The Silent Assassin.: How stealthy kidney diseases are interwoven in the fabric of our society.

By Shariq Ahmad

A wise man once asked 2 blind men to describe an elephant. One touched the trunk and the other handled the tail. Neither of them had encountered an elephant previously. Would you say that they were both accurate when the first man described the elephant as a large python and the second one as a rope?
After being a physician for 31 years, Dr. Ahmad has found that many of his colleagues are struggling to bridge the gap between the information available in medical literature and patients and family members' comprehension. He believes medical professionals leave a lot to be desired in terms of navigating the labyrinth of medical literature. Although The Center for Disease Control and the American Society of Nephrology do a stellar job conveying knowledge to kidney disease patients, there is more to be shared. Nine out of ten patients with kidney disease are unaware of their diagnosis. The medical literacy rate for Black Americans is only 2% and only 14% for White Americans. This book is an attempt to bridge the gap between the latest medical knowledge and a layperson's health care literacy, so that patients and family members can feel equipped to make major decisions about their healthcare and wellbeing.

• Language: English
• Publisher: BookBaby
• Release date: Jan 16, 2023
• ISBN: 9781667881324

Book preview

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© 2022 Shariq Ahmad

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the publisher, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law.

Print ISBN: 978-1-66788-131-7

eBook ISBN: 978-1-66788-132-4

Table of Contents

Preface.

Chapter 1: Historical Perspective of Kidney Disease

Chapter 2: The Mammoth Magnitude of a Silent Killer

Chapter 3: Acute Kidney Injury.

Chapter 4: Cost of Kidney Disease

Chapter 5: Racial Disparity in Kidney Diseases

Chapter 6: Diet and Renal Disease

Chapter 7: Nutritional Supplements and Medications Unsafe in Kidney Disease

Chapter 8: Choice of treatment modalities for treatment of End Stage Renal Disease.

Chapter 9: Palliative Care For End Stage Renal Disease Patients

Chapter 10: Drug Abuse and Kidney Failure

Chapter 11: Psychiatric Illness in Patients on Dialysis

Chapter 12: Pregnancy and Kidney Disease

Chapter 13: Employment and Kidney Disease

Chapter 14: Burnout of Nephrologist

Chapter 15: Covid-19 and Kidney Disease

Chapter 16: Nephrology Work Force and its Direction and Future

Preface.

A

wise man once asked two

blind men to describe an elephant. One touched the trunk and the other handled the tail.

Neither of them had encountered an elephant previously. Would you say that they were both accurate when the first man described the elephant as a large python and the second one as a rope?

Courtesy of Creative Commons Zero; Public Domain Dedication

As a nephrology fellow, I considered myself a diligent student and worked really hard on understanding the diseases, their pathophysiology and medical management. In other words, I had mastered the pixels but not the big picture. I now know that despite the sound theoretical knowledge, I wasn’t much different than the two blind men, and my understanding of nephrology and the big picture was not only missing, but I didn’t recognize its absence either. After being a physician for thirty-one years, like a lot of my colleagues, I feel that the gap between the information available in medical literature and what our patients and family members understand is ineffable, maybe like the Grand Canyon. We as medical professionals still leave a lot to be desired in terms of negotiating the labyrinth of medical literature and translating it to common language, in bite-sized, digestible pieces for patients and their family members to understand. We can go into a plethora of reasons as to why such is the case, e.g. time constraints and pressures of medical practice, etc, however, the fact remains that our community as whole is literally in the dark about some serious and consequential diseases like kidney disease and more needs to be done. Although the Centers for Disease Control (CDC) and American Society of Nephrology do a stellar job of conveying such knowledge to our kidney disease patients, it is not nearly enough. This is not hyperbole as nine out of ten patients who actually have kidney disease are unaware of their diagnosis. The medical literacy rate for Black Americans is only 2 percent while for White Americans, it is a meager 14 percent. My angst over this low medical literacy is shared by the majority of my colleagues. This is not because of the dearth of knowledge amongst medical professionals but an understanding that the conveyance of such knowledge to the community is imperative for their survival.

My nephrology colleagues will back my claim that when they see a patient referred to them for the first time with Chronic Kidney Disease, it is usually met with surprise by the patient and their family members. Unfortunately, an unignorable percent of such patients have medical records that reveal a story which suggests the start of kidney disease several years ago. Some would say, Yeah, we know that my doctor said something like my numbers were not looking the best but nothing to worry about. Or Why wasn’t I told anything about it?

The available information floating on the internet, which may often be misleading, creates stress, confusion, fear, and more questions than answers, if you simply attempt to read it without contextualizing it and without perspective.

This book is simply an attempt to bridge this gap and also discuss topics, which are either not discussed and taught in detail during nephrology and internal medicine training or taught in a limited manner with a few lectures. The journey of training of a medical professional is difficult and has tremendous time constraints. The education of a new kidney specialist does not end when they graduate from their respective institutions. A look from a different angle allows a fairly different perspective and sometimes stepping back may allow a more complete view of the whole picture.

Who can use this book?

My hope and wish is that this book is helpful to patients and family members, who want hardcore scientific answers to major decisions about health broken down in simple and plain English. I wish that the word dialysis is not automatically met with lassitude and a fatalistic approach born of anecdotal stories of another patient but a more realistic and pragmatic approach. I hope my family practice and internal medicine colleagues, nurse practitioners and physician assistants, teachers and educators would also browse through topics of their choice to enhance their understanding from this insider’s look at the field of nephrology and may find at least some portions of this book useful for their respective practices. I feel a resident in training or a nephrology fellow may also have an angular look at this field since this book does not talk about specific diseases or their management but gives the reader a bird’s eye view of the field. Also simply anyone interested in an insider’s look at the world of kidney diseases may also find this book of value.

This book has sixteen self-contained chapters, which can be read independent of whether or not you care to read the rest of the book. It is also not an opinion book but based on already available hardcore medical science and research that has furthered not only my own knowledge base but has also answered a lot of questions that I feel patients and their family members and loved ones remember after they leave the kidney clinic. The stress of receiving an initial diagnosis of kidney failure often leads to a state of shock enough to halt the intellectual inquisitiveness only to be replaced by a myriad of emotions like disbelief, anxiety, depression, and fear. I sincerely hope that readers will find this book helpful and will feel a badly needed sense of relief with optimal understanding of kidney disease.

Please note that although all the stories and histories in this book are real, names, initials, locations, age, etc, have been altered to protect the identity of patients in accordance with the law. This book in no way would replace advice from your health care provider and should not be used by patients for that purpose. It merely serves as an additional guiding tool to enhance your knowledge and understanding of the field of nephrology.

Chapter 1:

Historical Perspective of Kidney Disease

A people without the knowledge of their past history, origin, and culture is like a tree without roots.

—Marcus Garvey

(Jamaican political activist and journalist.)

If you don’t read the newspaper, you are uninformed. If you read the newspaper, you are misinformed.

—Mark Twain,

writer and humorist.

M

y infatuation with history has

frequently found practical use, so here is my humble attempt to recount what may have transpired in the world of nephrology, and give credit to characters who deserve and shine light on some long-forgotten heroes in the world of medical science.

The word nephrology comes from an ancient Greek word, Nephros, meaning cloud. It is an analogy that compares kidneys producing urine to the fact that clouds produce rain.

Although nephrology is a relatively young field, one can trace its roots as far back as 1550 BC. German Egyptologist Georg Ebers (1837–1989) found descriptions and illustrations of renal cyst and stones in mummies mentioned in Egyptian Ebers Papyrus. During the mummification process, the kidneys and the heart were left behind. The right and the left kidneys represent the good and evil in the afterlife.

Courtesy of Wikimedia Commons Public Domain

A similar concept existed in traditional Chinese medicine, where kidneys represent balance and harmony.

Hippocrates: Courtesy of Creative Commons Attribution-Share Alike 3.0

Corpus Hippocraticum written by Hippocrates of Kos (460–370) mentions the conditions of kidney and urinary bladder. Aristotle (387–322) attempted to describe the anatomy of the human kidney based on his observations of fish and birds. Famous Greek physician Galen (130–201 AD) described the function of the kidney in producing urine and suggested that the kidneys were filters of the body.

Aristotle: Courtesy of Wikimedia Commons Public Domain

During the Roman Era, a physician to Julian the Apostate suggested in Collectiones Medicae that urine was produced from blood along with the description of ureters and urethra. Descriptions of urine were taught for over five hundred years in famous medical schools of Western Europe such as Schola Medica Salernitana in Salerno Italy.

Canon of Medicine by Abu Ali al-Husayn ibn- Abdulla ibn Sina of Persia (980–1037) performed clinical trials and focused on the anatomy of the abdomen and described the kidney.

Abu Ali al-Husayn ibn- Abdulla ibn Sina; Courtesy of Creative Commons Attribution-Share Alike 3.0

De Humani Corporis Fabrica is a masterpiece collection of human anatomy drawings by Andreas Vesalius (1514–1564).

Richard Bright (1789–1858) is considered the father of modern nephrology and worked at Guy’s Hospital in London. He was the first to note albuminuria and edema as markers of kidney disease, which later became known as Bright’s disease.

Guy’s Hospital, London: Courtesy of Creative Commons Attribution-Share Alike 3.0

Claude Bernard (1813–1878) first described extracellular fluid space and this Milieu Intérieur (interior milieu) now referred to as homeostasis was first recognized.

Fight or Flight, a term we are all familiar with and which is considered inherently essential for the survival of organisms, was first coined by an American physiologist Walter Bradford Cannon (1871–1945). We now recognize our adrenal glands, secreting cortisol, adrenaline or noradrenaline, located on top of kidneys as responsible for this inbuilt survival mechanism.

It was only in the early part of the 20th century that Arthur Robertson Cushny wrote in The Secretion of Urine, published in 1917, that secretion and absorption from the kidney occur at the same time. He was also able to describe acid found in the urine of carnivores and alkalinity of urine in herbivores.

Model of Kidney Section: Courtesy of Creative Commons Attribution-Share Alike 4.0

In 1873, Researchers Champion, Pellet and Grenier developed an instrument that analyzed the content of sodium content in plant ash samples which would be the invention of what we now know as a flame photometer.In the 1940s this instrument was able to measure sodium and potassium content in the serum and urine for the first time. During World War 11, John P. Peters of Yale University helped understand electrolyte and water physiology.Many attribute evaluation of sodium disorders as the domain of Nephrologist to this discovery.

Birth of Hemodialysis

Thomas Graham was the first person to describe dialysis in 1854. He was a chemist at Glasgow University. He is known for his famous Graham’s law of diffusion. He first described the principles of diffusion and osmosis and introduced the idea of a semipermeable membrane. He prepared a bell-shaped structure with the wide-open end of the bell covered with a semipermeable membrane. He then suspended the bell-shaped vessel inside of a large container. He filled the bell-shaped vessel with urine and the large container with distilled water and after several hours, he boiled the contents of the large container and showed residues of urea and sodium chloride, suggesting that urine had passed through the semipermeable membrane. It took an additional sixty years before this concept was refined sufficiently enough to be used in patients. Graham recognized that kidneys remove the toxins accumulated in the body through a similar mechanism of filtration, secretion, and absorption.

The development of such semipermeable membranes, which subsequently became a functional dialyzer for dialysis machines was the mutual effort of several pioneers. Adolf Eugen Fick (1829–1901) was the first to use Colloid membranes to selectively separate small molecular weight substances from blood by the same process of diffusion described in the paragraph above by Graham. During and thereafter for several years, research included attempts to dialyze animal blood across semipermeable membranes against saline solutions.

Vivi Diffusion Apparatus was developed at John Hopkins University School of Medicine by Abel et al. This filtering device was composed of cellulose trinitrate tube and hirudin solution, obtained from leech heads, and was utilized as an anticoagulant.

Johns Hopkins; Courtesy of Creative Commons Attribution-Share Alike 3.0

Around the same time, Charles Leonard von Hess and Hugh McGuigan from North Western University in Chicago suggested the necessity of using anticoagulation to prevent clotting during the process of dialysis.

The first human dialysis was performed at the University of Giessen in Germany by a German physician George Hass in 1924 on a uremic patient. He was also the first to use heparin as an anticoagulant to prevent clotting of the dialyzed in 1928. Initial hemodialysis membranes were flat and were made of cellophane produced like cellulose but dissolved in carbon disulphide and alkali. The solution passed through a slit and was washed multiple times to obtain a transparent semipermeable membrane.

Wilhelm Johan Pim Kolff was credited to be the pioneer and inventor of the initial dialysis machine born February 14, 1911, Leiden, Nederland. During World War II, when Germany invaded Netherlands, Kolff was taking care of casualties and took special interest in acute renal failure. In 1943, he used a cellophane membrane and an immersion bath using a rotating drum hemodialysis system to assist with the treatment of acute renal failure. During the war, Kolff improvised and used a washing machine, orange juice cans, and sausage skin, while working in a remote Dutch hospital to develop his first dialysis machine.

Kolff’s first dialysis machine: Courtesy of Wikimedia, Public Domain

Initial