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Episode 268:
Show Notes
In this episode of "The Real Health and Weight Loss Podcast," host Dr Mary Barson speaks with Dr Karen Dwyer, a kidney and transplant specialist with over 20 years of experience. They discuss the prevention and management of kidney disease through lifestyle-focused approaches, particularly improving metabolic health.
About Our Guest:
- Dr Karen Dwyer is the Director of Nephrology and Kidney Care Services at Royal Melbourne Hospital and a Professor at The University of Melbourne, with over 20 years of experience in clinical nephrology and a strong focus on prevention and wellness through lifestyle medicine. She is known for combining evidence-based treatments with a patient-empowerment approach and is a committed advocate for gender equity and healthcare access for marginalised communities. Alongside her clinical work, she leads and collaborates on innovative research and plays an active role in medical education and peer learning.
The Silent Nature of Kidney Disease:
- Kidney disease is often undetected until significant damage occurs
- Diagnosed through blood tests showing reduced kidney function and protein leakage
- By the time it's detected, kidney disease is already established
Treatment Philosophy:
- Emphasises root cause treatment using higher protein, low-carb nutrition
- Takes a complementary approach - medication AND lifestyle changes work together
- Goal is to use the lowest effective medication dose possible
- Neither dismisses medication nor relies solely on it
Holistic Health Benefits:
- Lifestyle interventions provide pleiotropic effects (multiple health benefits beyond just kidney function)
- Improvements in sleep quality make it easier to implement other healthy changes
- Addresses metabolic health comprehensively, not just kidney-specific issues
Prevention Focus:
- Strong emphasis on preventing kidney disease in the first place
- Particularly important for people with high blood pressure
- Early intervention through lifestyle changes can be transformative
Connect with Dr Karen
- LinkedIn: www.linkedin.com/in/karen-dwyer-9776522b
The conversation highlights how kidney specialists are increasingly recognising that addressing underlying metabolic health through nutrition and lifestyle changes can be more effective than traditional symptom-focused approaches alone.
Episode 268:
Transcript
Dr Mary Barson (0:04) Hello, my lovely friends. I am Dr Mary Barson.
Dr Lucy Burns (0:09) And I'm Dr Lucy Burns. We are doctors and weight management and metabolic health experts.
Both (0:16) And this is the Real Health and Weight Loss podcast!
Dr Mary Barson (0:21) Hello lovely listener, Dr Mary here, and today I am very excited to be joined by the fabulous Dr Karen Dwyer. Karen is a kidney and transplant specialist with over 20 years' experience. She's trained at Melbourne University and at Harvard, and she is passionate about improving metabolic health in people with kidney disease and high blood pressure—not only to improve their health, but also to help prevent kidney disease in the first place. Karen uses lifestyle-focused approaches, including a higher-protein, low-carb nutrition plan, to get to the root causes rather than just, you know, merely managing symptoms. She brings deep expertise and a fabulous fresh perspective. Thank you so much for being here, Karen. It’s absolutely wonderful to have you with us. Could you please tell our lovely audience a bit about your journey and what has drawn you to lifestyle medicine?
Dr Karen Dwyer (01:27) Absolutely, Mary, and thanks so much for asking me to be on the podcast. My journey — I am a kidney specialist, and I’ve been practicing in kidney medicine for over 20 years now. I think probably in the last 10 or so years, it became really clear to me that everything I was doing was very reactive. I was treating many people with the same condition, and it would work for a little while, and then we’d go backwards. It became very clear that our approach to medicine is very much reactive — it’s episodic, it’s a band-aid approach — and it got me thinking about the root cause of disease, so moving further upstream. Then, I think over the COVID years, I really did a deep dive into that and was listening to lots of podcasts and following different people online who were really challenging our current approaches. I slowly started to pull in that, and now that becomes the bulk of my work. It’s very clear to me that many of the chronic diseases — whether it be kidney disease, high blood pressure (which I see a lot of), diabetes, heart disease — they’re all metabolic diseases. And so they’ve all got that really common root cause. I think my practice now is very much as it is metabolic but also as a kidney specialist. I don’t know if there’s such a term as a metabolic nephrologist, but that’s perhaps what I think I am.
Dr Mary Barson (03:10) I think there is now. I love it. Metabolic nephrologist. You should take it on. Could you tell our listeners more about that link between metabolic disease and metabolic health and kidney disease, and the various ways in which that can take place?
Dr Karen Dwyer (03:35) Yeah, so absolutely. So kidney disease is a condition that is often silent. People often don't know that they have kidney disease, and we detect it when there's a reduction in the kidney function on blood tests and potentially you're also leaking some protein from the kidney, and by the time that happens, kidney disease is established. So if you've got protein that's leaking into the urine, that suggests that you've got a scar. A bit like if you cut your hand and it heals, you get a scar. We can get these little scars in the kidney. So what we want to do is think about what's driving those scars, and if we think about what we're taught in medical school as the causes of kidney disease, it's things like high blood pressure and diabetes, and together they are the biggest cause of kidney disease, but also things like excess weight, particularly around the tummy, smoking, and heart disease. And so when we sort of put that together, we need to kind of move even further upstream. So what's causing the diabetes and the high blood pressure which is then causing the kidney disease? And that's when we realise that this is very much a metabolic condition. And the link between metabolic health and diabetes, I think a lot of people, particularly your audience, are very much aware of, but perhaps the link between metabolic disease and blood pressure, they may not be so aware of. And in the last few years, my teaching has changed completely. At medical school, we're taught that 95% of high blood pressure is due to your genetics and the other 5% is a secondary cause, whereas I've kind of flipped that paradigm now and I say 95% of high blood pressure is driven by insulin resistance, which again, I know your audience is very familiar with. And if you look at the science behind it, when you've got insulin resistance, insulin acts directly on the kidneys and makes us retain salt and therefore retain water, and that will drive up our blood pressure. And it also has a direct effect on the blood vessels. So instead of blood vessels relaxing and allowing that blood to flow through, they become very tight and stiff, a bit like a lead pipe, and between the fluid being retained and these little lead pipes, it's pushing our blood pressure up. So of course, when we start a blood pressure tablet, we get an initial response, but again, it stops working. So we need to move upstream, look at trying to improve our metabolism, and then of course, there is a role that we may need some medicines to completely support somebody's health, but it allows us to use the lowest dose possible and that minimises side effects. And so there's a lot that is beneficial if we improve that metabolic health to start with.
Dr Mary Barson (06:19) Yes, it improves multiple aspects of our health and our life, and I love what you said about medication. Medication is useful and powerful, and we don't want to dismiss it, but we always want to be able to use the lowest effective dose where possible, and it's not like medication or lifestyle — it's very much both, and that they complement each other. And sometimes you don't need the medication, and sometimes you really do, and both are okay.
Dr Karen Dwyer (06:48) Absolutely, yes.
Dr Mary Barson (06:49) How do you then — you see, as a kidney specialist, our kidneys are incredibly important. Tell us the ways in which you help your patients improve their metabolic health. What's the journey that they would go through?
Dr Karen Dwyer (07:02) Yes, so I think probably one of the things to start with is people don’t expect me to be talking about that when they come to see me because they’ve come to see me about their kidneys, and kidneys often don’t have many symptoms associated with them. So chronic kidney disease is a very silent disease — you can lose up to 90% of your kidney function before you may develop symptoms. So it’s one of these things that is just bubbling along in the background, and so I see my role as to support people to live their best life. They want to feel well, so, you know, I start just about every consultation with “How can I help? What are your concerns, and how can I support and help you with those concerns?” — because inevitably, they’ll be linked with metabolic health, with the kidneys, high blood pressure — and so it’s really addressing symptoms. And from symptoms, we can then integrate those lifestyle pillars to improve health and well-being.
Dr Mary Barson (08:03) And what are those lifestyle pillars?
Dr Karen Dwyer (08:04) So the big one for me is certainly nutrition. I think that’s certainly the most pervasive. So I talk a lot about nutrition, physical activity, sleep, and stress. And if the conversation is not sort of progressing, I often look towards sleep because everybody wants a good night’s sleep, and so often that’s something that people can see some opportunities for change and see some immediate outcomes — whereas perhaps sometimes changing other aspects of lifestyle can be somewhat challenging. But they’re the four main pillars, and I also like to talk about circadian rhythm and getting some early morning sun. But yeah, probably the big four are the sleep, activity, nutrition, and stress.
Dr Mary Barson (08:51) Yes, and I bet some people would be surprised having this conversation with their kidney specialist when they've been sent to see you because the problem has been detected in their kidneys, but it's absolutely fantastic because this is what is truly going to have what we call the pleiotropic effects. It's going to affect not just one aspect of your health, but many, many aspects of your health. And sleep is good — if you have a good night's sleep, it becomes much easier to create room in your brain to make other changes.
Dr Karen Dwyer (09:21) Yeah, absolutely, and I think the education component is really important and linking these things together, and I do hope that that's quite empowering for people — to have the understanding that the heart disease that they may have and the diabetes and the kidney disease — sort of having all those conditions, I think, can be very overwhelming. I have this, I have this, I have this, I have this — but in actual fact, we have one issue that, if we can bring those all back to that root cause, perhaps that's a little bit more manageable for somebody to come to terms with and also to make the change, because you do see one change could have these pleiotropic effects. So I could be improving my blood pressure, I could be improving my diabetes, I could be improving my kidney function — wow, that's a good return on investment. So it's not sort of going, well, today I'm only talking about your kidneys — because kidneys don't walk into my room. A person walks into my room. So it's trying to, yeah, trying to address it more in a holistic wraparound approach.
Dr Mary Barson (10:26) Yes, I love that wraparound care, and as a general practitioner I just— I just love to hear you say that, and I know that this is how most doctors think — that we are whole people, we're not just little single organs on a stick, brain on a stick or kidneys on a stick — we are whole people, and we're whole people living our lives. And like, disease is like that interface where suffering kind of filters through and interacts with our real lives, and that's where we need to help people — we need to help people with how they're living and then the choices they're making, and then they are able to nurture their whole bodies back into health. I would love to hear if you could — I don't know how to share specific stories — but you could even talk more generally, or if you do have specific stories, you could share about how people are able to improve their health sort of working on these pillars of health that you describe.
Dr Karen Dwyer (11:23) I think a lot of people don't realise they've got the power to change, and perhaps it's the language that we use. We talk about chronic disease, and chronic disease sounds very permanent and progressive, and it's chronic so it's there for a long time, and perhaps it's there all the time. And I think we do need to change that narrative in medicine, and sometimes our language is awful. Like, you know, chronic kidney disease — we talk about stages, stage one through to five — and I once had somebody come in, and they were so worried because they said, "Well, I've been told I have chronic kidney disease stage three, and there are only five stages." It's like, oh my goodness — what a great learning for me — because you're a long way from trouble, but it doesn't sound like it. No, it sounds terrible. Yeah, so language really matters. And so I think the first thing is that a lot of people would love the opportunity to take charge of their health, and they don't know what they can do. And so when you provide the information that by making some changes in this domain, this domain, or this domain, these are some of the potential effects — most people that I find really, really enjoy that and really take it on. Not to say that it's simple or it's easy, but you know, if you're there to support along the way, then it's possible and there is hope. I did have a case just recently — in fact, I saw this person only last week — and he's blown me away, and I did say to him if it was okay I would love to share his journey in all these different forums, and so I do have consent, of course I will keep it anonymous, but it was just such a striking example to me of what is possible. And so this man I saw at the start of May, and he was really unwell — so unwell that I admitted him straight to hospital from outpatients due to his really high blood pressure. He was very wobbly on his feet, he was carrying lots of fluid, and just in a really, really bad way. And for the first five months of this year he'd been into hospital I think three times, so this was the fourth admission in five months. And in a few days in hospital, of course I did multiple changes to medications, but one of our big things to focus on was nutrition because the diabetes was not that well controlled, and he just was, you know, running on empty. I often use the analogy that we are a car and we need a full tank of petrol — but it needs to be the right petrol. Don't fill me up with diesel if I'm a petrol car because that's just not going to work. So his kidney function was quite poor at the time — it was sitting at around 20% and it had been even a little bit lower — but he couldn't work on the farm, he’d just retired, and he was, you know, in a really, really bad spot. And I think he thought that perhaps this was the start of a really serious decline. So he went home, and we were just touching base, and I saw him last week — so it's just a little bit over a month, maybe six weeks since I'd seen him — and he is incredible. So he is energetic, he's back out on the farm, he isn't carrying any fluid, his blood pressure is much better, his kidney function is now sitting at over 40%, and his diabetes is down under 5% — or under 6%, so it's 5.5%. And he said to me he knows it's the fuel that he was putting into his body wasn’t right. He needs protein to be able to be out on the farm, and he's got that realisation now, and it's really easy now for me just to do little tweaks along the way because he's taking charge of his health and well-being. And it was just so dramatic to happen so quickly — from someone that I wasn't quite sure if he was going to get, you know, any recovery of kidney function and, you know, start of do we need to talk about dialysis and, you know, what's going on next — and he's just, he's a different person. And it happened so quickly that it's blown even my mind how quickly he's taken charge, and kudos to him, because it was just, you know, a few bits along the way. But, you know, I guess when you look at your life and you can't do the things that you want to do, it's a big decision point, isn't it? And he made the decision, and he needed the support, and off we go. So that was really wonderful. And I've got a few people recently that have just, you know, they make you really happy. And, you know, one person that — and I don't get to discharge people from my clinic very often — but I recently was able to discharge someone, and I go, it's amazing, you've fixed everything. I'm here if you need, but I don't think you need me, so it's wonderful.
Dr Mary Barson (16:38) I do love that. It is such an inspiring story. He turned his health around by being motivated, by having the right information, the right support, and being able to do it. You mentioned nutrition is one of the main pillars — certainly it's one of our main pillars. I mean, we align almost completely. I think we probably actually do align completely in how we feel about the pillars of lifestyle medicine. Protein — I would love to ask you, as you are, you know, a nephrologist, a kidney specialist, about protein, because this is the question we get a lot: that we encourage people to prioritise their protein, and we go for about that one gram of protein per kilogram of body weight per day. But people can be afraid of that, particularly if they've been told they've got some kidney impairment, because there is still this lingering idea that you must limit protein if you've got kidney impairment. Could you tell us more about this?
Dr Karen Dwyer (17:34) Yeah, and I think that lingering idea is a really nice way to frame it. And look, it wasn't that long ago where the mantra was: if you had kidney disease, we needed to restrict protein because the protein was putting, you know, too much pressure on the kidneys and causing a declining kidney function. And that narrative arose from studies many, many years ago that perhaps weren't as well conducted as, you know, you might like — and also at a time where we didn't have other approaches that do support kidney health. And so it's interesting — things are changing, and even our overarching guidelines have now changed to increase that protein requirement during the day to, I think they say, 0.8 per gram per day. I use one because the maths is so much easier. But I also think we need to remember that that's a minimum. So 0.8 that we have in our guidelines is a minimum, and of course, we need to adjust that to what else is going on for that individual in terms of age and activity and, you know, other parameters. So I think one is a nice starting point. There has been a lot of recent publications looking at protein in kidney disease, and it's really great to see that everything is supporting a higher protein intake. And just a couple that come to mind — there was quite a large epidemiological study looking at frailty and kidney disease, and below 0.8 grams per kilogram per day, there was your greater frailty. And so higher protein, less frail, and lower mortality, which was another big study. So I think we're getting a lot of supporting literature and evidence to show that we need protein. Because if we don't have protein, we lose our muscle mass, and therefore our kidney function looks a little bit better. So in some ways it's a little bit of a numbers game with kidney disease, and protein certainly doesn't cause kidney damage. And what we now see is that it really does support kidney health.
Dr Mary Barson (19:41) Yes, it's a fair bit, isn't it? Like, if we're gonna say — just because maths, I'd say maths is easier — one gram of protein per kilogram of body weight a day. So if you weigh 90 kilos: 90 grams. 100 kilos: 100 grams. 70 kilos: 70 grams. That's the minimum — you want to be having more. How do you help people make that change? Because for a lot of people, that actually can be a fairly dramatic increase in protein.
Dr Karen Dwyer (20:07) Yeah, absolutely — and I think that's the key. If you tried to go from a sort of a low protein up to your, you know, 80 or 90 grams per day in one hit, you won't get there. So I like to just at least highlight the importance of protein, and I'm looking for ways for incremental increases. For example, I have a couple of sayings — so that, you know, whenever you eat, just to look where your protein is. Can you identify it? And that might be, you know, whether it's Greek yogurt or a bit of cheese or whatever — but we're always looking for some protein. And then I put a lot of emphasis on that first meal of the day. So when you break your fast — whether that be at 7 a.m. or midday, whatever works for you — we want to make that a protein-rich meal and try to get at least somewhere between the 20 to 40 grams of protein, depending on your size, with that first meal. And I think that's really important for many reasons. You know, certainly it fills up the tank so that you do have a full tank for the day — so it's great from an energy perspective. We're not going to get that big burst of insulin that you might get with a high-carbohydrate meal, so it's less inflammatory. And so I think that's really important. But also, our bodies work on cells and enzymes and, you know, it needs the right fuel to work for the day — and all our enzymes are made up of protein. So if we're not providing protein, it's really hard for our body to actually work properly. So I really aim to work on that first meal of the day — let's try and get a protein-rich meal — and then we work on the subsequent meals across the day if that's needed. You know, sometimes it's just that first — we just need that first meal and things are trucking along really well and people feel well and then that's great. But those sort of incremental changes and really emphasising that first meal — I love that.
Dr Mary Barson (22:13) That's doable and actionable — the actionable advice. Yes, I would love to ask you also about salt, because this is another question we get asked a lot. And how do you guide people who are on a higher protein, lower sugar, lower processed food diet — that's what you encourage them to eat — how do you guide them with salt intake, especially in the context of kidney disease?
Dr Karen Dwyer (22:38) Yes, so again this is another thing that has been really drummed into us for many, many years — that we need to avoid salt because it causes high blood pressure, and we need to avoid salt from a kidney perspective. But again, we need to think about this in context. So if we have high insulin levels, then absolutely, we need to think about not taking excess salt, because the insulin is really doing a lot of that anyway. So I mentioned before that insulin works on the kidney and it makes us retain salt — and when you retain salt, you therefore retain fluid. So if you're reducing your insulin level, then all of a sudden your kidney just wees out a lot of salt and therefore a lot of water. And that's why, when you first start eating with less carbohydrates, the initial weight loss can be quite significant — and that's mostly water. So we're just getting rid of all that fluid, and in that situation, then you do need to have a little bit of salt. So I think, you know, we need to think about: which crystal are we talking about? We've got salt and we've got sugar. And if you're eating sugar, you need to be very careful of salt. But if you're not eating sugar — whether that be refined or through carbohydrate or whatnot — then you may well need some salt. And, you know, I'm always very conscious that as people change their diet, we need to watch out for feeling lightheaded or dizzy or cramping — and these are signs that perhaps we either need to cut back on some other medications (in the case of dizziness and high blood pressure tablets, for example), or perhaps there's the need to add a little bit of salt. Because we also know that the majority of our salt in our diet comes from ultra-processed foods — and if you're not eating those, you're not getting that excess amount. So it's not as easy as what we make it out, is it? You know, just "don't have salt" — there's a lot of nuance to it. And if you're eating real whole food, a little bit of salt is probably okay. But of course, it does need to be considered in the context of your health conditions and your medications. But it's, yeah, it's something worth discussing with your clinicians or your tribe as to what is going to work for you.
Dr Mary Barson (24:57) Yes, thank you — that is good, sage, and sensible advice. You mentioned right at the start that kidney disease is a silent disease — like, people can lose up to 90% of their kidney function before they start to show symptoms. So for our beautiful listeners out there who are perhaps concerned about their kidneys or they just want to check in on their kidneys — what could they do?
Dr Karen Dwyer (25:23) Yeah, absolutely. So I love this question because we want to be proactive, don’t we? So there’s a really simple test to do called a kidney health check, and this is where — from your doctor — you ask for a kidney health check. It involves a blood test to look at your kidney function by a number, and a urine test to see if you’re leaking any protein, and a blood pressure. And those three parameters are what we utilise to determine if there’s any evidence of kidney disease. We recommend a kidney health check for anybody that has pre-existing diabetes or high blood pressure or heart disease, or that excess weight around the middle. Absolutely, I would encourage you to have a kidney health check. But it’s also important to have a kidney health check if you’ve got a family history of someone with kidney disease — so you may have a parent or a grandparent or somebody that’s been on dialysis or had a transplant or had kidney issues. If you’ve ever had an episode — and often this is when you’ve been admitted to hospital for something else — and that you may have had what we call an acute kidney injury, and that’s where the kidney function might deteriorate a little bit, but the kidneys are quite resilient and they do recover function. But just like when you cut your hand, it heals with a scar — we can get that same sort of process happening in the kidney. So we recommend to have your kidneys checked if you’ve had a kidney injury at any time. And if you don’t have any of those factors, then we would just suggest having a kidney health check at age 60 if you’re non-Indigenous, or if you’re an Indigenous person, to have a kidney health check at age 18. And the reason for that — there’s quite a discrepancy there — is that we know amongst First Nations Australians that there’s an excess burden of kidney disease. It tends to present quite early and can progress quite rapidly. So again, we want to be very proactive and identify if there’s any issues as early as possible. But if you’re being proactive, then that allows us to really engage in that prevention space as well and try and support so that you don’t develop any kidney problems.
Dr Mary Barson (27:36) Yes, that is fantastic because our kidneys are extremely important. So it's pretty easy, isn't it? It's a pretty quick and relatively painless test that you could get with your GP or your health team.
Dr Karen Dwyer (27:47) Absolutely, yep.
Dr Mary Barson (27:49) I love it. So what do you think is sort of the future, or your future hopes, of where do you think that we are heading with managing chronic kidney disease?
Dr Karen Dwyer (28:00) You know what we know is that our current health system is is in crisis really you know general practice is underfunded and there's not enough general practitioners to see everybody in the community and as I said that you know the funding models perhaps not not ideal public hospitals are overstretched and probably again underfunded and so we've got this chronic disease that continues to to rise but our ability to support people is more constrained and that really does then lead to reactive episodic care and it leads to burnout so we have people actually leaving the profession so what I would really love is for us to sort of really look at the health system and prevention is so much better than cure so if we've got the resources in place and the education and the time that we can really move very much upstream and walk with people along this journey rather than having these touch points every now and then which is adding another band-aid to you know a long list of band-aids so I think our health system does need reform in how we are able to serve the community and I also think we need to look at there's a concept called values based health care and there's there's multiple aspects to that there's you know person centered values based health care what's important to that individual and how do we support that person meeting their goals then we've got to think about values based in terms of the investigations that we do and the care that we provide and where we provide that care and who provides that care so you know there are certain things that probably I shouldn't be doing but perhaps you knoYou know, what we know is that our current health system is in crisis, really. You know, general practice is underfunded, and there's not enough general practitioners to see everybody in the community. And as I said, the funding model is perhaps not ideal. Public hospitals are overstretched and probably, again, underfunded. And so we've got this chronic disease that continues to rise, but our ability to support people is more constrained. And that really does then lead to reactive, episodic care, and it leads to burnout. So we have people actually leaving the profession. So what I would really love is for us to sort of really look at the health system. Prevention is so much better than cure. So if we've got the resources in place, and the education and the time, then we can really move very much upstream and walk with people along this journey, rather than having these touchpoints every now and then, which is adding another band-aid to, you know, a long list of band-aids. So I think our health system does need reform in how we are able to serve the community. And I also think we need to look at—there's a concept called values-based health care, and there are multiple aspects to that. There's, you know, person-centred, values-based health care: what's important to that individual, and how do we support that person meeting their goals? Then we've got to think about values-based in terms of the investigations that we do, and the care that we provide, and where we provide that care, and who provides that care. So, you know, there are certain things that probably I shouldn't be doing, but perhaps, you know, if I had a health coach, they could be providing those multiple touchpoints that I'm doing very infrequently. So I think we need to rethink chronic disease and move very much upstream into the prevention space if I were had a health coach they could be providing those multiple touch points and I'm doing very infrequently so I think we need to rethink chronic disease and move very much upstream into the prevention space.
Dr Mary Barson (30:13) Thank you so much, Dr Karen Dwyer, for giving us your time today. It has been a wonderful and eye-opening conversation, and you have shared some extremely valuable insights — so thank you very, very much.
Dr Karen Dwyer (30:29) It's my absolute pleasure, Dr Mary, and I look forward to working with you further in other projects. Thanks.
Dr Mary Barson (30:34) Yes, very exciting. Bye now.
Dr Lucy Burns (30:40) The information shared on the Real Health and Weight Loss Podcast, including show notes and links, provides general information only. It is not a substitute, nor is it intended to provide individualised medical advice, diagnosis or treatment, nor can it be construed as such. Please consult your doctor for any medical concerns.
