The two bean-shaped organs in our bodies that filter out toxins from our body require constant care and maintenance. Unlike the liver, the kidney, when damaged, progresses steadily, making it difficult to reverse illnesses associated with it. Hence, it’s crucial to prioritize their well-being. On this Kidney Day, we had the opportunity to speak with Dr. Sanjeev Gulati, Principal Director in the Department of Nephrology & Kidney Transplant at Fortis and immediate past president of Indian Society of Nephrology.

In this insightful conversation with Associate Editor Somi Das, Dr. Gulati delves into key strategies for preventing kidney damage, discusses upcoming innovations set to revolutionize dialysis, and examines the persistent challenges hindering kidney donation in India.

Excerpts from the interview:

Q: What are the early signs that your kidney is not functioning at its optimal health and needs immediate attention?

A: The early stages of kidney disease are often silent, with no symptoms at all. The only way to detect kidney disease in its early stages, such as stage 1, stage 2, and even early stage 3, is through screening, including simple tests like urine and blood tests.

If you are looking for symptoms, the symptoms of kidney disease, which typically appear late (around stage 3B or stage 4), include swelling throughout the body and high blood pressure. High blood pressure can be one of the very early signs of kidney disease, which is often mistaken for a risk factor for heart condition and leads people to consult cardiologists. However, it has been shown that blood pressure and kidney function are closely related, so high blood pressure can indeed be a symptom of kidney disease. Other symptoms include froth in the urine – indicative of proteinuria, and hematuria, which is the presence of blood in the urine. Additional, more subtle signs may include weakness and an inability to perform normal activities due to low hemoglobin levels, leading to unexplained anemia. A loss of appetite can occur very late in the disease. In children, particularly, poor growth could be a sign of underlying kidney disease.

Q: What are the initial screening tests?

A: The first test we consider is Microalbuminuria, which is measured in the first morning sample. We assess the albumin-creatinine ratio, and if it is abnormal, the test should be repeated at least once to confirm the diagnosis of Microalbuminuria. This condition is the earliest sign of kidney disease.

Secondly, we conduct a blood test known as a kidney function test. In this test, serum creatinine is a well-known marker, but we no longer rely solely on serum creatinine. Instead, we evaluate a parameter called the estimated Glomerular Filtration Rate (eGFR), which is calculated based on your serum creatinine and your age. The eGFR, representing the percentage of kidney function, is likely a more sensitive test than serum creatinine alone for detecting early stages of kidney disease.

Q: Is there a connection between consuming alcohol or smoking and the early onset of kidney diseases?

A: Not directly. Alcohol is more commonly associated with liver diseases. However, smoking has been linked to the faster progression of kidney disease. It doesn’t necessarily cause kidney disease, but if someone with kidney disease smokes, then the deterioration of kidney function can accelerate significantly.

Q: Let’s discuss the issue of kidney donation and transplants. What are the challenges patients face in finding the right donor?

A: First and foremost, for everyone’s information, if you have stage 5 chronic kidney disease, meaning your kidney function is less than 15 percent, there are only two life-sustaining treatments available: dialysis and kidney transplant. On social media, you might find numerous treatments advertised by various practitioners, ranging from outright quacks to alternative therapy proponents. However, I want to assure everyone that for stage 5 kidney disease, any treatment outside of the established medical protocols is essentially quackery. These alternative treatments lack the scientific validation required for any medical intervention to be considered legitimate. Every licensed treatment must undergo four phases of clinical trials to ensure its safety and efficacy.

Now, back to your question about dialysis and transplant. A transplant generally offers a better quality of life, is more cost-effective in the long run, and provides complete rehabilitation for the patient, freeing them from the constant hospital visits required by dialysis.

Regarding kidney transplants, each year, we see an addition of two to three hundred thousand patients with stage 5 kidney disease to the pool, but only ten to twelve thousand kidney transplants are performed. This creates a significant gap.

Addressing the issue of finding a kidney, it’s important to dispel the myths often propagated in movies about buying and selling kidneys. According to the Human Organ Transplantation Act, such transactions are illegal and punishable by imprisonment. If you need a kidney, the legal route is to seek a donor within your immediate or extended family, which includes first or second-degree relatives.

Another option is cadaveric organ donation, which, unfortunately, is still in its nascent stages in many countries. Much more effort is required to increase awareness and participation in cadaveric organ donation programs.

Q: Can you elaborate on the challenges regarding cadaveric organ donation? And why exactly is there so much difficulty in finding suitable donors?

A: With the trend towards smaller families and diabetes being one of the most common causes of kidney disease in our country, finding a suitable donor within the family can often be quite challenging. Diabetes, as you may know, runs in families, and a diabetic individual is typically unfit to be a donor. Therefore, although the rules require looking to first or second-degree relatives for a donor, this can sometimes be difficult.

The alternative option is cadaveric transplantation. Here, there is much we can do collectively as a community to bridge the demand-supply gap. Cadaveric organ donation involves many misconceptions that need to be addressed. For instance, while many people express a willingness to donate their organs after death, it’s crucial to understand that organs can only be harvested for transplantation from individuals who are brain dead, with their hearts still beating. This usually involves patients who have suffered from severe road traffic accidents or strokes.

Considering India has one of the highest rates of road traffic accidents globally yet one of the lowest organ donation rates, it’s clear that significant efforts are needed in this area. Promoting the pledging of organs during one’s lifetime should be a priority if we aim to address the gap between the demand for and supply of organs.

Q: Have there been any initiatives by the government or the private sector to promote organ donation awareness, especially regarding kidneys?

A: Yes, indeed. Prime Minister Narendra Modi has highlighted the importance of organ donation in his ‘Mann Ki Baat’ radio sessions. The government has established the National Organ and Tissue Transplant Organization (NOTTO) as a central body responsible for promoting organ donation and ensuring the transparent allocation of organs, thus preventing any unethical practices. This nodal organization ensures that the process is conducted cleanly and transparently.

However, we cannot rely solely on government efforts. This is where Non-Governmental Organizations (NGOs) play a crucial role. A notable example from the southern part of India is the Tanker Foundation, which has done remarkable work in this field. Similarly, in Gujarat, there are organizations that have significantly contributed to raising awareness about organ donation. Furthermore, groups like the Rotary Club should also intensify their efforts to dispel myths and overcome hesitancy around organ donation.

It’s interesting to note the regional disparities in organ donation rates. States like Telangana, Andhra Pradesh, Kerala, and Gujarat have shown commendable performance, whereas Maharashtra is lagging behind. The northern states, in particular, are significantly behind in terms of organ pledging and donation rates.

However, it’s worth noting that even these higher rates are considerably lower than those seen in many Western countries. A significant factor contributing to this discrepancy is the difference in consent models: Western countries typically employ an opt-out system, meaning that individuals are presumed to be willing organ donors unless they have explicitly stated otherwise prior to experiencing brain death. In contrast, India follows an opt-in model, requiring explicit consent from the individual or, in the event of brain death, from the nearest relatives.

This process can be particularly challenging in India, as the relatives, often in a state of grief or shock, may not be in the best emotional state to make such critical decisions. Compounding the issue are various myths and misconceptions, including fears of body mutilation and religious beliefs suggesting that organ donation might affect one’s afterlife. However, through discussions with religious leaders under the auspices of the Indian Society of Nephrology and the Indian Society of Organ Transplant, it has been clarified that no religion outright prohibits organ donation.

This highlights the urgent need for increased education and awareness efforts within the community to address these challenges and misconceptions surrounding organ donation.

Q: As you mentioned, kidney donation faces many challenges, and dialysis remains a very painful process. In terms of technological advancements, what do you think is the next big innovation in nephrology that will change how kidney treatments are conducted and provide significant relief to patients on dialysis?

A: There are two major innovations in this area. First, dialysis has been miniaturized into what we call a Wearable Artificial Kidney (WAK). It is currently undergoing patient trials, having already been through animal trials in the U.S. This device, which you can wear in your jacket, functions round the clock, much like your own kidney. The WAK offers patients the freedom to travel and more dietary liberty, which is not currently possible for patients on traditional dialysis.

The second significant innovation is the development of artificial kidneys, which are also in advanced trials. Recently in the U.S., an artificial kidney was implanted into a brain-dead donor. Since the donor had passed away, it was ethically permissible to test the kidney in this way, and the device successfully cleared toxins from the body, passing the test. I believe that within the next few years, we should see both of these treatments becoming available to patients.

Q: People who are on dialysis often go through psychological trauma because it’s a never-ending process, and it’s very painful. What advice do you have for them? How do you keep them motivated to carry on with life?

A: There are support groups and NGOs available, such as the Kidney Warrior Foundation. It’s a national organization led by a woman who donated a kidney to her son and then recognized the existing gaps in support, so they’re doing a great job educating patients. There are also local patient support groups, and we have seen patients continue with dialysis for many years. Essentially, it’s about finding a way to cope with the disease because fighting it is the only option. However, it’s important to acknowledge that there’s a tremendous amount of financial stress, which in turn puts mental stress on families, making it a challenging journey.

Q: Dialysis is always covered under insurance, right?

A: For most patients, especially when looking at data from India, it’s important to note that dialysis for people below the poverty line is now covered by the PMJAY. However, for the average individual, it often becomes an out-of-pocket expense.

Some individuals are fortunate enough to have their dialysis covered through corporate insurance or have been proactive enough to secure health insurance. It’s worth mentioning that health insurance penetration in our country is disappointingly low, which is a point of concern for many. Instead of prioritizing life insurance, it’s advisable to consider health insurance.

Insurance coverage also depends on the duration of the policy. Only a small segment of our patients receive coverage, and by and large, most are paying out of their own pocket. The cost of dialysis can vary significantly from city to city, but it’s generally around ₹45,000 a month, including medications, which is reasonably expensive.

Q: Finally, what should one do to maintain good kidney health as a preventive measure?

A: Chronic kidney disease is a progressive condition, meaning that once the kidneys are damaged, there’s a relentless progression from stage 1 to stage 5 kidney disease.

I often tell my patients and community members that your kidneys are like diamonds: once damaged, they cannot be repaired. So, take good care of them while you’re alive. And how do you take good care? There are seven golden rules:

Periodically check your blood pressure, and if you have high blood pressure, ensure it is under very good control.

Get your blood sugar checked and maintain tight control over it. Diabetes is incidentally the most common cause of chronic kidney disease in our country, with hypertension being the third most common. Both of these disorders are lifestyle-related. Unfortunately, people often don’t take them seriously in the early stages and only start paying attention once their kidneys are damaged, at which point there is very little we can do.

Avoid over-the-counter self-medications, especially painkillers, which have been linked to kidney diseases. Anti-acidity drugs like omeprazole and pantoprazole, if taken for prolonged periods, have also been linked to kidney issues. Similarly, we have seen cases where alternative therapy practitioners have loaded patients with heavy metals, resulting in kidney damage. Always seek expert opinions and opt for scientifically validated therapies.

Smoking is harmful to the kidneys, just like it is to the heart and lungs. So, stop smoking.

Diet has become very important. You should follow a healthy diet, which means low in salt and rich in nuts, vegetables, salads, and fresh fruits. It should include fewer carbohydrates and more proteins, along with a good amount of healthy fats. Essentially, a balanced diet, but definitely low in salt, as salt predisposes one to hypertension.

Engage in regular exercise and avoid being overweight. We’re seeing an almost epidemic level of obesity in our country and population, largely due to changes in diet and lifestyle.

Finally, invest in an annual health checkup. I think the best way to do this is on your birthday. Give yourself the gift of life, as we call it, by getting a health checkup done. Of course, you should go out to a restaurant and celebrate, but start the day with a health checkup to ensure everything is in order.