Hello, I am Dr. Jo Dong-hyuk, a specialist in internal medicine and nephrology based in Los Angeles, USA, providing comprehensive care for patients. I often receive many questions about where to receive treatment. To address this, I am introducing myself today. Many viewers of my channel are in Korea, and it seems that there is some misunderstanding that I am a doctor based in Korea. As a result, a few people have come from Korea to Los Angeles to see me for treatment. Just yesterday, someone came to see me from Korea along with a friend. I have mentioned in other videos and live broadcasts that even if doctors in Korea see patients for just two to three minutes, they can often provide appropriate medical diagnoses and treatments. However, they may not always have the opportunity to explain the reasons or mechanisms behind the diagnoses and treatment methods thoroughly, and they might not be able to accurately assess the patient's situation.

I feel a sense of regret that we are limited to standard treatments due to the inability to make judgments. Of course, there are issues with incorporating patient education into consultation time. However, I want to emphasize that these doctors are absolutely not neglecting patients or providing nonsensical treatments. The reality is that the cost of medical care in Korea is so low that it is a necessary adaptation to avoid hospital deficits. We must understand this. There are appropriate responses needed for each patient's situation, which is why I and other doctors are conducting educational broadcasts on platforms like YouTube. I am not recording this video to highlight the unfortunate realities, but rather to clarify misunderstandings and to find solutions to the problems caused by these realities. Today, I will...

I would like to talk a bit more about protein intake for kidney patients because many people have misunderstandings about this topic. There also seems to be some controversy among nephrologists, so I feel it's necessary to clarify. This is also related to a story from someone who came from Korea yesterday. Should protein intake be reduced for patients with kidney disease? The conclusion is yes; for kidney patients, it is advisable to reduce protein intake to prevent the deterioration of kidney function. However, there are unfortunate incidents where dietary choices can cause problems, so the realistic answer is that it depends. This does not apply to every individual patient. I will provide a more detailed explanation on this. Proteinuria, which is the presence of protein in urine, is one of the significant causes that can worsen end-stage renal failure.

Therefore, there is a substantial amount of evidence through numerous studies that reducing proteinuria delays the deterioration of kidney function. First, we do not fully understand the exact mechanism by which proteinuria damages the kidneys. However, it is currently somewhat understood that when proteins pass through the glomeruli, which serve as the kidney's filter, they cause physical damage. 

The first mechanism involves the increase of reactive oxygen species, which further damages the glomeruli and increases proteinuria. The second mechanism involves transforming growth factor-beta (TGF-beta), which causes sclerosis in the kidneys, worsening proteinuria. 

To reduce proteinuria, there are treatment options available, including medication therapy, particularly ACE inhibitors and ARBs, as well as steroid treatments.

Recently, there are also studies on low-protein diets in conjunction with SGLT2 inhibitors as a treatment. Based on these studies, the American Kidney Association has guidelines. In the 2020 update, they evaluated patient outcomes to assess treatment intentions. The guidelines recommend a low-protein diet as one method to reduce proteinuria. This low-protein diet suggests that patients should consume 0.5 to 0.6 grams of protein per kilogram of body weight per day. However, for diabetic patients, the recommendation is slightly higher, suggesting 0.6 to 0.8 grams of protein per kilogram of body weight per day. Over the past 20 years of seeing patients, I have never instructed anyone to consume a specific number of grams of protein in this way, except for just two instances.

I have mentioned it before, as the patient was asking very detailed questions, but I advise against thinking in terms of specific grams to consume. The reason is that adhering to a precise gram amount is ultimately unfeasible, and there is also a lack of credible clinical trials that support the claim of consuming a specific number of grams. Additionally, treatment must be slightly different for each patient because the treatment varies based on the patient's current situation, weight, dietary habits, and various other diseases. Therefore, it is difficult to specify an exact number of grams to consume. For example, advising to eat 0.5 grams per kilogram of body weight is not a figure meant for the patient; it is rather a rough guideline provided by nephrology specialists at conferences for other nephrologists.

The degree serves as a guideline; it is merely a guide that can be modified according to the patient. From the patients' perspective, they might think, Since such a large clinical trial was conducted, shouldn't we follow it exactly? However, the reason it isn't that simple is, first, clinical trials on dietary treatments separate the control group and the experimental group, providing the same-looking medication, but the control group receives a placebo while the experimental group receives the actual medication. After administering the treatments in the same environment, they can differentiate the results. However, it is impossible to provide the same meals everywhere, and it is also challenging to insist that patients only eat specific foods. Furthermore, patients often do not adhere to such restrictions, making it practically impossible. Even if it were possible to control meals, the clinical statistical data or clinical trials on dietary adjustments are only conducted over a short period.

There is a disadvantage in that it cannot be done. This is because if we extend it over a long period, we would tell 1,000 patients that from now on, they should eat meat every day and not eat anything else on top of the meat. In another group, we would say to absolutely not eat meat or any other protein and only eat greens for ten years. Even if we offer them money or benefits, it is 100% certain that people will not participate in that. Therefore, we cannot do that, and we can only conduct clinical trials that focus on very specific aspects in a short time. 

So, today I am going to share a story about someone who flew to LA airport just to see me and came directly to our hospital. This person had a proteinuria of 1 positive and kidney function decline with a GFR of about 50. They do not have diabetes, but there is a slight amount of proteinuria and mild hypertension.

She mentioned that her blood pressure fluctuated between 130 and 150, and she was not currently taking any medication for it. However, eight years ago, due to another health issue, she underwent a very strict diet. After being told that her kidney function was poor and experiencing slight proteinuria, she switched to a nearly vegetarian diet. Over the years, she lost more than 10 kg, and now, at a height of 170 cm, she weighs 56 kg, resulting in a BMI of 19.4. Despite this, she feels that she has become even thinner than before. Since that difficult time eight years ago, she has been extremely fatigued and feels weak, as if she has been unable to recover for the past eight years. She expressed that she thought she might die and even wrote a will. I informed her of the necessary guidelines.

Stop the low-protein diet. You should not continue with this kind of diet. It's important to eat a certain amount of meat and enjoy your life. This person experienced significant muscle loss due to an extremely low-protein or ultra-low-protein diet. I believe that since they had very little fat, losing 10 kg in that weight resulted in almost all muscle loss. Consequently, they naturally became weak and started living like a sick person. Therefore, please stop the low-protein diet and consume a sufficient amount of protein. It is also essential to engage in strength training for muscle recovery, which is crucial for the overall health of the patient. To reiterate, while a low-protein diet can reduce proteinuria in the kidneys and prevent the deterioration of kidney filtration rates, it can frequently lead to malnutrition, as seen in many other clinical trials.

It is reported that in these clinical trials, rather than assessing the overall condition of the patients to provide treatment, the focus is only on diet and proteinuria or diet and filtration resistance. Therefore, it is not an experiment that treats the patients' overall health. As a result, there is only a partial view of the information, and doctors do not use it accurately for patient treatment. Most follow this approach, but I advise against doing so in this particular case. Therefore, the conclusion is that if the patient is very worried, it is better to let them eat whatever they want. I suggested that they can eat anything they desire because, despite that, they are someone who strives for health. Even if they eat anything, they will still maintain a relatively healthy diet. To reiterate, appropriate protein intake is important for nutrition.

Ataxia and muscle loss should not be treated so dramatically that you feel you need to eat only a few grams. A diet that causes significant weight loss in a non-obese person is not good. Third, do not stress; live comfortably. I mentioned that this is almost the end of the consultation, but if you are looking for specific medication treatments, I can add three points. 

First, you can take ACE inhibitors or ARB medications. ACE inhibitors include drugs like lisinopril, while ARBs include losartan, valsartan, and olmesartan. It is advisable to maintain blood pressure around 120 to 130. More importantly, these medications help reduce proteinuria and are beneficial for preserving kidney function, so we may consider adding these medications. 

Second, consider taking statins, such as atorvastatin or rosuvastatin.

I mentioned this because this person had a scan, and it showed that one kidney has shrunk. This could indicate that the shrinkage is due to vascular disease affecting that kidney. Since there is some vascular disease present, we can consider using medications from the starting class to help prevent the worsening of the vascular condition. Additionally, we can consider using SGLT2 inhibitors. This class of drugs has emerged in the last three to four years. Although this medication has only been available for about ten years, the mechanism by which SGLT2 inhibitors alleviate kidney strain caused by proteinuria is already known, and it has been reported to be effective. However, I also mentioned that given the current state of the patient, taking all these medications may not be very beneficial, especially since the patient is in their mid-80s.

Because of the degree, statins can help preserve the blood vessels from becoming more blocked. However, if the person currently does not have a stroke or myocardial infarction and is in their 80s, the effectiveness of protecting the blood vessels in the kidneys may be somewhat uncertain. If they were in their 70s or 60s, I would be more inclined to recommend it. However, I want to clarify that this could be misunderstood. I am not suggesting that being 80 means they should just go and die or that the medication is unnecessary. The reason is that if we are in our 80s and the medication helps delay the gradual blockage of blood vessels, the effects of this medication may take 10 to 20 years to show any significant clinical benefit. Therefore, we need to consider the necessary time for these effects to be clinically meaningful, especially for those in their 80s.

In the middle, I think it could be ambiguous. However, if a patient is in their 80s and already has conditions like myocardial infarction or stroke, I currently believe that we must use starting-line medications. Due to various patient situations and the interactions with other diseases, the advice given to each patient may differ slightly, which can lead to different treatment plans. Therefore, I did not convey everything discussed in today's lecture directly to that patient. There were many things I discussed with them during the consultation yesterday that differ from what I presented in today's lecture. The reason I conduct these lectures on YouTube is to inform a broader audience about common treatment guidelines for such situations. When treating a patient, I consider their condition, circumstances, and any other diseases they may have.

While looking at the current situation and discussing different topics, I urge all of you watching this video to consult with your doctor about your treatment. It is important to pursue the best and safest treatment options. Thank you.

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