The existence of the ESRD program has led to an unfortunate lack of attention by nephrologists and by funding agencies to treatment of chronic kidney failure in the stages before dialysis. Sadly, while nephrol-ogists and internists may recognize kidney failure, they may advise no treatment, telling patients to wait until they're symptomatic, at which point a funded treatment program is available for everyone. Doing this would make sense if the results of dialysis and transplantation were totally satisfactory, but they are far from it.
Some physicians ignore laboratory evidence that their patients have early kidney failure and fail to tell them, for example, which drugs might help, which drugs to avoid, or mention anything about the dangers of smoking or the benefits of nutritional approaches. In some amazing cases, year after year physicians fail to tell patients that they have kidney disease. Predialysis renal failure seems to be nearly unique in the extent to which it is neglected.
Even the experts tend to neglect the dangers of kidney disease. For example, the American Diabetes Association's book for patients, Complete Guide to Diabetes, does not mention self-tests for urine protein and devotes only four pages (out of 446) to kidney disease, even though this is a major problem for patients with diabetes.
Consumer Reports recently featured an article entitled "Taking Charge of Diabetes: Self-Care Is Crucial and Widely Neglected." Yet the article makes no mention of testing for urine protein and instead is devoted entirely to testing blood sugar.
Self-tests for serum creatinine or cystatin C level are not currently on the market, but either one could be devised easily.
One reason that few patients get any advice on treatment for pre-dialysis kidney disease is that widespread skepticism exists regarding the value of this treatment. I'm not entirely sure why this is the case, but I have a strong suspicion that physicians like myself who work with pre-dialysis patients may have oversold our approach to the point where other nephrologists have become increasingly skeptical. This skepticism is particularly prevalent among academic nephrologists, less so among practicing nephrologists and internists, many of whom try to achieve the same aims as are outlined in this book. It is also true that physicians in general are skeptical of dietary treatments, preferring to administer medications.
The use of a supplemented very-low-protein diet predialysis continues to be "controversial." Furthermore, some nephrologists, such as Gerald Schulman and Raymond Hakim, go so far as to state, "Protein intake [in predialysis patients] . . . should not be permitted to fall below 0.8 g/kg per day [56 g per day, in a 70 kg person]." On the contrary, Drs. Mitch, Maroni, Kopple and I believe all patients should have a trial of a protein-restricted diet before being placed on dialysis, as we pointed out in our editorial in the journal Kidney International in 1999. Many patients will exhibit striking improvement in symptoms, and the diet presents no risks.
Some of this skepticism can be attributed to our claims that predial-ysis treatment can slow the progression of chronic renal failure, a claim that has been difficult to document in a way that convinces everyone. Skepticism on this issue has led to an illogical disinterest in predialysis care. Even if progression cannot be slowed by diet, careful predialysis care is worthwhile.
It is essential to differentiate between two possible benefits from predialysis treatment: (1) slowing the rate at which kidney function fails, and (2) reducing symptoms at any given level of kidney impairment. The first remains somewhat controversial (although I am convinced of its validity), but the second has been unequivocally established for at least 100 years. If you think about it, you will realize that these two possible benefits are closely interrelated. Dialysis typically is begun when symptoms reach a certain level of severity. If symptoms can be reduced (without change in kidney function), dialysis can be deferred, at least for a few months.
A third and even more important aspect of predialysis treatment that has not been adequately emphasized is control of all those aspects of chronic kidney failure that not only can cause symptoms, but can cause premature and sudden loss of remaining kidney function or cause death in patients whose kidney function was still relatively well maintained before such complications occurred. In fact, many patients begin dialysis not because their kidney failure progressed to the end stage, but because one or more of the complications caused such severe symptoms that dialysis was the only obvious solution. Some of the more common complications that can precipitate dialysis are congestive heart failure caused by salt and water overload (Chapter 8), severe acidosis (Chapter 10), high serum potassium (Chapter 12), high serum calcium (Chapter 13), and the use of drugs that cause acute kidney damage (Chapter 19). Other complications, including hypertensive crisis and stroke (Chapter 9), can cause death long before the end stage is reached.
Careful attention to all of the many aspects of kidney failure in the predialysis stage will not only permit a nearly symptom-free existence up to the point that dialysis or (preferably) transplantation may become unavoidable (and will significantly postpone that point, perhaps indefinitely), but will also make it possible to avoid the large list of complications that may occur as kidney function gets worse.
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