1. Dr. Ku, I understand that high blood pressure and diabetes are major causes of the so-called End Stage Renal Disease or ESRD. Which is the more common cause? Has the incidence of ESRD risen significantly over the years?

High blood pressure and diabetes are major causes of the so-called End Stage Renal Disease or ESRD. The dialysis population increased from 2100 patients at the end of 1998 to 3400 patients at the end of 2004. Each year about half the number of new cases are due to diabetic nephropathy. Longstanding hypertension by itself is assessed to be the primary cause in only about 5% of new cases. However, uncontrolled hypertension is an important contributor to rapid deterioration from early kidney failure to advanced kidney failure needing renal replacement. Thus, no matter the cause of kidney failure, hypertension has to be controlled well even though it was not the original cause of kidney failure.
 

2. For the benefit of our lay readers, can you tell us how high blood pressure and diabetes can cause ESRD?

High blood pressure causes renal failure because the high pressures are transmitted into the delicate structures within the kidney causing injury to the cells over the long term. Also, high blood pressure leads to hardening of the blood vessels (artherosclerosis) reducing blood supply to the kidney further causing damage.

In diabetes, high blood pressure also develops and causes injury as described above. Furthermore, the high glucose level in the blood combines with proteins (in the blood and also within the structures in the kidney) and these proteins are then deposited in the kidney and are difficult to clear and also cause damage to the kidney.

3. Experts have predicted that diabetes might soon account for half of all patients with ESRD. What advice can  you give to our readers with diabetes to reduce their  risk  of  having  diabetic  kidney disease (diabetic nephropathy)?
 

Reduction of risk of diabetic nephropathy requires the following strategies:

(1) Excellent blood glucose control (HbA1c <7%)

(2) Excellent blood pressure control (BP<130/ 80mmHg)

(3) Use of special medications that reduce both blood pressure and pressures within the kidneys, e.g. ACE inhibitors and angiotensin receptor blockers (e.g. Cozaar, Approvel)

(4) Reduced protein intake in those with kidney failure (S) Excellent control of lipids

4. Prevention is all important What do you think are possible  measures that patients and the country can take to stem the rising tide of ESRD?

Prevention is dependent on early detection and treatment and occurs at two levels:

(1) Regular screening for early detection of diabetes and pre-diabetes in order to take preventive measures for patients about to develop diabetes and to treat diabetes aggressively at the early stages before complications set in

(2) Screening for microalbuminuria in patients with diabetes to detect those at risk of developing nephropathy and to initiate aggressive therapy (as in question 3)

5. Renal dialysis is expensive especially to the lower income group. How does KDF make dialysis affordable?

KDF provides highly subsidised dialysis treatment to the very needy. To fund the subsidies, KDF carries out fundraising activities throughout the year to raise $3.5 million yearly. More than 90% of our patients pay less than $600 out of their pockets for dialysis fees each month. For patients who cannot afford to pay at all, we have the 'Adopt-a-Patient' scheme.

Throughout our ten years of serving needy kidney patients in Singapore, KDF is fortunate to have garnered the support of many generous individuals and corporations who have contributed in various ways. Despite the current philanthropic outlook, we remain relentless and resilient in our fund-raising appeals such as "Bits of Hope" (regular donation programme) subsidised medication scheme,' Adopt-a-dialysis station' programme, etc. This year, as we embark on our tenth year, we hope to get more public support for events like our annual flag day and other activities.

6. Apart from Haemodialysis (HD). there is also the home-based Peritoneal Dialysis.  Can you tell us  the major differences  between the two  methods  and which  group of  patients  will be  more suited to one or the other?

Peritoneal Dialysis (PD) makes use of the peritoneal membrane (the lining of the abdominal cavity) as the filtering membrane to conduct dialysis. Fluid, also known as dialysate, is filled into the abdominal cavity via a surgically implanted tube and allowed to remain for four to six hours so that "toxins" from the body can diffuse through the peritoneal membrane into the dialysate which is then discarded. This cycle is repeated four times a day and takes about 30 minutes each exchange (old dialysate drained and new dialysate instilled).

PD is more suited to young children and also for patients with heart problems and a tendency to bleed. This is because haemodialysis is a more "aggressive" form of dialysis; it is intermittent and blood pressure may aggravate heart problems. Also blood is removed from the body to run through a dialysis circuit and in children, the blood volume is very small and this becomes technically very difficult. Finally, patients on haemodialysis require the use of heparin to reduce clotting of blood in the circuit and this can increase the risk of bleeding. (Refer to Table I )

Table 1 

Differences	PD	HD
Advantages
Type of dialysis	Continuous	Intermittent (3 times a week)
Needles	No needling	Needles involved
Diet	More liberal because of continuous dialysis	Need to restrict more - fluid and potassium
Mobility	More mobile	Need to sit for 4 hours during dialysis
Lifestyle	Less disruptive, home-based	Need to go to dialysis centre. Time off work may be required
Disadvantages
Body image	Tube sticking out	No tube
Bathing	Tub baths not allowed	Can take any form of baths
Infection	Infection may occur	infection of access may occur but less likely

7. I understand that there are over 640 names on the wait list for transplantation. Is transplantation a viable alternative for those with ESRD and who would be suitable candidates? What do you think can be done to make kidney donation acceptable and how can the transplant list be shortened?
 

Transplantation is the treatment of choice for ESRD. However, not all patients are suitable for transplantation. Those not suitable are those with

(1) severe cardiac conditions that may not be fit for anaesthesia

(2) strokes that have residual physical disability

(3) cancer or other conditions that reduce the expected life expectancy. Cancers can also flare up after transplant because of the use of drugs that suppress the immune system.

(4) active infections (include Hepatitis C and B)

8. Finally, Dr. Ku, going forward, what do you see as the role of KDF in the future?

KDF will continue to do what it set out to achieve in 1996. We will continue to be committed to our existing patients who need lifelong dialysis treatment. Apart from treating patients, one other mission of ours is education of the patients, the public and the professionals. As a pioneer in treating the needy, KDF will continue to do the good work for those who knock on our doors and we will not let our patients down.

•     Nephropathy refers to damage to, or disease of the kidney.

• Microalbuminuria refers to protein of the blood plasma manufactured by the liver.