CKD | The kidneys are two bean-shaped, fist-sized organs located in the back of the abdomen. Their work of scrubbing waste from blood is unglamorous. Think of them as the body’s housekeeping staff, toiling quietly, but vitally, behind the scenes.

Now these intricate filters are increasingly under siege, bearing the brunt of some of the world’s most prevalent chronic diseases.

The kidneys are casualties of soaring rates of obesity, hypertension, diabetes and metabolic syndromes, said Diana Jalal, MD, associate professor of renal medicine at the University of Colorado School of Medicine. These conditions, which damage the kidneys and decrease their ability to function, have in turn spurred a significant increase in the prevalence of chronic kidney disease, or CKD.

Jalal is medical director of the growing Chronic Kidney Disease Clinic at University of Colorado Hospital. The clinic opened in September 2012 to handle the increasing number of CKD patients referred to the Renal Diseases and Hypertension Clinic at UCH by primary care, endocrinology, cardiology and urology providers.

Business at the CKD Clinic, which is open Fridays from 8 a.m. to noon on the seventh floor of the Anschutz Outpatient Pavilion, started slowly, Jalal said, but volume has steadily increased. The first Friday in May, providers were scheduled to see eight new patients and eight returns, she said.

But the new clinic was not created simply to cut Renal Clinic waiting times, she added. “We realized that treating chronic kidney disease demands a multidisciplinary approach that includes dietitians, nurse practitioners, social workers, dialysis, and educational sessions,” she said. The goal: help patients improve their quality of life, avoid hospitalizations and delay dialysis or kidney transplant.

The need to meet this challenge has steadily grown over the past 25 years, particularly among people 60 years of age and older and those with diabetes and hypertension, which are by far the most common causes of CKD. The National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) reports the percentage of people in the United States 65 years of age and older with new cases of CKD more than doubled between 2000 and 2008. The percentage of people 60 years and older with stage 3 CKD increased from 18.8 percent in 1988 to 26 percent in 2008, according to the NIDDK.

As those rates have increased, costs to treat the disease have soared. The United States Renal Data System reported that in 1993, the costs of treating CKD in patients 65 and older consumed 3.9 percent of overall Medicare expenditures. In 2010, the percentage ballooned to 17 percent, or $41 billion.

Declining kidney function means wastes build up in the blood, leading to a host of symptoms, including fluid retention, fatigue, weight loss, nausea, confusion and many others. Left untreated,CKD – identified by the estimated glomerular filtration rate, which measures the kidneys’ ability to filter wastes from the blood – can progress to end-stage renal failure, requiring either dialysis to mechanically remove waste from the blood or kidney transplant.

But the kidneys perform other important functions. They release hormones that stimulate bone marrow to produce red blood cells and regulate blood pressure. They also activate vitamin D, which is essential for healthy bones. A cascade of comorbidities therefore often follows CKD.

“It’s a versatile organ with many roles,” Jalal said. That complexity and the demands of managing it – with healthy diet; appropriate medications, such as ACE inhibitors to control hypertension and slow the progression of kidney disease; and lifestyle changes – make patient education particularly important, she added. An initial patient visit to the CKD Clinic may take over an hour.

“It’s key to catch people early so we can help them control their blood pressure and their diabetes, for example,” Jalal said. The visit includes a lengthy history and physical, an assessment of risk factors and a general workup that can include labs to measure protein in the urine – a sign of CKD – blood tests and ultrasound imaging.

The visits are also an opportunity to speak with patients about the disease, the problems it causes and ways to control it, said Kate Brady, BC-ANP, an advanced practice nurse with the Renal Medicine Department at CU.
“Chronic kidney disease management and education is my passion,” said Brady, who has worked with CKD and dialysis patients for nearly two decades. “To slow down progression of the disease, patients must be part of the team. With more information they are empowered to do something about it.”
In addition to counseling patients during clinic sessions, Brady also leads hour-long Medicare-billable education sessions for stage 4 CKD patients – those on the edge of end-stage renal disease – helping to explain what the disease is, what they can do to manage it, the medications used to treat it, how to improve their quality of life, and their options if they must go on dialysis.
Fifty-seven-year-old Vincent Garcia, for example, was diagnosed last year with stage 4 chronic kidney disease. When he had his initial visit with Brady, his glomerular filtration rate was 17, placing him on the cusp of end-stage renal failure.
“I felt weak, fatigued,” Garcia said. He compared the symptoms to a bad case of the flu.
With Brady’s help, he’s nearly doubled his kidney function. But Brady helped to prepare him for dialysis, explaining the options.

It’s not unusual, Brady explained, for people to learn of their kidney disease only when they have very little function remaining and must have dialysis.

“It’s very much a silent disease,” she said. “When a person suddenly learns they must have dialysis, it can be overwhelming.”
After Garcia decided on a peritoneal access route for home dialysis, Brady set up a consult for him with the hospital’s Home Dialysis Unit to provide additional education and support.
Hard choices. If patients reach the point of needing dialysis, not choosing it is also a viable option, Brady said. “I tell them it’s their right to make that medical choice,” she said, “It’s not a sin; it’s a personal decision.” If a patient chooses to “die in comfort,” Brady brings in palliative care to assist.

But there are many avenues for help before patients reach that point, Brady said. For example, she draws on the expertise of dietitians, who can help patients manage protein, sodium, sugar and fat intake. Even seemingly harmless foods like bananas pose risks because poorly functioning kidneys can’t process the potassium, which in turn can disrupt heart rhythms.

The CKD population at UCH is diverse, Brady added, and in need of help from social workers who can assist with finances, family relationships, and mental health issues such as depression that can sap the motivation patients need to manage their health issues. Social workers also provide assistance for patients who elect to go on dialysis.

Brady takes a hands-on approach to care, sometimes calling patients at home if she senses a problem with fluid management or high blood pressure. She takes those who are ambivalent about dialysis on tours of the units so they can speak to others undergoing the procedure.

Similarly, the education sessions she leads give patients isolated by their disease a chance to talk to others enduring the same kinds of pain and frustration.

“They see they are not alone,” Brady said. “One of them will hear a question and say, ‘I was thinking that but didn’t want to ask.’”

Meanwhile, Jalal’s renal medicine colleague, Michel Chonchol, MD, will soon join her in the clinic. With the nurse practitioners, they will provide CKD education and services to any patient visiting the renal practice.

“We want patients to leave the clinic with a good understanding of their condition,” Jalal said.