Integrative Medicine combines practices and treatments from alternative medicine with those of conventional medicine. It bridges the gap between lifestyle and functional medicine, and conventional medicine. It is crucial in managing complex chronic diseases such as kidney disease. Here, we will discuss Integrative Nephrology.
Integrative Nephrology
Integrative Nephrology focuses on six primary areas which identify individualized risk factors for kidney disease to develop a personalized lifestyle modification plan that can be incorporated into patient management. The purpose of this publication is to discuss the integrative approach to kidney care in detail.
This is important because chronic kidney disease (CKD) affects millions of Americans and is often associated with comorbid conditions such as cardiovascular disease, diabetes, and hypertension.
According to the USRDS data, almost 15% of the US population has CKD (1 in 7 people), and 1 in 3 are at risk for CKD. Similar statistics are found throughout the world. In addition, nearly 800,000 people suffered from ESKD (end-stage kidney disease) as of December 2018.
Current approach
One in nine patients with kidney disease doesn’t know they have it. The current conventional medicine approach relies on patients to develop signs or symptoms of an illness that is often silent. It tries to identify risk factors such as diabetes and hypertension and depends on busy providers to screen patients for early signs of kidney disease. This delays kidney disease detection and interventions that could reverse it.
Additionally, some kidney diseases are due to autoimmune diseases. Unfortunately, current models of care do not allow providers to identify the predispositions, triggers, and modifiers for these disorders.
Finally, it is thought that less than 10% of kidney diseases are due to genetics. The approach to these overt hereditary diseases has mainly relied on providers observing the progression to ESKD and managing complications.
Most of the tools available to health providers are limited to pharmaceuticals designed to manage diabetes, hypertension, and hyperlipidemia. While these tools are helpful, they tend to encourage the patients to live with their disease instead of attempting to reverse it.
In addition, the current fee-for-service (FFS) model does not allow enough time for the provider to get to know their patients well, identify their risk factors, screen them, and treat them properly. Providers also have to jump through hoops, such as prior authorizations and clunky electronic health record metrics, which do not benefit patient care.
Medicare spent $81 billion on FFS for beneficiaries with CKD in 2018. That is more than 22% of Medicare FFS in that year. This does not include the $49.2 billion that Medicare spent on ESRD services. Yet, despite this massive spending on kidney disease and treatment, there continue to be gaps in identifying people at risk for CKD and preventing and treating CKD.
Integrative Approach to Kidney Care
Integrative Nephrology aims to identify the root cause of kidney disease and sift through multiple factors contributing to the disorder. It mainly focuses on six primary areas or principles which identify individualized risk factors for kidney disease to develop a personalized lifestyle modification plan that can be incorporated into patient management. This approach considers genetics, environment (diet, nutrition, toxins), lifestyle, the gut-kidney axis, and pharmacological interventions.
The six basic principles that Integrative Nephrology uses to assess, address, and treat kidney disease are:
· Genetics and epigenetics
· Nutrition
· Environmental toxin exposure
· Gut-kidney connection
· Lifestyle risk factors
· Pharmaceuticals
Addressing these areas starts with educating patients and providers. Using Integrative and Functional Medicine tools can help develop a personalized lifestyle modification and treatment plan through which the patient can be coached.
Education
Shifting the paradigm from the conventional approach to an integrative requires investing time and effort in educating the patients and raising awareness of this silent and deadly disease.
In addition, it is crucial to educate various providers on the principles of Integrative Nephrology and the tool required for personalized assessment and testing. This often necessitates a team approach.
Personalization
The integrative approach to kidney disease requires a team of trained integrative nephrologists, dietitians/nutritionists, and coaches. It assesses and analyzes all the factors associated with six principles to tailor a “lifestyle modification plan” that can be incorporated into the conventional medicine approach to an individual’s kidney disorder.
Coaching
However, it is not enough to prescribe the patient a lifestyle modification plan. This is because it takes, on average, 66 days for a patient to develop a new habit. Some even need more than six months to establish a new habit. Therefore, patients need guidance in purchasing groceries, preparing meals, stress management, dealing with relationships, managing sleep, etc.
This gap can be filled by coaches trained in the integrative approach to kidney disease. They can guide patients under the supervision of nephrologists and dietitians/nutritionists. A coach can even be a medical assistant who is adequately trained. This approach has been studied and found to improve diabetes and cholesterol control. Coaches have been used in the UK for that purpose. They are integral to the success of our integrative approach to kidney health.
Join us to end the kidney disease epidemic and receive the FREE Report “5 Pitfalls to Avoid When Caring for Kidney Patients”
The Principles of Integrative Nephrology
Genetics of kidney disease
The most significant advance in kidney disease in the past few years has been the use of genome-wide association studies (GWAS) in various kidney disorders. In these studies, various kidney diseases were statistically linked to specific variants in the genetic code.
Current evidence suggests that genetics play a role in the development of kidney disease. Common genetic disorders associated with kidney disease include polycystic kidney disease, Alport’s Syndrome, and Fabry’s disease. However, the advances in genome-wide association studies helped identify several hundred other genes linked to kidney diseases. This made genetic testing a valuable tool for identifying CKD risk factors and managing them.
However, genetics is one of the factors that lead to the development of kidney disease. For genes and their variants to contribute to a disease, we need to understand all the factors that explain why people with even the same variant may have different outcomes. Therefore, understanding the interaction between genetics, epigenetics, and the environment is crucial.
In essence, genetics provides the blueprint that may predispose a person to kidney disease, while other factors such as nutrition, lifestyle, and environmental toxin exposure may enhance or counteract that genetic predisposition. Or, as it has been described: genetics loads the gun, and the environment pulls the trigger.
Epigenetics
Epigenetics is a developing field that studies how a person’s behavior and environment can cause changes that affect the way genes work. Researchers found that these factors can cause changes in the DNA, such as histone modifications, methylation, and cytosine hydroxy-methylation. These changes, in turn, can increase or decrease gene expression.
So, just as good lifestyle habits can reduce disease risk by turning off problematic genes, poor decisions can increase our disease risk by turning them on.
Lifestyle factors like diet, sleep, meditation, and exercise, for example, are things we have control over and tremendously influence genetic expression. Limiting exposure to environmental toxins (like food additives, pesticides, heavy metals, and plastics) and supporting the body’s natural detoxification pathways is another essential aspect to keep in mind.
Therefore, identifying genetic predispositions through genetic testing can help providers develop a personalized lifestyle modification plan to promote healthy, beneficial gene expression. This can even be done for genetic disorders like polycystic kidney disease.
Pharmacogenomics
Variability in response to pharmaceutical therapy is due to multiple, complex individual variations in fundamental physiological differences like age, sex, weight, metabolism, absorption, organ function, and disease state. These variables mean patients require monitoring, dose adjustments, and sometimes alternative therapy. Thanks to advances in the field of pharmacogenomics, clinicians can use genetic information to personalize drug therapy. This is the basis of precision prescribing and has a significant benefit in prescribing kidney transplant medications.
Nutrition in CKD patients
Nutrition plays an essential factor in the progression of CKD and outcomes of kidney disease patients. Dietary changes such as low protein and very low protein diet with keto-acid analogue supplementation have been associated with slowing the progression of kidney disease. In addition, a growing body of evidence supports the recommendation for a plant-based or a plant-dominant diet for CKD.
How a nutrient is packaged can also influence its effects on the body. Some forms can be harmful, while others can be beneficial. Dietary phosphorus, for example, when ingested in processed food, can have higher bioavailability and is more dangerous for kidney patients. On the other hand, a diet rich in plant-based whole foods (and rich in organic phosphorus) is recommended for kidney disease. This form of phosphorus is less harmful to the kidney patient.
In general, processed food is devoid of micronutrients and can be high in sodium and phosphorus. It can also potentially contain toxins. Processed food should, therefore, be eliminated for kidney patients.
When considering nutrition for kidney disease, one should also consider food preparation methods, which can lead to the formation of advanced glycation end products (AGEs). AGEs form when sugars react with various foods at high heat, making the food more inflammatory. They have been implicated in diabetes and kidney disease. Cooking methods can also affect the micronutrient content of vegetables.
Furthermore, micronutrients such as zinc and selenium exert many biological functions throughout the body. Zinc deficiency, for example, is well-established in CKD (for more about this, read this blog). In addition, many of the medications that kidney patients use can lead to nutritional deficiencies. Identifying and supplementing these deficiencies can also improve the outcomes of CKD patients. For more about this, read here.
Finally, realizing that nutrients don’t work in isolation is crucial. Biological functions are more complex and involve multiple nutrients and vitamins as cofactors. These complex interactions may explain conventional research’s failure to identify the link between a single nutrient and various outcomes.
Vitamin D, for example, interacts with vitamin K2 and magnesium to optimize bone and vascular health. Likewise, b vitamins are given as a B-complex because of the interactions between multiple B vitamins in biochemical pathways.
Individualizing a nutritional “prescription” for a specific patient, therefore, requires diligent evaluation of nutritional status, drug-induced nutritional deficiencies, nutrient interactions, and nutrigenomics.
Supplements under nephrologist supervision
Traditionally, nephrologists have been opposed to providing supplements to kidney disease patients. This is supported by case reports of supplement-induced acute kidney injury. In addition, there is no doubt that the supplement industry is poorly regulated. However, as mentioned above, many kidney disease patients suffer from nutrient and micronutrient deficiencies. Therefore, an individualized and comprehensive assessment of nutritional status is necessary to optimize care for these patients. Supplementing these deficiencies under the supervision of nephrologists using high-quality supplements can fill this gap. You can read this well-written blog on how to choose a high-quality supplement.
Environmental toxin exposure
Each year, 220 billion tons of toxic chemicals are released into the environment. In addition to the liver, the kidneys are essential for the biotransformation (the breakdown) of many of these chemicals. They are also the primary route of elimination for many. Furthermore, some substances selectively accumulate in the kidneys and cause chronic kidney disease or even kidney cancer.
Environmental toxins, therefore, should be assessed and addressed in a comprehensive plan for kidney health. For example, polyfluoroalkyl substances (PFAS) are a family of greaseproof, waterproof, and non-stick industrial compounds. They are used in hundreds of consumer products, including ones touching your food and skin. You might have heard of them as “forever chemicals” or Persistent Organic Pollutants (POPs). Researchers have shown that they can lead to kidney damage.
Even chemicals thought to be problematic only in the past are becoming a current environmental issue. For example, toxins such as arsenic, lead, and cadmium are found in processed beverages, drinking water, and cigarettes. All three have been implicated in the development and progression of kidney disease. In fact, lead is one of the major risk factors for kidney disease worldwide.
Decreasing exposure to these chemicals and others is essential in preventing kidney disease. Understanding the genetics involved in metabolizing and excreting these toxins can help individualize their management.
In addition, improving the body’s ability to bio-transform them can slow down the progression of kidney disease. This can be accomplished by a personalized nutritional evaluation and lifestyle modification program. Pharmaceuticals can even be used to clear high levels of toxins when indicated.
The gut-kidney connection
Dysbiosis and intestinal permeability are implicated in many systemic inflammatory and immune-related disorders that lead to chronic disease. Dysbiosis describes unfavorable alterations in the gut microbiota, including the overgrowth of harmful bacteria or poor growth of good bacteria. The normal integrity of the gut can be compromised by dysbiosis and cause systemic complaints, even in the absence of overt gut symptoms.
The gut-kidney connection refers to the relationship between gut integrity, microbiome diversity, and kidney disease. The connection between the gut and kidneys is very complex. Still, we can break it down into two major categories: the gut-derived uremic toxins and the inflammatory immune response that can trigger kidney disease.
Research has established a relationship between gut microbes, gut integrity, and kidney disease. This occurs through very complex biochemical and immune mechanisms. The presence of “good” bacteria has been associated with immune changes that inhibit inflammation. The use of probiotics and prebiotics that produce favorable changes in the microbiome has also been associated with gut changes that reduce many uremic toxins associated with advancing kidney damage.
Comprehensive gut assessment and restoration protocol
Conventional medicine and research realize the importance of the gut microbiome. Its literature is even paying increasing attention to gut integrity. However, the approach to studying various interventions focuses on using “the scientific method” to isolate a single modifier, such as probiotics or symbiotics, and assess its benefit. In doing so, they usually fail to address other aspects of gut restoration and mucosal repair that may be required to achieve desired outcomes.
A more comprehensive and individualized approach is the so-called 5R protocol. In this protocol, providers help patients remove potential triggers to gut hyperpermeability, replace nutrients and digestive aids that are deficient, reinoculate good bacteria when needed, repair gut integrity and motility, and rebalance lifestyle factors for a healthier gut.
Lifestyle risk factors
In nearly all guidelines, lifestyle modification is the first step recommended for managing chronic diseases. Yet, guidelines often fall short of describing what lifestyle modifications patients should be applied and how. It is often thought that lifestyle modifications are limited to diet and exercise. Smoking and alcohol consumption are sometimes added to the mix.
There is no doubt that diet and exercise are essential. In fact, diet is so important that we made it an independent principle of our integrative approach to treating kidney disease. However, lifestyle modifications go beyond that to managing stress, sleep, and having healthy relationships.
Many CKD patients live stressful lives. They may have stressful jobs, toxic relationships, and underrecognized sleep abnormalities. All these lifestyle problems, in addition to diet, exercise, and smoking cessation, can influence the progression of kidney disease.
Managing stress through breathing exercises, meditation, and yoga can have a tremendous impact on blood pressure and diabetes control and can even slow the progression of kidney disease.
In addition, healthy relationships have been associated with better cardiovascular outcomes. Giving and receiving support, affection, help, and advice can trigger the release of stress-reducing hormones. Social relationships can relieve stress. Lowering stress positively affects heart health, insulin regulation, and the immune system and strongly benefits kidney health.
Pharmaceuticals
Nothing in our integrative approach to kidney health is against using medications to manage kidney disease. However, studies showed that an average kidney disease patient takes nine medications. Our integrative approach utilizes medicines as a last resort. In some instances, medications are necessary while simultaneously addressing the other basic principles (genetics, nutrition, etc.) to prevent rapid loss of kidney function.
For example, if a patient is experiencing vasculitis (inflammation of the blood vessels), managing and decreasing inflammation using immunosuppressants may be essential to avoid the rapid loss of kidney function. This can be done parallel with a “root cause” workup that investigates environmental exposures, gut-kidney factors, other lifestyle choices, and events that could have triggered or perpetuated the vasculitis.
Furthermore, when using medications for kidney disease, one must pay special attention to a few unique issues. First, the dosing of medicines often requires changes based on kidney function. The kidneys excrete many medications or their metabolites, and adjusting their doses is essential to avoid toxicity.
Second, providers need to pay attention to drug-drug interactions that are more important in kidney patients due to the higher number of medications involved. Third, what should be noticed by many providers is the drug-nutrient interactions. Many medications used for kidney disease are associated with nutrient deficiencies that can affect outcomes. For example, the use of ACE inhibitors, which is common in kidney patients, can be associated with zinc deficiency.
Tools of Integrative Kidney Care
While conventional medicine utilizes simple, tried, and true tools for evaluating and managing kidney disease, Integrative medicine uses tools that dig deep to identify the patient’s individual characteristics to help develop a personalized plan.
Conventional medicine, for example, uses tools such as basic metabolic panels, renal panels, urinalysis, urine albumin to creatinine ratio, urine protein to creatinine ratio and serologic testing, and even kidney biopsies. However, while these tests may help identify the type of kidney disease the patient is suffering from, they do not detect the root cause nor help the patient and provider navigate through a personalized approach to rid the patient of that disorder.
Integrative Nephrology utilizes tools such as genetic testing, environmental toxin exposure evaluation and testing, nutritional evaluation and testing, evaluation of gut integrity and microbiota, and lifestyle assessments.
Genetic testing
Testing for evaluation
Various methods for identifying genetic variants associated with kidney disease have been used. The exome is that 2% of the genome that codes for all biological proteins. Next-generation sequencing is a new technology that allows DNA sequencing of the entire human exome within a single day. It also captures a broader spectrum of variations that can affect the genetic code.
This revolutionary technology can identify mutations associated with CKD. It can also recognize variants associated with an increase in the risk or severity of CKD. It is now available for kidney disease patients (Natera’s Renasight test). This “broad-panel genetic testing” type can transform care for patients with kidney disease.
Testing for management
Many companies also provide pharmacogenomic testing to guide medication prescribing to avoid toxicity and side effects. One of these companies is Genetworx which provides a comprehensive report. Even Quest Diagnostics offers pharmacogenomic testing.
Nutrigenomic testing is also helpful in guiding nutritional evaluation and management for many kidney patients who tend to grapple between nutritional deficiencies and excesses. Unfortunately, the field of nutrigenomics is still in its infancy. While companies such as Nutrition Genome and Nutrigenomix can be used for that purpose, these tests may still need to be standardized.
Nutritional assessment and testing
A comprehensive nutritional assessment includes anthropometric measurements of body composition, serum protein, micronutrients, and metabolic parameters, clinical evaluation of altered nutritional requirements and social or psychological issues that may preclude adequate intake, and dietary intake. A collaboration between an Integrative provider and a dietitian or nutritionist is essential for this assessment.
Techniques for measuring body composition of fat and lean body mass include anthropometry and bioelectric impedance analysis. Devices such as bodystat or inbody can be used for that purpose.
A 3 day-diet recall can be used to identify dietary intake of various nutrients. In addition, multiple tests are commercially available to assess different nutrients and metabolic parameters. Genova’s NutrEval is one of our favorites.
Environmental exposure assessment and testing
Various surveys have been developed for assessing environmental toxins exposure. The CDC has a comprehensive questionnaire that can be used for that purpose. The Institute of Functional Medicine also developed a survey that can be downloaded here.
Unfortunately, after chronic exposure to heavy metals and forever chemicals, our bodies adapt and store them in tissues such as fat or bone. So, a simple blood test may not detect these substances. The best analysis to detect them is a provoked urine collection. This requires your physician to order a medication that helps release these substances from their storage.
However, a simple analysis is unprovoked timed 6-hour urine collection can be a starting point. We like Doctor’s Data Urine Toxic and Essential Elements test for that purpose.
Gut integrity and microbiota testing
Gut health questionnaires can be used as a starting point during patient intake. The World Gastroenterology Organization, for example, has a patient questionnaire that can be useful.
However, it is essential to realize that more than these questionnaires may be required, and patients could have dysbiosis and increased intestinal permeability without gut symptoms.
This is why we recommend using stool testing for dysbiosis and intestinal permeability. We like Doctor’s Data GI 360 stool tests and Diagnostic Solutions GI map test (the latter is more comprehensive).
Lifestyle assessment
Assessment for lifestyle factors usually involves a comprehensive intake form that asks the patient about various rituals related to sleep, relaxation, exercise, and relationships. We recommend updating these assessments at least annually. You can download our comprehensive intake form here.
Barriers to an integrative approach to kidney disease
To implement an integrative approach to kidney health and disease, providers need more time to get to know their patients, identify their struggles and challenges, and guide them. This is crucial to tailor a lifestyle modification plan individualized to the patient and the specific kidney disorder.
In addition, it requires adequate provider, dietitian, and nutritionist integrative training. The availability of trained integrative coaches is also crucial for this approach to succeed.
Many providers have used the direct patient care model to implement an integrative or functional medicine approach to chronic diseases. However, this approach is disadvantageous to many kidney disease patients, many of whom are in more vulnerable populations.
Therefore, it is critical to implement changes in the healthcare reimbursement model that allow for more time with patients and reimbursement for nutrition, lifestyle management, and coaching. This approach could save costs in the long run and provide more years of kidney health and better quality of life for patients.
The Bottom Line
Our integrative approach to kidney disease focuses on identifying individualized risk factors for kidney disease to develop a personalized lifestyle modification plan that can be incorporated into the patient’s medical management. The patient will then be coached to help them succeed in achieving these modifications and build new healthier habits. The current reimbursement model needs to change to accommodate this approach which could reduce costs and improve kidney patients’ outcomes.
