Testing a Lyme vaccine; signs of kidney disease: Upstate Medical University's HealthLink on Air for Sunday, May 21, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a researcher tells how teenagers can participate in a study of an experimental Lyme disease vaccine.

Kristopher Paolino, MD: "... Say you're out walking around, and you go to the park, and you get bit by a tick. Those antibodies in your blood will be taken up by the tick in the blood meal and inactivate, or prevent, the bacteria from spreading from the tick to you. ...

Host Amber Smith: And Upstate's chief of nephrology explains how kidney disease is diagnosed and treated in its early stages.

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. ...

Host Amber Smith: All that, plus a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn about the early stages of kidney disease. But first, a researcher studying a new Lyme disease vaccine is recruiting Central New York teenagers.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Kids and teens can help develop a vaccine against Lyme disease that's being studied in a clinical trial available in Syracuse. My guest, Dr. Kristopher Paolino, is leading that study. He's an assistant professor of medicine and of microbiology and immunology at Upstate, and he specializes in Lyme and other tick-borne diseases.

Welcome back to "HealthLink on Air," Dr. Paolino.

Kristopher Paolino, MD: It's my pleasure.

Host Amber Smith: Tell us about this investigational vaccine, VLA15. I understand it's made by Pfizer.

Kristopher Paolino, MD: Actually, it's made by a company in Europe called Valneva, and Pfizer and Valneva joined in an agreement back in, I think, 2020 to help co-develop the vaccine and push it through the final stages of development.

Host Amber Smith: So is this a new medication?

Kristopher Paolino, MD: Technically it is. It is based off of the old Lyme vaccine that many people don't remember, that was FDA approved back in, I think it was the late '90s, early 2000s. It's got some subtle changes to the development of the vaccine that make it a little bit different, so technically it is a new vaccine.

Host Amber Smith: How is it designed to work?

Kristopher Paolino, MD: It's interesting. So most vaccines that we receive, we receive the vaccine, and then our body mounts an immune response, so that if we were to be infected or come in contact with an infection, the antibodies will attack those viruses or bacteria and help prevent the infection from developing. That's what we see with flu and COVID vaccines.

This is actually a very unique vaccine in the sense that it targets the outer surface protein A, which is expressed on the bacteria of the Lyme bacteria, inside the midgut of the tick. So what happens is you get the vaccine, you develop these antibodies, and then, say you're out walking around, and you go to the park, and you get bit by a tick.

Those antibodies in your blood will be taken up by the tick in the blood meal and inactivate, or prevent, the bacteria from spreading from the tick to you, so it's almost more of a transmission-blocking vaccine, so it's definitely unique in that sense.

Host Amber Smith: That is interesting. Now, has it been shown to be safe and effective already?

Kristopher Paolino, MD: Yep. So again, it's similar to the vaccine that we had back in the late '90s, which was shown to be effective and overall was felt to be very safe as well. This vaccine has already gone through Phase 1 and Phase 2 studies, and it's already in the midst of a larger, Phase 3 study that started back in August of 2020.

It has been shown to be safe, based on those earlier studies, and this major Phase 3 study is going to look to show effectiveness of how well it prevents people from getting Lyme disease.

It did show in the Phase 2 studies that it had a very strong immune response. So the hope is that when people get this vaccine, it will help prevent Lyme cases from developing if you're bitten by a tick.

Host Amber Smith: Now, why is it important to find people age 12 to 17 who are willing to be test subjects for this?

Kristopher Paolino, MD: Whenever we have a new vaccine that comes out, we always want to make sure that it's safe for all populations. So with the larger Phase 3 study, they are enrolling pediatric populations all the way up through adults.

This study, which is kind of an offshoot of that other study, even though it's a separate protocol altogether, is a Phase 3 study just looking at the safety in pediatric populations, so the study will be looking at 5- to 17-year-olds , and they'll break it down between two different groups.

There'll be five- and 11-year-olds in one group, and then 12- and 17-year-olds in the other group. And we're basically just going to be collecting data on any side effects, adverse reactions that anybody might come across, typically things like arm soreness, redness in the arm, fevers, fatigue, headaches, those kind of things, after vaccination.

Host Amber Smith: Does Lyme disease affect kids the same way that it does adults, potentially?

Kristopher Paolino, MD: It does. There may be some subtle differences. Lyme can affect anybody. There may be a slightly increased risk in children. There have been a few studies to indicate that age ranges between 5 and 9 have a higher peak in number of cases, but overall, anybody can get Lyme.

There may be some differences in how they present. So, younger children might have more irritability. They may be more likely to have fevers, potentially more likely to have joint pain or swelling because they may not identify the tick on them until very much later, when they develop the longer symptoms of late disseminated Lyme disease.

Host Amber Smith: So I wanted to ask you to go over what Lyme disease is and the damage it can do. You mentioned some of the, I guess, more common symptoms, the fevers and the joint pain. Are there other telltale signs that people should be on the lookout for?

Kristopher Paolino, MD: Sure. There are different stages, if you will, of Lyme disease.

So, there's early localized Lyme disease. That's the bullseye rash that everybody is aware of. So, within anywhere between three days and maybe 30 days of a tick bite, you can develop an expanding red rash. it doesn't always look like a target rash or a bullseye. It could be just a confluent red rash that develops from the tick bite and usually gets to the size of a softball, or much larger in some cases, that might be associated with flu-like symptoms, aches and pains, chills, fevers, headaches. Fevers can get quite high in some cases. And then as the infection kind of progresses, if somebody maybe doesn't have those symptoms or doesn't have the rash initially to recognize Lyme, they can go on to develop other manifestations.

Early disseminated cases would include things like heart involvement or Lyme carditis, where it can cause inflammation in the heart, can cause heart abnormalities in terms of how well your heart is able to conduct electrical activity. And people can get very slow heart rates that can be potentially life threatening.

Neurologic infections, or Lyme meningitis, otherwise known as neuroborreliosis, is another early disseminated presentation. People can have really severe headaches. They might have problems with bright lights, neck stiffness, as well as all the other typical flu-like illness symptoms that people can develop.

And then there's also late disseminated infections, where you can have Lyme arthritis, where you get that joint swelling, joint pain, typically in the knees, but really any joints can be involved in the cases of Lyme arthritis, and this is something that occurs several months, generally, after the initial tick bite.

Now, on top of that, there's also more of a long-term process that can happen, and the reasons for these symptoms are still kind of up in the air. Some people hypothesize that there's a persistent infection. Some others hypothesize that there's neurologic damage or joint damage or maybe autoimmune development.

There's a lot of different reasons floating around. There's a lot of data and science that's being done to try to identify that, but these patients can go on to have chronic fatigue, chronic headaches and migraines. They can have cognitive issues where they feel like they have brain fog. They might have chronic joint pains, numbness and tingling in their hands and their feet. There's a whole variety of symptoms that people can suffer from. So if we can prevent those people from getting Lyme in the first place, I think it'll help with a lot of the suffering that people deal with.

Host Amber Smith: Are you able to diagnose that someone has Lyme with a blood test?

Kristopher Paolino, MD: Yep. That's the way that we diagnose it.

I've talked about this issue in the past. Early in the case of Lyme, the tests are not super helpful. So if you have like a bullseye rash, I generally wouldn't recommend ordering a blood test in this region. I would just treat for Lyme disease because you may only have a positive test in maybe 20% to 40% of those cases because our bodies need time to develop the antibodies, rather than identified in these blood tests to make the diagnosis. The later you get in the infection, the more time your body has to develop the antibodies, so by the time somebody has late disseminated infection with joint pains and joint swelling, generally everybody's going to have a positive test at that point, so the longer you've had it, the more severe the disease, the more likely you're going to have an immune response. It's not 100%, but it's close to it.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Kris Paolino. He's leading a study at Upstate Medical University of an investigational vaccine against Lyme disease, and he's recruiting people age 12 to 17 to participate.

Anyone who's interested can learn more at 315-464-9869, or by sending an email to trials, that's [email protected].

Now, what type of people are you looking for in the trial? Ages, genders, races?

Kristopher Paolino, MD: Primarily, we are going to be looking at the 12- to 17-year-old group. We are not participating in the younger age group, so it's a smaller cohort of patients that we're going to be identifying and including. So 12- to 17-year-olds, any gender, any race, would be enrolled in the study.

Host Amber Smith: If someone has had Lyme disease before, are they disqualified from participating?

Kristopher Paolino, MD: This is a great question. This is a yes-and-no answer.

If you have had Lyme disease diagnosed, of any sort, in the past three months, you are not enrollable in this study, all right? Now if you had a bullseye rash four months ago, then you would be allowed in the study. The people that are definitively not included are people who have those later-onset manifestations of Lyme disease.

So if you've been diagnosed with Lyme carditis, the heart involvement, Lyme meningitis or Lyme arthritis, those are typically the Lyme manifestations that are not going to be enrollable.

Host Amber Smith: Are there other things that would disqualify someone from participating?

Kristopher Paolino, MD: I think anytime we're doing a vaccine study, we generally don't enroll people who have any immunodeficiencies, so people going through cancer therapy, people who have had transplants of any sort, people who are on long courses of steroids, we generally will not enroll those patients if we're going to be checking maybe the immune response down the road.

The other thing that's probably more important, just given the timing of the study, is anybody who's had a tick bite in the past four weeks,we won't be enrolling those individuals.

But if you had a tick bite, say, last year or six months ago, assuming you didn't develop one of those manifestations of Lyme I mentioned, you'd be enrollable in this study.

Host Amber Smith: And how many people are you looking to enroll? Because this is one of several sites, right?

Kristopher Paolino, MD: Correct, yeah, so they're looking to enroll globally, for the entire study, about 3,000 children between the ages of five and 17.

We are trying to enroll as many as possible. The goal is to try to get this study filled and done and completed as quickly as we can, so we can get that data, so that we can then have Pfizer go ahead with Valneva and try to get that FDA approval as soon as we can.

Host Amber Smith: Will every participant receive the vaccine?

Kristopher Paolino, MD: Another good question. The answer is no. This is a randomized, controlled study. Most studies that are like that are going to be in a one-to-one ratio, so for every person that comes in, one person will get the placebo (an inactive dose, used for comparison in testing), one person will get the vaccine. This study is a bit different because it's more of a three-to-one ratio.

So if four people come in for enrollment in this study, three of them may get the vaccine, one of them would get the placebo. So there's a good chance that you will get the vaccine, but we won't know who gets the vaccine until much, much later in the study.

Host Amber Smith: So at the end, after everything's completed, will the people find out whether they got the vaccine or the placebo?

Kristopher Paolino, MD: The protocol does not specify whether or not they're going to unblind people. My guess is that will be the case once the study is completed, but not until then. So people won't probably know if they received the vaccine or not until well after the study is completed and closed, just to try to avoid any bias in the study, in the data.

Host Amber Smith: What's involved at the visits?

Kristopher Paolino, MD: It's actually pretty straightforward. There'll be a screening visit that will bring people in, we'll discuss their medical history, tick exposures, things that I had already mentioned in terms of the inclusion/exclusion criteria. And then, if they are found to be eligible for enrollment, we would be able to do the vaccination.

Vaccinations are going to be on multiple different dates throughout the course of the study. So there's going to be the day zero injection, and then there'll be another injection at the two-month mark, a third injection at the six-month mark and then a fourth booster injection at the 18-month mark.

And at each of these injections, you'll receive a vaccination, but there are no blood draws as part of this study, so people won't be getting those typical tubes of blood taken for any additional testing. And we're primarily just going to be looking at any kind of side effects that people describe to the investigators.

And we'll be collecting that data through the use of an e-diary that people can download on their phone as an app, and they'll fill it out on a frequent basis for the purpose of the study.

Host Amber Smith: So they need to be willing to commit to 18 months, roughly, of time?

Kristopher Paolino, MD: Actually 24 months, so there'll be an additional phone visit at the 24-month mark, and I believe there's also a phone visit at the 12-month mark.

Host Amber Smith: Now, I understand the participants are volunteers, but do they receive any sort of compensation?

Kristopher Paolino, MD: Yep. As of right now, my understanding is that it will be a $100 compensation per visit in the clinic, and that will be for their time, their effort and participation overall.

Host Amber Smith: Being that these people are 12 to 17 years old, are they going to need their parents' permission in order to participate?

Kristopher Paolino, MD: We'll do a consent and assent process, so we need consent from both of the parents or legal guardians, as well as, assent, or consent, in a sense, to participate from the patient themselves.

Host Amber Smith: What happens if a study participant gets a tick bite or contracts Lyme disease during the trial?

Kristopher Paolino, MD: That will be something that we will collect and will identify, similar to monitoring for other side effects and other things. We'll want to know if somebody developed a tick bite, if they developed Lyme disease or other tick-borne diseases and will collect that data. But they'll be receiving care through their primary care providers.

Host Amber Smith: Do you think that the things you learn from this age group is going to apply to other age groups as well?

Kristopher Paolino, MD: It'll add to the data that's being developed. I think, from the prior studies in Phase 1 and Phase 2, we have a good base of data from those trials.

I think the big Phase 3 study that's already ongoing is going to be where we're going to see a lot of this data, and this additional study is just going to add to it.

Host Amber Smith: Well, Dr. Paolino, thank you so much for telling us about this.

Kristopher Paolino, MD: Thank you for having me.

Host Amber Smith: My guest has been Dr. Kristopher Paolino, an assistant professor of medicine and microbiology and immunology at Upstate.

And for more information about this study, call 315-464-9869 or send an email to [email protected].

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," many people with kidney disease have not been diagnosed.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

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 "HealthLink on Air," 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 "HealthLink on Air," with 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: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more talk about early-stage kidney disease.

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.

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: 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: 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.

I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Ruth Mahr is a poet and an economist. She finds inspiration for her poetry often in Upstate New York's natural settings. But her poem "Home" demonstrates her poet's eye is equally meticulous indoors.

"Home"

is where the heart is

where the stove warms

yesterday's leftovers

where the refrigerator's

stocked with beer

and running cold

where the wash hangs

on a line strung up

in the basement

where toys and games

gather dust

in the hall closet

where the furnace

purrs

its winter silence

where a tea mug

on the table

is half full

and the bed

upstairs

half empty

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," why does baby food contain lead?

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at Healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

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