The prevalence of kidney disease in Alabama is extensive. Of the 37 million Americans living with kidney disease, a significant number of those people live in Alabama. World Kidney Day, celebrated annually on the second Thursday in March, campaigns for kidney health across the globe.
“Regionally, the high incidence of kidney disease in the southeast is a major complication of other diseases such as hypertension, obesity, and diabetes,” says Anupam Agarwal, M.D., executive vice dean in the School of Medicine and director of the Division of Nephrology, whose been a practicing kidney physician and researcher for over thirty years.
Heat maps for diabetes, obesity, stroke, and kidney disease show that chronic diseases appear in the same areas. “Alabama is always a hot spot for these chronic conditions. It’s a growing concern.”
Agarwal, who is known around campus for his superior mentorship and contagious altruism, says he became fascinated with nephrology when he learned about the interconnectedness of kidney disease to other systemic conditions and treatment options.
Taught by the Father of Indian Nephrology, the late Dr. Kirpal Singh Chugh, Agarwal says that “Nephrologists help patients get back to near normalcy through dialysis and transplantation, while at the same time managing conditions such as diabetes, high blood pressure, and more to improve kidney health.”
A compounding crisis
Agarwal explains that it’s important to know kidney complications can be of significant magnitude since the kidney is closely linked to multiple organ systems.
“More importantly, Black/African Americans, Latinx and Hispanic communities, and other underrepresented minorities have a much higher predisposition to kidney disease,” he says.
This disparity could be related to genetic factors, specifically a gene called ApoL1—a component of high-density lipoprotein that transports cholesterol and certain fats through the bloodstream from the body's tissues to the liver. Mutations in the ApoL-1 gene render Black/African Americans more susceptible to kidney disease.
Plus, with increased incidences of high blood pressure and other underlying conditions, the chances of kidney disease are much higher in communities of color.
In the same way, Agarwal says that social determinants of health deeply contribute to the kidney disease burden in Alabama, an issue that’s been publicly exposed by the COVID-19 pandemic.
“Social determinants of health compound the chances of kidney disease even more. Diet and salt intake, access to health care, and access to exercise make a huge difference in kidney health.”
“We still see patients who show up in the Emergency Room who have never had their blood pressure checked and have never seen a doctor—their entire lives—due to mistrust in medicine and/or lack of access to health care. They have end-stage kidney disease needing emergent dialysis and ultimately a transplant.”
Agarwal with Selwyn M. Vickers, M.D. FACSCOVID meets a pre-existing epidemic
Multiple studies in the U.S. and Europe have noted high increases in Acute Kidney Injury during the COVID-19 pandemic.
A study of 4,000 participants by Mount Sinai, published in September 2020, describes “troubling consequences of COVID–19 on the kidneys, including Acute Kidney Injury, which occurred in 46% of hospitalized patients, one-fifth of whom required dialysis.”
Even after hospitalization, many people suffer long-term kidney complications from COVID-19. In a recent study of >5,000 U.S. veterans hospitalized with COVID-19, 32% had Acute Kidney Injury. Of significant concern was the fact that 47% did not recover to baseline kidney function by discharge, highlighting that chronic kidney disease is an important post-acute sequelae of COVID-19.
“The virus enters the cell through a protein called ACE2. And, outside of the lung, the kidney has a very high content of the ACE2 protein,” Agarwal explains. “The outcomes for otherwise healthy people and the impact on the kidney is still unknown. Studies are ongoing and more needs to be done.”
People with existing kidney disease are at a higher risk of long-term complications from COVID-19. “Those on dialysis and who have received kidney transplants can get very sick.”
While the burden of kidney disease in Alabama was already high, the COVID-19 pandemic adds an additional obstacle for those living with kidney disease, as well as their treating physicians.
Agarwal (top left) during his fellowship in the Division of Nephrology at the University of MinnesotaAdvocating for those with kidney disease
Inspired by his father’s profession in pathology, Agarwal has devoted his life’s work to helping patients with kidney disease.
He says there was a defining moment in childhood when he knew he wanted to practice medicine.
“My dad brought a specimen of the heart in a formalin-filled jar to my fourth grade class. He explained to my class how the heart works and gets its blood supply, and I remember thinking ‘wow, I want to practice medicine.’ That was tremendous for me.”
Agarwal considered other specialties in medical school, like neurology, but ultimately decided on nephrology because of the impact of dialysis and transplantation on saving lives of patients with kidney failure.
“I met one of my mentors, Brian Pereira, M.D., who was a fellow in nephrology at that time —and he said, ‘have you considered nephrology? In this field, we can help our patients through transplants and dialysis. You could also work in the intensive care unit managing fluid and electrolyte disorders and also take care of general medicine patients,’ and I knew then that I would be a nephrologist.”
After his residency and fellowship in India, he wanted to come to the U.S. to practice academic medicine, but worried he was too old—at only 29 years old. “By the time you are 29 in India, you are expected to have a family and be settled down. But, my brother who was living in America encouraged me to take my USMLE steps, obtain my visa, and eventually get situated here.”
Agarwal had a phone interview with the University of Minnesota where he received a fellowship position and was mentored by Karl Nath, M.D., currently at the Mayo Clinic in Rochester.
After several years living in both Minnesota and Florida, he was recruited to UAB in 2003.
“I love what I do. I love the field of nephrology because we can treat patients with multiple options, be it transplant or dialysis, or treating other underlying conditions like fluid and electrolyte issues. Those living with kidney disease don’t have to die, they can be saved.”
Agarwal with Tika Benveniste, Ph.D., and Robert Kimberly, M.D.Cutting-edge research at UAB
Agarwal has also dedicated a portion of his professional work to training the next generation of nephrologists, as well as to finding new therapies and discoveries on kidney disease in his laboratory.
“The collaboration at UAB is like nowhere else in the country. Plus, we take a bedside to bench and back to bedside approach with our research.” This method propels findings and creates momentum in discoveries.
At the O'Brien Center for Acute Kidney Injury Research, funded as one of eight NIH Centers in the country, Agarwal’s laboratory is currently studying a specific protein, heme oxygenase-1, and learning how to exploit this protein to protect against Acute Kidney Injury and kidney disease.
“It turns out, this protein may also have a protective effect against COVID-19 in the kidney,” he says.
His research team, in collaboration with Drs. James George and Steve Rowe, are working in UAB’s SEBLAB to continue efforts on studying COVID-19’s impact on kidney health using animal models.
“Living Well with Kidney Disease”
Agarwal says this year’s World Kidney Day and Kidney Health Awareness Month are more important than ever due to the major complications presented by COVID-19 in kidney patients. “It’s a time to be reminded of preventive measures. World Kidney Day aims to provide education on kidney health and resources for those impacted by kidney disease.”
This year’s theme of World Kidney Day, celebrated in 2021 on March 11, is “Living Well with Kidney Disease.”
Agarwal explains that one reason so many have kidney disease undetected is that it does not cause any pain during early stages of the disease. Kidney disease is found through blood work, having blood pressure levels checked, and urine tests.
“Staying up-to-date on annual physicals is a great way to stay protected.”
Agarwal also says that kidneys can be protected by eating a well-balanced diet, aiming for a healthy weight, managing blood pressure, reducing stress, and exercising. For those living with diabetes, having blood glucose maintained with treatment can help prevent kidney disease.
Additionally, following CDC guidelines are critical to maintain kidney health during the pandemic. Simple guidelines like washing hands, wearing a mask, and social distancing can help prevent COVID-19 infection, which ultimately protects the kidneys.