With a recent surge in cases, renal failure has emerged as a pressing concern within the medical community. Renal failure, also known as kidney failure, represents a significant health challenge characterized by the kidneys’ inability to adequately filter waste products from the blood. The escalating incidence of renal failure underscores the importance of understanding its causes, symptoms, and treatment modalities to mitigate its impact on individuals’ health and well-being.
The Indian Practitioner recently explored the complexities of renal failure in our interaction with Dr. KS Nayak, Chief Nephrologist at Vrinchi Hospital, Hyderabad. Dr. Nayak shared his views on the condition’s underlying mechanisms, risk factors, and modern strategies for its management and prevention.
The Indian Practitioner (TIP): How should a family physician recognize signs and symptoms of acute renal failure, and what investigations should be ordered immediately before nephrology referral?
Dr. KS Nayak (Dr. KSN): The clinical features include: decreased urine output (oliguria or anuria), nausea and vomiting, anorexia (loss of appetite), fluid retention and peripheral oedema, increasing breathlessness (due to pulmonary oedema, or pleural effusions), and, if the patient is volume depleted then postural hypotension and dehydration may be noted. Frequently non-oliguric acute renal failure is first noticed because of symptoms of electrolyte abnormality.
Other clinical features may relate to the cause of the renal failure for eg. drug hypersensitivity – generalized rash and polyarthropathy, rhabdomyolysis – muscle pain, malignant hypertension or diabetes – retinal changes, hepatorenal failure – jaundice and stigmata of liver disease.
TIP: What in clinical practice are the common prerenal, intrarenal, and postrenal causes of acute renal failure, and what are the different treatment approaches?
Dr. KSN:
Pre-renal causes:
Hypovolaemia for example due to acute haemorrhage, burns, circulatory failure – heart failure or shock, and Sepsis.
Treatment: Correction of the cause. Prognosis depends on the cause.
Renal causes: Acute tubular nephropathy for example due to ischaemic acute tubular necrosis, acute interstitial nephropathy for example in ascending urinary tract infection, acute glomerulonephritis – Goodpasture’s syndrome, haemolytic uraemic syndrome drugs – cytotoxics such as cisplatin or streptozotocin, aminoglycosides such as gentamicin, tetracyclines, NSAIDs, ACE-inhibitors, malignant hypertension, following mismatched blood transfusion, multiple myeloma, and hepatorenal syndrome.
Treatment: Generally, arenal biopsy to determine the exact cause. There may be a need for ICU treatment with hemodialysis/automated peritoneal dialysis temporarily. The condition may becompletely treatable and recovery can be complete.
Post renal causes:
Obstructive lesions like stones, prostatic hypertrophy, and congenital obstructive disorders.Treatment: Surgical intervention.
TIP: Chronic kidney disease is a silent disease, what risk factors and comorbidities should be identified by a physician and how should the patients be regularly screened?
Dr. KSN: The commonest risk factors/causes are Diabetes Mellitus, long-standing poorly controlled hypertension, polycystic kidney disease, chronic glomerulonephritis, chronic tubulointerstitial nephritis, and reflux nephropathy. Regular BP monitoring and blood sugar control are necessary. Ultrasound abdomen is an excellent screening test.
TIP: How do alterations in the gut microbiota composition influence the pathogenesis of renal failure, and what therapeutic interventions targeting the gut-kidney axis show promise in preclinical and clinical studies?
Dr. KSN: The gut microbiota can have pathobionts (bad bacteria), which disrupt the integrity of the gut epithelial lining, and leakage of toxic material into the bloodstream affecting the kidney. This can happen due to bad dietary habits such as excessive red meat
consumption. The nurturing of symbionts (good bacteria) can counteract this. Use of Pre and Probiotics, and a plant-based diet can promote the growth of symbionts, as shown in preclinical and clinical studies. We use them regularly with significant benefits.
TIP: How much do you feel is the impact of environmental toxins, such as heavy metals and nephrotoxic medications, on the development and progression of renal failure, and how can we mitigate such exposure to manage the burden of kidney disease?
Dr. KSN: Heavy metals are extensively used in agriculture and industrial applications such as the production of pesticides, batteries, alloys, and textile dyes. Prolonged, intensive, or excessive exposure can induce related systemic disorders. The kidney is a target organ in heavy metal toxicity for its capacity to filter, reabsorb, and concentrate divalent ions. The extent and the expression of renal damage depends on the species of metals, the dose, and the time of exposure. Avoidance of exposure to heavy metals, by strict legal regulations is mandatory.
TIP: What are the latest drugs in managing CKD and how are SGLT2 inhibitors impacting CKD management in people with and without diabetes?
Dr. KSN: Ketoanalogues, SGLT2 inhibitor therapy, and GLP-1 receptor agonists are some of the proven drugs for the treatment of CKD in diabetics and non-diabetics. We have a large group of patients who are on the set treatments and have been off dialysis for several years.
TIP: Could you tell us in brief the kind of dialysis techniques being used today, and their relative indications and risks.
Dr. KSN: Apart from hemodialysis, we have related techniques of Haemodiafiltration (HDF) Continuous Renal Replacement Therapy (CRRT) in the ICU. An excellent form of treatment, of which we are global pioneers, is the use of Emergent Start Peritoneal Dialysis, whereby an automated machine(APD) is used to start peritoneal dialysis immediately upon patient presentation in the ICU. This can be used both for Acute Renal Failure and CKD. Xeno transplantation with the usage of gene-edited pig kidneys for transplantation has already been initiated and may become a regular affordable treatment modality in less than a decade.
TIP: What are the benefits and risks of cadavericrenal transplant over live family donor transplant?
Dr. KSN: When no family donor is available, a cadaveric renal transplant may be the only option. Prolonged waiting list and cost of treatment are the main drawbacks of cadaveric transplants. We performed the first cadaveric kidney transplant in Andhra Pradesh in 1996.