Editorial 1 : Low on salt: turning the spotlight on kidney donors
Context
- There is a great deal of attention paid to the recipient of a organ transplant, and rightly so, but the backbone of live kidney transplantation for transplant surgeons is also to make sure that donors do not face the same problem in the future.
Before the donation
- Before donating the donor is fully evaluated to make sure the person is completely normal. Age-matched kidneys may be ideal but usually 18 to 60 years is accepted. Between 60- 70 years, an exceptional kidney function and health may permit donation. Blood group matching is usually required but O can donate to any group.
- Minor ailments may not be a contraindication for donating.Diabetes or pre diabetes, obesity, hypertension, kidney stones, etc. require special attention. Medical evaluation is always biased in the donor’s favour. Diabetes in the donor is usually an absolute contraindication. Hypertension with easy control with a single tablet is permitted.
- It is also essential that the kidney function on special test is at least 75 ml per minute There should no protein leak. Metabolic workup in persons having small stone is a must. Those with multiple stones should be rejected. Normally the evaluation should favour the donor and the better working kidney should be left behind with the donor.
After the donation
- After the donation the person requires life long follow-up. Immediately after the surgery the kidney function drops by almost half and the single kidney starts working more to compensate for the loss of the other. This is a process of hyperfiltration at the microscopic level and compensatory hypertrophy at the gross level.
- Donors require to periodically monitor blood pressure. Kidney function and protein loss should be checked at least once a year. Almost one third of donors would develop hypertension over several years but this almost the same incidence as in the general population. A small percentage would develop protein leak in the urine.
- It is essential that the donors are instructed properly with regards to diet, exercise and avoidance of drugs toxic to the kidneys. DASH diet (dietary approaches to stop hypertension) would be ideal. Sufficient vegetables, fruits, whole grains, lean meat, moderate restriction of salt and sugar, and avoidance of transfats is essential.
Salt and Kidney
- The WHO and other medical associations caution on the importance of salt restriction to 5 gms per day in the general population. The 5 gms includes salt present in natural food, salt added during cooking and hidden salt present in preserved or packed food like bread and noodles. Restriction of salt reduces not only blood pressure but also strokes and kidney failure.
Calculating kidney function
- Creatinine is produced by muscles in the body and excreted by the the kidneys. Since normally only kidneys remove the creatinine ,its measurement in blood reflects kidney function .
- Mathematical formulae adjusting for age, weight and sex are used to calculate kidney function and express as eGFR(Glomerular function rate).
- Protenuria or protein leak is a more sensitive test and 85% of the kidney diseases are detected earlier than creatinine estimation. Protein has a large molecular weight and does not appear in the urine unless the microscopic vessel (glomerulus)in the kidney is damaged or it is secreted by tubules.
- The quantity of protein loss in the urine reflects the kidney damage and is used as a measure to see the response for treatment.
- Proteinurea unlike creatinine is not only a marker of kidney disease but also a cause for progression of kidney disease.
- This understanding has led to the development of several group of drugs which would lower protein loss to reduce damage to the kidneys. They include the anti renin system (ACE and ARB) group of drugs, the SGLT2 inhibitors, anti aldosterone drugs etc.
Conclusion
Context
- Infosys founder N.R. Narayana Murthy sparked a debate last week by urging young Indians to work 70 hours per week, citing Japan and Germany as examples of countries that grew because their citizens worked harder and for longer hours to rebuild their nations in the aftermath of the Second World War. He further noted that India’s worker productivity is one of the lowest in the world.
Worker productivity vs labour productivity
- The only conceptual difference between the two is that the ‘work’ in worker productivity describes mental activities while the ‘work’ in labour productivity is mostly associated with manual activities.
- Productivity of an activity is usually measured as the quantum of output value per unit of labour (time) cost at a micro level. At a macro level, it is measured in terms of the labour-output ratio or change in Net Domestic Product (NDP) per worker in each sector (where working hours are assumed to be 8 hours per day).
- However, in certain types of services, especially ones involving intellectual labour, measuring the value of the output independently is very difficult, so the income of workers is usually taken as proxies to suggest productivity.
- Productivity in a more sophisticated usage is an attribute not of time but of skill.
- Human capital including education, training, nutrition, health etc., enhances the ability of labour to become more productive, or churn out greater quantum of value within the same number of working hours.
- Based on this understanding, the reduction in the number of working hours does not hamper the value of output produced, but in turn enhances the leisure and quality of life of workers in real terms, while the value added to the economy could still be increasing, nominal wages remaining the same.
Link between worker productivity and economic growth
- While an increase in productivity made through any sector is likely to affect the value added and the accumulation or growth in the economy, the relationship between the two could be quite complex.
- If by prosperity we intend to suggest prosperity of the workers, this may or may not be true.
- It is noted that the increase in incomes or the prosperity of the richest people is not quite explained by their productivity.
- On the contrary, this prosperity is either linked to hereditary transfers of wealth upon which the rich are earning yields (he called this patrimonial capitalism) or to the ‘super managerial’ class who seem to be deciding their own exorbitant pay packages, quite arbitrarily, not related in any way to their productivity.
India and worker productivity
- As incomes are seen as a proxy for productivity, there is a fallacious inference about productivity of workers in India being low.
- A U.S based multi-national workforce management firm, has in fact observed that Indians are among the most hard working employees in the world.
- On the other hand, Picodi.com an international ecommerce platform has observed that India ranks one of the lowest in terms of average wages per month globally.
- Informal employment in both the unorganised as well as the organised sectors has been on the rise through the course of economic reforms.
- The dubious claim of increased formalisation has been limited only to bringing activities under the tax net. This has however had no impact on improving labour standards or working conditions.
- Even in the formal manufacturing sector you find an overwhelming presence of Micro-Small-Medium Enterprises (MSME) which are labour intensive.
- Studies have also found that there is a systematic process of cost cutting through wage cutting in these enterprises.
Way forward
- Japan and Germany are neither comparable in terms of the size and quality of labour force nor in terms of the nature of their technological trajectories or their socio-cultural and political structures.
- India presents a unique case and any arbitrary comparison would only lead to dubious analytical inferences and fallacious policy prescripts.
- Enhancing social investments, focusing on exploring domestic consumption potential for increased productivity with a human centric assessment of development achievements is the way to a more sustainable and desirable outcome.