Last Wednesday we talked about referrals to the renal team.I insisted that anyone suffering Diabetes type 2 and/or High blood pressure needs at least a quarterly check of their Kidney Functions.However why is that important?What if the kidneys have started receiving some form of injury?What next?
See,Chronic kidney disease is categorized in stages 1 to 5.The fifth is what we call End Stage Renal Disease.This is unfortunately where many of our patients on dialysis are.This is because kidney failure as a progressive disease easily gets misdiagnosed as other things.From Malaria(everyone’s favorite tropical disease),to peptic ulcers.
#TeamPhoenix,I want you to understand that these stages can only be qualified as so after a series of blood works.Every stage calls for some specific interventions.Please note that you do not go back.I mean,if you are at Stage 5 and you get a kidney transplant,you do not go back to Stage 1.You remain in the stage you were at,only with a long term renal replacement therapy.
To the exemplary seniors of mine and other specialists,the staging outlined below is for general population education and not critical analysis of the disease.I know there are many sub-stages but allow me to stick to the following.
This is mainly asymptomatic.Namaanisha,hakuna kitu unahisi.You feel alright.The underlying problem is there for instance High blood pressure or Diabetes.The damage to the kidneys is still minimal and the kidneys can still make urine.#TeamPhoenix,si mnakumbuka urine is what we are very interested in as the basic indicator of kidney health?
As a Nephrology nurse,urine excites me. Stop rolling your eyes.It is not some fetish you evil-minded children.I love it when people produce urine .That way I can tell the health of their Kidneys.Ask any renal nurse near you if this is true.(where is the winking emoji?)You will be at Stage one depending on the results of your Creatinine levels.That means you will have some blood drawn and tested.Alafu the doctor or renal nurse will do an estimation of Glomerular Filtration Rate;a calculation.
Please do not give up on me for using hard terms.Let me explain:Estimated glomerular filtration rate (eGFR) is the rate at which your kidneys are making urine by clearing wastes per minute.Normally about 120-125mls/minute/1.73m2 in males and 115-118mls/min/body surface area in females .This varies with age,race,gender and such according to https://www.kidney.org/atoz/content/gfr.
In stage one the test is greater than 90mls/min/body surface area.However with associated minimal degree of injury to kidneys.Notably,we find proteins in urine and that is an alert that something is not quite right with the kidneys.Approach to management is mainly slowing the disease progression.
The eGFR is 60-89mls/min/body surface area.The kidneys produce urine but it is very diluted.Meaning wastes are not being cleared as they should be.If the primary problem was not high blood pressure,we start seeing high blood pressure setting in.You urinate a lot and mostly can’t have a good night’s sleep because you keep waking up to pee.
Now,this is the point where we medics mess it up easily.Those signs will most likely make us diagnose you with Diabetes type 2 if we do not take a keen interest in your presentation.
Approach to management again involves slowing down disease progression.
#TeamPhoenix I want you to understand a little something.That kidney failure is progressive and slow.Especially slow.Between stages it can take years and the worst is that we expedite the onset of Stage 5 by mismanaging Stages 1-3.
Sio kupenda kwetu.I am always amazed by the level of genuine ignorance Doctors have on matters Renal failure.Either they ignore it or entirely mismanage it.That says s0mething about need for some form of awareness to us the service providers.
The eGFR is 30-59 ml/min/body surface area.Let not these figures terrorize you.We will do the calculations.
Interestingly you can still lack symptoms.However other systems start feeling the heat.You will present with anemia(low blood level) and we will treat it.You may present with high levels of thyroid hormones and I am sorry to say we may treat you for goiter only.Your cholesterol (bad cholesterol) goes up and we ask you to watch what you are eating and give you some medicines to lower it.
Friends,if we were to practice in some serious set ups,if we were to be healthily healthy about our health,we should be able to discuss with you the source of your problems.We should be able to talk.If one is Diabetic,the National Kidney Foundation recommends that we create a vascular access (Arteriovenous Fistula) at this stage.(https://www.kidney.org/professionals/guidelines/guidelines_commentaries/vascular-access)
The eGFR is somewhere between 15 and 29 ml/min/body surface area.Some patients start dialysis at this stage because the body can’t keep up with the excess wastes and fluids.We start running.If lucky,you do not stat dialysis but get a kidney transplant immediately.That is a good thing but it never happens in my motherland.At least I have not seen it happen.
The eGFR is below 15mls/min/body surface area and we are already on hemodialysis or peritoneal dialysis which I told you is not readily available in Kenya.Here we are talking about a patient whose body is so toxic that they need dialysis to sustain life.We call it end stage renal disease because the end is nigh.Every system is tops- turvy.The heart,liver,bones and every organ that can hurt hurts and the person is in so much distress.Financially it is a mess too and they need dialysis to survive.
Trips to the renal unit become the thread by which their lives hang.And we as the renal team ask ourselves,did we have to get here this quickly?
What if we the person came to the Nephrologist at Stage 1?Could we not have at least added a few more sunrises and sunsets to this person?Perhaps another opportunity to finish that project they have been saving up for?Maybe see another child in school?
Free the limited dialysis machines for some more desperate and acute patients?
I think we can if we wanted to.But will we when we want to finish the queue on the outpatient medical clinic and rush to the next available locum?