Martin Schreiber, Jr., MD
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Martin Schreiber, Jr. During the next hour, Dr. Schreiber will answer your questions about slowing the progression of kidney disease, the effect of hypertension on your kidneys and nutritional changes for kidney health.
Dr. Schreiber was named Chairman of Nephrology & Hypertension in 2005. He obtained his medical degree from Wake Forest University Bowman Gray School of Medicine, and completed his residency and internship at Cleveland Clinic. He completed fellowship programs at Cleveland Clinic and Massachusetts General Hospital in Boston. He is board certified in Internal Medicine and Nephrology. Dr. Schreiber is a member of the American Society of Nephrology, the International Society of Nephrology and the International Society of Peritoneal Dialysis. In 2007, Dr. Schreiber was named "Man of the Year" by the National Kidney Foundation for his tireless efforts in treating kidney disease. His areas of interest are diabetic renal disease, home dialysis, heart failure and renal disease, anemia and renal failure
Dr. Schreiber, thank you for joining us today to answer questions. Let’s begin with some general information about kidney disease.
Twenty six million American adults have chronic kidney disease (CKD) and millions of others are at an increased risk. High risk groups include those with diabetes, hypertension and family history of kidney disease. Early detection can help prevent the progression of kidney disease to kidney failure. Nephrologists in Cleveland Clinic's Glickman Urological & Kidney Institute are the experts in treating chronic kidney disease (CKD). The innovative model of health management focuses on educating and involving the patient in his or her care. The team at Cleveland Clinic works to slow the progression of CKD, identify risk for cardiovascular disease, and evaluate CKD patients to decrease risk for complications from surgery for other conditions. We hope that many of the online questions today will help explore these topics further.
Speaker_-_Dr__Martin_Schreiber: Great - let's begin with the questions.
kiddj: What are the causes of kidney disease?
Speaker_-_Dr__Martin_Schreiber: The main causes of kidney disease are uncontrolled hypertension, diabetes and failing kidney transplant. Other causes include: congenital abnormalities, polycystic kidney disease (PKD); Glomerulonephritis (GN) and acute kidney injury around the time of surgery which can lead to chronic injury over time.
jr1hpflf: What should a person informed 2 months ago, of a GFR of 69, do every morning, noon, and night, in order to slow the progression of kidney impairment? The person has already dropped more than thirty pounds through walking and diet and recently added Lopressor to meds.
Speaker_-_Dr__Martin_Schreiber: For any patient, who demonstrates a decrease in kidney function, the value should be verified and a plan for stabilization of function should be developed. Components of this life plan include: optimization of blood pressure, control of lipids, smoking cessation, blood sugar control if diabetic, avoidance of high phosphorous foods in the diet, repletion of Vitamin D deficiency (which is common in the Midwest region of the U.S.) and appropriate weight control.
HildaB: If I have a family history of kidney disease, when should I start getting tested? What tests should I get?
Speaker_-_Dr__Martin_Schreiber: Any patient who has a family history of kidney disease should make sure that their doctor checks a blood pressure, urinalysis for blood and protein and also obtains a serum creatinine.
Fitzie: Can my family doctor treat kidney disease, or do I need to see a specialist?
Speaker_-_Dr__Martin_Schreiber: Any patient that has an abnormality in kidney function or has been told that they have "kidney disease" should be seen by a Nephrologist (kidney specialist) to determine the cause of the kidney disease. This may require a kidney biopsy or other diagnostic studies.
Marlene: I have a family history of kidney disease and diabetes. I was diagnosed with diabetes 5 years ago. What can I do to prevent kidney disease in myself and in my children?
Speaker_-_Dr__Martin_Schreiber: Currently there is no clinical genetic testing approach to predicting the development of diabetic kidney disease. It is critically important to optimize blood sugar control and achieve supra-normal blood pressure control (less than 120/70). I would ensure that your children do not develop hypertension, microalbuminuria or hyperglycemia.
saturn: How often should one's blood be tested to check on status of progression of CKD?
Speaker_-_Dr__Martin_Schreiber: The most common blood test to diagnosis kidney disease or injury is the serum creatinine test. This test value is entered into a formula which calculates an estimated level of kidney function referred to an eGFR.
The National Kidney Foundation has encouraged that patients with an abnormal serum creatinine value have an eGFR calculated. This helps stage patient disease and guides both how frequently testing should occur and what special interventions the primary care physician should be utilizing.
Every patient with hypertension or diabetes should have a urinalysis (UA); a check for protein in the urine and a blood pressure measured.
saturn: What is a normal lab range for protein in the urine?
Speaker_-_Dr__Martin_Schreiber: It is less than 160 mg.
Pregnancy and Renal Disease
johnQ: I have kidney disease. Is pregnancy out of the question? Should we look into adoption?
Speaker_-_Dr__Martin_Schreiber: Decisions regarding the advisability of pregnancy should be openly discussed by both the patient and physician (Nephrologist.) The level of kidney dysfunction, degree of proteinuria and level of blood pressure may determine the safety of pregnancy for both the mother and infant. A number of patients with kidney disease can have very successful pregnancies. Even patients on dialysis and after kidney transplantation can become pregnant and deliver healthy infants.
Polycystic Kidney Disease
mk: I have kidney cysts. One cyst is quite large. Can anything be done or do we let nature take its course. I am 75 yrs old.
Speaker_-_Dr__Martin_Schreiber: Polycystic kidney disease (PKD) is a well known cause of kidney failure. As the number of cysts in the kidney increase and the cyst size increases, this will replace normal kidney tissue. The degree of replacement will determine the level of kidney dysfunction and predict the rate of kidney disease progression.
It is common for patients without PKD to have several (less than 5) cysts noted in the kidney and yet have no family history of PKD. Once a cyst is identified, a determination should be made whether or not this cyst (cysts) possesses any risk for renal cancer. Cysts may be classified as simple or complex. A simple cyst is most likely benign, while a complex cyst may have an increased risk of cancer. Complex cysts may active diagnosis and follow-up.
kathyp: I have Polycystic Kidney Disease (PKD) which showed up in my mid 30’s. Now my daughter was diagnosed with it at age 14. My other 3 children (in their 20’s) have not been diagnosed with it. Should we all go through genetic testing? What does it involve?
Speaker_-_Dr__Martin_Schreiber: In families demonstrating the inheritance of PKD undergoing a renal ultrasound can help diagnosis the presence of cysts in the kidney. Cysts can develop before or after the age of 20 and therefore screening siblings too soon may not identify kidneys at risk.
Genetic testing is primarily utilized in situations where the mother or father have PKD and there is a concern about risk for the fetus to possess the gene.
Most siblings with a family history of PKD should undergo ultrasound to determine the presence of absence of cysts. However some children may not develop cysts until they are much older. Genetic testing is primarily utilized for fetal risk.
Falling: I have a large cyst in one kidney. The kidney still functions, but I want to know if it can be aspirated or in some way reduced in size.
Speaker_-_Dr__Martin_Schreiber: Typically we do not aspirate or surgically unroof a cyst unless it is causing significant symptoms to the patient. These usually include intractable nausea and vomiting, malnutrition and debilitating pain.
KF: I have PKD and I am most concerned about: 1) progress on a cure for this disease and 2) specific information on what my diet should be to slow the progress of the disease -- what foods to include and which ones to exclude.
Speaker_-_Dr__Martin_Schreiber: What I can tell you is that dietary protein restriction may have less of an affect in slowing progression of PKD than other kidney diseases. Yet, decreasing caffeine, increasing water intake and lowering salt intake may be helpful. Currently there is no cure for PKD. There are a number of laboratories through the world that are working on finding a cure.
End Stage Renal Disease (ERSD) and Dialysis
elpayne: I have ESRD and currently on dialysis. Cause is high blood pressure. Doctors are still struggling with keeping my blood pressure down. If I have a transplant could this still be a problem?
Speaker_-_Dr__Martin_Schreiber: Uncontrolled hypertension prior to transplant increases the risk for significant risk for controlling hypertension post transplant.
pitterpatter: I recently started dialysis. How do I go about finding a dialysis center if I want to visit out-of- town relatives for the holidays?
Speaker_-_Dr__Martin_Schreiber: The best thing to do is to consult your social worker.
SEM: I have two questions. The first one is how can I get more protein into my husbands diet that is on Peritoneal Dialysis? The second question is: it common for PD patients to have and outbreak in huge bumps and have a bad smelling breath?
Speaker_-_Dr__Martin_Schreiber: For patients needing extra protein, I would strongly encourage protein supplements either in a liquid or powder form. Need to answer question about the bad breath…..
elpayne: What is your view on bone marrow use in kidney transplant to reduce use of anti-rejection medication and does the Cleveland Clinic participate in his procedure?
Speaker_-_Dr__Martin_Schreiber: Cleveland Clinic does not use bone marrow stem cells prior to transplantation. There are several centers in the United States exploring this approach, but as of yet this is not the standard of care.
saturn: Would ACE inhibitors be used in Stage 3? Why or why not?
Speaker_-_Dr__Martin_Schreiber: ACE inhibitors and ARB's can be used to slow the progression of CKD. They can be used in Stage 3 CKD under close monitoring by the physician.
saturn: Can a course of daily buffered aspirin over 6 months cause kidney disease? What about taking baby aspirin daily for the heart?
Speaker_-_Dr__Martin_Schreiber: No - a standard course of daily aspirin or baby aspirin over 6 months typically does not cause kidney damage.
Diabetes and Renal Disease
bubby: I am a 73 year old woman recently diagnosed with type 2 diabetes. I have high blood pressure, controlled with medication and am also on Metformin. My glucose readings are within normal range. My eGFR is 48. How concerned should I be? My primary care physician says that we can watch this.
Speaker_-_Dr__Martin_Schreiber: Both diabetes and hypertension can cause kidney disease. If uncontrolled, this may contribute to kidney disease progression. Kidney function can decrease normally as a person ages especially over the age of 65. The eGFR calculation may not be as accurate in people over the age of 65 compared to younger individuals.
While an eGFR of 48 represents a decrease in kidney function, this does not require special intervention other than blood pressure control, lipid control, adequate blood sugar control and the appropriate diet. Individuals with an eGFR less than 60 should discuss with their physician how concerned they should be and the appropriate intervention. But some of the decrease at age 70 may be due to normal aging.
Focal Segmental Glomerulosclerosis (FSGS)
cdubose1970: I have FSGS and Nephrotic Syndrome. Mine was found in the peri-hilar region and they believe it was early detection. How soon do you think I will have to go on dialysis?
Speaker_-_Dr__Martin_Schreiber: FSGS with Nephrotic syndrome may progress over time to end stage kidney disease (ESRD) requiring dialysis if there is no response to treatment. FSGS may progress at different rates depending on the type seen on kidney biopsy and the degree of damage from FSGS in the kidney.
cdubose1970: Because I have FSGS and Nephrotic syndrome my physician has me on high blood pressure medication but I don't have high blood pressure. Will this have a bad affect on my heart? I'm on Lisinopril and Diovan and well as a water pill called Demedex.
Speaker_-_Dr__Martin_Schreiber: Some patients require medications which have a risk for future cancer which typically is small and this risk is balanced by trying to achieve a treatment response which would delay or prevent progressive damage to the kidney.
Certain blood pressure medications are utilized to lower the pressure within the filtering units of the kidney called glomeruli. One does not need hypertension to justify their use and if used appropriately they should not adversely affect the heart.
Membranous Glomerulonephritis Neuropathy (MGN)
LM: Hello, I am a 26 yr. old female, married, and mother of 2. I am diabetic of 17 years, was recently diagnosed with membranous neuropathy, as well as diabetic neuropathy. I have been seen by my specialist, we have tried several meds, and nothing is helping. I need help, please. I know there has to be something that can be done to extend my future with my family; will you please help me and let me know if the Cleveland Clinic can do this for me? Thank you.
Speaker_-_Dr__Martin_Schreiber: Patients with diabetes can have an alternate reason for kidney disease other than diabetes. Membranous nephropathy can occur in diabetes and require specific therapy to reduce the amount of protein being spilled in the urine. The diabetes can make the treatment of membranous neuropathy more difficult, but not impossible.
Reviewing the kidney biopsy, assessing kidney function and degree of protein excretion are important determinants of appropriate therapy.
If you like there are several physicians with expertise in this area at Cleveland Clinic: James Simon, MD; Marc Pohl, MD; Surafel Gebreselassie, MD.
Nutrition and Renal Disease
saturn: What is the current thinking on reducing protein grams in ones diet to the equivalent of ones body weight?
Speaker_-_Dr__Martin_Schreiber: The medical community is divided on the effect of reducing protein in the diet to delay progression of kidney disease. Patients that reduce protein to the equivalent of ones body weight in kilograms may become nutritionally malnourished. While reducing phosphorous and sodium and while watching potassium appear to be very important in dietary management.
miller678: I am trying to follow a low protein diet, but I am an avid exercise fanatic. I do not feel like I have enough fuel in my tank compared to when I could eat high protein meals. Do you have any suggestions?
Speaker_-_Dr__Martin_Schreiber: Energy is derived from 3 components. They are carbohydrate, fat and protein. If you exercise on a regular basis, you need to have a certain energy intake per day. You may become tired since you are not taking in enough energy. I would meet with your dietician or nutritionist to review your daily dietary intake, since I suspect your energy intake is low on your current diet.
saturn: What is the maximum amount of phosphorus that should not be exceeded in a CKD (chronic kidney disease) diet?
Speaker_-_Dr__Martin_Schreiber: Phosphorous intake should be reduced to 600-900 mg daily.
duttycalls: I continue to experience kidney stones, although these are never calcium based but staghorn formed by chronic kidney infections. Is there a way to prevent these from recurring?
Speaker_-_Dr__Martin_Schreiber: Patients who have recurrent kidney stones whether calcium, uric acid or staghorn should have a complete workup to determine both the cause and the best approach to treatment. Since recurrent stone disease can lead to kidney damage, defining the best therapy is critical. It is essential for patients with staghorn calculi to control the infection and this may require attention to the infecting bacteria and both Infectious Disease and Nephrology consultation.
jr1hpflf: Can a patient with a lowered GFR (reading was 51, now is 69) take flu vaccine during the course of the three hepatitis vaccinations?
Speaker_-_Dr__Martin_Schreiber: Yes - patients with CKD can receive the flu vaccine and Pneumococcal vaccine in most clinical settings. I would check with your physician.
Exercise and Medication
jr1hpflf: Taking Lopressor, Lisinopril, HCTZ, Clonidine, and Potassium for high blood pressure. For the "best training effect" from walking, should a person begin the workout a couple of hours before taking pills?
Speaker_-_Dr__Martin_Schreiber: I would monitor your blood pressure pattern during the course of the day on this multi-drug regimen. I would avoid vigorous exercise when the pressure is low and try to coordinate exercise activity when the blood pressure is status quo during the course of the day.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Schreiber is now over. Thank you again Dr. Schreiber, for taking the time to answer our questions today. Since we did not get to everyone's questions, Dr. Schreiber has agreed to answer them and we will post them on the transcript. Please check back in a week or so. We simply ran out of time with everyone's enthusiastic participation today.
Speaker_-_Dr__Martin_Schreiber: This was great. Let's do it again!
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