Celebrated every year on the second Thursday of March, World Kidney Day this year emphasized on the theme: Kidney Health for Everyone Everywhere - from Prevention to Detection and Equitable Access to Care. Despite the growing awareness of renal & kidney health, there is the paucity of data about people with chronic kidney diseases (CKD) in India. According to estimates, the number of new patients diagnosed with end stage kidney disease who began treatment is over 1 million per year and rising.

The concerns of kidney disease in India is also due to the inequality in access to healthcare between urban and rural populations, low healthcare spending by the government to this cause and socio-economic challenges. Increased focus on early detection and prevention of kidney disease along with participation from specialised medical service providers will pave the way to greater awareness and understanding this neglected space.

ET this month looks at the 'The Renal Challenge: Understanding the world of Kidney patients'. On the Podium, Dr. Valentine Lobo from KEM Hospital, Pune, explains the challenges in addressing the growing numbers of kidney related concerns in India.

In the Thinking Aloud segment, Jay, shares the fact that unlike other medical conditions, renal & kidney conditions have long been neglected and it is time to assess this subject and address challenges accordingly. In the We Recommend section, Prasad reviews Maria Konnikova's 'The Biggest Bluff' which is about the author's quest to succeed in the world of high-stakes poker while also drawing parallels about human nature.

In Figures of Speech, Vikram's toons 'pass' on some good advice!

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With its large and medically under-served population, opportunities abound in the Healthcare industry in India. The rise of the private sector in medical care was heralded by the Apollo Hospital under its visionary leader, Dr. Pratap Reddy, and since then many others have followed suit. The government has also understood that this is too large a field for a monopoly player to do justice to it and has endorsed the role of private firms in the sector, albeit very slowly and perhaps reluctantly. Consequently, many specialty hospitals have sprung up for cancer, cardiac, ophthalmology, etc.

A field that needs greater attention is Renal or Kidney disease. Neglected for many years, only in recent times has it been recognized that kidney disease is a chronic, non-communicable disease that deserves notice given the increasing number of cases in India. With the large number of diabetes cases in India, it is not surprising that chronic kidney disease (CKD) is generating more awareness now, as hypertension & diabetes are the common causes of CKD.

If undetected or ignored, kidney ailments end up as CKD when the malaise becomes chronic and the patient needs dialysis. The challenge in India is not just the paucity of nephrologists but also enough dialysis centres. Coupled with this is the high cost of dialysis as this is a long-term expenditure. If things worsen - a situation medically called end stage organ failure - the only answer is kidney transplant.

Any form of organ transplant brings its own set of challenges - both medically and financially - and apart from the emotional trauma, there is a major cost to the entire family. The crippling nature of this disease is therefore a cause of societal concern that deserves our attention.

The circumstances surrounding the nature of this medical condition has become a business opportunity too. While peritoneal dialysis can be done at home, globally there are chains of dedicated Renal clinics that serve as a good option to the regular hospital visits that become necessary when dialysis is required. In India, this has been recognised and pure-play global majors have begun operations either by funding entrepreneurs or by tying up with those intending to make a start. It is a matter of time before we see major branded players making a name for themselves in this field, either at regional levels or even nationally. If it could be done in Pathology, Ophthalmology, Dental, etc., there is no reason to doubt why this cannot be executed in Renal treatment too. The other avenue of growth will be Home Healthcare. Technology has made it feasible to bring quality care to the residence of patients and a beginning has been made in some cities in India for renal care too.

It boggles the mind that access to good health care is still an urban phenomena. Expert estimates are that for Renal care too 90% of the dialysis facilities are in urban India. Taking cognizance of this, the government announced the Pradhan Mantri National Dialysis Programme (PM- NDP) in 2016 to provide free dialysis treatment in district hospitals through a public-private partnership model but as in many things, the impact is peripheral as yet.

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ET:  In India, it is estimated that over 7.8 million people live with chronic kidney diseases. What are the main causes of these diseases?

VL:  In India as in many other countries, the main causes of chronic kidney disease are diabetes and hypertension (high blood pressure). With change in occupations and lifestyles, the incidence of diabetes has increased markedly in India earning it the title of "Diabetes Capital of the World". A large number of patients do not receive early diagnosis or treatment of the above conditions and often come to attention only when complications develop. Additionally, over the counter medications like pain killers and many traditional medications have been implicated in causing chronic kidney disease (CKD). It is a myth that medications do not have side effects. All medications in all practice of medicine have side effects yet many are taken without prescription, supervision and almost always without monitoring. This definitely contributes to CKD. In addition, a new form of chronic kidney disease of unknown cause (CCKD-U) has been described in agricultural workers from Andhra Pradesh, Telangana, Goa and Kerala.

ET:  What are the challenges in addressing the growing numbers of kidney related concerns and how can these be tackled, especially during Covid-19 times?

VL:  The main challenge is early diagnosis and monitoring. The traditional marker of kidney disease - the serum creatinine - becomes abnormal only when 50% of kidney function is lost, and so better markers are required. Even when treatment is started, it is necessary to have a regular follow up to monitor the progress of the treatment and the disease. India is estimated, in some studies, to have a prevalent 235 patients with kidney disease per million population and this is increasing. The total number of Nephrologists in India is around 2,000, and half of them are in Mumbai, Delhi and NCR, Bangalore, Hyderabad, Chennai and Kolkata. The remaining 1,000 are scattered to cater to the total population. This is particularly challenging for ensuring early diagnosis, treatment and follow up. The COVID-19 pandemic has put an additional strain on all resources and fear of COVID has also kept people from their regular hospital follow ups.

ET:  Kidney donations can play an important role in saving the lives of many people. How does India fare in this regard?

VL:  India relies largely on a living related kidney transplantation program. Around 7,000 transplants were done per year in pre-COVID times, while the number of patients with end stage kidney disease in India is estimated to be roughly 1.8 lakhs. India has the highest number of deaths due to road traffic accidents in the world and therefore a very high number of brainstem deaths, estimated at around 1.47 lakhs in 2017. Even if 10% of these brainstem dead patients had been organ donors, there would have been no need for living donor kidney transplantation in India. Fortunately in recent years, the number of deceased donor transplants has been increasing thanks to the work of numerous zonal transplant coordination committees now supervised by a central organization the National Organ and Tissue Transplant Organization (NOTTO).

ET:  Technology plays an important role in medical sciences. Can you elucidate how technology is benefiting those who face kidney related ailments?

VL:  Self-monitoring of blood sugar and blood pressure has become possible for almost all patients thanks to the development of accurate compact meters for these measurements. This allows better management and monitoring of diabetes and blood pressure, the two largest contributors to kidney disease. Telemedicine has further increased the reach of self-monitoring under supervision.

ET:  World Kidney Day is celebrated every year on the second Thursday of March. What is your advice to our readers on caring for our kidneys especially at the workplace?

VL:  Drink plenty of water. It is the single most important intervention. If you have diabetes or hypertension make sure you do not miss your medicines and check-ups. Self-monitoring is a useful and accurate way of checking but must be supplemented by physician visits. Avoid over the counter medications and alternative medication, unless under close supervision and when manufactured by a reputable firm. If you have kidney disease make sure you tell this any other practitioners like dentists, emergency room physicians, paramedics so that they can avoid prescribing / administering drugs which may be harmful.

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This is the fascinating story of how Maria Konnikova with a doctorate in psychology became a master poker player, learning the game from scratch - she didn't even know how many cards there were in a deck!

Why Poker? In the game of life that we all play, Maria was in search of the answer to the question - How much of your success or failure can you take credit for and how much is based on just chance or dumb luck?

John Von Neumann, the genius, was the father of game theory. His entire theory was inspired by a single game - poker. Von Neumann wrote "Real life consists of bluffing, of little tactics of deception, of asking yourself what the other man is going to think I mean to do, and that is what games are about in my theory". Unlike other card games or even chess, poker represents the ineffable balance between skills and chance that mirrors life. In the short term, anyone can get lucky and win. It's your skill that helps you in the long term, to win as much money as you can with your best hands, all the while losing as little as possible with your worst hands. To play the long game, you need to survive long enough to respect the power of luck and the role of variance. True skill is really knowing your own strengths and weaknesses.

The central message of this book is leave your certainty at the door. There is no such thing as a sure thing ever. You will never have all the information you want, and you will have to act all the same.

This book isn't a primer on No-Limit Texas Hold'em poker, but a primer on how to navigate through life's uncertainties by understanding the 'grey' in most choices by thinking in terms of probabilities. However, Maria reminds you to be aware of the law of small numbers: we think small samples mirror large ones, but they really don't. As Historian Edward Gibbons warned us back in 1794, "the laws of probability, so true in general, are so fallacious in particular."

The first real lesson she learnt by playing poker was not how to win but how to lose well. In life, when we are on a winning streak, we rarely stop to analyse our process and learn from our success. Setbacks, disasters really teach us by bringing in objectivity. 'When things go wrong, other people see it as the unfairness that is always surrounding them that they take it personally. They look for someone or something to blame. They don't step back to analyse their own decisions, their own play, where they may have gone wrong themselves.'

As her coach and the word's number #1 poker player Erik Seidel told her that the beauty of poker is that generally delusion is punished. You may get away with an illusion of control in the short term, but if you persist, no one will know your name in a few years. In real life, we can remain deluded indefinitely. In fact Erik's mantra for success over the years (US$ 30 million worth of earnings) is 'less certainty, more inquiry'.

In poker as in life, there is no perfect way to play the hand you are dealt with, only a constant process of inquiry. To do so you have to listen, adjust, be self-aware and be disciplined. All of which allows you to make good decisions which according to Maria, is the real objective of poker.

Poker is about 'picking your spots' to adapt and strategize. Know when to be aggressive and how to be aggressive. You can't play scared in the game of life. Maria shares some great examples of how she used her understanding of poker while negotiating with publishers, based on the incomplete information available to her.

There are many more insightful lessons in this book.

This book is inspiring at many different levels especially if you are aspiring to achieve a BHAG (big hairy audacious goal). Her journey could be yours; she has described her transformation with such clarity and feeling that it prepares you for the road ahead should you choose to embark on such a journey of mastery.

How much does poker really resemble real life? Nassib Taleb believes we cannot use games as models of real life because in life, the rules derived from games can break down in unforeseen ways. It's called the ludic fallacy - life is messy and games are not.

For Maria, poker essentially taught her to deal with losses at a game level and which when translated to a life level, helped her tremendously in managing uncertainty and to be more resilient through the wealth of skill she acquired, the depth of her decision-making ability and her emotional strength and self-knowledge.

'The biggest bluff of all is that skill can never be enough. That's the hope that allows us to move forward in those moments when luck is most stacked against us, the useful delusion that lets us push on rather than give up.'

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