- In SL, nearly 10% of the population has CKD
Gradual, progressive and irreversible loss of kidney function over several months to years is called chronic kidney disease (CKD). When someone has CKD, kidney function declines continuously and slowly.
After a long period, it reduces to a stage where the kidneys stop working almost completely. This advanced and life-threatening stage of disease is called end-stage kidney disease (ESKD). In the early stages of CKD, signs and symptoms are minimal. Symptoms appear only when the disease is advanced. Common symptoms related to advanced CKD are weakness, loss of appetite, nausea and vomiting, swelling of the body and generalised itching. Most of these symptoms are non-specific, and unless kidney disease is suspected in the presence of these symptoms, diagnosis of CKD is likely to be delayed.
The magnitude of the impact Chronic Kidney Disease (CKD) has on Sri Lanka
CKD in Sri Lanka has a big disease burden. The numbers vary from district to district due to additional burden from so-called ‘CKDu’. Overall, in Sri Lanka, about 10% of the population has CKD. Therefore, we have over 2,000,000 patients with CKD, of which most cases have diabetes mellitus. In the North Central part of Sri Lanka; Anuradhapura, Polonnaruwa, and Badulla Districts, in addition to CKD, there is a disease called CKDu (Chronic Kidney Disease of Uncertain origin). CKDu has impacted almost 15-22% of the population in those areas. Overall, the kidney burden in these areas is high.
Is CKD a public health problem in Sri Lanka?
The Annual Health Bulletin of 2022-2023 listed urinary system illnesses, including CKD, as the third leading cause of hospitalisation and also the ninth leading cause of death occurring in the hospitals in Sri Lanka. Annual health statistics of 2021 showed that diseases of the urinary system was the fourth leading cause of hospital admissions and had accounted for nearly more than 3000 deaths per year.
Furthermore, a comprehensive study conducted in Sri Lanka had indicated that approximately 10% of the population in Sri Lanka is afflicted by kidney-related ailments. There has been a notable increase in the burden of CKD in the country in the last two decades with the ‘diabetes epidemic’ and identification of Chronic Kidney Disease of uncertain aetiology (CKDu) in agricultural communities. ESKD is associated with a significantly reduced quality of life and mostly affects people in the working age group. This adversely impacts their capacity to earn and socio-economic status.
Plans for World Kidney Day and its importance in Sri Lanka
The World Kidney Day was founded in 2006 by the International Society for Nephrology to address issues related to kidney diseases. It is marked in the second week of March, and as such it will be held on 13 March. The Day is a global movement to create awareness amongst the public and healthcare professionals, on identifying and treating issues around kidney health. Since Sri Lanka has a significant kidney health issue, which has been ongoing for some time, we use the World Kidney Day (WKD 2025) to build awareness in Sri Lanka about the related issues.
National Institute for Nephrology Dialysis and Transplantation (NINDT) plans in lieu of WKD 2025
The NINDT is in line with the international theme ‘Are your kidneys OK?’, we planned a series of events. The programme was structured on three principles, the first is to empower and give knowledge to the healthcare staff. The second to make the public more aware of the risks and treatments. Third was to facilitate the organ donors of Sri Lanka, who we are thankful for giving the gift of life to others.
The felicitation ceremony, the first of its kind, was held on 14 March. There was also a kidney health awareness walk, which was held on 9 March and was centred around NINDT and the locality. As such, we conducted workshops for our doctors, nurses and the para-medical staff during this period. The NINDT also organised a public awareness campaign, using all forms of media. In the pipeline, there are several awareness-building videos which will include advice from specialists on how to keep kidneys healthy and safe. They will also address how to plan treatment with medical advice, for those who are already suffering from kidney issues.
A booklet containing instructions for kidney disease patients was published by Consultant Nephrologist Dr. Anupama De Silva in Sinhala and Tamil languages and will be available free of charge for patients attending clinics at the NINDT.
Who should get their kidneys checked? Who is at high risk for developing kidney problems?
If you have diabetes, high blood pressure, a history of cardiovascular disease (i.e. heart attacks, heart failure, stroke), if anyone in your immediate family has a history of kidney disease especially with diabetes and high blood pressure and polycystic kidney disease, if you are from an area where the chronic kidney disease of uncertain aetiology (CKDu) is endemic If you have a history of structural problems in your genito-urinary tract and recurrent kidney stones If you had been on medications known to impact your kidneys in the long run (i.e. painkillers) If you have a history of multi-system/chronic inflammatory condition (i.e. SLE, vasculitis) If you have had any previous episodes of temporary reversible deterioration of kidney function (Acute Kidney Injury) with infections and exposure to certain medications.
Issues related to the quality of groundwater as a factor for CKDu
Yes, groundwater quality has been a contributory factor. This is because in those areas the groundwater is found to contain heavy metals. It is suspected that most of the heavy metals originated from the unregulated use of certain types of agro chemicals, weedicides and pesticides. The groundwater has been contaminated with Cadmium, Arsenic etc.
Screening tools
Urine Tests Urine full report (UFR) is a simple, inexpensive and a very useful diagnostic test. Abnormalities seen in the UFR would provide important clues, but a normal report does not rule out kidney problems. Presence of protein in urine (proteinuria) is seen in various kidney diseases. It should never be neglected. Smaller protein leaks in urine may not be detected in a urine full report. Urine Albumin Creatinine Ratio (UACR) is useful to detect significant urinary protein leaks in early stages of CKD. Blood tests blood levels of creatinine reflect the function of the kidneys. Creatinine is a waste product which is removed from the blood by the kidneys. When kidney functions decline, blood level of creatinine rises. Higher the value, greater is the degree of kidney damage.
Screening done; what’s next?
Patients will need to adopt a healthy active lifestyle; healthy dietary habits, reduce dietary salt intake, stopping smoking, maintain a healthy weight, exercise regularly and remain physically active on a regular basis. Achieving prescribed targets of blood sugar and blood pressure control is of utmost importance in patients with diabetes and high blood pressure. Doctors looking after these patients will prescribe medications to treat associated complications and mitigate cardiovascular risks. As these health conditions take a longer time to progress, regular follow up is needed to ensure smooth transition to ESKD. Early detection and meticulous management is the only feasible and cost effective way to treat CKD and delay the need for dialysis and kidney transplantation.
Once diagnosed, how does treatment work?
Mainly, we can treat the stage of CKD and or treat the causes of CKD. For example, if CKD was caused by diabetes, we treat that and control it. We also control conditions such as blood pressure and control protein leaks. This is to prevent further growth of CKD. There are five stages of CKD. We treat the relevant ailments of that particular stage. The complication of each state needs to be managed while the main cause is addressed. This way, we can manage the situation and improve it without allowing the situation to deteriorate to the level where dialysis or kidney transplantation is needed. Sometimes, depending on the cause, some cases can be 100% treatable. CKD can also be managed to a great extent, without letting it progress to the end stage. Despite all these measures, if a patient reaches stage five; the end stage renal disease, there are options to manage the situation. In such cases, there are occasions where we can go for a preemptive kidney transplant, without going for the dialysis stage. This is because in some cases, kidney transplants are the best option for the patient. Where dialysis is needed, there are two types of it. One is hemodialysis where the patient goes to a center where his or her blood is filtered and cleaned via machine. The other form, peritoneal dialysis where a cleansing fluid is passed through a catheter tube into part of the abdomen known as the peritoneal cavity. There are other options of dialysis as well.
How kidney transplantation works
Getting a kidney transplant is a complex process. In Sri Lanka we have two types of organ donation, live donation and a deceased donation, where organs are donated from someone who has passed away. Since we have two kidneys, some people donate one to those in need. The other form of donation, if a parent or families of a brain dead donor is agreeable to it, the deceased kidney can be donated. To receive a kidney donation, a patient has to be prepared to receive it. Since the body will view the new kidney as a foreign entity, the blood groups and relevant HLA protein markers and PRA markers need to be properly matched to the donor organ, to ensure success, and prevent organ rejection by the host body. Once you get a proper match from a donor, the surgery is rather a simple procedure.
The process of receiving a kidney from a deceased donor
There is a legal process when we use a live donation, where no financial benefit to the donor is allowed. There is a process of ethics and a committee at the hospital and the Ministry of Health oversee the process to ensure that it is done properly. At the same time, for donations from a deceased donor, again the relatives and close family members must be happy to do so and give consent. Only with consent, the organs can be harvested. This is carried out by a specialised team at each hospital. The team is led by an anaesthetist. Internationally, there is a declaration on organ trafficking and we in Sri Lanka adhere to the same guidelines.
Let's discuss two of the main causes of Kidney disease – uncontrolled Diabetes and High Blood Pressure.
Diabetic Kidney Disease (Diabetic Nephropathy) and how to prevent it
How common is kidney disease in diabetic patients? It is estimated that 40% of diabetics will suffer from kidney disease in their lifetime. It is also interesting to note that Diabetes is the leading cause of Chronic Kidney Disease which requires dialysis or Kidney transplantation worldwide.
Screening
Type 1 Diabetics should be screened 5 years after the diagnosis.
Type 2 Diabetics should be screened as soon as they are diagnosed and then yearly after that.
Why does Diabetic Nephropathy occur?
There are a few factors that contribute, but one of the main reasons is persistently high blood sugars which in turn damage the kidney cells (Glomeruli) which in turn start filtering more protein that is needed for the body. Poor management of blood pressure could be another important factor in the accelerated worsening of a Diabetic Kidney.
Diagnosis
For this we need to do an Urine Albumin Creatinine Ratio (U.ACR) and depending on the quantification of protein filtered through the kidney we classify as either Microalbuminuria (30-300 mg/g) or Macroalbuminuria (>300 mg/g). This also needs to be repeated and confirmed in three months ideally. Confirmation can be obtained with an Ultrasound scan of the Kidneys.
How do you categorise the severity of Diabetic Nephropathy?
Blood tests for Serum Creatinine and eGFR (estimated Glomerular Filtration Rate) needs to be assessed and depending on these findings your doctor will categorise into separate entities to assess risk and how to manage forward. The most commonly used classification is the KDIGO (Kidney Disease Improving Global Outcomes) classification, where there are five stages of Chronic Kidney Disease with Stage 5 being End Stage Kidney Disease which requires Dialysis or Kidney Transplantation.
Medications that help decrease proteinuria in Diabetic Nephropathy?
There are a few medications which help to control proteinuria in a diabetic kidney. A few examples are Enalapril, Ramipril, Losartan, Telmisartan and Valsartan to name a few common ones. Most diabetic patients with proteinuria would be on one of the above drugs if there are no contraindications to start them. These need to be titrated according to serum creatinine and the serum potassium levels by checking them regularly.
Is Metformin safe in Diabetic Kidney Disease?
It is completely safe in early stages of Diabetic Nephropathy and only should be stopped by the treating doctor when the kidney function is impaired to a significant degree. This is quite important in treating diabetes and is a mainstay medication which needs to continue until the treating physician deems it necessary to stop it, according to guidelines or patient factors. Do not stop Metformin on your own as its benefits outweigh the risks most of the time in Diabetic patients. If you are having side effects like bloating, nausea or vomiting consult your doctor and then stop.
What are the newer medications which are available that help in treating Diabetic Kidney Disease?
SGLT2 Inhibitors (Sodium-Glucose co-transporter 2) like Empagliflozin and Dapagliflozin are relatively new drugs and are freely available in Sri Lanka now. These medications have been recommended to be started after Metformin or coinciding with it to give the best results to prevent Diabetic Kidney Disease.
GLP1 (Glucagon-like peptide-1) agonists are a new class of drugs which are also available in the private sector as Injections or oral medications which have shown benefit in treating Diabetic Kidney Disease. Exenatide and Semaglutide are the known drugs in this class.
High Blood Pressure: A silent threat to your kidneys
Hypertension in Sri Lanka Recent studies reveal that nearly 28.2% of adults in Sri Lanka are hypertensive, equating to one in every four adults. The prevalence of hypertension is rising steadily, fuelled by factors such as an aging population and shifting lifestyles. Hypertension, or high blood pressure, refers to the excessive force of blood against the walls of the blood vessels as the heart pumps blood through the body.
A growing concern linked to high blood pressure
Our kidneys filter around a litre of blood every minute, removing waste and excess fluid to produce urine. However, high blood pressure can damage the kidneys by constricting blood vessels, reducing blood flow, and impairing their ability to filter waste effectively. This leads to a dangerous cycle where kidney function deteriorates further, contributing to kidney failure. High blood pressure is the second leading cause of kidney failure in Sri Lanka, following diabetes.
The importance of blood pressure screening
Experts recommend that adults aged 40 and older without a history of hypertension check their blood pressure annually by your doctor. For those aged 18-39 with no risk factors, a check-up every two to five years is advised. Individuals with a family history of hypertension or those at higher risk should undergo more frequent screenings.
Preventing kidney damage from high blood pressure
The most effective way to prevent or slow the progression of kidney disease caused by hypertension is to keep blood pressure under control. This can be achieved through a combination of medication and lifestyle changes, such as:
- Taking prescribed medications consistently to manage blood pressure.
- Being physically active, with at least 150 minutes of moderate-intensity exercise per week
- Maintaining a healthy weight (BMI between 18.5 and 22.9)
- Quitting smoking and alcohol consumption
- Managing stress through relaxation techniques or therapy
- Eating a healthy diet, which includes a reduction in sodium intake and an increase in fruits and vegetables
It is essential to note that the medications prescribed for high blood pressure do not cause kidney damage. On the contrary, failing to control blood pressure through medications can lead to irreversible kidney damage.
Conclusion
Chronic Kidney Disease is a silent killer that progresses gradually, often going unnoticed until the late stages. While diabetes and hypertension remain the leading causes, urological conditions such as kidney stones, recurrent urosepsis, and prostate enlargement significantly contribute to kidney damage.
The good news is that CKD caused by these conditions is largely preventable. By adopting a healthy lifestyle, staying vigilant about urinary symptoms, and seeking timely medical intervention, individuals can protect their kidneys and maintain optimal health. Raising awareness about these urological causes of CKD is crucial for early detection and prevention. The key to reducing CKD-related complications lies in education, lifestyle modifications, and regular medical check-ups. Let’s take proactive steps today to safeguard our kidney health for a healthier future.
PHOTO Ishan Sanjeewa
Dr. Anupama De Silva, Consultant Nephrologist at the National Institute for Nephrology Dialysis and Transplantation (NINDT)
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The views and opinions expressed in this article are those of the author, and do not necessarily reflect those of this publication