A Balancing Act of Care

Joe Gatto’s health journey has been full of surprises. When he was born in 1953 with a heart defect, doctors told his mother they wanted
to do exploratory surgery. But there was a problem.

The doctors said if they did the procedure, Gatto wouldn’t survive. His mother said “No way!” She opted to not risk the surgery so she could give her child a chance of survival.
Survive he did, and Gatto didn’t need an open-heart surgery until he was in his early 20s. Later, he was also diagnosed with atrial fibrillation and cardiac amyloidosis, also known as stiff heart syndrome.

In October 2022, Gatto unexpectedly lost the use of his kidneys. “It was sudden,” he says. “I didn’t expect it. No doctors told me this was coming. It was like bam.”

To treat Gatto’s fluid buildup due to the stiff heart, doctors prescribed powerful diuretics, and they took a toll on his kidneys. “It never clicked for me that I was killing my kidneys at the same time,” he says.

Like Gatto, many patients with heart disease face the need to take diuretics to reduce fluid buildup that puts a heavy strain on the heart. But diuretics come with a cost, as they can harm the kidneys. Gatto says that if he hadn’t taken the diuretics, he would have swelled in weight even more and wouldn’t have been able to walk. Something had to give.

Working Together

Tom Palmer had a different path than Gatto, but the final destination was similar. Palmer had his first heart attack at 38 years old. He’s now had a total of seven. Then, after a routine physical with his primary care physician in 2018, he was also diagnosed with kidney disease.

Palmer, too, was prescribed diuretics to get the fluid out of his body from congestive heart failure. Unlike Gatto, however, Palmer’s nephrologist quickly realized this medical path would be tough on his kidneys and decided to intervene by coordinating with Palmer’s cardiologist.

“They’ve been talking and sending blood work to each other ever since,”Palmer says. “They have to balance the medication, and they’ve been willing to work together.”

By collaborating, Palmer’s doctors took him off the diuretics in favor of a medication more suitable for him.

Balancing Act

While Gatto and Palmer’s kidney disease occurred later in life, Hollee Stanton’s third son, Gabriel, was in a much different situation. During Staton’s pregnancy, doctors told her Gabriel would be born with a heart defect and kidney issues.

“It’s difficult to balance [treatments because of ] how interconnected the heart and the kidneys are,” Stanton says. “I had no idea [of the connection] prior to Gabriel.”

Because Gabriel was born with both heart and kidney conditions, Stanton has been able to work with a team of doctors treat her son’s two major medical conditions simultaneously. Together, they have been coordinating his care from the very beginning.

“We sometimes feel like his heart doctors focus only on the heart and his kidney doctors focus only on the kidneys, and it takes a lot of intentionality to get them to both think about Gabriel as a whole person.” Stanton says. “It is easier for us because we do see Gabriel as a total person and we’re not only concerned about a certain area.”

In all three cases, Gatto, Palmer and Stanton all wished they had known more about the connection between the heart and the kidneys so they could have asked doctors more questions about how the two can be treated together.

The Heart/Kidney Connection

Fundamentally, a person’s heart pumps blood throughout the body, including to the kidneys. The kidneys then filter the blood, removing waste and excess water along the way.

Medically, the two are even more interconnected. When the heart isn’t functioning properly, the kidneys may not get the oxygen-rich blood it needs to perform its duties. Without properly functioning kidneys, excess fluid may not be removed, which can increase blood pressure and make the heart work in overdrive.

“The [standard] treatment for heart failure includes diuretics to prevent pulmonary congestion [build up of fluid in the lungs], and one of the costs of that is a decrease in kidney function,” says Dr. Bill Lombard, a retired nephrologist and the former medical director of the Mount Baker Kidney Center in Washington state. “If [diuretics are] used excessively, you cease having the decrease in pulmonary congestion and you get worsening of kidney function.”

Dr. Lombard is on a mission to help patients with cardiovascular disease be aware of the risk factors of developing chronic kidney disease (CKD). “One of the critical messages I want people to hear is that chronic kidney disease, if it is detected early, can be treated,” Dr. Lombard says, “and its course can be dramatically slowed or prevented from progressing.”

He suggests patients with hypertension (high blood pressure) or diabetes get checked for kidney disease. Those with a family history of CKD are also at risk, as are members of the African American, Hispanic, Native American and Alaska Native communities.

 

At the CDC website minuteforyourkidneys.org, anyone can answer a few questions in a one-minute survey to see if they’re at risk for CKD. The results can be a good conversation starter with your doctor.

Dr. Lombard notes that detecting CKD early takes a proactive approach since there are often very few initial symptoms. If someone waits until symptoms occur, it’s often too late. A routine physical with lab work included can help make the diagnosis.

He also says that almost all kidney disease is progressive. “The majority of patients who die on dialysis die from cardiovascular complications,” he says.

Treatment Options for Chronic Kidney Disease

“Chronic kidney disease is much more common than most of us, including those in the medical profession, realize,” Dr. Lombard says. “It is one of the more underdiagnosed diseases. One out of three Americans over the age of 18 are at risk.”

Additional risk factors include diabetes, high blood pressure and obesity, so managing these conditions is imperative. It’s also important to look at family history of kidney disease and inherited kidney disorders to under- stand any genetic components. Past damage to the kidneys and older age are also factors that play a significant role in kidney health.

With that in mind, what you’re not doing or taking to manage kidney disease can be as important as what you are doing and taking, especially when it comes to cholesterol and blood pressure.

Cholesterol above normal levels can actually accelerate the progression of CKD, notes Dr. Lombard. “Additionally, if a person has a high level of protein in their urine, they should target a lower blood pressure, closer to 120 over 70,” he says. Over-the-counter as well as prescription drugs must also be evaluated.

Anti-inflammatory drugs such as naproxen and ibuprofen can be harmful to the kidneys, and antibiotics like sulfa drugs can cause acute kidney injury. As such, it makes sense to work with your doctors to determine what is appropriate for your individual situation.

It’s also important for nephrologists and cardiologists to work together when it comes to managing drugs being used for hypertension and heart failure, such as ACE inhibitors and angiotensin receptor blockers (ARBs). Dr. Lombard says some doctors might consider having their patients stop these drugs based on how the kidneys respond even though there could be adverse consequences to the heart. Again, this is where the balancing act part comes in.

“Sometimes you have to sell the kidneys to save heart,” Dr. Lombard says. “You can live with kidney failure; you can’t live with heart failure.”

Looking Toward The Future

Joe Gatto credits his girlfriend Cheryl O’Neill with saving his life multiple times. As a nurse, she’s often the first to recognize when Gatto needs medical intervention from his team of doctors in New York. He’s managing his CKD with dialysis three times a week and, being a drummer his whole life, he hopes his heart will hold as good a rhythm in the future as he does behind the drum set.

For Tom Palmer, he is managing his stage 4 kidney disease and credits his team of doctors working together for his great care. He hopes to rebound from recent back problems so he can return to the golf course. In the meantime, he’s keeping busy learning new card tricks, but it’s really his positive attitude that’s propelling him forward.

And Gabriel Stanton continues to defy all odds. At 14 years old, doctors thought he’d require a kidney transplant by now. He just entered stage 3 kidney failure and, when the time comes, he has not one but two kidney donors lined up.

“We already have people scheduled who have done the initial rounds of matching,” Hollee Stanton says. “One is older, and her daughter is younger, so if he ages past the mother, her daughter is willing to donate.”

What’s more, the Stantons are entering a new season where Gabriel is learning how to advocate for himself. His mother is proud to hear him ask doctors questions about how heart intervention will affect his kidneys or reminding his doctors he needs an IV for hydration.

“Gabe handles it like a champ,” she says. “He really is a warrior, and I tell him that a lot. I would prefer he not have to do battle like this, but he does amazingly well and we learn so much from our kids.”