Mount Sinai nephrologist on helping kidneys go the distance

Mount Sinai nephrologist on helping kidneys go the distance

BY Katie Charles
DAILY NEWS STAFF WRITER

Wednesday, October 14th 2009, 4:00 AM

The specialist: Dr. Brian Radbill on chronic kidney disease

As medical director of the dialysis program and clinical director of the renal division at Mount Sinai Hospital, Dr. Brian Radbill is a nephrologist who specializes in chronic diseases of the kidney. His group practice sees more than 1,200 patients with CKD and his dialysis program oversees 200 patients.

Who's at risk

Chronic kidney disease is a gradual decrease in the kidneys' ability to filter waste and excess water from the blood. "The name implies what it is," says Radbill. "Your kidneys aren't doing the job they're supposed to do, which is clean the blood of waste products." Kidneys are also involved in red blood cell production, blood pressure regulation and activating the form of Vitamin D that helps maintain calcium levels and bone structure.

"The kidneys keep your blood from becoming acidic, and they also regulate the amount of salt and water in your body," says Radbill. "So people can get volume overloaded when their kidneys fail."

Chronic kidney disease is very common, affecting 26 million Americans and costing Medicare $57 billion in 2007. "As the kidneys become more and more damaged, the end result is scarred, shrunken kidneys," says Radbill. "There is really no cure. The things we do can slow the progression, but we can't undo the scarring." For this reason, prevention and early detection are vital in fighting the disease.

There are many possible causes of chronic kidney disease, but the most common are diabetes and hypertension, or high blood pressure. "Diabetes is by far the number one cause of chronic kidney disease and end-stage renal disease," says Radbill. "Diabetes is an issue in this country, because we have a problem with obesity, which often comes along with diabetes. About 20%-40% of patients with diabetes will develop CKD, he said.

Certain groups have an elevated risk of chronic kidney disease - such as all people over age 60. "Both men and women are affected," says Radbill, "but some ethnic groups are more affected than others. African-Americans and Hispanics are at increased risk in comparison to Caucasians." Others at high risk are patients with lupus and multiple myeloma cancer, and those with a family history of kidney disease. But everyone should be aware of the threat, says Radbill. "Some people have chronic kidney disease without any of the risk factors."

Signs and symptoms

One of the most challenging things about chronic kidney disease is its ability to grow silently for years. "Often, patients have no symptoms, despite having lost 50%-75% of their kidney function," says Radbill. Kidney disease is measured on a scale of 1 to 5, with 1 the earliest and 5 the end stage. "A lot of patients are diagnosed at stage 3 or 4 without any warning signs," says Radbill.

Some patients do show symptoms, the most common being fatigue, headaches and high blood pressure. Some patients will get swelling in their feet, ankles, legs or face and eyelids, even in the early stages.

Diabetics can have excess protein in their urine, which they may notice as unusually foamy urine. But a common misconception is that kidney disease always causes urinary symptoms. "A lot of people say, 'How I can I have kidney disease? I put out urine just fine,'" says Radbill. "But output of urine isn't a great indicator. It's the quality of the urine, and that's something you can't see."

Once kidney disease progresses far enough, it can cause far more dramatic symptoms. "Patients who have advanced disease can lose their appetite, feel nauseated, have a bitter or metallic taste in their mouth," says Radbill. "If they have too much fluid in their body, it can enter the lungs and they have trouble breathing." Other patients experience itchy skin and have trouble sleeping or concentrating.

Traditional treatment

Though there's no cure for chronic kidney disease, doctors can slow it and help patients manage symptoms. Treatment options depend on the underlying cause and how far the disease has progressed. "If someone has diabetes, you want to control it very well," says Radbill. "Patients with diabetes who have good glucose control can often control their kidney disease, and controlling blood pressure can do the same thing."

Doctors now have medications to control the protein level of a patient's urine. "The more protein in the urine, the faster your disease will progress," says Radbill. "These medications, ACE inhibitors and angiotensin receptor blockers [ARBs], have been shown to not just decrease blood pressure, but also decrease protein in the urine. They're the standard of care."

Another key component of managing chronic kidney disease is avoiding anything that can damage the kidneys - including smoking and using NSAIDS drugs like ibuprofen (Motrin, Advil) and naproxen (Aleve). Patients should also discuss any medical testing they might get with their doctor. "For certain radiological studies, like CT scans, they give intravenous contrast dye that can harm the kidneys," says Radbill. "And when patients go for a colonoscopy, they may be told to drink a bowel preparation that contains high levels of phosphate, which can cause kidney damage too."

In the past, some doctors recommended that patients go on a low-protein diet. However, recent studies have shown that the diet isn't effective, and that patients risked malnutrition. "I recommend a normal protein diet, though not a high-protein diet," says Radbill.

Once kidney function drops below about 10%-15%, patients have end-stage renal disease, which requires dialysis or a kidney transplant to keep the patient alive.

"Dialysis is basically kidney replacement therapy," says Radbill. "It replaces the function of the kidneys." Doctors are working to build awareness, get patients screened and control early-stage kidney disease before it becomes end stage. "We focus on prevention, so that patients can avoid dialysis or transplantation," says Radbill. "We try to keep patients off dialysis for as long as possible, but it's never too late to help people."

Questions for your doctor

Radbill advises patients to take a proactive stance by asking doctors about kidney disease. A diplomatic way of phrasing the question would be, "I'm concerned I might have kidney disease. Can you check me for it?" Most patients are diagnosed after age 60, but a good question for younger patients is, "Am I at risk for developing chronic kidney disease down the line?"

If you are diagnosed with chronic kidney disease, the key questions are, "What stage am I in the disease?" or "What is my GFR?" GFR, or glomerular filtration rate, is a number (from a blood test and mathematical formula) that measures how well the kidneys filter waste from the blood.

What you can do:

Get screened for diabetes and high blood pressure.

These diseases are the most common causes of kidney failure, so good blood pressure control and glucose control can prevent chronic kidney disease from developing in the first place.

Get simple blood and urine protein tests.

At your next physical, ask your doctor if you can get a serum creatinine blood test and urine albumin test. "Some doctors will do a basic screening urine test using a dipstick - but that misses early cases," says Radbill.

Stop smoking.

Smoking speeds the progression of kidney disease.

By the numbers

- An estimated 26 million Americans have chronic kidney disease.

- 400,000 have stage 5 disease.

- Medicare spent over $57 billion in 2007 on patients with chronic kidney disease.

- The total cost of end-stage renal disease program in the U.S. was $23 billion in 2006.

http://www.nydailynews.com/lifestyle/health/2009/10/14/2009-10-14_mount_sinai_nephrologist_on_helping_kidneys_go_the_distance.html