INVITED EDITORIAL

Personal Reflections on the Interdisciplinary Team

Kidney disease is both universal and unique with eachperson experiencing CKD differently. Kidney disease

is a family affair affecting immediate, extended families,and associates. What follows are reflections from 2 verydifferent perspectives. In the first, a physician relates theexperience of her husband developing end-stage kidneydisease and the impact on their lives. In the second, atransplant patient and first-time mother relates her life-long experience with kidney disease.

ISteve Williams, a 55-year-old businessman who wasgifted at banter, irreverently funny, and loyal as a beaglewas the love of my life and the man I would marry.At a glance, I could identify Steve as a lovable poster

child for metabolic syndrome. Diabetic for more than 20years, Steve's hemoglobin Alc level was 10% when wemet, and 5 years earlier, he had a coronary artery bypassgraft. As a physician, I harbored no illusions about Steve'shealth. I knew it was likely that he would develop furthermedical problems but was totally unprepared for the com-plications ahead.With peripheral neuropathy and early diabetic retinop-

athy already, it should not have surprised us that kidneydisease would follow. Although Steve had experiencedinsidious symptoms of CKD (bloating, fatigue, and dys-pnea) for years, he became very sick very fast. Simulta-neous episodes of bronchitis, a severe sinus infection,and a dental abscess tipped Steve's precarious balanceinto an alarming free fall.His weight ballooned with dozens of extra pounds. His

tongue swelled and he bit it repeatedly, dulling his enun-ciation. An unfamiliar mental fogginess, made him soundless “crisp,” almost intoxicated. I worried his business col-leagues might think him inebriated.I struggled to avoid serving as Steve's physician, but I

could see that he was in trouble. Compulsively, I orderedlabs at my own hospital. Steve's serum creatinine crept upfrom 2.6 to 4.1 then to an alarming 10.2 over an aston-ishing 2-week period. His estimated glomerular filtrationrate plummeted to 5.2.I was afraid to leave Steve alone. He grew unsteady, and

his body started to get twitchy. Steve's outstretched handswould flap repeatedly, exhibiting asterixis—an ominoussign of encephalopathy.Steve's nephrologist recognized his acute-on-chronic

kidney failure and directed us to the emergency roomfor admission.As we sat in the emergency room, playing “hangman,” a

word game, to pass the time, the word “urination”stumped my brilliant playing partner. In the examinationroom, the doctor, reviewing his blood and urine tests

� 2014 by the National Kidney Foundation, Inc. All rights reserved.1548-5595/$36.00http://dx.doi.org/10.1053/j.ackd.2014.05.002

Advances in Chronic Kidney Disease, Vo392

described them as “impressive” which is a euphemismfor “awful.” I was relieved beyond measure to have Steveadmitted.A whole flock of young doctors saw Steve that evening,

each asking the same set of questions and expressing sur-prise and concern at his answers. Steve said later that theylooked terrified.“They thought I was “CTD,' I bet,” said Steve, refer-

encing a politically incorrect acronym, “circling thedrain.”Hemodialysis began in the morning, and in 2 treat-

ments, 30 pounds disappeared and Steve's mind beganto resurface.Steve and I both recognized that the lives of our whole

family would be irrevocably changed. We did not knowwhat to expect, but we understood we had to plod for-ward. Neophytes in unfamiliar territory, we would followthe expert guidance of those around us—people for whomkidney failure was routine.We went to Northwest Kidney Centers' “Kidney School”

learning Steve's stark options: hemodialysis or peritonealdialysis. Transplant was the best option, of course, but notpossible in the short term.Then, a third choice:“The third choice is no treatment and sometimes that

is the best option for a person,” explained the kindlysocial worker. “If a person with kidney failure choosesno treatment, death usually occurs within one to twoweeks.”Steve and I would come to refer to the third option as

“Door number three.”Only 1 choice made sense for us: learning to do Steve's

hemodialysis at home on Bainbridge Island allowing usflexibility for our complicated schedules and comfort forSteve. We trained diligently at the Kidney Center everymorning for about 5 weeks.Every once in a while, the hard reality would hit us

“What happened to derail our lives so completely?” Thereseemed no way out of this nightmare. It was heart-breaking, and nothing could be done to change that.As I arrived to pick Steve up after a dialysis run at the

Kidney Center, I looked around at the other patientsand realized all these patients would have been deadhad it not been for kidney dialysis.I gathered up Steve and we headed to the Bainbridge

ferry. I reminded myself that Steve too would have diedhad it not been for the miracle of dialysis.

IIWhat is the true meaning of “gift of a lifetime?” When 2years old, I was given the gift of a lifetime, kidney disease.Early on in life, I was diagnosed with CKD, which ulti-mately led to dialysis, 2 kidney transplants and more .Also, did I mention all the great people I havemet along the way?I underwent my first transplant at 14 years with my

mother as my donor. During one of my appointments, I

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Invited Editorial 393

remember my nephrologist stating at that time that trans-planting teenagers can be difficult regarding adhering tothe immunosuppressant regimen and dealing with theside effects. So, I decided .challenge accepted!My family and health care team played a vital role in the

success of not only my health but also achieving my lifegoals. During my first transplant, I decided the field ofnutrition was fascinating and I wanted to become a kid-ney dietitian. While in college, pursuing dietetics, I wasdiagnosed with chronic rejection; however, I continuedto work and completed my undergraduate and master'sdegree.After working as a kidney dietitian for a few years, I

found myself with end-stage kidney disease again andon dialysis. At that time, my nephrologist worked witha physician assistant (PA), and I really admired the teamapproach to manage patients. It was then I decided Iwanted to pursue becoming an advanced practitioner.However, my transplant had failed, and I was on dial-

ysis.I continued to work full time as a kidney dietitian while

on dialysis. I also volunteered with various kidney organi-zations, then I got “the call.” I underwent my secondtransplant from a generous family who had to say good-bye to their daughter way too soon. From their generosity,doors opened that I had never dreamed of.During my recovery, I realized my second transplant

had brought another gift, the opportunity to become aPA. Working as a nephrology PA allows me the opportu-

nity to not only apply my clinical skills but also my “lifelessons.” I will never claim that my experience is thesame as someone else's, but it does allow me to have asmall perspective on what my patients are going through.For example, my main goal is to make sure patients un-derstand the treatment methods and outcomes we strivefor. I have found that if patients understand the “whys,”their adherence with our recommendations is better.There is also the frustration of constantly dealing with

managing a chronic illness; it can be exhausting at timesand feel like another job, except you do not get paid. Ihave taken pride in that job as I would any job and Ihave sat back and found it did provide a paycheck, justnot a monetary one. The most recent gift kidney diseasehas bestowed on me is the birth of my healthy baby boy.Fortunately, I learned early on that the most important

part of the multidisciplinary team is “me”; however, Icould not have accomplished anything without the sup-port of my family, health care team, and most importantly,my donors. And, in the end, it is all about perspective.kidney disease to me is the gift that keeps on giving.

Linda Gromko, MDCase 1

Mandy Trolinger, MS, RD, PACCase 2

Queen Anne Medical Associates, PLLC, Seattle, WA; andDenver Nephrology, Lone Tree, CO