A day in the life of a nephrologist

Evi Nagler, nephrologist and guideline specialist, identified inconsistencies in guidelines for managing hyponatremia in recent research published in BMC Medicine. For World Kidney Day, we asked her to tell us about a typical day in the life of a nephrologist, how she was inspired to work in nephrology, and some of the challenges she faces.

08:00 AM Monday morning. My first patient is Marie*, who is in her 50s. She has type 2 diabetes and her kidney function has been on a downward spiral for the past year. It has come to a point where we need to have a conversation about renal replacement therapy. She will need to think about modality choice, home-based versus in-center techniques, hemodialysis versus peritoneal dialysis, and ultimately also kidney transplantation.

I admit I find such conversations difficult to have. I know she must have expected this day to come and yet I know the news will hit her hard. I know she will attempt to process the information I give her. And I know she will fail and understand very little after the word ‘dialysis’ has crossed my lips.

02:00 PM. I am called to Accident and Emergency to see Maureen*. Her husband had brought her in after her general condition had started deteriorating a few days ago. She had felt progressively tired the past few months, had lost her appetite, and had been experiencing muscle weakness for the past two days. Her labs reveal a creatinine of 7 mg/dL, her potassium is up to 8 mmol/L, and her kidneys appear shriveled on ultrasound.

She is a ‘crash-lander’, a person who presents with end-stage kidney disease, requiring renal replacement treatment upon presentation. She had seen a few doctors in the past, but had never heard of anything being wrong with her kidneys. It continues to baffle me how many of these people we still see. People with progressive chronic kidney disease, often secondary to hypertension or diabetes, who have been unaware of their kidney problems.

People who have not benefited from preventative care (lifestyle-changes, appropriate antihypertensive treatment including ace-inhibitors, tight glycemic control,…) and need to be started on dialysis without the opportunity to be counselled appropriately concerning modality choice.

To me, Maureen is living proof of why we desperately need initiatives such as World Kidney Day

To me, Maureen is living proof of why we desperately need initiatives such as World Kidney Day to raise awareness of the importance of our kidneys to our overall health and to reduce the frequency and impact of kidney disease and its associated health problems worldwide.

09:00 PM I am on–call tonight. I have just received an offer for a kidney. The scheduled recipient is Malcolm*. He has been on the waiting list for the past three years and is both excited and anxious when I meet him on the ward. He is good shape, the labs come out clean, and he is good to go. I sit down, sip my coffee as I wait for him to come out of theater…

How I got into nephrology

I remember a story my former professor of nephrology used to tell in class. In the early 1990s two women under the age of 50 presented to an academic hospital in Brussels with rapidly deteriorating kidney function due to interstitial fibrosis.

The women had shared a desire to shed some weight and had both visited the same weight loss clinic. Intrigued by the coincidence, the nephrologists in charge the women’s care surveyed the principal dialysis units in the area and found seven additional women with similar profiles.

They identified a regimen involving Chinese herbs as the plausible culprit, and had it immediately removed from all dietary plans. In the years after the initial discovery of a disease which would later be called Chinese herb nephropathy, the number of patients who were documented to be poisoned had run into the fifties. As a student, that tale spoke to my imagination, as I had been drawn to medicine mainly for the romance surrounding diagnostic mysteries such as these.

I had been drawn to medicine mainly for the romance surrounding diagnostic mysteries such as these.

Of course there was an idealistic longing to help others, but if I am honest, I chose medicine mainly for the riddles I imagined it would present. I decided then and there I would pursue a career in kidney disease.

Although the story painted a more glamorous picture of life as nephrologist than I would lead in reality, and I have never felt close to the Sherlock Holmes I imagined my predecessors to be, I do face my share of diagnostic challenges if not on a daily, at least on a weekly basis. And although I no longer feel excited at the prospect of dealing with glomerulonephritis, I can still marvel at the analytic skills of my senior colleagues.

What are the biggest challenges about working in this field?

Last week I spent 55 hours at work, that’s 11 hours a day. On Saturday I had admin to catch up with. Sunday halfway through brunch, I suddenly remembered I had forgotten to call a patient with her lab results…it is a crazy life.

I often think tomorrow will be different. I will work less. I will work better. Allow fewer interruptions. Be less stressed. I never do and never am of course. I realize it is more a disease of our time, than a challenge specific to working in nephrology.

But it is a pressing one. Don’t get me wrong, I love this job and I wouldn’t trade it for the world. At least, not yet. But in talking to senior colleagues I do see how too much for too long can simply be too much. How getting the balance right is imperative, for the quality of one’s own life, but also for quality of the service we provide.

What’s the most important thing you think non-specialists should know about nephrology? A hitchhiker’s guide.

Our former chief of the orthopedics department had understood quite well that people remember very little of what they are taught – something that doesn’t just apply to orthopedic surgeons.

There were three things he made a point of teaching every student, three rules he professed would shield anyone from vital orthopedic misjudgments regardless of which specialty they chose. I remember them to this day. I have often thought about this list in relation to my own discipline and I guess it would hold the following:

  1. ‘Show me a man’s urine, and I will tell you who he is or what he is made of.’ A urine sediment and proteinuria screen form the basis for any differential diagnosis in nephrology. Order these two tests before calling the nephrologist and you will receive nothing short of praise and admiration.
  2. Be careful with the prescription of non-steroidal anti-inflammatory drugs, avoid giving them for prolonged periods of time, especially in the elderly, people treated with ace-inhibitors (or angiotensin receptor blockers) and those with pre-existent kidney disease. Check kidney function before and while you do, and stop at the slightest sign of kidney function deterioration.
  3. In case of acute deterioration of kidney function, always check for nephrotoxic medications. Temporarily reduce/stop antihypertensive medications (especially ace-inhibitors and angiotensin receptor blockers) in case of low blood pressure and dehydration.

Follow these rules, and you will single-handedly avoid many of the cases of acute kidney injury we see in daily practice.

* Names have been changed to protect patient confidentiality

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