Towards a world free of kidney disease….. by Nadeeka Rathnamalala

10^th of March 2016 is World Kidney Day. Many activities take place around the world to raise awareness of risk factors for kidney disease, encourage systematic screening for high risk groups, encourage transplantation and advocacy of governments to take action and invest further in screening and treatment. Despite these efforts especially by organisations like World Health Organization (WHO) and International Society of Nephrology (ISN) we are still not equal in terms of access to treatment.

Sharing my own experience would perhaps shed more light on this. Having done my initial training in general medicine in Sri Lanka I came to the point where I had to undertake further post graduate studies in a subspecialty in Medicine. When I picked renal medicine, the common response from members of my family was “Are you sure?” Kidney disease outcomes were perceived as being worse than cancer due to limited access to dialysis. When I started my training in 2010 there were only 90 functioning haemodialysis machines in government hospitals in Sri Lanka for a population of 20 million (estimated prevalence of Chronic Kidney Disease (CKD) between 4-8%). Haemodialysis had been first introduced to the country in 1983 and attempts to introduce Chronic Ambulatory Peritoneal Dialysis (CAPD) had not been successful as the cost was much greater than the cost of in centre haemodialysis given that no plants for PD fluid production were in the region. Live donor transplantation was an available option but limited by long waiting lists in the government sector and availability of donors. I went through my training attending on patients who would present breathless with fluid overload due to ad hoc haemodialysis. The limited dialysis slots had to be prioritised according to the severity of symptoms. When I came over to the UK to complete my training in nephrology I was amazed by the free and unlimited access to renal replacement therapy. What was more they were transported back and forth from the dialysis centre at no personal cost!

On my return to Sri Lanka in 2013, to take up my first job as a consultant I was hit hard by the reality. I was appointed to be the only nephrologist in the southern province of the country to provide care for a 2 million population. I was to be based in the tertiary care centre in the region with 7 haemodialysis machines and facilities to perform a live donor transplant every fortnight. I also had funds to have a further 10 patients on CAPD. The hemodialysis machines were working around the clock and at any given time a couple of machines would be having technical faults leaving me with five functional machines at a given time. The total number of patients registered in the clinic was just above 1000 (at least 150 end stage renal disease requiring dialysis) and there would at least be another 5 to 8 in patients requiring dialysis in the hospital. The way I could prioritise was to give preference to the patients with acute kidney injury (with the hope they would recover) and those awaiting live donor transplantation. Everyone else who did not have a plan but were in end stage renal failure had to be fitted in to the left over slots. Despite our best efforts many patients lost their lives due to inadequate dialysis.

That is the heart sinking story of kidney disease in the developing world. 80 % of the dialysis population is in Europe, North America and Japan while the rest of the 20 % is distributed in the vast regions of South America and Asia. These figures are a reflection that dialysis is a luxury mostly the rich can afford. Though disparities in renal care are greater in the developing world, there is data to support inequalities in provision of care to the more disadvantaged populations in developed countries. For example, in the United States ethnic minorities have a higher incidence of end stage renal failure while in Australia figures show that aboriginal Australians are 4 times more likely to die of CKD than the non indigenous Australians.  

Concerted effort on prevention and early detection would be the way forward to minimise these disparities in the future. World kidney day is a global awareness campaign that aims to do just that. This year the theme is “kidney disease and children – act early to prevent it” and aims to highlight the importance of protecting kidneys from an early age. We hope to have a booth in DGRI on 10^th March to hand out leaflets and badges to join in this world wide effort of raising awareness of kidney disease. We hope that staff as well as visitors will take the time to come visit us and support the world kidney day initiative.

Dr Nadeeka Rathnamalala is a Locum Consultant Nephrologist at NHS Dumfries and Galloway

Prioritisation in NHS Scotland by Ewan Bell

I have to make it clear from the outset that the views expressed here are my own – these are my personal views.  They are nothing to do with being Associate Medical Director in NHS Dumfries and Galloway and do not reflect any local management or Board view! I’m writing this as an avid armchair follower of politics, current affairs and economics! I should also stress that I am a member of no political party.

To put my views in context, I should state that I believe that there are 2 fundamental and essential pillars of a fair society;

• Equality of opportunity; in real terms this means free access to education and zero tolerance of discrimination
• Free healthcare; people should not suffer or die because they can’t afford to pay for health-care

I am a passionate believer in the concept of the NHS and free health-care for all. My mum and dad tell me stories about how their grand-parents couldn’t afford to go to see the Doctor. In my view this is unacceptable, incompatible with a fair society and must remain in the past. 

On one hand we have increasing costs due to advances in health-care technology, changing demographics, increased expectation and the costs of prescribing. And on the other hand we have limited resources. Demand will always outstrip capacity. Just about every health-care system in the world is wrestling with this challenge, no matter whether they are publicly or privately funded. There will never be unlimited resources, or indeed adequate resources, to provide all health-care, free of charge, for all people. So how should we, as a society, respond to this challenge?

Let’s consider an analogy.  All households have a defined income. We might moan about it and complain, but there’s not much we can do about it. So how do we respond to this? Most organised households will budget and align expenditure with income. There are fixed essentials, such as tax, national insurance, council tax and rental (or mortgage) payments, over which we have little control. But there are other outgoing costs which can be varied and influenced by the household (maybe not enthusiastically), such as, for example, food, clothes, heating, alcohol, etc. If times are hard, then a household will pull back to the fixed essentials and moderate spending in other areas, or to put it another way, the household will prioritise its spending.

If we apply this approach to health-care, then we need to start debating and defining the essentials of health-care and what can we pull back from. In other words, we really are going to have to start discussing what we should be focusing our limited resources on and what we should stop doing, as not all interventions are equal.

I suppose this goes back to my initial views on the pillars of a fair society. To maintain free health-care for critical, core services in the NHS, we are going to have to start redefining what health-care means and acknowledge that we can’t continue to provide the current range of interventions and services, if we want a sustainable NHS for the future.

So, what are the essentials and what should we stop doing?

Dr Ewan Bell is a Consultant Biochemist and Associate Medical Director for NHS Dumfries and Galloway