Key to Kidney Health

Leading Nephrologist of Mumbai, Dr Rushi Deshpande speaks in-depth about how to prevent lifestyle diseases that adversely affect the kidneys and the remarkable progress that medical science has made in their medical treatment

In the earlier days, the kidney was thought of as one part of the body and there were hardly any instances of ailments related to it. Since when did that change?

Dr Deshpande: Lifestyle diseases are on the rise. India is deemed as the diabetic capital of the world. Unfortunately, if you go to any dialysis unit, you will find that 60 per cent of the patients are there because of diabetes. Thus, kidney-related issues have definitely increased. The number of patients undergoing dialysis does not represent the actual numbers. Hence, the burden of kidney disease in the community is huge. The more the awareness, the better it is, because if diagnosed early and treated properly, a lot of kidney diseases can be reversed or at least halted from worsening.

What are the factors that put stress on the kidneys?

The most common factor that puts stress on the kidney is diabetes, uncontrolled blood pressure, addiction to tobacco, urinary tract infection, kidney stones, over-exercise and some people, unfortunately, get cystic kidney disease.

In the corporate world, stress levels are highest in terms of lifestyle, in particular. What are your observations about the age when people get this disease?

Amongst lifestyle diseases, hypertension and diabetes are definitely on the rise amongst young corporate managers. These are a result of a combination of two factors one is the genetic factor, which is not modifiable, and the other is the environmental factor, which means your lifestyle. A lot depends on how many hours you sleep, how stressed you are, what your eating habits are, your exercise routine, your weight all of which add to a healthy lifestyle and prevention of disease.

When we go into the history of why the patient has developed a kidney problem, we frequently observe that he or she has led a very stressful lifestyle for a long period. Which means, he or she has not paid any attention to diet, or exercise, or followed proper medical treatment, including having medicines on time. By the time they realise they have faltered, it is too late. The damage has occurred.

Do you recommend a change of lifestyle to your patients, along with your expert treatment?

Dietary advice is a big component of nephrology or kidney practise but that plays a significant role in secondary prevention. Primary prevention means preventing kidney disease by controlling the factors that might lead to progressing to the next stage which is dialysis or a kidney transplant.

What diet and exercise you prescribe?

Diet prescription depends on the cause which has led to the kidney problem. We prescribe relly low salt diet, calorific reduction for people who have diabetes or obesity, protein intake which needs to be restricted because if you eat more protein, more waste builds up in your blood, and your kidney disease becomes worse. The challenge in diet planning is to balance the low protein intake without causing malnutrition. Many of our patients need a specialised kidney dietician to get that fine balance. For a person with a kidney stone disease, diet plays an even bigger role – you need extra fluid intake, less uric acid in your diet, less oxalate containing diet in short, a specific dietary plan depending on the nature of stones that are formed.

Do you advocate non-vegetarian food?

For prevention, we advise less portions of non-vegetarian food as they are rich in protein, salt, phosphorus and uric acid, which are all detrimental to the health of a kidney patient. Once they are on dialysis or have a successful transplant, we can review their intake of non-veg food. In fact, if the patient is on dialysis, we actually encourage them to have more protein. At that time, they are catabolic, so they need protein to protect themselves.

Do you think patients are more sincere about having medicines than following the diet and exercise regimen?

Medicines are an essential part of the treatment but in addition to that, the disease progresses much slowly with patients who are more compliant with the prescribed dietary and exercise regimen.

'Medicines are an essential part of the treatment but in addition to that, the disease progresses Much slowly with patients who are More compliant with the prescribed dietary and exercise regimen'

What is the exercise that you recommend?

We recommend 30-45 minutes of aerobic exercise for the healthy heart, thrice a week.

How does a person come to know that his or her kidneys are not functioning properly?

Unfortunately, kidneys have a lot of reserves; unless a person has a significant loss of kidney function, one will not know that he/she has kidney disease. It is like blood pressure; it is like a silent disease. You often find out about it when it’s too late. For patients with blood pressure or diabetes, we recommend that you check your kidney once a year after the age of thirty; don’t wait for the kidney to tell you that it is not well. The more active we are in detecting early, the more active we are in delaying the progression.

Coming to kidney transplant, tell us about the progress made in medical science.

The first kidney transplant was done more than 60 years ago. Since then, the science have evolved a lot, to the point today, that even if the patient’s blood group do not match, I transplant them routinely. An average transplant patient has a good life of 15-20 years after transplantation; of course, they do need to take medicines on a regular basis. In terms of medicine, science is progressing rapidly as every couple of years you have a new medicine that comes on board and that helps transplant patients in managing that disease better.

People often talk about political leaders, Sushma Swaraj and Arun Jaitely, who could not survive a kidney transplant...

Most of the patients with kidney transplant who die, including the two you spoke about, pass away due to unrelated factors. Most of our patients may have a functioning kidney, the cause could be heart ailments, infections or cancers. It is important to remember that it is not always the kidney that fails. Kidney disease does not occur in isolation. If the patient also suffers from diabetes, then it will also affect the heart, the brain, and by kidney transplant, we cure only the kidney; we don’t cure the brain or the heart. Those require independent treatment. And if that is not taken care of, of course, they can have a cardiac problem.

Getting a cadaver is difficult; has it become easier over the years?

I will not say it is easier even though the number of cadaver donations is increasing because of more awareness, thanks to the media and the community at large. Thus, a lot of patients are getting a second life. I work as the chairperson of the Zonal Transplant Coordination Committee (ZTCC), Mumbai, and I can tell you that the number of cadaveric kidney transplants this year is the largest in the history of ZTCC.

Do you think that those who donate kidneys have retained good health? What is it that has changed in the community?

There are two different kinds of donations. One is a cadaveric donation, where a brain dead patient’s family decides that instead of burning or burying the organs, let us give it to somebody for use. And because that act is viewed so positively, cadaveric transplant rates are rising. Are they enough? Not at all because the number of kidney patients has increased so many folds that cadaveric organ donations are not able to keep pace. Today, 90% of our transplants are living donor transplants which means, according to a law that prevails in our country only blood relatives are allowed to donate a kidney to their family. So, donations frequently come from parents, spouses, brothers, and sisters, particularly for younger patients. The youngest recipient that we had was a child weighing just 12 kgs.

How does one go about, with kidney donation?

For kidney donation, there are forms available. They are called organ donor cards, All of us should fill them and keep them with us, although that consent is not enough for me to take your organs and pass them to somebody else. I still need your family’s consent, should the unfortunate stage come where the person is brain dead. But if you have an organ donor card signed with you, then the family is much more comfortable taking that decision. Because they know that it is not their decision, it is yours. They are just implementing it.

Is there any relationship between donor and donee after the operation?

Actually, there is none. We don’t like the donor’s family to connect with the recipient’s family. The reason why this is followed everywhere around the world is that you don’t want them to be a party to problems that may arise with the patient in the future. Because you have done what you could do to help them, and that should be the end of it. Beyond that, allowing access to the recipient’s life might actually cause them more grief than benefit.

What is dialysis, why do you come to that stage, and how does one live after that?

Dialysis is a treatment for kidney failure. There are lots of functions of the kidney. The three important ones which are replaced by dialysis are volume balance, fluid balance and removal of waste materials. The other functions like production of certain hormones are not replaced with dialysis. Dialysis does not cure the kidney; it does not harm the kidney. Dialysis works instead of the kidney, so dialysis will be required for two forms of kidney problems, one is acute and temporary like kidney failure like in the case of malaria. That is acute care dialysis. There is the second one which is permanent. Permanent means the kidneys cannot recover. They become small or shrunken, or because of diabetes, one or both have failed. If your doctor has confirmed that it has failed irreversibly, then it is a permanent form of dialysis.

There are two types of dialysis - blood dialysis and stomach dialysis. Stomach dialysis is called peritoneal dialysis, which can be done at home by the patient or the family. There is a tube inserted in the stomach and you just put the medicine into the stomach, keep it for a few hours and remove it. The medicine will do the job of removing extra water and removing the waste. It can be done by the cycler at night or it can be done manually. The other dialysis is blood dialysis or hemodialysis. The common form of dialysis in our country is hemodialysis; 95 per cent of patients do their dialysis in this form. One reason for that is because peritoneal is more expensive and the other reason is that not many doctors are trained to do peritoneal. I was fortunate to train with Doctor Oreoplolous, who was the father of peritoneal dialysis, when I was in Toronto, Canada. Blood dialysis is done over four hours, thrice a week, and it is lifelong. I have some patients on night dialysis for eight hours, thrice a week, and they are doing far better than regular dialysis patients.

Somebody I know had done dialysis for nine years and he was very positive minded. He was a corporate entrepreneur, so he used to have his dialysis and even go on his office trips to the UK. Was that a case of mind over matter?

Patients with a positive attitude do very well on dialysis. Once a patient understands this is giving an extension to life, he or she should go through it without worry. Once the positive attitude comes, these patients live an active life. I have patients who work 9am to 5pm and come for dialysis from 6pm to 10pm. And go back home after dialysis. That is how well they can take it.

Dialysis in itself is a very good treatment, and we have patients with renal failure, who are living 20-25 years after the diagnosis, with dialysis, and transplantation, you don’t have to choose one. You can be on dialysis, get a transplant; even if the transplant fails, you can come back on dialysis, have a second transplant; the limitation is not of the availability of treatment.

"Because that act is viewed so positively, cadaveric transplant rates are rising. Are they enough? not at all because the number of Kidney patients has increased so Many folds that cadaveric organ donations are not able to Keep pace"

Where did you study in your school days?

I am from Mumbai and besides school, I had my nephrology training there. I was in Toronto for a few years before I decided to come back. Since the last 14-15 years, I have been working in Mumbai.

Canada is the best place to live in, why did you come back?

This is our home country, so definitely, there is a strong reason. I was awarded the Gold Medal in Nephrology by Dr APJ Abdul Kalam. His conversation with me was a life-changing experience.

Why did you think of becoming a doctor, why not any other profession?

I think I could have only become a doctor. Firstly because I love medicine. I feel connected with my patients, I feel good when somebody gets healthy. I feel a sense of satisfaction. I don’t think I could have done anything else.

You mentioned about the social work that you do, can you elaborate?

The last 10-11 years, I have been working as a visiting honorary faculty at Tata Memorial Hospital. I have helped them establish the dialysis unit there. I am the only nephrologist attached to that hospital, which is the biggest cancer centre in the country. We do help a lot of patients with cancer, if and when they need it in case of a kidney problem.

What do you think of the doctor patient deficit that has cropped up over the years?

That is a part of the overall social problem. How we are as a society will also mirror in everything that we are doing, including the doctor-patient relation. One of the most important relationships between a doctor and a patient is the trust that should not be breached. If you go to a doctor with the doubt that he is too commercial, then you should not go there in the first place. Secondly, from the doctor’s perspective, he/she is in a profession, not in business. Of course, he/she will make his cheque at the end of the month by doing the work that he or she is involved in, but that should not be the overall aim of doing what he/she are doing. That should be a side product.

What do you think about patients seeking a second opinion?

I personally think the second opinion is taken when there is a trust deficit between the doctor and the patient. If the doctor has explained every-thing to the patient and their family transparently, they might not need another opinion.

Do you have any expectations from the government regarding making dialysis or transplant easier for the common man?

Ours is not a country which can really afford dialysis for everybody that needs it. Ours is a country where only a transplant can solve the burden of this huge chronic kidney disease epidemic. The government should and must relax the rules for kidney transplantation. Nuclear families are a trend; donors are difficult to get in a nuclear family. As a result of this, people are going where places are not good for transplantation, which are not following the law or they are going abroad and getting it done, which gets exorbitant.

You served in Canada for a few years, did you find anything good about Canada that can be replicated here?

They have a very strong public health programme which we are lacking. Since we are a developing country, our resources are concentrated on fighting communicable diseases, sanitation and TB. Whereas that world is now concentrated on silent diseases like heart disease, cancer and kidney diseases. In those countries, a patient does not have to worry about the cost of the treatment whereas our patient’s primary factor that drives treatment is, what is the cost?

Tell us about your family.

We have a small family, my parents, my wife and my two children. My wife is a radiologist. She has a private clinic. My children are still in school. The elder one is in a high school, 9th grade and the younger one is in the fourth grade.

What is your take on child upbringing?

A happy family is what they need for their all round growth. Parents need to be everything; they need to be mentors, guides, depending on the various phases of a child’s life. You cannot be only in one role. You will have to be a friend at times, and mentor at others.

What is your advice to youngsters who want to get into the medical profession?

They should not lose their passion. Because the medical world drives you crazy; you put in end-less years of hard work to achieve your specialisation, and there is a stressful environment in some hospitals.

Are you happy with the medical education in India?

Medical education here is at par or better than in other countries. We really have a good education system in our country. It can be made better. The concept of classes for entrance exams is new to me, earlier it was not the case. I think that should not be the way medicine should be driven. The way we learnt medicine was much better, I feel, today, children are worried from the first year of the medical school regarding what specialisation they will choose. Things needs to change.

What is your take on private colleges?

Our society cannot take the burden of higher education. Students and their families should be responsible because ultimately how many of us give back to society? Private medical colleges are here to stay and they are serving a good purpose and people should fund their own education and not depend on others to do it.

What is the philosophy of life that you live by?

I don’t treat my work as a job. For me it is a way of life, it is my passion and it is the only thing that I do best. On holiday, after a few days, I don’t feel very comfortable. I am much happier when I am in my workspace, so I am a little different. I love my work, I love my patients; I try to do the best for them. I think all of us should cross that barrier of treating our work as a job. I enjoy it every single minute.

Tips to corporate managers, on how to prevent lifestyle diseases…

If you treat your work as a passion and not as a job, stress levels will go down. Eat right, sleep well, and exercise regularly.