'PeduliLindungi' (Care-Protect) has become two very popular words today because they represent a very effective success in stopping the spread of Covid-19. 'PeduliLindungi' is a government website and application that is very useful in responding to Covid-19 developments, including providing information on Covid-19 vaccinations, latest swab data, and registration of individual vaccinations.

These two words mean that we care for each other and protect ourselves, including tracking infected people in the crowd. The hope is that we can be vigilant and protect each other from further exposure to Covid-19.

As a matter of fact, the substance of 'care and protect' needs to be developed not only for the Covid-19 disease. The government and all of us need to pay attention to all lines of health towards acute and chronic diseases, including chronic kidney disease (CRD). Given that there is a lot for the government to pay attention to in sectors that affect health, it would be wise for the government to consider the priority sector approach recommended by the multidisciplinary committee in the UK (Smith & Jacobson 1988).

The committee recommends priority sectors, such as living habits and health services. For living habits, habits that are very dominant in influencing health today are smoking, diet, physical activity, and alcohol. As for the preventive service sector, the dominant sectors that determine at this time are maternity services, dental health, immunization, early detection of cancer (especially breast and cervical), and detection of high blood pressure.

Given that DM and hypertension are the main contributors to the increasing prevalence of CRD, most of them (except for services for pregnant women and early cancer detection) are very suitable to be used as a basis for formulating the 'PeduliLindungi' from CRD program.

Before the presence of special website or application for CRD, the main manifestation of 'PeduliLindungi' was always reminding each other to take care of the kidneys properly and providing information if someone already had kidney problems so it would not get worse.

Learning from 'PeduliLindungi', the government or the scientific community must continue to develop and integrate a wider range of specialized website/application services, including for chronic diseases. For example, the Ministry of Health with its new organizational partner has launched a pilot cough referral program with the SwipeRX application in June 2021, as well as the ALISA (Automatic Alarm Fluid Control Hemodialysis) application created by Inda Rian Fatma Putri from Universitas Airlangga in 2019.

Application findings for other chronic diseases need to be synergized so that the 'care and protect' attitude is more comprehensive. Related to Covid-19, these various chronic diseases are comorbids that need to be monitored as part of the 'care and protect' from fatalities. It is better if existing websites/applications are provided with features for chronic diseases, including CRD, so that when Covid-19 subsides, those sites will continue to provide wider benefits.

Kidney miracle

We do have to 'care and protect' the kidneys. We all should always be fully aware that the kidneys are amazing. The organ as big as the fist of a hand is still far more magical and superior than its imitation, the dialysis machine which is as big as a small refrigerator.

The kidneys are able to perform many important tasks to keep us healthy by working with various other organs in the body to balance body fluids, get rid of body waste, produce hormones, regulate blood pressure, perform functions in making red blood cells, and maintain bones healthy.

At first glance, this is easy to understand. However, the reality is that there are a series of major problems in which life processes are as complex as any other biological process in the body.

Amazingly, from 1,000 liters of blood filtered a day, 100 liters of fluid are produced, all of which are returned to the body. Finally only 1.5 liters left which will be excreted into toxic urine every day! This amount was found in those who drink 1.5-2 liters of water per day assuming all their organs are working well. When their drinking water is added another 1 liter, the urine that comes out adjusts its water input to become 2.5 liters of urine.

Similarly, in principle, when a person eats very salty food, the urine will adjust the salt intake so that the urine becomes more abundant because the excretion of salt requires water solvent. This miraculous process that allows the body to stay healthy will turn into a catastrophe when the kidneys are damaged or the heart does not work normally. The catastrophe is in the form of life-threatening severe suffocation. The milder form is swelling of the whole body.

Data from Basic Health Research in 2018 shows that the prevalence of chronic kidney failure in the population aged over 15 years in Indonesia is 0.38% or around 739,208 people. According to BPJS Kesehatan data, kidney failure ranks fourth after heart disease, cancer, and stroke at a cost of IDR 2.3 trillion (heart disease IDR 10.3 trillion, cancer IDR 3.5 trillion, and stroke IDR 2.5 trillion).

One of the most expensive treatments for kidney disease is a kidney transplant and dialysis or hemodialysis. Judging from the large costs borne by the government to treat CRD problems, it can be understood that the problem of kidney disease in Indonesia is very urgent.

So was the brief explanation of the damage of this paired organ that has a major impact on a person's life. Furthermore, slowly but surely, kidney damage will silently eat away various systems in the body. The brain may have a stroke. The heart may experience heart failure, or a lethal heart attack. The retina of the eye becomes blind because of bleeding, and many others. In addition, mentally, the conclusion of the doctor's diagnosis that the patient's kidney had been damaged deeply pierced the patient's heart, like a lightning strike in bright daylight.

In short, people with CRD suffer far more, including suffering in solitude, away from attention or help. Finally, they will deal with CRD on their own, depending to their existing capabilities. Even if there is now BPJS Kesehatan, apart from not being able to cover all CRD patients as expected, the kidney problem can overwhelm the BPJS funding.

However, that does not mean the road is a dead end. It's time for us to take our conscience more seriously to reduce the burden on CRD's growth. The cheapest way is still to trace a 'rational roadmap' through preventive ways accompanied by early detection and adequate treatment and follow-up so that it does not turn into CRD. The key word remains 'care and protect' our kidneys.

Drinking enough water is primary. Smoking, alcoholic beverages, excessive herbal medicine, and soft drinks that can slowly damage the kidneys need to be avoided. Diabetes and high blood pressure need to be watched out for because they are the main risk factors for CRD. Lifestyle factors that can increase the risk of developing chronic kidney disease need to be avoided.

In addition, there is another side of prevention that needs to be considered, that is the education for all medical professionals about their main role in detecting and reducing the risk of CRD, especially targeting people at high risk. At an early stage, a systematic screening program for the threat of CRD in all patients with diabetes and hypertension needs to be supported. The next stage is to encourage community involvement to be more active in caring for the kidneys. One of the efforts is to activate the 'PeduliLindungi' system from the CRD.

In a broader context, CRD needs to be seen as a failure to address socioeconomic problems. This means that CRD is not seen as a disease that is caused by a single and individual cause. Although it involves causative agents (eg diabetes and hypertension) and biological processes, chronic kidney disease cannot be separated from its social setting at a macro level.

Therefore, in the larger context, CRD is part of the excesses of social problems. The more severe the socioeconomic condition of the patient, the higher the prevalence and the more severe the complications. If this is considered when making prevention policies in a more macro scope, this feels very human and easy to reduce the incidence of CRD.

Today, salty snacks are increasingly popular. In fact, a person only needs 3-4 grams of salt a day for a healthy life. More than this amount, the sodium salt will overwhelm the kidneys to respond and result in an increase in blood pressure. If this condition continues without stopping, the effects will quickly lead to chronic kidney failure and end up on dialysis, or a scary kidney transplant.

Currently, fast food restaurant chains (which generally serve low-fiber foods, far from the standard value of 20-30 grams per person per day) are rapidly expanding in strategic locations in each city as a consequence of industrial development. So is the rush of energy drinks, high in calories, and carbonated.

All these foods and drinks 'torture' the kidneys. This lifestyle change creates a new culture, the habit and pleasure of consuming foods and beverages containing substances that have the potential to trigger kidney damage. Too pampering the tongue, which is only as wide as three fingers, is very risky to make our kidneys and lives miserable.

'PeduliLindungi' by regulation

To suppress the counterproductive excesses of the industrial era, there must be a 'care and protect' step from the government. The government needs to make regulations so that packaged food companies measure the appropriate number of calories and sufficient fiber. The nutritional content in each packaged food and drink is very important to prevent high risk of causing diabetes, hypertension, and other metabolic diseases. The amount of essence or chemical dye used is also limited to the minimum amount tolerated by the body.

Regulations for companies regarding the health of their employees are also important. Another form of implementation of healthy living is by requiring companies to do exercise together once during working hours, as well as requiring young workers to take stairs without an elevator if they have to go upstairs just several floors apart. Such policies will help keep the workers fit in their daily activities.

Thus, identifying and linking the socioeconomic environment that has the potential to trigger the number of patients with kidney failure, and then reforming it with the firmness of state policies, is a realistic strategy, and it is not difficult to do and at a low-cost.

Various parties, such as health authorities, health professionals, clerics, priests, social activists, and others, must be actively involved in the program. Government authorities in particular need to be encouraged to take action and invest in further kidney screening to control the CRD epidemic. The existing system needs to be rejuvenated in a more innovative way.

The main message is that chronic kidney failure is a common and dangerous disease, but it can be prevented and treated. The trick is that we always 'care and protect' our kidneys by living a healthy and proper life. Mainly, do not overdo it in enjoying the delicacy. Behind the sweet, salty, delicious, and savory taste there is a 'mine' of disease, with the intention that we consume it excessively.

Remember, that we must take care of God's grace. Let's move and launch a new paradigm: Towards prevention-based health with 'PeduliLindungi from CRD!'.

Djoko Santoso
Nephrologist
Professor, Faculty of Medicine, Universitas Airlangga
Chairman of the Health Assembly, the Indonesian Ulama Council, East Java

Translated from Indonesian:
“Peduli Lindungi dari Penyakit Ginjal Kronis” by Djoko Santoso
Media Indonesia, 3 November 2021, page 6