LISA CLARK: I'm Lisa Clark. Thank you for joining us for this webcast. The statistics are sobering. An estimated 1 out of every 12 people in America suffers from kidney and urinary tract diseases. Kidney disease is one of the most expensive chronic disease to treat, and partly due to an aging population, it has become the ninth leading cause of death in the U.S., but it is also true that many kidney ailments are preventable and many are treatable. In the next few minutes we'll tell you how you can take an active role in the health of your kidneys.
Joining our discussion this evening, Dr. Leonard Stern, thank you for being here. Dr. Jai Radhakrishnan. Thank you as well.
First, the bad news. Kidney disease is often very hard to diagnose. One of the articles I read stated that you could have a reduction of as much as 75% of normal function before you're even aware that your kidneys are starting to fail. Is that true?
JAI RADHAKRISHNAN, MD: That's absolutely correct, Lisa. There are two issues here. The first is that you have a tremendous amount of reserve in the kidneys before any symptoms manifest, and typically we don't see patients come in with any problems until they're down to about 25 or 30% below normal. The second issue is that the symptoms that accrue from kidney damage are so vague that you might easily ascribe it to something like depression or fatigue from working too hard, and in reality there's a lot of damage being done in the kidney that could lead to a lot of problems like high blood pressure and anemia. Again, it's basically difficult to detect.
LISA CLARK: Now, you are specialists. It would behoove a general practitioner to really acquaint themselves with the symptoms and warning signs of various kidney diseases, and as you say, that's a very difficult thing to do, but let's talk about some of the things that your doctor might look for that you might look for, say, in acute situations.
LEONARD STERN, MD: You might look at it from a slightly different perspective. The general practitioner that sees a patient will typically do screening blood work, and the majority of the time, the patients that we would see would be people whose blood work is abnormal, where some measure of kidney function -- we use a marker called the serum creatinine, which is a general gauge of kidney function. When that number is elevated, then the general practitioner might suspect that there is something awry with the kidneys.
Another screening test the general practitioner could use would be urinalysis, where they look for the presence of protein or inflammatory cells. Sometimes the blood work, in addition to the creatinine, might give the practitioner a clue that there's a problem. The serum protein level, the albumin, might be reduced, or the lipid levels or cholesterol might be elevated. All could be features of subtle kidney disease.
In the early presentations of kidney disease, unless there's a fulminant disorder, the general practitioner will not detect anything. Fulminant disorders are disorders called acute glomerular nephritis, things of that sort, which are systemic illnesses that present with a variety of features -- high blood pressure, swelling of the legs, bleeding in the urine, difficulty breathing -- a major illness requiring hospitalization.
The more subtle forms of chronic kidney failure are very indolent. If the patient told the physician that they're urinating more frequently at night, that might be an early, subtle symptom of chronic kidney failure that would largely be discarded, thinking they drank too much before they went to bed.
LISA CLARK: Do most urine tests that you get at a general physical screening cover these sorts of levels that you're talking about, the creatinine and albumin?
LEONARD STERN, MD: In general, those are routine screening tests so that the standard blood work would look for an index of kidney function, as well as liver function and the blood count and things of that sort.
LISA CLARK: If you have any of the symptoms, you should let your doctor know, of course -- any of the major symptoms for kidney disease. Maybe we should just hit those really quickly. They include frequency of urination, change in frequency of urination?
LEONARD STERN, MD: Frequency of urination might be a symptom of a urinary tract infection, and many people get urinary tract infections. It's very common in women, very common in older men with prostate disease, not necessarily a cause of kidney failure or an acute symptom related to an illness.
JAI RADHAKRISHNAN, MD: It should lead one to seek advice from a practitioner, because it could well harbor a kidney problem.
LISA CLARK: What other source of things might a patient notice about their physical situation that changes?
JAI RADHAKRISHNAN, MD: If a person feels perfectly and suddenly feels run down, tired, weak, they should definitely seek help from a practitioner. Kidney failure could be the cause for all this. If there's pain in the flanks where the kidneys are, if you have pain down there and it's recurrent and disabling, especially, you should definitely get seen, because there could be a stone sitting there, causing progressive kidney damage. If you have a burning of the urine, if you feel scratching in the skin, these are some of the signs, or you've lost your appetite just out of the blue, for no reason, or you're not able to concentrate, your mind's wandering. All these could say that you could have pretty severe kidney disease that needs to be looked at.
LEONARD STERN, MD: But these are very major symptoms, and the vast majority of patients are not going to feel these until their kidney function is virtually far gone, so early symptoms are extraordinarily subtle. They may be, as I described before, they might urinate more frequently at night, or their ankles might be swollen, or the screening test will have shown that their blood pressure is mildly elevated. Those could be the first presentations of some subtle form of kidney disease. When patients lose their appetite, it's generally far advanced. That means this indolent disease has progressed, unbeknownst to both patient and physician.
LISA CLARK: In addition to various forms of urinalysis, doctors may also do some kinds of blood work to pick up problems with kidney function.
LEONARD STERN, MD: Sure. Screening blood tests are done. We use a few different markers of kidney function. As I mentioned before, the serum creatinine is a widely used index. The BUN is a widely used index. The serum potassium. The bicarbonate is an index of the acidity of blood. The kidney is an organ that regulates homeostasis. It is directly responsible for controlling the acidity of blood, and as the kidney fails, our blood becomes more acid. That's readily identified with blood tests. Even things like the blood count -- the kidney makes a hormone that regulates our red blood cells, and during the process of chronic kidney failure, the hormone fails and we don't make enough red blood cells. The symptoms of that are related to anemia, which are fatigue and sleepiness and poor concentration, none of which are really symptoms of kidney disease. So we have troubles with these symptoms because they overlap. Anemia symptoms and kidney disease symptoms look alike. We can treat the anemia symptoms by replacing the hormone. Once we do that, many of the symptoms of kidney disease largely disappear until the illness is very far advanced.
LISA CLARK: If you do suspect you do have kidney disease and you get tested and that is indeed the case, what can you do. How do you proceed from there?
JAI RADHAKRISHNAN, MD: There are certain blood tests. For example, if you suspect lupus, there may be blood tests to look for lupus. But a lot of times we may need to resort to what's called a kidney biopsy. This is done through the skin, and it's an invasive procedure, no doubt, but it's not all that uncomfortable. It's a very special needle. You take two little snips from the kidney portion that's important, and then have the pathologist look under the microscope, and he can then furnish a specific diagnosis.
LISA CLARK: There are certain people who definitely need to keep a close eye on their kidney function, and those are people who have hypertension or diabetes. Both are very strongly linked to impaired kidney function.
LEONARD STERN, MD: Also, a group that has an inherited disorder called polycystic kidney disease. The natural history of this disease is that the patient who has this will develop kidney failure, typically in their fourth or fifth decade, and this is an inherited disorder, so there would be a strong family history.
LISA CLARK: Jai, what about people who have recurrent urinary tract infections or the incidence of kidney stones? Are they more susceptible to developing serious kidney disease that might lead to kidney failure?
JAI RADHAKRISHNAN, MD: Yes. People who get an infection of the upper urinary tract, especially if there's blockage -- like a stone, for example -- could certainly lead to kidney failure if not treated and managed.
LISA CLARK: But if it is treated and managed, is that an indicator that they are then more susceptible to other forms of kidney disease?
JAI RADHAKRISHNAN, MD: No. Essentially, it's directly related to direct damage because of the infection. So if you manage to treat the reason why the patients are getting frequent infections, you're basically okay.
LEONARD STERN, MD: Or you manage to figure out why the patient is making frequent stones, and if we could prevent that, then we could largely prevent the kidney failure related to stones and infection.
LISA CLARK: What happens when you have kidney failure?
LEONARD STERN, MD: Unfortunately, the kidneys are essential organs for life, and untreated a patient would die. But in the last 30 years we have techniques called dialysis or transplant that act as substitute functions for the kidneys, for our own kidneys. With dialysis, patients can maintain life with reasonable quality, but not normal quality, because they're dependent on an artificial means of kidney replacement, but they can live reasonable lives.
Transplantation would be the treatment of choice for kidney failure, but unfortunately, because of organ shortages, we can't provide transplants for everyone. At this point, the number of transplants done in the United States has been stable for a decade. About 9,000 per year and that’s dependent on a shortage of kidney donors. And despite public awareness programs, we’re really unable to raise that number.
LISA CLARK: So, you would encourage people to not only sign their donor cards but also to be vigilant about your health. And make sure that when you go to the doctor -- A) that you do go to the doctor -- but that when you go that you get a good, full screening of all of your systems.
LEONARD STERN, MD: Absolutely.
LISA CLARK: Again, thank you so much. There's so much information that we've tried to cover here, and I really appreciate all of your help in helping me walk through it. Thanks to Dr. Leonard Stern and to Dr. Jai Radhakrishnan, and also many thanks to you for joining us in our web audience. I'm Lisa Clark.
©2007 Healthology, Inc.