Health Bulletin - October 2024

My Kidneys are Bad: Do I Need Dialysis?

Ms. Shrika A. Reddy, 7th Grade, Castle North Middle School,
Newburgh, IN

Dr. Narothama Reddy Aeddula, MD, FACP, FASN
Consultant Nephrologist, Deaconess Health System, Evansville, IN
Clinical Assistant Professor of Medicine (Adj),
Indiana University school of Medicine
email: healinghandshealth4@gmail.com

Many new patients ask this question when they visit a nephrology clinic. Understanding what kidneys do and what it means to have kidney disease is a crucial part of medicine. Let’s discuss.

The kidneys are about the size of your fist and weigh around 10-12 ounces. Though small, they are incredibly efficient organs, as they filter approximately 200 liters of blood a day (2 gallons per hour). They perform several vital functions, including removal of nitrogenous wastes, fluid regulation, and the balance of electrolytes, minerals and acid-base levels. Additionally, kidneys adapt and play a pivotal role in blood pressure control and produce erythropoietin, a hormone needed for hemoglobin production.

Chronic kidney disease (CKD) involves a gradual loss of kidney function. In the early stages of CKD, one might have few signs or symptoms, and many don’t realize they have kidney disease until it has advanced. CKD is classified into 5 stages (1(mild) to 5(severe) with a higher stage referring to advanced disease.

Kidney health is assessed through blood and urine tests. The estimated glomerular filtration rate (eGFR) calculated from blood creatinine and/or cystatin-c levels, reflects kidney function (normal is >90 ml/min/1.73m2). A urine test is used to detect signs of kidney damage, such as protein (proteinuria by checking uACR), blood and red blood cells (hematuria), white blood cells (pyuria) and other sediment. It’s important to note that eGFR varies with age.

An initial kidney ultrasound checks for obstructions, kidney size and echogenicity. Additional blood tests may screen for connective tissue disorders, viral markers, and complements etc. In some cases, a kidney biopsy is necessary to determine the exact cause of kidney disease.

CKD symptoms develop gradually with disease progression and may include nausea, vomiting, loss of appetite, fatigue, confusion, foamy urine, sleep problems, muscle cramps, swelling in the feet and ankles, dry and itchy skin, high blood pressures, frequent urination, shortness of breath and chest pressure, pain etc. Unfortunately, some patients may have few or no symptoms until the disease is well advanced.

The most common causes are diabetes mellitus (DM), hypertension (HTN), heart disease, obesity, advanced age, a family history of kidney disease, smoking, alcohol use, and excessive use of pain medications (NSAIDS) among others. Nearly 70% of kidney disease can be attributed to DM (1in 3) and HTN (1 in 5). For many people, the causes are multifactorial.

CKD affects 37 million people in the USA (1 in 7 adults) and unfortunately 90% of those with CKD do not know they have it.

Though 37 million people have CKD, less than1% of people reach end stage renal failure (ESRD) each year, which requires kidney replacement therapy (KRT) such as transplant or dialysis support. Advanced CKD increases the risk of cardiovascular disease, hypertension, fluid overload(hypervolemia), anemia, metabolic acidosis, mineral and bone disorders, high potassium(hyperkalemia) among other complications.

Cardiovascular disease is the leading cause of death in patients with CKD.

Treatment for the CKD involves lifestyle modifications and appropriate medical management based on the underlying cause. Common treatments include the use of angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) to lower blood pressure, sodium-glucose cotransporter-2 inhibitors(SGLT2i), nonsteroidal mineralocorticoid receptor antagonists, glucagon-like peptide-1 receptor agonists, diuretics for fluid balance, antiplatelet agents, statins along with erythropoietin and phosphate binders in advanced stages.

One in three adults in US (33%) are at risk of CKD and is the 8th leading cause of death. People at high risk should have regular checkups to screen for CKD. You can check your risk of CKD here,

https://www.kidney.org/kidney-quiz/

To prevent CKD, manage your hypertension (keep systolic blood pressure lower than <120 mm hg), control blood sugar levels, maintain healthy weight, eat a balanced diet, and avoid smoking and alcohol. Stay active for 30 minutes, at least 5 days a week (aim for 8000 steps a day if under 60 years old and 6000 steps if over 60). Avoid nonprescription pain relievers unless supervised by a physician and be cautious with polypharmacy, herbals, and excessive supplements including creatine.

With an estimated 37 million CKD patients in the US, it’s challenging for the roughly 9000 US-based nephrologists to manage all of them. Most of the patients in early stages of CKD can be managed by primary care doctors. However, patients with advanced CKD or CKD of unknown cause including unexplained hematuria or proteinuria should be referred to Kidney doctors.

Most people with CKD can still live productive lives at home and work achieving the best possible outcomes. Less than 1 % of existing CKD patients progress to ESRD each year, meaning many will never require kidney replacement therapies such as kidney transplantation or dialysis. Early detection and appropriate treatment are crucial for slowing the disease progression.

While CKD can lead to serious complications, often due to heart disease, many people live long and happy lives after diagnosis. It’s important to attend all your checkups and work with your physician on a treatment plan.

Dietary choices depend on the underlying cause of CKD, such as diabetes etc. Key elements of a kidney-friendly diet include, avoiding high-salt foods (<2 g of sodium per day or <5 g of sodium chloride per day), consuming more plant-based foods compared to animal-based foods, and limiting ultra processed foods. It’s advisable to maintain a protein intake of 0.8 g/kg body weight/d in adults with CKD stages 3–5 and avoid high protein diets such as animal protein keto diets with over 1.3 g/kg body weight/d of protein. Need to watch out for high phosphate, potassium diet in advance stages (stage 3b to 5) and consult health care providers, dieticians for further personalized advice.

Unfortunately, if the eGFR falls below 20, your kidney doctor will prepare you for kidney replacement therapies (KRT) such as kidney transplantation or dialysis. You may not need the dialysis till the eGFR drops below 15 and you have symptoms or complications.

Kidney transplantation is considered the gold standard, with survival rates exceeding 90% at five years. The next best options include peritoneal dialysis, home hemodialysis, and in-center dialysis. While kidney doctors strive to keep patients away from dialysis whenever possible, they will guide you through the process if KRT is necessary. Think of dialysis as a bridge to transplantation. For those who are not eligible for a transplant, dialysis can sustain life for many years, with some individuals living up to 20 or even 30 years.

National Kidney Foundation (NKF)
https://www.kidney.org/kidney-topics/chronic-kidney-disease-ckd

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
https://www.niddk.nih.gov/health-information/community-health-outreach/information-clearinghouses/nkdep

American Association of Kidney Patients (AAKP)
https://aakp.org/center-for-patient-research-and-education/educational-brochures-and-resources/

Indian Renal Foundation (IRF)
https://indiarenalfoundation.org/

In summary, chronic kidney disease (CKD) involves a gradual loss of kidney function, often going unnoticed with minimal symptoms until its advanced. It progresses through five stages and is caused in two thirds of cases by diabetes and hypertension. Treatment focuses on lifestyle changes and medications to slow progression. Not everyone with CKD is at risk of dialysis; early detection, appropriate follow-ups and timely treatment can help prevent ESRD, which can be effectively managed with transplantation or dialysis.

References:

National Kidney Foundationhttps://www.kidney.org/professionals/kdoqi
KDIGO https://kdigo.org/guidelines/

Editors’ Note: The article is written by Ms. Shrika A. Reddy, a seventh grader who aspire to be an author. All the medical content is provided by qualified physician, Dr. Dr. Narothama Reddy Aeddula.