A simple answer to kidney disease

Preventing kidney disease is the best way of not only saving lives but also taxpayers’ money because kidney disease is the most expensive disease to treat, according to Professor Tony Meyers, the National Kidney Foundation chairperson.

Patients with kidney failure, an advanced irreversible stage of kidney disease, have to be put on a dialysis machine, which works as a kidney.

There are two types of dialysis machines available to patients: haemodialysis, in hospitals, and peritoneal dialysis, which can be operated by patients at home.
But the cost of dialysis is high: each patient on dialysis sets the government back R200 000 a year, according to both Meyers and Professor Charles Swanepoel, a consultant nephrologist at Groote Schuur Hospital in Cape Town. “So, if you are going to spend that amount of money on one person when the rest of your population hasn’t got food to eat, I think you’ve got to take stock on what to do about it,” Meyers said.

In both Europe and the United States patients generally experience kidney failure only after they have reached 60, but in South Africa it tends to strike at a much younger age.

“The common cause of kidney failure in the African population, about 50% to 60%, is high blood pressure. The important thing is that this occurs to young persons with the average age of about 39 years. They are not 65 years old like in America and in Europe,” said Meyers.

According to the department of health, the most common causes of kidney failure are diabetes and hypertension. But in Limpopo, the provincial health department said, HIV/Aids is also becoming a major cause of kidney failure.

Swanepoel said the reason for this might be because of the government’s earlier reluctance to offer antiretro­viral (ARV) therapy. “It might be that now we are still seeing the end result [of that] and now that the ARVs have been rolled out the disease will diminish,” he said, adding that it had been proved that ARVs decreased deaths from kidney disease by 57%.

Meyers said that the best way to prevent kidney failure is to make it the patients’ responsibility. “So what you have to know [is] if there is a person in your family who had a stroke [or] high blood pressure. Those people [who do] must go for a blood check annually from the age of 20 years,” he said. “Even if an individual hasn’t got [access to private hospitals, he or she] can go to a local clinic, Dis-Chem or a clinic in the rural areas—there is a nurse there that will check his or her blood pressure.”

Deaths can be avoided
The foundation’s website said 70% to 80% of all chronic kidney failure deaths can be avoided by prevention, early diagnosis and the proper treatment of hypertension and diabetes.

Meyers said about 300 to 400 per million of the black population, the majority of patients in the public sector, go into kidney failure every year. But despite these large numbers, according to the department, the country has only 70 registered and practising nephrologists catering for both the private sector and the state—and some provinces do not have even one in state hospitals.

“Unfortunately we do not have a resident nephrologist but [we] do have the services of a visiting nephrologist on a quarterly basis,” the Limpopo department of health said in a written response to the Mail & Guardian.

The Eastern Cape’s biggest metro, the Nelson Mandela metropolitan municipality, also does not have a nephrologist. Livingstone Hospital in Port Elizabeth has only a specialist physician who is supported by nursing staff. The whole province is catered for by only two nephrologists.

Owing to the high cost of dialysis, few state hospitals have machines and patients have limited access to them. The national department has acceptance guidelines for dialysis treatment in public hospitals.

“Before it is decided that dialysis is a suitable option for an individual there should be a full assessment of the patient’s healthcare needs, such as economic, social, school and work circumstances. “The consequences of long-term dialysis are significant on the patient and their families,” reads a document that was signed by the former minister of health, Barbara Hogan, in 2009.

A paediatric nephrologist practising in Gauteng, who did not want to be named, said: “What we normally do is that every patient who goes on to dialysis is given a choice to say what he or she wants [peritoneal or haemodialysis].”

Dialysis not a cure
The downside of peritoneal dialysis is that the patient needs a storage area for the boxes of fluid used by the machine. “So if you live in a shack — it’s a bit of a problem. Two, you must have a tap with running water where you can wash your hands to connect your dialysis machine and preferably you should have a room and preferably there must be electricity,” she said.

Dialysis is not a cure for kidney disease but is generally used while patients are waiting for a kidney transplant—which tends to be a long wait. According to the department, only 290 kidney transplants were performed in the country in both the private and public sectors in 2009. Swanepoel said Groote Schuur performs between five and six transplants a month and there are 180 patients waiting for a transplant.

“We must be doing more; we don’t transplant enough. But donors aren’t forthcoming. We don’t have people giving us kidneys,” said Swanepoel. But the biggest problem, according to Meyers, is the current state of primary healthcare.

“We have got to put our house right not by increasing the budget to the dialysis and transplant units but by increasing the budget and expertise to the clinics [that serve] the poorest of the poor. Get that right and you would have done an enormous job for the kidney foundation.”

Second chance for lucky few
At the age of 14 doctors told Sudley Adams she had kidney disease.

Her life took a dramatic turn in 2009 when this condition developed into nephrotic syndrome and later she was diagnosed with kidney failure. Now, for the rest of her life, unless she gets a kidney transplant, she has to wake up at 3am every second day of the week to go on haemodialysis.

Her life had to change completely: “I can’t drink any more,” she said, laughing. “It’s a complete lifestyle change; your life revolves around a clinic now. This is four hours of your day. So, your spare time, you use that absolutely to the fullest. I rest a lot.”

From her neck, a plastic pipe runs down her chest under her skin and comes out just below her breasts. “I always call it a pipe in my boob,” she said, joking. The exits, where the dialysis machine is connected, are always covered with plaster.

But the pipe will be removed as soon as a fistula vein has been built into her left arm to perform the same function. Almost half her inner forearm is black with scars, evidence of surgery performed to build the vein.

Adams, who is on a medical aid, considers herself lucky compared with kidney failure patients in public hospitals—she describes dialysis as her second chance. “I would hate to be in a public hospital in this situation. I don’t think I would have survived 2009.”


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