Renal Reality

Renal Reality
By James N. Dillard, M.D.

(May 5, 2010) “Don’t it always seem to go that you don’t know what you’ve got till it’s gone,” wrote Joni Mitchell in her 1970 hit song, “Big Yellow Taxi.” She was writing about our environment and the miles of parking lots that she was dismayed to see from her hotel window in Hawaii. The sentiment is more resonant today than ever.

When it comes to our health, there are precious organ systems that we never think about until they fail. They are not trendy, sexy issues. Colon health, youthful skin, and erectile dysfunction seem to dominate our shared health consciousness.

Yet there is a quiet epidemic of kidney failure going on in this country. According to the National Institutes of Health, one in nine Americans over the age of 20 has evidence of chronic kidney failure. Half a million of us are treated with dialysis or transplantation each year, 26 million have kidney disease, and 19 million adults are in the early stages of kidney failure. Rates of kidney disease have doubled in the last decade.

Acute kidney failure can often be reversed, but poorly treated chronic kidney failure usually moves into end-stage renal disease. Unfortunately, when the tissue is lost it doesn’t come back.

You don’t want to go down this road. Hooking up to a machine twice a week or getting a kidney transplant with a lifelong need for drugs to suppress kidney rejection is worth tons of prevention. The treatments are risky and very expensive.

Fortunately, there is a lot you can do to prevent falling into this predicament. Early detection and treatment can keep weak kidneys from progressing to failure. Controlling your diet, diabetes, blood pressure, and inflammation are the keys to prevention.

Forty percent of those entering a dialysis program have diabetes, 20 percent have hypertension, and 15 percent have inflammatory kidney disease. The remainder have autoimmune disorders like lupus, congenital abnormalities, drug injury to the kidneys (as with the aspirin-class, anti-inflammatory drugs), or other problems.

Few functions of the body are as important as what happens in the kidneys. These bean-shaped organs are tucked up under the back ribs, where they are protected from injury. The fine structure consists of a meshwork of delicate filters and tubules that are biochemically quite sophisticated.

The fluid portion of the blood is first dumped through a tiny basket called the glomerulus. This is the site of much kidney disease because of inflammation and chemical injury. Long tubules then recollect what the body wants to keep. Multiple specific pumps release certain things and retain others.

Our ability to filter the blood of impurities, to control blood pressure, to regulate the concentration of minerals in the blood, to offload excess fluid, or to hold onto fluid in times of thirst all resides within the kidneys. That may be the reason that the kidneys are one of the first major organ stops for blood after it leaves the heart.

Like Joni Mitchell’s song, by the time your kidney blood tests rise into the upper range of normal, you’ve already lost over half of your functioning kidney tissue. The estimated glomerular filtration rate is a primary measure of kidney function, though a more modern calculation, the Modification of Diet in Renal Disease Study equation, is the best way to measure kidney health.

End-stage renal disease was universally fatal before the advent of kidney dialysis. In 1943, the Dutch physician Dr. Willem Kolff constructed the first artificial kidney at the University of Groningen Hospital in the Netherlands. Dr. Kolff donated one of his first five drum dialyzers to Mt. Sinai Hospital in New York City after World War II. The procedure did not become widely available until the late 1960s.

Dialysis is the process of running your blood through a complicated machine that cleans the blood and replaces needed minerals. It is sometimes referred to as “life, death, and a washing machine.” There are several kinds of dialysis now, including washing your blood by way of the fluid in your abdomen, or peritoneal dialysis.

All forms of dialysis are burdensome and bear significant medical risks. Surprisingly, Osama bin Laden has apparently survived for many years on the run despite his dependence on renal dialysis. Kidney transplant patients live 10 to 15 years longer than those left on dialysis.

The first human-to-human kidney transplant was performed in 1933, but it wasn’t until 1954, when Dr. Joseph Murray at Peter Bent Brigham Hospital in Boston performed the first truly successful kidney transplant from one twin to another. During the 1960s, advances in tissue matching and immunosuppressive drugs led to more successful transplants.

There are major problems with the United States transplantation system. If you happen to have a failing heart, liver, or kidneys, you will almost certainly die without getting a transplant. Over 80,000 Americans are currently awaiting kidney transplantation, and 4,000 people die each year waiting for a kidney.

Medications that can help a bit with kidney failure include phosphate binders, immunosuppressants, and kidney hormone blockers. These powerful drugs are fraught with side effects.

Chronic renal failure is a strong risk factor for both new and recurrent cardiovascular disease. Medicare enrollees with a chronic kidney disease diagnosis have a 5 to 10 times higher risk of death than those with frank end-stage renal disease, probably because so many die of cardiovascular disease before they reach that stage.

If you have slowly worsening kidney blood tests within the normal range, or protein in your urine, you need to take this seriously. Your doctor can help you, and the National Kidney Foundation has developed the Kidney Early Evaluation Program (KEEP). More information is available online at kidney.org, or by calling 800-622-9010.

You don’t have to let kidney failure pave over the paradise of having your own beautiful kidneys, or drive you into the parking lot of dialysis and a transplantation waiting list. You can know what you’ve got before it’s gone, and keep it.
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Questions can be directed to Dr. James N. Dillard at jdillard@ehstar.com.

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