CKD Research

Diabetes, Dialysis and Research

Graham Abra




Dr. Graham Abra, MD: Diabetes is a big deal in kidney disease. It's the leading cause of both chronic kidney disease and end-stage kidney disease that requires transplantation, dialytic therapy, or intensive conservative care.

Christopher Springmann: That's Dr. Graham Abra, a Clinical Assistant Professor at Stanford University and Senior Director of Medical Clinical Affairs at Satellite Healthcare. Dr. Abra is joined by colleague Paul Bennett, PhD, Director of Medical Clinical Affairs at Satellite Healthcare.

Thanks to both of you for joining us today on NephTalk from the beautiful studios of Stanford University in Palo Alto, California. Before we get into the posters and the oral portions that you're presenting at the ASN-- or American Society of Nephrology-- meeting, can you give us a linkage between diabetes and dialysis?

GA: It's the leading cause of both chronic kidney disease and end-stage kidney disease that requires transplantation, dialytic therapy, or intensive conservative care. It's a major issue that nephrologists and other professionals who work with patients with kidney disease deal with.

CS: Diabetes, dialysis, congestive heart failure-- comorbidities are an enormous challenge for nephrologists. What are your thoughts about that, Dr. Abra?

GA: I would agree. These comorbidities are things that both are causative of kidney disease in many cases, as well as contributory and complicating. They're complicating in that many of the additional manifestations beyond kidney disease-- such as heart disease, cerebral vascular disease, stroke-- are serious issues that patients deal with that managing clinicians need to be aware of and, of course, treat. These are major things that we think about and help to manage with our patients.

CS: Paul Bennett, how does all of this relate to your work?

PB: The comorbidities treatment, the dialysis treatment itself, the medications that end-stage kidney disease patients need to take, as well as the side effects of the treatment and the restrictions that they need to be on, all lead to a lot of effects. And people don't want to go out anymore-- sedentary effects where people are sitting around and don't really feel like doing a lot. What we'd see is people who have kidney disease-- which may develop over five, 10, 15, 20 years of their life-- they reach end-stage kidney disease where what we see is their comorbidities or their other symptoms or other side effects-- which include muscle disease, which include bone disease, which include anemia or low red blood cells in their body-- it's up to many of the providers to try and arrest that and to try and think of options and strategies to ensure that people do keep moving. So that's where my work fits in.

CS: Dr. Abra, let's discuss your poster, your presentation at the American Society of Nephrology, Compounded Amino Acid Peritoneal Dialysis as an Alternative Volume Management Strategy in a Diabetic Patient, a fascinating title. How would you encapsulate that for the audience?

GA: It's, first, important to acknowledge as a physician and a scientist that this is a case report. So it's a hypothesis-generating report of an individual patient that we hope stimulates thought and potentially future research. The poster goes over an individual patient's case who had diabetes, was treated with peritoneal dialysis, and was having increasing challenges with high blood pressure, large fluid-related weight gains that unfortunately were not being well-controlled with the standard management, which would include things like dietary sodium restriction, the use of glucose-sparing peritoneal dialysis solutions, such as Icodextrin and, unfortunately, the use of higher and higher dextrose concentration solutions to remove more fluid during the peritoneal dialysis.


The strategy that we hit upon-- because the patient was getting to the limits of what we typically do-- was to try the use of a compound amino acid solution that was combined with a standard dextrose solution. And what this did was it provided the patient with a solution with high osmolarity that was able to remove a lot of fluid without loading the patient with a lot of dextrose, with a lot of sugar, that in patients with diabetes can lead to limitations on how much fluid ends up getting removed because of the way that it destroys the mechanism by which fluid is removed from the blood to the peritoneal dialyzate.

CS: Dr. Abra's team was able to show in this individual patient that she had declines in her weight and blood pressure with the use of this compounded amino acid solution. GA: The patient themselves actually provided their own natural experiment in that, unfortunately, here in the United States, these types of solutions are only really available when insurance coverage is there to cover the cost of them. This particular patient lost her insurance coverage for this compounded amino acid solution. So we saw the benefits while she was on it and the metrics that we were following-- weight and blood pressure. And then she lost the ability to have this covered. And she stopped it.

And we saw the weight gain come back. And we saw the blood pressure rise again. And then, after a period of some months, she actually had her insurance reinstated and she went back on the compounded amino acid solution with similar beneficial effects seen. So we thought this was an interesting management strategy to bring to the attention of the kidney community to stimulate thought and potentially future research around these types of solutions.

CS: Sharing knowledge-- especially first person case histories, success stories-- is really a hallmark of medical education among professionals at meetings like this because your poster, your presentation, in essence may ring a bell somewhere down the road with one of your colleagues who encounters this same situation. Is that a fairly accurate assessment on my part?

GA: That's absolutely right. We are seeing larger and larger numbers of patients with diabetes on dialysis in terms of absolute numbers. Increasingly, we will run into these management kind of challenges. It's important for us to think about how we're going to address them.

CS: Paul, let's discuss your oral abstract session and how that relates to Dr. Abra's work. That session is entitled, The Effect of a Combined Resistance and Cardiovascular Exercise Program on Peritoneal Dialysis Patients, a Pilot Randomized Control Trial which, by the way, we covered to some extent in a recent NephTalk program with Dr. Dyer Diskin.

Keeping patients healthy is very, very important. And it's very crucial for patients who have an expectation and aspiration to have a kidney transplant. Could you expand on that?

PB: Dr. Abra painted a very clear picture of the struggles that these peritoneal dialysis patients have who have end-stage kidney disease. He described a patient who had trouble with their weight, with their fluid gains, given the amount of dextrose that is normally used and normally absorbed in patients with peritoneal dialysis. And to go back one step is these patients have a catheter that's implanted in their peritoneum, which is the lining in between all of the organs in the abdominal cavity.

And this causes-- you know, there's some interesting outcomes that people are actually walking around with this catheter. However, that has certain restrictions when-- both psychological and physical restrictions, we think. Our research was about looking at that and trying to explore the best way of addressing the hesitancy and the lack of knowledge that is unknown about exercise programs for people with peritoneal dialysis.

We teach patients to do their own dialysis. Then they go home, and they have a machine that puts fluid in and out, often overnight. They can do it during the day, too. But we're trending to more overnight dialysis.

So the patients are actually sort of in bed for a certain period of time-- eight to 10 hours-- with their peritoneal dialysis exchanges. And then they've got the whole day free. So, hopefully, they can do things and they can live, and contribute, and have as much of a normal life as possible.

CS: What conclusions have you discovered that you will present at the ASN meeting?

PB: We've found that patients want to exercise. And, really, that was one of our major questions. We had 75 peritoneal dialysis patients. And two-thirds of those who were eligible for the study wanted to be in the study, which was a three-month exercise band study.

The most important intervention piece was that we had an exercise physiologist who were meeting with the patients every month for three months. And what we measured was their physical function tests through three different physical function exams and measures. And we also measured their patient outcomes-- well, patient-reported outcomes, commonly known as PROMs-- things like fatigue, cramps, pain, breathlessness, anxiety, those sorts of things, as well.

In all of the measures, we found improvement in the exercise group and, in particular, the physical function tests. Funnily enough, in appetite and sleep, they also improve, which is not unsurprising given that most of us who aren't on dialysis, the more we exercise, the better appetite and the better our sleep. Exercise is good for everyone.

CS: Do patients ever mention the possibility of a transplant? That they are doing the exercise program in part because they want to be ready when the call comes?

PB: In one word, yes. This is very common in many of our patients who they need to be at a certain fitness level and a certain health level before we transplant them. So this is vital that they continue to exercise and maintain the best health that they can.

GA: And I would just add to that, it's increasingly common that transplantation programs are bringing in dialysis patients when they are close to receiving a kidney transplant to assess their functional status, their ability to exercise. And it's a key marker of whether or not someone's going to be able to successfully go through the surgery and then be able to be functional afterwards and do well with their transplanted kidney.

CS: In fact, Satellite Healthcare is also sponsoring research which is directed at recommending exercise programs to end-stage renal disease patients before they're on dialysis.

GA: Exercise is good for everybody. It doesn't matter what clinical condition you've got.

PB: However, the difficulty is, is when people become symptomatic-- and that's often when Dr. Abra sees them more and more-- they don't put exercise at the top of their list. And, unfortunately, many of us-- nephrologists, nephrology nurses, social workers-- we don't have the skills and the knowledge to provide the appropriate exercise for them.

We can say, ah, go for a walk for 10 or 15 minutes. And bump that up, if you can. However, we don't really know the best-- and this is why in our study was important to involve exercise physiologists or kinesiologists, or athletic trainers to be that person to present goals for the patient, talk through those processes, the physical activity goals that they have, whether it's walking the dog, getting out of the car, going shopping. These are the important things that patients who are on dialysis often just can't do and lose the strength to do that.

What's so vital is that they maintain their health and their physical activity just if they are on the transplant list and if they can get a kidney transplant.

GA: You know, very important for our dialysis patients who want to remain functional in their lives or who want to remain working. I have a patients in my mind on peritoneal dialysis who has very basic questions about how much can I do at work. And, as Paul was pointing out, we don't have great guidelines around, are there any limitations? What are they? And how hard can you go? So the work that Paul's doing is important.

CS: That's really the link, isn't it, to couple patient education with the research that you're doing and then apply that knowledge as specifically, as personally, as you can? You obviously need more information.

PB: Yes and no. We have information. We know that exercise works. It's actually providing and being able to show, and model, and coach people who are in the most need of it. That's what they get trained in university, college, to do.

Many go to athletic sports clubs and that to do that role. But they are vitally important in the care in chronic disease, in particular chronic kidney disease.

CS: How important is follow up with the exercise professional in terms of not only acting as a coach, perhaps a bit of a cheerleader, someone giving affirmations, and holding people accountable? Accountability is pretty crucial.

PB: You and I know that if we exercise with another group, we want to keep up with them, if we're running with them or if we're bike riding with them. Many of us need to go to a gym to have that affirmation. And, unfortunately, many of these patients just don't have the time, or the energy, or the ability, and sometimes the money because of their income losses in a way. So we actually have to work a bit harder to provide them with an opportunity to do this motivation, and goal-setting, and checking. And that's exactly what these exercises professionals do.

CS: I would like to ask you both the same question. And I'll start with Dr. Abra. Graham, what would you like your colleagues and, of course, our NephTalk audience to take away from your ASN-- American Society of Nephrology-- poster?

GA: Diabetes is a leading cause of both chronic kidney disease and end-stage kidney disease. And it's going to be increasingly important for us to understand how we provide the best possible care for this group of patients. Our particular poster, we hope stimulates thought and further research around how we provide optimal peritoneal dialysis care for patients with diabetes.

I'm excited about Paul's work, not just to patients with diabetes, but really to all patients who are on peritoneal dialysis, which is a type of kidney replacement therapy that has many benefits for patients, and we will likely see increasing use of in coming years.

CS: What are your thoughts, Paul, in terms of when you walk away from the audience, finish your session at the ASN meeting? What do you hope the takeaway value will be, especially in terms of actions that people might take?

PB: The understanding that people who are receiving peritoneal dialysis can do fairly normal activities, and we should encourage them to live life, and not restrict their lives. Because sometimes we do that, as clinicians. We say, you can't, can't, can't.

These people can do core exercises. They have to be careful because of the catheter in their tummy and their comorbidities that they do have. But they still can do these. So I think the can-do attitude, if we don't know how to do that as nephrologists and nephrology clinicians, we should get some help with that and maybe employ or maybe contract exercise professionals to our clinics to provide that service.

Having exercise professionals in a dialysis clinic, or in a home-training clinic, or a incentive clinic, it just changes the culture. Even the staff come along and say, look, you know, I need a little bit of help with this. Can you help?

CS: It sounds like the two of you really enjoy collaborating together.

GA: Paul and I definitely enjoy each other. We do ride bikes.

PB: We do ride bikes together.

CS: Oh, there we go. Phew.

PB: One of the features of what Dr. Abra and two of the other doctors who we worked closely with in the research group-- Dr. Schiller and Dr. Hussein-- the common features that we all have is care for our patients and wanting them to have not just a good quality dialysis, but a good quality life.

CS: And it's been a great pleasure having both of you on NephTalk today. Happy Diabetes Awareness Month. I think we've increased awareness of how important these comorbidities are and their respective treatments. Thank you very much.


This is NephTalk, a podcast series created with nephrologists in mind, from Satellite Healthcare, a not-for-profit dialysis provider and clinical researcher, with a special focus on home, as the industry's home dialysis leader. I'm Christopher Springmann, and thank you for joining us.