Women in Nephrology

You know, in addition to being National Kidney Month, March is also National Woman’s Month. Once again, I decided to combine the two and write about women in nephrology. Nefrologia [English edition] started us off with names you may or may not recognize:

“ Internationally, in an attempt to highlight the work of women in the scientific field, the International Society of Nephrology (ISN) wanted to pay tribute to women who had collaborated closely in the development of the specialty…

Dr Josephine Briggs, responsible for research at the US National Institutes of Health in the 1990s on the renin-angiotensin system, diabetic nephropathy, blood pressure and the effect of antioxidants in kidney disease.

Dr Renée Habib (France), a pioneer of nephropathology in Europe. She worked with the founders of the ISN to establish nephrology as a speciality.

Dr Vidya N Acharya, the first female nephrologist in India inspiring the study of kidney diseases, dedicating her research to urinary infections and heading a Nephrology department in Mumbai.

Dr Hai Yan Wang, head of department and professor of Nephrology at the Peking University First Hospital since 1983, president of the Chinese Society of Nephrology and editor of Chinese and international nephrology journals.

Dr Mona Al-Rukhaimi, co-president of the ISN and leader of the working group on the KDIGO guidelines in the Middle East, as well as a participant in the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.

Dr Saraladevi Naicker, who created the first training programme for nephrologists in Africa and the Kidney Transplant Unit at Addington Hospital.

Dr Batya Kristal, the first woman to lead a Nephrology department in Israel and founder of Israel’s National Kidney Foundation. She conducts her current research in the field of oxidative stress and inflammation.

Dr Priscilla Kincaid-Smith, head of Nephrology at Melbourne Hospital, where she promoted the relationship between hypertension and the kidney and analgesic nephropathy. The first and only female president of the ISN, she empowered many other women, including the nephrologist Judy Whitworth, chair of the World Health Organization committee.”

I turned to BMC Nephrology to learn a bit about another woman in nephrology, Dr. Natalia Tomilina. This is from an interview with Dr. Tomilina:

“For me specializing in nephrology happened by chance. After graduating from university, I worked as a general practitioner, and very soon realized that I needed something more than just routine clinical practice; I needed to grow professionally. In 1962–1963 the hospital where I worked introduced a nephrology program. It was not yet a nephrology unit, just 20 beds on the internal medicine floor for patients with kidney diseases. At the time, nephrology as a specialty was only starting to be recognized both in the Soviet Union and in other countries. I was lucky to have met Professor Maria Ratner, who invited me to work with her. I could have moved to the hospital’s research institute, but it seemed to be less interesting, so I chose nephrology and Professor Ratner became my mentor. I found it fascinating, and I have continued to be fascinated by nephrology all my life….”

More recently, as I wrote in March 29’s 2021 blog:

“Dr. Vanessa Grubb first approached me when she was considering writing a blog herself. I believe she’s an important woman nephrologist since she has a special interest in the experiences of Black kidney patients. Here is what University of California’s Department of Medicine’s Center for Vulnerable Populations lists for her: 

‘Dr. Vanessa Grubbs is an Associate Professor in the Division of Nephrology at UCSF and has maintained a clinical practice and research program at Zuckerberg San Francisco General Hospital since 2009. Her research focuses on palliative care for patients with end-stage kidney disease. She is among the 2017 cohort for the Cambia Health Foundation Sojourns Scholar Leadership Program, an initiative designed to identify, cultivate and advance the next generation of palliative care leaders; and the 2018 California Health Care Foundation’s Health Care Leadership Program. 
 
Her clinical and research work fuel her passion for creative writing. Her first book, HUNDREDS OF INTERLACED FINGERS: A Kidney Doctor’s Search for the Perfect Match, was released June 2017 from Harper Collins Publishers, Amistad division and is now in paperback.’ [Gail here: Dr. Grubbs writes the blog, The Nephrologist; has the YouTube channel, Real Kidney Talk with The People’s Nephrologist; and is an advocate with her Black Doc Village.]

I think Dr. Li-li Hsiao should also be included in today’s blog since she has a special interest in the Asian community and their experiences with kidney disease. The following is from the Boston Taiwanese Biotechnological Association:  

‘…. She is the Director of Asian Renal Clinic at BWH; the co-program director and Co-PI of Harvard Summer Research Program in Kidney Medicine. She is recently appointed as the Director of Global Kidney Health Innovation Center. Dr Hsiao’s areas of research include cardiovascular complications in patients with chronic kidney disease; one of her work published in Circulation in 2012 has been ranked at the top 1% most cited article in the Clinical Medicine since 2013. Dr. Hsiao has received numerous awards for her outstanding clinical work, teaching and mentoring of students including Starfish Award recognizing her effective clinical care, and the prestigious Clifford Barger Mentor Award at HMS. Dr. Hsiao is the founder of Kidney Disease Screening and Awareness Program (KDSAP) at Harvard College where she has served as the official advisor. KDSAP has expanded beyond Harvard campus. Dr. Hsiao served in the admission committee of HMS; a committee member of Post Graduate Education and the board of advisor of American Society of Nephrology (ASN). She was Co-Chair for the ‘Professional Development Seminar’ course during the ASN week, and currently, she is the past-president of WIN (Women In Neprology [sic])’”

Just in case you wondered, Zippia [billed as the job experts] showed 47.37% of nephrologists were female as of 2021. And, yes, they did earn less than their male counterparts: 88 cents to the male’s dollar. From all the different sites I looked at, there is still a pay gap between the two genders. All I have to say about that is, “Huh? This IS 2024, isn’t it?”

Until next week,

Keep living your life!

Opting Out of Dialysis

Last week, Steve Belcher RN interviewed me on his new podcast Health Talk: Conversations For A Better Life Podcast. During the podcast, he mentioned Renal Conservative Therapy. I didn’t know what that was. Listeners’ questions about it started appearing on the screen, too. Of course, it then became clear what the topic of today’s blog would be.

As to what Renal Conservative Therapy is, let’s turn to the UK’s National Kidney Foundation for their easily understood explanation:

“The aim of treatment conservative care is your wellbeing and quality of life.

Conservative care (also called supportive care) aims to:

• treat and reduce any physical symptoms of CKD such as:
– tiredness
– feeling sick
– itching
– swelling and breathlessness

• protect and maintain any remaining kidney function (where possible) by:
– controlling your blood pressure
– changes to your diet
– changes to your medication

• provide emotional, social and spiritual support
• plan for the future

Your care will be shared between the Renal Unit, your GP [Gail here: that’s what we call PCP or primary care provider here in the US.] and community services you may need. You will be seen in clinic, or have an appointment by telephone or video call, by a doctor and/or a specialist nurse, who will see you as little or as often as needed. The nurse specialist for supportive care will support you and your family at home and liaise with other services you may need.”

I understand what it means now, but honestly, I couldn’t figure out why anyone would choose this rather than dialysis or a transplant. Now, you’ve got to remember that I have neither been on dialysis nor had a transplant, so I didn’t really know what I was talking about.

The National Institute of Diabetes and Digestive and Kidney Diseases made the reasoning behind this choice clear to me:

“People who wish to focus their care on the quality of their life may choose conservative management.

For most 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 can feel like an added burden, especially for people who have other serious health problems. Dialysis may not prolong or improve the quality of life for people who

• are elderly and frail
• have other serious health problems, such as dementia, heart failure, or cancer”

I couldn’t help but wonder if choosing Renal Conservative Therapy would shorten your life. I turned to KidneyCare UK for help in answering my question:

“It is difficult to be accurate about life expectancy, as this depends on your individual medical conditions, general level of health and the speed that your kidney disease has progressed.”

I found that interesting since some trusted sites mentioned a year or two, while others made it clear that your age, general health, comorbidities, and living conditions all will affect how long you may live with Renal Conservative Therapy.  

Steve mentioned that Renal Conservative Therapy is not palliative care. The National Institutes of Health explained why:

“You may hear conservative management called comprehensive conservative care, supportive care, nondialytic care, and comfort care. You also might hear the term ‘palliative care,’ which is one part of conservative management. Palliative care addresses the physical, psychological, and spiritual needs of someone with a serious illness.”

Frankly, I found this confusing since some of the sites I looked at considered the two to be synonymous.

Hospice kept popping up in my searches. That made no sense to me since Renal Conservative Therapy is to keep you comfortably alive as long as possible, while hospice exists to help you die comfortably. Back to The National Institute of Diabetes and Digestive and Kidney Diseases for a definition of hospice:

“Hospice is a program of care and support for people at the end of life. A trained team of health professionals and caregivers provide symptom and pain relief as well as emotional and spiritual support. The hospice team also supports family caregivers.

With hospice care, you may choose to die at home or in a home-like hospice setting instead of in a hospital.

Medicare, the federal health insurance program, covers hospice care.”

What we’ve figured out here is that Renal Conservative Therapy is not hospice and may or may not be considered palliative care depending upon your source.

Let’s see what else I can find out about Renal Conservative Therapy for us. PubMed seems to summarize the information I’d been looking for:

“At a certain point, patients with kidney failure will need to decide whether or not to start kidney replacement therapy, i.e. dialysis or kidney transplantation. An increasing number of patients choose to forgo dialysis or transplantation and opt for conservative care. In part, this trend is explained by the ageing population of patients with kidney failure and a more limited survival benefit for dialysis in older patients. Conservative care is a holistic, patient-orientated treatment, aimed at quality of life, advance care planning, reducing symptom burden, and slowing the deterioration of kidney function. As such, conservative care is an active treatment and not merely forgoing kidney replacement therapy….”

I’m interested in the history of this type of kidney failure treatment but was unable to find any information about that. Please let me know if you have any information about this. However, the following from the Mayo Clinic posted last month may be a clue:

“If your kidneys can’t keep up with waste and fluid clearance on their own and you develop complete or near-complete kidney failure, you have end-stage kidney disease. At that point, you need dialysis or a kidney transplant.

• Dialysis. Dialysis artificially removes waste products and extra fluid from your blood when your kidneys can no longer do this. In hemodialysis, a machine filters waste and excess fluids from your blood.

In peritoneal dialysis, a thin tube inserted into your abdomen fills your abdominal cavity with a dialysis solution that absorbs waste and excess fluids. After a time, the dialysis solution drains from your body, carrying the waste with it.

• Kidney transplant. A kidney transplant involves surgically placing a healthy kidney from a donor into your body. Transplanted kidneys can come from deceased or living donors.

After a transplant, you’ll need to take medications for the rest of your life to keep your body from rejecting the new organ. You don’t need to be on dialysis to have a kidney transplant.

For some who choose not to have dialysis or a kidney transplant, a third option is to treat your kidney failure with conservative measures. Conservative measures likely will include symptom management, advance care planning and care to keep you comfortable (palliative care).”

Notice that conservative measures, what we’ve been referring to as Renal Conservative Therapy, is treated as an add on rather than an established therapy.

Until next week,

Keep living your life!

It Gets a Little Confusing

I’m familiar with hospice, as I’m sure quite a few of us are.  Way back in 1988, they came to my folks’ house for my father when he had pancreatic cancer. When my mother could no longer physically take care of him, he was moved to a hospice facility. Although I lived in New York and they lived in Florida, I spent quite a bit of time in hospice with my father. I was terrified and wholly unaware of what this was or what they were doing for us. Thank goodness they were there to help us. 

The Hospice Foundation of America tells us what hospice is: 

“Medical care to help someone with a terminal illness live as well as possible for as long as possible, increasing quality of life. 

An interdisciplinary team of professionals who address physical, psychosocial, and spiritual distress focused on both the dying person and their entire family. 

Care that addresses symptom management, coordination of care, communication and decision making, clarification of goals of care, and quality of life.” 

When I had pancreatic cancer two years ago, it wasn’t hospice that I heard discussed, but palliative care. One problem, I didn’t know what it was. Get Palliative Care explains: 

“Palliative care is specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family. 

Palliative care is provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. Palliative care is based on the needs of the patient, not on the patient’s prognosis. It is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment.” 

Let’s take a look at these two different concepts. What’s the difference between them? Hospice is for those “with a terminal illness,” while palliative care is for those “with a serious illness.” Well, isn’t a serious illness terminal? 

Photo by Karolina Grabowska on Pexels.com

No, it isn’t. Some of you knew that already, but some of you didn’t. Terminal means end, like a train terminal… or the end of life. According to Johns Hopkins Medicine – in the medical sense – serious means: 

“Vital signs may be unstable and not within normal limits. Patient is acutely ill. Indicators are questionable.” 

Serious is not necessarily critical. Remember that the next time you call a hospital to ask about the condition of a friend or family member. 

I knew palliative care grew from the hospice movement, but I didn’t know how or why. I turned to UPMC (University of Pittsburgh Medical Center) Palliative and Supportive Institute for the answer: 

“…. Palliate comes from pallium, the Latin word for ‘cloak’. [The English teacher in me just had to include that information.] To palliate is to cloak, or cover up, the symptoms of an illness without curing it. This meaning grew into the idea of alleviating or reducing suffering.  

Palliative care got its start as hospice care, often delivered by caregivers at religious institutions. Dame Cicely Saunders, a British physician, founded the first formal hospice in 1948 specifically to care for patients with terminal illnesses. Her success in improving her patients’ quality of life led her to introduce the concept of hospice care to other physicians, who quickly recognized the value in respecting people’s wishes and needs at the end of life. Caregivers began to understand that these values could apply to patients without terminal illnesses as well.

A New Way of Caregiving

In 1990, the World Health Organization (WHO) recognized palliative care as a distinct specialty dedicated to relieving suffering and improving quality of life for patients with life-limiting illnesses or serious injuries. WHO described the goals of palliative care as the prevention, assessment, and multidisciplinary treatment of physical, spiritual, and psychological problems. Palliative care was now an established entity, separate from hospice and sometimes administered along with curative treatments, but hospitals were rather slow to adopt the practice.  

The Growth of Palliative Care 

Palliative care eventually began to catch hold in hospitals across the United States. Between 2000 and 2011, the prevalence of palliative care in U.S. hospitals with 50 or more beds has increased more than 157% (according to the Center to Advance Palliative Care). Today, palliative care programs ensure whole-person healthcare for patients in approximately 75% of all hospitals with more than 300 beds. As more people begin to understand and appreciate the benefits that palliative care offers, the specialty has become available in nursing homes, ambulatory care centers, and home care programs.” 

Photo by Anna Shvets on Pexels.com

Inpatient palliative care is widely accepted in the U.S. now, but what if you want palliative care at home? What can be done for you without entering the hospital?  

“Medical evaluations, including monitoring for common symptoms like nausea, vomiting, pain, and anxiety 

Prescribing medications to ease these symptoms 

Additional medical applications like treating wounds and other medical needs 

Physical therapy and other rehabilitation needs 

Providing emotional and spiritual support in addition to physical 

Providing social interaction 

Providing guidance on navigating the healthcare system and understanding individual healthcare needs” 

Thank you to Crosswords Hospice and Palliative Care for the above information. 

This is starting to sound a lot like home health care. I wondered if the two were the same. The Alliance had a wonderfully simple clarification and even included hospice: 

• “Home health services help you get better from an illness or injury, regain your independence, and become as self-sufficient as possible. 
• Palliative care is a form of home health care in which patients face chronic or quality of life-limiting illnesses, and focuses on the relief of symptoms, pain and stress. Patients may receive curative treatments. 
• Hospice is for patients with a limited life expectancy, who are no longer receiving curative treatments for any terminal illness.” 

By the way, The Alliance is a pretty interesting group. This is how they describe themselves: 

“Employers are the second-largest purchaser of health care in the country, yet typically have little say in its price – which has gone up every year since 1996 – or its quality. However, by self-funding and banding together to leverage their purchasing power, employers can generate more control over their costs and demand better care for their dollar together.  

The Alliance serves as the voice of those self-funded employers who are tired of health care as usual; we’ve been creating clarity in health care for over 30 years by providing transparent, creative approaches to network and benefit plan design to unlock savings where others can’t – or won’t – using Smarter NetworksSM and sophisticated data mining and analysis.” 

What does any of this have to do with kidney disease? Palliative care is for kidney disease, too. 

Until next week, 

Keep living your life!