Curing Kidney Problems Permanently

Kidney Function Restoration Program

The All Natural Kidney Health & Kidney Function Restoration Program is a compilation of the best and most effective natural treatments for kidney disease from around the world. The system is meant to complement your usual medication and not to replace it. This easy to understand kidney disease program can help you make better-informed decisions about what is the right thing to do to support your kidney and return it to its former healthy state. The techniques shared in this program will help cure and retain your kidney back to its natural wellness. You may even be able to postpone or entirely avoid dialysis or a kidney transplant forever. The All Natural Kidney Health and Kidney Function Restoration Program contain zero filler and is fully backed by modern-day scientific research. Everything contained in this program is safe, natural, and with good safety profiles, proven case studies and doctor recommended. Many of the products including the diet, herbs, and supplements have been used safely in other countries for many years and in several hospitals in the United States. Read more...

Kidney Function Restoration Program Summary


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Dialysis deferral 4 years

Norton Cox, a 77-year-old retired NASA engineer, was referred in April 2000 with a five-year history of high blood pressure and chronic kidney failure. He also had an enlarged prostate. Despite treatment with an ACE inhibitor, serum creatinine concentration had increased to 3.3 mg per dl. He had had one episode of amnesia three years ago, which left him with some problems with memory ever since. He complained of muscle cramps, but only after playing tennis. He had no other symptoms. He was placed on a very-low-protein diet supplemented by essential amino acids. In the ensuing two years, his kidney function (measured every three months) has not changed. He remains essentially free of symptoms. He may never go on dialysis.

Patients with Kidney Failure Caused by Drug Abuse

Nephrologist, who advised against the program they were following and recommended that he instead take 70 g of dietary protein per day. The nephrologist also said that Leigh should get ready for dialysis. However, the couple persisted with dietary treatment. By October 29, 2002, Leigh's serum creatinine level was back down to 3.5 mg per dl and his serum urea nitrogen level was 32 mg per dl. Serum albumin level is normal (3.9 g per dl). His nephrologist now tells him that it may be possible that he will never need dialysis. Leigh is currently consuming between 40 and 50 g of protein per day and taking 10.5 g of amino acids per day. He has no symptoms, and plays tennis, gardens, and goes to the gym.

The Production of Dialysis Fluid

Catridge Renal Care

Historically the production of dialysis fluid was by the manual mixing of concentrated electrolyte solution with water in a large tank, which was then heated and pumped to the dialyser 1 . With the advent of single-patient proportioning systems in the late 1960s, the production of the dialysis fluid moved to the patients bedside and whilst this approach remains the most widely used, alternatives such as a central delivery system or systems that incorporate pre-mixed dialysis fluid continue to be used 2 . Early single-patient proportioning systems used sodium bicarbonate for buffering, but problems arising from the formation of calcium carbonate meant that this approach was abandoned in favour of acetate 3 . Acetate remained the buffer of choice until the early 1980s when, with the increased use of high-efficiency dialysis treatments and the availability of new technology to minimise calcium carbonate formation, bicarbonate re-emerged as the preferred buffer. The preparation of...

Chronic Kidney Disease 2007

9th International Conference on Dialysis, January 24-26, 2007, Austin, Texas 7 Finances of the Independent Dialysis Facility 12 Dialysis and Nanotechnology Now, 10 Years, or Never 18 The Basic, Quantifiable Parameter of Dialysis Prescription Is Kt V Urea Treatment Time Is Determined by the Ultrafiltration Requirement All Three Parameters Are of Equal Importance 31 Impact ofthe Change in CMS Billing Rulesfor Erythropoietin on Hemoglobin Outcomes in Dialysis Patients 39 Diabetes Changing the Fate of Diabetics in the Dialysis Unit 48 Major Difficultiesthe US Nephrologist Faces in Providing Adequate Dialysis 53 What Is Needed to Achieve a Hemoglobin of 11.0-13.0 g dl in End-Stage Renal Disease 69 Inflammation and Subclinical Infection in Chronic Kidney Disease A Molecular Approach 77 Managing Complexity at Dialysis Service Centers across Europe 90 Treatment Time and Ultrafiltration Rate Are More Important in Dialysis Prescription than Small Molecule Clearance 99 Increasing AV Fistulae and...

Is Remission of Kidney Failure Possible

There has been a lot of talk recently about remission of chronic renal failure. A decrease in the loss of protein in the urine, in the absence of kidney failure, or when the kidney disease is acute, certainly does occur. But a small scarred kidney is not going to grow back into a normal one, no matter what. There is no such thing as remission of chronic renal failure. However, arresting the progression of the disease is a real possibility, as shown by a number of publications and by several detailed accounts of patients given in Chapter 22. If kidney failure can be arrested permanently before it gets severe enough to cause symptoms, the only problem for the patient is the drugs and or diet that must be followed for this situation to continue. This is not remission, but arrested progression. I did have one case of real remission (page 160), in which kidney function rose to normal. This must mean that the low kidney function seen at the patient's first visit was caused not by chronic...

Patients with Hypertensive Kidney Disease

Chester Land, a black retired postal supervisor, was referred at age 61 with a 20-year history of hypertension. By age 59 his serum creatinine level was elevated, though he had no symptoms of kidney disease. Physical exam showed only hypertension, but kidney function was severely reduced. He was prescribed a very-low-protein diet supplemented by essential amino acids or ketoacids (in addition to his antihypertensive drugs and diuretics). A few years later a routine lab report raised the spectre of severe intestinal bleeding, until the lab error was discovered. At age 66 a blood test for prostate cancer was reported as abnormal and confirmed by prostate biopsy. He underwent a course of radiotherapy. During eight years of dietary treatment, kidney function did not worsen nevertheless, he eventually started dialysis. Despite some complications, he is still doing fairly well, having received a transplant. In retrospect, dietary treatment probably deferred dialysis for about four years.

Changing the Fate of Diabetics in the Dialysis Unit

In a symposium on diseases of kidney reported in 1971 Williem J. Kolff was quoted as saying in 1938, 'Gradually the idea grew in me that if we could only remove 20 g of urea and other retention products per day we might relieve this man's nausea and that if we did this from day to day, life might still be possible' 8 . Dunea 8 started his article after this statement and wrote, 'Within three decades dialysis has revolutionized the field of nephrology and opened new vistas in the treatment of uremia. Yet, dialysis gradually outgrew its difficult beginnings and became established among the great medical achievements of our age.' In this article there is no mention of the diabetic ESRD patient. A year later in 1972, Ghavamian et al. 9 report on 9 patients with renal failure resulting from DN who were treated by hemodialysis. The average duration of diabetes was 21 years and the average duration of nephropathy was 26 months. One patient survived for more than 3 years. The others survived...

Gout and Kidney Failure

Gout is much more frequent in patients with chronic renal failure than in the general population. The explanation lies in the body's control of serum uric acid levels. Uric acid normally is excreted in the urine, but when kidney function decreases, uric acid excretion decreases and, as a result, blood levels tend to rise. An elevation above 6 mg per dl tends to cause precipitation of uric acid in joints (causing gout) and also in the kidneys, sometimes leading to a uric acid kidney stone. In addition, diuretics such as thiazides and furosemide, which people with kidney disease often use, increase uric acid levels and make gout more likely. Gout also may be the cause of kidney disease. High uric acid levels (over 13 mg per dl in men and over 10 mg per dl in women) can lead to chronic renal damage.

Hypertension in Hemodialysis Patients

Hypertension occurs in 90 of patients starting hemodialysis and persists in 70-90 of hemodialysis patients in the US 57 . In the large, multicenter Hemodialysis (HEMO) Study more than 70 of patients were hypertensive by JNC VI guidelines, and almost 75 required antihypertensive medications 58 . This is contrary to the situation in the late 1960s, when strict control of true dry body weight was practiced and the majority of patients did not require antihypertensive agents 59 . There is a consensus that most patients on dialysis have volume-dependent hypertension. Only a small proportion of patients have vasoconstrictive hypertension requiring bilateral nephrectomy in the past 59 or blood The possibility of controlling blood pressure in a reno-prival state by drastic reduction in dietary salt intake was first shown by Kempner 60, 61 in the 1940s. It was subsequently shown that the beneficial effect of the 'rice diet' on hypertension was related to the lowering of plasma volume and...

The Withholding and Withdrawal of Dialysis

Two other topics need to be addressed, unpleasant though they are withholding of dialysis and withdrawal from dialysis. Either is fatal within a few weeks. Withholding dialysis obviously comes up for discussion only when the burdens of dialysis treatment are expected to exceed its benefits. It is not hard to imagine circumstances under which this could be true. Dementia, multisystem disease including cancer, and extreme old age come to mind. In the early days of chronic dialysis, people over a certain age were automatically refused government-subsidized dialysis in Great Britain and other countries, and this issue keeps coming up. For a time people with diabetes were turned down. Present practice in the United States is to accept just about anybody. Clearly some of the people being placed on dialysis cannot be expected to receive much benefit from it. Withdrawal from dialysis, which is an even thornier issue, is very common. As noted earlier, the official U.S. government report for...

Coping with Kidney Disease

A 12-Step Treatment Program to Help You Avoid Dialysis Coping with kidney disease a 12-step treatment program to help you avoid dialysis Mackenzie Walser, with Betsy Thorpe, and contributions by Nga Hong Brereton. Part I Looking at the Disease of Kidney Failure 2 Are You at Risk for Kidney Failure 17 3 Symptoms of Kidney Failure 27 Part II How to Treat Kidney Failure 4 Treating Kidney Failure 35 16 Step 12 Know the Medications That Slow the Progression of Renal Failure 130 Part III Tracking Kidney Failure, Dialysis, Transplants, and More 17 Keeping Close Watch on Your Kidney Failure 139 19 Safe and Unsafe Medications for Patients with Kidney Failure 163 20 Transplantation as an Alternative to Dialysis 167 21 When to Opt for Dialysis 172 22 Patients Who Have Avoided Dialysis 180 Kidney disease is a huge, underrecognized and undertreated problem in the United States. In Coping with Kidney Disease, I hope to raise awareness about this disease among patients and their families and...

CASE 4 Progressive Diabetic Nephropathy Case Description

This 39-yr-old woman was diagnosed with type 1 diabetes mellitus at the age of 7 yr, during an evaluation for chicken pox. Presenting symptoms included weight loss and frequent urination and was found to be in ketoacidosis. Complications from diabetes at present include neuropathy, nephropathy, and proliferative retinopathy. Her only other medical problem is hypertension.

Behaviors and Medical History That May Lead to Kidney Failure

Nonprescription analgesic drugs, sometimes called nonsteroidal anti-inflammatory drugs (NSAIDs), sold singly or in combinations, have the potential to cause kidney failure, when taken long term. Examples are Advil, Aleve, Alka-Seltzer, aspirin, BC Powder, Ecotrin, Excedrin, ibuprofen, Motrin, Tylenol, Vanquish, and many others. Combination drugs seem to be especially dangerous. NSAIDs are probably the most widely used drugs in the United States, but no one knows for sure how many patients with chronic kidney failure got there because of these drugs. If you must take medication for chronic pain, don't take it for more than a few days at a time. Anyone taking these drugs for more than a week at a time should check their urine for protein at least once a month as described in Chapter 3. If there is protein in your urine, stop the drugs immediately and check again after a week or two. If protein persists, see your doctor. There is a group of patients whose renal disease is clearly caused...

Cachexia in Chronic Kidney Disease

Many reports indicate that in patients with advanced chronic kidney disease (CKD) and those on dialysis there is a high prevalence of PEM, up to 40 or more, and a strong association between malnutrition and greater morbidity and mortality 25 . CKD patients not only have a high prevalence of malnutrition, but also a higher occurrence rate of inflammatory processes. Many conditions leading to malnutrition and wasting may also cause inflammation. Oxidative stress may be a major underlying cause for both conditions 26 . Since both malnutrition and inflammation are strongly associated with each other and can change many nutritional measures and clinical outcomes in the same direction, and because the relative contributions of measures of these two conditions to each other and to poor outcomes in CKD patients are not yet well defined, the term 'malnutrition-inflammation complex syndrome' (MICS) has been suggested to denote the important contribution of both of these conditions to end-stage...

What Is Kidney Failure

Kidney failure means loss of some (but not all) of the filtration capacity of the kidneys, which can be caused by a fall in blood pressure, a blockage of the blood circulation to the kidneys, blockage of urine outflow, or by disease of the kidneys themselves. Many different kinds of kidney disease are recognized, all of which cause loss of filtration capacity, but some of which are rapidly reversible. These reversible types of kidney failure are known as acute kidney failure. Acute kidney failure can be caused by drugs toxic to the kidneys, by a severe reduction in kidney blood flow (for example, during surgery), and by many other causes. Urine output usually falls drastically, and waste products accumulate in the blood. But amazingly, complete recovery can occur within a few weeks. Patients often need dialysis temporarily. Chronic kidney failure is generally not reversible, but often (though not always) gets progressively worse. When about two-thirds of filtration capacity is lost,...

The Diagnosis of Kidney Failure

How many people actually know they have chronic renal failure and have been properly diagnosed in order to receive treatment Unfortunately, the answer to this question is not known even approximately. In a study reported at the American Society of Nephrology meeting in 2000, 889 U.S. relatives of dialysis patients were screened. The majority had signs of kidney disease, but most of these people were unaware of their renal risk status. If we compare this statistic to people with diabetes, 70 percent of diabetics were aware that they had diabetes, while only 10 percent of subjects with evidence of chronic renal disease were aware of having it. Perhaps most alarming was the observation that the patients' physicians, when sent the results of the survey, often failed to change any aspect of their treatment. (We'll discuss this more in the next chapter.) A survey of 1,436 adults in Venezuela revealed six individuals with persistently elevated creatinine levels, without apparent cause for...

How Big a Problem Is Kidney Failure

Over 300,000 patients have end-stage renal disease and are currently on dialysis in the United States, and another 300,000 to 400,000 in other countries. (Hundreds of thousands of others who need dialysis in third world countries don't get it for economic reasons.) By 2010 there probably will be about 650,000 patients with ESRD in the United States, if the same rate of increase continues. Some of this increase represents wider availability but kidney failure also seems to be getting more common. These are the only statistics about the prevalence of kidney disease that have any reliability, and they do not measure prevalence of all cases of kidney failure they measure the prevalence of end-stage kidney disease only, when dialysis is essential to survival. The prevalence of all cases of kidney disease in the United States can be estimated from large surveys of apparently normal samples of the population, in which a main indicator of kidney function, serum creatinine concentration, is...

Are You at Risk for Kidney Failure

Most people who have early kidney failure are unaware of their condition because of the notable lack of symptoms in the early stages. (We discuss symptoms in Chapter 3.) This is true in the case of other diseases too (like diabetes and hypertension) but is particularly common in kidney disease. So those people who are at risk for kidney failure, either because of inherited susceptibilities or risky behaviors, should be aware of the possibility of contracting a kidney problem. In Chapter 3 we discuss how easy it is to discover the presence of kidney disease by utilizing a simple at-home test, but first let's find out whether you fall into one of the at-risk groups.

Genetic or Family Predisposition for Kidney Failure

Men are slightly more susceptible to kidney failure than women. African Americans comprise 30 percent of those with end-stage kidney disease (ESRD), almost twice their frequency in the population at large. Native-born Americans and Pacific Islanders are also particularly susceptible, but anyone can get kidney disease. The following groups of people are at high risk for developing kidney disease owing to inherited susceptibility. Relatives of People on Dialysis As mentioned, a majority of first-degree relatives of patients (siblings, children, and parents) with ESRD have signs of kidney disease and usually are unaware of it. The explanation is uncertain, but this observation suggests that congenital or familial factors may be of major importance. A check on urine protein and blood pressure of those at risk could identify most of those who may develop kidney failure. Such individuals need to check their own urine protein and their own blood pressure and report to their physician if...

Dialysis Prescription

The only widely accepted method to quantify the dose of dialysis is the fractional clearance of urea from body water or Kt VU, where K is dialyzer urea clearance, t is treatment time and V is the urea distribution volume (KDOQI) which is considered to be a dose surrogate for removal of low molecular weight toxins. There have been two prospectively randomized, controlled trials (RCTs) of dialysis therapy 1, 2 and in both these trials the dialysis dose was tightly controlled with urea kinetic modeling (UKM). In contrast there have been no prospectively RCTs on the effect of treatment time on outcome. Over the years large observational studies (OSs) have not shown a consistent effect of treatment time on mortality until recently two fairly large OSs were report- ed which statistically show an association of longer treatment time with lower mortality 3, 4 . However, the validity of OSs, which might be characterized as 'guilt or innocence by association', have recently been seriously...

Diseases That Lead to an Increased Risk of Kidney Failure

Sometimes it's the diseases you already have that can cause trouble for your kidneys. The most common culprits include diabetes and hypertension. A few patients develop kidney failure secondary to potassium deficiency. People with either kind of diabetes (insulin-dependent and non-insulin-dependent) may get kidney failure after a decade or more of suffering from this disease. People with diabetes now comprise the largest group of patients starting dialysis in the United States and account for a large portion of the deaths from kidney failure. Diabetic kidney disease is relatively easy to detect in the early stages, because traces of protein appear in the urine. However, only one-third of subjects with traces of protein in their urine (microalbuminuria) will go on to develop full-blown kidney disease, with substantial amounts of protein in the urine. People with diabetes can and should test their urine for protein at least once a month. (Details of this test are given in Chapter 3.)...

Cystic kidney diseases

Autosomal dominant PKD is the prototype, and by far the most prevalent, inherited cystic kidney disease. Diagnosis is based mainly on renal ultrasonographic findings, in at-risk subjects belonging to ADPKD families 4 . Normal renal ultrasonography after 30 years of age excludes the diagnosis, but this is not true for younger subjects. Genetic diagnosis may therefore be required in rare instances (i) when living related kidney donation is considered in at-risk subjects aged less than 30 years (ii) in young at-risk subjects belonging to families with intracranial aneurysms (iii) in young subjects who 'need-to-know' for various reasons, including family planning or professional choice and (iv) in the very rare PKD families in which rapidly progressive ADKD appears in the first years of life and carries a high risk of recurrence in siblings. In these cases, linkage analysis is often the only method available. Indeed, the direct identification of mutations has been performed so far in a...

Anaemia and renal failure

Anaemia is an important complication of renal failure as a result of the loss of the capacity to synthesize erythropoietin. However, iron deficiency is also an important cause of erythropoietin resistance. While ferritin is a good marker of iron status, this is less true in patients with a chronic disease such as renal failure. An alternative proposed marker is soluble transferrin receptor, the level of which is influenced by iron status but not the coexistence of chronic disease. Daschner and colleagues 31 have investigated the efficacy of both ferritin and soluble transferrin receptor in the monitoring of erythropoietin and iron therapy in 27 patients on dialysis (11 haemodialysis and 16 peritoneal dialysis). They studied the relationship between erythropoietin requirements and various parameters of erythropoiesis. A significant correlation was shown between the erythro-poietin efficacy index (erythropoietin dose divided by haemoglobin concentration) and soluble transferrin receptor...

Does Eating Too Much Protein Cause Kidney Failure

One speculative cause of kidney failure is eating too much protein. The beneficial effect of protein restriction on the symptoms and the course of renal disease, discussed in Chapters 4 and 7, has logically led to the question as to whether a high intake of dietary protein can cause kidney disease. Some authors have gone so far as to recommend that older people in particular should cut down on dietary protein in order to reduce the incidence of kidney failure. The evidence supporting the idea that high protein intake damages the kidney is unconvincing. The only experimental evidence supporting this idea comes from studies done on rats, especially after removal of one kidney and part of the other. Rats develop renal failure with age almost universally. (Many lab rats don't live long enough to get it.) The predominant lesion is a process called glomerulosclerosis. Although it was at first reported that protein intake was a determinant of this process, caloric intake was later shown to...

Symptoms of Kidney Failure

Kidney failure, unlike disease of many other organs, does not lead to symptoms that point to the site of the problem. Pain in the kidney region, for example, is an unusual complaint, and contrary to what you might expect, patients with chronic kidney failure rarely note changes in urination. There is no change perceptible to the patient in the volume, color, appearance, or odor of the urine. Some persons with early renal insufficiency get up to urinate during the night more frequently, but this is by no means universal and has so many other causes that it cannot be considered a symptom of kidney impairment. While both the minimal volume of urine (during dehydration) and the maximal volume of urine (formed during water loading) are progressively reduced as kidney impairment becomes more severe, patients with chronic kidney failure almost never notice the change. Patients who develop the nephrotic syndrome (see Chapter 18) often notice foamy urine (due to its high protein content),...

The Problem with Dialysis

Dialysis is life-saving, and we are lucky to have it to extend the lives of those with kidney failure. The difficulty with this program, apart from its high cost, is that it is a far from ideal solution for most patients. Regular dialysis is an enormous physical burden. Many dialysis patients do not feel well and suffer from fatigue or sometimes more specific complaints, such as weakness, itching, muscle cramps, shortness of breath, and nausea. Only about half continue working the others collect disability benefits. The death rate of patients on dialysis in the United States is still alarmingly high, over 20 percent per year, although it has fallen steadily since 1988. Part of this high mortality is attributable to the fact that a significant number of new dialysis patients are near death from other causes. Most of these deaths are apparently from cardiovascular disease, but the proportion is difficult to pin down from the available government reports. The 1999 summary, entitled U.S....

Treating Kidney Failure

Until about 1970, kidney failure meant death. When the kidneys stop functioning, harmful wastes build up in the body, blood pressure rises, and excess fluid may be retained, sometimes causing heart failure. As discussed in Chapter 1, the kidneys perform so many complex functions that in the past it was difficult for the medical community to treat kidney failure. Now there are three ways to treat kidney failure dialysis, transplantation, and diet. None of these choices, however, is an ideal solution. It must be recognized . . . that dialysis and transplantation represent the epitome of what Lewis Thomas has dubbed half-way technology methods, only modestly satisfactory, that place great demands on time and resources that are needed only because we are as yet unable to come to grips directly with the processes underlying the diseases that destroy the kidneys and make end-stage disease a reality to be dealt with. This burden will be reduced only when we have improved our understanding of...

High Blood Pressure and Kidney Failure

Hypertension (high blood pressure) is a common feature of renal failure. It appears in most patients at some point as the disease progresses. The reasons for hypertension in almost all patients with chronic kidney disease (in addition to those whose hypertension is their primary disorder) are complex, but have to do with hormones produced by normal kidneys that regulate blood pressure, especially hormones that control sodium balance. In susceptible people, retention of sodium increases blood pressure, and hormones that increase the sodium content of the body tend to be produced in increased amounts. Other hormones may play a role in hypertension as well, including parathyroid hormone and insulin, both of which tend to rise in patients with hypertension. The body tends to pro duce decreased amounts of substances normally released by the kidneys that lower blood pressure. For these many reasons, high blood pressure is a very common feature of kidney failure. Because hypertension further...

The Low Protein Diet and Predialysis Treatment

Before putting any patient on dialysis, doctors have an obligation to tell the patient that there is an alternative available, namely dietary treatment and close follow-up to watch for the other conditions that could endanger the patient with kidney failure. The low-protein diet is discussed in detail in Chapter 7, and other complications and their treatments are discussed in the following chapters. But let's explore the case for (and against) this alternative treatment that I advise as a first line of treatment. Let me explain the benefits of the low-protein diet and predialysis care. We have reported that in 76 patients, a very-low-protein diet with a supplement of amino acids or ketoacids safely defers dialysis for an average of more than one year. Good nutrition was well maintained during this time, despite the low intake of protein. This is critical, because protein malnutrition at the start of dialysis bodes ill for survival. A similar study was conducted by French researcher...

Water for the Production of Dialysis Fluid

Generally patients undergoing three times weekly dialysis treatments utilise dialysis fluid flow rates of between 500 and 800 ml min, which corresponds to the use of 120-200 litres of fluid over a 4-hour treatment session. In contrast to the normal population, who not only are exposed to significantly lower volumes of water and in whom the gut offers a high degree of protection from impurities that may be present, dialysis patients are not only exposed to higher volumes of water, but during dialysis only the semi-permeable membrane present in the dialyser separates their blood from the dialysis fluid. Thus many of the permitted contaminants in drinking water have the potential to cause problems in dialysis patients (table 1). To minimise risks from such exposure, standards for water quality such as the AAMI RD62 in the United States have been developed and implemented. These define the maximum permitted contaminants with compliance linked to reimbursement. The attainment of the...

Justification for Short Dialysis

Three factors were necessary for the widespread acceptance of short dialysis economic incentives, technical feasibility, and medical scientific justification 10 . Economic incentives were demonstrated by early proponents of short dialysis. In the meantime, very efficient dialyzers had been designed and their values demonstrated in short-term studies 11, 12 . Nevertheless, short-term studies would not be sufficient for the widespread use of short dialysis. Some scientific support and a mathematical formula were needed to define an adequate dose of dialysis and justify short treatment duration. Square Meter-Hour Hypothesis and Dialysis Index The first such formula was developed in the early 1970s. Uremic peripheral neuropathy was a common complication of hemodialysis and very resistant to treatment. This complication was not dependent on urea and creatinine concentrations, but was rare with 24-27 h weekly hemodialysis on standard Kiil dialyzers and in patients on peritoneal dialysis....

Evolution of Dialysis Duration

In the early 1960s chronic hemodialyses were long procedures, usually 20-40 h week on standard Kiil dia-lyzers in-center 5 or 8-10 h three times weekly at home 6 . The first trials of shorter dialysis duration were at- Dialysis Clinic, Inc. tempted in the late 1960s. Schupak and Merrill 7 indicated that shorter dialysis sessions (total duration of 1216 h week with the use of coil dialyzers) achieved biochemical control similar to that achieved on Kiil dialyzers with longer dialysis durations. The tendency to shorten dialysis duration continued in the 1970s. The major incentive was the need of more intensive utilization of dialysis centers because the number of candidates for chronic dialysis markedly exceeded the availability of treatment facilities 8, 9 . In the late 1970s, an increasing number of centers in Europe and in the US followed this trend. Short dialysis had a tremendous appeal to the patients once they were told that the results were not worse than those with long dialysis.

Advantages of Long Dialysis Large T

From the above discussion, the advantages of long dialysis to the patients are obvious better tolerance of dialysis, better control of blood pressure, better removal of MMs, better rehabilitation, and longer survival. The average ratio of patients to dialysis personnel is 3-4 to 1 in the US. Because of better tolerance of dialysis with fewer hypotensive episodes, the same ratio in Tassin is 6 to 1 56 . Thus, the financial disadvantage of longer dialysis may be blunted by a reduced staff requirement. Long di Dialysis Quality The acceptance of this index was based on insufficient data and their false interpretation. In the NCDS study the tendency toward lower morbidity with longer dialysis duration was rejected as statistically insignificant because p was 0.06 instead of 0.05 (sic ). However, the power of this study was low because of an insufficient number of patients, short study duration (52 weeks) and disregard of residual renal function, which must have been substantial as many...

Problems with Short Dialysis Small t

In the first paper on shorter dialysis duration, Schupak and Merrill 7 reported a markedly higher rate of hypertension problems than in the early reports with longer dialysis 5, 6 . The French Dialysis Registry reported a gradual decrease in hemodialysis duration during the 1970s and a higher rate of hypotensive episodes 25 . In 1983, the European Dialysis and Transplant Association reported 'the proportion of deaths in the Federal Republic of Germany was twice as high in short dialysis' 26 . An early warning that a short duration of dialysis was associated with multiple problems related to water and sodium retention came in the report by Sellars et al. 27 . Exchangeable sodium was significantly increased with short dialysis, and more patients required antihyperten-sive drugs. Another warning came from Germany in the report by Wizemann and Kramer 28 in 1987. They did not observe any significant differences in serum biochemistry between short (2.5 h) and long dialysis (4 h), except for...

Clinical Assessment of Dialysis Quality

One may ask what index of dialysis adequacy should be used instead of Kt Vurea. It is tempting to give a simple formula, easy to implement and easy for bureaucrats to control. If such a formula were really developed, nephrol-ogists would not be needed in dialysis centers - computer programs and dialysis technicians would suffice. I do not believe that such a formula will be developed any time soon as dialysis is a very complex procedure. The use of rigid, quantitative guidelines (e.g., spKt Vurea of 1.3 per dialysis) assumes that all patients behave identically in response to therapeutic maneuvers, like the mean of the group, but this is not true 88 . Medicine is still an art, not exclusively science the individual approach assumes that there are differences among patients which require adjustment of the dialysis prescription for each patient based on clinical symptoms and signs. It is better to use clinical judgment instead of misleading formulae. During the early years of chronic...

Diagnosing and Measuring Kidney Failure

How can kidney failure be diagnosed Kidney disease can be detected by imaging techniques, such as X rays of the abdomen, sonograms of the kidneys, or intravenous pyelograms. But with the exception of X rays, which might show small kidneys (indicating the presence of renal failure), imaging techniques are ordered only if kidney disease is already suspected. Thus these techniques are not generally a means of detecting kidney disease, even though they can be definitive if kidney failure is already suspected. The best screening test for chronic renal impairment is on a sample of blood. Let's find out why blood constituents change in concentration in early kidney failure. Consider now what would happen if one kidney were removed. The remaining kidney would excrete any given constituent at a rate half as great as did two kidneys before. The constituent would therefore accumulate in the body, causing a progressive rise in its concentration in the blood and in its rate of excretion....

Keeping Close Watch on Your Kidney Failure

This chapter is an important one to read to find out more about how your kidney failure is diagnosed and measured, whether your disease is being measured accurately, and whether you are getting worse. You do not need to read this chapter to find out the best way to treat your kidney failure effectively. But if you like to be well informed about the details of your disease, please read on. The information provided is particularly useful for people with kidney failure because, as noted earlier, physical symptoms are not a reliable guide to judging the severity of kidney failure or to the rate at which kidney function is decreasing. Lab measurements are the key.

Safe and Unsafe Medications for Patients with Kidney Failure

Adverse drug reactions and drug interactions are common in renal failure. Since most drugs and drug breakdown products are excreted via the kidneys, even partial loss of kidney function alters the response to a given dose. Kidney disease may change not only drug elimination, but also drug absorption and distribution throughout the body. One such effect often observed is diminished protein binding of drugs in the plasma, owing to low serum albumin level, thereby increasing the concentration of free drugs in the blood. The amount of free drug in the blood is responsible for the drug's effects. If you take a given dose of drug, the extent to which the drug gets bound to your serum albumin will have a major effect on your response The less drug that gets bound to albumin, the greater the drug's effect on your body. Thus a lower dose of the drug may be better for you. which is converted to normeperidine, the metabolite that combats pain Demerol itself does not combat pain. But...

Myeloma cast nephropathy

Myeloma cast nephropathy (MCN) is the most common form of myeloma renal disease and frequently progresses to chronic renal failure. It is often precipitated by dehydration, hypercalcemia, and use of diuretics or nons-teroidal anti-inflammatory drugs, all causing a reduction in glomerular filtration. Renal failure is reversible in about 50 of patients.8-10,46 The physical basis for light-chain nephrotoxicity has not been elucidated. The initial finding that the isoelectric point of light chain was the determinant for its nephrotoxicity has not been con-firmed.45 47 Nevertheless, coprecipitation of light chain and Tamm-Horsfall protein in distal tubules leads to obstructing cast formation, tubular atrophy, disruption of the basement membrane, interstitial inflammation and fibrosis and eventually nephrosclerosis, all features characteristic of myeloma kidney.4648

Measuring the Quality of Life in Predialysis Patients

Before they started on dialysis, apparently never having been seen before by the investigators. At least, I hope this is the case, since the patients were clearly neglected, presumably by their physicians. Not only did they have low albumin levels, indicating malnutrition, but their bicarbonate levels were not even measured. We can assume, therefore, that acidosis (low bicarbonate level) was very common and often severe, as documented by Raymond Hakim and Michael Lazarus, who reported serum bicarbonate levels in 911 predialysis patients at Harvard. Good predialysis care can almost totally prevent low serum albumin or bicarbonate levels.

Transplantation as an Alternative to Dialysis

The first kidney transplant was performed in 1954, at Peter Bent Brigham Hospital in Boston by Dr. Joseph E. Murray, from one identical twin to another. In 1990 Dr. Murray shared the Nobel Prize with another transplant pioneer, Dr. E. Donnall Thomas, who was the first to perform a successful transplant of bone marrow. In the decades since these first transplants, we've learned much about how to prevent rejection of transplanted organs, and kidney transplantation has become a good alternative to dialysis. If you have progressed to end-stage renal disease (ESRD), a kidney transplant may be the preferred treatment for you. Transplantation has even been recommended to infants, elderly patients, diabetic patients, and those with other significant health problems who would not have been candidates in the past. A kidney transplant offers improved quality of life over both kinds of dialysis. Patients who do well after transplantation generally report improvement in vitality and freedom to...

What a Kidney Transplant Involves

Kidney transplantation involves placing a healthy kidney from another person into your body. This one kidney takes over the work of your two failed kidneys. Before transplantation can be considered, your physicians need to determine if you are healthy enough to undergo the surgery. Cancer or other significant diseases might make transplantation unlikely to succeed. During the transplant, the surgeon places the new kidney inside your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Your blood flows through the new kidney, which makes urine and regulates your bodily content of many substances, just as your own kidneys did when they were healthy. Often the new kidney will start making urine as soon as blood starts flowing through it, but sometimes as long as a few days may pass before it starts working. Unless they are causing infection or high blood pressure, your own kidneys are left in place. Most people remain in the hospital just a few days...

When Should You Start Dialysis

In my opinion, many people are started on dialysis too early in their kidney failure. Dialysis should be avoided as long as possible. In recent years, doctors have begun starting patients on dialysis earlier and earlier, in the hope of thereby reducing some of the complications of dialysis. Because it has been demonstrated repeatedly that late referral by a primary care doctor to a nephrologist increases the subsequent morbidity and mortality of patients, some doctors have inferred that patients who see a nephrologist earlier and go on dialysis sooner will fare better. Not so. The issue has been obscured by the fact that late referral to a nephrologist often means urgent initiation of dialysis, which is well known to increase death rates. In fact, when patients who are already under a nephrologist's care are started on dialysis late (that is, with relatively advanced kidney failure) are compared with those started earlier (that is, with relatively mild kidney failure), no difference...

When to Opt for Dialysis

Despite all the work that you may have done in following the advice and treatment plans given in this book, and working with dietitians and your doctors, you may find that one day you do need dialysis. When kidney function gets very low, dialysis is necessary to replace the work of healthy kidneys and to remove waste products from the blood and body fluids. The two types of dialysis, hemodialysis and peritoneal dialysis, are very different. first treatment, an access to your bloodstream must be created in the wrist. You may need to stay overnight in the hospital, but many patients have this procedure done on an outpatient basis. This access provides an efficient way for the blood to be carried from your body to the dialysis machine and back without causing discomfort. The two main types of access are a fistula, in which an artery is connected directly to a vein, and a graft, which connects an artery to a vein with a synthetic tube. When you go in for your regular dialysis, you're...

Patients Who Have Avoided Dialysis

Here are stories of some patients who came to see me or contacted me regarding their kidney failure. I have recommended dietary treatment to all of them who were symptomatic and offered others the opportunity to start dietary treatment as well, after explaining that there was no evidence that it helped in the presymptomatic stage. (A few wanted to try it anyway.) As you will see by reading in particular the story of Leigh Dell, all of this can be done by telephone and does not require people to come to Johns Hopkins. About 5 percent of patients referred to me have declined to try a very-low-protein diet.

Patients with Kidney Disease Secondary to Obstructed Outflow of Urine Interstitial Nephritis

Ernie Ball is a computer systems analyst. When he was 38, he visited his doctor because he had pain in his flanks. A urine test showed protein plus red cells, and his doctor told him that he had a urinary tract infection and urethral stricture. Leg swelling appeared soon thereafter. He had taken analgesics (aspirin or Anacin plus Dristan) daily for years because of headaches. By age 40, he had high blood pressure and signs of moderately severe kidney failure. At age 56, by which time his serum creatinine concentration was 6.4 mg per dl, indicating severe kidney failure, he started a supplemented very-low-protein diet. He succeeded in deferring dialysis for four more years by means of a very-low-protein, low-salt diet plus either amino acids or ketoacids, antihypertensive drugs, diuretics, calcium, zinc, iron, vitamins, and sodium polystyrene sulfonate.

Dialysis deferral 5 years so far

Another example of avoidance of dialysis for several years with the aid of a supplemented very-low-protein diet is Mory East, a 32-year-old physician. At age 10, he developed recurrent fevers and was found to have defects in the ureters, which drain urine from each kidney into the bladder. These defects limited the outflow of urine from his kidneys and led to frequent urinary tract infections. He was operated on at that time, and the ureters were reimplanted into the bladder. Afterward he did better but had continuing protein in his urine, showing that his kidneys had been damaged. Two years ago X rays of the kidneys, after dye injection, showed that the drainage systems on both sides were dilated by the back pressure from the bladder. His kidney function had fallen to about half of normal. As his function continued to deteriorate, further surgery was performed on both sides to improve outflow. By this time he noted some fatigue but had no other symptoms. Physical exam was negative...

Dialysis deferral 2 years

Ella Johnson, a 49-year-old school teacher, came to Johns Hopkins in 1994. Polycystic kidney disease had been diagnosed from an abdominal scan four years earlier, although it was not seen in an X ray of the kidneys at age 22. The X ray was performed because she had recurrent urinary tract infections ever since age 18 and had required urethral dilatations. High blood pressure had been present for nine years and had been treated with a variety of drugs, including an ACE inhibitor. She had no symptoms of kidney failure. Her mother had had polycystic kidney disease too and had been a patient here. Ella had two healthy children. Physical exam was normal except that the left kidney could be felt easily and was therefore considerably enlarged. started fish oil and gets regular exercise. She does not smoke. During nine years of follow-up, she has progressed very slowly (1.8 ml per minute per year). At this rate she will be well into her 70s before she needs dialysis or transplantation.

Patients with Polycystic Kidney Disease

Doris Balboni, a 67-year-old retired nurse with polycystic kidney disease, was found to have severe renal failure, with a glomerular filtration rate of 10.2 ml per minute and a serum creatinine concentration of 4.2 mg per dl. She was placed on a very-low-protein diet supplemented alternately by an essential amino acid mixture and by a ketoacid amino acid mixture, both devoid of tryptophan. (Tryptophan was omitted because the Food and Drug Administration had decreed that it could not be used as a dietary supplement until the cause of a severe form of muscle disease, related to one particular commercial source of tryptophan, was clarified.) Serum tryptophan concentration fell, reaching a low of 4.16 uM (normal is 34 to 66 uM this may be the lowest ever recorded). Serum transferrin concentration and albumin concentration also fell progressively, becoming distinctly subnormal by six months. At this point Doris was clearly suffering from clinical protein deficiency caused by lack of...

Ca Kinetics in Dialysis Therapy

The primary purposes of Ca kinetic modeling during dialysis are (1) to quantitatively assess Ca mass balance during dialysis with current therapy (2) to determine the feasibility of predicting Ca mass balance from key dialysis prescription parameters so that it can be prospective-ly prescribed and controlled in dialysis therapy, and (3) to minimize accumulation and inhibit vascular calcification and mortality. There are no reported studies that we are aware of attempting to develop a model to analyze Ca mass balance during dialysis. A review of this subject in PubMed for the past 30+years indicated the most complete balance data were contained in a paper by Hou et al. 1 published in the American Journal of Kidney Disease in 1991. They reported mean serial blood levels and total net dialysate flux every 30 min in 6 patients on three different concentrations of CdiCa - 3.50, 2.50 and 1.50 mEq l. These mass balance data are extremely useful but the authors did not attempt to formulate a...

Dialysis deferral 5 years

Denton Farris, a former businessman, developed urinary protein and red cells at age 65. Blood tests showed that he had a kind of kidney disease called IgA nephropathy but only mild loss of kidney function. Because of recurrent muscle pains caused by a rare disorder called polymyalgia, he was taking 5 mg per day of prednisone. An ACE inhibitor was prescribed for hypertension, which necessitated the addition of sodium polystyrene sulfonate to prevent high blood potassium concentration. As his renal function declined, a very-low-protein diet was added, supplemented alternately by amino acids or ketoacids. Later, additional antihypertensive drugs and diuretics were also added. He took ketoconazole intermittently, with uncertain effects on progression. Erythropoietin injections were added. Finally, at age 74, he went on dialysis and died a year later, after withdrawing from dialysis.

Ca Mass Balance over the Complete Dialysis Cycle

Ca mass balance (accumulation in the body) will be determined by the net intake of Ca minus the removal of Ca as schematically depicted in figure 1. The volume of distribution for ionized Ca (VCa2+) is defined as being anatomically equal to the extracellular fluid volume (VECW). The ultrafiltrate during dialysis is considered uniformly removed from VCa, a well-mixed pool of ionized, diffusible Ca 2+. There is virtually no quantitative understanding of the magnitudes of intake, removal and accumulation with current dialysis therapy. We hope that we can learn to predict and control mass balance and the risk of Ca accumulation in the vascular system through use of kinetic modeling of Ca in dialysis therapy.

Dialysis deferral 3 years

John Traylor, an unemployed black youth aged 23, was referred with a history of kidney disease starting at age 14, with the appearance of protein in the urine on a routine exam. A kidney biopsy showed glomerulonephritis. By age 18, serum creatinine began to rise, reaching 4.0 mg per dl. Except for intermittent gout and high blood pressure, he had had no symptoms. Physical exam showed only obesity. (By this time blood pressure was controlled with drugs.) Blood potassium level was alarmingly high until an ACE inhibitor was discontinued. Blood pressure was hard to control. Allopurinol was prescribed for gout, but repeated episodes occurred despite the drug. A very-low-protein diet plus essential amino acids was prescribed at age 24. Kidney function continued to decline. Ketoconazole plus low-dose prednisone was added at age 27. Progression slowed. This regimen was continued for three more years, until he finally went on dialysis at age 30.

Renal Failure

Eighty-nine patients with chronic renal failure underwent bone density testing of the spine using QCT (90). Sixty-six were receiving long-term hemodialysis. In the 23 patients not on dialysis, spine BMD was 9 lower than predicted normal values but this difference was not statistically significant. In patients receiving dialysis however, the average z-score was -1.3. In 42 patients on dialysis who were followed over 8 months, spinal BMD by QCT decreased an average of 2.9 . Osteosclerosis was found in 11 patients on dialysis. In a cross-sectional study, 45 patients on continuous ambulatory peritoneal dialysis (CAPD) were evaluated using DXA (91). Total body, spine, and proximal femur bone densities were assessed. BMDs were not significantly different from an age-matched control population. The authors concluded that the prevalence of decreased bone density was not increased in CAPD patients. They also noted that BMD in the lumbar spine, femoral neck, and Ward's area was increased...


How Dialysis Works Back in 1912, the idea of an artificial kidney was conceived at Johns Hopkins School of Medicine in the Department of Pharmacology, where I now work. Dr. John Jacob Abel, the first head of this department, with Leonard Rowntree and Benjamin Turner, tested and then published their experience with an artificial kidney in dogs. The principle is quite simple, but the practice is not The blood is exposed, through a membrane permeable to water and small molecules but not permeable to proteins, to a solution similar in composition to body fluids, but minus the products of protein breakdown that accumulate in the blood when the kidneys fail. These products diffuse across the membrane, reducing their level in blood and body fluids. Abel, Rowntree, and Turner intended to use this technique to remove drugs toxic to the kidney from patients' blood. Sometimes artificial kidney treatment is used for this purpose even now. But most of the time it is used to treat kidney failure....

Peritoneal Dialysis

Peritoneal dialysis uses the lining of your abdominal organs to filter your blood. This lining, called the peritoneal membrane, acts like an artificial kidney. A dialysis solution of minerals and sugar (dextrose) travels through a soft tube into your abdomen. The dextrose draws wastes, chemicals, and extra water from the tiny blood vessels in your peritoneal membrane through the membrane and into the dialysis solution. After several hours, the used solution is drained from your abdomen through the tube, taking the wastes from your blood with it. Then your abdomen is filled with a fresh dialysis solution, and the cycle is repeated. There are three varieties of peritoneal dialysis continuous ambulatory peritoneal dialysis, continuous cycler-assisted peritoneal dialysis (which requires a machine), and a combination of the two. Patients usually can perform peritoneal dialysis at home without assistance. The most common problem with peritoneal dialysis is peritonitis, a

How to Work with Your Doctor

I do want you to be a well-informed patient and to take the knowledge that you learn in this book to your doctor. Take the Assessment of Care Quiz below, and find out whether you are receiving the best care possible for your kidney failure. An outline of the treatment options that might help your disease is presented after the quiz. If your doctor is unresponsive to these options, discuss with him or her why that may be. If you do not feel comfortable with the answers, consider changing doctors.

Salt and Water Excess

Salt (sodium chloride) problems are much more prevalent in patients with kidney disease than water problems and are not as easy to treat. One reason is that humans don't have true salt hunger (or salt satiety), as many species of animals do. So we continue to consume salt (or to avoid it) whatever the needs of our body may be. By contrast, when we need water, we get thirsty. Americans eat more salt than people in many societies, and it is particularly difficult for us to learn to eat foods without added salt. As the kidney is the only route for salt elimination, problems with salt retention are extremely common in patients with kidney disease. This is a universal problem in patients who have the nephrotic syndrome, as explained in Chapter 18. Salt retention always entails retention of a certain amount of water, as well, for reasons already explained If you take salt with little or no water, you get thirsty because the concentration of dissolved solids in

Measuring Your Own Blood Pressure

All patients with kidney disease should learn to measure their own blood pressure in the arm how often they need to take the measurement depends on whether it is high or not if it is normal, check it at least once a month to make sure it stays that way. If you have high blood pressure, check it and record it at least once a week, at about the same time of day. Show your blood presssure log to your doctor. If your blood pressure is consistently elevated, or if protein is consistently in your urine, see your doctor. Current recommendations are to keep mean arterial blood pressure (systolic pressure plus two times diastolic pressure, divided by three) under 95 mm Hg in patients with renal failure. This is lower than has been recommended in the past. A blood pressure of 130 80, for example, signifies a mean arterial pressure of 97 mm Hg and is slightly high. Pronounced hypertension (say, over 160 100) can not only damage the As noted earlier, there is a strong relationship between...

Step 7 Treat Anemia and Iron Deficiency

Anemia, or low red cell count, low hemoglobin concentration, and low hematocrit, is seen sooner or later in many cases of renal failure. Anemia occurs in patients with kidney failure because the hormone that signals the bone marrow to produce more red cells, erythropoietin, is synthesized in the kidney, and this process may be inadequate in people with kidney disease. Anemia in patients with chronic renal failure may cause shortness of breath on exertion and even frank heart failure. Anemia severe enough to cause symptoms is seen in about one-third of patients.

Successes Challenges and Opportunities

The combination of national and regional vascular access initiatives supported by new medical technologies has successfully increased national AV fistula prevalence from 26 in December 1998 to 33 in December 2002 and 42.9 in June 2006. Regionally, AV fistula rates range from 37.1 in Virginia and Maryland (ESRD network 5) to 59.5 in the Pacific Northwest (ESRD network 16) 11, 17 . During the same period, catheter use has increase from 19 in December 1998 to 27 in December 2002 and remained at 27 in December 2004 17 . Although programs to increase fistula prevalence do not necessarily increase catheter use, they can unless combined with concerted catheter reduction efforts. Currently, there is no routine coverage for chronic kidney disease (CKD) care and few CKD programs. These programs increase permanent access placement and decrease catheter use surrounding dialysis initiation. In the US, most patients require placement of a central venous catheter for dialysis initiation. Even in...

Materials and Methods

Nine critically ill patients with acute renal failure (ARF) requiring CRRT were included in the prospective observational cohort study. For all subjects a diagnosis of 'severe sepsis' was made according to the criteria of Bone et al. 8 including (1) at least 2 systemic inflammatory response syndrome (SIRS) criteria (2) confirmed or suspected infection, and (3) multiple organ dysfunction syndrome. The study protocol was approved by the hospital ethics committee. kidney transplant, graft failure (renal vein of transplant kidney and iliac vein thrombosis) kidney transplant, acute graft rejection ESRD End-stage renal disease DM diabetes mellitus HT hypertension CHF congestive heart failure CA cancer RRT renal replacement therapy CVVH continuous veno-venous hemofiltration IHD intermittent hemodialysis. Continuous veno-venous hemofiltration (CVVH) was started in each case when a 'failure' level was denoted using the RIFLE criteria. RIFLE is an acronym indicating Risk of renal dysfunction...

Patients with Diseases of the Glomeruli

Cary Moulin, a 40-year-old laboratory technician, was referred for treatment of glomerulonephritis, known to be progressive for the previous 19 years. He was an avid jogger, running about 48 miles a week. Physical exam showed only high blood pressure. His serum creatinine level was quite high (5.5 mg per dl), as was his serum urea nitrogen level (95 mg per dl normal is less than 22 mg per dl) yet he had few symptoms. In response to a very low-protein diet supplemented by essential amino acids, serum urea nitrogen fell to 33 mg per dl. He also received antihypertensive drugs. He alternately took supplements of either essential amino acids or ketoacids for the next five years, at which point he finally went on dialysis. Subsequently he received a transplant.

Current Conclusions with Regard to Ca Modeling

(1) A model of Ca balance during dialysis has been developed from review of polished data. (4) Interdialytic Ca mass balance studies will be required to assess mass balance over the complete dialysis cycle and optimization of Ca balance during dialysis. (5) When the model is fully validated it should be possible to reliably prescribe and analyze Ca mass balance during dialysis.

The NCDS Dosing Controversy and HEMO

In addition to the step function in outcome shown in figure 4 , continuous linear and exponential functions relating probability of failure to Kt V could also be written with equivalent p values as described in the mechanistic analysis paper 7 , Subsequently others strongly argued that outcome should be an exponential function as shown in figure 5A because of accumulating OS experiences which indicated continuing improvement in outcome up to spKt V 1.40 8 , The HEMO study 2 was subsequently undertaken to evaluate the benefit of higher dialysis doses in a RCT. The HEMO study design The UKM universe of dialysis dosing The UKM universe of dialysis dosing Fig. 6. Observational studies reported during the pilot phase of HEMO were interpreted to show that spKt V < 1.40 was inadequate dialysis. These studies had a profound effect on HEMO and moved the standard therapy area up to spKt V 1.4. Consequently the domain of NCDS dosing controversy over 25 years was not even studied. Fig. 6....

What Do Kidneys Do and What Happens When They Fail

Picture Kidneys Labeled

Before we look at what you can do when your kidneys start to fail, it's a good idea to review the basics on how the kidneys work in the body. With this knowledge, you will get a better understanding of why the kidneys are so important in the functioning of your body and the extent of the damage that can occur to your health if things do go wrong. From the kidneys, the ureters conduct urine to the bladder, which empties through the urethra. Blood is supplied to the kidneys by two renal arteries from the aorta, the main artery of the body. Reprinted by permission from Kidney Failure, the Facts, by Stewart Cameron, Oxford University Press, 1996. From the kidneys, the ureters conduct urine to the bladder, which empties through the urethra. Blood is supplied to the kidneys by two renal arteries from the aorta, the main artery of the body. Reprinted by permission from Kidney Failure, the Facts, by Stewart Cameron, Oxford University Press, 1996. Erythropoietin, a hormone that stimulates the...

Medications for High Cholesterol

Sometimes, despite making changes to their diet, some people continue to have excessive serum cholesterol concentrations. This situation occurs in patients with the nephrotic syndrome, and in those diabetics who have relatively high rates of protein excretion. These high serum cholesterol levels usually can be treated readily in patients with and without renal failure, including people with diabetes, by the administration of a statin drug. These drugs are just as effective in renal disease as in its absence, and no more toxic. They are being used more and more widely, and seem to have other beneficial effects some may reduce the incidence of Alzheimer's disease, and some may reduce the incidence of osteoporosis. Also, muscle damage can occur from statins and can lead to the release into the blood of a protein from damaged muscle, myoglobin, that can cause the kidneys to shut down entirely. This form of acute renal failure has caused the deaths of a number of patients and recently has...

Reported Clinical Studies

The serial measured and model calculated Cpi Ca and CdiCa values are plotted for the Hou data in figure 3. The calculated values agree very closely with values observed with all three dialysate concentrations when MCa is adjusted with equation 9. The powerful effect of M-Ca can also be seen. The values for CpiCa have nearly reached equilibrium with Cdi Ca when MCa 0 in the calculations. Note that although there is some change in CpCa2+, the plasma concentration is far from equilibrium with CdiCa2+ after 4 h of dialysis with substantial positive and negative Ca concentration gradients. The Ca buffer pool was very effective to minimize change in CpiCa. The properties of this pool will be discussed further below. Koo et al. 3 reported CpCaT with CdiCa 0 values in 7 studies of 6 patients with hypercalcemia and renal failure due to malignancies. They reported CpiCaT values pre-dialysis, at 1 h of dialysis and postdialysis, and Kt Vu. VCa was estimated as 11 liters and D Ca was estimated to...

High Phosphate Foods Warning

As we explained in greater detail in Chapter 13, phosphorus (as inorganic phosphate) may accumulate in the blood of people with kidney failure, and can exacerbate kidney damage. Most patients following the very-low-protein diet do not have high blood phosphate levels, because low-protein foods are typically low-phosphorus foods as well. But occasionally people have a problem with high serum phosphate despite following the very-low-protein diet. They should consume high-phosphorus foods (see later) in limited amounts or avoid them entirely. Common foods in order of their phosphorus-to-calorie ratios are listed in Table 2. The reason for listing them in this order is the same as the reason for listing protein content in relation to calories You are liable to limit your intake of these foods by satiety.

The Lack of Effective Care

Kidney failure is often undertreated by doctors. Patients frequently are told to come back for care only when they are in such discomfort that they are ready for dialysis. Numerous articles have been published in medical journals reporting various means to slow the downhill course of kidney disease even so, most patients never receive these treatments. Untreated kidney failure usually progresses to end-stage renal disease, at which point dialysis or transplantation becomes essential for survival. Every year some 60,000 people start dialysis in the U.S. But many people on dialysis don't feel well. In fact, dialysis is so grueling that, according to the official government report of the U.S. Renal Data System for 1999, 1 in 5 patients withdraws from dialysis before death. In other words, in effect they commit suicide. It should be noted, however, that death by withdrawal from dialysis is usually a good death, meaning that suffering is minimized. But clearly it is best to avoid dialysis...

The Scope of the Problem

Like Horace, millions of Americans have reduced kidney function (that is, kidney failure), and don't know it. At least 6 million people have an elevated blood level of creatinine, a likely sign of kidney failure. Among older people with diabetes or hypertension (which includes the majority of older people), 1 in 8 has kidney disease. Among noninstitutionalized adults in the U.S., 1 in 10 has either an abnormal amount of protein in their urine or reduced kidney function, or both. Americans of all ages have kidney failure, especially older people, blacks, and Native Americans.

Ketoconazole and Low Dose Prednisone

Ketoconazole inhibits the synthesis of cortisol, the main glucocorticoid hormone produced by the adrenal cortex. High rates of production of cortisol are associated with faster progression of chronic renal failure, while low rates of cortisol production are associated with slow progression or no progression. These observations led us to the hypothesis that ketoconazole administration on a long-term basis might slow the progression of renal failure. One problem with this concept is the well-known escape phenomenon When cortisol production is inhibited, adrenocorticotrophic hormone (ACTH), derived from the pituitary gland, increases and stimulates the adrenal gland to produce more cortisol. We have found that this escape can be prevented by administering a low dose (2.5 mg per day) of prednisone (a synthetic glucocorticoid) at the same time. ACTH levels do not rise, and the block in cortisol synthesis persists. We have published the results of our study on the effect of ketoconazole...

Why You May Not Have Heard about This Treatment

The existence of the ESRD program has led to an unfortunate lack of attention by nephrologists and by funding agencies to treatment of chronic kidney failure in the stages before dialysis. Sadly, while nephrol-ogists and internists may recognize kidney failure, they may advise no treatment, telling patients to wait until they're symptomatic, at which point a funded treatment program is available for everyone. Doing this would make sense if the results of dialysis and transplantation were totally satisfactory, but they are far from it. Some physicians ignore laboratory evidence that their patients have early kidney failure and fail to tell them, for example, which drugs might help, which drugs to avoid, or mention anything about the dangers of smoking or the benefits of nutritional approaches. In some amazing cases, year after year physicians fail to tell patients that they have kidney disease. Predialysis renal failure seems to be nearly unique in the extent to which it is neglected....

MEMS and ECF Volume Sensing

Critical to the success of an automated dialysis platform is on-line real-time estimation of ECF volume, a complex engineering problem in its own right. Esopha-geal Doppler monitoring (EDM), pulmonary-artery catheters, and peripheral waveform analysis all provide measures of central hemodynamic parameters. Bioimped-ance and hematocrit monitoring may provide estimates

The Low Protein Diet Versus Other Diets

Carmelo Giordano and Sergio Giovannetti in Italy first reported on the use of very-low-protein diets supplemented by essential amino acids in chronic renal failure 40 years ago. Although their clinical results were impressive, their diets, which contained very small amounts of protein, were almost intolerable. Jonas Bergstr m and his associates in Sweden were the first to recommend what I am now referring to as the very-low-protein diet. This diet contains about 22 g per day of protein for an average-size individual, much less than the average U.S. intake of about 100 g per day of protein. The reason this very low intake of protein is acceptable to most patients is that the sources of dietary protein are not restricted any food that stays within these limits is acceptable. This feature is critical, and is possible with the addition to the diet of supplements containing all of the essential amino acids as such or as their biochemical equivalents. Hence there is no need to be concerned...

Motivation for the Very LowProtein Diet

Nevertheless, the diet may be beneficial before symptoms develop, especially for people who lose a lot of protein in their urine dietary protein restriction reduces urinary protein excretion. (See Chapter 18.) It may also be beneficial in children with chronic renal failure. Some patients won't consider following such a diet. Other patients are determined to try a supplemented very-low-protein diet even before they become symptomatic, in the hope that the progression of their kidney failure may slow. There is certainly no evidence that protein restriction accelerates the progression of kidney failure, and there is no reason to fear any adverse consequences, such as protein deficiency, provided that the diet is properly supplemented with essential amino acids and is prescribed by a dietitian.

Vitamin C Effects on Erythropoiesis

The management of anemia utilizes much of the resources dedicated to patients on dialysis hemoglobin, ferritin, transferrin saturation, erythropoietin therapy and the intravenous administration of iron complexes (IV-iron) are reviewed extensively for each patient, with dose adjustments monthly or even at more frequent intervals. Improved vitamin C status may lead to improved anemia management in these patients. The biochemistry of vitamin C and iron are intimately related at the level of the gastrointestinal tract, vitamin C helps maintain iron as Fe2+, which is more soluble than Fe3+ at the alkaline pH of the small intestine, and is more readily absorbed across the intestinal mucosa 12, 13 . However, the iron requirements of dialysis patients are greater than most persons with normal renal function, and several investigations 14, 15 have reported that oral iron supple ments have limited ability to meet the iron needs of these patients. The consensus among dialysis clinicians is...

The Assessment of Care Quiz

Take the following test to assess the quality of care that you are receiving from your doctor to treat your kidney failure. You will need access to your latest lab values from a recent exam. If you do not have a copy of this report, call your doctor's office to ask for a copy. The first two questions are intended to ascertain if you have kidney failure and are not scored. Questions 3 through 14 are scored as 0 to 10 points each and are intended to assess the quality of care you are receiving. 1. Do you have kidney disease As noted in Chapter 4, the quickest way to find out (although it is not infallible) is to check your urine for protein. Buy paper test strips from the pharmacy and hold a strip in your urinary stream. If you have protein or glucose in your urine, the color will change (see package insert). If the color doesn't change, you probably do not have kidney disease (or diabetes) and do not need to take 2. Do you have kidney failure Look up your blood serum (or blood plasma)...

Does Protein Restriction Cause Malnutrition

One of the most tenacious misconceptions about kidney disease is the idea that increasing protein intake will improve protein nutrition. Logical though this seems, the opposite is more commonly the case. Most patients with chronic kidney disease receive no dietary counseling and therefore make no change to their diets. For most Americans, this means a relatively high-protein diet. (We eat about twice as much protein as we need, on the average.) As the kidneys fail, products of protein breakdown progressively accumulate in the blood. Appetite falls off, and nausea and vomiting may occur. People consume fewer calories than they need, and malnutrition rears its head. Indeed, when dietary treatment is omitted, wasting develops sooner or later. But any number of reports have documented that wasting is not a feature of properly treated kidney failure. In a paradox that has not been generally recognized, protein restriction improves protein nutrition. The largest study of protein nutrition...

Phosphorus Restriction

(2) Since dietary phosphorus ingestion is closely related to protein intake, phosphorus restriction bears the risk of developing protein malnutrition. For dialysis patients a protein intake of 1.0-1.2 g kgbody weight day and maximum phosphorus intake of 1,000 mg day has been recommended, but a much lower mean dietary intake has been reported with 53.7 8 28.6 g for protein and 903 8 468 mg day for phosphorus 21 . Achieving adequate dietary protein intake will, in most cases, be associated with higher phosphorus intake.

The 24Hour Urine Test

Another worthwhile lab test for people with kidney disease is the measurement of protein and urea nitrogen in a 24-hour urine collection. Measurement in a single urine sample is less informative, because it varies considerably from hour to hour. A 24-hour urine collection gives a much more precise estimate of just how much protein the kidneys are spilling and how much urea is being produced.

How I Came to Write This Book

I have spent 45 years here at Johns Hopkins University on the full-time faculty in the departments of pharmacology and medicine. Over the past 30 years, my colleagues and I have studied and worked with adult patients suffering from kidney failure, in the hopes of treating them effectively to delay dialysis. Through my studies and those of others, I have become convinced that the best treatment for those suffering from kidney failure is a very-low-protein, supplemented diet, with careful monitoring of lifestyle and of blood pressure to keep kidney failure from progressing. I wrote this book to share with you this knowledge, and hope that you can use it to learn to live with your kidney disease. A quantity of a chemical substance equal to the number of grams that participate in a particular chemical reaction with one mole of reactant End-stage renal disease Microgram (one millionth of a gram) The average of a number of observations The value above which half of the observations fall,...

Tracking Treatment Success

Many treatments have been advocated to slow the downhill course of kidney failure. Before one can evaluate the effect of any treatment, though, a good method for measuring the rate of loss of kidney function is necessary. Traditionally creatinine levels have been used for this purpose. When these values are plotted as reciprocals against time, they usually form a straight line. (See Figure 17.1a and Figure 17.1b.) If creatinine values are plotted against time without taking reciprocals first, you may get the impression that the progress of your kidney failure is accelerating, when it is in fact progressing at a constant rate. The reason for this result is If creatinine excretion (UV) remains constant and kidney function (creatinine clearance, UV P) steadily declines, then 1 P must decline steadily too (Figure 17.1b). The slope of this line is a measure of progression (it needs to be multiplied by an average value of 24-hour cre-atinine excretion, UV, in mg per day, in order to come...

Patients with Diabetes

Marshall Wynngarden, a 34-year-old physician, came to Johns Hopkins in 1986, with a history of insulin-dependent diabetes since age 9 and renal failure since 1983. He was complaining of fatigue, arthritic pains, sexual dysfunction, and muscle cramps. Despite an ACE inhibitor and moderate protein restriction, his kidney function declined. In 1988 he was started on a very-low-protein diet, supplemented by amino acids alternating with ketoacids. Symptoms improved, but he continued to have difficulty with control of his diabetes. Kidney function continued to decline slowly, and he finally decided to start dialysis in 1992, after four years.

Treatment of Excessive Potassium

In less urgent cases, sodium polystyrene sulfonate, an exchange resin taken in the sodium form that is not absorbed in the intestine, but takes up potassium in exchange for sodium and is excreted in the stool, can be taken by mouth. This drug is expensive and difficult to take. (It tastes like sand.) It is usually dispensed in sorbitol suspension so as to reduce its constipating effects. However, in some patients the sorbitol leads to diarrhea or to more serious intestinal problems. Other laxatives may be safer and may in fact lower potassium somewhat when given alone (that is, without the SPS). SPS without sorbitol is also available (Kionex). In mild cases, reduction of dietary potassium also may help, though in my opinion that idea is a nonstarter. I never use this last option because small doses of SPS are so effective and these patients already struggle with a multitude of dietary restrictions. If there is associated acidosis and the hyperkaliemia is...

The Goal Achieving Neutral Phosphate Balance

Neutral phosphorus balance is achieved when total body phosphorus generation (GiP) is balanced by total body phosphorus elimination (JiP). Whole body iP generation is dependent on (i) intestinal iP and protein absorption and (ii) the amount of iP released from or deposited in endogenous tissues, such as bone. Phosphate binders (PBs) are used to decrease GiP by effectively lowering intestinal phosphorus absorption. In the face of lacking renal function, iP elimination in dialysis patients is almost completely dependent on dialytic iP removal. It is therefore clear that a neutral phosphorus balance can only be achieved when the total amount of iP, which has either been intestinally absorbed or released from endogenous tissues during the interdialytic phase, is completely removed by dialysis. Since phosphate removal during dialysis is limited, as delineated below, the only way to achieve neutral balance with current treatment strategies is to lower GiP to a minimum by optimizing the...

Salt and Water Deficit

Salt depletion is uncommon in chronic kidney disease, other than salt depletion caused by too vigorous use of diuretic drugs, as explained below. Some patients show a tendency to waste salt that is, their kidneys (unlike normal kidneys) continue to excrete salt even when the body content is on the low side. But this defect is not likely to lead to symptomatic salt depletion unless dietary intake of salt is severely restricted and or diuretic drugs are overused. Hyponatremia (low serum sodium concentration) is much more common in patients with chronic renal failure than is hypernatremia (high serum sodium concentration). Hyponatremia in itself causes no symptoms unless it is severe. When patients drink too much water during their glomerular filtration rate (GFR) determination, they may develop very low serum sodium concentration, accompanied by severe headache and, rarely, by convulsions. This doesn't usually happen in people with normal or nearly normal kidney function because their...

Dietary Treatment of the

The nephrotic syndrome has been mentioned throughout the book as something that is different from kidney failure, but which often ends up causing kidney failure. Let's examine exactly what the nephrotic syndrome is and how it can be treated. The nephrotic syndrome is defined as a very high rate of excretion of protein in the urine (greater than 3.5 g per day), a low level of albumin in the blood (less than 3.5 g per dl), and edema (swelling of soft tissues, such as the ankles, the abdomen, and around the eyes). Most patients with the nephrotic syndrome also show markedly elevated levels of cholesterol and other lipids. This condition is a form of kidney disease distinct from kidney failure. The causes are numerous, including toxic reactions to drugs, allergic reactions to bee stings, various infections, cancer, a huge list of systemic diseases, and various disorders of the heart and blood vessels. For unknown reasons, young children are often affected. Cow's milk protein intolerance...

Essential Amino Acid Supplements

Supplements of essential amino acids also improve nutrition (as evidenced by an increase in serum albumin levels, which reflect protein nutrition) in patients on hemodialysis, even without dietary protein restriction. Since they already are eating substantial amounts of protein, this is hard to explain. A randomized double-blind comparison study was performed on 29 patients on hemodialysis who had subnormal levels of serum albumin at the start. After three months, those on the amino acid supplement showed a significant increase in serum albumin concentration. The problem with this treatment was compliance Patients grew tired of taking so many pills, and as the study progressed, they skipped more and more doses, or stopped taking supplements altogether. A parallel comparison in 18 patients on peritoneal dialysis failed to establish a significant effect on serum albumin level, perhaps because there were too few patients enrolled. Additional studies are in progress. It is hoped that the...

Dependence of Symptoms on Lab Results

Although the symptoms of chronic renal failure are well known and are believed to be the consequence of chemical abnormalities of the body fluids, there have been few attempts to relate these symptoms to specific abnormalities. In an effort to see if symptoms can be correlated with lab results, Ramesh Mazhari and I conducted a study based on the symptoms of 167 patients with chronic kidney disease (renal failure or the nephrotic syndrome). They were graded as to the severity of the disease, based on their biochemical abnormalities, and the severity of their anemia. We chose four symptoms to analyze in detail fatigue, muscle cramps, itching, and nausea and vomiting. When we placed most of these patients on dietary treatment, in many cases symptoms improved or disappeared. In the second analysis, we documented the level of each of the lab measurements we used to determine severity of kidney failure when, during follow-up and worsening of their renal failure, these same symptoms...

Microbiological Quality

Febrile reactions were common in the early dialysis procedures. The electrolyte concentrates in use today are manufactured in accordance with internationally recog nised standards such as ISO 13958, Concentrates for Hae-modialysis and Related Therapies. The acid concentrates do not support bacterial growth, however liquid bicarbonate concentrates have been shown to support bacterial growth and there may be a rapid increase in levels after dilution 22 . High levels in the dialysis fluid lead to pyrogen reactions and fever 23, 24 . Intact bacteria cannot cross the dialyser membrane, however bacterial products such as endotoxins, muramyl di-peptides and exotoxins, potent inducers of cytokines and stimulators of the acute phase response, are able to transfer leading to the stimulation of mononuclear cells and contributing to chronic inflammation associated with long-term hae-modialysis therapy. Such transfer is related to the type of dialyser membrane (cellulosic vs. synthetic) and the...

Increasing AV Fistulae

The pathways to increased AV fistula prevalence are now clearly delineated in the K DOQI recommendations and Fistula First change concepts 11, 12 . Patients should be referred for evaluation for access placement approximately 6 months before dialysis initiation. Arterial and venous mapping, typically by ultrasound is performed to identify appropriate vessels for AV fistula creation 13 . This provides visualization of arteries and veins including the approximately 50 of vessels that are not apparent on physical examination. To minimize early AV fistula failure, arteries should be 6 2 mm in diameter, without dampening of the waveform and without a significant pressure differential between the arms. Veins should be

Length with Mortality in Australia and New Zealand

This study was reported simultaneously 4 with the DOPPS study. It was an OS using data from the Australia New Zealand Dialysis Registry (ANZDATA). It is of interest to note that 20 of patients in ANZADATA are on home dialysis which is not a generalizable therapy category with external validity in view of the very low frequency of home dialysis in most countries. Further, the dialyzers most often used are low flux which also raises question about the generalizability of the data. Certainly arguments about time and minimum mortality cannot be compared in low flux compared to high flux therapy.

Architecture Pore Geometry and Steric Hindrance

Existing polymer membranes used in dialysis and ultrafiltration have been extensively studied. The pores in such membranes are formed by extrusion and solvent casting techniques. The geometry and surface chemistry of the pores arise from the chemistry of the polymers and the fluid dynamics of the casting process. In general, the hollow-fiber membranes are fairly thick or employ a multilayer scaffold for mechanical support, and have a distribution of pore sizes rather than a regular array of uniform pores. Pores in conventional polymeric membranes tend to be either roughly cylindrical, have a round orifice terminating a larger channel, or have a structure resembling an open-cell sponge. Extensive description of porous structures used in commercial ultrafiltration and microfiltration may be found in 9, 10 . It is not clear that any of these structures provide optimal geometries for membrane filtration for two reasons.

Step 4 Treat Salt and Water Problems

One of the main jobs of the kidney is to regulate the salt (sodium chloride) and water content of the body, that is, the salt and water balance. It is not surprising, therefore, that patients with kidney disease have problems regulating the balance of salt and water, problems that become more troublesome as renal insufficiency gets more severe. In patients on dialysis, for example, who have little or no kidney function remaining, the regulation of salt and water balance becomes critical and must be watched very closely. Even people who have some residual kidney function are at risk to retain salt and water together (or separately see below), which can cause the heart to fail.

Medications for High Blood Pressure

Before getting into specifics about drug treatment of high blood pressure in people with kidney disease, I want to emphasize some general principles. Drug treatment of high blood pressure in people with kidney disease is not the same as drug treatment of people who have high blood pressure without kidney failure. Nevertheless, the categories of drugs that are used are the same Chlorthalidone, another thiazide, recently has been shown to be particularly effective in preventing heart failure, at least in people without kidney disease. ACEIs cause a persistent chronic cough in many patients, which often goes undiagnosed for months ARBs apparently do not have this effect. The most serious limitation of these two classes of drugs, however, is that they cause potassium retention. As noted in Chapter 12, this is more insidious than potassium deficiency, because there are few if any symptoms associated with potassium excess, which can cause sudden death it is frequently undiagnosed. Unlike...

Water Excess without Salt Excess

At the other extreme, when the concentration of dissolved solids gets below a certain limiting value, we lose all interest in drinking fluids. Our brains stop producing antidiuretic hormone. In the normal subject, this causes the urine to become very dilute and to increase enormously in volume. As a result, the concentration of dissolved solids returns to a normal value. In the subject with kidney disease, by contrast, there is little increase in urine flow and the urine doesn't become as dilute. Low concentration of dissolved solids is seen more commonly in patients with kidney disease than is high concentration of dissolved solids. This condition, when severe, is called water intoxication its symptoms are variable, but often there is a severe headache.

Loss of Appetite Nausea and Vomiting

Loss of appetite, nausea, and vomiting are well-known symptoms of severe kidney failure. Typically they appear when the blood urea concentration gets quite high, but some changes in appetite, particularly an aversion to meat, may occur much earlier. Weight loss is uncommon early on. Our study, summarized in detail at the end of this chapter, suggests that anemia may be a significant factor in nausea and vomiting unlikely though this seems. Dietary treatment, as outlined in Chapter 7, usually improves appetite.

Step 8 Treat Potassium Problems

There are two problems with potassium levels among patients with chronic renal failure. One is too little, and the other is too much (medically known as hyperkaliemia). Excessive potassium is a much more common and dangerous problem than potassium deficiency, so let's look at it first.

Nonsteroidal Antiinflammatory Drugs

Long-term use of any of these drugs is likely to aggravate kidney damage and occasionally to initiate it. If you are taking any of these drugs long term, testing your urine for protein once a month or so is a good idea. If you have protein in your urine, stop the drugs and repeat the test a week or so later. If the protein is still there, tell your doctor. Two of the most commonly used drugs, aspirin and acetaminophen, have been studied extensively to determine if they adversely affect patients with chronic kidney disease. For example, in a recent study, 918 Swedish patients with newly diagnosed kidney failure and 980 control subjects were asked about their prior consumption of these drugs. The people with kidney disease reported taking both drugs two and a half times more frequently than the controls, suggesting that these drugs may have aggravated kidney disease. Some people (in both groups) reported a lifetime consumption that totaled more than 50 pounds, which sounds unbelievable...

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