Complementary and Integrative Health in Kidney Care

Josephine P. Briggs, MD

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KN: You direct a center that underwent a name change from the National Center for Complementary and Alternative Medicine to the National Center for Complementary and Integrative Health (NCCIH). What is the significance of the change from “alternative medicine” to “integrative health,” especially with regard to kidney care?

Dr. Briggs: Many population surveys have shown that the use of true “alternative” medicine by Americans—that is, alternative practices instead of conventional care—is not common. Americans are generally using complementary approaches as adjuncts to conventional care, integrated with conventional care. And integrative care, especially for pain management, is increasingly offered in a variety of health care settings across the country, including hospices, nursing homes, and military facilities. Mind-body approaches such as relaxation techniques have potential application in dialysis units.

KN: At Kidney Week 2014, you were presented with the John P. Peters Award for outstanding contributions to improving the lives of patients and to furthering the understanding of the kidney in health and disease. Tell us how your focus on translational research brings a better understanding to the usefulness and safety of complementary and integrative health.

Dr. Briggs: As a researcher and physician I have long been aware of the challenge of building rigorous clinical evidence. In many areas of science we talk about the challenge of moving from the bench to the bedside—turning the ideas that we pursue in the laboratory into improved health strategies for patients in need. But we also face the challenge of going from the bedside back to the bench—capturing the observations and wisdom of experienced practitioners to aid in building clinical studies that help develop a rigorous evidence base. Translational research helps us address these challenges. It also addresses a third hurdle—ensuring that new scientific insights actually lead to improved health care in our communities. All of these challenges are as relevant to the NCCIH as any other National Institutes of Health (NIH) institute or center.

For promising complementary approaches, we need and continue to constantly ask ourselves tough questions:

Do we have the understanding and needed methodologic tools to perform definitive human subject studies on this therapy?

Do we have adequate proof-of-concept data to justify the investment?

Do we understand dosage and bioavailability?

Have we developed surrogate markers that establish that the intervention has an effect?

If we can’t answer “yes” to these questions, then what do we need to do to move this research to the next step? To address gaps in this area, the NCCIH has funded several initiatives to develop tools and methods for translational research.

KN: How many people in the US use complementary or integrative approaches to health care?

Dr. Briggs: Approximately one-third of American adults use complementary and integrative health approaches.

KN: Recent reports have found a large degree of contamination or faulty labeling of herbal and dietary products available for purchase as complementary remedies. Does the NCCIH provide resources for, or recommend any best practices for, selecting complementary therapies that have clearly identified safety profiles?

Dr. Briggs: Our web site provides a great deal of information about the safety of dietary supplements. As well, we link to safety alerts and recalls from the US Food and Drug Administration: https://nccih.nih.gov/health/supplements/wiseuse.htm

KN: Are kidney patients who use complementary herbs or supplements along with traditional medical approaches in their care likely to tell their physicians about the complementary approaches?

Dr. Briggs: We do not have data collected specifically on kidney patients. However, we do know from past surveys that a large number of patients do not discuss the use of complementary health approaches with their physicians.

KN: How can nephrologists help make their patients more aware of potential herb–drug or supplement–drug interactions?

Dr. Briggs: We recommend that physicians or medical staff ask patients about their use of these supplements when asking about any other medication the patient may be taking. As well, patients should be encouraged to discuss these products with their physician in an open dialogue.

KN: Outbreaks of aristolochic acid nephropathy (also called Chinese herb nephropathy or Balkan endemic nephropathy) demonstrate the potential for nephrotoxicity that some herbs possess. What are the most common herb–drug or supplement–drug interactions that affect kidney health?

Dr. Briggs: Regarding nephrotoxicity, the Chinese herb that raised everyone’s awareness regarding aristolochic acid is Aristolochia fangchi. Several other plants in the Aristolochia genus also contain aristolochic acid and therefore should be avoided because of potential nephrotoxicity. I am not aware of other plants that cause this type of direct nephrotoxicity. For drug interactions, the first one that comes to mind is St. John’s Wort, which should be avoided by anyone who has had a kidney transplant because it will interact with the immunosuppressants that transplant patients commonly take and therefore could cause organ rejection.

KN: Kidney patients often have multiple other chronic conditions. How can a complementary or integrative approach fit into their care?

Dr. Briggs: Many of the mind and body therapies are used to help with symptoms, such as pain management. Some of these approaches may help promote a healthier lifestyle and provide patients who have limited mobility and other health concerns with more options for lower-impact exercise options, such as yoga and tai chi.

KN: Are there any special considerations or different methods investigators must use when conducting complementary health research and evaluating its outcomes?

Dr. Briggs: The research we fund uses the same rigor as any other institute and center at the NIH. Where we are unique at the NCCIH is that many complementary approaches are readily available in the marketplace. As a consequence, the NCCIH sits at the crossroads between research and real-world consumer use. The general public wants to know what works and what doesn’t, and health care providers also want reliable information. Complementary health approaches are being integrated into the care offered in many nursing homes, hospices, and hospitals, and these health care organizations want good information to drive decisions about which therapies to provide or recommend.

The NCCIH wants to take on the challenge of meeting this need. Often, the kind of rigorous, high-quality data that would answer these questions are not yet available. This unique situation has made us aware of the importance of better methods to do real-world, or pragmatic, research. Driven by this interest, we volunteered about 4 years ago to take on a major administrative and leadership role in an NIH Common Fund initiative called the Health Care Systems Research Collaboratory. This program is engaging health care delivery organizations as research partners, with the goal of building methods to conduct rigorous large-scale clinical trials in real-world settings. Through the Collaboratory, the NIH is pioneering the development of approaches to conduct large-scale, cost-effective clinical research studies in the settings where patients already receive their care.

KN: What is (are) the most common misconception(s) people have about complementary medicine in general, and the NCCIH in particular?

Dr. Briggs: I think some people are unaware of what we research here at the NCCIH. About half of our portfolio is dedicated to mind and body therapies, mostly looking at symptom management, and the other half to dietary supplements, including safety and efficacy. About one-third of our portfolio is dedicated to pain research. The most common reason people turn to complementary health approaches is for pain management, which is why this area of research is so important to us at the NCCIH. Pain is a huge public health burden, and people are looking for options, outside of drugs and other conventional medicine, to help with their pain. We’re researching options to give people gentler ways of managing their pain.

KN: What will be the most promising areas of research at the NCCIH over the next 5 to 10 years?

Dr. Briggs: Symptom management, mainly pain management, will continue to be a promising area of research, as will research on how complementary health approaches can help promote healthy lifestyles, wellness, and disease prevention. Another focus that is becoming more central to our research at the NCCIH is our work on pragmatic trials through the Health Care Systems Research Collaboratory.