Archive for category Patient participation

Checklist for the Kidneys — a disease without symptoms

checklistIf your doctor says your kidneys are not working 100% …  is that a problem?  ABSOLUTELY!  You need your kidneys in order to stay alive and when blood tests begin to show kidney problems it means you have lost a lot of kidney function already — at least 50%.  So, the wise doctor and the informed patient need to run a checklist to do the right things.  If you wait until you have symptoms of complete kidney failure, it’s too late.

The main blood test for kidney function is serum creatinine — abbreviated Cr.  The kidneys have a large reserve capacity; in fact, a person can donate a kidney and still have the creatinine (Cr) blood test be “within normal limits”.

Many things can go wrong with the kidneys that range from the fairly simple to the terribly complex.  For instance, kidneys can be damaged simply by the bad effects of high blood pressure or by esoteric autoimmune diseases (“friendly fire” where the body’s defense against germs is accidentally directed at healthy kidney tissue).

You need to know 4 things to estimate your kidney function:

  1. Serum Creatinine (Cr) as measured on a blood sample.
  2. Your age (in years)
  3. Your race (black or not-black)
  4. Your gender (male or female)

Then you calculate another number called eGFR (estimated glomelular filtration rate) based on the items 1 – 4.  Often, this is automatically calculated by the lab — if not get the answer from many online web sites like the National Kidney Foundation eGFR calculatorThe normal value is 100 but it’s not considered abnormal until it is below 90.

STAGE eGFR DESCRIPTION TREATMENT (also see tables below)
1 90+ Normal kidney function but urine findings or structural abnormalities or genetic traits point to kidney disease. Observation, control of blood pressure.
2 60-89 Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease Observation, control of blood pressure and risk factors.
3A or3B 45-59
30-44
Moderately reduced kidney function Observation, control of blood pressure and risk factors.
4 15-29 Severely reduced kidney function Planning for endstage renal failure.
5 below 15 or on dialysis Very severe, or endstage kidney failure (sometimes called established renal failure) Dialysis or transplant.

Now to the checklist mentioned above (Clin J Am Soc Nephrol 9:1526-1535,2014.):  All is well if you have no known kidney problems, the eGFR is above 90, the urinalysis (U/A) is normal, and you have no genetic predisposition to kidney disease (like a family history of polycystic kidney disease). Otherwise, you have stage 1-4 kidney disease so check off the items below to make sure important tests and treatments are obtained.
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Slow the progression.

checked_checkbox Keep blood pressure below 140/90
checked_checkbox Check HbA1c and keep below 7% for diabetics.
checked_checkbox Every year check urine microalbumin/Cr ratio.
checked_checkbox If ratio is above 30 start ACE or ARB drugs.
checked_checkbox Work to stop smoking.
checked_checkbox Avoid NSAIDS (aspirin like products) or other toxins.
checked_checkbox Keep LDL cholesterol below 100.
checked_checkbox Get pneumonia vaccination every 5 years.
checked_checkbox Get Influenza vaccination each year.

Find and treat complications.

checked_checkbox Check hemoglobin and Iron — keep in satisfactory range.
checked_checkbox Check calcium, phosphate and PTH — keep in satisfactory range.

Referral to nephrologist.

checked_checkbox eGFR is below 30.
checked_checkbox Protein remains in urine despite initial treatment.
checked_checkbox Persistent elevated potassium.
checked_checkbox Can’t keep blood pressure below 140/90.
checked_checkbox eGFR falls by 30% in 4 months without explanation.
checked_checkbox Cause of kidney problems is unclear.
checked_checkbox Anemia needs treatment with erythropoietin stimulating drugs.
checked_checkbox Elevated phosphate or PTH.

So, this seems complicated?  TRUE.  That is precisely why a checklist is needed.  And, that is why the informed patient needs to go over this checklist with the primary care provider.  Print a copy of this post and take it with you to an appointment to start the discussion.

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What Can You Do For Healthcare?

jfkAsk not what healthcare can do for you .. ask what you can do for healthcare.  The US healthcare system is in trouble — doctors don’t listen to patients and charge too much, there is an increasing shortage of healthcare providers, waiting lists are longer, hospitals often give patients infections rather than prevent them, insurance companies extract high profit and they pay CEOs millions of dollars without much patient benefit.

Yet in this environment patients ask for more engagement with providers (meaning more face time), ask for more informed choices (meaning more education),  ask for lower price  insurance (meaning congressional action), and ask for shorter waiting times (meaning expanding the healthcare workforce).  ASK…ASK…ASK.

There is no question the US system needs change and there is no question people are not getting the attention they need.

So what can people do?  Perhaps you have some answers to the question.  Here are a few suggestions:

  • volunteer to help others figure out medical bills
  • volunteer to help in doctors’ offices pass out educational materials
  • be outspoken if healthcare workers fail to use alcohol hand gel before visits
  • volunteer to be on quality assurance committees in doctors offices and in hospitals
  • volunteer to do Internet searches to find health information for friends and relatives
  • volunteer to take people who don’t drive to health care appointments
  • don’t go to doctor appointments unprepared — have your records and test results in hand.
  • send messages to your congressmen any time you experience long waiting times, high drug costs, complexity of health insurance, or high prices of medical devices.  If you don’t get results don’t vote for them again.

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