Dale Lupu has firsthand experience with the difficulties facing aging kidney patients. Her mother, who is 91, has one decree: She doesn’t want to go on dialysis.
The blood filtration treatment was originally developed to prolong the lives of younger patients suffering from end-stage kidney failure, said Dr. Lupu, an associate research professor at the George Washington University School of Nursing and one of several GW faculty members to receive large grants for research related to kidney disease. Kidney disease is the focus of many new initiatives across campus, including the establishment of the Ron and Joy Paul Kidney Center.
Now, Dr. Lupu says, an increasing number of patients over 75 are on dialysis. And according to her, they may not be making the most informed choice when they take that step.
“As people get older, the failure of kidneys is not the only thing happening,” she explained. “Patients suffer from heart disease, dementia—the whole package of advancing frailty. Of those, kidney disease is something we can do something about. So it’s being offered to people, and they’re going on it. But what we’ve discovered is that [dialysis] is not necessarily a happy place for someone who is suffering from the multiple other health problems.”
She said the issue is communication between patients and doctors. According to her research, very few patients remember having conversations with their doctors about what would happen if the treatment did not go well.
“Patients in general are not being prepared or given a real choice—not just about whether to do [dialysis] or not, but to understand what’s going to happen if they do,” Dr. Lupu said.
Many later regret it. A Canadian study of end-stage kidney patients found that 61% regretted having chosen to undergo dialysis.
Treatment tailored to your values
Dr. Lupu’s research is aimed at minimizing those regrets. Aided by a $600,000 grant from the Donaghue Foundation, she and her team will test patient education materials, including the introduction into the care planning process of a nurse or social worker serving as a “coach.”
The coach, she said, would help patients articulate their values—whether, for instance, they would choose to trade potentially lifesaving hospital procedures for more time at home with their families. The coach also would help patients understand the consequences and possible outcomes of their various treatment options.
“It’s not that we want to keep people off dialysis,” she said. “It’s that we are alarmed that people are telling us they haven’t had these conversations. There’s a sense from some patients that they’re just getting on a conveyer belt. Instead, we want them to feel like they’re really involved, they know what’s coming, they have support, and they’re doing what works for them.”
Treatment tailored to your DNA
Hypertension, or high blood pressure, is one of the leading causes of kidney disease—and popular medical wisdom suggests a one-size-fits-all treatment.
“Normally everybody with hypertension is told not to eat salt,” said Ines Armando, an associate research professor of medicine at the GW School of Medicine and Health Sciences.
The problem, Dr. Armando said, is that decreasing salt in the diet will lower blood pressure for only 50 percent of hypertensives, called “salt-sensitive.” As for the other half, known as salt-resistant: “[Those patients] can decrease salt all [they] want, but it won’t have an effect on [their] blood pressure,” she said.
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| Pedro Jose and Ines Armando. |
Moreover, low sodium intake can actually increase the blood pressure of about 15% of patients; this phenomenon has been termed “inverse salt sensitivity” or “counter-regulation”.
It might seem obvious that treatment for these two types of patients should be very different. But determining which type a patient is can be difficult. At the moment, it involves a long hospital stay with a special diet—“not something we can do with millions of patients,” Dr. Armando said.
So Dr. Armando and Dr. Pedro A. Jose, a professor of medicine and physiology at SMHS, are working to find a more efficient way to determine what each individual patient needs. They are supported by a $909,000 grant from the National Institutes of Health’s National Heart, Lung and Blood Institute.
Their work centers on a particular gene, GRK4, which has been linked to high blood pressure. Some variants of ths gene seem associated with salt sensitivity and salt-sensitive hypertension, while other variants of this gene are associated with salt-resistant hypertension. Variants of genes other than GRK4 may be the cause of inverse salt sensitivity.
“If we can find the molecular defects that are involved in salt sensitivity, salt resistance and inverse salt sensitivity, then we’ll be able to produce new therapies [for hypertension],” Dr. Armando said.
She said the process also will be a window into the expanding field of pharmacogenetics, or personalized medicine. A patient’s genotype could help pinpoint what will be their most effective treatment.
“You do not necessarily treat the same disease in different persons with the same remedy,” Dr. Armando said.