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...

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....

Motivation for the Very LowProtein Diet

This diet is very likely a radical departure from the diet you're accustomed to. Many favorite foods may become taboo. Furthermore, some patients never feel satisfied on this diet and are chronically hungry. It certainly takes some getting used to, particularly when you must keep track of every gram of protein that you eat. The best advice I have to offer is to experiment with it keep track of recipes and meal planning so that ultimately you're eating meals that appeal to you. Patients often...

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...

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...

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...

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...

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...

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...

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...

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. During hemodialysis treatment, your blood travels...

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...

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...

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...

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...

Measuring the Quality of Life in Predialysis Patients

Recently some publications have assessed the quality of life in predialysis patients. Unfortunately, none has yet assessed the quality of life in predialysis patients on different regimens. Several publications also purport to document the usual biochemical abnormalities seen in predialysis patients. Again, the authors seem to forget that the results reflect the quality of care that has been provided more than the fundamental characteristics of the predialysis state. A striking example is a...

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...

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,...

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...

Dialysis deferral 4 years

Larry Phee, a former government employee (paper shuffler, in his words), came to Johns Hopkins eight years ago at age 67, with a 40-year history of insulin-dependent diabetes. For five years he had known of kidney involvement, and also had been hypertensive. Urinary protein was said to be 0.8 to 1.0 g per day, but we found only about 350 mg per day. He had been on insulin, an ACE inhibitor, and allopurinol. He had restricted dietary protein to about 50 g per day. His symptoms included muscle...

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...

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...

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...

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...

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...

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...

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...

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. As mentioned, a majority of first-degree relatives of patients...

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...

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...

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...

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...

Figure 171a and 171b

Time course of an ideal filtration marker (see text) as kidney function declines in a patient with Assumption 1 Kidney function, calculated as the rate of excretion of the marker divided by its plasma concentration, P, declines steadily with time. Assumption 2 Excretion of the marker, which is produced by the body at the constant rate, remains constant with time, despite decreasing kidney function. Consequence 1 Plasma concentration, P, of the marker increases at a progressively increasing rate...

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...

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...

Ketoconazole and Low Dose Prednisone

Ketoconazole (Nizoral) has been used extensively to treat fungal infections for a number of years. Ketoconazole also is used in renal transplant recipients to reduce the rate of metabolism of cyclosporine, thereby lowering the dosage requirement of this expensive drug. 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...

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...

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...

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...

Dialysis

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...

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...

Coping with Kidney Disease

A 12-Step Treatment Program to Help You Avoid Dialysis and contributions by Nga Hong Brereton, M.S., R.D., I.B.C.L.C. Copyright 2004 by Mackenzie Walser, M.D., and Betsy Thorpe. All rights reserved. Published by John Wiley & Sons, Inc., Hoboken, New Jersey Published simultaneously in Canada Design and production by Navta Associates, Inc. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical,...

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...

What Do Kidneys Do and What Happens When They Fail

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. The two kidneys lie in the abdomen on the muscles of the back, near the waist, and are about 5 inches long. The urine formed from each kidney passes...

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...

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...

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...

Patients with Kidney Failure Caused by Drug Abuse

Leigh Dell, age 73, has never been to Johns Hopkins, because he lives too far away. He has had protein in his urine for many years (perhaps as a result of taking Advil over a period of years following a leg fracture). He learned in August 1999 that his serum creatinine level was elevated (to 2.9 mg per dl) and his serum urea nitrogen level was 58 mg per dl (normal is less than 25 mg per dl). His wife, after some reading, decided to start a low-protein diet and tried to assemble an essential...