Know Your Options

By Beth Piraino, MD

Beth Piraino MDI met a 26 year old woman recently who was referred by a friend of the family for a second opinion. I seem to get a lot of new patients in this way.  She was found to have advanced kidney failure, and needed to go on dialysis immediately.  Unfortunately, the prior year she had seen her primary care doctor for headaches and was noted to have a blood pressure of 140/85.  But no kidney function tests were given.  She was placed on ibuprofen and acetaminophen, and when she still did not find any relief, she was referred to a neurologist specializing in headaches.  Migraines were diagnosed, but at this visit her blood pressure was 150/90.  Again, no kidney tests were done, but fortunately the ibuprofen, which can damage the kidneys, was stopped.

A few months later, on a return visit, her blood pressure was 180/110 and she was told to “go home and monitor her blood pressure.”  Instead, she wisely took herself to the emergency room, where a kidney biopsy showed advanced chronic glomerulopathy.  She was placed on hemodialysis but her catheter did not work well. It was replaced but when that one did not work and she required yet a third catheter within 10 days of starting dialysis, she became even more distressed. As a young, single woman with a career, her entire life had been turned upside down.

Upon discharge from the hospital, she came to see me for another opinion.  After reviewing the biopsy, I confirmed that dialysis was indeed appropriate.  She had heard about peritoneal dialysis (PD) and wanted to learn more about this option.  A nurse educator and I explained how it worked, and, after a visit to the home training program, she chose to switch to peritoneal dialysis, which had much less interference with her life. We also began the transplant process.

Peritoneal dialysis is an excellent choice for many and certainly for a young person with few other medical issues.  Such patients have superior survival.  Nocturnal PD—which is a slower, longer dialysis treatment that takes place at night while you sleep—interferes little with her daily activities.    This story highlights the importance of giving patients’ choices before starting dialysis. While in-center hemodialysis is the right choice for some patients, it should be a choice and not a default decision by the doctor. Her story also illustrates the importance of educating more doctors about the need for kidney function testing in those with high blood pressure.

Awareness and earlier recognition of kidney disease may have resulted in avoidance of dialysis through a pre-emptive kidney transplant or avoidance of non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, in a person with advanced kidney disease. The progression to kidney failure may have been delayed through medications to reduce high blood pressure and protein in the urine.   Researching and discussing your options with your doctor will help you implement the proper treatment plan for you.

Dr. Beth Piraino is the President of the National Kidney Foundation.

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