelihood of CKD development, which progressively increases the incidence from myocardial infarction, stroke and cardiovascu -lar related mortality.⁴

CKD gradually develops into end-stage renal disease (ESRD) and renal failure, which require hemodialysis or peritoneal dialysis, and in extreme cases a kidney transplant.¹

What is the financial and eventually emotional burden of kidney diseases?

WHO estimates that by 2040, more than 5 million patients with kidney failure will die prematurely due to lack of treatment.⁵ The cost of kidney disease, especially renal failure and CKD is high worldwide. Governments of both developed and developing countries are struggling to treat kidney failure. In Sweden- patients dependent on regular dialysis, with transplanted kidney, and with CKD, elevated the healthcare cost by 30-fold, 10-fold and four-fold respectively.⁵ The United States spent $87.2 billion to treat CKD patients and an additional $37.3 billion for people with ESRD only in 2019.6 This figure is more than Bangladesh’s national budget! In Bangladesh each session of dialysis costs taka 3,000 to 5,500 in private facilities and taka 500 to 520 in government and charitable organizations. Additionally, the demand does not commensurate with the availability of dialysis service. Due to high cost and limited facilities, regular dialysis has become unaffordable for 10 percent of patients who need it and 40 percent patients who are already on dialysis stop their treatment after three to four months.⁷

Sadly, almost 90 percent of patients in developing countries like Bangladesh, India, Pakistan, and Nepal die without treatment or with partial treatment as the cost of managing the disease is beyond the capacity of the majority. On the other hand, it is estimated that if knowledge is disseminated about the prevalence, severity, consequences and causes of kidney disease, it may prevent fatal kidney disorder in 60 percent of cases.

What is the National Strategy to bring awareness towards kidney disease?

The numbers of the expected disease burden and the cost of management suggests an urgency to spread awareness regarding the disease and its symptoms, and preventive actions. People from all tiers of financial abilities, especially the low-and medium-income families need to be brought under screening to avoid catastrophic health expenditure.

To this end the theme of World Kidney Day 2022 was- “Kidney Health for All–Bridge the knowledge gap to better kidney care”. ⁸

Since there is virulent growth in the volume of kidney diseases, it should now be a national agenda for ordinary citizens, medical professionals, policy makers and investors to participate in dialogues and learn more about this critical organ of our body.

What are the functions of the kidney?

The living body is a collection of complex biological actions. 70% of total energy generated in the body is expended to keep the organs functioning and healthy, 10% is needed to digest food and 20% is used to perform activities.⁹ Liver and kidney are the two main organs that metabolizes food and drugs, and kidney is the organ that removes the toxic chemicals produced from all bodily actions. It purifies the blood and produces urine through which all toxic substances are removed. Kidneys are called the master chemists of our body that help produce red blood cells, keep bones strong, control blood pressure, maintain water balance in the body, and regulate growth in children.10 The kidneys continuously balance the levels of minerals like sodium, potassium, calcium, iron, and zinc in our body. Any imbalance of these can even cause death. Kidney health is essential for our survival.

What is kidney failure?

If due to any reason the function of kidney is reduced or damaged, then it is called kidney failure.

What is Acute Kidney Injury (AKI)?

If the good kidney suddenly, for some reason, loses its function quickly, within hours to days, it is called acute kidney injury. For example, sudden or Acute Kidney Injury may follow from diarrhea, vomiting, hemorrhage, acute inflammation, painkillers, adulterated food, or obstruction of urine flow. If AKI is detected and treated at an early stage, the kidney can be completely cured.

What is Chronic Kidney Disease (CKD)?

A person is diagnosed with having chronic kidney disease if there is either abnormalities of kidney function or structure which persists for over three months.¹¹ CKD progression can be measured by the estimated glomerular filtration rate (eGFR). An eGFR number of 60 and up is considered normal.¹²

What are the stages and prognosis of chronic kidney disease?

According to Kidney Disease: Improving Global Outcomes (KDIGO), CKD classification is dependent on etiology, glomerular filtration rate, and presence of albumin in the urine.¹¹ At stage one eGFR is normal or high and at stage five, eGFR falls below 15%.¹³ If the disease is diagnosed between the first and fourth stages, the kidneys can be kept well, and complications related to the disease can be prevented through treatment, diet, and healthy lifestyle practices.

Once CKD is diagnosed, treatment must be initiated. Depending on the severity it may be conservative or more invasive dialysis or even a kidney transplant. The alarming aspect of CKD is, it increases the risk of heart disease by many folds, along with increasing the rate of stroke development.¹⁴ Hence, CKD is called a disease-multiplier.

What precipitates chronic kidney disease?

There are modifiable and non-modifiable CKD risk factors. The non-modifiable risk factors include old age, South Asians, non-Caucasians, females, family history, family history of hypertension and diabetes, and genetic predispositions.¹⁵

The modifiable risk factors are uncontrolled diabetes mellitus, hypertension, obesity, smoking, sedentary lifestyle, unhealthy food, adulterated food, excessive use of pain killers, random use of antibiotics, insulin resistance, and dyslipidaemia. Most of these risk factors are closely related to our lifestyle. Amongst children there are congenital defects that later affect the kidneys, a gap in awareness about the importance of treating scabies and sore throats may later turn to nephrotic syndrome.¹⁵

Renal stones, family history, urinary tract infection, obstructed uropathy are other causes of chronic kidney disease.¹⁵

What are the symptoms of CKD? How is it diagnosed?

CKD is difficult to determine as it is asymptomatic in nature in the early and moderate stage. The symptoms start manifesting in stages 4 and 5 when almost 80 to 90 percent of the kidney functions are destroyed. It is usually detected in routine blood or urine testing. Some of the common symptoms in later stages are nausea, vomiting, loss of appetite, fatigue, weakness, sleep disturbance, oliguria, muscle cramps, oedema in ankles and feet, shortness of breath due to pulmonary oedema, uncontrolled hypertension, and sometimes skin pigmentation.¹⁵

KDIGO guidelines to detect CKD are enumerated in Table-1.

People who have hypertension, diabetes mellitus and a few more of the modifiable risk factors should screen their kidneys atleast once a year. Regular screening of kidney functions that measures eGFR, serum creatinine, blood urea nitrogen (BUN), albumin in urine and imaging are some of the tests that will help detect kidney function from an early stage.¹⁶

How do we keep our kidneys healthy?

In 50 to 60 percent of cases, fatal kidney disease can be prevented if a healthy lifestyle is maintained.

1. Active Physical Lifestyle:

An active lifestyle that includes regular exercise, sport activity, and just 30 minutes brisk walk at least five days a week will prevent kidney disease. This will also control the underlying threat factors like T2DM, hypertension, high cholesterol, and coronary artery diseases.

2. Management of Hypertension and T2DM:

Hypertension and T2DM are the major precursors of not only kidney failure but also heart disease, brain stroke, and blindness. Controlling blood pressure to keep it under 130/80 mm of Hg along with controlling blood sugar is a must. In Bangladesh 20 to 30 percent adults have hypertension but more than 50 percent of the total cases remain unaware. As a general rule in primary care, blood pressure should be measured three to four times in a year for diagnosis purposes.

3. Healthy Diet and Avoiding Obesity:

A moderate and balanced diet, inclusive of essential macro-and micro-nutrients is the basis of enduring health. Extra salt, over spicy, over-fried burnt food, and animal oil like cow fat, ghee, butter should be eaten in moderation. Overeating and overweight increases inflammation of the body that leads to multiple organ disease affecting daily life activities.

4. Drinking Sufficient Water:

Drinking sufficient water helps flush the kidneys of toxins. The recommended intake is three liters of water a day for an elderly person. People with a history of kidney stones, frequent urinary infections, outdoor workers, workers in factories should drink more water to ensure that the color of urine is like water. However, people with excess water in their body should drink water as prescribed by the doctor.

5. Abstain from Smoking:

An analysis by the WHO showed that 66 million people die worldwide every year due to smoking alone. Smoking causes kidney damage, kidney cancer, and urinary tract cancer. In addition, smoking is considered the root cause of deaths from heart disease, stroke, lung cancer, mouth and esophagus cancer. People already compromised with kidney function should avoid smoking.

6. Avoid Self- Prescribing:

Long-term use of painkillers, especially NSAIDs can cause kidney damage.¹¹ Various studies show that 10 to 15 percent of kidney failure occurs due to drug consumption. Also, excessive intake of self-prescribed antibiotics can lead to kidney damage. The extent of this damage often depends on the dose and duration of the medication. Again, due to allergies to some drugs, even a small dose can cause kidney failure, so no medicine should be taken without consulting a doctor.

7. Avoiding Negligence in the Treatment of other Diseases:

It is important to teach mothers to avoid neglecting sore throat and scabies in children. In cases of severe diarrhea, oral saline is a must to replenish minerals and fluid as the severity of diarrhea may cause acute kidney failure. Hygiene maintenance from hand washing, toilet hygiene, washing raw food before cooking, keeping environment clean helps reduce avoidable diarrhea, gastroenteritis, and urinary tract infection.

8. Regular Screening of Kidney Function:

Kidney disease is a silent killer. Often there are no symptoms till 70 to 80 percent of the kidneys are destroyed. The high-risk individuals- the ones with diabetes, hypertension, swelling of the face and body, those who have kidney stones, obstructive diseases in the urine, history of urine infection, family history of kidney diseases, and people over 40 -should screen for kidney disease at least twice a year.

Health is wealth, truly. The recommendations will not only benefit in protecting kidney diseases but will overall preserve good health and build strong immunity against many forms of communicable and non-communicable diseases. Considering the cost of managing diseases, it is less expensive to take preventive actions. A disciplined lifestyle is self-preservation and more importantly it sets an example for the next generation to follow holistic living.