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This blog aims to make "evidence-based medicine" understandable to the lay person
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Tuesday, April 25, 2017

When do you really need to start seeing a nephrologist (a kidney doctor)?


I often call kidney disease the "Rodney Dangerfield of Medicine". It gets no respect! Well, outside of the medical community, the same could be said for nephrologists (to a certain extent)! No one is quite sure what they do, or why does anybody need to see one anyway.  For some, we are just another version of urologists. Nephrologists, as the readers of this blog know are physicians who specialize in the diagnosis and treatment of kidney disease, electrolytes, high blood pressure, dialysis, kidney stones, etc. 

My medical assistant, Kristina, spends a good portion of her time calling patients about their upcoming appointments (which often have been made by patients' primary doctors). Here is how a typical conversation goes:

-Kristina: "Hi, this is Kristina. I am calling from Dr Chauhan's office about your upcoming appointment with us".

-Patient: "You are calling from where?"

-Kristina: "Uhh, Dr Chauhan, the nephrologist. Your doctor sent us a referral note saying he talked about this with you. That you need to be seen by a nephrologist for elevated creatinine (or protein in the urine, or high blood pressure)? They made an appointment for you".

-Patient: "Neph-what"?

-Kristina: "The kidney doctor"

-Patient: "Uhh...ok. And why do I need to see you again?


The conversation goes on for some time till Kristina has worked up a pretty convincing argument about why it might be beneficial for the patient to come in for something that their primary doc recommended. Most patients follow through; a few don't. Typical responses for refusal are, "I pee fine. Nothing is wrong with my kidneys", or "my kidneys don't hurt". Or even, "I am already seeing a urologist"! As we know, peeing or not peeing, or pain in the kidneys, are not necessarily the symptoms of kidney disease


Image courtesy of Imagerymajestic/ FreeDigitalPhotos.net


I don't blame anyone for this confusion. Its partly the nephrologists' fault (we haven't been good at educating people of the nephrologist's role; not until someone is already on dialysis). It also has to do with the nature of the disease. Chronic kidney disease (CKD) is a "silent killer". It destroys your kidneys slowly and you don't feel a thing. Not until it is almost the time for dialysis, even at which time the symptoms can be very vague like fatigue or insomnia. In other words, if you go to your primary doctor and tell him that, "doc, I am tired"; well...it could be so many other things that could be making you tired. It would usually take a specialist to put two and two together and pin the blame on kidney disease. When things don't hurt, you really have to be motivated to pay attention to it. A similar situation is created when diabetic patients don't pay attention to their blood sugar control because, well, it doesn't hurt. Pain, the great motivator, is usually amiss when it comes to kidney disease. 


Finally, (and thankfully this is not usual) some primary doctors would really not recognize the importance of an early referral. Not one, but multiple medical studies have clearly proved that patients who are referred late to nephrologists are  more likely to die, or progress to dialysis! Here are a few more links to important studies done is this regard here, and here


So when should you definitely be evaluated by a kidney doctor. Well, based on the evidence cited above, definitely by the time someone's creatinine is high enough for them to be called CKD Stage 4. That would mean a GFR of less than 30. Not doing so, as mentioned above, does increase the risk of the patient progressing to dialysis, as well as the risk of death.


The art of practicing good nephrology is really all about prevention. But often times, regardless of the preventive steps that nephrologists take, it can be hard to appreciate that. One could come away with the impression that "what is the point of seeing a kidney doc when everything is going ok for now", or "you didn't do anything since you didn't prescribe any pill". I have got these reactions from physicians and patients alike. In a healthcare system where  prevention is under-recognized, under-rated, and under-paid, and treatment is glorified and expensive, we seem to be losing sight of our priorities. Consequently, patients with chronic diseases (CKD, diabetes, hypertension, etc.) have been at the losing end.


Talk to your physician about the status of your kidneys, especially if you have typical risk factors for developing kidney disease, like diabetes or hypertension. Should your GFR be below 30, you certainly should request to be seen by a nephrologist. 


(As I type this, the Microsoft word processing software keeps drawing a red line below the word, "nephrologist". The spell-checker keeps giving the alternative "correct" spelling options that include, "neurologist", "necrologist", and "phrenologist". Darn it!)




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