Methods of treating kidney diseases in Poland

Chronic kidney disease is often referred to as a silent epidemic. And not without reason, because they do not give any specific symptoms in the early stages of development. Their treatment is still a considerable challenge for both doctors and patients. We talked about this with prof. Kazimierz Ciechanowski, head of the Department of Nephrology, Transplantology and Internal Diseases of the Pomeranian Medical University in Szczecin, and prof. Michał Nowicki, head of the Department of Nephrology, Hypertensiology and Kidney Transplantology at the Medical University of Lodz.

Non-specific symptoms make early diagnosis difficult

According to statistics, as many as 90% of Poles suffering from chronic kidney diseases have no idea about their problem. The situation is more serious than we think, because the failure of this organ is more common than diabetes, which makes it a disease of civilization.

What symptoms lead patients to visit a nephrologist?

Prof. Kazimierz Ciechanowski: – Kidneys get sick insidiously. The most serious kidney diseases, such as glomerulonephritis, can be asymptomatic for a long time. Symptoms can also be completely uncharacteristic: general malaise, fatigue, decreased exercise tolerance, edema, hypertension. Special attention should be paid to hypertension. If it occurs in a person under 35, it usually has some cause – most often it is kidney disease. In young people – their glomerulonephritis. When it comes to the kidneys themselves, pyelonephritis is painful – pain in the lumbar region, i.e. in their localization, increasing when the area is shaken (the so-called positive Goldflam symptom), accompanied by fever and changes in the urine noticed by the patient himself (urine). cloudy, foul-smelling).

Urinary tract diseases, especially cystitis, are more symptomatic. The pain is very intense, with the urge to urinate, which is given in small portions and in an intermittent stream. As a rule, there is no fever, but the symptoms are so strong that the patient (more often young) literally howls in pain – like a wolf. Hence the folk term for cystitis – “catch a wolf”.

An attack of renal calculus is very painful, but it is also pain that comes from the urinary tract, not the kidneys themselves. The pain is so strong that the sick person (more often men) “walks up the walls”. Women describe this pain as much worse than the pain of labor.

As I said, the kidneys suffer insidiously, so be “nephrologically vigilant” and regularly – at least once a year – do a general urine test, the result of which may suggest suspected glomerulonephritis. Untreated, in more than 50% of cases, it may lead to their failure with the need for renal replacement therapy – dialysis or kidney transplantation. The second such test is the measurement of creatinine in the blood. The laboratory presents the result together with the so-called estimated GFR (eGFR), which is the amount of glomerular filtration, which assesses the basic function of the kidneys.

Prof. Michał Nowicki emphasizes that the symptoms of kidney diseases may resemble other diseases, which may extend the diagnosis: – Kidney diseases are usually asymptomatic or mildly symptomatic and therefore remain unnoticed for a long time. It is only in the case of significant renal failure that weakness or easy fatigue due to exercise appear. Unfortunately, these are uncharacteristic symptoms that occur in many other diseases, including those as common as cardiovascular diseases, such as heart failure.

In the earlier stage of kidney disease, symptoms such as bilateral swelling of the feet and legs, foaming or turning brown urine, or high blood pressure may appear. Increased blood pressure in a young or middle-aged person without hereditary hypertension is the most common symptom of kidney disease. It is worth remembering this.

Dialysis as a renal replacement therapy

Dialysis is a procedure for removing electrolytes from colloidal solutions, which uses a semi-permeable membrane. Thanks to this, the function of the kidney is replaced, which is i.a. removal of metabolic waste products, toxins, breakdown products of medications taken, but also regulation of blood pressure. Dialysis is usually performed 3 times a week for about 5 hours a day, which can cause patients great discomfort.

Who is dialysis therapy intended for and what are the effects?

Prof. Kazimierz Ciechanowski: – Dialysis therapy is for those whose kidney function is insufficient to remove metabolic products, regulate the water-electrolyte and acid-base balance or regulate blood pressure. Dialysis therapy replaces (ineffectively) the functions of one’s own kidneys – it allows you to live. Without kidney function and without dialysis, a person can survive 10–14 days. Dialyzed “record-holders” survive on dialysis and thanks to dialysis even more than 30 years. Of course, it would be better if they could receive a kidney transplant. But that’s another story.

Prof. Michał Nowicki: – This treatment is intended for two groups of patients, i.e. for those who have the so-called acute kidney injury, which is assumed to be reversible, provided that the failure of the kidneys is temporarily replaced by dialysis. This allows the kidneys to regenerate and take action. The second group consists of chronic dialysis patients who have developed complete and irreversible renal failure or the kidneys were removed for some reason, e.g. bilateral neoplastic tumors or metastatic calculi. We always try to qualify such a patient who undergoes chronic dialysis for kidney transplantation, which is a better method of replacing the own functions of insufficient kidneys.

Kidney transplantation as a chance for a longer life

Kidney transplantation is currently the most beneficial treatment for kidney failure. This organ can be obtained from both living and dead donors. It is worth emphasizing, however, that the average lifetime of a transplanted organ from a living donor is approx. 15 years, while in the case of the deceased, only 9 years.

The most comfortable situation for the patient is when the kidney comes from a close family member, including siblings or parents. The relationship of the donor and recipient is not, however, a necessity. The law also allows for emotional dependence, including partnerships or friendship. Regardless of the relationship between the donor and the recipient, prior to transplantation, the donor must undergo a series of laboratory and diagnostic tests, including tissue compatibility assessment. Contraindication to transplantation are some comorbidities, including diabetes mellitus, hepatitis B and C, cancer and arterial hypertension.

Kidney transplantation may be performed using techniques known as minimally invasive, including laparoscopy or with manual assistance. As a result, the patient leaves the hospital or clinic very quickly, and the time of his recovery is significantly shortened.

Other methods of treating kidney disease in Poland

Dialysis and kidney transplantation are not the only methods of treating kidney diseases in our country. The choice of therapy depends on the patient, the stage of his disease, as well as the presence of other diseases. Changing eating habits and lifestyle is no less important.

What methods are used to treat kidney diseases in Poland? Do they differ from those used in other countries?

Prof. Kazimierz Ciechanowski: – In Poland, all methods of treating kidney diseases that are used in the civilized world are available and used. Infectious diseases such as pyelonephritis are treated with antibiotics – both on an outpatient basis and in a hospital. Glomerulonephritis is treated with steroids and immunosuppressants, e.g. cyclosporine, cyclophosphamide, imuran, mycophenolate mofetil. It is a treatment carried out by specialists – nephrologists. Infectious diseases can be treated by any doctor. The effectiveness of the treatment of infectious diseases is estimated at almost 100%. Some become carriers of pathogenic bacteria, and carriers, like asymptomatic bacteriuria, are rarely treated. The effectiveness of treatment of glomerulonephritis is lower and amounts to 70–90%. Early diagnosis (often confused with infectious inflammation) and appropriate specialist treatment are important.

Prof. Michał Nowicki: – The basis of treatment is the so-called renal-protective treatment, based primarily on lifestyle modifications, such as weight loss, dietary protein restriction, salt restriction, increased physical activity. Pharmacotherapy includes drugs from the group of antagonists of the renin-angiotensin aldosterone system (convertase inhibitors and sartans) and good control of blood pressure, if it is elevated (recommended blood pressure is <130/80 mmHg). Good glycemic control in people with diabetes is also crucial. The results of several recent major studies have shown that some new generation oral antidiabetic drugs, such as SGLT2 (phlosin) inhibitors and GLP-1 analogues, can effectively protect the kidneys from damage.

What are the challenges facing nephrologists in Poland today?

Prof. Michał Nowicki: – The challenge is, above all, a more effective and earlier diagnosis of kidney diseases in our country, which will allow the implementation of the treatment described above in the initial stage of the disease and protect the patient from renal failure and dialysis.

Prof. Kazimierz Ciechanowski: – Last year, the number of dialysis patients in Poland (and worldwide) decreased. About 19% of dialysis patients were infected with the COVID-20 virus, of which about a quarter of the infected died.

The pandemic has reduced the availability of health care, so nephrological patients also reach the clinic or hospital late, with a significantly worsened nephrological condition. This significantly reduces the effectiveness of the therapy. Many patients are hospitalized with the urgent need for dialysis treatment. This is similar to the situation from a quarter of a century ago, when we did not have such developed vigilance and nephrological care. We have and will have patients who are more ill, neglected in terms of health, and therefore much more difficult to treat. With less hope for the effectiveness of the therapy. It is a big challenge for us.