On the occasion of World Kidney Day, Medical Review aiming to increase awareness about the disease that often gets buried under the prevalence of breast cancer and heart disease Interviewed Dr. Mohammad Akmal, Professor of Medicine in the Division of Nephrology at University of Southern California, Los Angeles, CA. He is also the author of a book “Shades of Life” Following are the excerpts of the Interview.
Q1 – Please tell us something about yourself?
Ans – I graduated from Khyber Medical College Peshawar, University of Peshawar, Pakistan in 1967. I did my residency in various hospitals in UK. Before immigrating to USA, I was a Medical Registrar in Medicine at Westcliffe-on-Sea Group of Hospitals, Southend, Essex from January 1973 till end of June, 1975. After two year of Fellowship in Nephrology at The Christ Hospital, Cincinnati, Ohio (7/1/1975 to 6/30/1977), I moved to California where I completed an advanced Renal Fellowship at Los Angeles County-USC Medical Center. I have been in the same institution since July, 1977 and currently, I am a Professor of Medicine in the Division of Nephrology at the Keck School of Medicine, University of Southern California, Los Angeles, CA. I was also a Medical Director of Dialysis Program in the same institution for more than 25 years. In addition to holding many positions in National Kidney Foundation of Southern California, I was a President of Scientific Advisory Board, and Chairman of the Board of National Kidney Foundation of Southern California. I was also a President of Southern California Counsel of Dialysis (Network # 18) for two years. Throughout my career I have received numerous Honors and Meritorial Awards.
Q2 – World Kidney Day is celebrated every year as a part of worldwide event. What are the objectives of celebrating World Kidney Day?
Ans – It is a global health awareness campaign and is celebrated on March 10 every year in more than 100 countries on 6 continents. The Mission of this campaign is to focus on the importance of the kidneys and to reduce the frequency and impact of kidney diseases and its associated complications. WKD is a joint initiative of the International Society of Nephrology (ISN) and the International Federation of kidney Federations. Official site is (http:www.worldkidneyday.org).
Q3 – What is the incidence of kidney disease/renal failure in the world?
Ans – During the 20th century, the pattern of disease morbidity and mortality has changed both in the developed world and the emerging nations. Noncommunicable and noninfectious diseases have surpassed the infectious diseases in causing morbidity and mortality. This change is reflected in the type of diseases that cause CKD. The major cause CKD is diabetes that is resultant of global pandemic of type 2 diabetes. Currently, there are 280 million people with diabetes worldwide. The rate of progression is extraordinary, and it is predicted that the number of patients affected by type 2 diabetes will double worldwide in the next 25 years. Beside North America, Europe and Australasia, and countries throughout Asia also have large number of their incident renal failure due to diabetes: Pakistan, 42%, Taiwan, 35%, Japan, 37%, and Philippines, 25%. About 30% of diabetic eventually progress to end stage renal disease. Studies from India have estimated that as much as 25% of family income may be consumed by the treatment of diabetes in an adult. The global cost of diabetes is now $150 billion, and will double by 2025. By then, India and China with very high prevalence of diabetes may be spending up to 40% of their health care budget on diabetes and its complications. High blood pressure, another major cause of CKD also is a global health problem. About one billion people worldwide have high blood pressure and it is expected that high blood pressure will affect 1.56 billion people by 2025. The prevalence of high blood pressure is estimated to increase by 28% in developed countries and by 80% in developing regions such as Africa and Latin America. The death rate from cardiovascular disease is 8 times higher in CKD, that is much higher than cancer. Millions of patients in many countries have CKD and fraction of them progress to dialysis and the rest usually die from cardiovascular disease before reaching the end stage.
There are 26 million with CKD in USA and many more millions are at risk, but only > than 600,000 patients on dialysis costing more than $30 billion. By the end of 2004, close to 1.8 million patients were treated worldwide with renal replacement therapy (RRT), 77% on maintenance dialysis and 23% living with a functional transplant. There is an incidence of approximately quarter of a million new cases each year. To date about 90% of patients benefiting from RRT live in the more developed countries of Western hemisphere, Australasia and Japan, while sadly, more than 5.2 billion people, 82% of the total world population, still either have no or limited access to RRT. Understandably, the treatment cost for such an ever increasing burden of CKD, even in the wealthiest countries is becoming unaffordable.
Q4 – How do you define chronic kidney disease (CKD)? What are the causes and symptom of CKD?
Ans – CKD is defined as kidney damage for greater than 3 months as evidenced by; abnormal kidney structure by imaging, abnormal function by urine/blood work or GFR < 60 ml/minutes. CKD is subclassified in 5 stages;
Stage 1 GFR > 90
(Damage but normal or elevated GFR)
Stage 2 GFR 60-90 ml/minute
Stage 3 GFR 30-60
Stage 4 GFR 15-30
Stage 5 GFR < 15
Causes of CKD: Diabetes is the commonest and hypertension the second most common cause of CKD and they together are responsible for more than 2/3 of cases. Other causes include glomerular diseases, tubulointerstitial conditions, vascular and cystic diseases, etc.
Q5 – Is CKD more prevalent among a particular age group or sex? If so Why?
Ans – The prevalence of CKD increases with age and highest amongst patients older than 65 years of age and women with age > 65 years have significantly higher prevalence of CKD (stages 3-5).. Overall, males have higher prevalence than women. The increasing age, obesity and diabetes seem to contribute. In USA, African Americans, Hispanics, Pacific Islanders, Native Americans and seniors are at increased risk.
Q6 – What is the survival rate of patients with CKD? What is the time line and prognosis for patients with CKD?
Ans – About 25-27% die annually but may increase to approximately 47% in stage 4 of CKD. The cause of death in CKD is cardiovascular disease in 50% of cases. The second most common cause of mortality is infections. The average life span is 3.5 years that is worse than lung cancer.
Q7 – Do you have any preventative advice for the general public for protecting their kidney function? Are there any hidden threats to kidney function that you think people need to be more aware of?
In addition to above causes of kidney damage, drug induced kidney disease by an indiscriminate use of drugs such as non-steroidal anti-inflammatory drugs may result in a serious kidney disease. The public needs to be educated about this problem. Similarly, antibiotics, diuretics and radiographic dyes should be used with caution to prevent kidney disease. Furthermore, it is important to see a doctor regularly to check blood pressure, bloods glucose, urine analysis, other relevant examination and tests.
Q8 – Treating CKD is costly especially dialysis and transplantation. What you prefer to your patients?
Ans – Renal disease is particularly expensive to treat in many cases. According to 2008 data from the USRDS, annual cost of peritoneal dialysis is $53000 and that of hemodialysis is $72000 (may be much higher in 2011). However, the amount may vary greatly depending on many factors that include frequency of dialysis, nocturnal dialysis, home dialysis, post-dialysis medications and nutritional support. The average cost of kidney transplant is about $54000, which covers the hospital, operating room supplies, staff, nurse, surgeon and medications in the hospital. Many patients prefer a kidney transplant as it is relatively cheaper and also it is one-time expense. Furthermore, it avoids the inconvenience of being hooked up to a dialysis machine frequently.
Q9 – How do you treat the complications of CKD and Please explain whether our specialists follow national guidelines for treating CKD?
Ans – Anemia, bone disease, cardiovascular disease including pericardial involvement, phosphorous and parathyroid derangements, calcium abnormalities, lipid changes, hypertension, gastrointestinal changes, neurologic and hematologic complications, etc. There are guidelines by national Kidney Foundation in USA and the specialists tend to follow these guidelines. There are also local protocols that are followed. European and other countries have also come up with similar guidelines. Specialists are entitled to deviate from the guidelines in special circumstances and in individual cases.
Q10 – Please give some preventive tips to protect the kidneys?
Ans – Kidneys can be prevented from further damage, commonest diseases causing CKD are recognized early and appropriately treated. Since CKD usually results from undetected/uncontrolled diabetes, hypertension, glomerulonephritis, urinary tract infection especially when there is an obstruction in the urinary tract due to an enlarged prostate in men, bladder neck obstruction in women and urinary stones, etc., all these predisposing factors/diseases have to be avoided /prevented right from the early age so as to achieve total protection against kidney damage.
Q11 – What is known about the way renal cell carcinoma (RCCa) develops, grows, and spreads?
Ans – It is also known as Hypernephroma. It originates in the proximal convoluted tubules, the very small tubes in the kidneys that filter the blood and remove the waste products. It accounts for 3% of adult malignancies. It is the commonest kidney cancer in adults that is responsible for 90-95% of tumors arising from the kidney and is the most lethal of the genitourinary cancers. Risk factors include; smoking, misuse of over the counter pain killers for a long time, and genetic conditions e.g., von Hippel-Lindau disease or hereditary papillary renal cell carcinoma. It is characterized by a lack of early warning signs and diverse clinical manifestations.
IN USA it afflicts more than 36000 patients annually and results in death of 12600 adults and children every year. About 50% of new cases are localized (limited to the kidney), 25% have advanced cancer at the time diagnosis, and another 25% are found to have regional kidney center. Eventually, approximately 50% will metastasize (spread to other areas, lung, liver, brain and bone). The risk of tumor is directly related to the size of tumor. RCC can grow locally into very large masses and invade through the surrounding fascia into adjacent organs. They also metastasize through lymphatic channels into regional and mediastinal nodes or by hematogenous routes primarily to the lungs, bone, and brain. Treatment options and prognoses are based upon clinical and pathologic stage. Cancer outside the confines of the kidney carries a less favorable prognosis than one confined to the kidney.
As the cancers are diagnosed early, nephron sparing surgery and thermal ablation are gaining acceptance for smaller tumors. Partial or radical nephrectomy is the standard curative treatment for larger tumors. When the cancer is confined to the renal parenchyma, the 5 year survival rate is 60-70% but it is significantly lower in patients with metastatic disease.
Q12 – What kind of therapy is available for RCCA?
Ans – It is resistant chemotherapy and radiation therapy, although some may respond to immunotherapy. Targeted cancer therapies such as sunitinib, temsirolimus, bevacizumab, interferon-alpha, and possibly sorafenib have improved the progression free survival but not have demonstrated improved survival yet.
Q13 – Please tell us about your book “Shades of Life?
Ans – Our book is the life story of my co-author’s son who developed kidney disease from reflux nephropathy complicated by high blood pressure and kidney failure. Eventually, he received dialysis followed by a kidney transplant. His mother gave him a kidney which lasted more than five years. After his kidney rejected he received hemodialysis and peritoneal dialysis. During that period he developed serious complications. However, this amazing young man was determined to achieve a PhD degree from a prestigious university. This dream was realized at University of Southern California in Los Angeles, California. He is also a fortunate man that his family is supportive. He got tired of dilysis, and this time his brother gave him a kidney which is functioning well. From this story one learns this lesson that determination, faith, and family support can overwhelm serious adversities and the person can achieve any goal of life he/she wishes.
Q14 – What is your message on the World Kidney Day?
Ans – To prevent serious kidney problem and its associated complications, it is important to visit a doctor regularly. Early detection of high blood pressure, diabetes and regular examination of blood and urine will reduce the frequency of kidney disease and slow down the progression of pre-existing kidney disease.
Q15 – How can awareness be created and what are the contributions of doctors?
Ans – Public education through radio, TV, seminars, and print media is of paramount importance. Nephrologists should volunteer to go to schools, religious temples, and community centers to spread the message of kidney disease. Primary care physicians should refer the patients to the nephrologists early for an appropriate treatment.