A DIFFERENT DRUM
DR. MALAYA SANTOS
Dr. Malaya Pimentel-Santos is a long-time community health advocate, having worked with several non-government health organizations. She is a fellow of the Philippine Dermatological Society and a professor of microbiology at the St. Luke’s College of Medicine.
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(First of two parts)
“The global burden of ESRD (end-stage renal disease) is concealed behind statistics which reflect only the number of people treated, not those who die of kidney failure or cardiovascular complications. This is particularly the case for LMIC (low-middle income countries), where resources to provide RRT (renal replacement therapy) are severely limited and where substantial underreporting of ESRD probably reflects a vast unmet need.”
– Sarah L. White et al., Bulletin of the World Health Organization
My friend Dr. Iris Isip-Tan, an endocrinologist who pens a popular health-related blog The Endocrine Witch, recently asked for support for her advocacy to help promote awareness about kidney disease and dialysis. This is a subject that actually hits quite close to home, because my maternal grandmother had to undergo dialysis in the last years of her life, after her kidneys failed due to complications from long-standing diabetes.
Loss of kidney function is incompatible with life. End-stage renal disease (ESRD) is the final phase of chronic (long-term) kidney disease, at which point the kidneys can no longer perform the task of waste removal and detoxification. ESRD is also referred to as chronic kidney failure, and in most cases the loss of function is permanent and irreversible.
While many different conditions can lead to ESRD, diabetes is the leading cause of chronic kidney failure worldwide. Other possible causes are hypertension, lupus, infections (pyelonephritis), polycistic kidney disease, and kidney inflammation (nephritis). It is important to emphasize that the management of kidney disease must include general health promotion and prevention of kidney damage. Since there are many causes of ESRD, the approach to prevention is also varied. Diabetic kidney disease (and its progression) is prevented by rigorous control of blood sugar, through a combination of diet, medications and lifestyle modifications, as prescribed by your attending physician. This approach also prevents other complications of diabetes, such as in the eyes and microcirculation.
Dialysis and RRT
Patients diagnosed with ESRD must receive renal replacement therapy (RRT) either through dialysis or a kidney transplant. Kidney transplantation will be the subject of the second part of this series. Dialysis, on the other hand, is a procedure that essentially serves as a substitute for the (non-functioning) kidneys’ role of cleansing, filtration and detoxification. There are two types of dialysis: hemodialysis and peritoneal dialysis. Each method has its own benefits and disadvantages, and one or the other will be recommended depending on the specific conditions of the patient, as well as the available resources.
With hemodialysis, the patient is hooked up to a machine that passes blood through a filter (dialyzer) before pumping it back into the body. Treatments are usually done in a hospital or specialized dialysis facility, typically last several hours and are repeated several times a week. Peritoneal dialysis can be done at home, using the patient’s own abdominal lining or membrane (peritoneum) as the cleansing filter. A special solution (dialysate) is placed into the abdomen using a special catheter. This fluid is left for several hours, during which it soaks up waste and excess fluid, after which it is drained and replaced, and the process is repeated.
Cost of renal replacement therapy
RRT requires considerable resources, and there are huge differences in socioeconomic conditions between and among different countries and global regions. A review by Wetmore and Collins, Renal Replacement Therapy (2016) discusses how recent advances in the management of ESRD have greatly benefited patients in affluent countries such as the United States, Canada, Japan and Western European nations, where access to RRT is near-universal, meaning that those needing RRT are able to receive the necessary treatments. Unfortunately, in developing countries, a large proportion of patients with ESRD are unable to access – or receive – these life-saving therapies, representing a vast ‘renal replacement therapy gap’.
In the Philippines where the majority of health expenditure is out-of-pocket, the diagnosis and recognition as well as the management of ESRD are hampered by a lack of access to health care. The Philippine Health Insurance Corporation (PhilHealth) has recently increased its coverage for hemodialysis to 90 sessions per year (instead of the previous 45 sessions). Nevertheless, in some areas, lack of health infrastructures continues to be an obstacle, often combined with other socio-economic, cultural and geographical barriers. Moreover, there are other associated costs such as medical visits, medications and caregiving-related expenses that, together, can sometimes bedevastating.
Looking back, managing and coping with my grandmother’s ESRD and dialysis forced the entire family to confront difficult questions and make equally difficult decisions relating to treatment goals, quality of life, autonomy, hospice care and resource allocation. As a physician, I did my best to address the medical aspects, which ultimately represented only one facet of the complex, challenging and emotional task of participating in end-of-life care.
September 2017 Health and Lifestyle