Centres of Excellence

Introduction & Department Highlights
The department of Nephrology has state of art Advanced Kidney Dialysis (AKD) unit which has been established at BLK Super Speciality Hospital. Senior Nephrologist has taken the challenge of providing Nephrologcal Services. The department is always focused to providing high quality medical care with a human touch.

The department is one of the first few centres in India to provide state of Art Renal Replacement Therapy. Under the guidance of Dr. Sunil Prakash, who is Chief Nephrologist and Senior Consultant, we are running the program.

Dr. Sunil Prakash did his DM in Nephrology from the prestigious All India Institutes of Medical Sciences. He was awarded FISN by university of Columbia, Missouri, USA. He has also trained under Dr. D. G. Oreopoulus in university of Toronto, Canada. He has started live related renal transplant program at Artemis Health Institute Gurgaon, the first of its kind in the state of Haryana. Currently he is the Director Senior Consultant and Head of Nephrology Department at BLK Super Speciality Hospital.

Dr. Ashwini Goel did his DM in Nephrology from PGI Chandigarh. He has more than 25 years experience in Nephrology. He worked as head of Nephrology at Holy Family Hospital for 20 years. He was also visiting consultant in Nephrology at the Escort Heart Institute for 18 years.

Kidneys
Kidneys are been shaped organs, each about the size of our fist. The two kidneys are located in the center of the body, at the back, on either side of the spine. Each kidney is made up of small complex units called Nephrons. Each kidney contains about ten lakh nephrons. The kidneys excrete metabolic waste products like Urea, Creatinine, Hydrogen, Potassium and excess water via urine.

The urine formation occurs in the kidneys round the clock and this formed urine is transported to the collectioncenter called urinary bladder via two draining tubes called ureters. (refer fig -1)

At an opportune moment we can void the urine via the urethra, the terminal part of this waste water outlet. A sphincter prevents urine from being passed involuntarily and prevents us from being incontinent. The internal morphology of the kidney in a cross section is also in figure -1

Figure -1

Function of the kidneys:
1. Keeps the internal environment of our body clean and healthy.
2. Excretes the metabolic waste products of food especially nitrogenous wastes.
3. Produces Erythropoietin Hormone which helps in blood formation.
4. Excrete metabolic acids and other toxic compounds
5. Contributes to healthy bone formation by making active Vitamin D
6. Maintains water and salt balance

In chronic Kidneys Diseases both the kidneys loses their functions and patients develop many problems

The most important point to remember is that even up to advanced stages of kidney failure, (CKD IV AND V) patients usually do not have any symptoms. Kidney disease are giant silent killers

The early symptoms of kidney failure includes
• Polyuria (Passing more urine)… Paradoxic
• Nocturia (Passing more urine during night)
• Pedal Edema, puffiness of the face
• Persistent aches and pains
• High blood pressure which is difficult to control
• Shortness of breath on mild exertion
• Inability to complete the family
• Fatigue, lassitude, tiredness

These symptoms can also be due to reasons other than kidney disease. The only way to know the cause is to visit your doctor

Investigation
The diagnosis is made by tests involving blood, urine and ultra-sound scan of the kidneys.Urine examination reveals loss of protein in urine with or without RBC, WBC etc.Blood investigation reveals increased urea, creatinine and electrolytes imbalance.Ultrasound of abdomen may show small shrunken kidneys. It is important to remember that in many CKD patients’ kidney size remains normal. A normal ultrasound for kidneys does not rule out CKD as is the case in most diabetics who have advanced kidney disease.

Following are the groups of patients who should take extra precautions
• Diabetics
• Hypertensives
• Patients having advanced cardiac diseases
• Kidney stones
• Past History of inflammation in the glomerulo (Glomerulo Nephritis)
• Hereditary Poly Cystic Kidney Diseases.

These high risk patients should go to a Nephrologist for checkup. Early diagnosis may lead to slowing the rate of kidney failure which means these patients can live longer without the need of dialysis.

Such steps reduce the patient’s morbidity significantly once he reaches the dialysis stage.

There are two types of dialysis available
1. Chronic Ambulatory Peritoneal Dialysis(CAPD)
2. Hemodialysis. Patients can choose kidney transplant pre emptively as an alternate to avoid dialysis.

Renal Replacement therapy
Once it is determined that renal replacement therapy will be required, the patient (along with his physician) should consider the advantages and disadvantages of three types of therapy.

1. Hemodialysis (in the hospital or at Home)
2. Peritoneal dialysis at home. (CAPD) and
3. Renal Transplantation (living donor or deceased organ donor, also called cadaveric donor)

Renal replacement therapies are treatments for severe kidney failure (also called stage V chronic kidney disease or end stage renal disease). When the kidneys are no longer working effectively, waste products and fluid build up in the blood. Dialysis takes over a portion of the function of the failing kidneys to remove the fluid and waste products.

It is typically needed when about 90% or more of kidney function is lost.

Dialysis
The choice between hemo or peritoneal dialysis is influenced by a number of considerations such as availability, convenience, underlying medical problems home situation, and age.

This choice is best made by discussing the risks and benefits of each type of dialysis with your concerned doctor and his support staff.

When to start dialysis?
It is recommended that dialysis begin well before kidneys disease has advanced to the point where life threatening complications affecting the brain, heart and lungs occur. If one starts dialysis very late, than the quality of life is not significantly improved even after receiving regular dialysis.

Emergency dialysis is usually given when
• Blood tests reveal very high BUN/Serum Creatinine
• Patient has severe shortness of breath due to –
  - Fluid overload
  - Severe metabolic acidosis

• Life threatening hyperkalemia (high potassium levels in blood)
• Bleeding diathesis due to uremia
• Pericarditis, i.e. fluid collection around the heart
• Patient is in altered mental state or has motor weakness due to involvement of nerves.

However a patient is advised to go for early dialysis electively and not to wait for an emergency, as the emergency dialysis has much higher mortality and morbidity risks.

Preperation for Hemodialysis

Mental preparation for hemodialysis should be made well in advance before its need arises.

Primary AV fistula is the preferred type of vascular access.

It requires a surgical procedure that creates a direct connection between an artery and a vein. During dialysis, two needles are inserted into the fistula vein. Blood flows out through one needle, circulates through the dialysis machine, purified and flown back through the other needle.One should get a fistula created usually two to four months before the expected start of life saving hemodialysis.

This will save the patient from temporary catheters, which are more prone to cause infections, injuries and clotting.

Home Hemodialysis
In foreign countries, patient and their relatives are taught to do hemodialysis at home usually at night time before sleeping. This is done anywhere from 3 to 7nights a week. One has to arrange for a hemodialysis machine, water supply unit, disposable, medicines and some chemicals. A separate room is also required. The patients remain in touch with their dialysis center by telemetry or otherwise.

In India due to costs and other issues this modality has yet to take off.

CAPD (Chronic Ambulatory Peritoneal Dialysis)

More common is the home CAPD in India.
A small plastic catheter is inserted in the patients’ abdomen by a simple surgery. The patient with his attendants are taught how to instill dialysis fluid in his abdomen through this catheter and then drain the used fluid out four hours later. This process has to be done thrice a day with all due precautions.

The advantage of this therapy is that

• It can be done in the home environment: so time, money and energy spent in traveling to hospital thrice a week, for hemodiaysis, is avoided.
• There are fewer requirements for blood transfusion
• Generally less restriction is placed on food and fluid intake
• Patient can pursue a normal lifestyle.

Some Do’s for the CKD patient:

• Take your medicines regularly
• Go for periodic checkups with lab tests as advised by your doctor
• Follow your diet plan faithfully
• Do the permitted exercises/physical activities regularly.
• Remain focuses in a positive frame of mind. Negative synergies will aggravate your disease process
• Regular relaxation techniques like yoga, pranayama etc.

And some Dont’s: Avoid the following 4D’s

• Dehydration: avoid dehydration especially in summer months.
• Dyes: unwanted CT and Angiography etc.
• Drugs: Kidney patients should consult their physician before taking any new drug.
• Depression: Avoid negative thoughts.

Diet
Diet plays an important part in management of kidney disease. A balance is made in keeping you healthy as well avoid excess protein load on your tiring kidneys.

Protein regulation

Potassium has to be restricted in diet; it is present in high amount in fruits, nuts and green vegetables potassium can be removed from the vegetables by leeching.

Sodium restriction: To reduce sodium content in diet, do not add salt during cooking or on the table.

Avoid

Foods which could be eaten freely (Low in protein and potassium and high in calories)

Sugar, arrow-root, sago preparation, unsalted butter, refined flour, rice preparation, vegetable oil. Vegetables especially after leaching.

As a patient of CKD your recommended diet will change over time, depending on how much kidney function you have and the renal replacement therapy you are on. The hospital dietician will explain the changes you need to make in your diet and help you choose the right food.

Link-1: Affidavit

Link-2: Affidavit

Authorisation Committee Meeting

Ask the doctor: Department of Nephrology

Talk to our transplant coordinator for assistance any time any where