Clin-STAR Journey Story

Listening to Patients Leads a Nephrologist to Geriatric Medicine and Aging Research

Nephrologist Anoop Sheshadri, MD, MAS, takes care of patients on dialysis who are waiting for a kidney transplant. Many of them are in their 50s or early 60s—young by the standards of geriatrics. But in terms of physical impairment, they are on par with people in the general population in their 70s or even older. Dr. Sheshadri began his research from the perspective of nephrology, seeking to improve both quality of life and the chances for survival to the time of transplant for these patients. But more and more, he has turned to geriatrics for methodologies as well as support from a diverse community of mentors and colleagues.

Dr. Sheshadri earned his MD in 2011 at the University of Texas Southwestern Medical Center at Dallas and continued there for his internship and residency in internal medicine. During rotations at a county hospital, he saw patients in the emergency room who needed immediate, life-saving dialysis—an experience that made him decide to pursue a fellowship in nephrology. He spent 2014-2019 as a fellow at the University of California, San Francisco, and also earned a Master of Advanced Study (MAS) in Clinical Research degree. Today he is an assistant adjunct professor at UCSF and the San Francisco VA Medical Center, where he sees patients treated with dialysis.

UCSF offered opportunities for Dr. Sheshadri to merge nephrology with another interest—exercise. "Cardiologists were doing interesting research on physical function and fitness, in terms of preventing cardiovascular risk and improving quality of life," he says. "I thought that type of research would be just as applicable to nephrology. The physical function of older patients waiting for kidney transplantation is even worse than in diseases like congestive heart failure or chronic obstructive pulmonary disease."

With his first mentor at UCSF, Kirsten Johansen, MD, Dr. Sheshadri carried out a pilot study to try to increase the physical activity of dialysis patients. They gave pedometers to 60 participants; half were also coached with goals to increase their weekly step count, and half received usual care. After three months, patients assigned to the intervention had increased their weekly steps by about 2,300 more steps than the controls.

The results were "somewhat surprising" to the nephrology community, says Dr. Sheshadri. Dialysis patients are often viewed as so sick and sedentary that motivating them to be more active can't be done.

Indeed, these patients have health-related barriers to overcome, both from kidney disease and by virtue of their chronological age. But during the trial Dr. Sheshadri noticed that "they also had really unique problems that we hadn't considered. In talking to patients, I discovered that they were concerned about falling even with light activity, or they lacked transportation to get to a place where they could walk." In addition, the tiring and time-consuming routine of dialysis made it hard for some to get out. And they needed more help from caregivers.

"Not many nephrologists are working on these quality of life issues," he says. "One of the big revelations for me going into the geriatric world was how, with core principles of geriatrics, you really get a more holistic understanding of what is going on with the patient."

Dr. Sheshadri incorporates geriatrics principles in his current research, which is laying the groundwork for a study of "prehabilitation" for patients awaiting kidney transplants from living donors. As in specialties like orthopedics, the idea is that building strength and muscle mass before surgery will speed recovery time and help minimize loss of physical function afterward. In September 2020, he received a Grant for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) award to support the research.

To start, Dr. Sheshadri is conducting interviews with patient-caregiver pairs. "Especially if you're designing behavioral interventions, doing this sort of qualitative background work is really invaluable. We're learning a lot about how to conduct interventions where you have to rely on a caregiver. My hope is that ultimately this will lead to a shift in how we think about dialysis, and in particular the transition to transplant, for older patients."

For other early-career clinician researchers curious about geriatrics, he has this advice:

• Look outside your specialty for mentorship. His current mentors include a general and transplant hepatologist (Jennifer Lai, MD, MBA, who first encouraged Dr. Sheshadri to pursue aging research), a transplant nephrologist, a geriatrician and a neurorehabilitiation specialist.
• Get to know your local geriatricians – go to divisional meetings, and learn from other people presenting their research.
• And, perhaps above all, talk to your patients.

"The solutions that we think of as standard have different ramifications for older patients," he says. "When you talk to patients and discover that this is true, new avenues for research present themselves."

To connect with Dr. Sheshadri or other aging researchers from different disciplines, join the Clin-STAR database.