Interview with a Nephrologist: CKD, Dialysis & When to Refer

Aug 13

Kidney disease can be one of those areas of primary care where it’s hard to know exactly where our role ends and nephrology begins.

When should you refer a patient with chronic kidney disease? What workup should you order before the referral? What should you do with proteinuria or microscopic hematuria? And what can you actually do to slow CKD progression while your patient is still in primary care?

In this episode, I’m joined by nephrologist and medical educator Dr. Rachel Hilburg to talk through the practical questions that come up when caring for patients with kidney disease in primary care.

We cover everything from urinalysis and CKD referrals to the Kidney Failure Risk Equation, kidney-protective medications, dialysis, and transplant—and even take a detour into hyponatremia.

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What You’ll Learn

In this episode, we cover:

When to refer a patient with CKD to nephrology
Why proteinuria and microscopic hematuria can change the urgency of a referral
How to use urinalysis to help distinguish nephrologic from urologic problems
What labs and imaging are helpful before a nephrology referral
When cystatin C can help clarify kidney function
How the Kidney Failure Risk Equation can help estimate CKD progression
What “goal-directed medical therapy” looks like for CKD
How ACE inhibitors/ARBs, SGLT2 inhibitors, GLP-1 receptor agonists, MRAs, and other medications fit into CKD care
How primary care can help prepare patients for transplant and dialysis
How to explain dialysis to patients in understandable language
A practical starting point for evaluating hyponatremia
How primary care and nephrology can work together when caring for patients on dialysis

Timestamps:

00:00 — Meet Dr. Rachel Hilburg and her path to nephrology

02:53 — When primary care should refer to nephrology

05:36 — Proteinuria, hematuria, and why urinalysis matters

09:18 — When abnormal urine findings need urgent evaluation

11:34 — What to order before a nephrology referral

15:11 — When cystatin C can help clarify kidney function

17:53 — Nephrology vs. urology: where should the patient go?

21:15 — How to use the Kidney Failure Risk Equation

24:50 — Making sure you understand the cause of CKD

28:40 — Goal-directed medical therapy for CKD

34:04 — Preparing patients for kidney transplant

39:44 — How to talk with patients about worsening kidney function

44:53 — A simple way to explain dialysis to patients

48:03 — Why no clinician ever feels like they know enough

53:12 — A practical starting point for hyponatremia

56:23 — When to refer hyponatremia to nephrology

59:14 — The primary care role for patients already on dialysis

1:01:42 — Don’t be afraid to call the nephrologist

Key Takeaways

Proteinuria matters—and it’s worth looking for.

One of Rachel’s biggest messages for primary care is not to rely on creatinine and eGFR alone when evaluating kidney disease.

Urinalysis, UACR, and urine protein-to-creatinine ratio can provide important clues about what is happening in the kidneys. Proteinuria—particularly when it occurs with microscopic hematuria—can raise concern for kidney disease beyond the more common causes like hypertension and diabetes.

An abnormal urine sediment doesn’t automatically mean “send them to the ER.”

Urgency depends on the whole clinical picture.

Protein, blood, dysmorphic RBCs, or RBC casts are concerning findings, but a patient with stable kidney function may need an expedited nephrology evaluation rather than emergency care. When those findings occur alongside an acute or rapidly worsening decline in kidney function, the evaluation becomes much more urgent.

Give nephrology a useful starting point—but you don’t need to complete the entire workup.

For a patient being referred for CKD, some of the most useful information to have available includes:

Serum creatinine, eGFR
Urinalysis with microscopy
UACR
Urine protein-to-creatinine ratio
Recent kidney imaging, when appropriate

Cystatin C can also be helpful when creatinine may not accurately reflect kidney function, such as in patients at extremes of muscle mass.

CKD management is more than watching the eGFR decline.

Once you’re comfortable with the likely cause of CKD, the next question is: What can we do to slow progression?

That includes optimizing blood pressure and diabetes management and considering medications with kidney-protective and antiproteinuric effects when appropriate.

Rachel walks through what she thinks of as kidney “goal-directed medical therapy,” including ACE inhibitors or ARBs, SGLT2 inhibitors, GLP-1 receptor agonists, mineralocorticoid receptor antagonists, and other medication options.

The Kidney Failure Risk Equation can help put CKD risk into context.

The Kidney Failure Risk Equation uses information including eGFR and albuminuria to estimate a patient’s two- and five-year risk of progression to kidney failure.

It can help clinicians think beyond CKD stage alone—and it also demonstrates why albuminuria is such an important part of risk assessment.

Primary care still has an important role as kidney disease progresses.

Nephrology may take the lead on dialysis planning and kidney-specific management, but primary care remains an important part of the patient’s team.

Keeping routine cancer screening and preventive care up to date can even become important when patients are being evaluated for kidney transplant. And for patients already receiving dialysis, communication between primary care and the dialysis team can help prevent duplicated testing, reconcile medications, and identify blood pressure or other issues occurring outside the dialysis unit.

A Quick Approach to Hyponatremia

We also talk about one of the electrolyte abnormalities that tends to make almost everyone uncomfortable: hyponatremia.

Rachel’s starting point is to first determine whether the patient has true hypotonic hyponatremia.

From there, useful initial information includes:

Serum osmolality
Urine osmolality
Urine sodium
Assessment of the patient’s volume status

Taken together, these findings can help narrow the differential and determine whether the patient needs urgent evaluation, additional outpatient workup, or nephrology involvement.

Want to Go Deeper on CKD Management?

If you want a more structured approach to managing chronic kidney disease in primary care, check out the Chronic Kidney Disease Management Course. We walk through CKD diagnosis and staging, monitoring, slowing disease progression, medication management, complications, and when to refer—so you know what to do between “this patient has CKD” and “they need nephrology.”

Learn more about the Chronic Kidney Disease Management Course.

The CKD course is also included in the Chronic Care Bundle, along with our courses on diabetes, hypertension, and kidney lab interpretation—designed to help you manage the chronic conditions that commonly overlap in primary care.

Explore the Chronic Care Bundle.

About Dr. Rachel Hilburg

Dr. Rachel Hilburg is a clinical nephrologist and medical educator whose practice includes chronic kidney disease, kidney transplant, dialysis, inpatient nephrology, and medical education.

She is also involved with NephSim, an educational resource featuring nephrology cases, teaching tools, and algorithms—including resources for working through hyponatremia.

The Bottom Line

You don’t need to become a nephrologist to take good care of patients with kidney disease.

Look beyond the creatinine, pay attention to the urine, quantify albuminuria, and make sure the presumed cause of CKD actually fits the clinical picture. Use the tools and medications we have to slow progression—and involve nephrology when you need them.

And, as Rachel reminds us in this episode: don’t be afraid to call the nephrologist.

Resources mentioned in this episode:

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Liz Rohr (they/them) (00:00.757)
Awesome. Thank you so much for being here. so do you want to share a little bit about how you got into nephrology and what your practice kind of looks like today?
Rachel Hilburg (00:11.116)
Yeah, I'd love to. so when I was in medical school I had some really wonderful mentors who were nephrologists. I loved medical education. So that kind of gave me a little bit of a taste of some role models, some potential people who maybe I wanted a career like them.
And then as I progressed through my training, certainly the types of cases, I fell in love with physiology and acid base and electrolytes and fluid balance, and all those things were just very interesting to me. And I kept running into more and more nephrologists who were great teachers and really, really loved their relationships with patients. So I followed in those footsteps. And now I'm a clinical nephrologist, so I mostly do patient care with a mixture of medical education for residents.
Residencies and medical schools and our fellowship programs. And my day to day with patients is a mixture of clinics, so folks with chronic kidney disease, kidney transplants, and then I see folks who are on different types of dialysis. I make rounds in the hospital and you know have a wide variety of outpatient care that I've really just enjoyed building longitudinal relationships with people. So that has kept me really happy and satisfied in my career so far.
Yeah.
Liz Rohr (they/them) (01:28.359)
I love that. I love that. That sounds like such a nice balance of the clinical care and the education. And I love that. yeah, and I've had such great experiences with nephrologists myself. I'm like so grateful that to have met you because I feel like I've always wanted to like have more nephrology relationships. And it's just been sort of like a little bit like, where are they? In terms of like I have just more overlap in terms of primary care with other specialties, less so with nephrology, but I love nephrology myself also.
So so yeah, what are some I guess to to start off, what are some of the things like so when we're in primary care, we're sort of seeing patients that at least I can speak to my experience, but what I've sh heard from other people and the audience is sort of like you're in primary care, you're kind of like this Jack Jill of all trades. And the things we're seeing in when it comes to nephrology stuff when it is sort of like, okay, does this person have CKD? This creatinine is elevated.
Like, I don't know, I th what are what are some of the things that you're seeing in pr in nephrology when it comes to the connection between primary care and nephrology? Like what are the conditions you're seeing once they actually get there? Cause I think that's a lingering question when it comes to every referral to a specialty is like, is this an appropriate referral? You know, what are the things that they're seeing? What are the things that they want to be seeing? So I guess maybe just starting with what are the conditions that you're seeing in nephrology that are being referred from primary care?
Rachel Hilburg (02:53.964)
Yeah, no, that's a great question. I I think the instinct and the majority of the time what people think is, you know, they have progressive chronic kidney disease or their, you know, GFR is declining, their kidney function is declining. We should get them over to a kidney doctor to think about things like transplant or dialysis. and I would say I I often prefer to even see those folks a little early, like stage three whenever possible. obviously you don't always have that luxury, you know, depending on access.
To specialists and other things, but it's nice to be able to build that relationship. So, one of the more common kind of diagnoses that we see is people who are being referred because they have chronic kidney disease, that maybe their primary care team has noticed that they're progressing, that maybe they're dealing with kidney disease and difficult to control blood pressure. So those tend to prompt some of the more characteristic referrals. There are electrolyte abnormalities as well that sometimes will.
Help out with like hyponatremia, but those are definitely the less common referrals just because of how many people have chronic kidney disease. I would say the the biggest kind of pickups that we're excited about when folks from primary care are sending folks over to us, it's if they've picked up proteinuria or proteinuria and microscopic hematuria. You know, those really raise red flags, and we really hope that those get picked up early and sent over to us so we can think about other causes.
Besides the usual hypertension or diabetes leading to either kidney dysfunction or or other issues. So I would say those are kind of some of those early pickups that my colleagues in primary care, I'm like, like I'm so glad you checked that. Like, let me get them into the clinic, let me see them right away. and then the majority though, I would say, is they certainly chronic kidney disease with high blood pressure or diabetes prompting that.
Liz Rohr (they/them) (04:49.774)
Definitely. And you and I talked about this when it came to the when it comes to the the CKD course as well as the electrolyte course that we have. I am I feel like I feel like the urinalysis is like the unsung hero of lab interpretation. And it might just be because I'm obsessed with nephrology, but I feel like this is this little tiny test that can actually give us so much information. So can we do like a little bit of a like a pearls of practice?
Rachel Hilburg (05:06.348)
Yes very much.
Liz Rohr (they/them) (05:17.368)
Just a quick highlight about proteinuria and hematuria I think that a lot of like students and maybe newer grads are not super comfortable with that. I feel like, yeah, do you do you want to touch on that in terms of what are some pearls about your analysis as well as dipstick that you would love for primary care providers to know with hemateria and proteinuria?
Rachel Hilburg (05:36.522)
Yeah, no, I'm glad you're as excited about it as I am. I it's like a mini kidney biopsy with no needles. So, you know, it can
Liz Rohr (they/them) (05:38.879)
Ha
Right. It gives so much information. You're like, wow, this is just like some dipstick that they came in for whatever with. Yeah, but go ahead.
Rachel Hilburg (05:49.963)
Exactly. And I think we think of it routinely if we're like, the person might have a UTI, we should check. But it's not always our go-to when we're thinking about as you said, hematuria or or proteinuria So really we're looking at the the dipstick for proteinuria it will pick up albumin. It doesn't pick up other types of proteins, but it will pick up any albumin that's kind of spilling into the urine. So it kind of ranges from nothing at all to trace to you know one, two, three plus. And so the the more you're picking up the
More were worried that they could have, you know, maybe something like a nephrotic disease or something that's causing protein to spill into the urine. And then you know, the dipstick can pick up blood by way of picking up heme or other pigments. So technically, if the dipstick is positive for blood, you still also want to have it sent for, or if you're fortunate enough like me, perform microscopy, or you spin it in a centrifuge and then look at it under the microscope, or the lab will do that if you order microscopy.
And that is correlating, making sure that that blood dipstick positive is also corresponding to red blood cells. And sometimes those red blood cells might just be normal looking red blood cells, and you're thinking maybe there's something going on in their bladder or you know in their genoturinary tract, and maybe that would be a urology investigation if there's nothing else going on, like protein. But from our perspective, sometimes that can signify inflammation in the kidney, especially if you see red blood cell casts
or what we call dysmorphic red blood cells, little red blood cells that have been like forced through that glomerular filter, then that is a a telltale sign that there could be something on going on, like a glomerular nephritis, which, you know, with those types of things, time can be kidney. So then we think about
Liz Rohr (they/them) (07:35.797)
Mm.
Rachel Hilburg (07:37.215)
you know, getting them referred, getting them biopsied for real with a real needle this time, and and thinking about treatment. But so just that those pieces of information when you're thinking about even someone with high blood pressure or someone with a decrease in their kidney function, those are definitely worth checking. you still if you see protein on the dipstick, want to quantify it with like a urine albumin creatine ratio and a urine protein creatinine ratio, but it definitely
Gives you sort of the early tip-off of whether you should be looking for something maybe a little bit more occult going on in the kidneys.
Liz Rohr (they/them) (08:13.977)
Definitely. Yeah. So that kind of I have a couple questions. Let me start with. Okay, so so I feel much more comfortable with urinalysis since our work together and over time. And I feel like I've it anecdotally in primary care, I've had hematuria, I've had trace proteinuria. I've never really seen the red blood cell casts or dysmorphic red blood cells. but like if that were to happen in primary care,
Like what is the in terms of like the the time is kidney, what are some like what would that situation look like in terms of like what you would see in primary care and like what is the kind of preferred route? So like would I call my nephrologist and be like, Hey, can you fit this person in this week or tomorrow? Or do I send them to the ER? Versus and I got like this is like a general situation, like you can't speak to every patient, of course, but like, yeah, what would that look like in terms of seeing that in a patient?
and like how urgent to see referral versus an ER.
Rachel Hilburg (09:18.722)
Yeah, I think that's a great question. And it really correlates with what their kidney function, what their GFR is doing. So, you know, if if you have someone with what we call like an active urine sediment, so that would be protein, blood, kind of a combination of those things, then it definitely sends off some alarm bells. If their kidney function is normal, like their GFR is above 60, or there hasn't been a dramatic change, let's say, you know, their creatinine has been very stable, it's more of a you
Know try to get them an expedited referral. There have been situations where you know maybe you're sending that urine because you're looking into an acute kidney injury or an AKI. And then that could even be a potential to send someone into the hospital to get an expedited workup and biopsy because something like steroids could be indicated to really help. So I would say it depends a lot on the GFR and if they're having a decline in their kidney function, especially if it's a rapid decline.
Then you really want to move faster. And you know, if you have a nephrologist on call, that would be a good time to pick up the phone. And they may even say, Hey, like send the person into the hospital. that way they can get a biopsy and treatment. But if it's something that you find, you know, maybe you're working up chronic kidney disease, their you know, kidney function has been about the same, but you're the first person really doing a deeper dive and you notice that they have those findings, I would say better to see their subspecialty.
nephrologist sooner rather than later, but you're not necessarily you know calling 911 on that.
Liz Rohr (they/them) (10:53.989)
Totally. And that's a great segue in terms of like what are I think a lot of people have the question of like, what do I order for testing before they get to a specialist versus what do I let the specialist order? So like, could you kind of help walk us through what you would love to see? A primary like you could also maybe touch on what sometimes you see, which is not great, but like what are the things you would love to see?
versus what sometimes you see in terms of like what we should do what we should be doing in primary care before we send a referral. For example, if somebody has we're suspecting CKD or they have a diagnosis of C K D.
Rachel Hilburg (11:33.975)
Yeah, definitely. I I think and I'll even take one step before that to say, especially now that the guidelines have added checking for albuminuria in patients with hypertension.
So I think, you know, any time that people check for proteinuria we're like really happy about it and it can really help guide the next steps and the workup. So if someone's being referred, whether it's for high blood pressure or or as you said, CKD, I think definitely trying to quantify their protein in their urine before they come. I usually recommend that that's just a urine albumin and a urine protein creatinine ratio. They can be spot. You don't need to send people for 24-hour urines. You can let us torture them.
Liz Rohr (they/them) (12:14.533)
Those are the worst. I hate those.
Rachel Hilburg (12:16.728)
Carry around the jug of urine everywhere. So you just have to send a spot. but we are always happy when that's been sent, plus a a UA for the reasons that we talked about of you know, if there is blood in the urine, that might, you know, guide our next steps. so definitely quantifying the protein. And then if they've never had, you know, I what I say to patients, they said, You've never had pictures taken of your kidneys, you know, we should do an ultrasound. So, you know, if they had a CT scan six months ago for maybe they went to the ER with belly pain and they're
kidneys look normal on that CT scan. You don't necessarily have to do an ultrasound unless there's been a significant change in their kidney function or they're you know describing like urinary retention or other things that might want you to get more imaging. But basically it'd be helpful if they've had quote unquote pictures of their kidney taken in the past year and we're usually totally happy with an ultrasound for that.
Liz Rohr (they/them) (13:08.613)
Cool. Cool. So it sounds like and this one of the ways that I teach about or conceptualize it for myself. And please jump in if I'm speaking misspeaking, but I'm thinking about GFR, creatinine, and like a basic metabolic panel, but usually people are getting that. The urinalysis, not just the dipstick, but a urinalysis, and like you said, the urine protein creatinine ratio and urine albumin creatinine ratio spot tests, and then a renal ultrasound.
Is that would that be the like package deal that would be nice to have before? Mm-hmm.
Rachel Hilburg (13:37.903)
Yeah.
Be really wonderful. and sometimes I will say, especially if you're sending them, maybe their creatinine is sort of on the border, or they might be sort of an extreme of muscle mass, or they're taking certain supplements or anything, it is helpful to think about sending a cystatin C. I think it's it's very reasonable to the defer that to nephrology as well. I think that's okay too. but if you have the lab available and maybe you're not sure, right? Maybe someone's kind of on the cusp, but they have more muscle.
Liz Rohr (they/them) (13:57.733)
Mm-hmm.
Rachel Hilburg (14:10.05)
Mass and you really want to clarify is that GFR actually low, or you know, maybe they just have their creatinine is a little bit higher. So that is potentially a good test to send. and then the last loving request is always to ask if they're taking a whole bunch of NSAIDs because if they're taking a whole bunch of ibuprofen every day, you know, you might actually have your answer there.
Liz Rohr (they/them) (14:25.742)
Yes.
Liz Rohr (they/them) (14:31.001)
Right, right.
Rachel Hilburg (14:31.69)
at some labs. But but definitely the the ideal, like if I could say bare minimum, the ideal bare minimum package would be urine tests and the ultrasound. Yeah.
Liz Rohr (they/them) (14:42.711)
Awesome. And two things, but let's start with cystatin C. for people who are not familiar, we have a lot of students listening on the podcast. how would you kind of sorry, losing my thoughts one second. How would you how would you kind of like explain what a cystatin C kind of simply for people of who are not familiar with that test?
Rachel Hilburg (15:02.808)
Where is it
Rachel Hilburg (15:10.54)
Yeah, I mean I think to understand the cystatin C it's helpful to sort of
understand exactly what creatinine is because you know creatinine is made by our muscles, it's not toxic to our body, it's sort of just this detective. And as our GFR is declining, creatinine is going to go up. It means that basically it's typically filtered through our glerulus and something's going on where it's not being filtered. So it's building up in the body. So you can imagine you know if it comes from muscle, if you have very little muscle mass your creatinine, you know, might normally be quite low.
And so even if you're getting a normal creatinine, let's say one milligrams per deciliter, that actually might be really high for someone with very little muscle. And then on the flip side, you know, if someone's taking a creatine supplement, or if they have a lot of muscle mass or they do a lot of muscle building exercise, you know, they may have a abnormal quote unquote creatinine that looks high but is actually in the normal range for GFR. So the calculation
For GFR uses creatinine to kind of estimate the kidney function. Now, cystatin C actually comes from nucleated blood cells. So there are other things that can make cystatin C inaccurate, like inflammation, but there are certain cancers, but it's not influenced really by muscle mass. So when you actually combine the two of them together, the creatinine and the cystatin C, that's what you know we've determined is the we, the royal we.
Liz Rohr (they/them) (16:43.748)
Mm-hmm.
Rachel Hilburg (16:44.496)
People who are doing amazing work to inform us is the most accurate way to kind of estimate people's GFR. So that's why we use this CKD-EPI you know, creatinine and cystatin C 2021 equation, and it kind of factors in, you know, recognizing that creatinine might not be the most accurate all the time. And cystatin C is not a perfect test, but sometimes it can help clarify some other things by not coming from muscle.
Liz Rohr (they/them) (17:13.477)
Cool, cool, awesome. and then in terms of the other thing I wanted to touch on is like what would be an example of you don't seem like a pet peeve kind of person, but like do you have any pet peeves of like when primary care refers to nephrology? Cause like we talked about the ideal referral and like
This might not even exist. You might not be like annoyed, but I feel like that's one of the things that primary care people worry about is like, my God, are they gonna be so annoyed with me? Are they gonna be so frustrated? I'm gonna be like this like dumb nurse practitioner or whatever. but yeah, do you have any of those situations where you're like, oof, this is not great.
Rachel Hilburg (17:53.431)
I mean, you're right. I I am maybe not the most pet peeve-y person, but but I will say I I think if you had to kind of pin me down and say it is really helpful to try to differentiate between a nephrology and a urology problem before sending someone over, especially, you know, coming to a kidney doctor can be pretty stressful. You know, patients can be pretty worried, you know, maybe they've heard of dialysis, maybe they don't know anything about kidney disease, but they never really thought there was anything wrong with their kidneys.
So the first part would be, you know, if there is something, so typically if there's let's say only blood in the urine and no protein and maybe their GFR is pretty normal, you know, many many people would recognize to do a urologic evaluation first, but to be fair, maybe not everyone would. And so thinking about the imaging and making sure that it's not a urologic issue or for instance, like cysts, masses, other things.
That are anatomic on the kidneys, those actually would go to urology. So that can be a helpful thing. Yeah, so if you see like a complex cyst or a renal mass, those would actually benefit from consulting urology and maybe they'll recommend like doing an MRI or something and then coming to see them. But if their kidney functions otherwise normal and they don't have you know protein in their urine per se, then they get that extra added stress step of coming through us.
Liz Rohr (they/them) (18:58.128)
interesting. Helpful.
Rachel Hilburg (19:23.224)
So then we'll send them. But I would say that I guess would be one of the patient times when I feel bad that they've come and like maybe paid for perking and or had a copay or something to see a specialist and realize that it it should actually go to urology. and then the other thing really is just, and this is probably across the board, but just making sure the patients know why they're coming. You know, it it's it's scary for them to come in and have never seen a kidney doctor before and and really be worried about.
Liz Rohr (they/them) (19:30.383)
Yeah. Yeah.
Liz Rohr (they/them) (19:46.245)
Yeah.
Rachel Hilburg (19:53.108)
Where they're at.
I will give a shameless plug for the like kidney failure risk equation, which is a good way to think about calculating risk and telling people what stage of chronic kidney disease they are. So it's not really a pet peeve just more of an obstacle that we face when patients come and we spend most of our visit like just explaining why they're here and and trying to put them at ease. I mean it's if they're you know, GFR is fifteen, we're not gonna necessarily be able to put them at ease. and we'll we'll try
Liz Rohr (they/them) (19:59.46)
Yeah.
Liz Rohr (they/them) (20:14.799)
Yeah.
Liz Rohr (they/them) (20:20.677)
Right, right.
Rachel Hilburg (20:24.528)
try to kind of help meet them where they're at. But I think probably, you know, more often I feel like in primary care people are just worried like, I just met this person, but their GFR is really low. I'm so sorry for sending to you so late. It's like, honestly, like what can you do? You know, you're just trying to help them out. But if you explain like who we are, then that always helps, I think.
Liz Rohr (they/them) (20:38.885)
Right. Right.
Liz Rohr (they/them) (20:45.753)
Definitely. And so for people who aren't familiar, the kidney failure risk equation is kind of in my mind is similar to almost the ASCVD risk calculator for and like the new PREVENT calculator for estimating someone's risk of like ASCVD events, but this is sort of a little bit more like estimating somebody's risk of kidney failure. So you kind of put in do you want to do you wanna talk a little bit about that tool if people aren't familiar with that one?
Rachel Hilburg (21:15.5)
Yeah, yeah. So
Basically, we came up of some interesting data that can help project sort of two-year risk and five-year risk of progressing to end-stage kidney disease, meaning like needing a transplant or needing to start dialysis. And basically, you plug in their GFR. So I usually recommend using that 2021 CKD-EPI equation. You plug in their GFR, some of the demographics like age, and they request North America or elsewhere, and then plugging in their albumin.
So you'll you will want to have their UACR. There's some other parameters that you can plug in, like certain electrolytes, but you don't have to. And it will give you what certainly what stage they're in, and then their two-year risk and their five-year risk of progressing to end-stage kidney disease. There are some recommendations there, like percentages of you know, what percent risk should you refer, what percent risk should you be thinking about dialysis access or transplant referral. Obviously, two years and five years, hopefully.
Is a short period of time in someone's lifespan, but it doesn't predict 10 years out or 20 years out, but you can kind of iterate it. I would say if you're looking at it and playing around with it, it can help emphasize the importance of albuminuria. If you plug in, let's say, the same GFR, the same person age, you know, and a very small amount of albuminuria, you'll get a pretty low progression risk. And then if you have a lot of albuminuria, even with the same other characteristics.
Liz Rohr (they/them) (22:22.948)
Yeah.
Liz Rohr (they/them) (22:32.825)
Mm-hmm.
Rachel Hilburg (22:47.542)
it really shoots up so it is sort of a helpful reminder of just how important the proteinuria is.
Liz Rohr (they/them) (22:53.857)
Absolutely. Absolutely. Let me just think for a second.
So we talked about referral.
Liz Rohr (they/them) (23:07.705)
and I edit these so we can always pause and do whatever.
Liz Rohr (they/them) (23:18.337)
Yeah, I think with albuminuria, I think that at least when I started out as a neural nurse practitioner, I felt just so mystified by all of the coming kind of like everything, nephrology, but I think once you have a system in place, it's it's not it's not that bad. But basically, like my kind of takeaway is like albuminuria is so important to monitor. And like one of the things like
I think when I I think when I was a newer grad, I was like watching patients with CKD and I felt like their kidney function was just declining. And I was like, wait, what are we doing for these patients? When do I refer them? Am I doing a good job taking care of them in the interim? So I guess I I there's kind of like two questions in there. One is you mentioned referring. Like people always ask me when to refer. And you and I talked in the past about, you know, CKD.
stages 3A versus 3B is actually a difference versus stage four. and then like there actually is kind of like in the same way, and I I don't maybe this is how just how my brain works, but I'm thinking about like this like little package of of diagnostic testing we're doing before, referral, there is sort of like a package of what we're doing in terms of the care plan for patients with CKD. So like I don't know, I guess if you if you can you kind of speak to that of like
We're not just watching patients' GFR go down. Like, what are we doing to care for CKD? Acknowledging that a lot of times this is a chronic condition, but we can't like do you know what I'm saying here? Like, I'm sorry, I'm having a hard time with my words here, but what is the kind of yeah, go for it.
Rachel Hilburg (24:49.986)
No, I I totally
Yeah, no, I mean I think to to what you're saying, I think the first piece of it, and and I definitely always try to hammer this home, is you know, make sure you're comfortable with what the cause of the chronic kidney disease is. You know, I mean there's a lot there's a huge group of our population that has diabetes, has hypertension, but it's always important to just make sure, you know, especially if they have a ton of protein in their urine, if they have blood in their urine, if they have, you know, other systemic symptoms, you know, maybe thinking like lupus.
Liz Rohr (they/them) (25:04.069)
Definitely.
Rachel Hilburg (25:23.184)
or a vasculitis or or other things that are definitely more rare. But certainly, especially if you're seeing that kidney function go down. And like you said, you're sort of like, my gosh, what do I do? How do I help this person? I think there's sort of two buckets that I think of. There's the diagnosis piece is like, let's make sure that this is really just diabetes. Right. And, you know, in certain places like where I work, you know, I have some resources of being able to do more kidney biopsies if we need to.
It's not always the case, but you can certainly send some blood tests, some different serologies to at least rule out some things, for example, lupus, if you're really not sure. but the the idea that this is all diabetes, that it is all hypertension, you don't want to necessarily fall into that trap every time. Most of the time you'll be right, but there will be a few folks that you could miss if you don't think outside the box a little bit and just make sure, like, okay, you know, does this person have a lot of protein like
Is it nephrotic range or getting up towards nephrotic range? Do they have other, you know, like I said, systemic issues? Do they have really bad anemia or their blood counts suggest maybe there's something else going on like myeloma? So you always want to think outside the box, especially with that initial diagnostic piece. and then as far as you know, sometimes that can be helpful just getting a nephrologist involved early if you're not sure if it's just diabetes or hypertension. if it is sort of just progressive chronic kidney disease.
And the more typical diagnoses, let's say, of diabetes, then you really want to be thinking: how do I slow progression? And how do I empower patients to you know try to make sure we are getting to dialysis or kidney transplant as slow or as far into the future as possible? You know, obviously optimizing their diabetes control is very helpful. hypertension, actually getting their blood pressure below 130 over 80 has really been shown to help slow the rate of.
Progression and we're really lucky now. I mean, there were years and years and years and years where all we had was RAS blockades so ACES or ARBS to be able to give patients who particularly who have protein in the urine to try to slow down the progression of kidney disease. now over the past you know, mainly two decades, we've had sort of an explosion of medication options, different things that we can try, different regimens that we can use to really try to slow things down.
Rachel Hilburg (27:52.683)
down. So I would say starting to get familiar with you know what some people call like GDMT or like goal directed medical therapy. You know, cardiology used to own it for heart failure alone. We've sort of started to adopt it for our renal GDMT or kidney GDMT. And so thinking about, you know, I'm happy to kind of dive into those a little more, but thinking about what those options are and how can we help patients get on those medications to really slow things down.
Liz Rohr (they/them) (28:03.725)
Yes. Take that away.
Mm-hmm.
Liz Rohr (they/them) (28:21.817)
Yeah. Yeah. So do you wanna do you wanna talk about the kidney version of GDMT? I just I like again, I just like love this little package deal of like, okay, this is this is the plan, these are the options. And like what are the goal like what is the goal directed? yeah, like what are the goals and what's involved in that?
Rachel Hilburg (28:40.278)
Yeah, definitely. So so first and foremost, really, it's blood pressure, trying to get blood pressure down, but you really want to choose agents that have kind of that double benefit of what we call like antiproteinuric properties and lowering blood pressure. So it's not that amlodipine or nifedipine don't work. They can be great blood pressure medications, but they don't necessarily have that double benefit for some of the cardiac benefits or lowering protein in the urine. So we really want to try to grab agents first and foremost the ACE.
or the arb. I'm kind of partial to arbs. and so things like lisinopril all these others, except for very, very specific conditions, you risk angioedema, which we definitely want to avoid. And then actually that dry cough can be pretty common and annoying.
Liz Rohr (they/them) (29:12.429)
Mm-hmm. How come?
Liz Rohr (they/them) (29:28.965)
Totally.
Rachel Hilburg (29:30.102)
So defin that's kind of the the still the core and all the studies that followed that showed benefit in other medications of those patients were also on that group of meds. So you know we really still think of it as the gold standard. And then you want to build kind of on top of that. So a lot of them are medications that came out from the diabetes realm. So SGLT2 inhibitors, things like empagliflozin dapagliflozin those are beneficial.
for patients with protein in their urine, whether or not they have diabetes. So we definitely try to put folks on those. And over the years insurance coverage has definitely gotten better with that, even in non-diabetic folks, although we still have our obstacles for sure.
Liz Rohr (they/them) (30:12.943)
Nice.
Rachel Hilburg (30:17.562)
the GLP1 agonists also in addition to weight loss and diabetes have now shown benefit in protein CKD, so that's exciting too. a little harder to get sometimes, but to say the least. so those are some of the core and then what are called like mineralocorticoid receptor antagonists, or things like sporonolactone, eplerenone those have certainly blood pressure lowering, but
Liz Rohr (they/them) (30:28.069)
Awesome.
Liz Rohr (they/them) (30:31.865)
Yes.
Rachel Hilburg (30:47.396)
Also antiprotineuric, and if you have either tried those or or sometimes even if not now, depending on patients' comorbidities, the non-steroidal version of that called finerinone there's some evidence there, and then there are sort of a couple other medications, so thiazides so hydrochlorothiazide, chlorthalidone which are great for blood pressure lowering, they do have some antiprotineuric effects, and as you and I have kind of dug through evidence and found the whole class.
of the non-dihydroperidine calcium channel blockers also. Now would I necessarily be putting someone you know right on diltiazem first up? Probably not. I'd I'd see what else I've got for me from the prior list. But it is nice to know right that there are a lot of medications that have kind of the double bang for their buck.
Liz Rohr (they/them) (31:35.717)
Totally, totally. let me just look at my my thing here.
Liz Rohr (they/them) (31:52.866)
So going back to the kidney, kidney failure risk equation, I really love that when you and I were working on the CKD course or review material, we sort of talked about how the kidney failure risk equation, it's not just it's like a really helpful tool for conversations with patients. And in addition, like it kind of led to that conversation of like what can primary care do in terms of like
Hold on, let me back up for a second. Okay. So thinking about the kidney failure risk equation, we're thinking about making sure that the underlying diagnosis, we're clear about what that is. We're doing our workup before we refer. and then we're thinking about the GDMT of like how to manage blood pressure, choosing agents that are lowering the protein in the urine.
and I think the other piece in in terms of like if we're doing all of these things for our patients, we're referring them to nephrology at that stage 3A, 3B, depending on what's going on with the kidney failure risk equation. One of the things that also came up when we were working together was the how to prepare patients for dialysis. And I think that was do you want to talk a little bit about that in terms of
Not just like what can primary care, what is primary care's role when it comes to patients who keep having this declining kidney function despite what we're doing? And then what are the things like kind of in tandem with that, how do we like support our patients in between referring to nephrology, especially in that context of like, I worked in in various FQHCs.
federally qualified healthcare centers and just like the access to care was not great in terms of like the patient's resources and stuff like that. So patients like ideally would be seeing nephrology on a specific kind of cadence of care, but they wouldn't always do that. And so yeah. So I guess, yeah, what are what are your kind of like I guess what are your kind of thoughts about that in terms of the progression to dialysis and how can we kind of support them on that journey when we've already gone through the kidney failure risk equation, the GDMT they've seen a neprologist.
Liz Rohr (they/them) (34:01.38)
What next? What happens next from there?
Rachel Hilburg (34:03.98)
Yeah, I think
And and that's one of the reasons I actually really love working kind of hand in hand with primary care providers is because you have usually a great relationship, a longitudinal relationship, maybe you even know family members, and you can also kind of help encourage the patient to advocate for themselves. and I I mostly think about transplant and making sure that patients who can potentially be transplant candidates are gonna really get all of that work up done and optimize that. Every part of
The country of the world is going to be a different situation of you know what qualifies for transplant. in the US, the GFR cutoff is going to be 20, but there are a ton of other things. there might be certain obstacles that can be overcome. one of the big things is actually just making sure that people are up to date on all of their you know age appropriate cancer screening. You know, you don't want to reach a point where you can qualify for a transplant, but now you have to figure out how to get a colonoscopy, you know. So making sure that we're up.
Liz Rohr (they/them) (35:03.639)
Right. Right.
Rachel Hilburg (35:05.634)
To date on all those things, you know, pap smears, mammograms, just having those things up to date can really put people ahead of the game with regard to the transplant process. not everyone is going to be able to be a candidate depending on what some of their other comorbidities are, but I usually err on the side of you know, let's let's try and and see and see what you can qualify for. certain things like substance use, in certain places, definitely tobacco smoking too, just trying to help people through.
those things that could potentially be a barrier to getting a transplant. so that's a great place to start and then I definitely talk more about like with the dialysis part as well.
Liz Rohr (they/them) (35:46.84)
Yeah. Well, I guess a question of like who are the people that and so I don't envision this being a primary care discussion. Like I would not broach the topic of transplant with a patient. but just for our knowledge, just saying that for the NPs listening. but like what what is who are you thinking about in terms of like cause that's like almost like not even on my radar, just because so many of my patients go straight to dialysis like
I'd I very rarely see a transplant patient. So like who who are the patients you're thinking about who may qualify for transplants? like what does that process look like?
Rachel Hilburg (36:22.242)
I mean, I would say almost on the flip side of like
There's a few reasons why they definitely couldn't, but otherwise, you know, definitely say, like, have you talked to your nephrologist about a transplant? you can actually refer as a primary care provider. You don't have to be a nephrologist to refer someone to get a transplant eval, and patients can actually self-refer. so encouraging that certainly. it's not your job to tell them, No, you don't qualify. and you know, so certain things like very advanced COPD, heart failure.
Liz Rohr (they/them) (36:41.997)
Mm.
Rachel Hilburg (36:54.672)
Uncontrolled infections, uncontrolled substance use, other things that can certainly be sort of a really big barrier that would disqualify people, at least while those things were active issues, certain things like malignancies that are metastatic or you know still actively in treatment. There's a a couple things that definitely would be like, ooh, I don't know that this would ever really work out. but again, that's not your responsibility to tell them that. And so
Liz Rohr (they/them) (37:19.577)
Yeah. Yeah. Yeah.
Rachel Hilburg (37:24.672)
For pretty much anyone, you know, it's did you talk to your nephrologist? Have they mentioned whether transplant could be an option? That kind of thing. and even you know, folks who are on dialysis, the hope is that the nephrologist at their center, the social worker who they're involved with through their dialysis unit is also encouraging those things. but you know, it's always helpful to have sort of that extra extra voice of a reminder. you know, it is living donation is the best type of kidney transplant.
Liz Rohr (they/them) (37:32.133)
Mm-hmm.
Rachel Hilburg (37:54.585)
transplant. So kind of getting you know patients to put themselves out there a little bit, it it can be really hard and knowing that they have another provider, maybe someone they've known for a long time kind of on their team can be helpful.
Liz Rohr (they/them) (38:06.369)
Okay, cool. That's good to know. and that kind of brings me to the couple questions about like dialysis, but I think where to start is what you were saying about like just at the beginning of our conversation, you were saying, like, can we have these convers it would be ideal if we can have conversations with the patients why they're going to nephrology in the first place. And I think I personally struggle with this when it when it comes to like my gosh, because then it's I'm just thinking about like the con like the various contexts, right? So I'm thinking about a patient who
is recently immigrated to the US, doesn't speak English, has, you know, severe hypertension, severe diabetes, severely decreased kidney function, and and I'm trying to like just it's almost like scatter shot, like, my gosh, okay, all the things all at once. so like there's that situation, and then there's somebody who it's like, I'm I'm sort of noticing you are who has like higher health literacy or, you know, just less barriers to care in terms of like the language barriers and
Stuff like that. And so there's a variety of different types of patients that are presenting, but I don't feel like I even feel confident with like the quote unquote easiest situation of like how do we talk to patients about this? Like, have you heard of dialysis before? And if somebody says no, then it's like that's a really I that's just really been really difficult for me, especially in these like shorter visits of like, okay, so do you know what your kidneys do? Do you know what dialysis is? Like, do you know what I mean? Like, I just I don't want to come from like a scare tactics.
perspective, it's it's just I have a really hard time with it. So what what how what thoughts do you have about having that conversation to prepare them to go to a visit? And like, yeah, any any thoughts on that?
Rachel Hilburg (39:43.629)
Yeah, I mean, I'll take the low-hanging fruit fruit first. As far as like someone who maybe you've been following for a while, you've noticed that their kidney function is declining. maybe you're starting the process of GDMT, or maybe you've, you know, just made sure and it's probably all from diabetes or whatever it might be. then I I think it's sort of about having a conversation of, you know, I've noticed that the the blood work that we check or the urine test that we check to keep an eye on your kidney function, they've shown that maybe the kidney function has gone down a little bit.
Liz Rohr (they/them) (39:45.625)
Yes.
Rachel Hilburg (40:13.692)
Sometimes you can ask, like, do they have any family members wh who've ever had any kidney issues, kind of segue in. And often, you know, if you have the luxury of having a referral center nearby or that they could have relatively easy access to, you know, then it's sort of a conversation of I always think it's better to, you know, get an expert involved on the early side, make sure that we're doing all the things that we can do to make sure that, you know, as we get older, kidney function is gonna decline no matter who we are, but we want it to be as slow as possible.
And then you can kind of engage the referral process or even saying why you're going to add a certain medication, right? To say our goal is really to make sure that any decline in kidney function over time is going to be, you know, very, very minimal. Often people will then ask, like, if it's reversible, right? If they're like, well, what can we do to make it go back? And you know, there are occasions, right? It's like, well, maybe if you stop the, you know, naproxen it might get a little bit better. Maybe if we get your blood pressure a little bit more control.
It can be better. But sometimes it's not the case, right? And CKD can just be a progressive disease, even if you're doing all the things. So then I usually say something to the lines of you know, unfortunately, usually when we see the changes in the numbers, we're thinking that there's some scar tissue that's developed in the kidneys. And usually that scar tissue is not reversible, but there's a lot of healthy tissue there that we can still protect by controlling your blood pressure, controlling your diabetes, starting these medications, and checking in with a nephrologist.
to make sure there's nothing else that we could be doing. And so I kind of frame it like that as far as the idea that there's scar tissue. you know, it doesn't always come up on imaging. It's something that you know you could really on only see under a microscope. So we would only do a biopsy if it was absolutely necessary, that kind of thing. so that was the easier one. And so
Liz Rohr (they/them) (42:00.976)
Mm-hmm.
Rachel Hilburg (42:05.038)
Still gonna be anxious, and then you just remind them like this is all just to make sure you have all the right people on your team, and you know, even if kidney function is declining, that you know, we're gonna do everything to to keep it slow and and you're already doing, you know, you're eating a healthy diet, etc. There are other resources that can, you know, sometimes provide encouragement to, like, I can refer folks from nephrology to a dedicated nutritionist. That's a a luxury to have in certain institutions, but you can also say, you know, sometimes in the
Could provide some counseling on maybe some diet focuses or other things. the other one, the other situation, I think it's always helpful to start off with saying, you know, have you ever been told that you know you have any kidney issues? I noticed some concerns on the labs or whatever it might be. It's a tricky disease, right, where it's asymptomatic pretty much until someone's GFR is usually less than 15 or even less than 10.
Liz Rohr (they/them) (43:00.485)
Yeah.
Rachel Hilburg (43:04.962)
and and it's other issues that are coming up that we have to deal with. I actually saw someone not too far in the past that, you know, came here from a country where they don't really know what family members died of. And, you know, they usually, you know, if they passed away pretty young, we'd it could have been from kidney disease, but we don't know.
Liz Rohr (they/them) (43:19.075)
Yeah.
Liz Rohr (they/them) (43:25.199)
Yeah.
Rachel Hilburg (43:26.176)
And so those can certainly be tricky conversations of again trying to figure out, you know, what are the next steps? Is someone on the brink of dialysis? You know, and sometimes they are, and you say, like, I'm so glad you're here, I'm so glad that I'm meeting you now. I have a colleague who I think could also be helpful, their expertise is in kidney disease, and it does look like from your labs that you do have pretty significant kidney disease. if you've already ruled out other things, then you know, sometimes it's good to be honest of saying.
Liz Rohr (they/them) (43:34.543)
Yeah.
Rachel Hilburg (43:56.113)
know, I I want you to to talk with them. There are, you know, treatments and therapies that we can try, but we also don't want you to run into an emergency where you feel so sick that you have to go right to the hospital and you haven't even heard about what we can do for kidney disease. Those are kind of some strategies. Obviously there's definitely gonna still be the situations where you know we can try all the things and people are still understandably really upset or really confused. but those are some strategies that I feel like have helped me over the past couple
Liz Rohr (they/them) (44:15.695)
Yeah.
Liz Rohr (they/them) (44:21.348)
Yeah.
Rachel Hilburg (44:25.996)
years and definitely hearing it from primary care teams, nephrology, kind of endocrinology even right, if they've seen someone for diabetes for a long time and now their kidney function is declining. So you kind of have a a toolkit of ways to try to help people, but it it it definitely can be tricky.
Liz Rohr (they/them) (44:45.623)
It's so tricky. Do you have any any ways that you kind of simply explain what dialysis is to patients?
Rachel Hilburg (44:53.228)
Yeah, so I think
A lot of it certainly depends on whether I'm meeting someone in the hospital or in the clinic. You know, based on, you know, the folks who you're working with, I think talking about like the clinic side of things is helpful. there are people who, you know, it it's always helpful to ask first, right? Like, have you heard of dialysis? and sometimes someone will say like, yeah, I have a friend or a family member is on dialysis and you can ask, you know, what kind of dialysis they do or other things. sometimes you're starting totally fresh and people say, No, I have no idea what dialysis does.
And then, kind of to your point that you said earlier, it's helpful to explain like what the role of the kidneys are on a day-to-day basis. You know, so I'll often explain that you know the kidney's job is to filter out the toxins, get out extra fluid, get out extra salt, and hold on to the things that your body needs day-to-day, but get rid of the stuff that could build up and make you feel sick over time. And then that's kind of a helpful segue into saying, you know, if the kidneys aren't working, then
those toxins are going to build up some of those electrolytes and other things that we don't want or we don't need or could be dangerous to us, you know, those are going to build up without something called dialysis. And what dialysis does is unfortunately it's not a cure or a treatment for the kidneys. It's a substitute and it can basically filter out those toxins, filter out that extra fluid, and do the job of the kidneys while they're not really working to their full capacity anymore.
Liz Rohr (they/them) (46:25.745)
I love that. That's so helpful. Thank you. I love having scripts of especially to share with people. Sorry.
Rachel Hilburg (46:30.04)
It worked.
I was just saying it it is, it's helpful 'cause
Liz Rohr (they/them) (46:35.364)
Yeah.
Rachel Hilburg (46:36.512)
I obviously like I get to have this conversation a lot, but if you're not having that conversation all the time, you sort of sometimes can feel like you're at a loss for words or there are so many people of all ranges of health care literacy who think that dialysis is a treatment and it's gonna heal the kidneys. And that's that's an important thing to kind of discuss early on because we wish that it would, but unfortunately it doesn't. Even a kidney transplant, right? It's not a cure. It's one of the best treatments we have, but it's not a cure. So I I think it's helpful to set
Liz Rohr (they/them) (46:52.313)
Yeah.
Liz Rohr (they/them) (46:57.988)
Yeah.
Liz Rohr (they/them) (47:07.887)
Definitely, definitely. I have a couple of thoughts that occurred to me. So kind of a little bit of a turn. One thing that's occurring to me is that you are involved with medical education and fellowship programs. And I think one of the hang-ups that people have as nurse practitioners, because I mean, I'm sure you're familiar with different dramas between the different specialties of primary care versus specialty versus PA NP MD
I would love to hear, I I try to share this with people in in real real clinical practice. I think we all struggle with very similar things. and so, but not everybody I think believes that. could you share some of the things that the students, medical students or fellows are kind of struggling with or having the hardest times with or asking the most questions about in your just anecdotal experience?
Rachel Hilburg (47:51.209)
Ha ha.
Rachel Hilburg (48:03.02)
Yeah, I mean I think
It's always just important to remember that like healthcare is an ama you've chosen an amazing thing to do, but it can be really hard and really challenging. I think there's always sort of the two pieces of it in my mind. It's the piece of just feeling like you'll never know enough, right? It's like there's always more to learn, there's always another paper to read, or there's always a new guideline coming out, like how am I even gonna keep up? And I always encourage the students and and I was taught this myself as a student, and sometimes I followed it and sometimes I didn't and got down on myself.
And that's okay too, and you kind of pop up afterwards to recognize that, like in general, if you are focusing your efforts on your patients, so if there's a question that comes up or a medication that comes up, or you know, a diagnosis or something, you know, dive into that, you know, read about that, look that up, ask, phone a friend, you know, put all that effort into really providing great patient care, and then the medical knowledge will come. I think it's really hard.
Liz Rohr (they/them) (49:03.268)
Yeah.
Rachel Hilburg (49:04.3)
When you're in the classroom setting for sure, right? Of feeling like there's not a person in front of you that you can necessarily relate it to, and you're just trying to learn every single thing on the planet. and then you learn it, and then a year later the guidelines change. So you know it can be discouraging, but I think when you make it about each individual patient, it can really keep you grounded and try to remind you that, like, yes, there are probably a million things on PubMed or whatever it might be that I could.
Liz Rohr (they/them) (49:07.311)
Yeah.
Liz Rohr (they/them) (49:18.573)
Yes.
Rachel Hilburg (49:34.193)
read, but like let me try to narrow it down to to some of the the key things that'll help me take care of this person. and so I think that that's across the board, you know, whether you're a PA, an NP, a a an MD, a DO, you know, anything, those are constant medical knowledge battles that we're always dealing with internally. I think the other piece of it then is kind of the whether it's like confidence or or interactions, like playing in the sandbox, right? And so I think, you know, the more we
Liz Rohr (they/them) (49:52.164)
Yeah.
Liz Rohr (they/them) (50:01.999)
Yeah.
Rachel Hilburg (50:04.026)
can all just remember that we're in this together and that we're all on the same team and sometimes it's you reminding someone that, you know
Liz Rohr (they/them) (50:11.235)
Yes.
Rachel Hilburg (50:13.326)
pushback or you know if if there's a subspecialist or or anyone who's like, what are you sending there? You know, it's like, we're all on the same team. I'm just trying to take the best care of this patient that I can. If you think this can be a phone call and you just have some suggestions to me, great, like let me know and and you know we'll refer back if blah blah blah. But most of the time, especially in in certain, you know, practices, it it's part of their small business model to see patients. So you know you shouldn't necessarily get a a ton of of aggravation
from that but but we do and we're all just trying to do what we need to do but I I would say just remembering that like we're all on the same team. I mean in my practice here I'm really lucky to work with nurse practitioners, PAs, fellows, DOs, MDs, or MAs, our nurses, you know, it it's it's important to just remember that we're all kind of trying to do the same thing.
Liz Rohr (they/them) (51:03.405)
Absolutely. And I so appreciate you saying that. Cause I think there's this, at least the culture of nurse practitioners is like people talk about having this running list when they're like a new grad. I definitely had this. And when I mention it, people like, my God, I have too. But it's almost like this running list of like, I need to read about this and this and this and this and this and this. And it's like all I can do is focus on this patient and like what happened today. And I think it can be really discouraging for people. And and it's just so helpful to hear you say that that's like a universal experience that's not unique to nurse practitioners.
and I think I'll just add two sense of like the I think I've heard this from physicians as well. And my I I've told this a couple of times, but one of my best friends is is a neurologist now. And he went through residency, he went through his fellowship, and then like he still didn't feel ready to practice. I'm like, bro, you had so many more years of school than than I did, but it doesn't matter because you're still like on your own, making your own decisions. So
Rachel Hilburg (51:49.538)
Mm-hmm.
Liz Rohr (they/them) (51:58.746)
So thank you for sharing that. And like the the medicine knowledge does catch up eventually, but it never ends also. So I wanna take go ahead.
Rachel Hilburg (52:05.494)
We're always see, we're always learning and you know there's probably always someone that might, you know, know a little bit more and so we phone we phone that friend. And that's
Liz Rohr (they/them) (52:16.205)
Right, right. Exactly. I want to take another left turn. so I I think I think everybody struggles with hyponatremia. big left turn. so you mentioned at the at the beginning that some of the some of the referrals you get are for elect for are for electrolyte abnormalities. And gosh
Rachel Hilburg (52:27.279)
big left turn. Got it. Okay, all right.
Liz Rohr (they/them) (52:40.749)
I don't know. What what I mean, you I know you I would love for you to share the resource that you have about hyponatremia but like do you wanna touch on some of the electrolyte abnormalities that you get referrals for or maybe just specifically hyponatremia? I think that would be really helpful. I think people really struggle with this topic.
Rachel Hilburg (52:58.956)
Yeah, no, I'm happy to and I could definitely we could spend like an hour on each electrolyte goes through
Liz Rohr (they/them) (53:03.673)
Totally. No, no, no, totally. Yeah, so maybe just just very briefly about hyponatremia referrals then. 'Cause it's it's endless.
Rachel Hilburg (53:11.554)
I would say, and you you mentioned, I mean we my colleagues and I have worked on an educational website called NephSim.com and we have some fun cases and some resources, and there's some cool algorithms to think about on there. And so one of them is hyponatremia, so feel free to check it out. but the the concept I think in my mind is, and you go through this in some of your content, you you talk about the thinking about is it is it really truly hyponeatremia in the sense that we think about like what's called hypotonic hyponatremia
I think of hyponatremia more so as the amount of water that's in our bodies. And hyponatremia is really an excess of water more than anything else. Apparently, the term hyperaquemia never caught on, though. But really, that would be more so what hyponatremia is hyperaquemia. But so when you think about it, it's like, okay, is that the real deal, or is there possibly a lab abnormality that's contributing to that? So checking the serum osmolality
Liz Rohr (they/them) (53:57.766)
Yes.
Rachel Hilburg (54:11.344)
Can be really helpful and get a sense of maybe someone actually has really high triglycerides or really high other types of proteins like in myeloma or other things, causing the serum sodium concentration to appear low based on the labs. But if you get a serum osmolality and it is truly low, you know, thinking under 290 is typically, or definitely under 280, you'd be like, okay, that's definitely low. that would point you to say, okay, this is true hyponatremia, it's truly.
hypotonic and that's really what our body cares about that's what our brain cells care about they don't like our tonicity being off one way or another so that's the time when you want to say okay like this is legit let's think about you know what could be causing this and I think the the three things typically that I would say you want to do at the same time is you want to send a urine sodium a urine osmolality and you want to get a sense of their volume status and you kind of want to do those things together
You know, you'll see a lot of algorithms out there that are say, like, volume status first, are they hypervolemic? Are they euvolemic Are they hypovolemic? And then kind of go from there for your differential. But I I advocate for trying to have those things kind of inform each other. and the first thing you can do in the primary care end is if you see that they are, you know, truly hypotonic, and certainly if they're symptomatic, send them over to the hospital. but if you send those things.
the serum osm the urine tests, and and get a sense of their volume status. That would be a great, we said before, like a nice little package to go to go over to neprology with. And and then you can kind of work up from there based on that, whether you think it's SIADH or you know volume related or potentially medication related. So I would say that's a really good place to start and you can kind of branch off from there.
Liz Rohr (they/them) (55:49.039)
Cool.
Liz Rohr (they/them) (56:05.381)
Totally. And so at what point so so just a recap, what what point would you want to see somebody with hyponatremia for like are you there to like assist with the further work up of like is this SAIDH or is that is that the appropriate time to send to you versus to another specialty?
Rachel Hilburg (56:23.374)
Yeah.
Really appropriate from a diagnostic perspective, right? Of saying this person's hyponatremic and I'm not really sure why. So that might be making sort of the diagnosis of SIADH or something else, and that's totally reasonable. or it may be that based on you know the testing you've identified that they have SIADH and maybe you've ruled out like you've looked for something like lung cancer that can be a cause. and you're sort of left with like just okay, this person has SIADH I'm not quite sure. Maybe it's related to medications.
like seizure medications or depression medications that you can't really stop and you just want help with management. but I think it's really reasonable to refer anywhere along the spectrum of diagnosis to treatment. But from a neprology perspective, you know, we we tend to really want to make sure that it's not anything reversible, right? So maybe a medication change, maybe other things. And then yeah it's a lot of it is management of typically SIADH and thinking about does this person
Liz Rohr (they/them) (56:59.546)
Mm-hmm.
Rachel Hilburg (57:24.14)
need you know solute supplements or like salt tabs or a different type of a diuretic or kind of some of the the nuances that you know we have the luxury of spending the a little bit more time on that one problem so we get to really dive in. and so that's those would be kind of the good things. I don't think you know if you see someone with hyponatremia if it's a one-off and they're asymptomatic and they seem fine you might want to repeat it before you know necessarily referring they will get hypo
Liz Rohr (they/them) (57:37.508)
Yes.
Rachel Hilburg (57:53.953)
Hyponatremia if they have an AKI. Just by your GFR going down, you will have hyponatremia because you're not clearing as much free water. So sometimes I'll say, well, it went down to like 133, but they had an AKI. Let's, you know, see once they're feeling better, repeat it. But then if they're still hyponatremic you know you say, hmm, their AKI is better. Why did they still have a low sodium? You know, it's totally reasonable to ask for help on the both the diagnosis and the treatment spectrum there.
Liz Rohr (they/them) (57:56.025)
Mm-hmm.
Liz Rohr (they/them) (58:22.917)
Totally, totally awesome. Well, yeah. so I'm trying to think, are there other things that you want to share about? I feel like there's just so much we could talk about. and you've already shared so much. but like, yeah, are there any things you wanna pearls of practice or things you wish we covered or you wish primary care providers knew?
Rachel Hilburg (58:43.958)
No, I mean I'd be interested to hear like what your listener if there's more things that your listeners want to know about, I'd be happy to to come back and talk more about that. I feel like we covered a lot of ground. I I think, yeah, the I guess that that that pet peeve thing, right? It's like, you know, there's always sort of the interpersonal piece. And so hopefully you don't come up with with someone who like isn't willing to help and then maybe to move on to someone else. But you know, in general, like our goal was really to have this this team approach. I would say the only extra thing
Liz Rohr (they/them) (58:47.919)
Yeah.
Liz Rohr (they/them) (58:58.233)
Mm-hmm.
Liz Rohr (they/them) (59:01.86)
Yeah.
Rachel Hilburg (59:13.882)
I would add is you know, we talked a lot about CKD, we talked a lot about like preparing for things like dialysis and transplant. I would say, you know, even once people are on dialysis, like we have a pretty big role in their lives. We're seeing them frequently. often we're adjusting medications like blood pressure medications and other things, but often you will see them on a non-dialysis day, you'll see them, you know, maybe in a little bit of a better mood as my light goes off.
Liz Rohr (they/them) (59:26.821)
Yeah.
Rachel Hilburg (59:43.631)
We'll see them maybe like having a better day or if they're not at dialysis. So I think just definitely keeping those lines of communication and and trying to get a sense of as their primary care provider, like who is their dialysis provider and and how can I keep that that line of communication open.
Liz Rohr (they/them) (59:57.369)
Yeah.
Definitely. Yeah. I th are there any thoughts about like I because I've definitely experienced that where I've had patients who are on dialysis and I'm almost like I'm not at like a loss of how to care for them, but it's so almost like I don't know. I think there's still like a lingering question in my mind is like, Am I doing everything I can for them? 'cause I know that they're still gonna be on dialysis and I nephrology is the one that's kind of like constantly looking at their lab values and stuff like that.
But yeah, like aside from like their other chronic conditions, like any other thoughts about how we can support our dialysis patients?
Rachel Hilburg (01:00:33.518)
No
That's a big part of it, is just sort of getting a sense from them, like how is dialysis going. when they come to clinic on a non-dialysis day, their blood pressure might be a lot different. So, you know, keeping the telling them, like, hey, let your nephrologist, your dialysis provider, know that your blood pressure was really low today, really high today. You know, getting a sense of you know what what medications are on it. If you for any reason are checking other labs, sometimes it's just about if you do have the luxury of getting like the labs from the dialysis unit, which is not always
The easiest thing to do, but sometimes you can spare them like a lab draw, you know, little things like that can sometimes they're going somewhere three times a week, usually. and home dialysis, usually a lab day once a month, and then a clinic visit once a month. So they definitely have other places where they're getting these things done. But yeah, I would just say on the one end, telling them, like, look, if there's something you are worried about, or you maybe I can talk to the nephrologist, or vice versa, and or I can inform.
Liz Rohr (they/them) (01:01:06.938)
Yeah.
Liz Rohr (they/them) (01:01:12.068)
Yeah.
Rachel Hilburg (01:01:31.626)
something that I noticed then usually it it can go a long way.
Liz Rohr (they/them) (01:01:35.865)
Awesome. Well, anything else you want to share with the people before we wrap up? I'll I'll be sure to share the resource. Sorry, go ahead.
Rachel Hilburg (01:01:42.016)
No. Don't be don't be afraid of us. Don't be afraid of us. We're pretty nice most of the time.
Liz Rohr (they/them) (01:01:49.114)
People are so sc honestly. So I have this video that I made when I first started this six years ago and it was about cold calling. And that was one of the kind of pearls of practice that I got in my first year, where it's like, it sounds so scary, but you can just call people. You can just call specialists and be like, hey, I have this patient. Like, and I I think you we all just kind of have a little need for a little bit of a thick skin because it does happen where people are grouchy and they're mean and whatever.
But like like you said, the moral of the story is like most people, like especially everyone I brought on the podcast is like, please call, please refer, please refer sooner. It's okay if you send them without all the labs. It's okay. So yeah.
Rachel Hilburg (01:02:27.18)
Yeah.
Right, these are all like best case scenarios when you've gotten everything. But if you know that they need a nephrologist, then they need a nephrologist, you know. So I I think it's it's hard, especially if you're practicing somewhere where you feel like really solo and that happens to subspecialists just as much as primary care, I think sometimes that you're sort of like operating in a vacuum. That there are still ways. There's there's other avenues, like there's forums. our American Society of Nephrology has different forums that you know, we all go and
Liz Rohr (they/them) (01:02:34.627)
Right, right.
Liz Rohr (they/them) (01:02:41.198)
Yeah.
Rachel Hilburg (01:02:58.57)
like okay you know maybe I'm not the world expert on you know a specific type of vasculitis but I'm gonna make that effort to to figure it out so there's everyone around you is also you know doing the same thing of just finding the best ways to get to the best answers for the patient so don't be don't be afraid
Liz Rohr (they/them) (01:03:17.549)
Awesome. Awesome. I love it. Thank you so much. And yeah, I will definitely see there's just so many, so many topics, but if there are other questions from the people, I'll definitely let you know.
Rachel Hilburg (01:03:27.234)
Yeah. Or what I'll say is maybe if you're afraid, do it anyways, which is what I tell my daughter, right? It's like it being brave is being scared and doing it anyways. So
Liz Rohr (they/them) (01:03:32.687)
Yes.
Exactly. Exactly. Exactly. I love it. Well, thank you so much for your time. This is so wonderful. And I know that people are gonna really enjoy it. So thank you. Absolutely.
Rachel Hilburg (01:03:44.76)
It was my pleasure. Thanks for having me.

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Liz Rohr