In conversation with A. Radhakrishnan, Dr. Ignatius stresses on the need for healthy lifestyle, kidney care and early detection by annual blood tests.
What is Nephrology and why did you choose it as a Specialty?
Nephrology means the study of kidneys (nephrons are the functional units of kidneys). I had many reasons to choose Nephrology. Medical profession today has advanced to a phenomenal level, but medical care has become fragmented and compartmentalised. While the amount of knowledge has multiplied manifold, it is impossible for everyone to know everything, and the drawback is that human touch is lost.
Nephrology as a specialty provides some of the most complex decision making challenges in the field of medicine and incorporates almost all sub-specialties of medicine. When kidneys lose function we are able to relatively easily, artificially replace those functions or do a kidney transplant. This is still fairly difficult or not possible for other organs. Unlike most other fields in medicine, majority of patients remain in a nephrologist’s care for life, making them almost an extended family.
Your education and experience?
With father serving in the Air Force, I was privileged to experience the diversity of India, every few years. These experiences added to my formal schooling, which happened in Kendriya Vidyalayas.
I completed my M.B.B.S. from Govt. Medical College, Bellary (now Vijaynagar Institute of Medical Sciences) on merit; my M.D. in Internal Medicine from St. Johns’ Medical College, Bangalore and subsequently joined the Dept. of Nephrology at St. Johns’ Medical College and Hospital, Bangalore. After a year, I was selected as Senior Resident at Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow. Selected through a national entrance test, I completed my D.M. in Nephrology from All India Institute of Medical Sciences (A.I.I.M.S.) New Delhi and before moving to Pune, I provided consultation at Fortis Hospital, Escorts Heart Institute and Holy Family Hospital in New Delhi.
In Pune, I was able to establish the Department of Nephrology at Noble Hospital, which now has one of the largest units providing world class dialysis facility with 31 stations including an ICU for critically ill patients. Managed by NephroPlus, it is also one of the few centres in India that provides maintenance dialysis to HIV positive patients and has performed renal transplant in HIV positive patients. I am also a senior consultant in Nephrology at Ruby Hall Clinic, Wanowarie, Pune which has a premium dialysis unit with 10 stations, also being managed by NephroPlus.
How important are good interpersonal skills, thorough attention to detail, patience, critical thinking skills, experience and strong problem-solving capabilities essential to a nephrologist?
All these are crucial. Most kidney patients have multiple co morbidities; they usually are diabetic, hypertensive and/or have heart disease. In addition they may have many other health issues. Usually they are on multiple medications, which may interact with each other or may need to be stopped or doses reduced due to reduced kidney function. It is even more complicated in critical care settings where fluid balance, electrolyte disturbances, acid-base abnormalities along with appropriate modification of medications become extremely crucial in managing patients. One needs to be extremely vigilant to not miss out anything.
Patients and their caregivers are already stressed once they are aware about kidney issues. In addition there may be a lot of myths, heresay or from online sources. It requires a lot of patience, counselling and tact to communicate well with not just the patients, but also their family and friends.
For critically ill patients who need emergency dialysis, there may be limited time for detailed counselling, and a delay can make the difference between life and death. Meanwhile there are situations where dialysis may be extremely risky and may not benefit. In these stressful situations good communication skills can help get the right message across.
Are there sufficient nephrologists in India?
India has about one nephrologist per million population. This is further skewed due to disproportionate distribution of specialists in urban areas. Lack of appropriate facilities does limit the ability of a nephrologist to provide reasonable care to a renal patient in rural areas. This and lack of adequate civic amenities dissuades many in moving there. However there seems to be a positive shift and now we are seeing more than one nephrologist in even smaller towns with facilities of dialysis and even renal transplant.
How far has India progressed in kidney disease treatments?
The number of people we see on dialysis and undergoing transplant is just the tip of the iceberg. There are patients many times over, who are suffering from lesser degrees of severity of kidney disease, majority of who aren’t even aware.
Data from limited studies done in India estimates a prevalence of CKD in upto 17% of adult population. While the main contributors of CKD in the West is from diabetics and hypertensives and are older patients; in India a large section of CKD is seen in the young and middle aged, in whom the primary etiology is undetermined and affects a significant portion of our population in their prime.
India is at par with the West in quality of services available at a fraction of the cost and is the second largest transplanting country after the USA. Even ABO incompatible transplants (mismatched blood group kidney transplant) are being routinely performed in India. Despite the relatively lower cost as compared to the West, treatment is beyond the reach for most.
What are the ways in which we can keep them healthy?
Majority of metabolic waste generated in the body are excreted by the kidneys. They are the primary balancing organs of the body; whether one is fasting or binging, kidneys will retain or discard excess of fluid / salts / other electrolytes like potassium / calcium/ phosphorous and magnesium.
Kidneys are essential to maintain blood pressure and in kidney disease more than 90% will have high blood pressure and need multiple medicines to control it. They activate Vitamin D which is essential for bone health. They also produce erythropoietin, a hormone essential for production of hemoglobin by bone marrow.
What are the signs of kidney/ renal failure?
Unfortunately, kidney failure in majority is asymptomatic. Kidney disease may progress to advanced degree without significant symptoms. One of the earliest signs of kidney disease is increased frequency of urination, especially waking up 2 – 3 times at night to pass urine. Other reasons are uncontrolled sugars, enlarged prostate, urinary tract infection or just a habit of having excess fluids before sleep. In early kidney diseases, some may develop protein leak in urine. This will present as foamy urine due to reduced surface tension. Other symptoms are swelling on the feet and face, lack of appetite and nausea, unexplained itching, breathlessness.
Some may be present first time after fractures from a trivial fall. Pain is a rare symptom of kidney disease and occurs when a stone blocks the passage of urine or in case of infection in the kidneys. Majority of renal failures are painless. Therefore it is imperative that one should be test oneself at least once a year for kidney disease.
What type of dialysis would you recommend?
There two forms of dialysis available. Hemodialysis – In centre or home and Peritoneal Dialysis – CAPD or APD. Hemodialysis process takes the blood from the patient and passes it through artificial membranes that filters and then returns the same purified blood back to the patient. In centre, Hemodialysis is the most common modality in India and there are about 1,30,000 patients on this. Some patients opt home hemodialysis which allows them the flexibility of time and more frequent dialysis. However, home hemodialysis is more expensive and is not covered under insurance.
Peritoneal dialysis utilises the peritoneal membrane (lining in the abdominal wall and around the bowels) to remove toxins from the blood and can be performed at home by patients themselves or their caregiver. It can be done manually through the day (CAPD) or by an automated machine at night (APD) while the patient sleeps.
Both forms of dialysis are equally effective. And choice is based on patient preference/ certain medical conditions/ logistics or availability of services.
What is the difference between AKI and CKD?
Acute Kidney Injury (AKI) is a sudden deterioration of kidney function; it may be due to infection/ sepsis/ reaction to certain medications such as pain killers or certain alternative remedies etc. These are usually reversible even if requiring dialysis, once the primary cause has been treated. However, even those who appear to have had complete recovery from AKI, should keep a regular check on their kidneys as they have higher risk of developing CKD (Chronic Kidney Disease) in future.
CKD is generally a slow progressive decline in kidney function and by definition irreversible. Most common cause for this is uncontrolled diabetes, hypertension, and indiscriminate use of painkillers.
How much would you recommend kidney transplant?
Kidney transplant is considered the best treatment for kidney failure, as the person can achieve near normal quality of life after transplant. However certain patients with multiple co-morbidities and poor long term survival may be unfit to undergo kidney transplant and may be better off on dialysis. Hence the decision needs to be individualised and not offered to unsuitable patients.
How often should one undergo blood tests?
Healthy persons should undergo a urine routine /microscopy, serum creatinine and eGFR at least once a year. CKD patients will be require to follow up as per their nephrologists` instruction, depending on the severity of CKD.
Are there support groups you can recommend?
Kidney Warriors Foundation is a patient and caregiver run foundation. Incidentally I had suggested the name to this group during its early days. There are local groups in most of the major Indian cities, through which patients interact and share their experiences. It also has its Facebook page https://www.facebook.com/kidneydiseaseadvocacy/ with patients, caregivers sharing experiences information and nephrologists to clear doubts.
Any other alternative therapies? Would you recommend Ayurveda? If not, why?
Any therapy that has scientifically proven role in treating kidney disease will be part of modern medicine and will not remain alternative. Unproven alternative remedies may be harmful. There is no strong data to suggest benefit from Ayurveda. Many believe that being natural, there are no side effects. I would counter that with ‘tobacco’ is also natural. Many preparations are not standardised and contain certain alkaloids and heavy metals which are toxic to kidneys, and may cause more harm by accelerating decline of renal functions.
Any awards?
I was felicitated with the Pune Healthcare Leadership award and Icons of Health, Pune award in 2018 by the Times of India Group. Although there is no better reward than the smile on a patient who has become better and their blessings, these recognitions do motivate one to serve patients interests in the best way possible.
Your message to people?
Kidney disease is painless till last stages and can be detected only by tests in early stages. Hence test yourself every year. Keep a healthy lifestyle, avoid tobacco and do not self-medicate. Prevention and early detection is way more economical than having to undergo dialysis or kidney transplant.
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A. Radhakrishnan
A. Radhakrishnan is a Pune based freelance writer, poet and short story writer. [/column]