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You probably don’t think much about your kidneys, but they’re always there quietly working to filter the bad stuff out of your body. They actually have other jobs, too, as nephrologist James Simon, MD, explains. Here’s a look at what they do, why they fail and how to keep them healthy.

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How to Be Kind to Your Kidneys with Dr. James Simon

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio, and we're here with Dr. James Simon.

Dr. Simon is a nephrologist specializing in high blood pressure and kidney disorders and today, we're talking about kidney health. Please remember this is for informational purposes only and it's not intended to replace your own physician's advice. Thank you so much for being here today.

Dr. James Simon:  You're welcome, my pleasure.

Nada Youssef:   All right, so I'm going to ask you some questions off topic to get to know you on a personal level.

Dr. James Simon:  Sure.

Nada Youssef:   All right, so what is your current guilty pleasure?

Dr. James Simon:  We're big Game of Thrones fans, so after the series finale, we started the ...

Nada Youssef:   You started to rewatch it.

Dr. James Simon:  ... whole series over, yeah.

Nada Youssef:   So you finished the whole thing, you know what happened, you're rewatching.

Dr. James Simon:  Right.

Nada Youssef:   Okay, no spoilers.

Dr. James Simon:  There's a big difference when watching it over a span of 10 years and watching every episode in a row.

Nada Youssef:   Yeah. There's something about binging a good show.

Dr. James Simon:  Yeah.

Nada Youssef:   Absolutely, I agree. If you could time travel, when and where would you go?

Dr. James Simon:  I'm a big revolutionary war buff. I've read a lot about it, I'm really fascinated about how some of the decisions were made and how things evolved that had lasting impacts on our country.

Nada Youssef:   Yes. So would you go just like a fly on the wall or do you want to be certain person?

Dr. James Simon:  No, I'd be a fly on the wall.

Nada Youssef:   Fly on the wall, watching it happen.

Dr. James Simon:  Mm-hmm (affirmative).

Nada Youssef:   Okay. Very cool answer. And then, if you weren't a physician, what would you be?

Dr. James Simon:  A landscaper.

Nada Youssef:   A landscaper.

Dr. James Simon:  My father-in-law was ... I do a lot of landscaping. Every house that we've lived in, and my father-in-law always said I should do that on the side.

Nada Youssef:   You like it?

Dr. James Simon:  Yeah, I love it.

Nada Youssef:   Good.

Dr. James Simon:  That's a the only artistic creative thing I can, I tend to do. I'm not a good painter or anything.

Nada Youssef:   That's good, you still get to do everything you love, then.

Dr. James Simon:  Yeah.

Nada Youssef:   All right, well let's go back to kidney. Cool. So first of all, let's talk about what is the function of a kidney.

Dr. James Simon:  So your kidneys basically clean your blood out.

Nada Youssef:   Okay.

Dr. James Simon:  So there are the filtration system for the body, but instead of like a water filter where the clean water comes out at the other end of the filter, with the kidneys, the bad stuff gets filtered through and that eventually gets turned into the urine.

There's a about a million individual microscopic filtering units in each kidney and their job is to get the extra ... the bad stuff out of the blood while keeping the good things like blood and protein inside the blood. So they clean the excess water, the toxins that we think about that build up in the cells over time and that are put into the bloodstream, acid, electrolytes like sodium and potassium get get taken out of the bloodstream. Because if you eat a lot of sodium, you have to get rid of it, right? So anything has to eventually get, end up into the urine, if it gets into the bloodstream. The liver does some detoxification too but the kidneys are really a main role for filtering the blood and keeping it clean.

Nada Youssef:   So blood filtration, kidneys?

Dr. James Simon:  They do a lot of other things. They help with keeping your red blood cell counts up, so kidney patients can get anemia because they're not producing a hormone that is necessary for producing your red cells. They're important in bone health, like we said, with acid base regulation so keeping the acid levels in your bloodstream regulated. They have a lot of other roles but those are the main ones.

Nada Youssef:   The main functions.

Dr. James Simon:  Mm-hmm (affirmative).

Nada Youssef:   What kind of things can go wrong with our kidneys?

Dr. James Simon:  Anything that affects those microscope- those little filtering units. They're called glomeruli and they're basically tiny sacks of blood vessels. So anything that can hurt blood vessels in general can hurt the kidneys. You can actually lose about half of your filtering units and still have good enough kidney function that it looks normal on our tests and it's because we have so many in reserve. But once you get down below that, then you can start having impaired kidney function.

The most common causes of kidney failure in America are diabetes and high blood pressure. Both of those affect the blood vessels in different ways. Diabetes has special effects on the filtering units that are a little different because of the high sugar levels and the things that can happen that way.

Now if you look beyond diabetes, there are certain medicines you can take that we can talk about later that can cause kidney problems. The kidneys are very sensitive to oxygen, so certain situations where the blood flow can drop, so if people have severe infections or situations called sepsis where they're not getting enough blood flow to their kidneys, or if their blood blood pressure drops during a surgery, the kidneys may be sensitive to that and get affected. In those situations, oftentimes it can be reversible, something we call acute kidney injury versus permanent kidney damage called chronic kidney disease.

We talk about kidney function is ... a lot of people come to my office and they were told they're in kidney failure. In reality their kidney, their labs just showed that the kidneys were just slightly off. There's a huge range between normal kidney function and complete kidney failure where people need to start dialysis so the first thing I do when they come in the room, if it's just moderate or mild kidney dysfunction, is I tell them, "You don't need dialysis," and they give a huge sigh of relief.

Nada Youssef:   Oh God.

Dr. James Simon:  Because of the misunderstanding, even among doctors, about what kidney failure is. That span is what we call chronic kidney disease. The way we measure the kidney function is a lab called creatinine is the most common way to do it. Creatinine's put out by your muscles and it's filtered up by the kidneys. So if you start to see increasing levels of creatinine, that would suggest that the kidneys aren't cleaning the blood out as well.

Now everybody has their own specific creatinine level because it depends on your muscle mass. So gender, age, ethnicity, all play a role in whether that creatinine is normal for you. So there is no one normal creatinine. What we do is we take those factors and we put it into a equation to estimate that GFR, that GFR is called the glomerular filtration rate and it's roughly your percent kidney function. I say roughly because at peak, we have about 115, 120 depending on your gender, but once it starts getting down below a hundred, it's easier just to understand as your percent kidney function.

The GFR is specific to you and it tells us where you are on that spectrum from perfect kidney function to failure. Then we divide it up into stages of kidney function called chronic kidney disease stages one through five. Stages one and two are relatively normal levels of kidney function so the GFR is going to be between 60, but north of 60, but you have to have something else going on with the kidneys. Either you're leaking blood or protein into the urine that you shouldn't be or you've lost a kidney for some reason. So not too many people get identified with stage one and two kidney CKD.

Most people get identified at stage three and that's because the GF ... the qualification for stage three is that you just have to have a GFR less than 60. Okay, and then so that's 30% to 59% kidney function. Stage four is what we call really a pre-dialysis stage where it's 15% to 29%, and then stage five which is complete kidney failure is less than 15%. That's when most people need to start dialysis, usually around 10% to 12% or have a kidney transplant.

Nada Youssef:   Okay, and then you can live with one kidney, is that correct?

Dr. James Simon:  You can live with one kidney, so that's why we can donate kidneys to loved ones or friends or even anonymous donations for people that need one.

Nada Youssef:   Sure. Okay, so what are some of the symptoms associated with kidney disease? How do I know I might be getting kidney failure?

Dr. James Simon:  Most commonly, early kidney dysfunction is asymptomatic. So you're not going to know. That's why people who are at risk for CKD, it's important that they get screened. But it's similar to high blood pressure, until it's severe, it's silent. And so it's another one of those silent killers.

As you get further down closer to dialysis, in the stage five CKD, you can develop what are called uremic symptoms and that ... they're very nonspecific, so if you get them and you don't know that you have kidney failure, you shouldn't think of kidney failure first. But the earliest signs are you may get nauseated especially in the morning, or you have an appetite and you smell food and then it just turns your stomach. You are actually nauseated all day, a bitter and metallic taste in your mouth. Those are the earliest signs. So someone we know has CKD and their GFR is in the teens and getting down closer to needing dialysis, we tell them, "Tell us when you're having those early symptoms."

Nada Youssef:   So they already know that they have some kind of disease by then?

Dr. James Simon:  They should, hopefully. Hopefully they do. Unfortunately there are people who present to us in kidney failure and then just never knew about it either because they weren't ... most commonly because they just weren't getting healthcare.

Nada Youssef:   Yeah, they weren't getting checked regularly.

Dr. James Simon:  Exactly.

Nada Youssef:   Sure, sure. So let's talk about the testing. What kind of testing is done for kidney health? Is that blood test or that urine test?

Dr. James Simon:  Both, actually. There's two tests. We talked about the creatinine lab value. That's, 99% of the time, that's part of a chemistry panel. Chemistry panels are very routine tests that are done on a lot of people and so that'll give you the creatinine and most labs now will tell you what the GFR is as well, so it'll give your percent kidney function.

Then the urinalysis, that's screening for protein in the urine or blood in the urine. Blood in the urine, there's a lot of different causes for blood in the urine. Kidney stones, kidney tumors, bladder problems, prostate problems, infections. But there are kidney ... oftentimes immune problems or genetic problems that can cause blood in the urine so anybody that has blood in the urine needs to be worked up both for kidney problems and urologic problems.

Nada Youssef:   Sure, sure.

Dr. James Simon:  So oftentimes they'll need a CAT scan or a cystoscopy by a urologist and ... but if we see blood and protein in the urine, that points more towards the kidneys and a kidney function problem.

Then we look for protein in the urine too. Protein can show up in the urine from a variety of problems, most commonly from diabetes. So oftentimes you'll see protein in the urine before you see kidney dysfunction in patients with diabetes. So we actually will screen them very closely for that.

We don't screen everybody for CKD. There are at risk populations, high blood pressure, we talked about people with diabetes, people with certain infections like HIV, certain native ethnicities. Indigenous populations are at high risk. If you've had cancer, especially if you're under ... while you're undergoing treatment, because there are a lot of chemotherapeutic agents or anti-tumor agents that can hurt the kidneys.

Usually, there's going to be a reason why you're being screened although nowadays, many, especially once you get into your 40s or your 50s a lot of primary care doctors with their annual visits will check every once in a while your kidneys. Or health insurance, if you want to get new life insurance or health insurance, they'll make you go through those tests to screen for it as well.

Nada Youssef:   So if you already have health insurance, what is a good age to get screening for kidney health?

Dr. James Simon:  There is no one cutoff. So if you're completely healthy ... I tell you the truth, if someone's completely healthy, probably once every couple of years, but again, there's ... the criteria are not really that explicit.

Nada Youssef:   Okay, but if you have diabetes or high blood pressure…

Dr. James Simon:  Definitely, you should it checked in at least once a year in those situations.

Nada Youssef:   Okay. So I want to talk about diet and exercise and how an important of a role it plays for kidney health, as it should be. What, in your opinion, is a kidney-friendly diet or renal diet and why?

Dr. James Simon:  So, you know, as we kind of discussed diabetes, high blood pressure, heart disease, which we didn't mention before, but cardiovascular disease is a common cause of kidney dysfunction. People with congestive heart failure, people with liver problems can have kidney dysfunction, and a whole host of other diseases that can lead to kidney dysfunction. So the kidneys most often are what they call an innocent bystander. They're just being affected by some other disease. Similarly, there is no one magic diet for people with CKD. If you have a general heart-healthy diet and keep your blood, cardiovascular system healthy, that's really what's best for the kidneys.

So I recommend a good heart-healthy diet, low sodium, 2,400 milligram is recommended for general ... most people, and that's very difficult.

Nada Youssef:   I was going to say, what do most people eat right now?

Dr. James Simon:  Most people coming into my office, if we do 24-hour urine collections, and again, that'll reflect roughly what they're eating, they're reading between 4,000 and 6,000 milligrams.

Nada Youssef:   4,000 to 6,000.

Dr. James Simon:  Even if they tell me they're never touching a salt shaker. If they're salting their food, it's north of 7,000 to 8,000 milligrams. It's just insane how much sodium is in all of the food we eat.

Nada Youssef:   And the normal?

Dr. James Simon:  The target ...

Nada Youssef:   The target, it's

Dr. James Simon:  It's not normal, but the target is less than 2,400 milligrams.

Nada Youssef:   Less than 2,400 milligrams.

Dr. James Simon:  2.4 grams.

Nada Youssef:   Wow, okay.

Dr. James Simon:  It's probably one of the more difficult diets for most people because you eat out, you've probably gotten that day's worth of sodium in that meal, you know. Anything with any kind of preservatives in, it's going to have salt in it. So you know, frozen dinners, anything that's processed, hotdogs, lunch meats, sausage, all that stuff can have a lot of salt in it. You know, jarred spaghetti sauces, barbecue sauce, ketchup, all loaded with salt. Anything in a can, unless it's says it's a 100% salt-free.

Nada Youssef:   So really go for whole foods.

Dr. James Simon:  Well, I recommend fresh, frozen vegetables; fruits and vegetables; and unprocessed meats. Really, it's the best way to go. Even then, you got to be careful though because chicken sometimes will be injected with sodium phosphates or flavoring or stewed in ... or kept in broth, and those are just salt solutions.

Nada Youssef:   So you get good quality meat too.

Dr. James Simon:  Good quality meats. It's hard because unfortunately, you have to pay more for to get food producers not to add stuff to your food. So it can be difficult for a lot of people to afford really healthy food because the most unhealthy food in America right now is the cheapest.

Nada Youssef:   It's the convenient one, on drive through.

Dr. James Simon:  Yeah.

Nada Youssef:   Yes, great. So what about alcohol? Alcohol, bad for your kidneys?

Dr. James Simon:  Not directly, no.

Nada Youssef:   Okay.

Dr. James Simon:  No. Again, in moderation. There's no reason people with chronic kidney disease can't enjoy a beverage every once in a while. Again, if you get dehydrated and anything that's going to dehydrate you can run the risk of the kidneys, especially if you already have depressed kidney function. Some people are on diuretics for their high blood pressure or if they have heart problems and so that's already going to challenge your kidneys, being on a diuretic because it dehydrates the kidneys a little bit. Most people do fine on diuretics and the kidneys tolerate it, but it is a risk factor for other causes of dehydration hurting the kidneys. So if you get drunk and pass out, you know, it could be harmful, especially if you do that repeatedly. Repeated reversible insults on the kidney can lead to permanent kidney damage.

Nada Youssef:   I see. Okay, so drink your water.

Dr. James Simon:  Stay hydrated, but don't overdo it.

Nada Youssef:   Don't overdo it. Okay. What's overdoing it?

Dr. James Simon:  There's no reason to force hydrate. Absolutely no reason, there's been no proven benefits. A lot of people are told that they need to drink half of their weight in ounces of water. There's no reason to do that. The kidneys are very good at figuring out how much water needs to stay in the body. So that's why in the morning after you haven't had anything to drink for six or eight hours when you're sleeping, your urine's nice and dark, because the kidneys have pulled extra water out of it. But if you're hydrating all day, then your urine clears up.

I generally recommend for most patients, unless certain situations, kidney stone patients need more water. Heart failure patients need less water because the heart can't pump the water around and they can get congestive heart failure. Water builds up in the lungs and they can't breathe.

But for most patients, four to six eight-ounce glasses of fluids a day, non-caffeinated and unsalted, you know, generally good ...

Nada Youssef:   Just water.

Dr. James Simon:  Yeah.

Nada Youssef:   Yeah.

Dr. James Simon:  Doesn't have to be just water, but primarily.

Nada Youssef:   Okay, so the diet that you mentioned, it's more of a preventive diet for renal disease. What about if you already have renal disease or failure, then what diet do you go for?

Dr. James Simon:  The diets become more difficult as the kidney function drops. Really, we have to limit certain things that the kidneys can't get rid of because they don't work as well. Now, if your potassium level and your phosphorus levels and your acid levels are fine, then a regular heart-healthy diet is all you need. But if you start having ... commonly, the potassium is going to be the common one to go up. If your potassium level starts rising into the abnormal ranges, we may put you on a potassium restricted diet.

The reason I say don't do that until your kidneys ... you need it, the lab show that you needed is because it's a lot of really healthy foods that are high in potassium and it becomes very hard to take care of yourself and eat a heart-healthy diet and still have a low potassium diet. So a lot of people come in and they have early CKD and they just put themselves on a renal diet and it's a hard diet. If the phosphorus levels start going up, you know, it may end up restricting protein intake, and other high phosphorus foods as well.

When you're on dialysis, that becomes harder because eventually it's, again, it's weird to think of, but you eventually stop peeing altogether when your kidney function is down to zero. So then you have to limit your fluid intake as well.

Nada Youssef:   Wow.

Dr. James Simon:  Because the more water and other fluids you take in between dialysis sessions, the harder the dialysis is on your body. Because they have to pull all of that out, and if you're on hemodialysis, in three or four hours.

Nada Youssef:   Wow. So what does a renal diet look like? Look, if we're just talking like foods, what kind of food are we eating?

Dr. James Simon:  You're trying to find low potassium fruits and vegetables. you know, we really, we have less-

Nada Youssef:   So no bananas, no spinach?

Dr. James Simon:  No bananas, citrus fruits tend to be high, oranges tend to be high in potassium. Then we tend to ... we don't want people to overly restrict their protein intake because malnutrition can be a real problem too but we do moderate the protein intake and try to regulate how much they take in. Again, that's if you have kidney failure or a really advanced kidney disease. Yeah.

So it can be hard, especially if you have diabetes. When you're trying to control your carbs, you can try to control your sodium and then you add in potassium and proteins and everything else, it can become a very complex issue. So we have nutritionists that if patients need help, we refer them to to help them with it.

Nada Youssef:   Great. So you hear a lot of these different things of people doing detoxes and things like that, kidney detox, anything like that that you want to talk about?

Dr. James Simon:  I still don't understand what the purpose of those is.

Nada Youssef:   Yeah.

Dr. James Simon:  There's a lot of ... the kidney's job is to detox.

Nada Youssef:   Is to detox, right.

Dr. James Simon:  And so is the liver.

Nada Youssef:   Right. So just keep it healthy?

Dr. James Simon:  Right. So if ... a lot of the detoxes are colonics. You know, to give people a lot of diarrhea and you know, suggestion that they're removing heavy metals. I don't want to minimize people's understanding of that kind of healthcare if they believe in it. But there's really no medical proof that any of that stuff is going to be beneficial to the kidneys.

Nada Youssef:   Right, right. Okay, good to know. So what about certain vitamins, supplements, herbal remedies that can maybe affect our kidneys? I heard vitamins could.

Dr. James Simon:  No, not really. A general multivitamin, even though it's not been proven to actually do anything for our health, people take them and in most cases, it's fine. If a kidney function does get really poor on your dialysis, you may need a special kidney friendly vitamin that takes out some of the calcium and some of the other things that that kidneys have problems regulating.

Supplements can be a problem, though. Chinese herbal supplements specifically, they call them Chinese herbal supplements because that's where they originated but you know, Southeast Asian supplements are often contaminated, not necessarily intentionally, but they're often contaminated with things that can be very harmful to the kidneys.

Nada Youssef:   Oh, okay.

Dr. James Simon:  And so that's one sector where where we try to tell people to stay away from, especially in, you know, they come to my office when they already have kidney problems. So I generally recommend, if you're at that point, why do something to risk your kidney function if you don't know for sure what it is?

The problem with over the counters and herbals and supplements is you don't know exactly what's in there. The FDA does not require that the people that manufacture it say exactly what is, test exactly what is in their product. Now there are good manufacturing standards that some supplement makers adhere to that are a little closer to reality, but there really is no regulation to say that what you're taking is actually what's on the label.

Nada Youssef:   Right, and it's not FDA-regulated at all.

Dr. James Simon:  They're not FDA-regulated and there haven't been studies on a lot of these things. A lot of the health benefits are more pushed either by the producer or by alternative medicine without what we would consider in medicine rigorous studies to prove them. So in patients with CKD, generally, you know ... then there are some things that are fine. Turmeric is ... or curcumin is something that a lot of people take and it's been shown to be safe, if not slightly beneficial in certain disorders so I don't have any ... you know, if I know it's safe and they really want to take it, that's great.

Nada Youssef:   Or you can put it in your food.

Dr. James Simon:  Yeah. You know, if I'm not sure what's going on with it and I look it up and I can't find any research on it, I, you know ... if it's one thing, if I know it's harmful, I'm going to tell him to stop it. Right?

Nada Youssef:   Sure.

Dr. James Simon:  So nonsteroidal anti-inflammatory drugs, Ibuprofen, Motrin, Aleve, Naproxen, anything you can take over the counter for fever or pain other than Tylenol or Acetaminophen, basically it'll say and say it on the bottle, NSAID. Those can be very harmful to the kidneys if you take them over and over and over again for long periods of time. So it's really hard because a lot of people with bad arthritis, these drugs are very effective. But if they take them every day for years on end, we have people come in in insignificant kidney dysfunction from taking these meds. Once your kidneys are impaired, we have to stop them because the kidneys become more sensitive the worse they get.

Nada Youssef:   Okay, I'm going to have you repeat that because that's critical. You said it's anything over the counter except ...

Dr. James Simon:  Basically except Tylenol or Acetaminophen. Acetaminophen is the generic ... Tylenol is the brand of Acetaminophen. But if it says NSAID on the bottle and so the ones that ... the most common ones are Naproxen which is marketed as Aleve, or Ibuprofen which is marketed as Motrin or Advil, those are the most common over the counter. But there are a lot of prescription NSAIDS that that doctors can prescribe too. Doctors usually are pretty good about checking kidney function before they prescribe them, but not always.

Nada Youssef:   Sure. So as a doctor, you're checking the kidney function, you did the urine test, the blood test, and you're finding out that they have high risk of kidney failure. What is the next step? What are the medications? What is it? What do you do?

Dr. James Simon:  My approach, so anybody with a GFR under 60 should at least have a conversation with a nephrologist. Oftentimes, if the kidney functions in the 50s and we don't see any high risk factors that they're going to progress on the kidney failure, you can live with kidney function in your 50s for the rest of your life and not know it. So a lot of times, I personally, will discuss, educate them, make sure that there's nothing high risk going on and then refer them back to their primary care doctor as long as their primary care is comfortable monitoring their kidney function once or twice a year just to make sure it's not progressing and then come back if it's getting worse.

But my approach is A, try to figure out what caused it, and a lot of cases we can't, okay, but if they have high blood pressure, diabetes that's been uncontrolled for long periods of time ... even well controlled diabetes can hurt the kidneys. It's just, it's not a normal state so the kidneys can get hurt, but the better your diabetes is controlled, the lower the likelihood that you'll get kidney failure from it.

So we focus on finding out what the cause was if we can and trying to slow the progression down. That generally is removing medicines that we think are going to hurt the kidneys, controlling blood pressure, controlling diabetes, making sure the heart's healthy and taking care of, if they have a cardiologist, we work with them to make sure they're there on a good regimen to keep the blood flow into the kidneys.

Then we also do some other things. Like I said, you can get anemic, you can get bone metabolism disorders, acid based disorders. Most of those are going to be at much lower levels of kidney function once you get in your 20s, so stage four or beyond, and we monitor those. But we also, we take care of the heart too so we're going to check cholesterol levels and if people need to be on cholesterol medicines.

Because the biggest risk for someone with chronic kidney disease is not that they're going to go on dialysis, is it's they're going to die of a heart attack or a stroke. The heart and the blood vessels do not like the kidneys not working well. So the risk is minimal at that GFR of 50 to 60, but if you have protein in the urine for some reason spilling protein in the urine, it makes that risk go way up. Both not only for progressing under kidney failure, but also for having heart attacks or strokes. But that risk goes up the lower your kidney function gets. And so we, that's another reason why we really pay attention to high blood pressure, the cholesterol, to diabetes, and try to work with the other doctors to help manage those. But oftentimes, we end up managing the high blood pressure, and ... but we work closely with the diabetic.

Nada Youssef:   Yeah. Because it goes hand in hand-

Dr. James Simon:  Yeah, it goes hand in hand, and kidney dysfunction actually causes high blood pressure. So it's almost a bad loop. Right. A lot of patients get referred to us for difficult to control high blood pressure, just because we have a little better understanding a lot of the different medicines and the nuances between one and another and we can identify side effects that may be caused by one medicine and switching over to something else that won't cause that side effect. So a lot of patients get referred to us who have high blood pressure.

Nada Youssef:   So with someone that has kidney failure and they have to go through dialysis, can you explain what dialysis is, what goes through it, and and when you need it.

Dr. James Simon:  Dialysis is needed ... so some form of kidney replacement therapy, what we call renal replacement therapy, is needed when you become uremic. Okay? So there is no one GFR number, that percent kidney function where you have to start dialysis. Ideally, if someone is young enough, so, and that's very center specific, if they can qualify for a transplant, we want to get them transplanted. That is the best way to treat your kidney failure. It restores some form of normalcy of life. You're not tied to a dialysis machine and it provides the best prognosis. You're going to live the longest if you have a transplant.

Unfortunately, because of shortages and organs and a lot of people are really sick, they may not qualify or may not be able to get a transplant. But we encourage everybody to try to list at least if they can qualify for a transplant, and you can list under 20, your GFR is under 20.

In my patients, if they're a good ... if I think they're a transplant candidate and they're getting down to the 20, 21, 22 I'll send them over to the transplant clinic to start the evaluation, because the minute they hit 20 then they get on the list and then you can start looking to see if you have a donor.

Nada Youssef:   This is a living donor, right?

Dr. James Simon:  Living donor's the best way to go. Living donation's the best way to go and like I said, it can be a living related donor from someone in your family, an unrelated donor like a spouse. You know, they have all these pairing networks now where you can sign up and they'll find a match throughout the country and ship the kidneys, you know, that way. There are a lot of different ways to get kidney transplants. It's really the best way to go. It sounds really scary.

Nada Youssef:   It does.

Dr. James Simon:  You know, for some reason, transplant sound so much scarier than dialysis, but it really is the gold standard treatment. It's the best way to go, absolutely. So, you know, sign your organ donor cards, you know, and then if you're in that situation, make sure that your nephrologist talks to you about transplantation.

Nada Youssef:   So kidney transplant first, but if not, dialysis is always an option.

Dr. James Simon:  If not, then dialysis. So when their kidney function's in their 20s, I try to send them to an education class, they'll talk to them about transplant and the different forms of dialysis. It's really important that the patient choose their form of dialysis that they're comfortable with. We have ... there's two different kinds, there's hemodialysis and peritoneal dialysis. Hemodialysis is where a machine cleans your blood out and then it puts the blood back into you. So it's constantly taking a little portion of your blood out and running it through the dialyzer, the filter and putting the cleaner blood back in.

That has to be done on repeated basis, so the most common form of hemodialysis is in-center dialysis, where you go to the dialysis unit three times a week, either Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. You have to go three times a week in most patients because if you don't, then you're going to end up in the hospital because you can't breathe or you're weak because your potassium is too high and need to get emergently dialyzed that way. So it's a very rigorous lifestyle.

Nada Youssef:   How long does this go for?

Dr. James Simon:  For the rest of your life.

Nada Youssef:   For the rest of your life, three times a week.

Dr. James Simon:  Yeah, but a typical treatment is about four hours.

Nada Youssef:   Wow.

Dr. James Simon:  So you know, you've got to get there half hour early and get set up and then you get taken down, so it's a four and a half, five-hour project three times a week. So it can interfere with work, you know, but it's important that people continue to work if they can while they're on dialysis to, you know, maintain that sense of purpose and activity.

Then there was home hemodialysis and there's different iterations of that where you do it several times a week or you can even do it shorter periods of time, five, six times a week. That just gives you the independence. You're not tied to the dialysis unit and you can do it at night when you're sleeping or in the evening and it allows people a little bit more independence. It's a little ... thought to be a little healthier. The studies haven't come out and really proven that it helps with a lot of things, that helps with blood pressure and some of the other medicines they can stop taking but it really is, it's just more of an independence and the ... Cleaning the blood out more frequently, just ... we think it's better for the body than the letting everything build up for three days and then getting it cleaned out in four hours and then letting it build up for another three days and then cleaning it out real quickly.

Nada Youssef:   Yes. Kidney transplant, number one, though, because that's quality of life-

Dr. James Simon:  Kidney transplant, number one. Of your dialysis, hemodialysis, which is in-center or home. And then there's the peritoneal dialysis. Now peritoneal dialysis is dialysis through your belly. The membranes of your intestines are actually good filters, so they'll put a catheter in your belly and it'll actually stick out of your belly and you do your own dialysis at home. Some people need to actually do the exchanges themselves during the day and others, most people can connect up to a machine that'll do it while you're asleep. But you have to do that every night.

The nice thing about it is, again, there's a little bit of an independence there where you can still maintain your lifestyle during the day. And you do it yourself, so you have to have good vision, be able to, good hand eye coordination, be able to be ... the sterile technique because of the risk of infections of the belly if you don't do it right, but we encourage anybody that's interested and can do peritoneal dialysis to do it. With all the increase in healthcare costs, it's a cheaper option. It doesn't cost as much and there is some evidence that people do better on it.

Nada Youssef:   Sure, sure. So when someone, let's say, are getting a kidney transplant, do they just need one then?

Dr. James Simon:  Yes.

Nada Youssef:   Okay.

Dr. James Simon:  You get a single kidney.

Nada Youssef:   Okay, single kidney. And then I know with liver, you don't even need the full liver, you just need-

Dr. James Simon:  But you need the whole kidney.

Nada Youssef:   You need the whole kidney. Okay.

Dr. James Simon:  We don't do partial kidney transplant. Every once in a while, this sounds horrible, but if a child passes away and they have two small kidneys, every once in a while they'll take both of them out ...

Nada Youssef:   And make it one ...

Dr. James Simon:  ... and give them and so it can equal to one bigger one. But most cases, it's a single kidney from a single donor.

Nada Youssef:   Okay. So, drink your water, eat healthy food, right? I'm just trying to think of here what-

Dr. James Simon:  Take care of your body.

Nada Youssef:   Take care of your body.

Dr. James Simon:  Take care of your body because you know, being overweight and eating a lot of processed foods increase your risk for high blood pressure and diabetes. So if you take care of your body, your kidneys will appreciate it.

Nada Youssef:   Yes. And then get tested at least once a year ...

Dr. James Simon:  If you have risk factors like diabetes, high blood pressure, or some of the other things that we talked about.

Nada Youssef:   Okay, but like if I'm healthy and I'm okay, I don't need to go ...

Dr. James Simon:  Your doctor should be, you should have an annual physical, all right? And your doctor will tell you whether you're due or not. And you know, if you're really concerned and there's a valid reason you're concerned, talk to your doctor they may test you just to make sure. If you have a family history of kidney disease, that does increase your risk too.

Nada Youssef:   Sure, sure.

Dr. James Simon:  You know, so there's a lot of different nuances to the recommendations. Typically, a healthy person just needs to get checked every couple of years.

Nada Youssef:   Okay. Sounds good. Anything else you'd like to add?

Dr. James Simon:  I don't think so. You know, we didn't talk about kidney stones. A lot of people can get kidney stones and that's something that we sometimes will treat as well. We'll prevent ... we work on the prevention side of kidney stones. The urologists will take out the kidney stones, and that if they get blocked up, they can affect the kidneys as well.

Nada Youssef:   Sure, sure.

Dr. James Simon:  Kidney infections or urinary tract infections that migrate up to the kidneys, those don't typically hurt the kidneys, but if they're severe enough, then you can get some scarring in the kidneys from that. Yeah, that's about it.

Nada Youssef:   Very informative. Thank you so much for your time.

Dr. James Simon:  You're welcome.

Nada Youssef:   Appreciate it. To schedule an appointment with Dr. Simon or another Cleveland Clinic nephrologist, you can call (216) 444-6771. Thanks again to all of our listeners and viewers for joining us today. We hope you enjoyed this podcast.

If you'd like to hear more of our Health Essentials podcast from our Cleveland Clinic experts, make sure you visit us to clevelandclinic.org/hepodcast or you can subscribe on iTunes. For more Cleveland Clinic health tips, news, and information, make sure you're following us on social media, Facebook, Twitter, Snapchat, and Instagram, @ClevelandClinic, just one word. Thank you. We'll see you again next time.

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