Dr. Maite Gil-Gonzalez is a Nephrologist working at the St. Maarten Medical Center (SMMC) for the past year. Having worked in Spain, she brings to the SMMC 17 years of experience in nephrology, particularly hemodialysis treatment.
Dr. Gil-Gonzalez chose this field of medicine when she realized that she liked working with the chronic patient, “I couldn’t imagine myself in a laboratory or in an operation room”, she says. “Then, my father was diagnosed with kidney disease. For two years I denied myself the possibility of becoming a nephrologist, but at the end I thought that I could help my father and more persons with my family’s experience.”
“I love dialysis; it offers the possibility to keep patients alive and in good condition. Dialysis patients are your second family, the nurses and technicians too. You see them three times a week, and you get involved in their lives and personal conditions.”
What is the role of nephrologists?
A nephrologist is the kidney doctor, the medical specialist –not the surgeon- who diagnoses and treats kidney diseases. The name comes from the Greek word ‘nephro’ meaning kidney. The kidneys can be affected primarily or secondary to other health problems, leading to acute or chronic kidney disease. When the kidneys stop working we provide the renal replacement treatment consisting of dialysis or kidney transplantation.
What is the main function of the kidney?
The main function of the kidney is to filter the blood, eliminating waste products. It also has important functions like maintaining electrolytes and correcting acid-base disorders, secreting hormones responsible for the creation of new blood; activating vitamin D and regulating Calcium-Phosphate metabolism which is responsible for bone-metabolism disorders.
Luckily, we have two kidneys, preventing the possible loss of one of them, so the other can continue working, compensating function, without symptoms and in healthy conditions.
Who is at risk?
Everybody can be affected anytime for an acute kidney injury, sometimes this may be related with dehydration or nephrotoxicity secondary to medication, for example, with anti-inflammatory drugs, widely used.
Regarding chronic disease, the most common cause is diabetes mellitus. In fact 33% of diabetic patients will develop a kidney disease. Hypertension or vascular disease is also important, so it is mandatory to pay attention to these patients to detect kidney disease and start treatment.
What are some kidney diseases?
A kidney disease is any disorder affecting the normal functions of the kidneys. Sometimes the patient may be treated by the nephrologist, urologist or internist.
- Glomerular disease: loss of proteins
- Urinary tract infections
- Kidney stones
- Genetic disorders: such as Polycystic kidney disease
- Other diseases that affect the kidneys: diabetes, hypertension, including pregnancy related hypertension, preeclampsia and eclampsia , inflammation of the vessels, lupus and some cancers
- Nephrotoxicity: drug or toxin that causes damage to the kidney
- Acute and Chronic/End stage kidney disease / Kidney failure, with need for replacement treatment.
What are the different types of kidney diseases?
- Acute: potentially reversible, although if experience repeats can result in a chronic damage.
- Chronic: defined as the presence of kidney damage, detected as proteinuria (protein in the urine), or decreased kidney function for at least three months. Divided in 5 different stages according to kidney function with subcategories depending on proteinuria (Classification from Kidney Disease Improving Global Outcomes, accepted all over the world, KDIGO 2012). The progression rate is not always the same.
When we talk about kidney failure we refer to the end stage of kidney disease.
Hence acute kidney failure does not always lead to dialysis?
Dialysis is a technique of renal replacement.Acute kidney injury does not always lead to dialysis though sometimes dialysis may be required for a limited time. Many of them, depending on the origin and severity, are reversible; sometimes regain 100% of functionality.
A doctor should investigate every time a kidney is deteriorating 25% of previous function and start some form of treatment to protect it, and prevent possible nephrotoxicity. Sometimes a patient with chronic kidney disease can also have an acute deterioration.
How does a nephrologist diagnose kidney disease?
One problem is the lack of symptoms at initial stages. Many times it is discovered by chance, or upon requests of several examinations, if the doctor is suspicious of it. Many times the diagnoses is done by the general practitioner, and referred to us. Some tests conducted are:
- Blood work and urinalysis
- Image tests: abdomen ultrasound
- Other test: urine culture, autoimmune study, electrophoresis-to rule out a tumor, hepatitis serology-to rule out hepatitis, kidney biopsy-to evaluate possible origin for kidney disease.
What is the main reason for kidney disease on St. Maarten?
Diabetes and hypertension, no doubt. It is not surprising, but it is the high prevalence of those diseases and the bad regulation and metabolic control, related with high noncompliance (to medication and healthy lifestyle) rate, and diet; salty and rich in carbohydrates. Despite lack of studies, most patients in chronic hemodialysis at SMMC were diagnosed at the time of needing renal replacement therapy. The diagnosis was based in clinical history and indirect findings (biopsy is not indicated), about 80% of the Dialysis Unit at SMMC are diabetic, and the reason for kidney failure was diabetic nephropathy. There is a high incidence of obesity, which complicates the management of diabetes and increase the proteinuria (protein in the urine), one of the predictive factors to slow the progression in chronic kidney disease.
What are some signs and symptoms of kidney failure that persons can make note of?
For chronic kidney disease (advanced stage)
- Waking to urinate several times at night
- Lack of appetite
- Fatigue, weakness and anemia
- Itching skin (mainly at night)
- Nausea and vomiting
- Chest pain
- Shortness of breath
What are some misconceptions about kidney disease?
- Low back pain is always kidney pain. In fact, almost never. Kidneys are only painful in infections (pyelonephritis or abscess), kidney stones, obstruction, or complicated cysts, otherwise kidneys are not painful, and of course, chronic kidney disease is not.
- Clear urine means I’m healthy. Not always! In advanced stages of chronic kidney disease, the urine can be extremely clear, because it is not useful to eliminate waste products; it is “almost water”.
- Sometimes a prostate problem that leads to difficult urination can be interpreted as kidney disease, when it is not.
How can someone prevent the unsought of this disease?
- Regular blood test and urinalysis – for the diabetic at least once a year
- Regular checking of sugar and blood pressure – mainly diabetic
What are treatment options for chronic kidney disease?
The general management of these patients leads to
- Identify possible reversible process and correct it
- Prevent or slow progression of kidney disease: correcting blood pressure, decreasing proteinuria, controlling diet and vascular risk factors: smoking, dyslipidemia, diet, water intake
- Adjust drugs needed, and avoid medication that are potentially toxic to the kidney
- Evaluate and treat the complications derived from the kidney disease and the secondary causes: anemia, metabolic acidosis-retention of acid in the blood, secondary hyperparathyroidism-bone diseases related to kidney disease
- Prepare the patient for future renal replacement therapy: vaccinations, vascular access, information about different techniques and transplant, appointment with nurses, dietitian, social worker
What is your outlook of kidney diseases on St. Maarten?
I am still making my statistics. It is important to measure data to know the patients we are treating, the prevalence of the most high risk diseases, complications and how to improve outcomes.
By now I can say that diabetes has a very important weight in the development of chronic kidney disease on St. Maarten, and that we have to think in planning some educational strategy to increase people’s awareness regarding kidney disease, because the referral is sometimes too late.
I can also assure that the dialysis department of the SMMC offers an excellent quality of care, with good facilities, monitors, dialyzers, water treatment room, medication, and last, but not least, dedicated and qualified personnel that makes life easier for those patients who are depending on this treatment that lets them live in good clinical conditions.