 Hello everyone, this is Dr. Ahmed Ergen. Welcome to SugarMD channel. Today I have a special guest because you have questions about the kidney. And guess what? Since I'm an endocrinologist, not a kidney specialist, I brought you a very fine kidney specialist today to answer your questions that came through the YouTube. So I brought the expert for you. I will ask the questions that you have brought up. And here's Dr. Jamie Andre. He is an associate nephrologist at the kidney care of Treasure Coast, South Florida. Welcome, Dr. Andre. How are you? Thank you. Good, Dr. Ergen. Very good. Thanks for having me. It's my pleasure. Of course, of course. Well, he sacrificed his Sunday for today. So we are very thankful for that. And I'm going to bring up the questions right now on my screen. So before we waste any time, let's get started on that. So the first question from our audience is that, how would I know if I have a kidney disease? And what are the common causes and symptoms of kidney diseases? So I think this is like two questions and one, but we can kind of answer shortly about this like, you know, so that they don't get confused. But like, let's go with the first one. How would I know if I have kidney disease? Excellent question. Patients usually come into my office. The first question I ask them is, do you know why you're here? And a lot of patients don't know. And that is the most common way that people find out that they have kidney disease is through their doctor referring them, because a lot of times they don't really know that they have kidney disease. The early stages of kidney disease, there's usually, it's usually silent. There's no real symptoms. So a lot of times people can have abnormal kidney function and not know it unless their physician or their primary doctor checks blood work. And from the blood work, they'll be able to determine if they have some kidney issues. So what's GFR? Like GFR is something that a lot of our audience aware of. So GFR is something that the doctors look at, right? And then the patient, so when should a patient be concerned, even if the doctor doesn't say anything, because patients can see their own blood work, when should they be concerned, when they look at their kidney profile and see the GFR is in a red zone or whatever it looks like. So what is the number that they're going to be concerned about? They should be. Sure. Typically when your GFR is less than 60% or 60 milliliters per minute, that's a good time for you to see a kidney specialist, because we've seen that that's when we start having issues related to kidney disease. Kidney disease can start much earlier than 60%. And usually our general doctors are doing a great job taking care of the primary causes of the kidney disease, such as high blood pressure diabetes. But once the kidney function goes less than 60 mLs per minute or a GFR of 60%, it's a good time to see a kidney doctor to help deal with some of the problems that can start occurring. So the next question they brought up is what are the common causes? So you just said the diabetes and high blood pressure. What else? What else can be the common causes of kidney problems? Good question. Other common causes, the first top three causes for kidney disease are diabetes, high blood pressure, and genetics, family history of kidney disease. But there are other causes, such as medications that cause toxicity to the kidney. Some patients may have blockages in their urinary tract, either from kidney stones or tumors or bladder problems. It's a lot of other causes, but in general those are the top. Heart disease, hypercholesterol. A lot of people think that dehydration will immediately cause kidney disease. So can you tell us more about the dehydration effect of dehydration on kidneys? Sure. So in our world, we look at kidney injury, and once the kidney is injured, it should be able to get back to normal. And if it doesn't get back to normal within three months, that's a sign that you have chronic kidney disease. So things like dehydration can cause a temporary injury. But if you're otherwise healthy and your kidneys are relatively healthy, you should get back to normal kidney function once you are rehydrated, and whatever caused the dehydration is kind of taken care of. But if your kidney function stays abnormal for more than three months, then we suspect that your kidney function will likely not improve and will term you as having chronic kidney disease. So sometimes, for example, patients will come in and their GFR is declining. And then when I bring that up, they say, oh, you know, I wasn't drinking, you know, water. Is that a good explanation, or do you think that they should be more concerned than that? Yeah, you know, a lot of times patients think that drinking water will fix the problem, but kidney disease is very complex. There are a lot of different factors that are going on that cause the blood work to look abnormal. If you are dehydrated, yes, we recommend drinking water. But if your kidney function is abnormal due to another cause, we need to address the underlying cause of the kidney problem rather than staying drinking water. And then the next question will be asking, what actually changes do I need during the treatment or recovery phase of the kidney disease? Yeah, I think this is one of the most common questions we get in the office. And it's, it's a challenge to say the least. In terms of dietary recommendations, we recommend dietary changes based on the level of kidney disease. So diseases like a spectrum, there's mild, moderate and severe kidney disease. And I think it's usually once you get into the more moderate to severe ranges that you really have to make dietary changes. And the purpose of these dietary changes is to reduce some of the load of work on the kidney, as well as reduce some of the buildup of toxins in your blood. So the literal dietary changes include changing, and this is all contingent on how low your kidney function is. For example, if your kidney function is above 60%, you may continue with your diet that helps prevent worsening diabetes and helps to control your blood pressure or the DASH diet we recommend, which is a diet that's heavily based on foods that will promote lower blood pressure. Which is plant-based diet, I would say, right? Excuse me? Such as like plant-based diet? Yeah. Onward to foods and plant-based? Right. We're seeing that plant-based diets may be a reasonable approach to help our patients. And so things that will help lower blood pressure, vegetables, plant-based legumes, things of that nature. But I guess is that what it is? As the kidney function tends to get worse, we've seen that some people have improved or their kidney disease has slowed down based on restriction of protein, dietary protein intake. So the theory is that as you eat more proteins, it builds up a lot of urea and nitrogen in your blood and acids also. And this increases the workload of the kidney as well as causes some inflammatory changes in the kidney and damage from reactions and things that are kind of complicated. So we encourage our patients to have less than 0.8 grams per kilogram of protein. If the GMP is below 60? Yeah. And low sodium, less than two grams of sodium per day. Also, in terms of potassium, potassium is an electrolyte that helps, you know, conduct electrical impulses in your muscles and, you know, your brain. And if they have abnormalities in their blood work, meaning your potassium starts to become too high because your kidneys are not able to get rid of it, we recommend a lower potassium diet. In the advanced stage, is it the low 30 GFR or 20 GFR? Good question. It actually depends on the blood work. And if you have high potassium, it tends to occur more in patients who have a lower GFR, but it can happen, you know, on a consistent basis. So we look at the blood work, you know. Correct. Awesome. Now it brings us to the keto diet because there's a lot of keto diet promoters out there without paying attention to, you know, other health situations that patients may have. So one person is asking, does keto diet help or hurt the kidney disease? Can too much protein or fat hurt my kidneys? Good question. Good question. And we've seen that a higher protein diet can cause the progression of the kidney disease to go faster, actually. And again, apart, do you think that the high fat with the meats and other things, I mean, I guess, depending on what kind of fat you're eating, but what do you think about overall the fat consumption because keto diet is 80% fat, I would say. Yeah. Yeah. And raising your serum cholesterol levels increases your risk of atherosclerotic vascular disease. And the kidney is just a, you know, very vascularized. So in theory, the higher your cholesterol from fats, the higher chance you could restrict the blood flow and the circulation in the kidney. And we would say that a lower fat diet would be more recommended. So it doesn't sound like keto is the ideal. That's the ideal. Yeah. That's what I keep telling my patients because half of the patients that I see in my clinic with diabetes have some sort of kidney disease. And I know keto helps with the blood sugar, but you have to kind of look at the whole scenario to look at holistically to make sure that you're not really hurting something else when you're trying to pick something. So next question. Why are there two different GFR ratings? But I think they're referring to non-African American and African American. So this question is kind of common as well. They're asking why there's two GFR ratings. Yeah, good question. For me, when I was in training, the thought was that, you know, I guess African Americans or people of African descent compared to whites or non-Africans. Africans had more muscle mass, so they produced more creatinine, and we had to consider that once we were comparing their filtration rates. But as of September of this year, 2021, the National Kidney Foundation, along with other groups, have worked to formulate a new glomerular filtration calculator that does not take it does not take to account a person's race. Race is believed to be something that's determined by society. It's not necessarily biologically relevant, per se. So it's a hotly debated issue that we've been working very diligently onto. Should we consider then, not every African American is muscular, of course, and so do you think that then if a white person who is muscular, what bodybuilders are, or just people who work out a lot, do you think that we should take that into consideration? If your GFR is a little bit low, what do you think about that? Good question. The GFR test or calculation that we use is really an estimate. It's not the most accurate way to determine someone's kidney function. There are other tests. So we use this GFR as a global kind of guesstimate of where you may be. It's like a range. So what do you do in your clinic when somebody comes and says, I heard that Dr. Andre said it's just a general thing. I want to know exactly what's going on. So what do you do for those people? What does the order? Great question. There's other things we could do such as 24-hour urine collection to determine how much creatinine is in your blood and compare how much creatinine is in your urine, and we determine the creatinine clearance. We also do the same thing with urea, which is the urea clearance, and these are far more better predictors of exactly how your kidney is functioning and its ability to filter out toxins, remove extra water, how much proteins are being excreted in your urine. Perfect. Thank you. Let's go to the next question. What can I do to keep my kidneys becoming more damaged? So I guess we're just looking for some general advice on preventing the progression. Knowledge, knowledge, knowledge is key. I see by far education talking to patients about answering questions that they have, helping them understand what's going on with their body is the first step. Seeing their doctors on a regular basis. Since kidney disease is a silent disease, a lot of times patients don't feel pain and they're still urinating so they don't really know that they have kidney disease. So having routine follow-up with your doctor or a kidney doctor is one of the best ways to protect your kidneys. What we do is based on where you are in your kidney function, we educate you on the proper diet, the proper medications, we monitor your risk factors such as the blood pressure, your sugar, we educate you on cholesterol. So I think you're just basically what they're trying to do. You're trying to optimize the health. So if your health overall is better, your kidneys will do better. Can we say that? Yep. And the way the analogy I use in the office is that your kidneys are like tires. You're using them every day. Once they start getting low, you can't really get them back to 100%. So you need someone to sort of keep an eye on the tires just to keep going to avoid potholes and to deal with any issues that you may have as you're going about your life. Great analogy, great analogy. And then the next question which is pertinent, will I eventually need dialysis or a kidney transplant if so, what is the timeline? Which is a hard to answer, but I didn't have an idea overall. Great questions. These are legitimate questions. With proper education and awareness, we can prolong and this is what we try to do is to slow down the progression of kidney disease. We can't really stop it yet for most patients with diabetes, high blood pressure related kidney disease, but we can prolong it through education, controlling the high blood pressure, controlling the diabetes. And in terms of timeframe, it's really patient specific. And there are different factors in terms of how well the diabetes is controlled, how well the blood pressure is controlled, how soon you saw the kidney doctor. There's so many different factors that determine if you'll need dialysis in the next few months or if you can have your kidneys for another 10, 15 years. But the first step is education. The second step is consistent monitoring and follow up. Is there any statistical population data that says if your GFR is below 60, how many percent of these people, regardless of their control just overall, end up in dialysis if they don't die from a heart attack or a stroke. And I tell this to my patients all the time, you know, you may worry about your kidneys, but if you're not worried about your cholesterol and blood pressure, you may actually have a heart attack or sudden cardiac death. You may not even need the dialysis because you may die earlier. But if you take care of your cholesterol and blood pressure and everything else, you know, you will have that time maybe to even end up with the dialysis. But then they still want to know, okay, well, let's say I did everything right or maybe halfway right, whatever, what is the overall general idea that they can say, okay, well, the statistics says that in five years or 10 years, I may become dialysis dependent. I'm going to surpass that so they can put a goal to themselves. Right. We're working on things called kidney failure risk calculators where we can plug in certain parameters such as your GFR at the time that we're seeing you, your age, your sex, how much protein is in your urine, you know, other parameters such as how high is your phosphorus in your blood and other things like calcium and things like that. And we can sort of give a guesstimate of the timeframe that it would take for you to progress to needing dialysis. But again, it's very patient specific and it really determines on those parameters in the blood work because those parameters in your labs and your blood work really show us how well your kidneys are doing. If you buy a used car, I keep using the car analogy, Toyota Camry, one person may have one Toyota Camry with this number of mileage or the same number of miles, but the way that the car was treated could vary even though both cars have the same mileage. So it's really difficult to determine. So we have to do it based on each car. What you're saying is they may never end up on dialysis if they really do a good job. So maybe they should actually put a goal in their head. I have a kidney disease, but my goal is to never end up with dialysis and does an achievable goal. Would you say that? It depends. It depends. There are no guarantees. All we try to really do is continue to follow where the kidneys are leading us and every intervention that we can do to slow things down or prevent progression we attempt. But there are no guarantees, unfortunately. Correct. Correct. Now, there's an interesting question here, I get that sometimes as well. Is foamy urine a symptom of kidney disease? Why do you do that? Great question. Yes and no. So if you are dehydrated and your urine is concentrated, meaning your body is holding onto as much water as it can because you haven't drank that much, whatever urine you do make may be very concentrated and it may have, you know, foam kind of appearance because of the elements that are in it. If your bladder is very full and you use the bathroom and the intensity at which the urine hits the toilet bowl water, in general, some medications actually can cause you to have foamy urine and you don't have kidney disease. But in general, it depends on the frequency. If you have episodes of foamy urine once a month or once, it shouldn't really concern you. But if you're consistently having foamy urine and other things like swollen legs, high blood pressure, uncontrolled diabetes, then yes, you should be concerned that you may have some kidney issues. It could be, you know, signs of kidney disease and you need to speak to your doctor right away. Awesome. Thank you. Now, does the next question is, does high blood pressure medicine help to prevent the kidney disease? It's kind of obvious, but you can maybe elaborate on that a little bit. Yes, sure. Yes, high blood pressure medications help reduce the systemic blood flow and also helps control some of the blood flow and circulation inside the kidney. Let's talk about that for example. Yes, we know the blood pressure medications will help the kidney. What medications are standard of care when someone has diabetes and high blood pressure? Excellent. You know, there's two stages of hypertension, stage one and stage two. And usually once you're above stage two, which is above 160 systolic or your top number is greater than 160, you'll probably need at least two medicines or more to help control your blood pressure. One of the main medications that we use to help control your blood pressure are ACE inhibitors, things like Lucinopryl or angiotensin receptor blockers, loci. Those are medications that affect the hormones that control your blood pressure or contribute hypertension. There are other medications that we use to help with the kidneys once patients have kidney disease and these medications include diuretics or medications that remove extra salt and water from your body. When you have kidney failure, your kidneys tend to have difficulty removing sodium from your body. And sodium is one of the main ways that your body holds on to water. Higher sodium in your body and more water in your body, your blood volume will be a little higher and your pressure will be a little higher. So we give diuretics or medicines to remove salt and water from you to help lower the blood pressure and to help reduce swelling. There are other classes of blood pressure medicines. We also give medicines such as, we're seeing a new medicine called Fenerinone, which helps counteract some of the high blood pressure hormones as well in the kidney and they've also been shown to reduce the progression of your kidney disease. Karen, there's a brand name, right? Yes, Karen. Also, we're using diabetes medicines, such as the SGLT2 receptor. So those medicines help remove extra sugar, but we're also seeing that they act like diuretics too and help slow down the progression of the kidney disease as well. So we're looking for all sort of the answers for these difficult questions. Problem solvers, we're trying. Awesome. Well, that was pretty much all the questions. We can definitely do another video as we have more questions. What's your final advice to our audience to have them prevent the kidney disease and if they do have a kidney disease, how to prevent them progression like in a nutshell? In a nutshell, understanding and awareness I think is the most important advice that I could give patients. If you have questions, do not hesitate to speak to your doctors. Searching the web can be very daunting. There's tons of information out there, a lot of good information and some questionable information, but your primary provider, medical provider who you trust would be a good source to help you navigate all of the information that's out there. And if needed, once your kidney function is less than 60%, it's a good idea to see a kidney doctor because they're a little bit more prepared to deal with some of the problems that can arise with the kidneys. And again, with education, monitoring, and just paying attention to your body, you can really do a lot to prevent yourself from needing things like dialysis or kidney transplant. Awesome. Thank you Dr. Andre. This was great. We really enjoyed it and I'm sure our audience will also enjoy. Thank you for spending time on a Sunday like this and we will hopefully meet you again. Awesome. Thanks. Very good. Hey guys, I hope you're enjoying this channel so far and I hope you subscribed already. If you didn't do it and if you did watch this video right there, I think that will help you too.