How To Prevent CKD Treatment Failures: Avoid These Common Pitfalls

In the previous episode (Episode 131), I discussed a comprehensive list of medications that have revolutionized the management of kidney disease over the past decade. However, I hinted at a concern: despite the advancements, I am skeptical about whether Pakistan will significantly benefit from these new treatments. Today, I will delve into the barriers that stand like a formidable wall between our patients and these innovative treatments.

Introduction

Assalamualaikum, I'm Dr. Waiz from Expert Consult Clinic, Lahore. In Episode 131, we explored a lengthy list of medications that developed countries use to improve the lives of kidney disease patients. These medications reduce complications and enhance the quality of life for patients, with some even helping to delay the need for dialysis and transplants. Over the next 5-10 years, we expect to see even more benefits as we monitor patients currently on these treatments and observe how effectively they can delay the progression of kidney disease.

However, I don't believe these treatments will be as beneficial in Pakistan. You may wonder why, if these treatments work in the U.S. or other developed countries, they might not be as effective here. The reason isn't that we're biologically different; it's that our cultural and contextual factors create unique challenges. Today, I'll outline these barriers in detail.

Barrier 1: Lack of Screening Culture

The first major barrier is the absence of a screening culture in Pakistan. In many developed countries, regular health check-ups, starting from childhood and continuing throughout life, are a norm. These screenings are vital for the early detection and prevention of various diseases, including kidney disease. Unfortunately, in Pakistan, the concept of regular health screenings is virtually nonexistent.

Most people in Pakistan only visit a doctor or clinic when they start experiencing symptoms. It's a reactive approach, rather than a proactive one. In my opinion, 99.99% of people in our country have their first blood test or health check-up only after they notice significant symptoms. By then, it's often too late, and the disease may have progressed to a more severe stage.

This lack of early detection means we miss the critical window where kidney disease can be managed effectively with the new medications. In kidney disease, early detection is crucial because the best time to intervene is during Stage 3 of Chronic Kidney Disease (CKD), when the Glomerular Filtration Rate (GFR) is between 60 and 30. Many of these new medications are not approved for use in Stage 4 or later, so if we miss the Stage 3 window due to a lack of screening, we miss the opportunity to use these treatments to their full potential.

Barrier 2: Initial Point of Contact

The second barrier is related to the initial point of contact for patients. Even when a patient is diagnosed with kidney disease, the first place they turn to for treatment is often not a nephrologist. Instead, many patients first consult a homeopath or an herbalist (Hakeem). This is a significant problem.

Homeopaths and herbalists often offer treatments that may reduce creatinine levels temporarily, giving patients false hope that they are on the mend. Meanwhile, the underlying kidney disease continues to progress unchecked. By the time the patient realizes that their condition has worsened, they may have already lost valuable time during which more effective treatments could have been administered.

This reliance on non-specialists means that many patients reach a nephrologist only after their kidney disease has advanced to a much more severe stage, such as Stage 4 or 5, when the options for effective intervention are limited. This delay in seeking appropriate care is a major reason why many patients in Pakistan fail to benefit from the advances in kidney disease treatment.

Barrier 3: General Physician Limitations

The third barrier is the general physician's role in the healthcare system. In many cases, after consulting a homeopath or herbalist, patients may eventually visit a general physician. While some general physicians are aware of their limitations and promptly refer patients to a nephrologist, this is not always the case.

In smaller towns and rural areas, general physicians often lack the necessary awareness or resources to manage complex kidney diseases effectively. Some may try to treat the patient themselves, despite not having the specialized knowledge required. This can lead to further delays in receiving the appropriate care, allowing the disease to progress unchecked.

Even in larger cities, where general physicians are more likely to refer patients to specialists, there is still a significant problem. Many patients believe that the best doctor is the one with the highest title, such as a Professor of Medicine or the Head of Department. This misconception can lead patients to seek out highly esteemed generalists rather than specialists in nephrology, which is a critical mistake when dealing with kidney disease.

Barrier 4: Misconceptions About Specialist Care

Another significant barrier is the common misconception that the best care comes from the most senior doctors, such as Professors of Medicine or Heads of Departments. While these doctors are undoubtedly highly skilled, they may not have the specialized knowledge needed to manage complex kidney diseases effectively.

Nephrology is a highly specialized field, and not every senior doctor, even those with impressive titles, is equipped to handle the intricacies of kidney disease. Patients who seek treatment from non-nephrologists may find themselves trapped in a cycle of ineffective care, as these doctors may not recognize the need for referral to a specialist. This is a serious issue, as it can prevent patients from accessing the most appropriate and effective treatments.

Conclusion

These barriers—lack of screening culture, reliance on non-specialists, limitations of general physicians, and misconceptions about specialist care—create significant challenges in the management of kidney disease in Pakistan. While the advancements in kidney disease treatment have the potential to improve patient outcomes dramatically, these benefits will only be realized if these barriers are addressed.

For the healthcare system in Pakistan to truly benefit from these medical advancements, there needs to be a concerted effort to promote early screening, educate patients on the importance of consulting specialists, and improve the referral process within the healthcare system. Only then can we hope to see the same level of success in managing kidney disease as seen in other parts of the world.