By Thomas F. Parker, III, MD 

The National Kidney Foundation (NKF) has developed a way to categorize kidney disease based on the level of kidney function remaining. Each one of the stages carries with it certain responsibilities for the patient and their physician. It is therefore important for each of the two parties to remind each other about these responsibilities and to have an understanding of the necessary actions to be taken by each. To gain an understanding, let’s take each stage of kidney disease and describe the most important questions patients should ask their physician. As we review these important questions, keep in mind the several pieces of information listed below: 

The kidney does more than just eliminate waste. The following list of functions the kidney does will remind you of why you are asking certain questions:
 
o Regulate salt and water
o Regulate blood pressure
o Eliminate and regulate certain chemicals such as creatinine, blood urea nitrogen (BUN), calcium, magnesium, phosphorous and uric acid
o Regulate bone metabolism through Vitamin D metabolism and parathyroid hormone
o Regulate red blood cell production through erythropoietin metabolism
 
If there is disease of the kidney, salt and water may be retained resulting in swelling and edema, the blood pressure may go up (hypertension), creatinine, BUN, phosphorous and uric acid will be inappropriately retained in the body resulting in symptoms such as fatigue, loss of appetite and gout, bone disease may result and anemia (loss of red blood cells) may also develop.
 
During the early stages of kidney disease, there may be no symptoms at all and you may feel perfectly normal. However damage is occurring due to the above aliments and therapy may be required to prevent additional complications.
 
So, when you have been told that you have kidney disease, you want to know the correct questions to ask. Regardless of the level of kidney function, there are certain questions to ask during the first visit with your physician:
 

1. What is the cause of my kidney disease? Is it something that I did (caused by medication such as overuse of aspirin or exposure to toxins), is it hereditary?
2. What is my current level of kidney function (What is my GFR?) and what stage does this level of function remaining put me in?
3. Is it stable or will it progress? 
4. What can I do to stop the progression of kidney loss?
5. What therapy do I need to start right now to prevent progression and to stop future complications (such as heart disease or bone disease)? 

Now let’s discuss additional questions to ask at each stage of the kidney disease. Most patients will not likely go from stage 1 to 2 to 3, and so on to stage 5. Some may find out that they have kidney disease when they are already at stage 4.
 
For reference, the stages of kidney disease are as follows:

NKF-K/DOQI Stages of Chronic Kidney Disease 

Stage	Description	GFR(ml/min/1.73m2)
1	Kidney damage with normal or increased GFR	>90
2	Kidney damage with mild decreased GFR	60 - 89
3	Moderate decreased GFR	30 - 59
4	Severe decreased GFR	15 - 29
5	Kidney Failure	<15 or Dialysis

The questions that you should ask for Stages 1 through 3 are very similar. In addition to those noted above, consider the following:
 
Stage 1 and 2 Questions:
 
1. Do I need to see a nephrologist (a doctor specializing in kidney disease)?
2. Do I have renal damage, or is the elevated creatinine or estimated GFR simply associated with aging or my size? Is it a normal variant? Many people with a decrease in renal function are simply at the low end of normal and no intervention or unusual precautions are necessary.
3. How much protein do I have in my urine and should I take medication to reduce it, even if it’s micro-albuminuria.
4. What is my blood pressure? If I need medication, are you prescribing drugs that have been shown to help preserve renal function?
5. Is my uric acid level elevated and should I take medication, even if I don’t have gout?
6. If I have progressive disease, do I need to alter my diet? How do I balance not becoming protein malnourished if you decide I need a restrictive protein diet? Is there really any evidence that the diet you are prescribing will be helpful?
7. Show me a plot of how my GFR is stable or deteriorating.

Stage 3 Questions:

1. All of the previous questions, plus:
2. If my kidney function has been deteriorating, I would like to begin my education about options for renal replacement therapy: various forms of dialysis and transplantation.
3. What is my Vitamin D level and do I need to be on supplements?
4. Is my parathyroid hormone increasing? If so, what do we need to do?
5. Is my blood pressure under optimal control? What do you consider optimal control to be?
6. Do I need a diuretic?
7. Am I becoming anemic?
8. Show me a plot of how my GFR is stable or deteriorating.
 
Stage 4 Questions:
 
1. I want to bring my family in for education and training about my options of therapy. It is my understanding that a transplant is the best form of therapy. What are you doing to assure that this will occur?
2. I want to schedule having venous mapping and an arteriovenous (AV) fistula access placed in the event I will need dialysis.
3. Do I have evidence of left ventricular (LV) disease? Do we need to schedule an echocardiogram, obtain a brain natriuretic peptide (BNP), or other study to determine if I do? If I do, what are we doing to decrease the risk associated with LV disease?
4. Is it time for me to be on Vitamin D supplements, phosphorous binders and erythropoietin-stimulating agents (ESAs)?
5. Is my blood pressure still being controlled as best it could?
6. Based on my progression of kidney failure, when do you believe that renal replacement therapy is justified?
7. When my GFR reaches 20, shouldn’t we start the transplant evaluation?
8. If I am not feeling sexual, what can you do about it?
9. If I am feeling symptoms of depression, what can you do to help?
10. Show me a plot of how my GFR is stable or deteriorating? At the current rate of progression, when might renal replacement therpy be necessary?. 

Stage 5 Questions:

1. Is my volume status optimally controlled? Do I have any evidence of volume overload?
2. Is my AV fistula access suitable for use now?
3. I have certain symptoms such as itching, shortness of breath, fatigue, nausea, decreased appetite, change in bowel function, headaches and metallic taste in my mouth. What can be done to help this?
4. When do we start the agreed upon therapy?
5. Have I done everything to assure the best care?
6. Have you, as my physician, done everything to assure the highest level of care?

Remember, there is no such thing as a bad question, just questions left unanswered. So learn as much as you can about kidney disease and become an active participant in your health care team...it's the key to living a fulfilling life.

The My Doctor Visits section of the AAKP My Health website allows you to record your upcoming doctor visits, write down what you discussed with your health care team and record questions for your upcoming doctor visits so that you don't forget. A new feature of AAKP My Health also allows you to send yourself appointment reminders. For more information, visit www.aakp.org/my-health.

Thomas F. Parker, III, MD, is a founding member of Dallas Nephrology Associates located in Dallas, Texas. He is currently Clinical Professor of Medicine at the University of Texas Southwestern Medical School, and Attending and Consultant at Parkland Memorial Hospital and Baylor University Medical Center. Dr. Parker is also Director of the Pre-Transplant Program at Dallas Transplant Institute. He has been honored by "Best Doctors in America" and is the 2010 recipient of the AAKP Medal of Excellence Award.

This article originally appeared in the September 2010 issue of aakpRENALIFE.

Posted 9/22/10.

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