Maggie McKay (Host): Welcome to Total Health Talks, your Cook County Health podcast, where we empower your journey to better health. I'm your host, Maggie McKay, and today we're going to talk with Dr. Kalyani Perumal, Chairman of the Division of Nephrology and Jayna Garner-Sharif, Renal Dietician, about kidney care, and early detection and power foods for prevention. Welcome. Thank you both for being here.

Jayna Garner-Sharif, MS, RDN: Thank you for having us.

Kalyani Perumal, MD: Thank you Maggie. We are very excited to be here talking about kidney disease. Thank you for the opportunity.

Host: Absolutely. Dr. Perumal, let's start with you. In simple terms, can you tell us what a kidney is and its purpose in our body?

Kalyani Perumal, MD: Sure. Kidneys are bean-shaped organs. A majority of us are born with two kidneys located on either side of the spine, just below the rib cage. One, closer to the liver on the right and the other one closer to the spleen. They serve very important function. They filter the waste from the blood and produces urine.

In addition to that, they also produce a very important hormone called erythropoietin, which is essential for red cell production. They also have an enzyme that activates the vitamin D we consume or take as supplements, to make an active form to prevent and protect the bone health. And they also regulate all our electrolytes and maintain normal balance in the blood. And they also get rid of excess water and minerals and salts that our body does not need.

Host: So basically kidneys are crucial. How is kidney function checked?

Kalyani Perumal, MD: In the United States, about 37 million people are affected by kidney disease. One in seven are at risk for developing kidney disease. However, nine out of ten are completely unaware of the disease. So therefore, most of the kidney disease are detected by blood and urine tests. So there is a substance called creatinine, which is generated from our muscle metabolism and from our diet and kidney removes this creatinine from the blood keeping their levels very low in the blood.

So if we see an increase in the serum creatinine, it signals there might be a kidney problem. We also measure blood urea nitrogen, which is also another waste product from protein metabolism. And their levels are also kept low in the blood by the kidney, removing it from the blood. If those levels go high, it also signals presence of kidney disease. So we start with a blood test measuring the serum creatinine and serum blood urea nitrogen, and we have several formulas called GFR equations where we put in the age, sex, and the serum creatinine to get an estimate of the kidney function. That helps the patient and the physicians understand the stage of the kidney disease and also helps us manage the complications associated with that level of GFR.

After we do the initial blood test, we also do the urine test for detection of protein in the urine. We all lose a certain amount of protein, less than a hundred milligrams of protein a day because kidney serves as a very tight filter preventing the loss of protein in the urine. So earliest sign, even before we detect an increase in the serum creatinine, we can see protein in the urine, which signals very early kidney disease. So therefore, patients who have diabetes and high blood pressure, we recommend testing the urine for protein at the time of diagnosis. So after the initial blood and urine tests, then we proceed with other tests like ultrasound or other imaging, depending on what we find with these blood in urine tests.

Host: And what are the common causes of kidney disease?

Kalyani Perumal, MD: Diabetes and hypertension are the two most common causes of kidney disease throughout the world. In addition to that, we also see kidney diseases due to variety of autoimmune diseases like lupus erythematosis, rheumatoid arthritis, and certain infections like HIV, hepatitis B, hepatitis C can also result in kidney disease.

And there are also genetic conditions like auto polycystic kidney disease where they are born with a genetic mutation. Over time, they develop multiple cysts in the kidney that affects the kidney function. And there are also other congenital diseases due to mutations in proteins that form the kidney structure.

Host: So I'm wondering if kidney disease progression can be prevented if it's diagnosed earlier or treated earlier?

Kalyani Perumal, MD: Yes, it depends upon the stage at which we diagnose a kidney disease. If it's really early detected by blood and urine test, we can definitely intervene, control the blood pressure, control the diabetes, periodically check the urine protein as well as serum creatinine. And now there are a number of medications that have been proven to halt or stop the progression of the kidney disease.

However, there are some kidney diseases like due to lupus erythematosis, sometimes, you know, they have very aggressive form of lupus in their kidney, which warrants not only detection, but aggressive treatment from the beginning and sometimes they do not respond very well to that medication.

So again, in those situations, really following them very closely, trying different immunosuppressive regimens will help at least protect and preserve the kidney function.

Host: Dr. Perumal, when does somebody need dialysis and are there different types of dialysis?

Kalyani Perumal, MD: Yes, Maggie. So for the first question, we generally consider dialysis when the estimated kidney function, ie, estimated glomerular filtration rate is less than 10%, which means, in simple terms, that patient has lost 90% of kidney function and they have 10% of kidney function, and that means that the toxins are accumulating in the blood and patients generally start having symptoms like fatigue, loss of appetite or altered taste perception, altered sleep pattern, chest pain, shortness of breath, swelling of legs or face. And these are all symptoms telling us that these toxins are affecting the patient and so hence time to start dialysis. And there are different types of dialysis. 

The conventional one is a hemodialysis where the patient comes to the hemodialysis unit and they're connected to the dialysis machine via a catheter or a fistula. And they stay and receive dialysis for three and a half to four hours, depending on the level of toxins in their blood. And that's done typically three times per week.

And then the other form of dialysis is the home therapy, which is called peritoneal dialysis, where the patients are taught to do dialysis at home, which is becoming very popular. Because of the nature of the dialysis, it's done in the home setting. Patients have full control of their dialysis. And also CMS has really encouraged our dialysis providers to offer that as a first option.

Then the last one is a home hemodialysis. So the dialysis that we do in the dialysis center, we can teach that modality to the patient so that they themselves can connect to the machine and receive dialysis every day. So to summarize, there are three types of dialysis, a conventional hemodialysis that's done in the dialysis unit, peritoneal dialysis and home hemodialysis are done by the patient at their home with the help of their caregivers.

Host: Is home dialysis something somewhat new? How long has that been around?

Kalyani Perumal, MD: It's been around at least for the last 15 to 20 years. Patients are more comfortable with the peritoneal dialysis because it's easier and they feel comfortable connecting themselves to the machine via a catheter that's placed in the abdomen. Whereas in home hemodialysis, they have to put a needle in the fistula and connect themselves to the machine, and majority of them are ambivalent about cannulating themselves at home. So generally, it's preferred by patients who have some exposure to healthcare. Either a nurse or someone who is very comfortable, or patients who have diabetes who are comfortable doing their Accuchecks. They're much more willing to try the home hemodialysis.

Host: When should a patient with kidney disease be referred for kidney transplant evaluation or, when should they be referred to a dietician?

Kalyani Perumal, MD: We generally recommend starting discussion about transplant when the GFR, when the glomerular filtration rate is less than 20. So I think that gives ample time for the patient to accept the idea that they may be needing a transplant, and also to start discussion with their family and friends about finding potential donors.

And now we know if they have a potential donor, and if they are good match, we can offer them preemptive transplantation, which means patient can get a transplant even before they need dialysis. And studies have shown improved outcomes in patients who receive preemptive transplantation.

So we want to start talking them early because it is a lot of adjustment for the patient in terms of or having accepting the idea they need transplant and also start talking to their family.

Host: And just very quickly, I had a coworker who got a kidney from another coworker and it worked out beautifully, and then another coworker went to another state to get on their list. How does that work?

Kalyani Perumal, MD: In terms of transplant, once we identify patient is first interested in transplant, we refer them to the transplant center and they go through extensive counseling and evaluation to make sure they are good transplant candidates. Once they are, they are eligible for transplant, then transplant center places them on the UNOS, the transplant list.

And again, every state has their own list and they also have a centralized registry. And in Illinois it's about six to seven years on waiting list to get a kidney transplant especially if they don't have someone in the family or friend or coworkers, as you said, be eligible for the transplant or a suitable match.

So some patients, you know, they prefer to go out of Illinois, to close by states like Indiana, Wisconsin, where the list is not that long as in Illinois. That's why sometimes they want to, be listed in two states, to get the best chance for early transplant.

Host: Jayna. Most patients on dialysis need to limit the amount of sodium in their diets, but how much sodium is safe and what are some ways to add flavor to a diet when you can't have sodium or very little of it?

Jayna Garner-Sharif, MS, RDN: So a lot of kidney patients, they hear low sodium diet and they automatically assume that that means no salt at all. But that is certainly not the case. Kidney patients should try to keep their sodium intake under about 2000 milligrams per day. But it's all about finding balance. So instead of focusing on just cutting out salt completely, it's more important to pay attention to processed foods, which are often hidden and packed with sodium.

For example, things like canned soups, frozen dinners, packaged snacks like chips or pretzels, deli meats and even certain breads, they can contribute a lot to your daily sodium intake. So rather than trying to eliminate sodium completely, it's more important to focus on those whole fresh foods that can meet your personal sodium need.

And a renal dietician like myself can be a huge help in navigating what that looks like. Now when it comes to flavor, don't worry. Kidney patients do not have to sacrifice the taste. There are so many different ways that you can season your food without adding extra salt. Things like Mrs. Dash, which is a salt free seasoning, garlic powder, onion powder. Spices like cumin, paprika, turmeric, which is one of my favorites. Fresh ingredients like garlics, onion, lemon, lime. It's just all about being creative and using what's available to make your meals just as delicious.

Host: Are there specific foods to maintain your kidney health?

Jayna Garner-Sharif, MS, RDN: So when it comes to managing kidney disease through nutrition, the key is balance. So most foods can fit into a kidney friendly diet, but instead of focusing on specific foods like bananas or oranges, it's more important to focus on an overall healthy eating pattern. Fruits, vegetables, and plant-based proteins, those should be the biggest part of your diet. However, there are some patients who may need to watch certain nutrients like potassium or phosphorus, but that is totally dependent on their lab values. It's crucial to remember that there's no one size fits all diet for kidney disease.

Host: What foods are especially harmful to the kidneys?

Jayna Garner-Sharif, MS, RDN: This is a favorite question of mine because patients are always like, do bananas hurt my kidneys? Do tomatoes hurt my kidneys?

Host: I'm thinking sugar Jayna.

Jayna Garner-Sharif, MS, RDN: Yes, patients are like no sugar. I can't eat any fruit because of the sugar. No, the only food that could potentially be harmful to your kidneys if you have kidney disease, is star fruit, and that's because it contains a neurotoxin. Other than that, most foods can be a part of a healthy diet with the right balance.

Host: Did you say star fruit?

Jayna Garner-Sharif, MS, RDN: Star fruit, yes. 

Host: Okay. And plant-based diets, let's talk about that. Can they work for kidney disease? Can that be helpful for some kidney patients eating more plant-based foods? And what exactly is a plant-based diet? Because I don't know what that involves really. How do you know if this diet is right for you?

Jayna Garner-Sharif, MS, RDN: Another great question. You're asking all the great questions. I love it. So, the way I like to describe plant-based diets to people, it's, I'm not encouraging people to be vegan or vegetarian. I just want you to eat more fruits and vegetables. So to answer your question, a plant-based diet can definitely be beneficial for patients with kidney disease.

In fact, it's often recommended because of the many health benefits, like better blood pressure control, improved blood sugar levels, lower acid in the blood, reduced protein in the urine, improved cholesterol levels. Just name a few. The idea behind it is simple. You're just incorporating more fruits, more vegetables, whole grains, nuts, seeds, and legumes into your meals.

And then you'll swap out those animal proteins like red meat or pork and even chicken for those plant-based options, and they can certainly slow the progression of your kidney disease. But of course, working with a renal dietician like myself can make all the difference in navigating the transition with ease and confidence.

Host: I think you need some guidance and some help. I mean I do. At least that's the way I work. I need lists. I need someone like you to say, try this and this. Because you already know all the tricks to make it palatable. So a plant-based diet is it fair to say, can prevent and even slow the progression of chronic kidney disease?

Jayna Garner-Sharif, MS, RDN: Certainly. I like to tell my patients if you want to preserve your kidneys, I'm not saying that you can go back and jump back from stage four to stage two, but if you want to preserve your kidneys, you can certainly do so by incorporating plant-based diet and eating more fruits and vegetables and things of that nature. 

Host: What about caffeine?

Jayna Garner-Sharif, MS, RDN: Caffeine, this is a great question. Patients are always asking this. Now, I'd always recommend that they get clearance from their physician, but if they aren't on any concerning medications, one cup of coffee per day is okay. But anything beyond that, especially when you're adding in the sugars and the creams, that can get a little concerning.

Host: Okay. Well thank you. That's all such useful information. Dr. Perumal is kidney disease hereditary?

Kalyani Perumal, MD: In terms of the cause of kidney disease, about five to 10% of patients have hereditary causes of kidney disease. The most common ones we see are the auto polycystic kidney disease, which is an autosomal dominant condition. Which means it goes from generation to generation. And these patients develop multiple cysts by the time they're 30 years old, and so they can have severe hypertension when they're very young, which can lead to progressive kidney disease.

Thankfully, we have a medication, if detected early. It can slow down the cyst growth and hence preserve the renal function. And there are other hereditary diseases that are typically either diagnosed in when they're very young by the pediatric nephrologist and once they reach an age of 18, they transition to the adult nephrologist.

And most of these patients are diagnosed very early on and preventive therapy started when they're, and even in their school years.

Maggie McKay (Host): Well, what kind of services around kidney disease do they offer at Cook County Health?

Kalyani Perumal, MD: We offer a wide range of services from renal clinics to dialysis programs. So we have renal clinics at all four locations. Here at Stroger Hospital, Provident Hospital on 51st Street. We have Blue Island Clinic and Core Center who takes care of the patients with infections like HIV, hepatitis B and hepatitis C, and we have clinics almost every day at all these locations.

We also have outpatient dialysis unit on the 51st street, where we have patients coming three times per week for the dialysis treatments. We also have a very small dialysis unit here at Stroger Hospital, not only to take care of very complex patients who need dialysis, but we also provide dialysis for patients who are admitted in the hospital.

We have rapidly expanding home program, peritoneal dialysis program where patients get started on home therapy and they're trained by our medical director. It is a team approach. So we have the medical director, Jayna, a social worker, and know PD nurses, PD coordinators who really hold the hands of the patient and ease them into this home therapy.

So we've been very successful and we are rapidly growing. We have about 30 patients already in-home program. And we also have a collaboration with University of Illinois at Chicago, to refer these patients for transplant. So we strongly believe dialysis is the bridge to transplantation. We want to be able to set the patient and get the patient healthy enough by providing adequate dialysis so they all can get their transplant.

So we are working with the University of Illinois transplant team to refer our patients for, the transplant in the hospital.

Host: That's got to be reassuring to people with kidney disease that Cook County Health has so many resources and all the bases covered. Thank you both so much for being here today and sharing your expertise. This has been so educational. Thank you.

Kalyani Perumal, MD: Thank you. Thank you for having us.

Jayna Garner-Sharif, MS, RDN: Thank you. Thank you for having us.

Host: Again, that's Dr. Perumal and Jayna Garner-Sharif. To find out more, please visit Cookcountyhealth.org/about/podcast. As we wrap up another insightful episode of Total Health Talks make sure to visit cookcountyhealth.org/podcast and subscribe to our podcast, share and connect with us on social media. Stay tuned for more engaging discussions. This is Maggie McKay signing off from Total Health Talks. Stay well.