About Our Renal (Kidney) Care

We conduct a comprehensive evaluation of all patients, including blood work, urine studies and imaging to identify the cause(s) of chronic kidney disease

• Clinicians are readily available to discuss difficult cases and to help guide disease and patient specific treatments
• Clinical trials available for many different kidney diseases
• State-of-the-art, evidence-based approaches to stopping/slowing the progression of chronic kidney disease focused on: high blood pressure, diabetes (if present), protein in the urine, acid build up, and nutrition.

• Kidney stones are common, often recurrent, and associated with many complications and pain
• Fortunately, kidney stones may be prevented
• Nephrologists focus on kidney stone prevention while urologists perform procedures to remove kidney stones when needed
• Diet, fluid intake, other medical problems, and family history can contribute to kidney stone formation
• Nephrologists will examine the patient and the patient's urine, obtain blood tests and 24-hour urine collections to determine what type of kidney stone is produced and what changes in lifestyle, diet and/or medications can help prevent future kidney stone development

We are fortunate to have tools that we use at the point-of-care (i.e., in the clinic) to further inform our care of your kidney issue. "Urinalysis" is our name for the examination of your urine during your visit. Before seeing you in the room, the office staff will ask you to collect a sample of urine. While you are visiting with the doctor, the staff will prepare your sample and the kidney doctors will do their best to analyze it during your visit after speaking with you.

The urinalysis is made up of two parts:

1. The dipstick is a test that can detect the presence of many different substances in your urine, including protein, blood, glucose, white blood cells and many more. We use these results to help diagnose and monitor your particular kidney issue.
2. We also look at your urine under the microscope. Urine microscopy enables us to visualize any red blood cells or white blood cells in addition to a number of other findings that may help us monitor your kidney disease.

We are also developing the use of point-of-care ultrasound. Your providers may decide during your visit that visualizing your kidneys, bladder, heart, lungs, or blood vessels, with portable ultrasound equipment, could provide even more helpful information for your care.

Taken together, these powerful and non-invasive tests will help provide us with further helpful information in caring for you.

• The kidneys help maintain the normal blood fluid, acid balance and electrolytes (these are elements and minerals like sodium and potassium).
• If a blood test shows that the acid balance or electrolytes are abnormal, we can help figure out why this has occurred and help find the right diet and treatment to improve the problem
• One of the most common blood test problems is when the sodium is abnormally diluted by water in the blood. This is called hyponatremia. When this is present, your Nephrology team can help determine the cause and how it is best treated.
• The kidneys play an important role in potassium excretion, so kidney providers can help patients with both low and high potassium. We may recommend a change in medication or diet to address these issues.
• Our team of kidney doctors enjoy exploring these complex issues with patients and partner with primary care doctors to help improve their care.

• The glomerulus, which is primarily the filtering component of the kidney, is comprised of a network of small blood vessels that allow the formation of urine into a separate compartment. This allows for the excretion of waste products without losing important cells, proteins, and other essential components that the body needs to retain.
• There are a variety of diseases that primarily affects the glomerulus. These often cause high blood pressure, fluid retention, swelling of the legs, and loss of kidney function.
• When evaluated by a nephrologist, there are hallmark signs of glomerular disease that can be observed in the urine and give some understanding of the underlying disease process. Often, a kidney biopsy will be needed to know what is causing the disease and what treatments are available.
• While the BIDMC nephrology division treats all types of glomerular disease, the division has a particular interest and expertise in a type of glomerular disease frequently found in African-American patients. This is called focal segmental glomerulosclerosis or FSGS and this disease has both a strong genetic basis and environmental triggers, and often leads to progressive kidney failure.
• There are a wide range of treatment options for glomerular disease and many ongoing clinical trials at BIDMC exploring new therapies.

• Polycystic Kidney Disease (autosomal dominant or ADPKD) is the most common inherited kidney disease in the world (over 12 million individuals affected worldwide).
• There are numerous reasons why kidneys may develop cysts and many of these do not cause permanent kidney damage or other problems
• ADPKD is transmitted to approximately 1/2 of the children of an affected individual.
• ADPKD has two main types: Type 1 (approximately 75% of patients) and Type 2 (approximately 25%). Type 1 is more severe with about 50% of patients developing kidney failure in their 50s, and about half of the Type 2 patients develop kidney failure in their mid-70s. About 20% of patients with ADPKD do not have a family history of the disease.
• The BIDMC Nephrology Division is recognized nationwide as a Center of Excellence, based on the clinical expertise we have in this disease and our active research studies that have been and are currently being conducted.
• Comprehensively evaluating patients early in the course of their disease affords an opportunity to alter the progression of ADPKD by employing the latest treatment approaches. Patients have the opportunity to enroll in the most current research studies where they can help themselves by helping others.

Genetic Kidney Disease

• Genetic factors can play a major role in some kidney diseases and influence the progressive loss of kidney function over years. Hundreds of different kidney disorders have been identified that result from mutations in single genes. These include disease of the glomerulus (the filtering part of the kidney), the tubule (which controls water and electrolyte handing) as well as disorders of kidney growth.
• Common genetic factors also play a role in kidney disease. For example, certain variants in the APOL1 gene are common in people of recent African ancestry and increase the risk of kidney disease.
• Physicians at BIDMC will work with patients to identify possible genetic causes of an individual's kidney issues. This many include DNA sequencing, extensive review of family history, and additional imaging and biochemical testing.

In some circumstances, the kidney doctor may recommend a procedure called a kidney biopsy to help diagnose certain types of kidney diseases.

• A kidney biopsy involves taking one or more very small pieces of your kidney for experts to look at with special microscopes.
• The biopsy is a day procedure. This means that you will NOT be admitted to the hospital and will go home later that day after the procedure.
• We will reach out to you over the phone to further explain the procedure and answer your questions.
• The biopsy is done with the help of ultrasound-guidance in order to get a clear picture of your kidney during the procedure.
• Though the kidney disease we are looking for may be affecting both kidneys, we only perform the biopsy on one of them. This provides our colleagues in the Pathology Department with enough information to help us make a diagnosis.
• For specific details about how the day of your biopsy will go, how to prepare, and helpful phone numbers, please read this kidney biopsy information sheet.

Every kidney patient's health journey includes major transition points. This may include starting treatment for kidney failure. Our goal is to tailor your kidney care to fit your lifestyle and your goals of care.

There are several treatment options for kidney failure. Learning about your options early is key to being able to make the best choice for you.

Kidney Transplantation

• Kidney transplantation is a treatment option for kidney failure that offers the most freedom and longest life expectancy for many patients.
• Referral to our transplant team for a pre-emptive kidney transplant would be our first priority. However not everyone is a candidate for kidney transplantation and dialysis is the treatment of choice.
• Sometimes a pre-emptive kidney transplant is not possible and dialysis is needed as a bridge to transplantation.

Dialysis

When kidneys fail, dialysis acts as a replacement. Dialysis is an artificial process that uses a special fluid containing a mixture of pure water and electrolytes to carefully eliminate wastes, salt, and extra water from the blood without removing substances the body needs. This process helps control blood pressure and keeps the body's electrolytes in balance by keeping safe levels of potassium, sodium, and acid in the blood.

There are two main types of dialysis: Hemodialysis (HD) and Peritoneal Dialysis (PD).

1. Peritoneal dialysis (PD)

• PD uses the thin lining that surrounds the abdomen called the peritoneum as a filter. During treatments, a cleansing fluid called dialysate is cycled into the patient's abdomen through a small, flexible tube called a PD catheter. The dialysate absorbs or pulls extra waste and fluids from blood vessels into the abdomen where it stays for a specified amount of time (dwell time). The PD machine then drains the fluid out of the abdomen and into a drain or waste bag and the excess wastes and fluids are removed from the body. Then, fresh dialysate is put back into the peritoneum to clean the blood once more. This filling and draining process is called an exchange or cycle.
• This type of dialysis can be done at home or at work.
• Peritoneal Dialysis is not for everybody. People who have had multiple abdominal surgeries may not be able to do this procedure. Scar tissue in the abdomen can prohibit an adequate amount of fluid from being instilled into the peritoneal cavity and interfere with dialysis effectiveness.
• For more information on peritoneal dialysis, please watch this video and visit this website.

2. Hemodialysis (HD)

• During hemodialysis, your blood goes through a filter, called a dialyzer, outside your body. A dialyzer is sometimes called an "artificial kidney."
• To be able to do hemodialysis there needs to be access to the blood. This can be achieved through a catheter (a large IV) but has a high risk of infection.
• Hemodialysis is best done through a "fistula" which is a surgical procedure done on your arm to allow access to your blood for hemodialysis treatment.

Dialysis Access Surgery

In-Center Hemodialysis

Hemodialysis can be done at an out-patient dialysis center near your home. You'll have a fixed time slot for your treatments, usually three times per week: Monday, Wednesday, and Friday; or Tuesday, Thursday, and Saturday. Each dialysis session lasts about 4 hours. When choosing a dialysis schedule, think about your work and child care or other caregiving duties.

• Nocturnal Dialysis: Some dialysis centers offer a nighttime option called Nocturnal Dialysis. These treatments occur at the dialysis center 3 nights a week while you sleep, which takes longer (6-7 hours). Nocturnal dialysis is usually offered Sunday, Tuesday and Thursday nights. Getting longer overnight dialysis treatments means:
  • Your days are free
  • You have fewer diet changes
  • Your liquid allowance (how much liquid you can drink) is closer to normal
  • You may have a better quality of life than with a standard hemodialysis schedule; longer treatment sessions may reduce your symptoms
• Home Hemodialysis: This option lets you have longer or more frequent dialysis, which comes closer to replacing the work healthy kidneys do—usually three to seven times per week, and with treatment sessions that last between 2 and 10 hours. Machines for home use are small enough to sit on an end table. The home option means:
  • A flexible schedule
  • Short daily hemodialysis—4-6 days per week for 2 to 4 hours at a time
  • Your doctor will decide how many treatments you need each week for home hemodialysis
  • If you choose to have your treatments at home, you'll still see your doctor once per month

For more information on hemodialysis, please review this video and this website.

Conservative Kidney Management (CKM)

As your kidney function declines, one of your biggest choices is whether to get Dialysis or Conservative (Supportive) Kidney Management.

• Dialysis is not for everyone. Dialysis does not cure kidney failure, but it may help you live longer and feel better. The older and sicker you are, the less likely it is that dialysis will help you. Some people will live as long and feel better with CKM which includes all medications, treatments and control of symptoms but does not include dialysis.
• For many people, dialysis may extend and improve quality of life. For others, this is not true. Dialysis may not lengthen life for all people who have kidney failure and is an added burden, especially for people who have other serious health problems that are not improved with dialysis.
• It's your choice whether to have CKM or dialysis.
• Your health care provider can help you and your family understand your health status so you can make an informed decision.

Conservative Kidney Management means your health care team monitors your care without dialysis or a kidney transplant. The focus of care is on your quality of life and symptom control. Your health care team —which may include a nephrologist, primary care clinician, nurse, dietitian, social worker, and a pharmacist — will help you create a plan to meet your care needs.

CKM treatment includes:

• preserving kidney function for as long as possible
• managing your symptoms, such as nausea, poor appetite, and your feelings
• managing other health problems caused by kidney failure, such as anemia
• maintaining your quality of life for as long as possible
• preparing for end-of-life care

Learn more about conservative kidney management and living well without dialysis.