Selected Podcast
Common Kidney Conundrums
Enuresis, hematuria and proteinuria are common pediatric kidney disorders, but the when do these problems warrant a referral to a pediatric nephrologist? What red flag symptoms require more urgent consultation and evaluation? New specialty-specific guidelines from the "Choosing Wisely" campaign were just released for pediatric nephrology in an effort to educate about unnecessary medical tests, treatments and procedures. In this podcast, Darcy Weidemann, MD, pediatric nephrologist at Children's Mercy Kansas City, discusses evaluation and management options primary care providers should consider prior to subspecialty referral.
Featured Speaker:
Learn more about Darcy Weidemann, MD
Darcy Weidemann, MD
Darcy Weidemann, MD, is a pediatric nephrologist at Children's Mercy Kansas City where she specializes in chronic kidney disease and environmental nephrotoxicology. Dr. Weidemann received her medical degree form Johns Hopkins School of Medicine in Baltimore, MD. She completed a pediatric residency and pediatric nephrology fellowship at Johns Hopkins Children's Center.Learn more about Darcy Weidemann, MD
Transcription:
Common Kidney Conundrums
Dr. Michael Smith: Our topic today is common kidney conundrums. My quest is Dr. Darcy Weidemann. Dr. Weidemann is the associate program director of the pediatric nephrology program at Children’s Mercy Kansas City. Dr. Weidemann, welcome to the show.
Dr. Darcy Weidemann: Hi, thanks for having me.
Dr. Smith: What an important topic today because I know… I mean let’s just be honest. Nephrology is a very complex specialty, and I think things that we can educate community doctors on when to refer and maybe when not to refer I think is very helpful. Again, thank you for coming on. Let’s start off with the red flag symptoms. What are some of the signs and symptoms that community physicians should really be aware of and urgently make a consultation to somebody like you?
Dr. Weidemann: Yeah. I think that’s a really good question, and I think it’s especially important because, and I think the reason why this might be an intimidating specialty to some people, is that kidney disease doesn’t always have a lot of signs and symptoms. You know the ones that we worry about in particular, so high blood pressure, hypertension. That really is probably a big red flag to us as nephrologists that there could be something going on either structurally with the kidneys or related poor function or chronic kidney disease. So, I can’t underestimate the importance of a well obtained manual blood pressure and making sure that that’s actually an appropriate number. If it’s not and if it’s truly elevated, to be honest, these are kids that we typically recommend getting evaluated relatively quickly. Ideally within the next week or two.
Other red flags that I think it’s important to keep in mind, for example, secondary enuresis. So, we define secondary enuresis as children who have bedwetting for… In general, secondary would be defined if they have been continent for more than six months and then all of a sudden, they start wetting the bed. That can be a little bit of a red flag that they may have underlying, for example congenital anomalies of the kidney and urinary tract, and/or chronic kidney disease or some of the more exotic kidney diseases that can present with polyuria.
Looking at the growth chart is also really important. So, if kids are falling off the percentiles, particularly height more than weight, but really, we see both patterns. The poor growth over time is also a big red flag to us. Those are probably the three biggest ones that we see, and these are all things that can be picked up by the primary care pediatrician in the clinic.
Dr. Smith: The expectation with those types of signs and symptoms is that they would reach out to Children’s Mercy or a specialist, like yourself, and get that more detailed workup for that sign or symptom. So that’s the red flags. Obviously, I think most of the time we’re dealing with more of the common symptoms and common scenarios, right. So maybe you can walk through some of the more common things that a community physician might see. What’s the expectation for them to work that up before they actually make a consultation?
Dr. Weidemann: Sure, yeah. That’s another great question. So, things that I think about, common referrals that I see, for example, asymptomatic hematuria. So, children who for whatever reason have had a urinalysis check and then had some blood in it. I think it’s really important to distinguish whether or not these children are symptomatic in that they’ve had visible hematuria, we refer to that as gross hematuria, or whether or not it just got picked up for some particular reason. Those are kids that depending on what the patient’s history is, I think really can determine whether or not they need to see a subspecialist. I will say it’s a very frightening symptom to many patients. I think they immediately think the worst things, although in the vast majority of cases children who have persistent microscopic hematuria very rarely end up having significant kidney disease.
So, in many cases, I think as long as pediatricians do a really good job excluding certain red flags and making sure, for example, there’s no evidence of chronic kidney disease, no evidence of protein in the urine or proteinuria or, for example, elevated blood pressures. Many of these kids, to be honest, I think can be followed in the outpatient clinic by a primary care doctor for a period of several months or even a year to see if this resolves over time.
Dr. Smith: Wow, very nice. So, in those kinds of cases, does Children’s Mercy have a program or a person that they can even… Maybe not necessarily make a formal referral but is there a hotline that clinicians can call and just kind of discuss a certain case with.
Dr. Weidemann: Oh absolutely, yeah.
Dr. Smith: Tell us a little bit about that.
Dr. Weidemann: Yeah. So, there’s a lot of pediatricians in the clinic who use this service. Basically, they can call Children’s Mercy and ask to be connected to their doctor’s, I think it’s the transport line, but there’s always somebody who’s on call 24 hours a day, 7 days a week. We’re more than happy to really walk through cases with pediatricians. If they have questions, if they're unsure if they should be referred to Children’s Mercy or not, we’re more than happy to have those phone consultations. To be honest, I appreciate them. If a pediatrician picks up a kid that they're worried about or they're worried about a red flag, to be honest these are the kids that I would like to have a conversation with the pediatrician about. Then I can really try to do what I can to expedite their workup. For example, if they need repeat bloodwork or any imaging or referral with other specialists, we are always more than happy to try to coordinate those services. It’s a big place and we know a lot of the people here and a lot of ways to get those done for patients that we need to.
Dr. Smith: Yeah. Understanding those red flag symptoms are important. In your experience in dealing with maybe a lot of referrals from the community, what can general practitioners do better in making that process work more efficiently. Is there anything that you would like to educate to make that referral process better?
Dr. Weidemann: Well, I think one thing would be it’s easy to pick up the phone. We’re always more than available. I'm always available by phone. I have some pediatricians who can find our emails and I'm happy to email back and forth with pediatricians if they have questions about mutual patients. So, I think that’s probably the first thing is that when in doubt, give us a call. Sometimes it’s easier to sort things through that way. So that’s one thing. I think trying to make sure that we can get the information to us as quickly as possible also can be quite helpful. Especially if we’re trying to put together a complicated referral, and really understanding what is it that the pediatrician’s already done and making sure that we have, for example, access to the lab reports or to the growth charts or ultrasound reports. Those kinds of things are so helpful for us, and I know the patients appreciate it if we’re able to review that information beforehand. And ideally save their insurance companies from repeating a lot of that testing if it’s already been done.
Dr. Smith: So, let’s move on. Tell us about the “choose wisely” campaign.
Dr. Weidemann: Ah, yes. The choosing wisely campaign. So, this is a project that was taken under by multiple foundations. I think it started with the American Board of Internal Medicine, although it’s really expanded into the American Board of Pediatrics. We in our own professional society, the American Society of Pediatric Nephrology, also adopted. Basically, what are these things that we can tell primary care doctors to try to save healthcare dollars and make a more cost-efficient system. It, interestingly, just came out. So, our pediatric nephrology specialty specific choosing wisely campaign just came out in the last month and a half. I think it came out in the end of July. Basically, trying to educate the public and educate pediatricians about the things in our specialty that we should do before we proceed with costly and expensive workups.
Dr. Smith: And how can a physician access this information?
Dr. Weidemann: Well, so a lot of different ways. It’s easily available online. If you just type in choosing wisely, you can actually see all the different subspecialty ones. It’s pretty available on the website. I’ll be talking about this tomorrow at the CAPS discussion just because I felt like this was going to be a really good platform to really work and educate the public and educate the pediatricians about what is it that we can do try to make a more cost-efficient system.
So, for example, in our field, several of the… There were five ventures that came out. Two of them are related to basically proceeding a test before you proceed with a costly workup. For example, several years ago the American Academy of Pediatrics said please stop getting routine screening urinalysis in all children as part of your well child care. We know that it can lead to several hundreds of dollars or even thousands of dollars if you're going to do a full workup. We know, for example, if you repeat a urinalysis three subsequent times, 96% of the time whatever abnormality was picked up will resolve over time.
Dr. Smith: Hm, wow. That’s a high number.
Dr. Weidemann: It’s a very high number. Again, these mild abnormalities on these screening urinalyses in some cases keep me in business. I think I don’t always need to see the vast majority of these patients because most of the time it will resolve over time.
Dr. Smith: Right. At the end of the day, the choosing wisely campaign is really going to lead to better patient care, right? I mean that’s the end result.
Dr. Weidemann: Yeah, absolutely. Better patient care, less costly interventions potentially. Hopefully a lot less worry on all parts.
Dr. Smith: So, let’s, in summary Dr. Weidemann, why don’t you tell us what would you like for community physicians to know about common kidney conundrums and the referral process?
Dr. Weidemann: Yeah. So, I think that the biggest thing would be to really look out for those red flags. So, if you're worried about kidney disease in a patient, make sure that you have really evaluated that patient’s blood pressure and that you have a very well obtained blood pressure that hopefully is in a reassuring range. Making sure that there’s no abnormal red flags in terms of poor growth, gross hematuria, edema. Those kinds of things that could be symptoms of underlying kidney pathology. I think, again you mentioned earlier. This can be a somewhat intimidating specialty for people because they can present in rather subtle ways. I think if you're ever concerned or worried or not sure, just pick up the phone. We’ve got at least eight people in our groups. We’re always very approachable. Happy to discuss issues with you guys and try to figure out what we need to do to figure out if the patient needs to see us urgently or if we can work with the pediatrician on getting a treatment plan and management plan in their medical home.
Dr. Smith: Very nice summary. Dr. Weidemann, thank you so much for the work that you're doing at Children’s Mercy, and thank you for coming on the show today. You're listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information, got to childrensmercy.org. That’s the childrensmercy.org. I’m Dr. Mike Smith, thanks for listening.
Common Kidney Conundrums
Dr. Michael Smith: Our topic today is common kidney conundrums. My quest is Dr. Darcy Weidemann. Dr. Weidemann is the associate program director of the pediatric nephrology program at Children’s Mercy Kansas City. Dr. Weidemann, welcome to the show.
Dr. Darcy Weidemann: Hi, thanks for having me.
Dr. Smith: What an important topic today because I know… I mean let’s just be honest. Nephrology is a very complex specialty, and I think things that we can educate community doctors on when to refer and maybe when not to refer I think is very helpful. Again, thank you for coming on. Let’s start off with the red flag symptoms. What are some of the signs and symptoms that community physicians should really be aware of and urgently make a consultation to somebody like you?
Dr. Weidemann: Yeah. I think that’s a really good question, and I think it’s especially important because, and I think the reason why this might be an intimidating specialty to some people, is that kidney disease doesn’t always have a lot of signs and symptoms. You know the ones that we worry about in particular, so high blood pressure, hypertension. That really is probably a big red flag to us as nephrologists that there could be something going on either structurally with the kidneys or related poor function or chronic kidney disease. So, I can’t underestimate the importance of a well obtained manual blood pressure and making sure that that’s actually an appropriate number. If it’s not and if it’s truly elevated, to be honest, these are kids that we typically recommend getting evaluated relatively quickly. Ideally within the next week or two.
Other red flags that I think it’s important to keep in mind, for example, secondary enuresis. So, we define secondary enuresis as children who have bedwetting for… In general, secondary would be defined if they have been continent for more than six months and then all of a sudden, they start wetting the bed. That can be a little bit of a red flag that they may have underlying, for example congenital anomalies of the kidney and urinary tract, and/or chronic kidney disease or some of the more exotic kidney diseases that can present with polyuria.
Looking at the growth chart is also really important. So, if kids are falling off the percentiles, particularly height more than weight, but really, we see both patterns. The poor growth over time is also a big red flag to us. Those are probably the three biggest ones that we see, and these are all things that can be picked up by the primary care pediatrician in the clinic.
Dr. Smith: The expectation with those types of signs and symptoms is that they would reach out to Children’s Mercy or a specialist, like yourself, and get that more detailed workup for that sign or symptom. So that’s the red flags. Obviously, I think most of the time we’re dealing with more of the common symptoms and common scenarios, right. So maybe you can walk through some of the more common things that a community physician might see. What’s the expectation for them to work that up before they actually make a consultation?
Dr. Weidemann: Sure, yeah. That’s another great question. So, things that I think about, common referrals that I see, for example, asymptomatic hematuria. So, children who for whatever reason have had a urinalysis check and then had some blood in it. I think it’s really important to distinguish whether or not these children are symptomatic in that they’ve had visible hematuria, we refer to that as gross hematuria, or whether or not it just got picked up for some particular reason. Those are kids that depending on what the patient’s history is, I think really can determine whether or not they need to see a subspecialist. I will say it’s a very frightening symptom to many patients. I think they immediately think the worst things, although in the vast majority of cases children who have persistent microscopic hematuria very rarely end up having significant kidney disease.
So, in many cases, I think as long as pediatricians do a really good job excluding certain red flags and making sure, for example, there’s no evidence of chronic kidney disease, no evidence of protein in the urine or proteinuria or, for example, elevated blood pressures. Many of these kids, to be honest, I think can be followed in the outpatient clinic by a primary care doctor for a period of several months or even a year to see if this resolves over time.
Dr. Smith: Wow, very nice. So, in those kinds of cases, does Children’s Mercy have a program or a person that they can even… Maybe not necessarily make a formal referral but is there a hotline that clinicians can call and just kind of discuss a certain case with.
Dr. Weidemann: Oh absolutely, yeah.
Dr. Smith: Tell us a little bit about that.
Dr. Weidemann: Yeah. So, there’s a lot of pediatricians in the clinic who use this service. Basically, they can call Children’s Mercy and ask to be connected to their doctor’s, I think it’s the transport line, but there’s always somebody who’s on call 24 hours a day, 7 days a week. We’re more than happy to really walk through cases with pediatricians. If they have questions, if they're unsure if they should be referred to Children’s Mercy or not, we’re more than happy to have those phone consultations. To be honest, I appreciate them. If a pediatrician picks up a kid that they're worried about or they're worried about a red flag, to be honest these are the kids that I would like to have a conversation with the pediatrician about. Then I can really try to do what I can to expedite their workup. For example, if they need repeat bloodwork or any imaging or referral with other specialists, we are always more than happy to try to coordinate those services. It’s a big place and we know a lot of the people here and a lot of ways to get those done for patients that we need to.
Dr. Smith: Yeah. Understanding those red flag symptoms are important. In your experience in dealing with maybe a lot of referrals from the community, what can general practitioners do better in making that process work more efficiently. Is there anything that you would like to educate to make that referral process better?
Dr. Weidemann: Well, I think one thing would be it’s easy to pick up the phone. We’re always more than available. I'm always available by phone. I have some pediatricians who can find our emails and I'm happy to email back and forth with pediatricians if they have questions about mutual patients. So, I think that’s probably the first thing is that when in doubt, give us a call. Sometimes it’s easier to sort things through that way. So that’s one thing. I think trying to make sure that we can get the information to us as quickly as possible also can be quite helpful. Especially if we’re trying to put together a complicated referral, and really understanding what is it that the pediatrician’s already done and making sure that we have, for example, access to the lab reports or to the growth charts or ultrasound reports. Those kinds of things are so helpful for us, and I know the patients appreciate it if we’re able to review that information beforehand. And ideally save their insurance companies from repeating a lot of that testing if it’s already been done.
Dr. Smith: So, let’s move on. Tell us about the “choose wisely” campaign.
Dr. Weidemann: Ah, yes. The choosing wisely campaign. So, this is a project that was taken under by multiple foundations. I think it started with the American Board of Internal Medicine, although it’s really expanded into the American Board of Pediatrics. We in our own professional society, the American Society of Pediatric Nephrology, also adopted. Basically, what are these things that we can tell primary care doctors to try to save healthcare dollars and make a more cost-efficient system. It, interestingly, just came out. So, our pediatric nephrology specialty specific choosing wisely campaign just came out in the last month and a half. I think it came out in the end of July. Basically, trying to educate the public and educate pediatricians about the things in our specialty that we should do before we proceed with costly and expensive workups.
Dr. Smith: And how can a physician access this information?
Dr. Weidemann: Well, so a lot of different ways. It’s easily available online. If you just type in choosing wisely, you can actually see all the different subspecialty ones. It’s pretty available on the website. I’ll be talking about this tomorrow at the CAPS discussion just because I felt like this was going to be a really good platform to really work and educate the public and educate the pediatricians about what is it that we can do try to make a more cost-efficient system.
So, for example, in our field, several of the… There were five ventures that came out. Two of them are related to basically proceeding a test before you proceed with a costly workup. For example, several years ago the American Academy of Pediatrics said please stop getting routine screening urinalysis in all children as part of your well child care. We know that it can lead to several hundreds of dollars or even thousands of dollars if you're going to do a full workup. We know, for example, if you repeat a urinalysis three subsequent times, 96% of the time whatever abnormality was picked up will resolve over time.
Dr. Smith: Hm, wow. That’s a high number.
Dr. Weidemann: It’s a very high number. Again, these mild abnormalities on these screening urinalyses in some cases keep me in business. I think I don’t always need to see the vast majority of these patients because most of the time it will resolve over time.
Dr. Smith: Right. At the end of the day, the choosing wisely campaign is really going to lead to better patient care, right? I mean that’s the end result.
Dr. Weidemann: Yeah, absolutely. Better patient care, less costly interventions potentially. Hopefully a lot less worry on all parts.
Dr. Smith: So, let’s, in summary Dr. Weidemann, why don’t you tell us what would you like for community physicians to know about common kidney conundrums and the referral process?
Dr. Weidemann: Yeah. So, I think that the biggest thing would be to really look out for those red flags. So, if you're worried about kidney disease in a patient, make sure that you have really evaluated that patient’s blood pressure and that you have a very well obtained blood pressure that hopefully is in a reassuring range. Making sure that there’s no abnormal red flags in terms of poor growth, gross hematuria, edema. Those kinds of things that could be symptoms of underlying kidney pathology. I think, again you mentioned earlier. This can be a somewhat intimidating specialty for people because they can present in rather subtle ways. I think if you're ever concerned or worried or not sure, just pick up the phone. We’ve got at least eight people in our groups. We’re always very approachable. Happy to discuss issues with you guys and try to figure out what we need to do to figure out if the patient needs to see us urgently or if we can work with the pediatrician on getting a treatment plan and management plan in their medical home.
Dr. Smith: Very nice summary. Dr. Weidemann, thank you so much for the work that you're doing at Children’s Mercy, and thank you for coming on the show today. You're listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information, got to childrensmercy.org. That’s the childrensmercy.org. I’m Dr. Mike Smith, thanks for listening.