How to prevent -- or live with -- kidney disease

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. One in three Americans are at risk for kidney disease, and many of them do not know it. Today, I'm talking about this with Dr. Michael Lioudis. He's an assistant professor of medicine and chief of nephrology at Upstate.

Welcome to "The Informed Patient," Dr. Lioudis.

Michael Lioudis, MD: Well, thank you so much, Amber. I'm delighted to be here today.

Host Amber Smith: Now, the kidneys are responsible for filtering wastes from our blood. In someone who has kidney disease, what happens to the wastes that need to be filtered?

Michael Lioudis, MD: Well, it depends on the type of kidney disease that somebody has, but what happens is, for the most part, we see a gradual buildup of these wastes, and over time, these wastes can actually lead to other medical problems that are kind of subtle until they really culminate to something that is much more overt.

Host Amber Smith: You said it depends on the type of kidney disease. And I guess I hadn't realized that there's more than one. It's not just kidney "disease." There are a variety of kidney "diseases." Is that right?

Michael Lioudis, MD: As we think about kidneys, and most of us have two kidneys, there are multiple different ways that things can get affected and cause kidney disease. And so the two most common types of problems that affect kidneys are diabetes and hypertension. In fact, those two combined are about 75% of the leading causes of kidney disease. But there's other things, too.

Medications can cause kidney disease, different exposures to toxins can cause kidney disease,different things that can happen along the course of a normal, everyday life, so sometimes it's subtle, which is why I'm glad that I'm here today to talk about kidney disease and what we can do to hopefully prevent it and decrease it.

Host Amber Smith: Are there genes that predict a person may be at risk for kidney disease?

Michael Lioudis, MD: So that it actually is our really our 21st-century question mark So we've identified many different types of genes that can lead to kidney disease. For instance, polycystic kidney disease: We know that two genes that are really the primary issues. We've also identified other genes that can cause disease, but that actually is really unlocking how we can hopefully identify, maybe in the future, who is going to be susceptible to kidney disease. And more importantly, if we can find that person that is susceptible, how can we help that person?

And would there even be some gene therapies that could come up?

But that's still far enough in the future that we're still not quite there yet, to be able to kind of put those two together and really prevent the onset of kidney disease.

Host Amber Smith: How do people usually learn that they have kidney disease?

Michael Lioudis, MD: There are so many people that have kidney disease, and yet don't really know that they have a disease. In fact, two out of five adults just in the States alone, don't know that they have severe kidney disease, and that's very, very troubling.

So what happens is, kidney disease is very subtle. And because we're born typically with a lot of extra kidney function, which is why we have many people in the United States and all around the world that can even donate a kidney to a loved one. And so they can still have a wonderful, long life with a single kidney. So when we think about it, it has to be some severe decrease in kidney function before somebody realizes that they have kidney disease, and it can be so subtle that, in fact, it could be just with weight loss, nausea, itchy skin, appetite loss -- it could be a lot of subtle things, that we could perhaps say, gosh, well, that was something that I ate the other day.

You can probably explain it away until you have so many of those symptoms happening all at once that if you have not had routine care, then you may not know about it until your kidney disease is far, far along and very severe.

Host Amber Smith: Is it typical for a person's primary care provider to just stumble upon a kidney disease diagnosis?

Michael Lioudis, MD: Well, in an ideal setting, Amber, people that are going on in for regular preventative care or yearly physicals, get a battery of tests that are usually done. That's in addition to your physical exam that you also get blood work and typically a urine test, too. And so for those patients, one of our early identifying markers for kidney disease really is a simple blood test.

And that is a simple blood test that's usually done at your well visit. And usually also a urine dipstick test, too, that's, again, done typically at your yearly visit. And so those are the first level screenings that can indicate that a person may have kidney disease. Now, what's also interesting is I have had referrals to my office from people that have gone into employee health fairs, they've gone on in for simple blood pressure checks, and all of a sudden, they find that they have very high blood pressure.

And they're told you have to go see your doctor. And that then leads to ultimately a referral to a nephrologist. So there's a number of different ways that somebody could be identified as having kidney disease, but ultimately it is going on in and having a checkup before.

Host Amber Smith: When a person is told that they likely, because they've had the urine tests and other things, when they're told that they have kidney disease, is it staged, like when you're told you have cancer, and they go through and give you a lot more detail? I'd like to think about those two aspects as kind of separate, so we're not talking cancer at all, but I understand where you're coming from. So I want to make sure that for our audience out there that's listening to us, well, kidney disease is not necessarily cancer, that's for sure.

Michael Lioudis, MD: But what we have there is there's five different levels of kidney disease. And then after that is a kind of a subset, the way that I think about it, that's called end-stage kidney disease, which typically means dialysis or the absolute need to get a kidney transplant, if that's available.

Host Amber Smith: So can kidney disease potentially be reversed, or once you have it, is it destined to become a chronic condition?

Michael Lioudis, MD: Really, we need to think about, what is it that has affected our kidneys? So if we think about it just separately, if we're thinking that wow, if we have uncontrolled diabetes, and we get that under control, can we help to decrease further damage?

The answer is yes, we expect that that is the case, if we could get that under control. Think about blood pressure, high blood pressure affecting the kidneys. I think about it as a jackhammer to the kidneys. Now that doesn't only affect the kidneys, it affects the heart, it affects blood vessels, the brain -- it affects the entire body.

And as we think about it with kidneys, it means if we can decrease that hypertension, get it under control, then we minimize additional damages. If we're taking over-the-counter medications, you group this one specific class called NSAIDs. Let me explain what that is. It stands for this thing called nonsteroidal anti-inflammatory drugs.

Think about it as Motrin, ibuprofen, Advil, Aleve, naproxen. These are drugs that are very common.Athletes take them, if you have a hard day at the gym, you had an injury, you're taking these things. If you have osteoarthritis, it really helps to decrease pain and inflammation. And they work. They work very well, but they're not designed for long-term use.

And so the problem ultimately is that when people are taking these things that are over the counter, and sometimes these over-the-counter medications or supplements are deemed, well, perhaps safer than something that's prescribed, but maybe they're not. Because in those cases, those medications can actually lead to direct kidney injury.

And so again, stopping those medications can sometimes actually decrease, reverse, help to improve kidney function. So it really is about understanding what goes into our bodies. What else is affecting our bodies? And then what things can we modify about our bodies to help our kidneys to be better?

Host Amber Smith: I'd like to understand a little bit more about the different levels of kidney disease.

So can you tell me what life is like for someone who has kidney damage and a mild loss of function, compared with someone who has more of a severe loss of function?

Michael Lioudis, MD: So, let's kind of think about that as three separate steps. So I typically think of mild as being stage one or stage two. And in fact, in those cases, it may have been an injury, it could have been an accident, could have been a bunch of different things, but quite frankly, that should not have an effect on a person's ability to exercise, live a wonderful, normal, long, healthy life. However, what it is, is it's just a reminder that all right, maybe you're not at 100% kidney function, but you may be very close to it. And so it's just an emphasis about making sure that you're doing the lifestyle changes to prevent it from moving from stage one or two to stage three, stage four, to stage five.

Now, typically that threshold where I think about things starting to change is right around that stage three. Now at that stage three, if you think about it, we have five stages of any disease and then dialysis, well, that stage three is right in the middle. And so that makes you perhaps more vulnerable. And so really increases the stakes that we need to emphasize.

What are the factors that got you to stage three? If it's diabetes, let's get that under control. If it's high blood pressure, let's get that under control. If it's the two of them, boy, I think about diabetes and high blood pressure as the Bonnie and Clyde on the 21st century, because those two things just rob you.

And you're not even aware that they're robbing until you have progressed to a point where I may not be able to reverse or stabilize, so that stage three is that that really that zone that a person, if they're in it that really we need to put a lot of emphasis and a lot of attention towards making sure that we have correct follow-ups thinking about good blood pressure control, cholesterol control, exercise, all the things that we think about as we think about leading a healthy lifestyle and really bringing it all to the table, especially at stage three. We should do it at any stage, but especially when we're thinking about that first one, two, and then three stages.

Because when we get the stage four and stage five, then the concern is that that person may be more susceptible towards progressing to the end stage, which is what we don't want.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Upstate's chief of nephrology, Dr. Michael Lioudis.

Regarding kidney health, there are some terms that may be confusing. What is GFR?

Michael Lioudis, MD: Oh, that is a confusing one, because what you'll see is on typical lab tests that come on out and very routine lab tests, Amber, you'll see that you'll have your sodium, your potassium. You'll have your electrolytes listed there, and you'll have something called the creatinine. And then you'll see right underneath there, it'll have GFR, but it'll have specifically EGFR. So let's talk about GFR and EGFR. So that stands for glomerular filtration rate.

Think about it as the efficiency of your car engine, but in this case, the efficiency of your kidneys, and so the higher, the GFR, well, the more efficient your kidneys are. It's not a percent, so I don't want our audience to really think about a GFR as well, if I can have 100 for my GFR, well, I'm at 100%, but if I have 50 at my GFR, I'm failing.

No, that's not quite how it works. It's kind of like a rate, but it is across a spectrum, and it gives really an indication to the ordering physician or advanced practice provider, an indication about how efficient are your kidneys. And it also helps out to think about, well, dosing medications, too. So, what do I mean by that?

When we take medications in our body, they get metabolized. Sometimes our liver metabolizes them. Sometimes our lungs metabolize them. But a lot of medications get metabolized by our kidneys. Basically that means they get utilized. Sometimes we take a medication once a day, twice a day, four times a day, depending on the medication, because how quickly it gets utilized in our body.

Michael Lioudis, MD: So if we have a medication that is otherwise metabolized by our kidneys, and our kidneys aren't as efficient, we may need to dose it a little differently so that we don't overwhelm the actual levels of this medication in the body. So it helps us to identify somebody whose kidneys aren't as efficient and helps us to go ahead and think about medication dosing.

And it also helps us to see about over a period of time what's happening to a person's kidneys, and are therapies that we're actually going ahead and implementing, are they working?

Host Amber Smith: So if someone had their GFR at a certain number and then six months later, or a year later, that number is lower. Is that something to be alarmed about or does that maybe naturally fluctuate?

Michael Lioudis, MD: Well, our level can fluctuate a bit and it can fluctuate a bit by our diet. It can fluctuate a bit by how we keep up with our hydration. But, when we have a change in that GFR, the question is, is it so-called transient? Which means not "is it temporary?" Is it just that, Hey, when we checked that at that point in time, it was just a little bit different, and then when we recheck it again, let's say it's right back to where it was before. Well, that's OK. But if we see it, that it's gone down a little bit, well, then it's, again, an indication is that durable or not of a change? Is it a beginning of a change that will continue to go down? And so what we need to do is, therefore, follow it over time, and that's really it. It's kind of thinking about our bodies over time.

When I look at a picture of myself from five years ago, I'm a lot different than I was, and so our kidneys will change, too, much like the rest of our bodies. But the question really is, is that a significant enough change that will impact how long we live, how we live and what we need to do in order to keep ourselves healthy over the spectrum of a lifetime.

Host Amber Smith: If somebody's physician has told them they're concerned about kidney disease, at what point should that person find a nephrologist like yourself to follow their care?

Michael Lioudis, MD: When somebody gets labeled as having kidney disease, that's a tough label.It is something that sometimes you just can't shake it off, and so it has implications for a person's life, how they think about themselves and how they move along and what kind of care do they then need afterwards? So that's a conversation that typically starts with their primary care physician or advanced practice provider, which identifies that level of kidney disease.

Now there's a lot of different factors that will then really push whether or not a patient needs to see a kidney specialist. So a lot of those factors depend upon how severe is this change or identification number in that spectrum of those five stages of kidney disease that we were talking about. And is there a family history where we've had other individuals, whether they're parents, grandparents, siblings that have progressed to end-stage kidney disease?

So there's other factors that would really make us push to see a kidney specialist sooner rather than later. So that's, again, the conversation that usually starts with the person that first identifies if there's a problem. And then that's where you really want to have just a free flow of information, so that your primary care doctor or advanced practice provider knows everything about you so that they can really help to guide you through what can be a wilderness of all these different options and things.

Host Amber Smith: If chronic kidney disease affects more than 37 million people in the United States, how are these people being treated in general?

Are there medications that will help the kidneys function better?

Michael Lioudis, MD: Well, there are, and it really, once again, depends upon why is that person having or being identified as having the disease? Now, the one thing that I kind of think about, again, is if a person is diabetic, well, getting on the proper medications for diabetes control will be key.

Measuring your hemoglobin A1C. People that have diabetes, know what I'm talking about with that hemoglobin A1C, which is a factor of kind of glycemic control, sugar control, over a period of months. If it's high blood pressure, being on anti-hypertensive medications, getting that down, getting that better controlled.

If it's other things that are causing it, well, then that's where usually you really get into seeing a nephrologist or an immune specialist.

Host Amber Smith: What percent of those 37 million people are liable to end up on dialysis and what percent are going to need a kidney transplant?

Michael Lioudis, MD: Well, we have 37 million people that have been identified as having kidney disease, but we only have roughly about 800,000 people that have progressed to the point where they either require dialysis or a kidney transplant.

So of those 800,000, a little more than 500,000 are on some form of dialysis. Now, you can say, wow, that's a big difference, 37 million to 800,000 that have gotten to a point where they've needed a transplant or be on dialysis. Well, there's a lot of people that move into different categories. We identify the issue, they get stabilized, they never progress down. Some people may pass away, along with age and other factors, but you know, fortunately not everybody, if you have kidney disease, will you get to the point where you need dialysis or kidney transplant.

Host Amber Smith: Is there progress on the creation of artificial kidneys that you're aware of?

Michael Lioudis, MD: There is, and actually, I was involved with the artificial kidney project at the Cleveland Clinic, where I came from, was there for over a decade. And so we were looking to go ahead and really figure out how to make an artificial kidney and give people more freedom, more hope.

We don't want to see anybody on dialysis in this country or anywhere. And being able to come up with an artificial organ that works well and is efficient, well, that's really our key hope, but we're not quite there yet. So we have still issues with miniaturization of the artificial kidney, being able to efficiently plant it -- what we're seeing is perhaps more optimism with xenografts, well, basically it is transplants from animals into humans that may not cause our immune systems to overreact. We recently had a patient that had a heart transplant that survived for a period of time and did well. And we're hoping that that's just the beginning for the future for transplantation, but we're not where we want to be with either one. Our goal is to keep original equipment, and that's what we really want to do. We want to keep people with their kidneys, to be healthy and to keep those kidneys healthy.

Host Amber Smith: Well, in terms of that, you've mentioned risk factors, but I do want to ask you a little bit more about risk factors for kidney disease.

Do both Type 1 and Type 2 diabetes increase the risk for kidney disease?

Michael Lioudis, MD: They do, and especially if they are uncontrolled. Now it's really not only that if they're uncontrolled, but it's also the length of time that somebody has been uncontrolled with their diabetes. Typically our patients that are Type 1 diabetics, they tend to be diagnosed earlier, uh, and may have had diabetes for a number of years, and with variable control. Our patients, though, with Type 2 diabetes may have a number of years of having sub- clinical diabetes, where it hasn't quite evolved into full, uncontrolled diabetes. Both are problematic, uh, but it is the length of time, and it is also the amount of uncontrolled time that a person's had diabetes.

Host Amber Smith: So is it the same with high blood pressure? If it's under control, does that mitigate the risk at all?

Michael Lioudis, MD: It does, Amber. So we need to think about blood pressure. It's a unique thing as we think about blood pressure control, because there's so many factors that influence our blood pressure -- whether or not we're active, what our salt intake is, what our weight is -- there's many different things -- our family history. Now odds are if mom or dad had high blood pressure and especially if they both had high blood pressure, we probably will also have a tendency towards having higher blood pressure. And so the question really is, well, if we can get that blood pressure under control with both lifestyle modifications and the proper medications?

Well, the answer is, yeah, I think we can mitigate those risk factors over time. And that's what's really important, is just being able to identify. And so that's one, again, another aspect of our bodies where we can have very high blood pressures and absolutely feel normal and not think that anything is going on or there's a problem. So to me, that's also another reason for going on in, having yearly physicals or going to health fairs or even going to your local EMS or firehouse. And they typically will check your blood pressure for free, or even some of our pharmacies, they'll have blood pressure cuffs -- you can go on in and get your blood pressure checked.

If you find that it is high, you can certainly go ahead and seek some medical attention. Let's find out why.

Host Amber Smith: What connection does heart disease have to kidney disease? Because I don't think of the hearts and the kidneys being connected.

Michael Lioudis, MD: I think of our bodies as one big domino set.

So if my heart's not doing well, my kidneys may not. My kidneys aren't doing well, well, my heart may not. My liver is not doing well. Well, my kidneys may not do well, so you can see where I'm going with this. We're one big domino set. So if we think about heart disease or atherosclerosis -- well, that's hardening of the arteries.

It tends to happen over time, we think about higher cholesterol. But our kidneys, which are about the size of our fist overall, well, they're filled with just a very delicate capillary, just this vasculature network there of blood vessels. And so really what happens to the heart from an atherosclerosis can actually happen to the delicate vessel network in our kidneys, too. So they're tied together, and we're all tied together, inside of ourselves. And so good heart health will equal good kidney health and vice versa. Good kidney health will also equal good heart health. So those are how I think about them very simply and how we're all tied together.

Host Amber Smith: What about someone who has kidney stones or repeated urinary tract infections? Does that increase your risk of kidney disease?

Michael Lioudis, MD: It sure can. So we need to think about both of those a little bit separately. So when I think about kidney stones, kidney stones cause more than a billion dollars in lost work revenue, you name it. People are in pain, ER visits. They are awful, awful things that people go through. And for reasons that I don't have a scientific explanation for it, they happen in the middle of the night on a Sunday. So it always happens at inopportune times. Kidney stones, what they do is, in addition to pain, local inflammation, well, they can actually, as they move, they can also cause obstruction, which basically means they can plug up the outlet, which is that ureter that comes off the kidney. It helps to drain urine. And so what happens is, when they plug out that outlet, then you can get a buildup of urine and pressure with pain that can cause very significant damage over time. Now, in addition to doing all that, as these kidney stones move -- and causing internal destruction, like a boulder crashing down on a mountain -- it just pulls a lot of other things with it. It can actually increase the risk for infection, so it can cause a localized infection with impacted stone that leads to significant pain, loss of kidney function over time, even, in fact, loss of the very kidney where that stone is causing those issues.

Now, when I think about urinary tract infections, well, they're really separate. So urinary tract infections can be caused from a multitude of different things. Now, urinary tract infections, typically a lower urinary tract infection, in women tend to be more susceptible than men for lower urinary tract infections.

Now that doesn't mean you also have something called a kidney infection. So we think about our kidneys, they tend to be higher than our bladder and you have tubes that connect down to the bladder and then their bladder drains on now through another tube called the urethra. Now the lower urinary tract infection really is a bladder infection, and it's just lower than the kidneys. But if that infection goes and travels on up, let's call it a pyelonephritis, or a kidney infection, and people that have recurrent episodes of pyelonephritis, (it) causes inflammation, scarring to the kidneys that can cause a loss of overall filter function. And so over time, that can certainly lead to overt kidney disease and loss of function.

Host Amber Smith: I'd like to ask you about some concrete things that people can do to lower their risk.

Where are the best places to live and work to reduce risk of kidney disease?

Michael Lioudis, MD: That is a tough question to answer because it's not necessarily about where you live or work. We have people that have wonderful, long lives; they live near the Arctic. We have people that have wonderful, long lives and live near the Sahara Desert.

And so our kidneys are designed to be able to be efficient and allow us to function well in both of those environments, as long as we're keeping up our hydration, avoiding exposure to sun, dehydration, or in another way that we think about it in the kidney world, volume depletion. So we want to think about keeping ourselves in balance and keeping ourselves environmentally sound. We don't want to get ourselves sunburned, but we can certainly enjoy the sun. Again, it's the combination of lifestyle modifications, eating well, exercising. So, you can work on an assembly line, you can work on a road crew, you can be anywhere that is a safe area, but making sure that again, you're treating yourself well, hydrating.

Host Amber Smith: Aside from water, what foods make up a diet that is good for the kidneys?

Michael Lioudis, MD: Well, when we think about that, water is really my go to, I must say. It's the best low-calorie drink in the entire world. So, there really isn't a substitute for water. But once again, if you feel that you'd like to put lemon in your water, to get hydration in a different way, or seltzer, those are all very useful, but when we're looking at a diet, we're really looking for a heart-healthy diet. If you're diabetic, it would be a diabetic diet. If I keep my heart healthy, it's going to keep my kidneys healthy. If I keep my diabetes under better control, because I'm really avoiding those sugary, refined sugar kind of diets, drinks, candies, ultimately, it's going to increase my ability to keep my kidneys healthier. So it's a heart-healthy or diabetic-healthy diet that will ultimately keep your kidneys

Host Amber Smith: Well, Dr. Lioudis, I really appreciate you making time for this interview.

Michael Lioudis, MD: Oh, it has been my pleasure, Amber, thank you so much.

Host Amber Smith: My guest has been Dr. Michael Lioudis, the chief of nephrology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. I'm your host, Amber Smith, thanking you for listening.