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Health // Doctor in the House
Rasa Fournier

Kidney Disease Treatment Options

Dr. Brian Lee
Nephrologist at Kaiser Permanente Hawaii

Where did you receive your schooling/training?

I completed my undergraduate studies in physics at Harvard University. I attended medical school at the University of Connecticut and completed my residency training at Mount Sinai Hospital in New York and my nephrology fellowship training at the University of Pennsylvania.

How long have you been in practice?

Thirteen years.

As a nephrologist, what do you do?

Nephrologists treat kidney disease. We devote a lot of our time to dialysis and kidney transplants, but we also care for patients with less severe chronic kidney disease, when the kidneys are damaged but have not yet failed. We specialize in other diseases of the kidney and hypertension, as well.

At what point does someone need dialysis?

Generally, when the kidney function drops below 10 percent, patients may become symptomatic. They get tired, lose their appetite, become irritable and may start losing weight. That’s the best time to begin dialysis.

What causes kidney problems?

There are many diseases that cause kidney failure. The most common that we see here is diabetes.

Nationally, less than 50 percent of kidney failure is caused by diabetes. We found that in Kaiser Permanente Hawaii, it’s nearly 75 percent. We also see kidney failure from high blood pressure, genetic diseases and other diseases.

How does dialysis work?

Dialysis is not a cure for kidney failure. It’s a way to survive kidney failure. There are two main types of dialysis. One is hemodialysis, where patients go to a dialysis center three times a week and have their blood cleaned by an artificial kidney. The other is peritoneal dialysis and you do it yourself at home. It’s a system where dialysis fluid is instilled into your abdomen, into the spaces between your organs. The fluid picks up toxins, and when the fluid is drained, the toxins also will drain out of you. About 90 percent of people choose hemodialysis.

People can choose either one?

Yes, if you have enough time to prepare. If someone has been seeing a kidney specialist, they have a chance to learn about the different kinds of dialysis and can choose a treatment option, including kidney transplantation. Unfortunately, many people in the United States do not get that chance and develop kidney failure before seeing a nephrologist. At Kaiser Permanente Hawaii, we’ve made it a priority to see patients earlier in the course of their kidney disease.

Last year, we won a national quality award for our care of chronic kidney disease. We created a system where the nephrologists search for patients who have significant kidney disease, but are not yet seeing a specialist. When we identify those patients, we either set up a referral or we send detailed advice to their primary care doctors. In addition, primary care doctors have their own sophisticated tools to make sure patients with kidney disease get their lab checkups regularly done, and to make sure they are taking the best medications for kidney disease and that tight blood pressure control is being administered. These systems have resulted in a lower rate of end-stage kidney failure and patients being better prepared for dialysis.

Has dialysis treatment improved or changed much in the past 10 years?

There has been a trend to better prepare people for dialysis and to move away from the use of hemodialysis catheters. This catheter is like a large IV that gets inserted into a major vein. It has two channels. With one channel you pull the blood out, and the blood is put through an artificial kidney and cleaned. You use the second channel to return the clean blood back to the body. The catheter works fairly well, but is prone to complications such as infections, which can be severe and usually lead to hospitalization.

Instead of a catheter, you want to have a dialysis access or fistula. This is a loop completely underneath the skin in the arm. You have to stick a needle through the skin to reach the access. These work really well and almost never get infected.

Another trend, which is still fairly new in Hawaii, is home hemodialysis. Rather than going to the center three times a week, people can now do their hemodialysis at home.

Why would someone choose to come in rather than do hemodialysis at home?

Only the most motivated patients seem to choose this, since it’s a lot of training and work. With home hemodialysis, you have to train to be your own nurse, which is intimidating. Many people are afraid to make serious mistakes and want to let the professionals run the dialysis. Let’s say you go through your whole life and have never driven a car, and one day somebody says you have to learn how to drive. You might say, “Oh, I’ll just take the bus.” That’s what in-center hemodialysis is like. The staff at dialysis drives the bus and all you have to do is show up. A lot of older and frailer people tend to choose incenter hemodialysis. The average age at which people start dialysis at Kaiser Permanente Hawaii is 62.

For people who are on dialysis, is it debilitating or can they still live a fairly normal life?

Although you have to spend many hours weekly with dialysis, most people who are on dialysis can live a fairly normal life, except as limited by other diseases they may have. For example, if you go on dialysis and you have heart disease, amputations and eye problems from diabetes – you’re likely not going to live a normal life. It’s not so much from the kidney failure itself, it’s the other aspects of diabetes that give you a worse quality of life. On the other hand, let’s say you have a genetic kidney disease and you’re on dialysis, you can live a fairly normal life. Not to say there aren’t challenges. We do find that people tend to get tired after dialysis. Maybe the afternoon or evening of the days you have dialysis you’re not at your best, but the rest of the week, you feel pretty good.

Anything else you would like to add?

I’ve worked with the National Kidney Foundation of Hawaii, and I’m excited to report it has set up a peer mentoring program. (To learn more or to be a mentor, call Dawn Pasikala at 589-5905.) No similar program exists anywhere, as far as I know. People who are just starting out on dialysis, who are anxious and don’t know what to expect, are connected with people who have experienced dialysis for a long time. The peer mentor can help to allay fears and give practical advice. It’s like having a big brother or big sister who is on dialysis. It’s a great program, and it has been in place for about a year.

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