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Chronic Kidney Disease
Sravan Jasti, MD discusses Chronic Kidney Disease. He shares the risk factors , when to screen patients and when you need to ask about Nephrology referral. He also covers medical management of kidney disease, interventions to prolong kidney survival and dialysis options available.
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Learn more about Sravan Jasti, MD
Sravan Jasti, MD
Sravan Jasti, MD is a practicing Nephrologist in Urbana, IL. He completed a residency at Mt Auburn Hospital. He currently practices at Carle Foundation.Learn more about Sravan Jasti, MD
Transcription:
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s posttest.
Melanie Cole (Host): Welcome. This is Expert Insights with the Carle Foundation Hospital. I’m Melanie Cole and today, we’re discussing chronic kidney disease. Joining me is Dr. Sravan Jasti. He’s a Nephrologist with the Carle Foundation Hospital. Dr. Jasti, it’s a pleasure to have you with us today. Tell us about the current state of kidney disease. What are you seeing?
Sravan Jasti, MD (Guest): So, the chronic kidney disease is something very expanding and like the current state if you look at the general population, about 25 million in the United States have chronic kidney disease. Out of which I think one million is more likely to progress. So, we are definitely dealing with a huge burden of population suffering from chronic kidney disease and it’s very important we follow those patients and decrease the progression of chronic kidney disease.
Host: So, then tell us Dr. Jasti, why is it that so many people don’t realize they have kidney disease until it shows symptoms? Why is that?
Dr. Jasti: Yeah, the problem is most of the people tend to think their kidneys are working well because they are urinating fine. They urinate multiple times a day, they don’t have any problems peeing, so I mean when it comes to kidneys, the only thing that this all about peeing but kidney also does more or less things like it also cleans the blood and not only makes the urine, but it also cleans the blood of all the toxins. So, by the time the symptoms arise which doesn’t happen until the kidney function is less than 20%, people don’t realize they have low kidney function. So, the best way to really test for your kidney function is through a blood test and not a urine test.
Host: Well then tell us a little bit about that screening for kidney function. When is it advised? Is this something that’s on the annual blood check? And tell us while you’re telling us that, about the terms creatinine and GFR, the glomerular filtration rate. Tell us what that means and how people are screened.
Dr. Jasti: Yup, that’s a very good question. So, there is definitely some discrepancy between the recommendations from the US Preventive Network and also the American College of Physicians who actually recommend against screening for chronic kidney disease in asymptomatic individuals and particularly those who don’t have any risk factors which is against our colleagues from the American Society of Nephrology who strongly recommend regular screening for kidney disease even in the absence of risk factors. And personally, I would recommend a case-based approach to detect kidney disease rather than the population screening. And I would definitely recommend screening for patients who have a history of diabetes, or hypertension or cardiovascular disease and certain infections like HIV, hepatitis, malignancy, autoimmune diseases and people who have recurrent kidney stones or recurrent urinary tract infections or even in patients who have a strong family history of kidney disease.
And the way I screen for the patients I would recommend for screening would include a blood test and a urine test. So, the blood test includes something called creatinine which is basically coming from our muscle. Our muscle produces like something called creatinine every day which is kind of like that creatinine which is excreted by the kidney. It is not a toxic waste, but it is something which is produced every day and excreted every day in the urine. If it is high in the blood, which is more than one, that means the kidney did not do the job of excreting that metabolic waste. And we put that number in an equation called a GFR equation. GFR itself is a very good indicator for the kidney function and because the creatinine also gets – there is also variation in creatinine according to the age, sex and race. It’s not the best way to estimate kidney function. So, that’s why we came up with another way to estimate kidney function which is glomerular filtration rate.
Host: Tell us, if someone finds these on their blood test, for the primary care provider, is this something that they can manage in the primary care setting? When do you advise referral to a nephrologist?
Dr. Jasti: Yes, good question again. So, certainly if the creatinine or the GFR is low, I would advise the primary care doctors to stage their chronic kidney disease which is staged into five stages. It could be 1, 2, 3, 4, 5 and I would like to encourage them to order urine tests for urine micro albumin creatinine ratio. The reason being the patients who are more likely to progress are the ones who have more advanced stages of CKD and the patients who are spilling a lot of protein in the urine or microscopic blood in the urine. So, certainly we like to be referred for sure when the kidney function or the GFR is less than 30 and certainly in patients who have macroalbuminuria which is more than 300 milligrams per gram of protein in the urine. And if the referring provider thinks that hematuria is not due to a urological condition which is like from the bladder or urethra and if there is a GFR decline more than 30% in less than four months without an obvious explanation; we like to be referred. And certainly once the GFR is less than 30, we tend to see more complications which is anemia of kidney disease, and bone and mineral metabolism disorders.
And once the potassium is more than 5.5, I think it’s a good idea to refer the patient as well. Or if the patient is developing more acidosis.
Host: What’s involved in medical management? If someone is below these numbers you’ve been mentioning today, what’s involved as far as medical intervention? What do you do first?
Dr. Jasti: Yeah, so when I see these patients in my clinic, I like to address their current risk factors, what is really causing their kidney function to decline. Is the diabetes or is it the hypertension or do they have a glomerular disease? So, first of all, I like to identify the cause of their chronic kidney disease and are they still at that risk, whether that means, or do they have uncontrolled hypertension of uncontrolled diabetes. So, I like to address that first. And usually if it is diabetes, then I tell them to talk to their primary care doctors or endocrine doctors for management of the blood sugars.
And I definitely like to address the high blood pressure and I like to manage that myself. And also, I like to identify the complications associated with low kidney function which could be like high potassium, or acidosis and bone mineral disorders and I like to check certain hormones called parathyroid hormone which can be elevated in chronic kidney disease. And if it is uncontrolled, it can lead to more complications in the bone and in the blood vessels.
And I also once their kidney function declines to less than 20; I like to send them for transplant evaluation, and I do discuss dialysis options which are available. And the last and most important thing is I want to address the medications they are currently on. Are these medications properly dosed and are they even appropriate to be used in chronic kidney disease and things like that.
Host: Very comprehensive answer Dr. Jasti. Thank you for that. So, while we’re discussing medications, risk factors, GFR, tell us a little bit about diet. Because primary care providers may not know about the association between kidney disease and diet as it starts to progress. What would you like them to know? What would you tell them about the nutritional needs that change as someone with CKD progresses in their disease?
Dr. Jasti: Yes, that’s a good question as well. Certainly, once we see the patients, it depends on the glomerular – like the stage of the CKD. If the patient is in the CKD stage 3, I would suggest a low salt diet like a cardiac diet which helps in regulating the blood pressures. And once the patient is in the CKD stage 4 where the GFR is less than 30; I would recommend a low phosphorus diet which means avoiding dairy and fruits vegetables which have high phosphorus which is most of the time, it tends to be dairy or like dark colors. I also tell them once the kidney function is less than 20, I would advise them on a low potassium diet and especially if they have high potassium even at the higher stage of GFR, I still tell them to avoid high potassium fruits and vegetables.
And when it comes to protein intake, the general recommended protein intake is 1 gram per Kg body weight. So, we don’t like fairly low protein diet either. It doesn’t really help. Or very high protein diet which can lead to more progression of kidney disease.
Host: So, when dialysis becomes the option, and this is something that you recommend; when is transplant considered and is someone on dialysis automatically on the transplant list? How does that work?
Dr. Jasti: Yes, so we typically like we screen patients for transplant evaluation so once – if they don’t have any major contraindications for kidney transplant, we usually send them to a transplant center for further evaluation. That happens usually when the GFR is less than 20. So, they get listed on the transplant once the GFR is less than 20 but I can still send the patient a little early even when the GFR is less than 30 to a transplant center to be even started on the evaluation process. And again, once the patient is on dialysis, they accumulate time for transplant on day one of dialysis. Even if they have not been evaluated in the past, if they are started on dialysis; they start accumulating the time for kidney transplant on day one of dialysis.
Host: That’s so interesting. Tell us what’s exciting? What’s on the horizon for chronic kidney disease? Where do you see this going in the next bunch of years?
Dr. Jasti: Yeah, so chronic kidney disease, I mean definitely we need to have a bigger focus on getting the major risk factors under control which is diabetes and high blood pressure. And in the future, I think like dialysis options are getting much bigger, so we are having more options for dialysis which includes home dialysis. If you look at the recent Trump administration like they give an order for more home dialysis for at least 80% of the patients who are to be started on dialysis. They are encouraging home dialysis instead of going to a clinic for in-center dialysis.
Host: Do you have any final thoughts you’d like to share with other providers?
Dr. Jasti: Yeah, so we definitely like to be referred when the kidney function is less than 30 and if patient has diabetes and they have high blood pressure; having those under control definitely helps in delaying the progression of chronic kidney disease. And we definitely like to be involved a little early especially in patients who are having significant protein leak in the urine because they are the ones who will progress to end stage renal disease much quicker than patients who don’t have protein leak in the urine.
Host: Thank you so much Dr. Jasti for coming on and sharing your expertise with us today. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at www.carleconnect.com for more information. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social channels. I’m Melanie Cole.
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s posttest.
Melanie Cole (Host): Welcome. This is Expert Insights with the Carle Foundation Hospital. I’m Melanie Cole and today, we’re discussing chronic kidney disease. Joining me is Dr. Sravan Jasti. He’s a Nephrologist with the Carle Foundation Hospital. Dr. Jasti, it’s a pleasure to have you with us today. Tell us about the current state of kidney disease. What are you seeing?
Sravan Jasti, MD (Guest): So, the chronic kidney disease is something very expanding and like the current state if you look at the general population, about 25 million in the United States have chronic kidney disease. Out of which I think one million is more likely to progress. So, we are definitely dealing with a huge burden of population suffering from chronic kidney disease and it’s very important we follow those patients and decrease the progression of chronic kidney disease.
Host: So, then tell us Dr. Jasti, why is it that so many people don’t realize they have kidney disease until it shows symptoms? Why is that?
Dr. Jasti: Yeah, the problem is most of the people tend to think their kidneys are working well because they are urinating fine. They urinate multiple times a day, they don’t have any problems peeing, so I mean when it comes to kidneys, the only thing that this all about peeing but kidney also does more or less things like it also cleans the blood and not only makes the urine, but it also cleans the blood of all the toxins. So, by the time the symptoms arise which doesn’t happen until the kidney function is less than 20%, people don’t realize they have low kidney function. So, the best way to really test for your kidney function is through a blood test and not a urine test.
Host: Well then tell us a little bit about that screening for kidney function. When is it advised? Is this something that’s on the annual blood check? And tell us while you’re telling us that, about the terms creatinine and GFR, the glomerular filtration rate. Tell us what that means and how people are screened.
Dr. Jasti: Yup, that’s a very good question. So, there is definitely some discrepancy between the recommendations from the US Preventive Network and also the American College of Physicians who actually recommend against screening for chronic kidney disease in asymptomatic individuals and particularly those who don’t have any risk factors which is against our colleagues from the American Society of Nephrology who strongly recommend regular screening for kidney disease even in the absence of risk factors. And personally, I would recommend a case-based approach to detect kidney disease rather than the population screening. And I would definitely recommend screening for patients who have a history of diabetes, or hypertension or cardiovascular disease and certain infections like HIV, hepatitis, malignancy, autoimmune diseases and people who have recurrent kidney stones or recurrent urinary tract infections or even in patients who have a strong family history of kidney disease.
And the way I screen for the patients I would recommend for screening would include a blood test and a urine test. So, the blood test includes something called creatinine which is basically coming from our muscle. Our muscle produces like something called creatinine every day which is kind of like that creatinine which is excreted by the kidney. It is not a toxic waste, but it is something which is produced every day and excreted every day in the urine. If it is high in the blood, which is more than one, that means the kidney did not do the job of excreting that metabolic waste. And we put that number in an equation called a GFR equation. GFR itself is a very good indicator for the kidney function and because the creatinine also gets – there is also variation in creatinine according to the age, sex and race. It’s not the best way to estimate kidney function. So, that’s why we came up with another way to estimate kidney function which is glomerular filtration rate.
Host: Tell us, if someone finds these on their blood test, for the primary care provider, is this something that they can manage in the primary care setting? When do you advise referral to a nephrologist?
Dr. Jasti: Yes, good question again. So, certainly if the creatinine or the GFR is low, I would advise the primary care doctors to stage their chronic kidney disease which is staged into five stages. It could be 1, 2, 3, 4, 5 and I would like to encourage them to order urine tests for urine micro albumin creatinine ratio. The reason being the patients who are more likely to progress are the ones who have more advanced stages of CKD and the patients who are spilling a lot of protein in the urine or microscopic blood in the urine. So, certainly we like to be referred for sure when the kidney function or the GFR is less than 30 and certainly in patients who have macroalbuminuria which is more than 300 milligrams per gram of protein in the urine. And if the referring provider thinks that hematuria is not due to a urological condition which is like from the bladder or urethra and if there is a GFR decline more than 30% in less than four months without an obvious explanation; we like to be referred. And certainly once the GFR is less than 30, we tend to see more complications which is anemia of kidney disease, and bone and mineral metabolism disorders.
And once the potassium is more than 5.5, I think it’s a good idea to refer the patient as well. Or if the patient is developing more acidosis.
Host: What’s involved in medical management? If someone is below these numbers you’ve been mentioning today, what’s involved as far as medical intervention? What do you do first?
Dr. Jasti: Yeah, so when I see these patients in my clinic, I like to address their current risk factors, what is really causing their kidney function to decline. Is the diabetes or is it the hypertension or do they have a glomerular disease? So, first of all, I like to identify the cause of their chronic kidney disease and are they still at that risk, whether that means, or do they have uncontrolled hypertension of uncontrolled diabetes. So, I like to address that first. And usually if it is diabetes, then I tell them to talk to their primary care doctors or endocrine doctors for management of the blood sugars.
And I definitely like to address the high blood pressure and I like to manage that myself. And also, I like to identify the complications associated with low kidney function which could be like high potassium, or acidosis and bone mineral disorders and I like to check certain hormones called parathyroid hormone which can be elevated in chronic kidney disease. And if it is uncontrolled, it can lead to more complications in the bone and in the blood vessels.
And I also once their kidney function declines to less than 20; I like to send them for transplant evaluation, and I do discuss dialysis options which are available. And the last and most important thing is I want to address the medications they are currently on. Are these medications properly dosed and are they even appropriate to be used in chronic kidney disease and things like that.
Host: Very comprehensive answer Dr. Jasti. Thank you for that. So, while we’re discussing medications, risk factors, GFR, tell us a little bit about diet. Because primary care providers may not know about the association between kidney disease and diet as it starts to progress. What would you like them to know? What would you tell them about the nutritional needs that change as someone with CKD progresses in their disease?
Dr. Jasti: Yes, that’s a good question as well. Certainly, once we see the patients, it depends on the glomerular – like the stage of the CKD. If the patient is in the CKD stage 3, I would suggest a low salt diet like a cardiac diet which helps in regulating the blood pressures. And once the patient is in the CKD stage 4 where the GFR is less than 30; I would recommend a low phosphorus diet which means avoiding dairy and fruits vegetables which have high phosphorus which is most of the time, it tends to be dairy or like dark colors. I also tell them once the kidney function is less than 20, I would advise them on a low potassium diet and especially if they have high potassium even at the higher stage of GFR, I still tell them to avoid high potassium fruits and vegetables.
And when it comes to protein intake, the general recommended protein intake is 1 gram per Kg body weight. So, we don’t like fairly low protein diet either. It doesn’t really help. Or very high protein diet which can lead to more progression of kidney disease.
Host: So, when dialysis becomes the option, and this is something that you recommend; when is transplant considered and is someone on dialysis automatically on the transplant list? How does that work?
Dr. Jasti: Yes, so we typically like we screen patients for transplant evaluation so once – if they don’t have any major contraindications for kidney transplant, we usually send them to a transplant center for further evaluation. That happens usually when the GFR is less than 20. So, they get listed on the transplant once the GFR is less than 20 but I can still send the patient a little early even when the GFR is less than 30 to a transplant center to be even started on the evaluation process. And again, once the patient is on dialysis, they accumulate time for transplant on day one of dialysis. Even if they have not been evaluated in the past, if they are started on dialysis; they start accumulating the time for kidney transplant on day one of dialysis.
Host: That’s so interesting. Tell us what’s exciting? What’s on the horizon for chronic kidney disease? Where do you see this going in the next bunch of years?
Dr. Jasti: Yeah, so chronic kidney disease, I mean definitely we need to have a bigger focus on getting the major risk factors under control which is diabetes and high blood pressure. And in the future, I think like dialysis options are getting much bigger, so we are having more options for dialysis which includes home dialysis. If you look at the recent Trump administration like they give an order for more home dialysis for at least 80% of the patients who are to be started on dialysis. They are encouraging home dialysis instead of going to a clinic for in-center dialysis.
Host: Do you have any final thoughts you’d like to share with other providers?
Dr. Jasti: Yeah, so we definitely like to be referred when the kidney function is less than 30 and if patient has diabetes and they have high blood pressure; having those under control definitely helps in delaying the progression of chronic kidney disease. And we definitely like to be involved a little early especially in patients who are having significant protein leak in the urine because they are the ones who will progress to end stage renal disease much quicker than patients who don’t have protein leak in the urine.
Host: Thank you so much Dr. Jasti for coming on and sharing your expertise with us today. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at www.carleconnect.com for more information. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social channels. I’m Melanie Cole.