It was a busy Wednesday afternoon in clinic in East Harlem, where the no-show rate can be as high as 50%, but this day it seemed like the show rate was more like 120%.
My patient panel for the day was diverse: from standard CKD management to managing the pitfalls of immunosuppression. Finally, my last patient of an exhausting day came in. One of my continuity patients with CKD stage 5, she came to partake in our monthly dance around the topic of dialysis access planning, which always starts well and ends with a fall.
“I know what that thing [fistula] in the arm is. My son just started on dialysis and has that in his arm,” she said. “Do you still really think I need that? I saw something on a website that can cure my kidneys. Can’t I try that?”
“Unfortunately, no, and I wouldn’t take anything over the Internet, especially something that promises that,” I replied.
“I know I have seen things in other countries that work. And people are growing kidneys all the time, she said. Maybe because you’re a young doctor you don’t know about these treatments, but that’s what I want. Isn’t there anything else I can do to get my kidneys back?”
Our answer to this question is too often in the negative, that we cannot do anything more for them.
We are limited in our medical management of symptoms of CKD, the side effects of our medications, and even the effectiveness of our treatments that are medicinally based. We have also grown to accept these unfortunate limitations as our standards of care. But is this acceptable? Are there alternatives in the treatment of kidney diseases, particularly with regard to symptom management and avoidance of dialysis?
After several visits involving counseling about dialysis planning, my patient came to me with full confidence that she had the answer to curing kidney disease, and was a bit annoyed with me that I had not told her about it. She had read about this miraculous drug on the Internet and had never felt better after taking it. The drug? Hydrogen peroxide.
To say that ingesting bleach is not curative is a bit of an understatement, and the potential harms could not be overstated. How could she turn to such a corrosive agent in an effort to avoid the treatment I had been recommending? She wanted something else to help her symptoms and provide an alternative to what I was offering. I don’t know that I could blame her—what I was offering was a lifestyle change that included dialysis 3 to 5 times per week with a commitment of several hours each session and no guarantees that the rest of her day would not be consumed with traveling and pure posttreatment exhaustion. She just wanted a different option.
Can we do better to help our patients feel better and consequently have better outcomes?
It is quite understandable that our patients look to alternatives to the treatments we recommend. Our treatments, particularly immunosuppressants, come with considerable side effects, as well as high costs, and perhaps may not be as effective as we would like. And many patients, like mine, would do anything to avoid dialysis—even, apparently, ingesting bleach.
The comorbid conditions that often plague our patients are many and are associated with considerable pain that in turn can often lead to opioid dependence, which has its own inherent set of problems. Not to mention the common symptoms in patients with CKD: nausea, insomnia, anorexia, and malnutrition, to name a few (1). International studies of CKD and ESRD patients have shown that more than 50% use alternative medicines to treat their underlying illness, and 40% of transplant recipients do the same (2). Physicians often fail to inquire about these alternative therapies, and also are likely not to be familiar with them, particularly herbal agents, although quite a few have been identified as clearly harmful. Yet, in 2018, we still have not been able to effectively manage symptoms, with or without these unknown alternative drugs.
Is there room for alternative care in nephrology? Is there something our patients can safely turn to in order to treat the pain associated with some symptoms of CKD?
Referred to by some as the “penicillin of the 21st century,” or even the “turmeric of 2018,” cannabis has shown some promise as an alternative in helping patients cope with chronic illnesses (3). Despite this, marijuana remains elusive in its potential—but only because it is federally illegal, thereby limiting the ability to test it in randomized controlled trials. The effects of marijuana use on kidney function have not been clearly defined, although there is evidence that cannabinoids can be as effective as codeine for pain management (4), and THC analogues have also been shown to be effective for chemotherapy-induced nausea and vomiting. Pain and nausea are two commonly reported and undertreated symptoms of patients with CKD, who perhaps may achieve the same benefit of treatment with cannabinoids as do patients experiencing side effects of chemotherapy, although this has not yet been studied.
It is not clear how many CKD and ESRD patients are currently using cannabinoids either recreationally or therapeutically. Given the potential therapeutic benefits without clearly defined harmful effects, it would seem cannabinoids may be a candidate for patients seeking alternative options in the management of CKD.
Cannabis is clearly not without its controversies, and it remains to be seen and understood who among our patient demographic might benefit from its use for medicinal purposes.
Seniors remain the largest demographic of patients with CKD, and increasing life expectancy comes with increasing comorbidities. Seniors also happen to be the fastest growing demographic of cannabis users (5). In addition to their heavy burden of comorbid conditions and associated symptoms, they also have more challenges to the practical aspects of living a life on dialysis, including transportation to and from treatments and the profound toll dialysis can take on quality of life. Older patients on dialysis are hospitalized more frequently, are more prone to experiencing symptoms, and have a reduced life expectancy compared to their younger counterparts under the age of 65.
As nephrologists, we are becoming more aware of the burden and intensity of care that is provided for older patients and consequently of the option for a more palliative approach to care, which may offer an improved quality of life at the expense of longevity (6). Despite this option, older patients often have consistently higher intensity treatments at the end of life rather than potentially alternative treatment courses that could be more appropriate.
It just might be possible that we can optimize the options for our patients by incorporating alternative care, such as with cannabinoids. As cannabinoids become more actively incorporated into society as a key player in the wellness industry, perhaps a key demographic target will be older patients seeking alternative approaches in their medical decisions, particularly when it comes to significant lifestyle choices such as initiation of dialysis. Perhaps a palliative approach to CKD and ESRD management would be more palatable if it could, in fact, be made more palliative?
According to the United States Renal Data System, Medicare pays an annual $55 billion for the population of CKD patients aged 65 or older, and $65 billion on all patients with CKD (1). This is an enormous cost, without an enormous benefit to patients, who remain with the same burden of symptoms and treatment options that have been relatively stagnant for decades.
The economic benefit to alternative care in nephrology is an area that has yet to be explored, but recent data have shown that cannabis has led to a considerable influx of revenue for state governments, which can be on the order of billions (7). Developments in the advancement of legalization of cannabinoids and continued growth in the US market should consider the voice of our patients, who are likely to grow increasingly dependent on the product in their pursuit of an alternative approach to care. Likewise, we may need to advocate this option as an extension of our other therapeutic options. At the very least, this option may prove to be an effective, if not a cost-conducive alternative.
Our patients are getting older, have more comorbidities, and also have an overwhelming burden of symptoms. We know that too often, we have to tell them that they “can’t get their kidneys back.” We know that many of our patients are already engaging in forms of alternative care without telling us. We know that sometimes those forms of care may be harmful, and that there are other types of alternative care that we just do not know that much about. We also know that there are potential benefits in some more controversial therapies such as marijuana, and we know that the astronomical costs of care in nephrology could use some control.
Even if we are not sure about the ultimate role of alternative care to help ease our patients’ symptoms, such care is already making headway in nephrology and may be here to stay.
Mukta Baweja is an Assistant Professor of Medicine and Nephrology at the Icahn School of Medicine at Mount Sinai in New York City. She serves on the ASN Public Policy and Advocacy Committee and is passionate about the changing landscape of public health and improving healthcare delivery. Twitter: @muktabaweja
Osman EA. Complementary and alternative medicine use among patients with chronic kidney disease and kidney transplant recipients. Journal of Renal Nutrition 2015; 47:466–471.
Syme R. Keep calm and live in New York City: The promise of CBD, the cannabis chemical that won’t get you high. The New Yorker, July 19, 2018.
Davison EA. Is there a legitimate role for the therapeutic use of cannabinoids for symptom management in chronic kidney disease? Journal of Pain and Symptom Management 2011; 41:768–778.
Wong EA. Healthcare intensity at initiation of chronic dialysis among older adults. Journal of the American Society of Nephrology 2014; 25:143–149.
DePietro A. Here’s how much money states are raking in from legal marijuana sales. Retrieved from Forbes: https://www.forbes.com/sites/andrewdepietro/2018/05/04/how-much-money-states-make-cannabis-sales/#78ae4729f181