Dr. Awais ZakaIn Pakistan, we have no system or culture for regular health checkups. Therefore, it almost always requires a serious illness, severe enough to double down a patient, to unmask a chronic health issue. Chronic kidney disease is no exception. During such illness, when a patient’s blood work is done for the first time, the abnormal creatinine can be a surprise, ranging from as low as 1.3 to as high as 5.3. Although creatinine 5.3, meaning stage 5, needs to be managed too, but it is creatinine 1.3 or its whereabouts that can be best served with timely diagnosis and management, the best opportunity to slow, stop, or even reverse kidney disease. However, we miss this window. Many patients teetering on the border of full-blown kidney failure inform me that they first learned about their kidney disease when their creatinine was 1.5, but they had no idea about kidney disease then. They get varied opinions about creatinine 1.5 from doctors, ranging from being normal and harmless to being the end of kidneys, a stage for which nothing meaningful could be done.
Note that there is nothing special about creatinine 1.5; I have picked this number as a marker of early kidney disease, and values below and above, like 1.4, 1.6, and 1.7, represent pretty much the same stage.
Traditionally, people of Pakistan tend to ignore their symptoms, such as headache, weakness, urinary abnormalities, and even high blood pressure or blood sugar. At best, they prefer to use home remedies or over-the-counter medicines. Surprisingly, they never ignore a highlighted number in lab reports. Why a population that can bravely ignore a blood pressure of 200 and blood sugar of 400 gets so incited by minor anomalies in labs remains beyond comprehension. Some remark that it is not the abnormal report that stirs patients into action; the real source of incitement is the vacuum created by the money a patient has spent on his health, particularly if it was his first time. To prove their claim, these observers present as an argument a behavior peculiar to Pakistani patients: those whose labs turn out to be normal remain unhappy, too. This proves, the argue, that the restlessness stems more from spending on their health than the abnormal labs.
Nevertheless, patients may ignore for years their headache and fatigue, blood pressure and blood sugar, but abnormal labs almost always bring them to the doors of healthcare. Creatinine 1.5 is one of them. Since after initial labs, a patient usually visits a general physician, an MBBS doctor, his first idea of kidney disease takes shape according to the description given by this primary doctor. And there are three prototypical views in Pakistan to look at creatinine 1.5.
Creatinine 1.5: It is Nothing
Many general physicians have no idea about kidney disease, creatinine, estimated glomerular filtration rate, and proteinuria. This medical illiteracy prevails more commonly in remote areas, villages where a general physician’s basic knowledge starts to rust as soon as he returns to his hometown, losing all connectivity with the medical community and updates in medicine. Gradually, he learns to diagnose diseases without labs, but not without a tradeoff: his ability to interpret labs wanes. These are the physicians who typically dismiss any deviation in creatinine as something insignificant, reassuring the patient that “it is nothing.”
Such an interpretation of creatinine 1.5 is devastating for public health at large. Assuming his kidney function to be normal, the patient continues the lifestyle that might have caused the kidney disease in the first place. For example, he may already know that he has diabetes or high blood pressure, but due to reassurance by his physician, he fails to connect his kidney disease with diabetes and thus makes no efforts to improve or reverse his diabetes.
Creatinine 1.5 is not normal. According to traditional textbook wisdom, a creatinine of 1.5 entails a loss of more than seventy percent of kidney function. Let’s assume for a minute that the situation is not as bad. Still, 1.5 is a remarkable rise in creatinine, one that should undergo rigorous diagnostic workup. If we want to decrease the burden of kidney disease in Pakistan, we must improve the skills of our general physicians in interpreting abnormal creatinine.
Creatinine 1.5: A Minor Thing
Some physicians do register creatinine 1.5 as an abnormal number; however, they fail to realize its actual value, thus unable to convey its importance to the patient. They may label it as early-stage chronic kidney disease, diagnose the underlying illness, such as high blood pressure or diabetes, start new medicines, or even dial up the previous drugs. Still, their actions fall far short of a multidimensional and multidisciplinary approach worthy of a kidney disease patient. These doctors keep piling up pills on pills for high blood pressure or diabetes regardless of their potential against kidney disease. They rarely measure urine protein, perhaps the most potent determinant of kidney disease progression. They almost never rule out more fatal causes of kidney disease, such as glomerular diseases, attributing the bump in creatinine simply to diabetes or high blood pressure.
This patient population forms the major part of any nephrology practice in Pakistan, those who have been on useless doses of non-kidney protective diabetic and blood pressure medicines, their creatinine continuing to rise. When they reach a nephrologist, they have already lost kidney function worth dozens of years.
Educating our physicians about the importance of elevation in creatinine or finding its underlying cause is not enough; they need to be trained in managing kidney disease as well. They must develop a basic understanding of kidney disease and the whole array of drugs available to slow down its progression. In addition, they must learn their limitations in recognizing and treating the complexities of kidney disease, delegating the care of such patients to a nephrologist in a timely fashion.
Creatinine 1.5: The End
Unfortunately, this foreboding view of early kidney disease, ridiculous as it may seem, also prevails in our society, propagated mainly by nephrologists rather than general physicians. I don’t believe that nephrologists actually mean to say that creatinine 1.5 is the last stage of the disease. However, our cultural context makes their message more ominous. First off, the intellectual gap between our physicians and the general population is broader than the Himalayas and deeper than the Mariana Trench. When a nephrologist, commenting on creatinine 1.5, tells a patient that seventy percent of the kidney has already been damaged, the patient thinks that, just like a phone’s battery, the remaining kidney, too, would die soon. Since doctors usually can’t afford the time to explain matters in a better light, the patient leaves the clinic devastated, the bad news sitting on his chest like a snake.
Then, it is not uncommon for some nephrologists to start deliberately with a taunting remark, such as, “Are you done with damaging your kidneys?” The patient takes these words to his heart, believing his kidney disease to be at an end. After this revelation, it is hard to convert such a patient to being positive and hopeful about his kidney health despite all the reassurance.
This view of creatinine is way more common than one cares to believe, and perhaps the saddest one, saddest because here we have a patient with the earliest possible sign of kidney disease who can live a fulfilling life for decades without any limitations, and yet he is plunged into depression and hopelessness. I have many patients who had stopped working, playing, and even talking, had stopped living, in other words, just because of this erroneous information about their kidney disease.
The Best Way
The best way to view creatinine is a balanced view. Ignoring it altogether or worrying to death—none of these help. In most cases, creatinine 1.5 amounts to stage 3 kidney disease, an early stage that, if managed well, can definitely be slowed down and possibly stopped or even reversed. It takes time for a patient to accept that he has a chronic illness, particularly one that may alter the course of his life forever. Our doctors must hone their knowledge and skills to interpret, explain, and manage abnormal kidney function tests. Moreover, they must polish their communication skills and be ready to tailor their explanations to match the intellectual level of the patient.
