Kidney Diease

Knowing Your Kidney Disease

Introduction (1)

This book is being prepared in order to encourage and make the patient understand pathologies of diseases of the kidney. Kidney disease affects end-stage renal disease, which is kidney failure, affect 400,000 patients currently in the United States today, of which new cases of kidney failure actually contribute about 120,000 patients per year annually. The importance of early identification and knowing h0ow to live with kidney disease in order to minimize the risk of progression and eventually ending on dialysis which is an alternate for individuals with the terminal stages of their kidney disease – is important The aim of this book is to provide a wellness to patients that are living with kidney diseases. There is an increasing proportion of patients that are now found to have kidney disease daily. Previously most patients were noted to start having kidney disease when they have symptoms, which usually is the late stages of kidney disease. But now we have increased our awareness on more testing a lot of patients are found to have various mild forms of kidney disease, and if the causes of this kidney disease are controlled on these patients, the disease will not progress into making the patient depend upon dialysis. Patients with mild form of kidney disease that follow regularly with their physician and have the causative factor for those kidney disease control, live normal lives in most cases without ending up on dialysis. It’s always better to know what your kidney disease status is because even many medications that are given to you for causes of other medical problems can actually worsen your kidney function. Other preparations or diets may also make your kidney disease worse.

Prior to development of kidney failure, most patients usually have slowly progressive form of kidney disease that eventually leads to kidney failure. Early discovery and monitoring of this kidney disease might actually slow down or prevent development of kidney failure in more than 90 percent of the population. Many diseases, many chronic diseases can affect the kidney. Diabetes currently forms over 40 percent of the causes of kidney failure today. But other chronic disease, like hypertension, autoimmune diseases like what we call like lupus or systemic lupus erythematosis, liver diseases, including the chronic infections, even medications taken over the counter or sometimes even prescribed by physicians, can slowly damage your kidneys and make you have renal failure. Regular monitoring follow up with your physician is always encouraged in order to know what your kidney status is doing and to better monitor how your kidneys are doing year to year.

Because the kidney has a close relationship with many other organs in the body, most especially the bone and it also sets the ideal environment in which other organs function. Most times as your kidneys slowly starts to fail, many other functions and conditions of the body will also be affected. Some of the chapters will be dedicated to discussing these particular scenarios where this happens and what are the things that can result from progressive dysfunction of the kidneys. At the end of this book we will have discussed the majority of the associated organ dysfunction that there is with kidney failure and we will also look at the possible treatment of these complications. We will make mention and talk about kidney replacement alternatives, including ending up on dialysis, what dialysis does for the body, what to expect if you are on dialysis, and what to expect as it relates to replacement of the kidney or get by kidney transplant.

If any question exists, a website address will be available at the end of this book where you can submit your questions and I have answers. But there is this book is not meant to be a replacement for follow-up with your regular physician or advice from your regular physician. Because the various dysfunctions that we will talk about in the later sections of this book do not necessarily have to appear in the same order and it varies from one patient to the other.
Acknowledgement

TABLE OF CONTENTS

Chapter 1. Various Stages of Chronic Kidney Disease

Chapter 2. Anemia (Blood Count)

Chapter 3. Bone Diseases and Kidney Disease

Chapter 4. Presence of Acidosis in Kidney Diseases

Chapter 5. High Phosphorous and Its Management

Chapter 6. Living with Kidney Stones

Chapter 7. Advanced Kidney Disease and Dialysis

Chapter 8. Kidney Transplants and How They Can Help You

Chapter 9

Chapter 1 KIDNEY DISEASE- knowing about the kidneys

. The kidney first of all is a (big) shaped organ that is located in your abdomen. Actually it’s said to be towards the back of the abdomen, what is referred to as the loins. And this is the area extending from just, if your fingers breadth below the lower end of your scapula, which is your wing bone, and then extending about four finger breadth below that is where your kidney is located on both side.

Humans are born with usually two kidneys, being some congenital cases people might be born with one. People born with one doesn’t necessarily mean you are at increased risk of kidney disease. Because most diseases that affect the kidney also affect both equally. But however, if you have one kidney and there is a trauma or kidney stones in that kidney, that can make you end up on dialysis quicker compared to somebody that have two kidneys. Most people with one kidney live their life normally without having seen a doctor or knowing about their kidney status, because the one kidney is usually functioning enough to carry you through life. The whole essence of kidney transplant or donation is based on this fact that one kidney is sufficient to do the whole work of clearing the body of toxins.

The kidney functions by filtering the blood, what that basically means is every substance – the kidney functions by filtering the blood and removing metabolites, that is the breakdown product of everything in the blood, and removing that toxins that can be harmful to our body. Most of these toxins are generated by breakdown of our body elements, like our body tissues or muscles, break down into tiny parts that intermetabolize or the tiny molecules that can sometimes be complex in the liver or are directly filtered away through the kidney into the urine, which is not (as critical.) When there is kidney disease, the removal of these breakdown products is reduced, thereby making the substances accumulate in the blood. As the kidney disease continues to progress, these substances start to affect the normal functioning of our body or the tissues in our body.

Take for example, creatinine is a breakdown product of our muscles. Our muscles are constantly breaking down and regenerating based on activities that we do. So creatinine, when muscles break down it generates end product like creatinine and urea. Now the creatinine and the urea are supposed to be excreted by the kidney into our urine. But the normal level of creatinine in our blood should be less than around 1. But when the kidney is affected, the creatinine concentrate, the level of creatinine that is removed by the kidney is reduced, thereby making the creatinine in the blood rise and making your level go higher in the blood to maybe 3 or 4 and in severe cases 6. And based on your age, creatinine can be used to estimate how much function the kidney is doing by calculating using the amount in the blood to estimate how much should have been removed by the kidney.

Normal kidney function is measured by how well the kidney removes toxins per minute. In an average individual, the kidney function should range between 90 to 120 ml per minute. However, for the purpose of your understanding we should just say 90 to 120 percent of the kidney function. The reason why I use percent is because it’s easier to explain percent rather than to say ml per second of blood is filtered through the kidney every minute, or ml per minute of blood is filtered through the kidney for every minute. Rather we will just say for the purpose of the rest of this book, we can just replace the ml per minute as percent. So it will be easy to understand.

When your kidney is working about 90 percent, it’s said to be normal. Kidney function improves from birth to early adulthood. And so about early adulthood, 30 to 40 years, your kidney function is most, or your kidneys are most functional. However, from there onwards your kidney percents are slowly decreased. The key word being slowly decreased by about one percent every year. So if for example a thirty-five-year-old man has a kidney function of 110 percent, every year the kidney function decreased by one percent, so by the age of 70 his kidney function should be expected to go down by 40 percent, so about 35 to 40 percent, so his kidney function should be roughly about 70 to 75 percent at the time he is 70, which is still enough to do all the clearance of toxins that the body needs to get rid of without giving any problem. Whereas if this patient has a condition that is affecting the kidney such as if he has uncontrolled diabetes, or uncontrolled high blood pressure, or if he has another autoimmune condition like lupus, the kidney rate of decrease may be accelerated and the individual might end up having a much lower kidney function even before he’s 50. Because what this does is that when you have any of that chronic conditions such as the ones mentioned above, they actually damage the tissues of the kidney and make the kidney function decrease quicker.

So for a young man with a kidney function of about 100 percent at the age of 30, if he later develop uncontrolled diabetes or he becomes severely obese later in his life, he might end up with a kidney function as low as 30 percent by the time he is 40 or 50. And this is more because if his diabetes remained uncontrolled for that period, the majority of patients with uncontrolled diabetes might even end up on dialysis, which is basically your kidney function below 15 to 20 percent even five years after onset of diabetes.

Based on the percent of kidney function, the kidneys are divided into five stages. Stage one is when your kidney function is between 90 to 120 percent, which is normal but you have a major risk factor for kidney disease, such as you are secreting a higher amount of protein in your urine which diabetes can cause commonly. Stage two is when your kidney function is between 60 and 90 percent; then stage three is actually between 30 and 59 percent; and then stage four is between 15 and 29 percent; and stage five is anything below 15, which in most cases requires you starting dialysis.

Dialysis is a process where a machine does the work of the kidney for you. That is a machine is connected to your body and then through the belly or abdomen or into your blood through a catheter in your neck or in your hand to clear and remove those metabolites that the kidney ideally normally should have removed and put into your urine that is excreted. But in this case, because your kidney function is not, the individual’s kidney function is not working very well, the person is started on dialysis just to replace the kidneys. The rest of dialysis we’ll discuss later in the later chapters. More detail about dialysis will be provided at that time.

Over 40 percent of people with end-stage, which is advanced kidney disease, that is stage four and stage five, are usually as a result of diabetes. The people with diabetes need to have very good control of their diabetes and their blood pressure in order to minimize for that damage of the kidney. Diabetes and many of the diseases, chronic diseases actually damage the individual tiny structures of the kidney, making that injury, making that damage replace itself with scarring. So the kidneys most times become smaller and scarred. And that scarred portion is not able to do the work of removing toxins. So while the other portions might still initially be doing the work, with increased damage to different tiny parts of the kidney, all of it becomes replaced with scar tissue and that makes the overall kidney function much lower than before.

One of the best ways to detect damage to the kidney is by the kidney spilling a higher than normal amount of protein in the urine. In a normal kidney state, no protein should be spilled into the urine. All the protein should remain in the blood. However, with damage to the kidney, the kidney responds by spilling a lot of protein in the urine. By checking the amount of protein in one’s urine by the physician, the patient can be said to have increased risk for kidney dysfunction even before the blood work starts to show any changes. We strongly advise diabetics to check their urine, to have a urine test to check how much protein has been present in their urine once every six months in order to address that once it starts to happen.

There are two forms of protein that can be secreted in your urine once you start this, the big form known as (overt) proteinuria, and there is the tiny form where they are not big proteins yet, but they are still kind of small tiny proteins that can be producing the urine. Medications can be used to decrease the amount of protein and reduce the damage to the kidney from whatever is causing that if found. Such medications may also work for blood pressure as well. However, with our without medications and control of glucose levels in diabetic patients, or control of blood pressure in patients with high blood pressure, minimize and reduce onset of damage to the kidney and progression of the damage to the kidney in most cases.
Chapter 1a. Various Stages of Chronic Kidney Disease

There are many pathologies( things and diseases) that can affect the kidney. Due to their presence of risk for injury to the kdieny from these disease stages of kidenys disease an be found.

2 types of kidneys disease the acute and the chronic pattern Acute – usually within few weeks or days , common in hospital from abx or even dye or contrast given during test including cardiac procedure ( heart rocedures like cath) . Iv contrats given during CT imaging can also demage the kdienys. In many times can happen even outside the hosp , like if you are sick or dehydrated or having been taking many nsaids . Routine abx that will take for symptoms like cough can demage the kdienys. Some routine meds that we take for our chronic ailmenets like dm, htn, can in certain conditions demage our kdienys though these medications are suppose to help us in long term

A patient with hypertension on medicine like lsinopril , also taking hydrochlorothiazide a diuretics which means it work by making you make more urine. When the patient developed diarrhea for example from gastroenteritis after eating contaminated food in a restaurant , the kieny function may temporaily go down and start to reover when the diarrhea stop. In thesi case not just the diarrahe make thekdieny function worse but in combination with the lsinopril and the hydrochrolotide that the patient was taking the overally effect contribute to eneoug demage to knock some portion of the kidney off .

Cheonic – refers to slow progression
Tyes and stages and relation of each stage and what to expect
Exmpales of patienst in each stage and what we are doing.

Chapter 2. Anemia (Blood Count)

Anemia basically refers your blood count. This refers to the amount of hemoglobin actually, the component of your blood that is the red blood cells which are the parts of the blood that actually carry oxygen to the blood tissues. The lower the level of the hemoglobin if it is below 12 for women or if it is below 13 for men, you are said to have anemia. The reason why it is lower in women compared to mean is actually because of the fats that women actually have more prone to low iron, which they lose during their menstrual period. However, as women become postmenopausal their hemoglobin count, which is their blood count, should be roughly about men of the same age.

Most times when you lose blood, you tend to become anemic in that you could lose blood because you are bleeding from the gastrointestinal tract, that is blood in your stool through your rectum. And then because there’s a problem in your colon that is making you to bleed or there might be a problem in your stomach, such as too much acid causing the blood vessels in your stomach to bleed slowly. Most of this blood is usually not noticeable, and only your physician can tell you if you are having blood loss by doing a test for blood in your stool. In very severe cases, the blood count, where you are losing blood very rapidly through the stool, your stool can become very dark. However, in most patients taking iron, it’s very difficult to really tell if the cause of your black stool is from blood loss in your stool or if it is because of the presence of iron in your stool, because the presence of iron that you take by mouth can actually make your stool dark.

In people with chronic kidney disease, they tend to become anemic; that is they tend to have a low blood count. And this usually because the kidneys secrete a protein known as urethral protein which acts as a signal or a stimulus that goes to the bone marrow and stimulates the bone marrow to produce red blood cells. And in a normal kidney state, this continuous secretion of urethral protein keeps your bone marrow producing blood. But when the kidney function starts to deteriorate, the production of this urethral protein actually can be affected and thereby reducing the signal needed for your bone marrow to produce blood. And that is giving you a state of anemia. The tendency for urethral protein not to be produced by the kidney does not, however, depend on, it’s not related to how low your kidney function declines. What I mean by this is that even if your kidneys are working at about 50 percent, you may still be anemic as a result of the kidney disease compared to some other person whose kidney function might be 30 percent and yet the patient is not anemic. However, before we always say that a patient is anemic due to kidney disease, you want to make sure the patient doesn’t have other causes of anemia or of a low blood count, such as you make sure that they don’t have any blood in their stool by testing their stool or by asking them for a colonoscopy where we take a tube with a camera and go through the rectum to look into the colon to see if there is any cause of bleeding there. Or we take a tube with the same camera or a scope like we like to call it and go through the mouth to look into the stomach, what is known as esophagogastroduodenoscopy or EGD.

In most cases when bleeding in the stool or in the colon is ruled out, then we are almost sure that the cause of the anemia in any patient that has a kidney function below 60 is most likely because of low blood count. However, the urethral protein, that is the kidney protein that is secreted, may also be affected when you have other chronic diseases such as lupus or rheumatoid arthritis or any other chronic condition that gives you a high state of inflammation like the ones I just mentioned. In patients with chronic kidney disease due to lupus or other disorders, they tend to have a high degree of anemia that is actually out of proportion to their kidney disease. This may be because these conditions also increase destruction of the red blood cells. That is, the red blood cell that is supposed to stay up to 120 days in your body from the time it is produced from the bone marrow to the time it is destroyed, may actually be staying much longer and so they volume or the count of the red blood cells is decreased at any given time. So these patients also tend to be very resistant to methods that we use to correct the anemia.

It is believed that because, actually when you become anemic because oxygen carrying ability is actually reduced, there is a tendency to become easily tired, easily fatigued, very weak, especially the lower your hemoglobin or your blood count is below 11. In severe cases where the blood count is below 9, you may become short of breath, you may start to have symptoms that look like heart failure, such as increased swelling, very short of breath when you lie down, feeling dizzy, having feeling of internal heat. And in some severe cases, especially if you’re heart is overworking and your heart was not optimal before, you might start having heart failure with the accumulation of fluid in your leg, more fluid in your lungs and increased weight gain.

Most patients that are anemic actually start to complain of increased weakness, and that is usually the first thing that they complain of when their blood count starts to drop. These changes, in the case of low blood count or anemia due to chronic kidney disease, the change is not very abrupt. It actually takes a long time, gradually over weeks to months. So if your hemoglobin was say 12 two months ago, it might come down to like 11.1 or 11 now and in another one or two months it might go down to 10. So it’s not something like your blood count was 12 or 13 a week ago and it dropped now to 10. Usually most times there is usually a second cause, like increased blood loss in your stool or increased destruction of your red blood cells from any autoimmune condition that can destroy red blood cells. And this is not likely due to the kidney disease.

In some cases where you have kidney stones, you may, especially when you are passing a stone, a stone can be irritating the lumen of the urethra and be making you bleed kind of like you have a stone rubbing against the skin and so you can bleed. And so in most people that are passing stones or they have stones, depending on the position of the stones, especially the stone is in the pelvis or is in the urethra. And in a few cases, if the stone is even down in the bladder, they may actually pass blood in their urine. And sometimes the bleeding may not be obvious, but it can only be seen when we test your urine, when we do what we call a urinalysis, that is testing your urine with a reagent that will notice that you are having tiny blood in your urine. But it becomes very obvious – you might start to notice increased dark coloration or just gross blood in your urine. But in most cases, this is also accompanied with flank pain or pain in your flanks or in your loins or pain when you pee. And usually this kind of presentation only lasts for a few days before either you pass the stone or the pain is bad enough that you come to the hospital. And so this cause of anemia is usually very obvious. Not the type that is the gradual type that you are most talking about when we talk about kidney disease itself.

Usually on most patients when you see them in the hospital, when your hemoglobin is between 11 and 12, even though it’s low we usually don’t do anything. We usually just tell you let’s keep monitoring it to see if you going to do blood work again in another one to two months, I may want to check your hemoglobin again. And if it’s low by this time, if it’s not below 11 before we start to give you medicine. This is actually because most times most patients don’t have symptoms. The majority patients don’t have symptoms when their hemoglobin, as long as their hemoglobin is above 11. Most patients start to have symptoms when their hemoglobin comes below 11, as I mentioned above.

So what we do is we can give you, because the problem in this kind of cause of anemia from the kidneys, because the kidney is not making enough of that protein called erythropoietin, what we do is we can give you urethral protein as an adjuvant. And usually the preparation of the urethral proteins are by injection, which can be given adding to your IV or under your skin. And the under your skin is not very painful, because it’s directly under the skin, not into the muscle or what we call intramuscular, but these actually are what we call subcutaneous, that is just to go under your skin with a tiny needle, almost like giving you like insulin. Usually we start by giving you a dose of this once a month, and checking your blood work, because we don’t want the hemoglobin to go too high above 13, because once it goes above 13 there is increased risk of high blood pressure or it can give you stroke in most cases. So we want your hemoglobin to be between 11 and 13 in most instances. So that is why we don’t give it to you when it is above 11 and we stop it when it goes close to 13. So most times we can start giving you the injection even before you end up on dialysis as once a month. And in some cases if the once a month dose is not improving your hemoglobin as much as we want to, we can increase it to once every two weeks or once every week, depending on what your blood count shows.

In many, many cases most patients with chronic kidney disease that have anemia also have iron deficiency. And so we always check for iron. And even if they don’t have iron deficiency before we start giving them the (dialysis), most of them eventually develop iron deficiency later because the iron is needed for you to make red blood cells. So even if they didn't have iron deficiency to begin with, they might develop it later. And in some cases even when they have iron deficiency, just correcting the iron deficiency by giving them IV iron or by tablet, correcting it with a tablet of iron, actually improves their blood count without most patients needing the artificial urethral protein or the protein.

Iron can be given in two forms – there is a tablet form and there is the IV form. A lot of inventions have been made and a lot of progress has been made recently in the provision of the IV form. Right now there are two formulations, there is one kind that you can give slowly over three to four hours, and you come back within a week to get a second dose. And that usually kind of keeps your iron stores high for about three to six months without you needing another dose. In some cases you might still need to get repeat dose within that time. And then there is a new form now that just came out, actually you can give by injection and within two minutes, and that one is much better in that you don’t have to stay in the hospital for three to four hours for each of the two doses. And this one is very fast and works very quickly within two minutes. A good thing about the pill, the pill iron on the other hand you have to take every day requiring maybe two to three tablets a day. The problem with the pill iron is that as you get older, the ability of your stomach to actually absorb iron is decreased. And so most people, even though they are on pill iron, they are still persistently deficient or low in iron stores. And also the pill iron actually gives you constipation, you know. Most patients are already prone to constipation and this is not like the best drug to take. So most times I tell my patient this and they usually opt for the IV iron instead of having to take the pill tablet every day for many months. I have risk of complication – black tarry stool, and even maybe no response to the medication.

Every time we give you the blood test we want to make sure that your hemoglobin is routine, is below 13 and that’s usually in order to prevent risk of rapid increase in your hemoglobin.

Chapter 3. Bone Disease and Kidney Disease

Bone disease and kidney disease may involve an organ known as the parathyroid and the (30.36). The parathyroid is an organ located in the neck just beside the thyroid. I know most patients confuse the thyroid with the parathyroid, especially because most times when they see their regular physician, they probably know that their thyroid is low and they are already taking medication for that thyroid or maybe in the past they have had a condition known as hyperthyroidism, like Grave’s Disease. But the part of it that we are interested in is not only the thyroid gland itself, but an organ that is beside it referred to as parathyroid (beside thyroid) as its name suggests. Now the parathyroid gland works closely with the kidney in controlling how much bone formation and the metabolism that goes on within the bone.

The kidney is needed in making of active vitamin D. We all have heard probably from our grade school that vitamin D is produced by exposure to the sun, which is true in a way, because the sun actually starts the process by activating cholesterol on the skin to start the formation of vitamin D. But the process also involves the kidney. The final production of vitamin D involves the kidney. So as the kidney function starts to go down, the production of vitamin D, the active form of vitamin D is actually reduced. And that decreases the amount of calcium that we absorb form the food we eat through our intestines, and also reduces the amount of calcium in our blood. If they amount of calcium in our blood is low, it makes the parathyroid production increase. The parathyroid makes calcium leave the bone and deposits it in the blood. So that it can reach all the other organs and function in more so all the activities of the other organs. So the more decrease in the kidney function the less vitamin D production, and the less vitamin D production you reduce the amount of calcium in the blood and causes the parathyroid to increase and make the bones thinner, because the bone starts to lose more calcium.

So the kidney plays an important part in the strength and the state of your bones. When the kidney function is very, very low and your bones become much weaker, most patients are prone to easy fractures. This is similar to what osteoporosis can do. That it can make people’s bones weaker, but in the kidney disease it’s a form of osteoporosis based on a different form, and we call it osteodystrophy. Basically what this is, is that if as the kidney disease gets worse, your parathyroid value level in the blood increases and your bones become weaker. However, in order to break this process of the weakening of the bone and increasing your risk for fractures, because any time you fall, instead of the bone being able to absorb the stress of the fall or anything, because now the bones is very weak, it’s not strong enough to absorb the stress. So any time you have a fall, your bones easily just break. I have had many patients, even very young patients in their twenties or thirties that have had fractures because their parathyroid has been very high. And this is because their kidney function is very low, which made their parathyroid become very high. Their bones, these patients’ bones fracture easily, almost as if they were like 80 or 90 years old with osteoporosis.

One of the ways to decrease this is not by taking more calcium because even if you take more calcium, the calcium will not really be absorbed because there is no vitamin D to absorb the calcium from the intestine. So unlike osteoporosis, taking more calcium in this case does not usually help. What will help is replacing the vitamin D that is not being produced by the kidney. Most times we start patients on tablet form of the vitamin D to replace the vitamin D. Some of the preparations of vitamin D currently available are once daily or even very high dose as once a month or once every two weeks. Most patients that come to me with kidney disease, I routinely check their vitamin D level, and in over 90 percent of cases, their active vitamin D level is usually low. And that will require us replacing it with medication, with a tablet of active vitamin D.

Please note I am using the word “active vitamin D,” because there is another form of inactive vitamin D that comes from poor nutrition, and this inactive vitamin D should be combated with active vitamin D, a process that requires the kidney. But if the inactive vitamin D is not even there to begin with because of poor nutrition, then the kidney can’t even make active vitamin D. So sometimes if we check for both the inactive and the active. And if the inactive is low, we also replace it while we are also replacing the active. In many patients the inactive may be normal, and so they just need to get only the active vitamin D replacement. The inactive vitamin D doesn’t do much in terms of control of the bone, but it is important in terms of how strong our muscles feel and how our walking is coordinated.

Now as we mentioned before, as the kidney starts to decrease, especially as it progressively goes below 50 percent, the ability to make vitamin D also gradually decreases, so the patient basically needs extra vitamin D. If this extra vitamin D is not provided and the calcium level in the body becomes very low, even before patient is prone to fractures, the patient might start having muscle twitching or increased weakness of the muscles, because enough calcium is not available to be used up in contraction of our muscles. Like when we move or when we do any activity, muscle contraction requires calcium. So as the kidney function decreases and the active vitamin D level also decreases, the calcium would decrease and thereby making the individual feel actually weaker and not able to do any strengthening exercises or endurance exercises. And in severe cases with very low calcium, the patient might have spasms of any of the extremities or even have seizures.

I had a patient once that had acidosis for many years. He was an immigrant into the country. And he ended up with advanced kidney disease. One of the ways he came into the hospital and he was diagnosed was by increasing weakness of all his extremities and he was feeling twitching. And it turned out that not only did he have acidosis, he also had very low calcium, which was contributing to this. By giving him enough vitamin D and correcting his acidosis, he felt stronger and because his kidney function was very advanced, we had to start him on continuous dialysis.

Once I explained to a patient about this relationship between the kidney and the bones, how there was the kidney disease, the increase in the PTH, the decrease in the vitamin D and the more calcium that is removed from the bone to be present in the blood to be used for other muscle activities or available to other organs that need it. The patient did describe it as, “Doctor, so are you telling me that it’s like a termite eating the foundation of my wood house, of my tree house, and now I’m making it very week and easily prone to break down.” And I said, “Yes, it is like termites eating the foundation of your tree house.”

In most cases when a patient on dialysis, even though the acidosis is corrected, but if they don’t have enough vitamin D, or if their PTH gland has increased in size to such a big aspect, this patient will continue to have removal of calcium from their bone and progressively making their bone weaker. Most times we continue increasing the active vitamin D supplement that we give them in the IV form or in the tablet form. And in some cases we may have to use another medication that directly reduces the parathyroid hormone level itself.

Even if some patients with very high parathyroid levels, even if some patients don’t have overt fractures, sometimes dislocation of the tendons of their lower extremities has been linked to this very high parathyroid level. It is believed that even if the bone doesn’t break, the areas where the tendons attach to the bones may actually tear. I have had patients that kept having ligament tears in their knees as a result of very high parathyroid. And she did end up with a gait abnormality and even ended using crutches because of this knee tear. And in some cases chronic arthritis from repeated surgeries to the knees may actually give you a gait problem when some people are on dialysis.

Chapter 4. Presence of Acidosis in Kidney Disease

Acidosis basically refers to too much acid in the body. One of the main functions of the kidney is to remove the acid that is produced from normal metabolism that is a function of the various tissues in the body. When we take in oxygen, oxygen is needed to break down the food that we eat which is glucose or amino acid or fatty acid – fatty acid from fat, amino acid from protein, or glucose from carbohydrates into smaller tiny acid forms and generate energy during that process. The breakdown of food actually involves adding oxygen to these food molecules and in that process to generate energy. We actually make acid. Now the acid in the body is moved into the blood from all different areas of tissue in the body, and this acid is actually removed from the kidney. And during process, the kidney also makes what is known as a base which counteracts the acid also in the blood.

So the kidney does two things – it removes the excess acid from the blood, and also it generates or it produces a base which goes into the blood to also convert the acid into salt and water. As the kidney function starts to decrease, the amount of acid that is removed and the amount of base that is generated in the kidney also reduce, therefore leading to increase in the amount of acid in the body. The level of acid in the body cannot be measured. The only way to do that is by measuring the amount of base left to neutralize the acid. The lower the amount of base left to neutralize the acid, it means the higher the amount of acid is left in the body. And so when we talk about acidosis, we are actually saying that there is too much acid and there is too little base left in the body. In most of the lab work, the amount of base left is represented as hc03 or bicarbonate level. Normal bicarbonate levels should be between 24 to 28 but when there is too much acid in the body, the bicarbonate level can be way below 24.

Increasing the amount of acid can give you increased weakness, drowsiness, lethargy, and in very extreme cases, it can give you confusion. Eating a high diet of protein can actually increase the amount of acid that is produced by the body, and most times increasing the amount of acid produced by the body also increases another electrolyte in the body known as potassium and increasing your potassium level as well. A higher amount of potassium because the body muscles need potassium, need a normal amount of potassium in order to function properly. Higher amounts of potassium can actually affect your heart and give you what is known as arrhythmia, meaning they can actually make your heart to start beating irregularly. And in most cases in very severe cases, when the potassium is very high it can actually make the heart stop, thereby resulting in death.

Another cause of very high acid in kidney disease is if you have chronic diarrhea because diarrhea actually makes the body lose the amount of base you have in your colon, and that sometimes may help to counteract the acid when the kidney function is not that good. But when you have chronic diarrhea and you lose a lot of base, the amount of acid in the body will actually increase.

Now, despite the fact that the decrease in kidney function makes you retain a lot of acid, there is no strong correlation by the amount of decreasing kidney function to the amount of acid that you will have in the body. Your kidney function may be low at 50 percent, yet you may have a lot of acid, depending on which area of your kidney is affected first by the disease damaging your kidney. Whereas in some people the kidney function may be as low as 25, yet they do not have too much acid. So it doesn’t really, even though the decrease in kidney function gives you acidosis, the degree by which the kidney function decreases does not necessarily also indicate the degree by which the acid in the body can rise. In very few people with chronic lung problems like emphysema or what the doctor would term COPD, the level of bicarb may be falsely elevated. However, by a complex calculation, especially if you have symptoms suggestive of acidosis, your physician may be able to identify the presence of acidosis, even though you’re bicarbonate in your blood work appears to be normal.

Most times, following up with the nephrologies, we identify this problem. Many patients, even though there are many things that can give you weakness, by increasing the amount of acid in the body is one common cause of weakness that most people don’t really identify.

Just as we mentioned earlier that chronic diarrhea can give you too much acid, the use of laxatives for increased constipation will also give you this, especially if it gives you a lot of diarrhea, and in most case having an increased loose stools and having acidosis by reducing the amount of laxative you have and decreasing the amount of stool that you are having or avoiding diarrhea, we actually sometimes help to correct the acidosis. Increased salt intake, once again, as it can also cause you high blood pressure and can also increase the amount of acid you have, because salt contains chloride which is a form of acid.

In some people with uncontrolled diabetes, with persistent elevation in their glucose level, the glucose can be broken down to a metabolite known as acetone and that can also increase the amount of acid you have. And as we mentioned before, high protein diet, especially with very low – as your kidney function becomes low, less than 40 percent in most cases, increases the amount of acid you have. Most times when acidosis is noted in your blood work and the doctor is going to prescribe a medicine called sodium bicarb or citrate or even potassium bicarb or potassium citrate for you. And that’s most times we correct the acidosis.

In the majority of people, because their acidosis is not that prominent in their day-to-day state, for example, if their kidney function is like 40 percent, and their acid level as measured with the bicarb level is 22, meaning they have too much acid, they’re not that severe. When they become sick, like if they have a urinary tract infection or they have pneumonia or they develop diarrhea from gastroenteritis, on top of the already too much acid, this may worsen their too much acid in the blood and make them now start to have symptoms such as more increase in their weakness or they become more lethargic or more confused. So correcting your acid even though it is slightly above normal, may actually prevent you from feeling much weaker when you develop any other acute illness on top of the renal kidney disease.

In very severe cases, especially when your kidney function is below 30 percent, your acid fails to correct we will start you on a medication to correct it. Dialysis might be able to replace the too much acids that is present in the blood. Even though we mentioned earlier that dialysis is usually reserved for patients below 15 percent, but if your kidney function is below 30 percent and you have too much acid that fails to correct with just medication alone, one of the things that can be done in this case would be giving you intermittent dialysis to remove the too much acid and replace with a lot of base.
Chapter 5. High Phosphorous and Its Management

Phosphorus is related to bone disease and kidney failure. But because we have a lot to say we are including it in this separate chapter. Phosphorus is a breakdown product of protein. It is an electrolyte that is present in the blood that actually we get from protein or protein breakdown. Most foods that contain high protein basically also contain high phosphorous. The phosphorous can actually, depending on the type of food, some food contains a higher phosphorous to protein ratio. And this may be food like dairy products basically contained in milk or cheese. These have a very high amount of phosphorous. Now what the phosphorous does is because phosphorous is a breakdown of protein, our body generates phosphorous every day especially from the diet that we eat. Phosphorous is very well absorbed through the digestive tract when we eat any of these protein foods.

And the phosphorous goes into the blood and in addition to phosphorous generated by breakdown of blood products, the phosphorous in the blood actually tends to be high every day. But however with a normal functioning kidney, the kidney is able to remove this excess amount of phosphorous regularly, thereby keeping the amount of phosphorous in our blood within a normal range of between 3 to 5. However, as the kidney function starts to go down, the phosphorous levels start to increase and this might lead to a very high phosphorous. Any level greater than 6 of phosphorous in the blood is said to be above normal range.

The phosphorous when it is high, one of the things it does that it can cause itching. This basically could be generalized that it is all over the body form of itching, especially when the phosphorous is above 8 or it could be limited to any specific area. Most times based on experience I have noticed that most people with high phosphorous have an increased your tendency to itch. So if you already have an area with that, it can make you itch, and your phosphorous becomes high, the high phosphorous may make you itch more. I had a patient once that had a cast because he had a fracture of his humerus, and he had a cast for a long time. But of his left humerus, that is the left upper thigh. He has had a case for a long time. But however when his phosphorous became high, he started to complain of itching more around the cast. And after we controlled the phosphorous and he came back to normal, the itching became much more bearable.

Also another patient that I had who had lower extremity swelling, and be wearing these compression stockings to decrease the swelling, also had a lot of complaint of itching when this phosphorous became higher than 8. And when it was later controlled, the itching seems much better. However, with some people the itching like I said before, could just be generalized , that is all over the body.

In severe cases, the phosphorous can combine with calcium in your blood and deposit in the blood vessels. This deposition in the blood vessels actually is like a cement deposition in a pipe. Basically your blood vessels are like a pipe that can become flexible or expand based on how much blood it needs to carry. But however, when the phosphorous and calcium deposit, especially if your phosphorous has been high for a long time, the deposit in the blood vessels can actually make the blood vessel wall thicken and become like stiff. And also reduce the amount of blood flow that it carries. If this happens in the blood vessels in the heart, it can actually make the patient prone to heart attacks or coronary artery disease.

In the blood vessels of the extremities, especially supplying the lower extremities, especially if the person is diabetic, this can reduce the blood flow to the lower extremities reducing the amount of blood flow available to your legs when you walk, thereby giving you pain in your legs when you walk. Sometimes it can cause reduce in the flow to the skin also, and so whenever the patient has an ulcer or a wound, the wound will be unable to heal because it’s not getting enough blood and nutrient because the flow to the lower extremities is reduced. I have had a patient that was on dialysis. He was also diabetic and obese. And he developed, he has always had very high phosphorous and was not taking medication prescribed for him. He later developed a wound in his leg and the wound couldn’t heal because the blood vessels carrying blood to the lower extremities had become thickened and the (lumin) size has reduced. So the patient ended up having amputation. Most times if you have a wound because the blood flow to the wound is reduced, the wound will refused to heal and actually get bigger in size and be very difficult to heal.

And so control of the phosphorous level is important to avoid these complications. The kidney normally, like we said before, the kidney normally removes this amount of phosphorous that we get from food. But as the kidney functions gradually decrease and the phosphorous level increases, there is a need to remove the phosphorous another way. One of the ways is actually by restricting how much phosphorous we eat. However, because we need protein for our daily functioning, we can’t really reduce to a huge extent the amount of protein we eat. We actually prescribe binders for patients. The binders actually, what they do is that when you take them with food, they actually bind or combine with phosphorous in the intestine and prevent it from getting into the blood. The phosphorous ends up being removed from the body in your stool.

There has always been a debate as to what is the best time to take these phosphorous binders. The phosphorous binders are best taken after the first two bites of the food. Because if you take it way before you eat, they might actually be broken down and excreted even before you finish eating. And if you take it after you finish eating, depending on if you are a slow eater or a fast eater. If you are a slow eater, the phosphorous may have already started to be absorbed in the body even before you take the binder. I had a patient once that had a phosphorous level that was high, above 6, and the patient was always taking medicine that I prescribed for her to bind the phosphorous. But it turned out that she was taking it after she finished eating. And she generally eats for over 15 minutes. And so I advised her to take it just after the first bite. And it turned out that at the next blood work, her phosphorous level was very much controlled. And so the best time of taking the phosphorous binder is optimal in controlling the phosphorous.

Most phosphorous pills that are available now include Phospherol, calcium acetate or PhosLo, and Renvela. The over-the-counter Tums that people sometimes take for indigestion actually also can bind phosphorous. And in some people I usually prescribe it for them to like just take Tums. A lot of people have complained about the sizes of these tablets, but most recently a lot of development has been made in terms of pharmaceutical production of these drugs. They are now available in some sachet forms of Renvela and PhosLo that you can actually mix with water and just drink. So instead of swallowing these big tablets, you can just drink it as you eat. Most phosphorous food, like I said, are also foods that contain protein. And examples of them include beans, nuts, milk products, cheese, pancakes, peas, creamed soup, macaroni, biscuits, hot dogs, sausage, chocolate, organ meats, liver, pork.

A lot of patients, especially patients on dialysis try to avoid these products. However their protein level will become very low. And so usually I advise them you don’t really have to try to restrict these products, but you can take them once in a while, but not in excess. But as long as you take binders with them. And if you are going to take any of these products, you could just take an extra binder. But in most cases I would advise people to continue eating what they regularly eat and to follow their blood work. It’s only when your phosphorous is high in your blood work that I might say okay, take an extra binder when you take ice cream or when you take any snacks or when you take any of these type of food substances.

Phosphorous control is important not only for the now, but in terms of in the future. Because (complexing) with deposition in your blood vessels after (combining) with calcium, usually may not be a good thing in the future because it might increase your risk for heart attack and decrease in your blood flow to your extremities.

Dialysis actually removes some phosphorous because is works to replace the function of the kidney. But the amount of phosphorous that is removed by dialysis is actually very small. Most people that were on binders before, once they start dialysis because dialysis replaces the function of your kidney, they always want to stop the binders, because they don’t want to take a table every time they eat. However, dialysis only takes out a small fraction of the amount of phosphorous. And because dialysis most times is three times a week, except you are on the daily dialysis which is more frequent, and it only takes a small amount of phosphorous. Most times you still need to be on your phosphorous binders, even when you start dialysis. Regular blood work by your physician will help determine when you need to come off this medicine instead of just stopping it on your own. Previously in the times past, aluminum containing binders were used for people with very high phosphorous, even on dialysis. However, because of a memory problem has been linked to aluminum containing binders, this is rarely used today. And it’s only used when we have people that have very severe complications of phosphorous such as very severe itching or they have poor wound healing from a decreased blood flow in their vessels and their phosphorous is still high that we have to get aluminum binders for them to decrease their phosphorous.

Chapter 6 or 7 Hypertension

Hypertension affects many in the population and is basically you’re said to have hypertension if you have kidney disease and you’re blood pressure which is the top blood pressure which is known as you systolic blood pressure is more than 130 or if you don’t have any kidney disease or absence of diabetes and you’re systolic blood pressure is more than 140. The diastolic the bottom rate very rare diseases give you a difference, a lack of correlation between the diastolic and the systolic so most times your diastolic should be more than 90 for you to say you have hypertension, but its rare to have a diastolic that is above 90 and the systolic is not more than 130 or 140 depending on if we are sure that you have presence of kidney disease or diabetes.

In most cases in an adults where over ninety percent of the adult population because of the hypertension it is usually genetic that is not really due to any of the acquired or what we call something wrong in any of that part of your body, but is due to a genetic disposition making your blood vessels become harden with time. The whole business of hypertension is because stiffening of the blood vessels requires increased blood pressure in order to allow blood to flow through these blood vessels. Basically, you could consider the blood network in the body consists of bigger blood vessels breaking into smaller branches more like bigger types that are coming from a water source now breaking into smaller pipes or tunnels that actually supply a particular home. If there is increased stiffness or clogging of the smaller types at the home the pressure needed in order to push blood through this clog here actually increase and that is a the whole business with hypertension. Ideally your blood vessel walls are supposed to be what they call pliable that is it’s easily distend by distending and enlarge when blood needs to flow through it. If the wall becomes very stiff, so when will blood needs to flow through it the pressure in order to make this blood flow through it actually has to increase and that is what when you measure with the sphygmomanometer what we basically call the blood pressure cuff and the blood pressure will be high.

Like I said before, many things can cause hypertension and most of them are genetic, but in a few cases increase in body size or an abdominal problem with the kidney or an imbalance in the hormonal system in your body can also make you have hypertension. Commonly, in many cases of hypertension are controlled with less than three medicines. By the time we are taking more than four medicine for high blood pressure is not effect to us what is known as resistance case which is a basically very difficult to control hypertension. One of the causes of this is if you are very, very obese or you have a problem with the blood flow to the kidney itself or you have a strong hormonal problem and that is when you’re doctors usually will check for this condition. Checking for the decreased blood flow to the kidney involved doing a test known as a special form of ultrasound. It’s kind of like a scan of the kidneys to look at the blood flow, whereas the other types can naturally be detected by blood work.

In a few cases especially in people that snore. Now this is usually a problem and most people that live alone are unable to tell if they snore or not, but commonly I ask my patient especially if they are overweight or obese or have a huge distention of their abdomen or have what you call a big gut are usually at risk if they snore at night. Most of them we usually say no because it’s difficult to know if you snore at night or not except if you record yourself, but if for many of my patients that come into my exam room with their spouse its easy to elicit that question by just asking your spouse. For most people that snore at night they may need to have a CPAP machine which is basically a machine that pushes oxygen to your brain when you sleep because the whole problem with sleep snoring is that during your sleep the flow of oxygen or the flow of air through your nasal pathway actually become reduced and that tends to wake you up into multiple state of inaudible) that is preventing from having a calm, restful night. Most people as they snore in the night also tend to feel very tired and drowsy during the day and this cycle may cause them to gain weight and the more you gain weight the more it worsens the problem of snoring or the problem of obstructive sleep apnea which further makes you gain weight and worsens your blood pressure so for these people that snore in the night it is good to break this vicious cycle by actually doing a sleep study test for them to see how much oxygen they get in the night. Almost all cases of people that snore in the night are referred for a sleep study eventually end up needing the machine to help them that pushes air through their pathway during the night. Basically, it means that they almost end up failing the sleep study and having to get this CPAP machine. The CPAP machine does help a lot for people with this cause of hypertension to decrease their blood pressure. I see many patients that on like five or six medications for blood pressure before we test to find out that they have obstructive sleep apnea and after they start using the CPAP not only do they have more energy during the day, but their blood pressure management require might actually decrease to less than three four, but there is no strong formula to predict by how much it will decrease your need for blood pressure medicine, but it does have help to reduce tension.

Also diet is a very important part that you need take in controlling of blood pressure. The majority of the medicine that will give you to control blood pressure actually does this by helping the body remove a lot of salt which you actually do by increasing the amount of urine that you make. Some of these drugs like the hydrochlorothiazide or furosemide or thiazide as for in spironolactone actually increases the amount of salt and in order to this effect is almost synonymous with taking salt, so taking less salt actually improves your blood pressure because what will happen is salt itself actually increase do your volume of fluid inside your blood vessels and they actually also increase your blood pressure because now you actually need a higher pressure to move a higher volume of fluid inside the blood vessel and so getting rid of this high volume of fluid or excess salt in your body we actually tend to improve your blood pressure. The need to improve blood pressure is more because with increasing hypertension for that increase in stiffness of the blood vessels and deposition of plaques into the wall of the blood vessels and the more it happens like plaque deposition in the brain it could result in a small plaques breaking off from big plaques in the brain giving you a stroke. In the heart, this same process can actually give you heart attack and also can worsen your kidney.

The relationship between blood pressure and the kidney is reciprocal. The more uncontrolled or the higher blood pressure the more it contributes to increase damage to the kidney tissue itself and then the more the kidney tissue gets damaged the more your kidneys are not able to remove the excess salt that you take in your food and the more it contributes to your blood pressure. Controlling the blood pressure has been noted to be one of the most significant things to do in terms of minimizing worsening of your kidney disease. Irrespective of the kidney disease, irrespective of the cause, blood pressure control we minimize progression of your kidney disease by a huge amount.

For most of my patients with high blood pressure I usually advise them to check their blood pressure regularly and to get a cuff and to check their blood pressure regularly. Most patients ask when is the best time to check your blood pressure and I tell them the best time to check your blood pressure is relative because the jugular blood pressure varies with the day. For all of my patients that walk through my office for a blood pressure problem I usually tell them to check their blood pressure four times for the first day after they been stable on medication. This is because blood pressure varies. Some people’s blood pressure is higher in the night than during the day. Ideally, for a normal patient, your blood pressure should be higher during the day and it will take a dip that is irrespective of the number, but when you are sleeping in the middle of the night it drops to a lower level and then goes back to what it was by in the morning, so the normal dips exists in a normal state. For people that have high blood pressure in the majority of the people the blood pressure still takes a dip in the night so even if your blood pressure run in the 160’s to 170’s during the day in the night it is supposed to drop to at least by some degree maybe to like 140 to 150’s in the middle of the night, so even though the blood pressure is still high, but it particularly dip in the night and this is what we call nocturnal dipping. For people that do not have this nocturnal dipping they are increased high risk for stroke. This is because most strokes, especially what we call ischemic stroke tend to happen in the night and so if your blood pressure drops low in the night it cannot protect you from having a stroke that you would have had by the increased high blood pressure. If your blood pressure doesn’t dip in the night it cannot make you at high risk for having stroke so that is why I tell my patient when they ask me what is the best time to take your blood pressure. Take your blood pressure four times the first day. Check it when you wake up in the morning. Check it around sometime in the afternoon. Check it again before you go to bed and then for the first two nights wake up in the middle of the night maybe around 2 to 3 a.m. and check your blood pressure again and that way it actually says how your blood pressure range. If you are the type that your blood pressure is higher in the morning than in the night then it will be good for you to check it at those times that you expect it to be the highest. If your blood pressure is higher in the morning than in the evening, but lower in the afternoon and in the night, then moving your medicine or adjusting your medication from a short acting medicine that works for a few hours to a medicine that will work for much longer hours or at the same dose could just control your blood pressure, so I tell my patients check your blood pressure four times the first day and let me know the result. Based on that, I adjust the medication and advise you to take the dose that period that it is the highest. Ideal blood pressure control should be your blood pressure at any time range in between 120 to 130’s. This is a good blood pressure because it is believed that this is the optimal blood pressure that the body needs to fully adjust and that prevents you having problems with low blood pressure such as headache, dizziness or increasing weakness.

Most times for people that have very high blood pressure the first time they come to the clinic if you reduce their blood pressure by a huge lot say for example a man comes in with a blood pressure of 180 and then over the next one week you give him a couple of medicines and it comes down to 130 usually this patient may complain of weakness. This weakness is because you’re body’s used to a blood pressure pushing at 180, now that you reduce it to 130 even though in the long run this will be good for the optimal functioning of your body and preventing you from stroke and heart attack, but in that meantime over the next couple of days you may feel initially weaker or more drowsy and so when my patient come in and complain of increased weakness after they have been on medicine I tell them wait on the medicine for about two weeks after control of your blood pressure before the feeling of weakness is because of the side effect of the medication and not just because your blood pressure has become better controlled because this feeling your body should get adjusted now to this change in blood pressure within a week of your having this improved blood pressure. I also advise patients take you blood pressure anytime you feel dizzy, so if the medication is working too much based on the dose then you’re having a lot of dizziness if people that have diabetes it might you’re blood pressure is lower at the same time you have dizziness then we may have to reduce the medicine. It is always good when you are started on a new medication to ask for the best way to reach your doctor because if you feel dizzy you may want to call the doctor and inform him of the dizziness and he may have to reduce the dose of the medication or decrease how you often you take it.

For people that their blood pressure does not drop in the night, taking their medicine close to their bedtime may actually be better for these people because this gives them a lower blood pressure during the night while they sleeping and actually help protect them from stroke. In terms of medicines or medications like Metroprolol, Atenolol or Coreg and even Lisinopril or the inaudible) family, actually giving it twice a day for some people. Now, the feeling is most of these drugs even though they are given twice a day is better to take them as close to twelve hours apart as possible because this drug may have a duration of actual meaning the time that this drug is most effective in your body might be between eleven to fourteen hours so taking the drug every twelve hours will give you much better blood pressure control than taking the drug less than twelve hours apart. I have a patient that was prescribed metroprolol b.i.d. and the patient was taking the medicine at 10 in the morning when he wakes up and again at 4 in the afternoon when he is usually eating supper. He was noticing that by between 5 p.m. and 7 p.m. he feels a bit dizzy or lightheaded whereas in the night from 10 p.m. to the next morning his blood pressure is running very, very high whereas in the night till the next morning he feels fine, so we checked a four times a day blood pressure checks for him at home and he told me that his blood pressure was very low between 5 to 7 p.m. because he was taking the medicine too close together so whereas after that his blood pressure was way high and his blood pressure in the morning before he takes the medicine were running in the 170’s whereas between 5 and 7 p.m. his blood pressure was dropping down to 110’s. We actually advised him to take the medicine at 7 or 8 in evening as possible and this actually gave him a good blood pressure control without actually giving that feeling of headache or dizziness or low blood pressure as it turned out to be in this case.

Like I said before, taking salt is one important measure to keeping your blood pressure low. Salt intake also involve the kind of preparation you make. It’s not just enough to say I don’t take salt, but if there is already a lot of salt in the food it might be sufficient salt. I usually add by expressing no added salt and try to stay on that diet for the first three days because usually the first three days is the toughest. After that your palate and you’re sensation becomes used to the low salt diet and you will be able to cope with it. For some people that complain that they cannot do salt reduction because they like salt they are so used to salt I say that no matter how used to salt you are and the taste buds die out and regenerate within a week and so if you start a low salt diet after within a week it is better that it is your new taste buds will be used to that low salt diet and that will actually help keep your blood pressure control while also allowing you to enjoy any food that you are having at that time.

Losing weight. Weight loss especially weight loss around the waist does help a lot by decreasing the amount of fat in the belly and helps your blood pressure or improve your diabetes. It’s not just enough to lose weight all over, but weight loss around the abdomen, the belly region of belly fat is actually more important in terms of medical benefit than generalized weight loss in all the other parts of the body.

In some cases, an increase of stress can make your blood pressure fluctuate. I had a patient once that his blood pressure was usually fine in the morning, but in the evening it is usually high and also his pulse rate which is relating that your home cuff will also show you it is also high and then after that question I was surprised to actually find out that the wife goes to work with the sister and they have a quarrel almost on a daily basis and when she gets home she tells me about it and that makes his blood pressure increase because all this stress from hearing the wife complaining to him about what happened in her workplace and his blood pressure starts to go up every evening, so I had to call the wife who was actually there in my office and I advised her to stop telling the husband stressful news every evening and naturally that did help to control his blood pressure.

Chapter 2. Living with Chronic Kidney Disease

When the diagnosis of chronic kidney disease is made a lot of things the patient should know is about living the disease. Usually the disease might be progressive, but depending on the cause or the kidney injury progression of the disease is usually slow. Sometimes some medications or even over the counter preparations or any help by medications can worsen the disease and make it progress faster. Also, adjustment of regular medications that the patients are already taking may be needed to made especially based on the level for kidney disease the patient is already at, at the time of diagnosis. What to know for every patient with kidney disease is avoidance of nonsteroidal anti-inflammatory drugs is one of the most common and often preventable advice that is given to patient to prevent worsen of their kidney disease. Commonly used medications like Ibuprofen, Naproxen or diclofenac belong to this class of nonsteroidal anti-inflammatory drugs. These preparations are usually in the forms of Motrin, Advil, Aleve or Ibuprofen. For most patients that have joint pains or I try to use as is usually the case or in the few people that have recurrent headache taking all that preparation that does not contain these above-mentioned medications is usually prescribed. We try as much as possible to avoid this medicine. However, for some of my patient that has very bad arthritis I still let them know that they could take the medicines once in a while as long as they limit the use of the intake of this medicine. Tylenol is usually safest for control of pain in this population. However, recent study have shown that high doses of Tylenol may result in have an increase risk for that, so the use of many doses of Tylenol daily should be used with caution. For most of my patients that have chronic pain, I usually tell them to take Tylenol, especially Tylenol Arthritis which actually seems to be better for management of chronic pain rather than the regular one or two tablets of acetaminophen (Tylenol). In many of these cases I also advise patient if the pain is very severe you could take one or two tablets of Motrin, but if you are requiring more than two tablets of Motrin or more than two times use for in a week we might need to go up to a higher level of pain medicine such as the opioids. Medications like the opioids are, especially containing Codeine or Tramadol are usually safer to use for pain even though this medicine because they contain opioid can increase your risk for drowsiness and sleepiness, but if you are having pain that is worse during the night these medications may be the best because they could give you a better night’s sleep.

I advise my patients to know that all the medications that you might be taking may be contraindicated or relatively used with caution as your kidney disease progresses. Medications like Benadryl doesn’t really affect the kidney, but as your kidney function gets worse these medications are usually cleared by the kidneys so as your kidney function gets worse this medications and they are what are called metabolized to accumulate in the body and if you are still taking them they are usually prescribed this way in a normal individual the medication can give you more side effects such as giving you more drowsiness and increased confusion, so taking all that medication needs to be adjusted by your physician or by nephrologist.

In many of my patients, they have increased body swelling because the kidney is not able to get rid of the large volume of fluid that we put in our body everyday. In a normal state, one would drink fluid and excess of the fluid in our body is removed by the kidney, but as the kidney continues to lose its function the majority of this fluid tends to stay in our body especially if we have let’s say heart disease. In many people they may not have a very pronounced heart disease but as the kidney gets worse this fluid accumulates. One of the signs that you are getting too much fluid in your body is that there will be leg swelling or swelling in what we call periorbital swelling which is swelling around your eyes, especially on waking up in the morning. Leg swelling can be seen at home by pressing one finger against your shin or your ankle and most times if there is a dip in which is actually like if it forms a hole that takes time to slowly get better it means that you probably have some leg swelling. Most patients will notice the leg swelling that in the initial case or in the early cases the swelling seems to be more during the evening, at the end of the day than in the morning, but after a while as the swelling gets more prominent as you accumulate more fluid the swelling starts to become more prominent irrespective of the time of the day.

The reason why the swelling is actually more in the morning rather than the night is more because the fluid tends to stay in your legs as you walk around during the rest of the day whereas you go to sleep in the night the fluid tends to accumulate. It’s more because of the same water finds this level the fluid tends to accumulate and some of the fluid might be in the subcutaneous that is our skin tissue in your back especially over your lower back or sometimes in your lungs. Most times this fluid tends to accumulate it becomes even more difficult to sleep at night or you might even be requiring or two more pillows extra in order to be in a relatively upright position to allow you to sleep. This is because the fluid in your lungs can affect your breathing and this is worse mostly at night. For most of my patients with kidney disease most of them will have to be on a diuretic which is a medicine that removes excess salt and water from your body. In the diuretic the most common ones that we use are a medicine like furosemide (Lasix), Bumex (bumetanide) or in rare cases ethacrynic acid. Hydrochlorothiazide is also one of the classes of meds that removes excess salt from the body, but as the kidney function continues to get worse hydrochlorothiazide does not work very well. Hydrochlorothiazide is also known HCTZ.

For many patients with increased swelling I start them on furosemide and a minimum they have be on the furosemide either once a day or twice a day depending on their level of swelling. However, furosemide will make you lose a lot of salt and water from your body and in the process of doing that it makes you go to the bathroom more often because now you have more urine flowing to your bladder coming out from the body. Most times if you have a bladder problem it can actually make that worse and make you actually go to the bathroom more often. For example, for a patient that I had had a big prostate problem that was affecting his bladder making him not to go too much a condition that was benign prostatic hyperplasia. He was able to control his voiding going only two times in the night. However, when he was started on furosemide because he does now have the moisture in the bladder the number of times he goes to the bathroom actually increased and he was now going up to three, four, five times in the night which was beginning to affect his sleep. The problem in this case is not just that the furosemide was making him go more often, but it was making a problem he relatively had before more prominent, but in many cases, most patients tend to take the furosemide when they are going to be at home. The furosemide actually works within the first six hours after it is administered. If you are going to go out for a dinner or a party you may want to take the furosemide knowing fully well that base within the six to eight hours after it is taken. You might want to adjust when you take the meds into account for the party.

Regular follow up of your weight is a good way to check to see how much fluid is removed from your body especially in terms of your swelling in the legs or around the face. It’s a good way to see how you are responding to the furosemide, but checking your weight daily is a much better way. In the first couple of days after you start furosemide you lose weight in most ideal situations because they aim is to remove the excess water and salt and that will make you lose weight. What I tell my patient most times when I see them before I start them on furosemide I know their weight and I advise them on depends on how much swelling they have I will advise them they need to lose about three to four kg. Then, checking their weight at home actually will tell me when they have achieved that target. For some it might be in a very few days. For some of them it might take a few weeks. Most times once your weight starts to go below the target weight that we have agreed upon it might be okay to reduce the dose of the furosemide. If you were taking it twice a day, we might consider making it once a day or if you were taking it once a day we might decrease the dose by half. I usually advise my patient when I see them to have a weight we agree upon a weight that we are going to target, so if a patient comes to me at 219 and he has leg swelling and facial swelling and he’s having shortness of breath and I feel he has too much fluid and salt in his body that he needs to get rid of we might agree to let’s a achieve a weight of eight to ten pounds loss which from the fluid and water over the next two weeks and I advise him to check your weight everyday once you get to that weight of 208 pounds then cut the Lasix down from maybe two times a day to once a day.

One of the things to know when you been on a diuretic is it can make your potassium low. Your potassium is another electrolyte in your body and taking potassium supplements is usually recommended, but in most cases I just advise my patient if you already have normal low potassium to eat more potassium containing foods such as fruits that we will discuss later. Eating these high potassium containing foods we increase their potassium preventing from going low while they are on furosemide. Based on cases because potassium is removed by the kidney, the potassium may already be high before you are started on furosemide and so it’s might still not be okay to eat too much of these high potassium foods. In some people that have very bad heart failure, the kidney disease may get worse or even better with the use of Lasix depending.

Also, it is also prudent to avoid other drugs especially substances which are not FDA approved. It is good to look at the label of many medications, especially these weight loss losing supplement because in most be prudent to lose weight, but then this weight loss losing supplement especially those that are not approved by the FDA or that does not say that they are approved may actually contain some substances that can damage your kidney. Taking medications from other countries or over the counter that are not recommended by your doctor are things that you want to avoid when you have kidney disease because this medication may not be effectively cleared in your body compared to when inaudible) and increase your risk for or that side effect of the medicine.

One of the common questions I get from many patients that have kidney disease especially at the time of diagnosis when you tell them they have chronic kidney disease stage wherever the first question they ask does that mean doc that I need to drink more water? Most times the answer is negative because water intake does not improve your chronic kidney disease. In some situations where you have an acute, what acute means is you have a sudden worsening of your kidney function especially over a few days and this is due to depletion that is you are dehydrated. Then drinking a lot of fluid including water may help your kidney get better, but in many cases where your kidney damage has been chronic which has happened over a couple of months or years, drinking any amount of water will not make that kidney much better, so what I advise patient is just keep yourself hydrated. If you are thirsty, drink, but otherwise don’t keep drinking with the hope of increasing your kidney function. In many cases, this may actually make some of your electrolytes worse if you keep drinking water especially in excess of salt intake because most of the patients with kidney disease also have hypertension and so drinking a lot of water in excess of salt intake may make your sodium which is an electrolyte in the body walls. What I tell patients is only drink when you are thirsty, but if they are dehydrated and they are having acute kidney injury then water will increase it so it should be a recommendation from your nephrologist on a case by case basis to how much if to drink more water or not. Otherwise, for generally I will advise just drink as in any other patient, drink when you are thirsty and don’t drink if you’re not thirsty. In some people that are on diuretics the furosemide that we’re talking about earlier and have lost weight to the extent of they no longer have any swelling in most of these cases if they have diarrhea or vomiting or anything that will make them lose fluid from their body or even if they are exposed to heavy sunlight like they are exercising a lot or they are in a very humid and hot environment they may actually lose a lot of fluid by sweating and so in all of these conditions where you lose a lot of fluid like I said vomiting, diarrhea, excess sweating it may be okay if you don’t have access to a lot of fluid to hold your furosemide because furosemide in these situations can contribute to make you very dry and that can give you dehydration and make your kidney worse, but however even if you have nausea, you have vomiting or you have diarrhea as long as you are able to drink or you still have evidence of swelling like swelling in your leg or in your face then continue the furosemide.

Chapter 7 Kidney Stones

Kidney stones is a common problem that affect the majority of people in the population and many times have a genetic predisposition with a strong link to family has been involved in development of kidney stones. Usually kidney stones is where a stone starts forming in your kidney. A stone literally because a stone is basically made up calcium substance. In most kidney stones a calcium combined with a phosphate or oxalate crystallize and multiple crystals join together to start forming a stone which may continue to grow and depending on if the condition is not causing the stone to form (inaudible). Many conditions that causes stone to form basically involve in simple sayings include conditions that will make any stone form in the outside the body like if you put too many of solutes together in a small concentration the solute will not dissolve. Basically this is what happens. The calcium that we excrete in our kidney usually will join with oxalate and then if the urine volume is not high enough it starts to form literally microcrystals and depending on the urine volume or the concentration of this calcium in the urine the microcrystals will aggregate and starts to form stones. In most people who have recurrent kidney infection they might have a different type of stone and this is usually a struvit stone. This stone forms because the recurrent infections can actually change the pH or the concentration of the urine now making some uric acid or some magnesium form a stone in this case. In many cases most family that have a history of kidney stones have an intrinsic problem with the way that their kidneys are able to handle this production of calcium. In other conditions, too much calcium passing through the kidneys that’s because you have a problem parathyroid or you are taking in too much vitamin D supplement can actually also make you have a stone. Of odd cases of stone formation, it is most important that the urine volume is high. This is just like in the common principle when these microcrystals form if a high urine volume is being produced daily it can actually flush this microcrystals away and prevent it from aggregating together to form a stone. That is why in many stone forms they don’t usually form stone if they are drinking enough even if they have a strong family history to form stones, but when they go through a couple of days without drinking and become dehydrated resulting in low urine volume then these stones starts to form.

One of the treatments we usually do for this patient is to make sure that the amount of fluid they are drinking is more than two liters a day that is roughly more than seventy ounces of fluid. This volume of fluid could be in a form of just water intake or coffee or juice and depending on if they have any other condition. If a patient that has diabetes and also have kidney stones I will advise them to just drink water or coffee or any low sugar or diet drink so that it doesn’t worsen their diabetes. Therefore, a patient that doesn’t have diabetes it may be apropos to drink anything as long as your fluid volume is more than two liters. However, if you are exposed to sunlight or your exercise and you sweat a lot then it might be prudent to drink way more than that. One way to gauge how much we are drinking is by how much you urine you are making. We usually send patient home to collect what we call a 24-hour urine collection for test. What that means is you start to collect urine from a specific time on day one and end at the same time on day two. Every urine that you pee you pee into the container. If I tell a patient, collect during from Wednesday to Thursday so that means on Wednesday morning say depending on say by 7 o’clock any urine you have pass you can go to the bathroom and try to pass urine not into the container, but into the toilet bowl and flush and after that specific time in this case say 7 o’clock then every urine you pass you put it into the urine container and then by 7 o’clock the next day, say on Thursday this time you go to the bathroom and make sure that you pass any urine remaining in you into the bowl. This collection actually will represent 24-hours of urine collection. We will use it to determine in many cases what type of stone you are most likely going to form. If you having a calcium stone, you may be having too much calcium in your urine, we can actually give you medications to decrease the amount of calcium you are making in that case. In some people you may be having too much of another substance like oxalate and we may actually have to adjust your calcium, but no matter what the condition whether you have too much calcium or too little calcium in your urine reducing your calcium intake by amount does not help this situation. It’s usually even for my patients that are having high calcium apart from giving them medication to correct the kidney excretion of calcium into their urine I still tell them to take their regular diet if only including with regular calcium intake because very hardly does excess calcium that you eat by mouth give you calcium stones rather excess vitamin D that you may be taking mouth or if you have a problem hypoparathyroidism (rare parathyroid hormone) is causing too calcium to leave your bone and be flushed out through the kidneys or if it is due to a problem with the kidney itself handling of your calcium then your calcium may be high in your urine but decreasing the amount of calcium you take by mouth may actually make this condition worse and so most people that even though they have calcium stone I still encourage them to eat a regular calcium diet. I might stop their vitamin D or even give them medicine to reduce their PTH fluid they still need to have a normal calcium diet, so after collecting their 24-hour period your urine volume should be more than two liters. This has not meant in medicine to be the volume of urine that you should be producing in a day in order to decrease your risk of forming more stones, so for most people that come in that have had kidney stones I usually do have a 24-hour urine is not up to two liters I usually encourage them to drink more fluid.

Most times kidney stones usually represent as a sharp pain that radiate from your loins where the kidneys are located down to your groin and get worse as you try to pee. In very acute cases where the stone is lodged around where your urine pathway depending on the particular area the pain can be very severe, but in most cases the pain seems to be more associated with passing urine or maturation. In rare cases you may feel a dull aching pain over your loins and this is usually when the stone is not attempted to pass through, but the stone has just lodged inside the kidney organ itself. In most cases of kidney stones having a CAT scan or a special ultrasound can show if they stone is in the kidneys or if it is located around the urine pathway. Depending on the size of the stone we might actually do what we call an electron-beam lithotripsy.

Basically, this is a procedure which involves sending sound waves to break your stone. However, this procedure is only of benefit when the stones are very big and cannot pass, but when these stones are actually small and deposit inside the kidney tissue itself the electron-beam does not really work very well, so in that case the only way to treat it is by giving you medications and by making you drink a lot of fluid to gradually decrease the amount of the kidney stones.

A lot of people have asked me if they have to keep drinking a lot of fluid for the rest of their life. Depending on the case, the majority of cases the answer is actually in the affirmative because of the genetic inherited predisposition to kidney stones it may, depending on what your other workup shows with you during tests, we might put you on medicine and if the exact cause is not found especially if it is genetic then you have to keep drinking that amount of fluid or taking the medicine that we put you on to increase your urine volume for the rest of your life, but if it is due to secondary problems like an obstruction of the kidney or a problem that is secondary to the kidney like the hypoparathyroid hormone causing calcium to come from your bone or higher amount of excess of vitamin D intake then decreasing diet will reduce your risk for calcium and may reduce your tendency to form kidney stones and so you might not necessarily have to keep drinking for the rest of your life.

Chapter 8. Living with Advanced Kidney Disease

If kidney function continues to get worse especially as it goes down to below 30 and in the 20’s range, your nephrologist might start to talk to you about a plan for dialysis. This is because as your kidney function goes down into the 20’s or below 20 ml/min., the clearance of toxins that we make from breakdown of food product and our body metabolism is not that great so these toxins or this breakdown of metabolite products actually tend to accumulate in your blood and some of them are noticed with regular blood draws, but what they do is they start to give you problems. One of the problems is that you might start to feel more nauseous. You might feel weaker. Your ability of your kidneys to produce a substance that relates to your bone marrow to produce red blood cells actually decreases and so you become more anemic. You may start to retain fluid and depending on the area of your kidney that is affected most times if it involves around the tubal area you may have start to retain a lot of fluid and actually make you gain more weight, more swelling of your ankles and your face and more shortness of breath maybe because of the fluid accumulation of your lungs all because of the low blood count (anemia).

In some cases as your phosphorous also begin to rise and what we mean by phosphorous is one of the breakdown products of metabolism. The phosphorous starts to deposit in the skin and it starts to make your skin itch and so itching is one of the features of worsening kidney function, so weakness, nausea, loss of appetite, weight loss in some cases, increasing shortness of breath, retention of fluid as everything from swelling of your ankles or of your face. The facial swelling tends to initially start more in the mornings when you rise from bed. You notice swelling around your eyelids what is known as periorbital edema and is usually as the day progresses as you move about the swelling might be decreasing so all of these are signs of worsening kidney disease and at that this time one of the things to start making arrangement for is dialysis which is basically removing these substances because the kidney cannot take them out which is removing them artificially.

There are two forms of dialysis most times that will be explained to you. One of them is what is generally known as the water dialysis and the other one is what is known as the blood dialysis or hemodialysis and the water dialysis is not the peritoneal dialysis.

In the hemodialysis, what that means is a needle where blood is drawn from you and run through a machine to remove the toxins and then blood is returned back to you during that process. Because the volume of blood that needs to be drawn out from you is high in order to remove the toxins, a big needle or a big access to your blood veins is needed. In order to achieve these we can put in a catheter into one of the big veins in your neck or we can connect one of the veins in your arm actually to create what is known as a fistula. Putting in a catheter in your neck is easier to do and does not require any time for maturation, so in most cases when you come to the hospital in very late stages of kidney failure and need urgent dialysis that may be the way we go. We put a catheter in your neck, but the problem with putting the catheter in your neck is apart from risk of bleeding there is also a high risk of infection and the catheter because it is placed in a big vein in your neck it is most times positioned very close to the heart. When you get an infection through this catheter it can easily spread to the heart and spread to the rest of the body making it difficult to treat. Because the risk of infection is very high the catheter placement is not very encouraged except when it is urgently needed. In most people that are being followed up by a nephrologist on a regular basis, as your kidney function starts to deteriorate below 30, the plan will be to put a fistula for you which is basically a surgery to connect a vein to the artery in your heart. Now the whole purpose of this is to increase the size of the vein in your hand. Most times we usually choice your non-dominant hand which means if you are mainly right-handed, we will prefer to put on your left hand. If you are mainly left-handed, we will prefer to put on your right hand except if the veins in your non-dominant arm are not as good as the veins in the dominant hand then the vascular surgeon may choose to put it on the same arm that you mainly use. Most times after the surgery which is usually a surgery that can be done on an outpatient basis. You come to the Center. They get it done for you and you may be able to leave the same day. In most cases after the surgery it takes about two to three months for the veins in the arm to become mature enough to be used for dialysis, but the good thing about the access creation which is actually the most recommended form of way to do the pro dialysis is that the risk for infection is much, much lower compared to the catheter. Now according to the guideline and the standard fistula maturation is recommended for everybody even if they have been on dialysis through the catheter for many years now, so for those that dialysis is needed urgently because the fistula takes the creation of the big vein takes up to three months to do then we might temporarily put in a catheter and then create the big vein later and once the big vein is mature enough then we remove the catheter and just do dialysis for them through the veins that we have created in the arm.

Typically what happens during the hemodialysis is when you come to the Dialysis Unit blood is drawn. The blood is connected from the dialysis machine to your source of blood such as the vein through a needle in the vein created by the fistula in your arm or via the catheter that you have in your neck and then blood is cycled through the machine fed and cleaned and they are returned to you through another opening on that same catheter or through an opening in a needle also placed at the big vein, the dilated vein now in your arm. Most times hemodialysis can only be done in a specialized Center which most times I can locate one as close as much as possible for you to your place of residence. In very rare cases, especially in the rural area, you may have to travel a couple of minutes to the Dialysis Center. However, currently based on your type of insurance now your co-pay, transport may be able to be arranged for you.

For the water dialysis, basically it involves connecting a catheter to your abdomen wall. What that means is to your belly area, so a catheter is placed under the skin in your belly area and through the catheter bags of water are connected to the catheter and they infuse and allowed to flow to your belly and then after a couple of hours you drain out the water. The convenient part of this thing is that it doesn’t involve your blood. It’s actually involves water that is given to you in bags and you can connect and disconnect it at home yourself, so the good thing about the peritoneal dialysis is that it can be done at home, but the patient has to be able to do it. What that means is if the patient is unable to move bags or connect or is not literate enough or is too weak then this might not be a good dialysis. However, if the patient is able to connect and disconnect it and know how to care for the catheter which is basically preventing infection and putting an ointment around it every day then this is actually the better form of dialysis. The convenience is because it can be given at home. You don’t have to come to a Center three times a week or thereabouts. In this form of dialysis a lot of people have been said to live longer with this form of dialysis than the hemodialysis, but however it varies and also depends on other risk factors that you may have. Follow up for this patient on this type of dialysis is usually done once every month or once every two months depending on the nephrology practice. Because the risk of living long survivor is higher with this peritoneal dialysis, this is now the most recommended form and is cleverly becoming the standard of care for most people. In very rare cases where you have an infection of the catheter we may switch you to hemodialysis while the infection heals and then after the infection heals, you can resume the peritoneal dialysis again.

Chapter 9. Kidney Transplant

A third option is to replace a kidney is obtaining a kidney transplant. This is a topic that everybody is interested in and is actually becoming more available than it was in the past. Nowadays more people are getting kidneys than it was possible ten years ago, but on the flip side if we don’t multiply getting kidneys, where more people are developing and surgery for that disease and are needing the kidney transplant than ever before, so a higher demand than the supply currently is actually balance for kidney transplant.

A kidney transplant is actually refers to taking a kidney from another patient and transplanting it into your abdomen connecting it to your bladder and to your blood vessels so that it can feed as blood for you. In most cases except when you’re kidneys are due to polycystic kidney disease or there is a tumor your own kidneys even though they are not working too good are not removed because even though they are not working too good that small fraction even if your kidney function is down to four percent it is still helpful. Instead the most times the kidneys are put in the lower part of the belly towards the front and just most times above the hip. The new kidney will now take over the function of clearing most of the toxins in your body. You will still be able to pee as normal through your bladder and through your ureter to the outside. However, kidney transplant is not easy to come by. Even though it has a lot of benefit, but it also has it’s own challenges because when you have the new kidney because the kidney is from somebody else and because it’s foreign your body immune system which is your body’s ability to fighting infection actually recognized that kidney as an infection and will try to fight it, so in most cases we have to give you medicine to reduce your body’s ability to fight for foreign bodies which is called immunosuppression. However this can make you prone to having infections otherwise. After a transplant, most people become prone to because of the medicine we are giving them to suppress their ability to fight the real kidney they become to prone to infections that are typically doesn’t affect a normal person that’s because it doesn’t effect in normal patient such as fungi infection and some viruses and some very rare virus infection that commonly are carried around, but usually does not give any symptoms. However, in these people with a kidney transplant it can become a major source of symptoms and that can actually kill patient, so most people with kidney transplant are strongly advised to adhere to their medication that prevents such a common infections.

The source of the kidney can be that from a donation from a living patient because we have two kidneys a patient can donate one to somebody else especially if they match in terms of their blood group and all their genetic parameters or it can be from somebody that has died what is known as deceased donor. The young, however, irrespective of the kids the younger the donor the less diseases the donor has the higher the risk of the kidney surviving in the patient that is receiving the kidney otherwise known a recipient.

Most kidneys from a living donor stay over ten years on average whereas most kidneys from donors that have died still don’t average over five years. However, we have to account for the fact that your body even though we give you medicine to suppress the rejection which is your body fighting the new kidney and thinking it is a foreign body or an infection that needs to be destroyed the risk for rejection where your body or when the suppression and go ahead to destroy the kidney could actually be high especially within the first year after you have kidney transplant. Kidney transplant, like I said before, is not benign. Apart from this risk of you having an infection, the risk of rejection is actually very high. I have seen a lot of people very frustrated after they get a kidney and within the first year the new kidney dies and they have to go back on dialysis. Not only is it frustrating it’s actually also depressing for these people and that is because they feel that they have lost, but most people fail to understand that this risk was there in the first place and that they are not entirely different and it affects a significant amount of people. Most cases that I have see where these people are very depressed because they think that they are the only patient out of eight hundred or thus that are to lose a kidney, but however the rates of having a rejection or having a major complication is essentially much higher than that and a lot of people waiting for transplant or that receive transplant don’t really think of that. It’s easier if you have good result from transplant, but people don’t really talk about the bad result from transplant. However, having said this, this is not to deter you from getting transplant because if you were the body of going for dialysis three times a day or doing dialysis at home every few hours every day and the benefit of having a transplant does for you which basically increasing your life expectancy having received a transplant is still way much better than remaining on dialysis. However, it’s always important to bear in mind that you might still need a transplant a few years later or even as soon as a few weeks later if the new kidney does not take or if the new kidney gets destroyed by own body system despite giving you the suppression.

A lot of people recently especially in major cities we get cases where people travel outside to a different countries to get kidney what they call the organ market, but however the standard of care in many of these countries is not very superb and even when those people come back to the United States the medications that they are taking does not really protect them against these infections and that is because most of these other institutions outside the United States does not account for this risk of infections and most of these people come back to the United States and die from major infections and will become rehydrated again and this might improve the kidney function back to what it was and before the whole event actually that is usually the first time you see them. When I came to the United States when after we give you a kidney transplant we follow you every week for a couple of weeks before changing it to every month if you are stable, but in this situation these people get transplant and the doctor sees them soon after just to make sure the wound is fine and prescribe medications for them without even adjusting the dose or even following up to see if the medicine are really protected them against those infection. Then they come back to the United States a month or two later and they are roughly within a year they develop major infections that make all their body organs fail and these are usually the people that actually die more from infections.

It is important where they are getting your kidney to make sure that you have all the prophylaxis or the medicine that will protect against infections. Usually Bactrim, fluconazole or diclofenac is anti fungi, but you might get some antibacterial especially the PCP infection and Acyclovir for against some viral infections a regimen on this that needs to be in every transplant organ recipient cocktail. In some cases, you might not be on diclofenac because if you don’t have a high risk of fungi or you might not be on Acyclovir for a long time, but Bactrim or its equivalent should be among the medicine that every recipient should make sure they are on whether in the United States or outside. It is always important to ask the physician especially outside the Country if you are on this cocktail.

Because of the risk or benefit ratio of getting transplant a lot of people have advocated that’s only the young relatively young below seventy years old people should be eligible for transplant and those above seventy should not receive transplant. They’re high but this is still relative of how a lot of people are above seventy that get transplant and they do very well. However, if the average patient to get a transplant has a lot to do with your age and the younger people actually tend to go first on the list more than the relatively older people. The average wait time also varies from place to place. In North Dakota for example this may be as low as two years whereas in New York it maybe about five years other districts may actually have more years average waiting list on the transplant.

Before people get transplant in order to make sure that the transplant is not a waste because transplant is safe is major subject we need to make sure that the people are optimized for the procedure. One of the things to do first is to rule out cancer, so an appropriate screening tests for cancers actually done like your prostate, rectal exam, checking your prostate level in your blood, doing a colonoscopy, getting a chest x-ray, making sure your heart is fit for the surgery whether with a stress test or just an echo and doing this test every year as long as your on the transplant list and for women adding a mammogram and a PAP smear is usually appropriate tests that we do. Some other tests might be needed if there is a problem with this major test or depending on the physician’s opinion. However, compliance is one major reason why a lot of people are not given a transplant. Obesity is actually also becoming another major reason and this is because if your patient is not compliant with coming for dialysis or taking their medication regularly then they are most likely not going to take the immunosuppressive medicine and the kidney might reject quicker and so the kidney will be a waste, so for most of those people and giving the kidney to somebody that is more compliant and more conscience to follow up is ethically sound and important. I have had in my course of experience to recommend to the Transplant Center to take patient off the transplant list because they are not even compliant to regular medications that you put them on. They take it one day and not the next day or something like that. However, obesity is becoming a major problem and this is because the wound around the area of the belly because if you have a lot of belly fat the wound around there will not heal and so a lot of people feel you should lose weight a lot especially more around the belly before you’re optimized to get a transplant.

In summary, transplant is always better than remaining on dialysis especially as your kidney continues to fail below twenty percent, but however we should all know that it comes with this risk, so that is why regular screening to make sure you are fit for surgery and regular follow up with your physician even before and after the transplant is highly important. I went in to give a talk once to a group of transplant recipients and transplant recipient hopefuls and immediately I start to tell them about the dangers of transplant is safe they give me a bad look. I could see they’re all glaring and angry with me, but after I started to explaining to them the importance of knowing about these dangers so that if it happens you won’t feel left out and depressed. As a result of that, they started to feel happy that I have actually informed them because most of them are initially told that transplant was a benign process that it can be done without any significant problem after.

Dialysis

Basically, hemodialysis liked we talked about in the previous chapter involved coming to getting blood drawn and run through a machine and then returned back to you. What basically that involves is coming to a Center where the dialysis is being performed. Most Centers are close to your house as much as possible, but in some cases especially in the big cities there is not provision for home hemodialysis. What this basically means is you have the machine that is being provided at home to the patient and they themselves can connect themselves to the machine and do the dialysis while they are sleeping at night through the blood, but in many, many Centers because of some financial regulations this is not an option to many people and the many Centers the patient has to come to a Center where it must connect based on the physicians or your nephrologists orders and you get the dialysis for usually four hours three times a week. Once in a while a blood work is done to identify how well dialysis is clearing your toxins. A normal good dialysis you should be cleaning over seventy percent of your toxins. Also, during dialysis the med now fluid is also removed through that process. By removing this fluid you may not need to be on a medicine to make you pee out more to remove any excess fluid from what you drink, but however in some people where they are significantly more fluid which translates to more weight then more fluid is taken out during dialysis based on the need to be on a fluid restriction and the amount of fluid is reached based on basically how much can be removed safely without dropping your blood pressure and how you’re estimated at that time and your physicians usually will make this adjustment for you once you start the hemodialysis.

Sometimes your blood pressure may be better and your medicine may have to be adjusted. Regular follow up with dialysis is important because in between dialysis you can actually accumulate more fluid and a naturally accumulate more toxins and during the next dialysis if you at the time miss dialysis some of these toxins rapid removal of these toxins may actually make you weaker. Most days when you start dialysis we gradually increase it up to the four hours or four hours thirty minutes maximum in most Centers. Then, if your dialysis class is very good the number can be decreased back again, so regularly every month your nephrologist will be making that adjustment if needed to your dialysis treatment.

In terms of the water dialysis, the prescription and depending on the solution that you use that is supplied to you to do at home can be altered or changed based on how much fluid you are gaining, but like I said water dialysis involves giving you more bags to connect to a catheter placed under the skin by your abdomen or your belly area and then you connect the catheter to the water bags and water fills your abdomen making your abdomen swollen and then you disconnect it, maybe move around for a couple of hours depending on the prescription. It’s usually about three to four hours and then come back and connect it to another empty bag and drain the water and again refill again. This you have to be doing every four to six times a day depending on the prescription which is more dependent on your size and how much toxins you are averaging. Then, in some cases depending on how well your belly wall is removing the toxins you may get a machine that does these exchanges for you while you are sleeping in the night, but these adjustments will be determined by your physician.

Chapter 8. Acute Renal Failure

Basically in this chapter I want to differentiate a form of renal failure that cause often but happened very quickly or that type we have been discussing that takes a slow progressive form. This acute type of kidney disease is known acute renal failure whereas the other type that happened slowly progressing over time and doesn’t get to reverse is known as chronic kidney disease. In acute renal failure or acute kidney injury, as there are some nephrologists will call it, there is usually a damage to the kidney or cause very quickly. This is actually more common than a lot of people imagine and it is known to happen in over five percent of people in the community or up to almost ten percent of people that get admitted to the hospital for any reason at all. Usually this can be caused by medications that including antibiotics that are usually given for any type of infection. Most times even regular use of NSAIDs like Motrin or Naproxen can usually cause it in the community. Though these NSAIDs are not good for your kidneys, but most times they might be helpful for arthritis so usually what I tell my patient is that should avoid taking NSAIDs or Motrin, Ibuprofen, Naproxen or diclofenac as little as much as possible, but they can still use it especially if you have a normal kidney function when they have severe pain. Antibiotics are usually given in the hospital for any type of infection and these antibiotics can injure the kidney. Many of the medications that are also given during the hospital or even outside the hospital can also damage the kidney, but these medicines are needed to treat the infection and most times after the antibiotics have been stopped the kidney function naturally get back to normal. In some cases, even when we are dehydrated like when we have diarrhea or we are vomiting the volume of blood flow that reaches the kidney actually reduced and you can have a form of acute renal failure. Now because acute renal failure happen very quickly most times in over ninety percent of occasions it also recover very quickly especially when the offender of drug or medication or condition is removed. Like if for example a middle-age or an elderly woman that was during the summer months that is sick with a fever, a condition that’s giving her a high fever and she’s vomiting and she’s also having diarrhea, she’s unable to get hold of enough liquid to drink and she might actually become a bit dehydrated and it will affect her kidney, but if she is given a lot of fluids either intravenous or by mouth and have diarrhea stop and the vomiting resolve she started. Another example if an elderly woman that is taking, has severe arthritis and she’s been consuming a lot of Ibuprofen or Motrin for the arthritis pain then the kidney function actually goes bad but after the period of arthritis is over or if the doctor switched her to another medication, that is a form of acute renal failure make that better. By definition any form of injury to the kidney that happens within a very short period of time such as less than two months usually we improve once the offending condition is resolved. This is totally like chronic kidney disease is rare. Most of the things that cause chronic disease has to be ongoing and progressive and is actually very slow form of kidney disease. In sometimes some overlap may exist between the causes of both acute and chronic such as once again the Ibuprofen and Naproxen that we take for pain even though they commonly give you acute renal failure they actually can sometimes can damage your kidney to the point that its irreversible that is the kidney function becomes permanently damaged.

Of note is that sometimes when there is no blood work once the patient has not had any blood work done for a while it is difficult for the doctor to know whether the cause of renal failure at this time is acute or if its chronic and sometimes both of them may coexist where you might have the patient that already have a chronic kidney disease before and then have another event on top that is giving him or her an acute injury on top the of the chronic form of injury to the kidney. Sometimes though with proper medical diagnosis and correction the acute part of the disease may get better, but the chronic part will still remain, so a patient’s kidney function may be running persistently at say fifty percent but when the patient gets dehydrated or is taking some antibiotics the kidney function may go down to thirty percent, so the acute form of decrease in the kidney function has occurred, but when the antibiotics is stopped or when the dehydration has resolved or maybe the NSAIDs or the drug the patient is taking is discontinued the kidney function will improve back by close or back again to way the way it was before say fifty percent and so most times I get this a lot from patients, a lot of patients who tell you oh I had this patient that was on dialysis before then she stopped dialysis and she’s still doing fine after many years or she had acute renal failure before or she had renal failure before and after a while the doctor told her she’s cured. This is not entirely true because the kidney function if its chronic and you’ve lost that kidney function it doesn’t get you don’t recover it, but however if you have an acute episode on top of that chronic that acute episode might get better so the patient might even end up on dialysis like a case that I have the patient who has a chronic form of kidney diseases had kidney function normally say around forty, but she had an infection. She had pneumonia. She was vomiting and she was started on some antibiotics that did treat infection, but towards the end the antibiotics caused it was found out that her kidney function had decreased to about ten percent. She actually started accumulating fluid. She became more short of breath and she was very weak and tired from acidosis which we will mention later and I eventually ended up putting her on dialysis for a while but after the antibiotics was all changed and some were discontinued a lot of the medicine that can affect kidney were removed, her kidney function started to get better and within two weeks she was off dialysis and her kidney function recovered about close to fifty percent where it was before so in this case the type of injury that she had even though she ended up on dialysis was a form of acute injury to the kidney because it happened within a few days or weeks before the time when she noticed she has renal failure and we were able to by making changes to her medicine, correcting all the change that could have effected the kidney were able to get her kidney function back to the point that she doesn’t usually need dialysis anymore and so she was potentially cured from dialysis even though no such cure from kidney failure really happened, but what happened is she recovered her kidney function that was temporarily lost from the offending agents to the kidney.

Chapter - 8. Hypertension.

Define htn Slow progression of htn and kidney disease Vicious circle of relationship Demage to tiny blood vesels called arterioles and increase damage to kdienys tissue . Htn taget blood pressure control

Htn in dialysis- can come off medications or can even need more

Risk of htn complications with more progression of kidneys disease

Complication of chf, stroke and pvd higher in ckd patinets

Hypertension which we’ve talked about as we are talking about can make your kidney disease worse, but however a lot of studies, a lot of medical journals totally report have shown that if you keep your blood pressure persistently between 120 to 130 as a top number or systolic and between 80 to 90 as the bottom one diastolically it slows down how quickly you kidney function get worse especially when hypertension is what is contributing to your kidney disease. Most times even if hypertension is not what is not contributing to your kidneys. Say for example you also have diabetes and diabetes is what is damaging your kidney your blood pressure control also had to tell me how quickly did diabetes damage your kidney, so hypertension control is very, very important in delaying progression of kidney disease. Most times I usually invite my patient that they should try and control their blood pressure so that it doesn’t go above 140 always, so if they can keep their blood pressure below 140 that is usually okay by me especially the top number below 140 and the bottom number below 90 that is usually okay because making it too low below 110 sometimes can make you feel dizzy, make you feel weak, make you pass out and once you start having a problem with dizziness especially when you stand up its always advisable and this is what I tell all my patients on blood pressure medicine it’s always advisable to check your blood pressure because the dizziness which is while standing especially from a lying a position or lightheadedness is more of a symptom of low blood pressure and it’s usually a symptom you might get if you were say dehydrated for example and so I usually advise my patient try as much as possible let’s check your blood pressure at home once or twice a day every day and if your blood pressure especially when I change their medications this is the advice I tell them take your blood pressure once or twice a day. If your blood pressure is still above 140 give me a call we might need to go up on the dose of the medication although you might need a medication blood pressure is always in the low side in the 100’s or below 120’s then give me and if you ever feel dizzy or lightheaded when you stand up suddenly its a sign that your blood pressure might be too low for you and you should give me a call we might have to reduce some of the medications that we are giving you.

Diet and the kidneys

Obesity and the kidneys Metabolic syndrome

Dm

Fsgs

Obesity and dialysis

What does your family traits contribute Unlike the heart, nostrong correlation in many disease , however some likel adpkd the family genes , in some rare disease like congenital receptor defects there may be electrolyte imbalance beaucse of imprope handling of

Describe adpkd

Dm nephropathy

Iga nephropathy

Thin basement mem disease

Membranous disease

Renal caluli- oxalate handling

Kdienys and the heart

Many disease