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NKC is the largest dialysis center in the country from which over 400 people have been receiving free dialysis services. "We are not in a position to continue free service. If the government does not release grant immediately, we would be compelled to stop the service," Dr Rishi Kumar Kafley, executive director at NKC, said. He said that the center has not been able to pay the money it owes to companies that supply dialysis kits and medicines.

According to Dr Kafley, the government has stopped making reimbursements since the last four months. He said that a lot of people would die if they are not provided free services. "The government should understand the seriousness of the issue," said Dr Kafley.

Several hospitals, including the NKC, have been providing dialysis service to renal patients free of cost after the Ministry of Health and Population (MoHP) promised to reimburse the charges.

The government allocates Rs 560,000 to each kidney patient so that they can receive free dialysis service for a year.
Each year more than 3,000 people suffer from renal failure and over 90 percent of them die within a few months. Doctors said that sedentary lifestyle and change in the eating habits are the main causes of renal problems. It is estimated that about three million people have been suffering from some kind of renal problems in the country.

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A study published in the March issue of the American Journal of Kidney Diseases projects that the number of new cases of chronic kidney disease (pre-dialysis) will grow significantly through 2030. More than half the U.S. adults aged 30 to 64 years are likely to develop CKD.

Treating kidney disease has become an expensive entitlement for the federal government. While employing various payment strategies over the last four decades to control costs, the number of patients in the ESRD Program has grown significantly. When the Nixon administration signed off on Medicare legislation establishing the program in 1972, it estimated a $35 million annual cost – and most of that would be recoup as people went back into the workforce.

That hasn’t exactly happened, and the cost of the program has mushroomed to around $16 billiona year. There is some justification for that – we suspect lawmakers in 1972 didn’t picture the more complicated patient that gets their kidneys cleansed today: those with diabetes, congestive heart failure, people arriving in the ER needing a temporary catheter and dialysis immediately. Half of the program’s costs are generated on the Part A side: hospitalizations.

Understanding CKD

The National Kidney Foundation, through its Kidney Disease Outcomes Quality Initiative, built the algorithm using a patient’s GFR to define the five stages of kidney disease, with increased progression from 1 to 4 and 5 being kidney failure.  But we really don’t dedicate the resources to using it and making it valuable; patients don’t get referred to a nephrologist early enough. It’s like being on a fishing boat out in the ocean trolling for tuna with a spinning rod. The opportunity is there; the tools are not.

It’s coming for many of us

For U.S. adults aged 30 to 49, 50 to 64, and 65 years or older with no CKD at baseline, the study showed that residual lifetime incidences of CKD are 54%, 52%, and 42%, respectively. The prevalence of CKD in adults 30 years or older is projected to increase from 13.2% currently to 14.4% in 2020 and 16.7% in 2030.

The risk for CKD in this younger age group is significant, the authors note. “This compares to lifetime incidences of 12.5% for breast cancer in women, 33% to 38% for diabetes, and 90% for hypertension in middle-aged men and women.”  

Among persons with CKD, stage 3a (considered moderate kidney disease) will be the most common stage at all points in time (5.5% today, 5.9% in 2020, and 8.1% in 2030) and account for the largest absolute increase in prevalence between current levels and 2030. Stages 2, 1, and 3b are the next most common. Estimates for stages 4 and 5 show relatively small changes over time. For adults 65 years or older, the prevalence of CKD is projected to decrease from 39.6% currently to 36.4% in 2020 before increasing to 37.8% in 2030. Among persons with CKD over 65 years old, stage 3a will remain the most common stage at all times (19.4% today, 18.1% in 2020, and 20.7% in 2030).

That may offer an opportunity to intercede and slow down the progression of kidney disease. We can do so much better work for patients while their kidneys are still functioning then when they cease to function.

Build the model, they will use it

Many dialysis providers have developed CKD clinics to do exactly that.  There is some motivation; many of these patients will eventually need dialysis and providers like to have nephrologists make those referrals. But what about expanding the ESRD Program, the federal entitlement, so that kidney treatment becomes a continuum of care for everyone. Diagnosed with Stage 3 kidney disease at 62 with no insurance? We are going to help you. Because in the long-term, everyone benefits: you the patient, Medicare, and caregivers.

In the AJKD paper’s conclusion, the author suggests the incident and prevalent counts through 2030 can help serve as a wake-up call: we have the opportunity to intercede and deliver care to slow the progression of disease. “…Better forecasts of the future burden of CKD can help planners prepare for future health care needs, raise individuals’ awareness about the importance of keeping kidneys healthy, and stimulate research on interventions to slow the progression of CKD.”

Great ideas. If we want to catch that tuna, let’s start looking for a bigger reel.

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08:00 AM Monday morning. My first patient is Marie*, who is in her 50s. She has type 2 diabetes and her kidney function has been on a downward spiral for the past year. It has come to a point where we need to have a conversation about renal replacement therapy. She will need to think about modality choice, home-based versus in-center techniques, hemodialysis versus peritoneal dialysis, and ultimately also kidney transplantation.

I admit I find such conversations difficult to have. I know she must have expected this day to come and yet I know the news will hit her hard. I know she will attempt to process the information I give her. And I know she will fail and understand very little after the word ‘dialysis’ has crossed my lips.

02:00 PM. I am called to Accident and Emergency to see Maureen*. Her husband had brought her in after her general condition had started deteriorating a few days ago. She had felt progressively tired the past few months, had lost her appetite, and had been experiencing muscle weakness for the past two days. Her labs reveal a creatinine of 7 mg/dL, her potassium is up to 8 mmol/L, and her kidneys appear shriveled on ultrasound.

She is a ‘crash-lander’, a person who presents with end-stage kidney disease, requiring renal replacement treatment upon presentation. She had seen a few doctors in the past, but had never heard of anything being wrong with her kidneys. It continues to baffle me how many of these people we still see. People with progressive chronic kidney disease, often secondary to hypertension or diabetes, who have been unaware of their kidney problems.

People who have not benefited from preventative care (lifestyle-changes, appropriate antihypertensive treatment including ace-inhibitors, tight glycemic control,…) and need to be started on dialysis without the opportunity to be counselled appropriately concerning modality choice.

To me, Maureen is living proof of why we desperately need initiatives such as World Kidney Day

To me, Maureen is living proof of why we desperately need initiatives such as World Kidney Day to raise awareness of the importance of our kidneys to our overall health and to reduce the frequency and impact of kidney disease and its associated health problems worldwide.

09:00 PM I am on–call tonight. I have just received an offer for a kidney. The scheduled recipient is Malcolm*. He has been on the waiting list for the past three years and is both excited and anxious when I meet him on the ward. He is good shape, the labs come out clean, and he is good to go. I sit down, sip my coffee as I wait for him to come out of theater…

How I got into nephrology

I remember a story my former professor of nephrology used to tell in class. In the early 1990s two women under the age of 50 presented to an academic hospital in Brussels with rapidly deteriorating kidney function due to interstitial fibrosis.

The women had shared a desire to shed some weight and had both visited the same weight loss clinic. Intrigued by the coincidence, the nephrologists in charge the women’s care surveyed the principal dialysis units in the area and found seven additional women with similar profiles.

They identified a regimen involving Chinese herbs as the plausible culprit, and had it immediately removed from all dietary plans. In the years after the initial discovery of a disease which would later be called Chinese herb nephropathy, the number of patients who were documented to be poisoned had run into the fifties. As a student, that tale spoke to my imagination, as I had been drawn to medicine mainly for the romance surrounding diagnostic mysteries such as these.

I had been drawn to medicine mainly for the romance surrounding diagnostic mysteries such as these.

Of course there was an idealistic longing to help others, but if I am honest, I chose medicine mainly for the riddles I imagined it would present. I decided then and there I would pursue a career in kidney disease.

Although the story painted a more glamorous picture of life as nephrologist than I would lead in reality, and I have never felt close to the Sherlock Holmes I imagined my predecessors to be, I do face my share of diagnostic challenges if not on a daily, at least on a weekly basis. And although I no longer feel excited at the prospect of dealing with glomerulonephritis, I can still marvel at the analytic skills of my senior colleagues.

What are the biggest challenges about working in this field?

Last week I spent 55 hours at work, that’s 11 hours a day. On Saturday I had admin to catch up with. Sunday halfway through brunch, I suddenly remembered I had forgotten to call a patient with her lab results…it is a crazy life.

I often think tomorrow will be different. I will work less. I will work better. Allow fewer interruptions. Be less stressed. I never do and never am of course. I realize it is more a disease of our time, than a challenge specific to working in nephrology.

But it is a pressing one. Don’t get me wrong, I love this job and I wouldn’t trade it for the world. At least, not yet. But in talking to senior colleagues I do see how too much for too long can simply be too much. How getting the balance right is imperative, for the quality of one’s own life, but also for quality of the service we provide.

What’s the most important thing you think non-specialists should know about nephrology? A hitchhiker’s guide.

Our former chief of the orthopedics department had understood quite well that people remember very little of what they are taught – something that doesn’t just apply to orthopedic surgeons.

There were three things he made a point of teaching every student, three rules he professed would shield anyone from vital orthopedic misjudgments regardless of which specialty they chose. I remember them to this day. I have often thought about this list in relation to my own discipline and I guess it would hold the following:

1. ‘Show me a man’s urine, and I will tell you who he is or what he is made of.’ A urine sediment and proteinuria screen form the basis for any differential diagnosis in nephrology. Order these two tests before calling the nephrologist and you will receive nothing short of praise and admiration.
2. Be careful with the prescription of non-steroidal anti-inflammatory drugs, avoid giving them for prolonged periods of time, especially in the elderly, people treated with ace-inhibitors (or angiotensin receptor blockers) and those with pre-existent kidney disease. Check kidney function before and while you do, and stop at the slightest sign of kidney function deterioration.
3. In case of acute deterioration of kidney function, always check for nephrotoxic medications. Temporarily reduce/stop antihypertensive medications (especially ace-inhibitors and angiotensin receptor blockers) in case of low blood pressure and dehydration.

Follow these rules, and you will single-handedly avoid many of the cases of acute kidney injury we see in daily practice.

* Names have been changed to protect patient confidentiality

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