My latest installation of Real Kidney Talk with The People’s Nephrologist centers around a common refrain I heard in kidney specialty clinics: I pee fine, so my kidneys are fine. Or some similar iteration, to which my response always included: All pee ain’t good pee. Check out the video for why this is true.
Like much of the denial I’ve encountered in my role as physician, I understand it is usually rooted in fear and mistrust. That, and the general lack of appreciable symptoms for chronic kidney disease until one won’t survive much longer without dialysis or a transplant.
I thought I was pretty effective of disabusing patients of the notion that passing urine was not the only determinant of kidney health. Until Mr. Hill.
When I met Mr. Hill he had just started going to see doctors. He had lost a lot of weight without trying and, when he started complaining about chest pain, his mother pushed him to get checked out. He was a mess for a 65-year-old man, but he was only 35. He had uncontrolled diabetes, high blood pressure and coronary artery disease (heart blockage)—all of which had contributed to his chronic kidney disease. By the time I saw him, his eGFR (estimated glomerular filtration rate) was around 40. So, his kidneys were only filtering about 40 milliliters of his blood every minute, when normal can be as high as 120 and the kidneys’ ability to do all their tasks (hint: it’s a shit-ton more than making pee) starts falling off at 60.
Who knows when all of his health issues started, but it was at least several years, which meant the damage done to his kidneys was irreversible. So, all we could hope for trying to protect his remaining kidney function for as long as possible.
Despite his best efforts (which never quite reached care goals, so there’s that) and mine, his kidney function declined pretty rapidly. Roughly 5 years later, he was facing the need to prepare for dialysis.
My practice has been to mention transplant and dialysis at a GFR of 20 because that’s when people eligible for kidney transplant can be placed on the wait list, with the caveat that we wouldn’t need to start talking seriously about dialysis until 15 with ongoing decline. I specify “ongoing” because some people will sit at a GFR of around 15 (or any other number) for years and I’ve seen too many people be pushed to get ready for dialysis at 20, only to be sitting with a fistula for so many years it may not even work when its actually needed.
Now, I had been seeing Mr. Hill every other month initially and more frequently as his kidneys deteriorated. And at each visit, I explained where his GFR was and what things his kidneys were no longer able to do. For years!
None of it stopped him from saying politely, “No disrespect, Doc, but I think I’d like a second opinion,” when his GFR was around 10.
I stepped out of the exam room to get a printed copy of his labs. There was so much red ink indicating abnormal results, I was reminded of a teacher’s red ink bleeding over a failed exam.
I thought, Hell, he could show these results to the janitor and the janitor would say, “Damn, Man. Your kidneys are jacked up!” There’s your second opinion!
But once back in the exam room, I just handed him the papers and said, “Don’t put this off. Your body may not wait for you to decide.”
He put it off. Just as I knew he would. A lot of people try to run away from this reality.
When he finally returned nearly 3 months later and said, “I went to see the other nephrologist and he agreed that I should get ready for dialysis. You know, it wasn’t like I didn’t believe you, Doc. It was just, like, hard for me to believe when I felt ok and…”
By this time his GFR was 6. Any day now his body would need dialysis in order to survive.
At this point, my goal was just to keep him out of the ER and hospital. Starting dialysis ought to be an outpatient process, where there is no unnecessary expense, procedures, exposures to other diseases, or fear the person wouldn’t get there in time.
Mr. Hill didn’t make it to the ER. He was 40.