Chronic kidney disease affects veterans in greater proportions than in the general population. So it is a serious and expensive issue for the Veterans Health Administration. Kidney disease and treatment are also the object of extensive research at VA. For an update on a topic that influences all public health, the Federal Drive with Tom Temin spoke with a leading researcher and the nephrology specialist at the VA medical center in Albuquerque, New Mexico, Dr. Mark Unruh.

Interview Transcript: 

Tom Temin  Doctor Mark Unruh, give us an overview of what is going on in the generalized area of dialysis of kidney disease outcome, because by some measures, it hasn’t advanced much since the 1940s.

Dr. Mark Unruh I think for me, I’m really excited for this moment in care of people with chronic kidney disease. You know, for those of us that take care of patients, the whole point of kind of working with veterans is to prevent people from going on to requiring hemodialysis or transplantation at this moment. There are a number of really exciting medications that have become broadly available for veterans. And, you know, it’s just a really exciting time as a nephrologist to care for veterans. You know, these medications are both related to the management of diabetes and diabetic kidney disease, with the SGLT-2 two medications, which are really kind of becoming more prominent and have like really remarkable effects on preventing and stage renal disease, as well as sort of specific mineralocorticoid antagonists that also seem to be of great benefit. So, I would say, like for general chronic kidney disease, I have not seen medications that have this degree of impact for the past 20 years since we kind of started with angiotensin receptor blockers and Ace inhibitors. And so, you know, this is like a time for veterans to make sure that they’re getting outstanding care in our system.

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Tom Temin All right. And you have been concentrating on dialysis for a lot of people with kidney disease. That’s the one step removed from a death sentence is to go on dialysis. And what’s going on in your research? What’s the goal here to try to improve that? Pretty cumbersome, frequent, and tiresome process.

Dr. Mark Unruh For, I guess, time with someone that cares for a lot of veterans who are on dialysis. I have a little bit of a different take. I would say, like in the U.S., we’re actually very fortunate that we have access to dialysis. There are other countries that are under resourced where you don’t have that opportunity. I like to say hemodialysis in particular, as a part time job that doesn’t pay very well. And there are many veterans that can, like, do exceptional things while they’re undergoing dialysis. So, for me, I think it’s kind of a remarkable thing that we’re doing. I agree with you in that, you know, it’s been a while since there’s been market innovation in hemodialysis. You know, fortunately, the kind of VA is sponsoring a number of studies now to kind of push that field forward. You know, we are actually doing a study of less frequent dialysis for people that are starting dialysis. And, you know, this is a concept that we’re sort of taking from peritoneal dialysis, which is a type of analysis where you use the stomach as a way to exchange and pull toxins off, where you use an incremental approach as the patient has a residual renal function, or they make urine. You probably need to do dialysis, the SLAs. And so, in the hemodialysis sector, or like in patients who are receiving hemodialysis right now in the U.S., people just start at three times a week. And that’s just standard operating procedure. So, you know, we’ve been asking the question like what a more veteran centric, pragmatic approach be to start at twice a week and see how people do and then as they need more as their residual renal function or their kidney function or urine output goes down, why not like add another session? And if they still have problems, theoretically you can add another session. We’ve done studies demonstrating that, you know, more frequent dialysis likely is beneficial as well from a quality of life and cardiovascular outcome standpoint. So, I think that, you know, the future state for in center dialysis is one that is very personalized. You know, depending on how much urine you’re making, that we can kind of adjust it to help you meet your goals.

Tom Temin We were speaking with Doctor Marc Unruh, a nephrology specialist at the VA medical Center in Albuquerque, New Mexico. And what about work on maybe the mechanics of dialysis? I mean, when you look at detection of blood sugar levels and stuff, look how far that’s come from constant pins, ticks to little buttons you wear and all kinds of jazz. Dialysis is still a big giant machine. You go to it, you get a book and sit there for three hours. What’s going on in trying to modernize that if it’s possible to do so?

Dr. Mark Unruh Yeah. No, I would say there’s a lot going on. So, with the kind of modernization of the dialysis machine, you know, there are machines. That can be put into people’s homes so that people do hemodialysis that you typically would do in the center in the home. They’re designed to be user friendly. That is not a common option in the United States at this moment. And, you know, I think that is an approach that requires the commitment of a patient who’s very focused on providing care for themselves, as well as a caregiver. In the VA and more broadly, across the U.S., there’s a movement to do home dialysis. That movement is often, peritoneal dialysis. Peritoneal dialysis has been around for a long time. It’s used much more frequently in other countries. It works really well for people that live in rural areas, like veterans who are in rural areas, and otherwise would have to drive a long way to get to a center. So, I think there is a kind of a progress in using PD as an option. There are innovations within kidney disease with dialysis that are kind of emerging. I would say there’s a lot of focus through a federal program, public private program, KidneyX that is focused on a wearable dialysis approach where you would be in effect, like have a backpack that is, doing the dialysis 24 over seven. One could imagine, you know, a future state where that would be an approach and perhaps people would have kind of the increased ability to be social, to work, to like, have a more normal or more standard diet. So those are all very exciting things. In addition, from a transplant standpoint, there was the recent news of xenotransplantation using genetically modified pig kidneys and putting them into humans. And we’re kind of, you know, really watching the outcomes of that sort of approach, because that could really be a terrific approach for our veterans who have end stage renal disease.

Tom Temin And just briefly, what extent of the veterans’ population have this? Is it outnumbering proportionately than the general population?

Dr. Mark Unruh I think that’s a great question. I think for our veterans, they have a little bit higher rate of chronic kidney disease than the general population. You know, across the U.S., if you look at adults, the rate is about 1 in 7. We’ll have mild to moderate to end stage chronic kidney disease. And among veterans, it’s more like 1 in 6. And, you know, among veterans who get their care at VA’s, there’s about half a million that have chronic kidney disease, of which 22,000 received dialysis. So, you know, it is something that impacts a lot of people. For me, that’s why it’s just really exciting to have these novel therapeutics that are emerging that really kind of highlight the link between metabolism and cardiovascular and kidney outcomes. And like, you know, it’s my hope in the future that we can use these medications early enough to forestall the need for dialysis or any sort of transplant.

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