Silent Assassin. (eBook)

Chapter 2:
The Mammoth Magnitude of a Silent Killer

JD is a pleasant sixty-seven-year-old longstanding diabetic and hypertensive patient, who was initially referred to my renal clinic for consultation. When I first told him that he had chronic kidney disease stage 4, likely as a result of diabetes and that his estimated GFR ( glomerular filtration rate) is 20 ml per min (only 20 percent of normal), he was shocked out of his wits. It took a while before I was able to calm him down and explain the details of his preexisting condition that he was unfortunately quite unaware of.

“But I have been seeing my primary care physician regularly and he never said anything about it,” he said.

TQ is another example of a relatively young forty-nine-year-old individual whose only complaint was mild nausea and “my wife’s cooking is not the same.” Needless to say, there was nothing wrong with her cooking, TQ was grossly uremic (toxins accumulating in his body from kidney failure) and his kidney function was 3 percent (GFR 3 ml/min) of normal value. His taste buds were therefore affected. He needed to be admitted to start dialysis the same day. I felt so much compassion for him and his wife at that moment. He did quite well on dialysis and is now awaiting a kidney transplant.

It is not so infrequent to consult on a patient referred for evaluation of renal failure and find the patient completely taken by surprise by the news that they have advanced kidney disease. It would be quite fair to say by evaluating old medical records that a significant proportion of such very surprised patients had had renal failure for a while, sometimes slowly progressive for years prior to their first referral to be evaluated for renal failure. This surprise usually turns into feelings of being upset and at times anger. “Why wasn’t I told anything about it”? is the usual conversation that ensues immediately thereafter. In yet some other cases, they were told that they have some degree of kidney disease but they still show surprise and shock. “But I feel ok. How can I have such advanced kidney disease?” This is a conversation that all practicing nephrologists are used to hearing and in a fatalistic fashion almost expect it. This goes to show the insidious nature of the disease that not only gives a false sense of security to the patient but unfortunately also their medical providers because of lack of signs and symptoms and hence sometimes delayed referral to the nephrologist.

Why should you care about this subject?

I will attempt to convince you that the following information can be lifesaving for yourself or your loved ones, and hence worth listening to and paying attention to. It is a subject that very likely affects someone you closely know, maybe a friend or a family member, and there is a high likelihood that they are not aware of the critical nature of their disease.

Courtesy of Wikimedia Commons; Public Domain

Common signs and symptoms of kidney disease

It is of utmost importance to understand that early renal disease does not usually produce any symptoms that point towards kidney disease. The majority of such cases are diagnosed by laboratory testing. Symptoms of toxin accumulation from kidney disease called uremia occur far too late and usually are precursors for dialysis requirement. It is therefore imperative not to rely on your symptoms or signs of kidney disease but catch it earlier by testing.

There are five stages of Chronic Kidney Disease. Stage 1 being an early stage and Stage 5 essentially End Stage Kidney Disease. Stage 1–mid-Stage 4 are usually asymptomatic. The usual symptoms of toxin accumulation called uremia occur in advanced Stage 4 going on to Stage 5 and therefore kidney disease may progress from Stage 1 to Stage 4 and may creep up, like a silent killer.

Also the symptoms usually don’t relate to urination till the very advanced Stage 5, and so due to their non-specificity, symptoms that occur as early signs of uremia can be easily mistaken as some other disease. For instance, nausea, vomiting, decrease in appetite, fatigue, lethargy, itching, and altered mental state are present in so many other diseases that without the presence of correlating lab reports, it would be difficult to relate those symptoms to kidney failure and hence diagnose kidney disease. By the time a decrease in urination occurs, it’s already a medical emergency.

The following diagram reveals the classification of Chronic Kidney Disease with lower numbers of GFR (glomerular filtration rate) correlating with worse kidney function.

Penn Medicine wrote in Penn Medicine Magazine, about “The underrecognized epidemic of Chronic Kidney Disease,” suggesting the same dilemma. The article suggested that 90 percent of people with Chronic Kidney Disease aren’t aware that they have it. The National Kidney Foundation and the International Federation of Kidney Foundations are running public awareness campaigns, especially in reference to diabetes and hypertension, which are the leading causes of Chronic Kidney Disease. Despite these efforts, the gap between the knowledge available to health care professionals and what trickles down to the general public is wide and gaping like the Grand Canyon. Obviously, a lot needs to be done in terms of public awareness in terms of early recognition, screen, and optimally timed referrals for treating kidney disease.

EYE-OPENING FACTS AND FIGURES

1. Not only thirty-seven million Americans have Chronic Kidney Disease, but millions more are at risk for developing it. Diabetes and hypertension are two of the most common reasons for Chronic Kidney Disease in Americans.
2. If you have diabetes, your chances of Chronic Kidney Disease are one in three. If you have hypertension, the chance of Chronic Kidney Disease is one in five.
3. Shockingly nine out ten patients are unaware that they are suffering from Chronic Kidney Disease because of the stealthy nature of the disease.
4. Nearly 810,000 Americans are living with kidney failure.
   • Nearly 570,000 are on dialysis.
   • Nearly 240,000 are living with a kidney transplant.
5. Diabetes is the most significant cause of kidney disease responsible for approximately half (47 percent) of the cases.
6. Kidney disease is growing at an alarming rate—with 1 in 7 or 15 percent of American adults are at risk of kidney disease
   Now simply imagine a family of seven or eight individuals with at least one of them with kidney disease and a 90 percent chance that he/she is unaware of their disease. That is a scary prospect.
7. Although kidney disease is more common in women as compared to men (14.3 percent vs 12.4 percent), for every two women who develop kidney failure, there are three men with end stage kidney disease.
8. As of February 2022, 92,000 Americans were on a kidney transplant waiting list. Last year in 2021, however, only 25,490 were able to get a renal transplant.
9. There were 5,971 living donor transplants performed in 2021 in the U.S.
10. There is a profound shortage of donor kidneys. Ninety-seven percent (135,000) of Americans who developed end stage kidney disease had to start dialysis and only 4,022 were able to get a preemptive transplant (kidney transplants performed before ending up on dialysis) in 2019. So there are not nearly enough kidneys donated to go around for every individual who develops end stage kidney disease.
11. The median waitlist time for patients with end stage kidney disease to receive kidney transplant is longer for older patients (46 -- 59.1 months) as compared for children seventeen years of younger (7.3 months). Median wait time is also longer for Black and Hispanic or Latino individuals as compared to white population. Most importantly, it is crucial to attempt to understand the reason for this disparity in health care provision amongst minorities in general and specifically in reference to median transplant wait time. This would allow us to understand modifiable factors to narrow this gap. Whether it is simply related to access to health care or additional factors are involved are worth studying in developing any kind of actionable intelligence and plan.
12. Kidney disease is much more common in minorities.
    • African Americans are 3.4 times more likely to develop kidney failure.
    • Native Americans are 1.9 times more likely.
    • Asian Americans are also at higher risk and 1.3 times more likely.
    • American Hispanics are 1.5 times more likely.
      Again, here the higher prevalence of kidney disease amongst minorities like many other diseases is such a consistent pattern that we owe it to our patients and ourselves to understand it in depth.
13. Kidney disease is a top ten killer in the US. More people die of kidney disease than breast and prostate cancer.
14. Kidney disease is more common as we get older. In individuals over seventy years of age, almost 44 percent have Chronic Kidney Disease. In people sixty-five years of age or older, the prevalence of kidney disease is 38 percent. Between the ages of 45–65, 12 percent of people have kidney disease. It is much less common between the ages of 18–44 years and occurs in 6 percent of people.