This week is kidney awareness week and although there are no reliable statistics it is estimated that 500 per million population per year suffer from end stage kidney disease. This translates to around 20 000 South Africans per year. In the Western Cape around 1 500 patients per year will present with kidney failure of which 80 percent need be treated in the public sector 1000 will be sent home to die from renal failure. Between Tygerberg and Groote Schuur Hospitals they can handle 150 new patients for dialysis. These numbers are expected to grown exponentially at seven percent per year.
Over and above Cape Town there are state dialysis facilities in Johannesburg, Bloemfontein, Pretoria and Durban with much smaller units in Worcester, Vredenburg, Hermanus, George, Port Elizabeth, East London, Umtata, and Polokwane. In many of the cases kidney disease can be linked to untreated hypertension, diabetes and obesity. Increasingly it is linked to HIV and tik abuse. South Africa is not alone. Estimates from the United States, where lifestyle diseases gobble up most of the healthcare budget, it is suggested that up to 10 percent of the entire US population may have early evidence of kidney disease and progression may be prevented by early intervention.
South Africa has been particularly hard hit with high levels of diabetes, hypertension and obesity (all precursors to kidney disease if untreated), says Professor Brian Rayner, recently appointed head of the Division of Nephrology and Hypertension at Groote Schuur Hospital. A University of Cape Town professor, Rayner points out that the rise in HIV disease has also played a big part in the rise in kidney disease. Rayner is forthright at a price tag of R100 000 per patient per year, the chance of receiving treatment is slim. The state cannot provide this service to everyone and the most cost effective treatment is really transplantation, says Rayner, a strong proponent of addressing the root cause of the problem. We need to save the kidneys by implementing good policies. But there seems to be this inertia among doctors about managing the disease. A simple blood pressure, blood and urine dipstick test, can very quickly confirm whether the kidney is functioning properly, says Rayner, adding that a person could lose 80 percent of their kidney function and still appear healthy.
However, kidney problems are not picked up early and with patient numbers rising and only 50 kidney specialists in the whole of South Africa, the picture is grim. We also have very few dialysis nurses and technologists, critical when you want to offer dialysis, says Rayner. Kidney disease is not a sexy topic like heart disease, however there is a very strong link between chronic kidney disease and heart disease, he adds. Rayner says there is definitely evidence of more young, Black men presenting with explosive hypertension and inevitably kidney failure.
We need pick these young men up early and we need policies to back this up, says Rayner. In the US, twice as many Black people are on dialysis. He sites a survey which showed that in the private and public health sector very few doctors were checking for kidney disease with only about half of patients presenting with kidney disease having any prior evidence of their blood pressure being controlled. Rayner said another contributing factor to the rise in kidney disease was the increasing use of methamphetamine (tik) as a recreational drug. Tik contributes to elevating the blood pressure severely which in turn damages the kidneys. Rayner confirms that although not always a popular decision, the hospital was not offering dialysis spots to tik addicts.
HIV positive patients are also currently not assessed for dialysis and end up being sent home to die. Several studies have shown that HIV positive patients respond well to transplantation. Rayner said the hospital was currently designing protocols to make provision for HIV positive patients. This is a new area for us and requires careful planning, he said, adding that his impression was that putting HIV positive patients onto antiretrovirals sooner than currently indicated, could also play a role in preventing kidney disease. Rayner concedes that making the decision on Thursdays as to who accesses dialysis and who is turned down is extremely difficult.
Its very stressful for everyone involved, but we have to try and make the best decision we can with the resources we have, he says. The panel asseses around six patients every week and is able to accept between one and two. Rayner said even if they were given more money the shortage of qualified personnel was a major hurdle. We need more staff and thats the bottom line. Outside of the major centres access to transplantation is very limited. There are large parts of the country with no facilities at all and unless the patients can travel or relocate they are doomed.
Patients suffering from chronic kidney disease, where the kidneys are failing, can be treated in one of two ways:
Hemodialysis: Blood is removed from the body and pumped into a machine (dialyzer) that filters the toxic substances out of the blood and then returns the purified blood to the person. An artificial connection between an artery and vein is made surgically to facilitate access to the blood stream. Patients have to report to the hospital three days a week for several hours.
Peritoneal dialysis: Fluid containing a special mixture of glucose and salts is infused into the abdominal cavity through a catheter where it draws toxic substances from the tissues. After several hours the fluid is then drained out and discarded. Patients are able to do this at home. It has to be done four times a day. Because they have a permanent catheter which makes them more susceptible to infections they are unable to swim or bath.