Diabetes, high blood pressure among factors to consider

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.

Today we're talking about the early stage of kidney disease with Dr. Michael Lioudis. He's an assistant professor of medicine at Upstate and the division chief of nephrology. Welcome back to "The Informed Patient," Dr. Lioudis.

Michael Lioudis, MD: I'm delighted to be here. Amber. Thank you for inviting me.

Host Amber Smith: Well, I guess the first thing is for people to know if they're at risk for chronic kidneys disease, so can we go over what the risk factors are?

Michael Lioudis, MD: One of the things that tends to be a big risk factor for patients that I take care of with chronic kidney disease is diabetes. High blood pressure and really even a family history of kidney disease can really influence whether or not somebody may be at risk. As we think about just diabetes and those three things, the family history, diabetes, high blood pressure, they can really increase your risk.

Host Amber Smith: Are men and women equally at risk?

Michael Lioudis, MD: Well, they're almost the same, and we don't know exactly why that women are a little bit more prone to kidney disease than men are.

It's basically like 13% or 14% women and 12% men. But it's different, and what I'd like to actually kind of tease out a little bit more is, there's kidney disease, and then, well, I'm sure we'll get into this, about dialysis. So not everybody that has kidney disease will ever progress to dialysis, so I want to make sure that we can separate those as we go along.

So what's the difference between men and women? Well, the thought is, and we don't have solid evidence on this one, but the theory is, well, women are more prone to recurring urinary tract infections, complications that can happen with pregnancy. And sometimes with pregnancy, they get eclampsia (a serious complication involving high blood pressure), large weight gains, other things that can specifically affect the kidneys during that time.

But men, even though they're a little bit less likely to have chronic kidney disease, they're the ones that can progress to dialysis, which is what we're all trying to avoid.

And that also is a little bit more complicated, too, because the theory is, well, maybe it's testosterone levels with men that are a little bit higher and that that may have an influence for progressing more rapidly with kidney disease.

Maybe it's the protective aspect of estrogen that prevents women from ultimately progressing as quickly to end-stage kidney disease. and then there's the other things that are those factors that are a little bit fuzzier. For instance, perhaps men engage in riskier lifestyle habits, perhaps men are more likely to smoke, for instance, more likely to consume alcohol, more likely to get into severe auto accidents. And so it's like a big pool of things that influence both. But at the end of the day, it's very similar factors that come into play for both men and women.

Host Amber Smith: What impact does obesity or being overweight have on the kidneys and how well they can function?

Michael Lioudis, MD: So, obesity is becoming a big epidemic in many countries that are more developed. And so part of where I think about obesity playing in this is, it's sort of like a "Bonnie and Clyde" (partners in crime). There's something else over there with obesity that then starts to rob somebody of their health.

For instance, people that are obese may have more of a tendency of having Type 2 diabetes. People that are obese may have higher blood pressures. And then other things, too, that are the subtle things. Think about heart disease. There's more of a risk of sleep apnea. Is there maybe more of a risk of a stroke for people that are obese?

And then it becomes even more complex than that because we think obesity is linked to so many bad things that people go through. Could it be that this is one thing that's coming on up in a lot of countries right now, which is fatty liver disease? Being obese can add to liver disease that then can subsequently cause kidney disease.

Metabolic syndrome that maybe some of our listeners may be familiar with, where you have high blood pressure, high blood sugars, high cholesterol. There's these thoughts about whether or not this causes more issues even with cancers. There's been some links between some types of cancers, colon, breast cancer, liver cancer and kidney cancer, with people that are obese.

Host Amber Smith: And I also was going to ask about whether our risk for developing kidney disease gets greater as we get older because I don't hear about kidney disease that often in younger people. Is this a disease for people who are older?

Michael Lioudis, MD: Kidney disease is not very prevalent in our younger patients, but there are types of kidney disease that do affect younger individuals that tend to be more inherited or that can be issues with regards to different type of medical problems that have taken place very early on. But the answer in short is yes, as we get older, we are at more risk for kidney disease.

However, I like to think about it as almost like that time where you get a relatively new car, and everything is working so nicely, everything is nice and smooth, but as it goes on, there's things that come on up and things have to be repaired, things have to be replaced, things that happen to that automobile as it gets older. People are in the same way, too. You can think about the accumulated mileage of not treating your high blood pressure very well, the accumulated mileage of not taking care of your diabetes very well. The accumulated mileage of living an unhealthy lifestyle, for instance, smoking, that may, over time, increase your risk of chronic kidney disease, and the more years that you engage in those unfortunately add up, and they can result in you having chronic kidney disease later in life.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Upstate's chief of nephrology, Dr. Michael Lioudis, about treatment for early-stage kidney disease.

From what I understand, it's hard to notice symptoms early in kidney disease, so what do you tell patients to look out for?

Michael Lioudis, MD: Well, that's the challenge, Amber, because kidney disease is a type of disease that you don't have symptoms until you are very well progressed. Up to about 90% of individuals don't even know that they have chronic kidney disease, and even basically 40% of those with severe kidney disease don't even know that they have it. And so, that is really not to scare our audience, but it is to empower our audience to go ahead and seek yearly physicals, so that they can go ahead, do the appropriate screening, get looked at and make sure that they're doing well. Because as with any problem, the sooner that you could go ahead and intervene or recognize it, the more options that are available for you to try, and with your health care team to try, and intervene and get it better and stabilize it.

Host Amber Smith: So there are tests that can tell us if our kidneys are healthy?

Michael Lioudis, MD: Indeed. So, Amber, there's two very simple tests that can be done, and usually these are done at everyone's annual physical exam. One is a urinalysis, which is a very simple way of looking at how the kidneys are, in some ways, removing some waste. You can tell a lot by making sure that there's no infection there, making sure that there's no protein in there, making sure that there's no blood in there, because urine should be sterile. And it's a very, very simple test to do.

Additionally, there's blood work, too, that can be done. And as most of us know, when we go on in and get our physical exams done, we get a cholesterol screening. We get a basic metabolic panel, but it is actually a very nice and easy screen that gives us something called the creatinine. Creatinine helps us to identify, well, how are we doing from a kidney perspective with filtering?

And it really helps our primary team to think about the individual and think, are they doing well or not doing well? It's a very useful test to do.

Host Amber Smith: Is there a recommendation for at what age people should start being screened for kidney disease?

Michael Lioudis, MD: They're not solid recommendations. However, many medical societies will say those that have high blood pressure, those that have diabetes should be screened for kidney disease. People above the age of 60 should be screened for kidney disease.

However, what we've realized is because of the simplicity of the urinalysis and the blood work that we ordinarily do, odds are that those are done anyways as a routine in most physicians' or advanced practice providers' offices.

Host Amber Smith: If you were developing kidney disease, would you feel pain in your kidneys, in your back, near where the kidneys are located? Is that how you would tell?

Michael Lioudis, MD: No, you actually wouldn't. People that talk about having kidney pain, in general, they may be thinking more along the lines of kidney stones.

So, kidney stones can cause kidney disease, and if we're really thinking about a proper definition, yeah, you're not supposed to have kidney stones. It does, and can cause, problems down the road, but mostly it's asymptomatic. There is no pain. You may find that perhaps with very advanced degrees of kidney disease that you can have trouble thinking clearly, itchiness, swollen feet and ankles, but not the kind of swollen feet and ankles that we get if we stand, on our feet all day long at work. This is something where if you were actually to press on that swelling, you can actually leave a dent. It's called edema. It's a different, pitting edema, to think about. Sometimes people can have even puffiness around the eyes, but again, those are very, very advanced levels of kidney disease.

Most people, again, it's very subtle. You won't have pain, you won't necessarily see a red-appearing urine. You are otherwise asymptomatic.

Host Amber Smith: You mentioned kidney stones. If someone has a history of having had kidney stones, does that increase their risk of developing kidney disease?

Michael Lioudis, MD: It does to the extent that it depends on the frequency of the stones and what else those stones cause, within a patient, because people will equate passing a kidney stone to some of the most excruciating pain that they've ever experienced. And as this stone passes, sometimes it can even obstruct, or basically block, the passage of urine from the kidney down to the bladder. And so when you have those instances, that can cause infection, that can cause kidney failure on that side.

Kidney stones themselves, they're a big burden to society and cost billions of dollars, lost wages for people, hospitalizations, pain and also sometimes even what people do to try and help to alleviate that pain, such as ibuprofen, Motrin, Aleve, naproxen, that can actually cause problems, too, down the road for individuals.

Host Amber Smith: Can you go over what the glomerular filtration rate means, the GFR? What does that measure?

Michael Lioudis, MD: Sure. So the glomerular filtration rate really helps to pinpoint a little bit better on the actual health of your kidneys in terms of how well they are functioning. And so what that is designed to do, it's an equation that takes into account age and sex and helps to put together basically a number that helps the provider to think about how the kidney is functioning at a snapshot in time.

And if you have a series of those numbers over time, and this is calculated off of blood work using that creatinine that we talked about a little bit earlier, and if you have that as a series of measurements over time, which can be months or years, then you can see also, and plot out, a rate of progression, where, is the kidney disease staying stable? Is it getting worse? How much worse? And it can help us to think about other different interventions or other different things along the way to try and prevent worsening of the kidney function.

Host Amber Smith: Is the GFR number, is it normal for that to fluctuate or be high one day and low the next?

Michael Lioudis, MD: No, it's a fairly stable number over time, and it can fluctuate just a little bit by small amounts, based on if you are, let's just say volume depleted, if you don't drink enough water, if you're not well hydrated. It can fluctuate just a little bit, but in most individuals it's a very consistent and reproducible number.

Host Amber Smith: Is it useful and accurate for all ages and genders and races?

Michael Lioudis, MD: Well, there's a few things to think about on that one, so let's kind of split it up into three separate questions with what you asked, and I'll take the last one first.

When the GFR and the equation was first put together, it took race into account. And there's these theories that perhaps people of African heritage may produce more creatinine, may have variations in muscle mass. And what it did over time is really not take into account the heterogeneity of our population here, where we can go ahead and say, well, maybe race isn't something that we should be including in medicine and in these kinds of calculations, because it may very well have underserved people of African heritage, so we're trying to remove that completely. And so thankfully we have far newer ways of looking at this, so race isn't included.

Now when we think about ages and genders, really we're looking at adults, and we're looking at it that it can be very good, especially when we're looking for people that are outside of basically Stage 1 or Stage 2 chronic kidney disease. So it is useful. It's another tool to help us to put together a picture and to really put forth a collaborative effort between the patient and the health care provider to really talk about and have a frank discussion about kidney function, what does it mean, where are they at, and what are things that are maybe affecting that kidney function?

Host Amber Smith: Now, you mentioned Stage 1 and Stage 2. How many stages are there of kidney disease?

Michael Lioudis, MD: There are actually five stages of chronic kidney disease, Amber, and then I think about one additional one after that.

There's five stages, stage 1, 2, 3, 4, 5. One is very mild; 5 is very severe. And then after that, it's people that will require dialysis, and so that's kind of the way that I think about it, and people sometimes do progress from Stage 1 to 2 to 3 to 4 to 5, and then to dialysis, or sometimes it can be very abrupt, depending upon circumstances or very traumatic medical events that go on.

Host Amber Smith: Is Stage 6, when you're on dialysis, is that considered kidney failure?

Michael Lioudis, MD: Kidney failure is basically, in a way, we kind of use it very differently. So let's not talk about dialysis as Stage 6, but its own separate category. But kidney failure is anything that is less than optimal kidney function. But just because you may have some decrease in your kidney function does not mean, and I want to really emphasize that for our audience, does not mean that you will progress to dialysis. I mean, we have 37 million people in this country that have chronic kidney disease, and we have about 650,000 people on dialysis.

So think about it as an upside-down pyramid, where you have a huge majority of people that have kidney disease, but relatively few that progress to dialysis.

Host Amber Smith: How long can a person last on dialysis?

Michael Lioudis, MD: There is no limit. I've had patients that have been on dialysis for over 25 years and going well. The challenge ultimately is, Amber, once again, kidney disease usually doesn't happen in a vacuum.

If somebody has diabetes, it may very well be that the kidneys are the first organs to actually cry, "Uncle!" They're the first ones to be affected. But that doesn't mean that that diabetes isn't affecting the heart, isn't affecting your immune system and its ability to fight off infection. And so what happens is that you may progress to dialysis, however, once you're at dialysis, those other chronic diseases are still there.

They don't go away. They've just unfortunately conquered the kidneys, but they're still having their way about, on the heart, on your muscle capacity, everything else that happens along the way. And so there isn't a set amount of time that somebody will be able to survive on dialysis.

However, that said, these statistics are not very good for dialysis. It is a form of artificial life support, much like we have a lung machine that can help somebody to breathe if they can't breathe on their own. Or these ventricular assist devices that can be used for a heart. It is a form of artificial life support, and so, be it as such, the odds are about 20% chance per year of passing away by being on dialysis.

Host Amber Smith: How many people on dialysis are waiting for a kidney transplant?

Michael Lioudis, MD: Well, we have probably in this country nearly 100,000 thousand people that are waiting for transplant. And as time goes on, and again, they're still staying on dialysis, if they've progressed to that point, or they have other things that are going on, there's a window of opportunity that we all experience in our lives of health, and being able to be healthy enough to undergo a transplant is also key, too. So the longer that somebody is on dialysis, potentially the more challenging it will be to ultimately get transplanted.

And so you may be a candidate now for transplant, but if you remain in the need for a transplant for many years, it may very well be that something else comes on up, and you no longer are able to go through a very big surgery or be able to adequately care for a kidney.

Host Amber Smith: So it sounds like a lot of people that are on dialysis are not going to get a kidney or are not on the list for it and won't, but the dialysis keeps them alive.

Michael Lioudis, MD: And it does.

And again, it is the net that we have, albeit not perfect, for people that go through all five stages of kidney disease and progress then to dialysis. Now, unfortunately, not everybody is a candidate. Hopefully, as time goes on, there's more and more research being done on organs that are from animals that could be more biocompatible for humans, but we're really not at that point in time just yet.

And so we're relying on people that are either altruistic donors, a loved one, donate to a loved one, or I've had some amazing individuals that have donated kidneys because they say, I've got two kidneys, I'd like to donate to somebody because I read about somebody being in the need for a kidney. I met a wonderful individual from Buffalo that was like that, just recently.

But many other organs are through the deceased donor pool, who tend to click their donor cards. And unfortunately there's way too many people that do pass away and take all their organs with them, when they could actually really help other people from kidneys, lung, heart, liver, et cetera.

Host Amber Smith: Is there any patient that's ever able to take dialysis temporarily?

Does dialysis help the kidney heal or get better, and then they don't have to have it anymore?

Michael Lioudis, MD: We tend to put people that have that kind of acute kidney injury, and we have them temporarily on dialysis while whatever the underlying cause that caused them to be on dialysis hopefully gets better.

Think about it this way, if you've ever burned your hand on a stove, and you're going out, and you burn it bad enough that you cause a blister, it doesn't look great the next day. In fact, it may even look a lot worse for the next couple of days, and then it starts to get better as it starts to heal. Think about an injury to a kidney that you can't necessarily feel or touch.

You could tell if you are no longer making urine, well, that could be an issue too, but giving it time to heal is what dialysis really provides that individual. So it just takes the place where their kidneys aren't able to suffice and allows them to go ahead and heal. So does dialysis help in healing the kidneys?

No, it just basically does what the kidneys would ordinarily do while those kidneys are hopefully on the process of healing.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Upstate's chief of nephrology, Dr. Michael Lioudis, about treatment for early-stage kidney disease.

People with kidney disease, how were they affected by COVID during the pandemic?

Michael Lioudis, MD: Kidney disease, really, should have been, and has been, thought of as a preexisting condition.

So as we were talking about people that were affected by COVID, those with preexisting conditions -- high blood pressure, diabetes, other infections, and chronic kidney disease -- they were at increased risk for further progression and with the complications that COVID could, actually, and did, unfortunately, cause many, many Americans and people all around the world.

Host Amber Smith: Let me ask you, if someone is told they have protein in their urine, does that indicate kidney disease?

Michael Lioudis, MD: Not necessarily. It depends on the age of the individual. Sometimes with some individuals, especially younger individuals, they may have asymptomatic protein and that can be teased on out with a very simple kind of urine collection testing that's done either at nighttime and also during the day.

But if you have protein in your urine, and if it's measurable to that extent, then it does mean that something may be amiss. It may be issues with medications, it could be issues with the other diseases we were talking about, especially with diabetes. And individuals with diabetes may have proteinuria, and that is a sign that perhaps their diabetes has not been very well controlled or that they have other additional factors in addition to the diabetes, such as morbid obesity, too, that that need to be addressed the best that we can.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Upstate's chief of nephrology, Dr. Michael Lioudis, about early-stage kidney disease.

So what should primary care doctors do with patients who they suspect may be developing early-stage kidney disease? Maybe they have some protein in their urine, maybe their GFR number is not exactly what it should be.

Where do they go from there?

Michael Lioudis, MD: That's where you have that conversation with your patients. Not every patient that has less than optimal kidney function needs to see a kidney specialist. It may very well be an opportunity to say, well, you know, if you are taking ibuprofen every single day for osteoarthritis, for instance, that is an opportunity to actually think about, well, how do we get off of that medication?

It may be opportunities to have a more frank discussion regarding weight and the negative effects that it's having on the body. It may be, again, a discussion to be able to say to someone, your blood pressure is not responding to lifestyle modifications. This is where we need to go ahead and now really look at and start antihypertensive medications.

It's all these different things where you could say the earlier that you touch this and make sure that you're putting together these interventions, the better off you will be and the fewer specialists, hopefully, that you'll need to see down the road.

Host Amber Smith: So at this stage, especially if it's early, can dietary changes make a difference, or do you already have damage to the kidneys that won't be reversed?

Michael Lioudis, MD: It depends on how long it has been going on for, Amber. If we think about somebody that is taking ibuprofen, and we've noticed that maybe there's a change, and we say, let's stop it. Let's repeat these labs, and let's see how this changes in a week. It may very well go back to normal, and we're like, whew, we caught this early. But if somebody has been taking it for years, and what could have been stopped early on, this damage has been going on for a period of time. And so maybe you can't stop it. Maybe what you can do is, you can prevent it from further deterioration, but once you've lost any function, It's very few instances that you can go and regain that back.

The kidney is a very interesting organ. It's about the size of your fist, Amber, and we have two kidneys, and if you bend your elbows all the way back and kind of put it towards either side of your spine, that's roughly where your kidneys are located, but they're full of capillaries, blood vessels and millions of microscopic filters that are filtering your blood all the time, 24/7. And so the filters themselves are, dare I say, a little fragile. If they get damaged, they don't regenerate. And so if they get damaged to an extent where it causes that permanent dysfunction, well, I can't fix those, but my goal is to make sure I can preserve all the other ones that are there.

Host Amber Smith: So if a patient has kidney disease, does it necessarily affect both kidneys?

Michael Lioudis, MD: Yeah, it's rare that it just affects only the one side. The one side would be that example back where we were talking a little bit earlier about kidney stones, and if you have a kidney stone that causes an acute blockage on one kidney, well, I can see that as causing just an individual kidney issue.

But ordinarily, what affects the right kidney affects the left and vice versa.

Host Amber Smith: Well, I'd like to have you focus a little on how we can keep our kidneys healthy. And you've touched on a few things I wanted to ask you more about. Why is ibuprofen bad for the kidneys?

Michael Lioudis, MD: Ibuprofen in short doses is fine. It's very tolerable. But over time, the benefits that we have from just decreased pain, especially with osteoarthritis and especially as we've had so many problems with narcotics and fentanyl and so forth, that used to be used far more frequently for pain control, people have resorted to using more ibuprofen.

I see this used quite often, especially in student athletes, because it really helps with relieving pain, especially after a tough game, a tough workout, et cetera. But what it does is actually, it affects prostaglandins in the body. So in short, what it does is, it can affect blood flow to the kidneys, and it can decrease blood flow to the kidneys.

So, over time, if you are decreasing blood flow enough to the kidneys, the kidneys will respond by, unfortunately, getting smaller and, unfortunately, causing this kidney disease to get more pronounced.

Host Amber Smith: I see. We also hear about salt in the diet, but I don't really understand why that's bad.

Michael Lioudis, MD: We need salt in our diets, Amber. You cannot get rid of salt entirely from our diets because it is a part of us, it is a part of what makes our cellular growth and processes and function take place. So sodium is really an essential component, but what we're really talking about here, Amber, is excessive sodium intake, and people especially that have heart disease and kidney disease, we really counsel them in trying to limit sodium to really know more than 2,000 or 2,500 milligrams per day. And the thought is that sodium in excessive amounts for some people that are what we call salt sensitive, what it can do is it can cause increased fluid retention, increased hypertension, and that in itself then causes cascade of effects downstream, especially with the hypertension aspect of things.

Hypertension is that one thing that affects every single part of the body. We're focusing on the kidneys, but the kidneys don't act in isolation. We're all one big domino set, the way that I think about us, and what's good for our kidneys will be good for our heart, which will be good for our liver, which will be good for our lungs, which will be good for our brain and decrease age-associated vascular dementia and other things that happen over time. Decreasing stroke risk. So the way that I look at it is, salt is absolutely necessary in our diets to some extent. It's just the excessive amounts that we look at, and, unfortunately, it is ubiquitous out in our diets and out in the community, especially if you go and indulge a little bit more in fast food. You'll find that they have very high rates of sodium.

Host Amber Smith: How do smoking or vaping affect the kidneys?

Michael Lioudis, MD: I think about smoking and vaping somewhat similarly. There's this kind of misconception that vaping is a healthier form of smoking.

That makes no sense. There is no healthier form of smoking. And the way that I look at it is, though you may not have more of the cigarette-related smoke inhalation that affects not only the increased risk of lung cancers and throat and oral cancers, but vaping itself has the nicotine components. And as we've seen troubling reports with regards to just some of the chemicals that are in the vaping liquids that can cause some severe lung problems.

But both of those things, over time, what smoking does is, it increases your risks of blood pressure and heart disease, and therefore subsequently causes that domino effect that we were talking about that can affect your kidneys. And we think, too, that it can cause some narrowing of the blood vessels and the capillaries within the kidneys.

And so again, the biggest thing about smoking is, it affects so many different organ systems, and the effects of nicotine, the addictive aspects of nicotine, and the chemicals that are in the vaping solutions ... there is no healthy form of smoking or vaping, unfortunately.

Host Amber Smith: Before we wrap up, how much water do we need to drink each day for our kidneys?

Michael Lioudis, MD: That was a big question that we had about 25 years ago, and well, how much is too much? Or what is the bare minimum of fluid intake that we need? It's very interesting, Amber. It was teased out initially over at the University of Pennsylvania, and basically what it found was, these studies, that you drink when you're thirsty. Instances where you need to consume more fluid than normal are really those instances, and there are specific instances, such as with recurring kidney stones, where the thought is that you need to have a very robust fluid intake of about 2 liters to 2 1/2 liters of fluid a day, ideally water, that will help to flush out these microscopic crystals out of the body before they become big stones.

The thought is if you throw a stone into a pot, it just goes plop; it goes right to that bottom. But if you put it into like a raging river, it should hopefully go downstream. And that's the thought about people that have any stones.

Well, how much water?

There are a lot of social media influencers that will say, well, you need to drink six to eight glasses of water a day in order to maintain healthy skin, healthy kidneys, healthy everything about your body.

But the truth is, it really is, drink when you're thirsty. And making sure that you are hydrated appropriately, and what that hydration will mean will vary based on just what you do. If today's a beautiful, sunny day in Syracuse, it's 89 degrees, we're going to be drinking a whole lot more than if it's one of those cold days that we sometimes may have.

Unfortunately, it's a wishy-washy answer, but it is about making sure that you are just cognizant that when you're thirsty, grab something and drink.

Host Amber Smith: I like that advice. Drink when you're thirsty. It's easy to understand and easy to do.

Thank you, Dr. Lioudis, for making time for this interview.

Michael Lioudis, MD: Amber, I was delighted to be here today. Thank you for inviting me.

Host Amber Smith: My guest has been Dr. Michael Lioudis, the chief of nephrology at Upstate, and an assistant professor of medicine.

"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.

This is your host, Amber Smith, thanking you for listening.