If you were to think of your body as a city, the kidneys could be considered the municipal wastewater treatment plant. Our bodies generate waste products. They’re shunted into the blood, which then travels to…
If you were to think of your body as a city, the kidneys could be considered the municipal wastewater treatment plant. Our bodies generate waste products. They’re shunted into the blood, which then travels to the kidneys for filtration. The waste products are removed and the clean blood is ushered back into the body to continue moving oxygen and nutrients where needed, and the cycle begins again. The ingenious system works 24/7 in most people, but can sometimes be disrupted by disease or injury. When this happens, you may need the help of a kidney specialist.
Nephros is the Greek word for kidneys, and nephrology is the study of kidneys. The specialist doctor who’s primarily tasked with caring for the kidneys is the nephrologist. The kidneys are two organs located towards the back of the body, just under the ribcage. They connect to the bladder via tube-like structures called the ureters. Waste products culled from the blood are pushed out of the body via the urinary system. For this reason, urologists also care for the kidneys, and it can get a little confusing which doctor is best for which instance.
“The thing I tell patients sometimes when they get confused about what a urologist does versus a nephrologist: A urologist is a surgeon and a nephrologist is an internal medicine specialist. It’s analogous to a cardiologist and a cardiac surgeon,” says Dr. Joseph A. Vassalotti, chief medical officer of the National Kidney Foundation and associate clinical professor of medicine in the division of nephrology at the Icahn School of Medicine at Mount Sinai in New York.
“Urologists treat more structural problems with kidneys and the urinary tract,” he says, and, as surgeons, can use surgical intervention to treat kidney problems. For example, in the case of kidney stones, a painful but common kidney problem that sends more than half a million people to the emergency room each year according to the NKF, “if the stones need to be treated surgically, a urologist would treat that.”
Depending on the size and location of the stone, which results from the crystallization of chemicals in urine, and whether it’s causing associated infection or blocking the urinary tract, Vassalotti says “that would require a urologist to do a procedure to remove the stones — to essentially crush the stone to allow it to be excreted the normal way,” via urine. However, a “nephrologist would get involved in treating or preventing the recurrence of the kidney stones,” with techniques such as increasing fluid intake and conducting 24-hour urine screening to look for metabolic risk factors for stone formation.
So while there’s some overlap in what urologists and nephrologists do, the urologist cares for the kidneys in the context of the urinary tract while the nephrologist is primarily focused on treating diseases of the kidney using internal medicine techniques. These conditions can include stones and infections, but also chronic kidney disease — a malady in which patients lose kidney function lasting more than three months. The National Institute of Diabetes and Digestive and Kidney Diseases reports that about 14 percent of Americans have CKD and 661,000 Americans experience kidney failure. “Each year, kidney disease kills more people than breast or prostate cancer. In 2013, more than 47,000 Americans died from kidney disease.”
Acute kidney injury, “which is a sudden loss of kidney function that usually lasts less than three months and usually develops in a period of hours,” is another condition a nephrologist may be able to help with. Other conditions patients sometimes experience include developing structural problems with the kidneys and cysts and tumors. Nephrologists also treat electrolyte disorders and imbalances and oversee dialysis for patients with advanced kidney disease.
All of these conditions can be difficult to spot. “For the most part kidney disease is described as a silent condition,” especially early in its progression, says Dr. Maria Bermudez, a nephrologist at Geisinger in Danville, Pennsylvania. “There may not be warning signs that tell patients we have a problem.” At later stages, patients may develop some symptoms, such as “extreme fatigue, nausea and vomiting. Some patients may describe a metallic taste in the mouth, lack of appetite and swelling and fluid retention if their kidney function starts to decline. These are signs and symptoms that may or may not arise, and it’s usually in our patients who have less than 5 percent kidney function left.” Prior to that, patients often say “they may be a little tired but nothing else will be noticed,” she says.
But there are some signs to watch out for. Certain inflammatory disorders of the kidneys can result in the presence of blood and protein in the urine, which will show up as a brownish tinge in the urine or foamy urine. “If you see any dark or bloody urine, that’s usually a red flag that something needs to be checked because we’re not supposed to have blood in the urine,” says Dr. Khaled Boobes, a nephrologist at The Ohio State University Wexner Medical Center. “If the patient notices foamy, frothy or bubbly urine, that’s a sign that there might be proteins in the urine, and we’re not supposed to have proteins in the urine.”
Often the first sign of a problem shows up in routine lab work. If you have diabetes or high blood pressure, your primary care physician or the doctor who manages these conditions will likely order regular blood tests to check your kidney function. “If you’re being followed by a primary care physician and there’s a rise in your serum creatinine levels,” that’s a sign of a problem, Boobes says. “When we see that going up, it tells us the kidneys are not doing their job.” (Creatinine is a metabolic waste product generated by the breakdown of the chemical compound creatine phosphate. It’s usually generated at a constant rate by the body, and serum creatinine levels measure how much creatinine is circulating in the blood. The Mayo Clinic reports that normal serum creatinine levels range between 0.84 and 1.21 miligrams per deciliter. If they rise above that range, it usually means something is wrong with your kidneys.)
The kidneys, it turns out, are delicate machinery. “In general, the kidneys are very sensitive to whatever goes on in the body so they’re one of the first organs to be affected by other issues,” Boobes says. Because of this and the known connection between diabetes and high blood pressure with kidney disease, “if someone has risk factors for kidney disease, such as diabetes and high blood pressure, it’s recommended that kidney function is checked regularly,” Bermudez says. Vassalotti adds that many patients with diabetes and or high blood pressure don’t realize they’re at risk for developing kidney disease. “One of the reasons to manage diabetes and high blood pressure is to avoid the development of kidney disease.”
But diabetes and high blood pressure aren’t the only risk factors for kidney disease. “Obesity, high cholesterol, a history of smoking, the presence of certain viruses such as hepatitis B and C, a diagnosis of HIV and any autoimmune or rheumatological diseases such as rheumatoid arthritis or lupus,” can all increase your chances of developing kidney disease, Bermudez says. In addition, if you frequently develop kidney stones or have many urinary tract infections, that can also increase the chances that you’ll develop chronic kidney disease later. “And last but not least, the presence of a strong family history of kidney disease,” is a major risk factor. “If a first-degree relative has had the need for dialysis or kidney transplant, it’s recommended that you get checked,” she says.
By and large, nephrologists focus on the prevention of kidney disease and try to help patients avoid the loss of kidney function. However, there are some areas of focus within the field, Vassalotti says. Interventional nephrologists may focus on patients having dialysis, while transplant nephrologists care for patients before and after a kidney transplant. Other specialists may focus on treating a specific type of kidney problem such as diabetes-related kidney disease, kidney cysts, kidney stones or how the vascular system is involved in kidney function. Critical care nephrologists spend a lot of time with patients in intensive care units, and there are other focus areas to some nephrologists’ practices.
When you need a nephrologist, your primary care physician is typically the best place to start in finding the right one for your situation. “In my opinion, a nephrologist who offers all the treatments for kidney failure and makes those available is probably practicing at a higher level than one who’s more restrictive or doesn’t offer all the treatment options,” such as different types of dialysis treatments, Vassalotti says. In addition, he says you should look for a nephrologist who communicates well, addresses your concerns and explains your treatment protocol in ways you can understand. Your nephrologist should also be able to coordinate with your primary care doctor to ensure you’re getting appropriate treatment for any other comorbidities you may have.
Asking for a second opinion can also be a smart move, Vassalotti says, especially if you’re uncertain about the treatment plan being recommended. “Sometimes even when the first nephrologist is a superb clinician and expert nephrologist, the patient can benefit from a second opinion. Even if it’s just confirmation, sometimes it helps patients to hear it in a different way. Or sometimes patients who are recommended to initiate dialysis are reluctant to do so,” but receiving that guidance from a second physician can help them feel confident that it’s the right choice.
“The other thing I would say is, I’m a big fan of nutritional therapy,” Vassalotti says, noting that “nephrologists who offer that are probably practicing at a different level than others. Not all patients want medical nutrition therapy, but there’s a lot of dietary concerns about controlling diabetes and high blood pressure. Especially when kidney disease is advanced, having access to nutritional therapy is helpful” in managing the disease and helping you feel as well as possible.
In addition to making sure you’re eating right and staying well hydrated (drinking plenty of water creates more urine which can help flush out infection-causing bacteria and other agents that can cause problems), Bermudez says using moderation when taking nonsteroidal anti-inflammatory drugs such as ibuprofen can help reduce the load your kidneys must bear. “Certain commonly used, over-the-counter pain medications, especially NSAIDs such as ibuprofen, could be extremely harmful to the kidneys, especially when used on a daily basis or over a prolonged period of time. That should be avoided,” she says.
And, if you have risk factors for kidney disease, it’s important to get checked out regularly. She says patients should advocate for themselves and ask their doctors to monitor “kidney function regularly because of the silent nature of the disease.” When caught early, kidney disease can be treated and managed, but once you’re beyond a certain point, transplantation and/or life-long dialysis treatment may be your only options.