Podcast - Navigating Kidney Care Options with Dr. Bobby Muthalaly

For some patients with advanced chronic kidney disease (CKD) or end-stage kidney disease (ESKD), active medical management can offer better quality of life than dialysis or kidney transplantation without necessarily compromising life expectancy. Yet conversations on whether to forego or withdraw from other treatment options can be challenging for patients and clinicians. In this episode of Kidney Health Connections, Dr. Bobby Muthalaly, president of Kidney Care of Oklahoma, sheds light on this often-overshadowed topic to help other healthcare professionals better support their own patients through these complex and deeply personal care decisions.

Dr. Muthalaly shares how his practice assesses patient needs and initiates thoughtful, compassionate discussions about modality options that honor the patient’s preferences and circumstances. He emphasizes the importance of trust, early engagement with patients, and involving families in shared decision-making.

Transcript

Welcome to Kidney Health Connections, a podcast exploring the future of kidney health and the rapid shift of value-based care, where you can learn about the latest innovations that are helping patients live healthier, more fulfilling lives. Here's your host, Dr. George Hart.

Dr. George Hart: We nephrologists and the patients we care for have long wrestled with the awkward reality of that for some patients, neither starting dialysis nor receiving a kidney transplant is the best treatment option. And in fact, choosing active medical management, or what we used to refer to as conservative care, can offer better quality of life while not necessarily compromising on the length of life.

Today we're fortunate to have with us Dr. Bobby Muthalaly, the president of Kidney Care of Oklahoma, a real-world nephrologist who will help us gain a better understanding of how these conversations take place in the community.

Bobby, really appreciate you coming today and spending time with us to, I think, share your experience and insights in what is really a challenging topic. I know in my 30 years as a nephrologist this was, you know, I think one of the largest challenges that I faced and my partners faced is, you know, how do we approach these delicate, difficult conversations that are frequently emotionally charged.

But before we get into that, I'd love to learn a little bit more about your practice there in Tulsa. So tell me about you guys.

Dr. Bobby Muthalaly: Yeah, we are based in Tulsa, which is a city in northeast Oklahoma. We are a fairly large group. We have eight nephrologists out of which two of them are doing only part time out of their choice. We have seven mid-level providers. Our dialysis population is comprised of about 790 plus patients, out of which more than 30 percent of them are in home therapy modality. We have a good transplant program doing about over 60 transplants a year on average. We have a very busy clinic; we have like 17,500 patients in our clinic population.

We actually also have a fellowship program and training, currently, three fellows. That program just began about six months ago. We also have telemedicine consultation ability for the rural community hospitals across various health systems.

Dr. George Hart: Pretty diverse patient population there in the northeast corner of Oklahoma too, correct?

Dr. Bobby Muthalaly: It is diverse.

Dr. George Hart: Bobby, you and I both know CKD patients, ESKD patients, they don't just have kidney failure. They have a lot of medical problems. And I think we nephrologists find ourselves taking on a more holistic role as CKD advances to ESKD and patients who are on dialysis are having to make those types of decisions.

So, like it or not, you know, I think we are on the frontline for helping patients walk through this and sort out what is the best choice for them specifically and helping their families understand this. What are some of the objective criteria that you're looking for that help you work with families to determine whether someone can be successful either with dialysis or a kidney transplant?

Dr. Bobby Muthalaly: We look at the patient as a whole. We look at how far advanced they are in age, and is there an association with significant comorbidities? Are they frail? Are they functional? Do they have dexterity? What are their hemodynamics? Do they have other significant medical problems that would not make dialysis tolerable? We look at all these things, present it to the patient, ask them, you know, do you think this is something that you would like to go through knowing that it's going to be difficult, but we'll allow you to take that decision.

Dr. George Hart: No, for sure. What are some of the probably objective findings that you need to interpret to be able to come to the conclusion that a patient's not going to do well with dialysis?

Dr. Bobby Muthalaly: Sure, sure. We look at their comorbidity burden. Most of them have some cardiovascular issue, heart failure issues, vascular issues. We look at their functionality, how frail they are, their nutritional status. We also look at psychosocial support. Those aspects are all taken together and we have shared discussion. We have a good discussion with the patient, his caregiver, his family, and then come to, you know, shared medical decision making.

Dr. George Hart: Yeah. That's important, I think, as we think through this. But there are objective concerns that might be raised. So low blood pressure would be one which could come from a couple of different explanations—heart failure, liver failure. These would be objective things that you're looking at.

Dr. Bobby Muthalaly: Yes, indeed.

Dr. George Hart: Any other objective concerns that come to mind that factor in?

Dr. Bobby Muthalaly: Yes. Some of it would be like dexterity, mobility, moving around to get to their dialysis centers or ability to do the dialysis, or their partner is not in a condition to help out.

Dr. George Hart: What I hear from you is maybe even a concern that attempting dialysis could make things worse. Can you elaborate on that concern a little bit? Because where I'm really kind of wanting the audience to understand is that there's a lot of thought that goes into the evaluation of a patient that leads you to this conclusion.

Dr. Bobby Muthalaly: Yes. Like you alluded to, you know, a patient with heart failure, with borderline blood pressures, someone with chronic liver disease, decompensated or compensated low blood pressure, they will not tolerate dialysis and they get into complications that end up with them being in hospital for prolonged period, undergoing invasive investigations, acquiring hospital acquired complications, even getting into the ICU. All these things, they do not tolerate these. And at that point that we say, you know, just let's focus on quality of life.

Dr. George Hart: Been in those conversations myself. How do you initiate that conversation with a patient or even, sometimes more complicating, with their families?

Dr. Bobby Muthalaly: Yes, yes. We like to see them early enough so we, you know, early in their chronic kidney disease stage. So we develop a rapport with them. They build confidence in us and we discuss their clinical situation. We go through all—as the disease progresses—we bring out all the options, we bring out on the table, put out all the options, and at that point of time, they're able to, you know, they understand us, and they know that we are making ethically and medically sound guidance and advice.

Dr. George Hart: They trust you.

Dr. Bobby Muthalaly: They trust. So it boils down a lot to trust.

Dr. George Hart: Yeah. It's a way harder conversation if you're meeting somebody in the heat of the moment.

Dr. Bobby Muthalaly: Yes, it is very true. It's very hard. It takes some time. Get them into clinic a little more frequently and then discuss these things.

Dr. George Hart: Once you've identified and had the conversations with patients and families, what are the next steps? You mentioned symptom management and some things like that. Can you elaborate a little bit more on how that works?

Dr. Bobby Muthalaly: So, like you alluded to in the beginning, our approach is more holistic. And so we look after the general condition that is associated with chronic kidney disease. They may have hypervolemia; we try and manage that. They may have fatigue from anemia, we try to take care of that. They may have bone pains. All those things we look into. Shortness of breath, if it's associated with volume overload, we look into and then help with their blood pressure control. Those are the main things.

Dr. George Hart: So the phrase active medical management actually means that you have to lean into the care of these patients?

Dr. Bobby Muthalaly: They become dependent on us because most of the time their primary care visits are like once a year or as needed, but we see them more frequently based on the stage that they are in. So they use us more as a primary care physician and we help out with whatever way we can.

Dr. George Hart: You mentioned hypervolemia, which for our audience means excess fluid which can be on the lungs, on the legs. How do you treat that?

Dr. Bobby Muthalaly: Yes. So again, you know, we know that diuretics are a double-edged sword. So judicious use of the diuretics, keeping it, you know, for primarily, fairly severely symptomatic volume overload. We emphasize diet, you know, talk about strict salt restriction. That's where a lot of these people, you know, get the volume situation and manage all those things on those lines.

Dr. George Hart: How do you decide the timing of when to involve palliative care or hospice?

Dr. Bobby Muthalaly: It again depends on the stage where we are in, the patient is in. And as we look at the trajectory of their disease progression, if it's fairly rapid and getting into that territory of getting into dialysis, and they have opted not to do dialysis and opted for the active medical management, we do touch upon the topic of hospice.

Sometimes, you know, they're taken aback and get a little upset about it, but we also emphasize that it's not the end of your life. Our goal is to keep you comfortable for the latter part of your life—symptom control, emotional support, access to 24/7 care, spiritual support, psychosocial support. They often, at that point when they realize, you know, that they're getting into that area, they understand it and they proceed.

Dr. George Hart: I mean, there's been some recent studies looking at select populations that would suggest that, in a well thought out way, patients can live as long or longer with this type of approach, are you seeing a similar outcome?

Dr. Bobby Muthalaly: They can live, you know, if their baseline condition is reasonable, they can live long and well compared to, you know, dialysis.

When they get into dialysis, they have the complications from dialysis, you know, they have more hospitalizations, they get new medications, they get unnecessary invasive investigations. And so, and it has been shown, you know, that there's a lot of data, personal experience, peers experience, that it just adds a few more days, a few more weeks. But that loss of quality of life, staying away from family, the expenses that are involved, all of these things, you know, we veer them toward emphasis on quality of life.

Dr. George Hart: So I think in a perfect world, everybody's on the same page. Family, daughters, sons, uncles, aunts, brothers, sisters. But that's not always the case. And you and I know this. How do you reconcile when the patient wants one thing, the family wants something different?

Dr. Bobby Muthalaly: Yeah, that's very difficult. That's very difficult. And very often, you know, they'll probably go against our advice and opt for a trial and, you know, we will say that's fair, you know, to try it. And if you don't, if you struggle, be open to this kind of management and hospice.

Dr. George Hart: In addition to the active medical management, though, you have to have conversations about the inevitability of end of life and what to do, what not to do. Again, can you walk this audience through what that looks like?

Dr. Bobby Muthalaly: Yes, yes. So again, it again depends on the trajectory of their decline. And you know, if it's fairly rapid, we will say, you know, you just have a few more months. If you're just going on the active medical management, get into hospice, focus on quality of life, staying away from the hospital, staying with loved ones, doing things on your bucket list that you would like to do, a little traveling, visiting other family members.

We've had examples of these on patients who have gone through this process. We give them advice that they will get spiritual advice. They'll get a lot of support, emotional support. They'll even get bereavement support at the end.

Dr. George Hart: You've mentioned spiritual support a couple of times, which takes different forms and different faiths. I assume that you have a network of people that you can draw upon so that people, no matter what their faith journey, have a resource to reach out to.

Dr. Bobby Muthalaly: Sure, sure. And this is primarily through the hospice companies.

Dr. George Hart: Gotcha.

Dr. Bobby Muthalaly: And they have a network.

Dr. George Hart: That's great. It's obvious you have a passion for this and are comfortable with these conversations. How about your partners?

Dr. Bobby Muthalaly: They are in this, too. They are in this, too. We have an excellent renal care coordinator who actually a few weeks ago gave a talk on this for the Interwell partners, and she's actively involved in the conversations. And we are all as a team. We all work together, exchange ideas, and when we realize that the patient is not suited for the dialectic route we go for active medical management, and we've come out with good results.

Dr. George Hart: You know, again, in my career, I had several specific patient stories that I can't forget and cherish in many regards. Are there any specific stories that stand out to you that you think would be helpful to illustrate this medical management idea?

Dr. Bobby Muthalaly: One that comes to my mind is somebody I had been seeing for about four years for chronic kidney disease 3 that progressed to 4. She had significant comorbid burden. She was in her 70s. She had severe vascular disease, diffuse vascular, atherosclerotic vascular disease, coronary artery disease. We had all discussions and, you know, she was open to all, all everything, including dialysis and active medical. So she progressed and came to the point that, you know, we discussed initiation of dialysis. She opted for the active medical management, and as her renal function parameters declined, she went into hospice, which was discussed earlier.

She was very bold about it. She went on to it. She lived about 11 months on hospice. She was able to do many things in that period. She spent enough time with her family, she visited family. She visited many states in the country. She did a lot of things out of her on her bucket list. And she had zero hospitalization. She was comfortable—we would get feedback from the hospice company. And she passed away peacefully. She had access to 24/7 care. She had very good emotional support. Her family, they were totally behind this, and they recognized that was the best thing for her.

Dr. George Hart: Yeah, I think a story that stands out for me was I was caring for an older gentleman. We were having all these conversations, and he came in to see me one day and he had a small, tiny cooler with him. I said, “What's in the cooler?” And he goes, “I'll tell you in a minute.” And we had our conversation. And finally he goes, “Are you done?” And I said, “Yeah, I'm done.”

He opened up the cooler. There were two beers. He opened the beers. We shared a beer at the end of the day there together. And he goes, you know, “Hey, this, this has been great, but I'm going to make my decision and we're going to celebrate it.” And that was kind of a defining moment for me that we can do this.

Dr. Bobby Muthalaly: I have come across a lot like this. Like this situation where they're relieved.

Dr. George Hart: That's right.Dr. Bobby Muthalaly: They get big relief. All along, they have that fear, this dialysis, the D word, just so scared.

Dr. George Hart: Yeah. This is great. It's nice to have a conversation with a caregiver who takes the time and cares enough to have these conversations. They're not easy.

Dr. Bobby Muthalaly: They're not easy, exactly.

Dr. George Hart: They can be gratifying and they are part of, I think, what we're charged to be as physicians. So thank you so much for joining us today.

And thank you to our listeners for tuning in. For more insights on how we can improve care for people living with CKD, please visit our website at interwellhealth.com and subscribe to Kidney Health Connections on the listening app of your choice.