Expert Q&A: KCH's Ken Wilund on Chronic Kidney Disease
- Ken Wilund
- Kinesiology and Community Health
- University of Illinois
- College of Applied Health Sciences
- Chronic Kidney Disease
The College of Applied Health Sciences has experts in many research areas. Today, we ask KCH professor Ken Wilund about his research on chronic kidney disease and the new Kidney Wellness Institute of Illinois.
VINCE LARA: KCH Professor Ken Wilund has established the Kidney Wellness Institute of Illinois, which is aimed at improving the health and quality life of patients with chronic kidney disease.
Typically, Ken, when I'm interviewing researchers here, I always try to find out what inspired their research. It's something that you may have experienced or something that happened to someone close to you. So I'm interested, what inspired you looking into chronic kidney disease?
KEN WILUND: My research background, both during my PhD program as well as my postdoc, was more related to cardiovascular disease as opposed to kidney disease. And I really got interested in the kidney population because of the high rates of cardiovascular mortality that they suffered from. Patients with chronic kidney disease die of cardiovascular disease more frequently than of anything else, including from kidney failure. Also, pathophysiology of their cardiovascular disease is really unique. So they don't develop necessarily the same type of problems that you have in cardiac patients, which most people think of atherosclerosis, or cholesterol deposits in the arteries. But kidney patients actually develop a lot more heart failure and vascular calcification. There's just a really, really unique pathology of disease. So I started reading more about this population, and then working with them just as a result of my background knowledge in cardiovascular disease.
VINCE LARA: Interesting. I noticed it in the project that you're starting up. Improving quality of life for CKD patients was a goal for the project. And obviously, improving quality of life is important for all of us, but why is it particularly important for CKD patients?
KEN WILUND: Because I think they have about the poorest quality of life of any population that I've ever been around. Indeed, if you talk to a lot of physicians, they will tell you that especially dialysis patients have a very poor quality of life. But it is important to recognize that CKD is on a continuum. You have people with mild, moderate, severe deficiencies and kidney function. But once they get to renal failure, they have to go on dialysis, and that requires them to go to a clinic, generally speaking, three days a week for about four hours. During dialysis, they essentially get their blood drained, filtered, put back in them. It's an artificial kidney, essentially, what they're exposed to. And they leave the clinic in really poor shape—a lot of fatigue, they're cramping, and they go home. And maybe they fall asleep, wake up, and they can't sleep for the rest of the night. They may then they feel a bit better the next day, but then they generally have to go back to the clinic the following day. And it's just this cycle of them feeling awful, getting a bit better, then going back to the clinic and feeling awful again. They also have a lot of muscle wasting, cardiovascular complications, bone disorders, cognitive dysfunction—they have so many different problems that impact their health and quality of life.
VINCE LARA: And part of the reason we're talking is that you just got a grant that allows for the development of the Kidney Wellness Institute of Illinois, KIWII for short. So where will KIWII be located?
KEN WILUND: Well, so DPI is based in Chicago. It's an Illinois initiative. So in terms of this institute, it's more of a virtual institute, I guess, or more precisely, it’s a collaboration of researchers, industry, government, non-government organizations. And what we're trying to do is develop initiatives that we think can help improve the health and quality of life of this population.
So we will have office space up in Chicago. But I'm the principal investigator on this, so I'm in Champaign. So it's—especially in times of COVID right now—it's definitely virtual. But it's more of a group of researchers that will be working together to, hopefully, solve problems that improve quality of life for CKD patients.
VINCE LARA: Yeah, my next question was going to be who the stakeholders will be. So it'll be researchers. Will hospitals and businesses also get involved, and I mention businesses because from the standpoint of wanting to limit health care costs, it's in their best interest to be involved in something like this?
KEN WILUND: Yeah, absolutely—especially dialysis providers—so there there's two primary dialysis providers in the United States, Fresenius and DaVita. There are others as well, including private dialysis clinics. But they spend a lot of money on treating this population. Most of the cost is covered by Medicare. But there's a lot of incentives for the clinics to save money. And we think that some of the things we can do-- if we can improve their health and quality of life, it keeps them out of the hospital or reduces medication costs, and there's a lot of potential cost savings associated with that. And we are going to try to capture that (the costs and benefits) with some of our projects.
VINCE LARA: Yeah, you mentioned some of the ways to try to improve health. What are the strategies that'll be proposed to increase activity for CKD patients?
KEN WILUND: Well, yeah, there's two things. One, we've got an exercise or physical activity component to a lot of what we're trying to do. We've also got a nutritional component as well. So it's not just about activity. It's about nutrition too.
And one of the things we've done—and I'm going to speak mainly about dialysis patients because it's just easier to talk about what's been done with them—but this applies to patients across the spectrum of CKD, including pre-dialysis CKD patients, dialysis, and transplant patients. But if you're just talking about dialysis patients, what's historically been done for decades is to do exercise with patients in the dialysis clinic. So they're somewhat of a captive audience. We know they're going to be there for three days a week, generally speaking. So we bring bikes to them. And we put them in front of the bikes, in front of their dialysis here, and they cycle. And it sounds good, and for some patients, it really does work well if they'll do it. But they're not really that interested in exercise and during dialysis, at least not a lot of them.
So we're actually trying to find ways to personalize their exercise prescription instead of mandating what they call intradialytic cycling, or cycling during their dialysis. We want to meet them where they are and say, hey, how can we get you to move more by any means necessary?
And if that includes cycling during dialysis, that's great. If it includes doing exercises in the waiting room before they get out of the chair, that's great. But a lot of them are going to want to exercise at home on the non-dialysis days. We've got to find ways to get them motivated to do that. That could involve getting family members involved. That could involve providing counseling on the phone or by Zoom, or whatever, by whatever means necessary, getting them moving at any time, not just during dialysis.
VINCE LARA: What are the other things you mentioned? There's a nutritional component to this as well, and some patients are reluctant to lower their sodium intake, which is key. So what kind of measures can you take to combat that?
KEN WILUND: The renal diet is really something that is very misguided. Just to give you a little background, it's not just about reducing sodium. The primary components of the diet that's prescribed for kidney patients is reducing phosphorus, and potassium, in addition to sodium. And the reason they want you to—especially for dialysis patients—reduce phosphorus and potassium, is because they're not producing any urine, so they're not clearing these substances. When you have kidney failure, and you don't produce urine, you don't clear these electrolytes from your system. So they restrict phosphorous and potassium in the diet. But to accomplish this, it requires restricting a lot of things that we consider healthy like nuts, fruits, vegetables, grains, legumes, and dairy.
And when you start restricting those types of foods that are high in phosphorous and potassium, there's NOT a whole lot left to eat. So the patients generally get very frustrated, and they just give up and eat just whatever they get their hands on, especially when they leave dialysis. They don't want to go home and cook. They're tired. So they eat a lot of fast food, which is high sodium. We know sodium is bad for me and you and relatively healthy people. But for dialysis patients that aren't producing any urine, high sodium—it causes thirst. Go to a movie theater, and eat some popcorn, and then try not to drink anything - it's impossible. So we really need is to limit sodium intake to reduce patient’s thirst.
The way we're trying to do this—we've been trying to do it for a long time through counseling, which is very difficult because salt is everywhere in the diet. And so you've got all these dietary restrictions that they're supposed to be on to limit phosphorus and potasium.
Dietitians are telling them to restrict all of these different types of foods. But we think a better approach is to focus primarily on reducing their salt intake. But it’s still a big challenge. So what we've started doing—and we've got some preliminary data suggesting this might actually work really well—we are trying to start off, instead of just counseling, provide low-sodium meals delivered to their home. The rationale behind this is we know we can't do this forever. But there are some meal services that provide low-sodium meals that are good for them. And we want to see if we can do this for a couple months-- a couple meals a day for a couple of months. Maybe that's going to help “prime” behavior change.
So the we provide the meals. They see the benefits. They're not as thirsty. Their mouth isn't as dry. They're not cramping during dialysis as much. They just feel better, and their blood pressure starts to come down. And when they see those benefits, especially feel better, and when they start to feel better, then we think they're going to be more willing to listen to our counseling and the low-sodium education we're providing them. So that's our strategy—short-term feeding that's going to prime long-term behavior change.
VINCE LARA: Another thing you mentioned in this proposal was that patient-reported outcome measures are often ignored. And I wonder why that's the case.
KEN WILUND: Well the primary reason—again, I speaking mainly for dialysis patients—is because the metrics that dialysis clinics are evaluated on for their performance are based on biochemical indices such as serum phosphorous or serum potassium, things like that, that are easy to measure. And serum albumin, which is a marker of overall nutritional status.
But those are things that the patients certainly don't care about because they don’t see them as things that affect how they feel. What affects how they feel is how much fluid they put on in between treatments. And then if they put more fluid on, you're going to have to take more fluid off. And the faster you take fluid off from the patient, the worse they're going to feel. They're going to start to cramp. They're going to be more fatigued.
And it's easier for clinics to measure serum phosphorous and potassium, which are problematic, than it is to measure sodium intake and how much fluid they're putting on. It's easier to measure how much fluid to take off, but not really how much sodium you're ingesting. In other words, it's easier to measure the things that the clinics are evaluated on, as opposed to their sodium intake.
VINCE LARA: And I wonder how quickly do you expect KIWII will be up and running. When do you think you'll start data collection?
KEN WILUND: So what KIWII is all about—we have several different initiatives that we've proposed in the funding that we received. So we're already starting. In fact we already have ongoing projects that are going to be rolled into what we're calling KIWII does.
For example, we've got one feeding trial where we're going to be starting to feed patients low-sodium meals. We're starting recruiting next week. Some of the exercise interventions and related initiatives we're doing, we will start very shortly. We have IRB (ethics) approvals to do some of the studies. But we're a little bit nervous about starting these programs before January, just because we're waiting to see what happens with COVID. If we started the research project and then stop in the middle, it's problematic. We could shut down. So we're probably going to start some of the exercise stuff after the new year.
Now, one of the exercise programs is, in addition to just trying to get patients to move more, a big initiative we have-- and I think this is really important—is we're trying to develop an exercise in CKD training program. In brief, we want to train people to be able to better develop and implement exercise programs in CKD patients. A lot of people have heard of cardiac rehab, but there is not such thing as renal rehab. With cardiac rehab, if you have a heart attack or stroke, you have the ability to work with an exercise physiologists or other exercise specialist to develop an exercise program. And it's reimbursed by Medicare.
But there are no programs like this for CKD. So what we're trying to do is train people to be able to deliver renal rehab. It's very different working with dialysis patients, in particular, than it is working with just your cardiac patients, because of the nuances of the three times a week dialysis sessions. The situation is similar for non-dialysis CKD and transplant recipients also. They all have unique components to their disease and how this disease affects their quality of life that they need some specialized training to be able to prescribe exercise in this population.