Management of Chronic Kidney Failure in Transition to Endemic

The Government is increasingly confident in responding to the downward trend in daily Covid-19 cases. Since February 4, 2022, the government has decided to open Bali to foreign tourist arrivals with quarantine procedures. Starting March 7, foreign tourists may enter Bali without quarantine. That is the policy to encourage Bali's tourism economy with the belief that the situation is getting better. Indeed, the curve is getting sloping even though it has not yet reached the safe level nationally. On March 14, 2022, daily cases only increased by 14,900, already a far decrease from the peak of the third wave on February 16 which reached 64,718 people.

This reduction was achieved due to a combination of things, such as health protocols, restrictions on social mobility, and, of course, the achievement of mass vaccination. The first dose of vaccination has reached 193,014,314 people (92.68% of the total target). The second dose of the vaccine has reached 150,280,634 people (72.16%) so that it is close to the state of herd immunity, as the epidemiologists say. However, immunity to the attack of new mutations of the omicron variant requires a third dose as a booster, which has only reached 14,013,132 people (6.73% of the total target).

Because all parties are focusing on dealing with Covid-19 pandemic, there is an important agenda that seems to get less attention, that is the handling and prevention of chronic kidney failure. We have just celebrated World Kidney Day (WKD), which in this year falls on March 10, which reminds us that we still have a responsibility to pay more attention to survivors of chronic kidney disease, especially since the Covid-19 pandemic is not over yet. This year's WKD 2022 theme is "Kidney Health for All", reminding us that there is still a knowledge gap in improving kidney health at the community level and at the same time still facing a pandemic.

In fact, people who have comorbidities are more at risk of dying from Covid-19. The National Disaster Management Agency (Badan Nasional Penanggulangan Bencana/BNPB) noted that patients with chronic kidney disease had the greatest risk of dying from Covid-19, which was 13.7 times compared to those without comorbidities. The comorbidities with the next highest risk were heart disease (9 times) and diabetes (8.3 times). Then, hypertensive and autoimmune patients have a 6-fold risk of death (BNPB, 8/5/2021).

Chronic kidney failure is ranked fourth among the eight catastrophic diseases (diseases that require high treatment costs and have life-threatening complications). Chronic kidney failure is also in the fourth place that sucks up the largest financing by BPJS. The order is heart disease, cancer, stroke, chronic kidney failure, thalassemia, hemophilia, leukemia, and cirrhosis.

Even though medical science and technology are advancing, the number of sufferers of chronic kidney failure continues to increase. In Indonesia, according to 2013 Basic Health Research (Riskesdas), the prevalence of chronic kidney disease (CKD) was only 0.2% of the total population and patients with kidney stones were 0.6%. However, in the 2018 Basic Health Research, the prevalence of CKD increased to 0.38%, a twofold increase. However, the Indonesian Nephrology Association (Pernefri) estimates that the actual number is higher than the calculation above. Research conducted by Pernefri in 2006 at several points in Java found that 12.5% or around 25-30 million of the population had decreased kidney function. This figure was much larger than the calculation of Riskesdas. However, since Covid-19 pandemic, basic health research has not been carried out again, so the latest developments in 2020-2021 are not yet known.

Because it belongs to the category of catastrophic diseases, patients with chronic kidney failure have a heavy burden when facing the Covid-19 pandemic, both from the risk of death and from the high cost of treatment. The disease itself is severe, the cost of treatment is also large. Routine dialysis (for those who choose this therapy) is certainly burdensome for the patient, in addition to reducing the flexibility of physical activity. Therefore, more careful management is needed for chronic kidney failure patients, not only when facing the Covid-19 pandemic, but also in the future for post-pandemic treatment. During a pandemic, of course the management will focus on curative or treatment. However, when the pandemic subsides, the management of chronic kidney disease must focus more on preventive policies, both for primary and secondary prevention.


Understanding chronic kidney failure

Chronic kidney disease can be caused by diabetes or other than diabetes. CKD caused by diabetes, commonly known as diabetic nephropathy, is a collection of symptoms of a disease generally characterized by decreased kidney function in patients with type 1 and type 2 diabetes mellitus. Glomerular filtration (one of the most important components in the kidney that functions to filter blood), and changes in the structure of kidney tissue.

In the early phase, diabetic nephropathy is often asymptomatic, and is usually characterized by an increase in kidney function (hyperfiltration). However, in advanced phase, clinical symptoms may be encountered such as increased blood pressure (high blood pressure), excessive protein content in the urine, swelling of body parts such as the legs, arms, hands and eyes, frequent urination, confusion or difficulty concentrating, shortness of breath, loss of appetite, nausea, vomiting, itching, and fatigue for no apparent reason. These conditions are actually the advanced stage of chronic kidney failure.

The number of people with diabetes mellitus continues to increase globally, from around 425 million people in 2017, it is expected to increase to 629 million people later in 2045. Since diabetes mellitus causes CKD, the increase in the number of people with diabetes will also increase the number of people with CKD. A study in the United States in 2009-2014 reported that the percentage of people with diabetes who had chronic kidney disease was 5 times higher than the population of people without diabetes (Zelnick et al, CJASN, 2017). In Southeast Asia, in 2017, the number of deaths from diabetic nephropathy was recorded to be approximately 2.5 times higher than in 1990 (Thomas, Current Diabetes Reports, 2019). The magnitude of the incidence and mortality due to diabetic nephropathy is what we should all pay attention to.

How does CKD occur and what components are involved? In people with diabetes mellitus, there are four main pathways that lead to gradual kidney damage: circulatory disorders, metabolic disorders, inflammatory pathways, and tissue structural changes. The process of this disease begins with poor blood sugar control in patients with diabetes mellitus. This causes an increase in blood sugar levels which then also increases sugar levels in the kidneys. As a result, there is an increase in the absorption of glucose along with sodium salts in the kidneys, which then stimulates the activation of the feedback system, and activates the hormonal system of renin-angiotensin-aldosterone (RAA). This activation of the RAA system causes an increase in blood flow to the kidneys and an increase in blood pressure.

At first glance, in the initial phase of the disease, this process seems to have a good impact because it will increase the glomerular filtration rate so that blood filtering is getting better. However, it should not be interpreted as such. What happens is actually the beginning of the disorder, so that over time this process will burden the work of the kidneys and eventually damage the tissue structure in the kidneys. Kidneys can be likened to a filter, which under normal conditions has a certain number and size of pores (holes) (about 40 amstrong), and then these pores are breaking down, causing the pores to enlarge. As a result, large proteins are not filtered, passing through, and are excreted in the urine.

In addition, renal tissue structure is also damaged by at least prolonged activation of the RAA system, leading to the formation of scar tissue in various parts of the kidney. Because healthy kidney tissue is replaced by scar tissue, the kidney's function of filtration (filtering the blood), reabsorption, secretion (removal of substances), and excretion (excretion of toxins) from the body becomes impaired.

Meanwhile, an increase in blood sugar levels also causes an increase in the formation of toxic compounds, for example, advanced glycation end products (AGEs, materials that are products of glycation reactions, glucose and protein reactions), which can cause inflammation in the body through the formation of oxidant compounds and free radicals. This inflammation will encourage the change from normal kidney tissue to scar tissue. Both the widespread inflammatory process and the long-term activation of the RAA system will damage tissue structure and decrease kidney function. This is what is often seen as signs and symptoms experienced by patients with chronic kidney disease, such as urinary disturbances, swelling of the legs and arms, and increased blood pressure.


Orientation to prevention

The process of CKD is very complicated and many organs and substances are involved. The process is also not instantaneous, but is a long accumulation of mild initial symptoms, then progresses to chronic kidney failure. This indicates that CKD can actually be avoided if preventive measures are taken early on, long before it becomes severe. If the stage of chronic kidney failure has been reached at an advanced stage, of course it will be very burdensome for the patient's condition.

Suffering from chronic kidney failure at least means having to do routine dialysis or even a kidney transplant, limiting physical activity, and being diligent in taking various drugs recommended by the physicians. Of course, this will cost quite a bit. Imagine the cost of dialysis once a week along with the medicines, of course it feels heavy for most of the people. If the Health Social Security Agency (BPJS Kesehatan) pays this fee later, the accumulation will suck up the state's finances so much that it will reduce the institution's ability to pay for all patients with various diseases.

The Health Social Security Agency (BPJS Kesehatan) noted that chronic kidney failure occupies the fourth position of eight types of catastrophic diseases (diseases with high medical costs and complications that can be life-threatening). BPJS 2019 data states that the first position is heart disease (13 million cases), followed by cancer (2.5 million cases), stroke (2.3 million cases), and chronic kidney failure (1.8 million cases). Research by the Indonesian Renal Registry (IRR, 2018) estimates that the number of patients with chronic kidney failure who require dialysis is around 499 per 1 million population or 0.0555.

Referring to data from the Ministry of Internal Affairs, the population of Indonesia in 2022 is around 273 million. That is, there are about 136,000 patients with kidney failure who require routine dialysis. This figure is still far below the United States (2021) and Japan (2017) which touched 558,060 and 332,376, respectively. We can imagine how many hemodialysis machines and supporting equipment, medicines, rooms, doctors and nurses are needed nationally. Therefore, the management of chronic kidney failure in the future must be more oriented to the prevention side. The causative factors must be identified and avoided so as to reduce the occurrence of chronic kidney failure.

The CKD discussed here begins with symptoms of uncontrolled diabetes and high blood sugar levels. That is, an effective prevention of chronic kidney failure is not to consume sugar excessively early on. Drinking soda, carbonated, and excessive energy drinks must be reduced as much as possible. Research by the Health Research and Development Agency (Balitbangkes) in 2004 showed that consumption of carbonated and energy drinks more than three times per month had a 25.8 times risk of developing CKD. Another study in Yogyakarta in 2008 showed that the risk of CKD increased by 6.6 times higher in people who like to consume energy supplement drinks.

Routine examinations to the laboratory to check blood sugar levels, including the content of HbA1c (A1c) which indicates the number of sugar bindings attached to hemoglobin, are also important. If blood sugar levels are found to be high, a medical examination needs to be done and blood sugar-lowering drugs or insulin injecetions may need to be taken according to the doctor's advice. Other important precautions are maintaining physical, psychological, and spiritual fitness, exercising regularly, maintaining a healthy diet, and trying to sleep 6-8 hours a day.

Basically, everything needs to be lived with the principle of 'enjoy, balance, limit'. Foods and drinks containing sugar can be enjoyed, but the amount is limited. In addition, this needs to be balanced with various types of food so that the body gets a balanced nutritional intake. A well-maintained diet, regular exercise, and a healthy lifestyle are important pillars of the strategy to prevent kidney failure. Hopefully, in the future the number of patients with chronic kidney failure will decrease.


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

Translated from Indonesian:
"Penanganan Gagal Ginjal Kronis pada Transisi Menuju ke Endemi" by Djoko Santoso
Media Indonesia, 14 March 2022