Cardiology has a heart attack, oncology has the fateful date of diagnosis, but there is no “kidney attack” to serve as a traumatic wake-up call for those at risk of kidney disease. There is no event that urgently changes one’s perspective; “From this point forward, you will pay attention to your kidneys and do what it takes to avoid serious illness and premature death.”
Kidney diseases occur quietly, without noticeable external symptoms. It progresses without one’s knowledge and it is easy to live in denial. Most of the world is focused on managing the advanced stages of chronic kidney disease with transplantation or dialysis once symptoms are apparent, rather than preventing the onset or progression of the diseases.
With an incredible increase in the number of people living with kidney disease, my passion is prevention kidney disease in the first place. If we can intervene earlier to promote and educate about kidney health, we can impact the number of people living with these devastating diseases. Unfortunately, measuring prevention is difficult and prevention is not incentivized in our health systems, despite the positive economic impact it would have.
Anyone who cares for patients with kidney disease will attest to the impact of socioeconomic factors on the kidneys. My two most valuable lessons about kidney disease prevention happened in very unexpected places; prison and dialysis.
Most people are surprised to learn that death rates decline early in incarceration, because they often do first time receive appropriate health care. Primary care providers (PCPs) often refer patients from prison to me early when a blood test reveals an increase in the inmate’s creatinine level. The population I see in my prison nephrology clinic is often younger, with few comorbidities, and with milder changes in kidney function. During these visits, not only do I get to check their kidneys, but I also have the opportunity to talk with them about topics such as risk factors, salt in their diet, NSAID overuse, and the importance of blood pressure medication. I have an audience in prison that I can teach early in hopes of preventing kidney dysfunction. In turn, I also have to educate PCPs about kidney monitoring and prevention.
Most would not consider prevention in patients who have already experienced complete loss of kidney function, but it is from this perspective that my second most valuable impact of prevention will come. Anyone who cares for patients with end-stage kidney disease (ESKD) knows that a higher-than-expected proportion of patients live in low-income housing, are food insecure, and often use food stamps and food pantries. although they have some of the strictest dietary needs. As I got to know the patients on my dialysis shift, I could see that childhood challenges, their limited access to food, their lack of access to health care, and their lack of understanding of health-related issues all play a role in the progression of kidney disease. It became apparent that if we had a system that wouldn’t let these high-risk people fall through the cracks, we could prevent them from needing dialysis and, frankly, so many other health problems.
These two healthcare facilities provided invaluable lessons: stay ahead of the curve through collaboration with other physicians, better monitoring, early referrals, and education. So how could I replicate this outside of prisons and before dialysis? Unfortunately, it is much more difficult in the “real world”.
For earlier referrals, PCPs need training to become more aware of risk factors for kidney disease and to monitor blood pressure, weight, smoking and family history, and type 2 diabetes. Unfortunately, too often these indicators appear to be less alarmed by other conditions requiring targeted treatment. They often do not have enough time to discuss how to limit the deterioration of these mild changes in kidney function. Also, there simply aren’t enough kidney doctors to go around. Although screening all patients with early disease would be great, kidney doctors are not available for prevention because there are so many patients who are in advanced stages of kidney disease and need focus. It will take a village, but going through media campaigns to raise awareness can be a good first step in highlighting the need.
Patient education may be helpful for some patients. One of my favorite success stories is a 46-year-old man who for years didn’t take his type 2 diabetes seriously. At 300 pounds, his diabetes and blood pressure were out of control and dialysis was inevitable. This brave man didn’t just want to end up on dialysis, he wanted a transplant and was actively looking for a living kidney donor. To be eligible, he had to lose 100 pounds and get his A1C under control, which he accomplished in a year and a half. A nurse and I worked to educate him about his diet and medications to get him going. He was one of the lucky ones, on dialysis for just three months before receiving a kidney transplant and his life back.
Unfortunately, a more typical example is a 41-year-old woman who visits me with her 20-year-old daughter; the joy of her life. Both have type 2 diabetes, obesity and kidney disease. She was referred to me earlier in the course of her kidney disease, but unlike my other patient, she does not have his motivation or its support system. I put her in touch with a nutritionist to explain her food choices, even while she’s partying, and enlisted her daughter for support at home. Despite her dedicated time and effort and promises to change, she didn’t. Although she was referred to me early on, I have so far been unable to get buy-in from her or influence her support network enough to improve her prospects.
Fortunately, I’m not the only one trying to prevent the pain, loss, and cost of kidney disease. It seems like every year new and promising doctor and patient education programs emerge. Many people, in medicine, social services, government and public care, are working to discover the pathways and ultimately the system that will support people early enough to shift our focus from kidney disease to kidney health.
Photo: peterschreiber.media, Getty Images