Hundreds of Interlaced Fingers
Page 20
How can I find out what caused my kidney problem?
While we usually check various blood and urine tests and look at urine with a microscope to get a sense of why someone has blood or protein in their urine, often a kidney biopsy is necessary to know exactly why—especially if the blood cells in the urine are misshapen or if there is 1 gram (1,000 milligrams) or more of protein in the urine. More than a few blood cells in the urine is never normal, but when they are shaped funny there is a problem with the kidney filters (glomeruli). Knowing exactly why allows more targeted treatment, helps us see how much irreversible damage was done, and helps us better predict prognosis. See chapter 12, Zebras, for more details on what a kidney biopsy entails.
How can I know how serious my chronic kidney disease is?
We estimate kidney function with an equation that takes into account the person’s blood creatinine concentration, age, gender, and, unfortunately, race (if Black or not) as a proxy for muscle mass. The result is a measure of how fast blood is being filtered through the kidneys, the estimated glomerular filtration rate (eGFR). In a young, healthy adult, the eGFR can be as high as 125 milliliters per minute—roughly 1/2 cup or 25 teaspoons of blood being filtered through the kidneys every minute of every day. Above 90 milliliters (18 teaspoons) per minute is considered normal kidney function. After age forty, we lose about 1 milliliter per minute every year (or 1 teaspoon every five years). We classify kidney disease into five main stages:
Stage
Estimated GFR (milliliters/minute)
Equivalent kidney function in teaspoons
Level of CKD*
Description
1
90+
18
At risk
Normal kidney function but has a risk factor for kidney disease (like a genetic trait or family history of diabetes)
2
60–89
14–not quite 18
Mild
Mildly decreased kidney function and abnormal amounts of blood or protein in the urine
3
30–59
6–not quite 14
Moderate
Start to see signs that kidneys aren’t working properly (like anemia or high phosphorus)
4
15–29
3–not quite 6
Severe
More problems with anemia, acid, calcium, and phosphorus
5
<15
< 3
End-stage kidney disease
Replacement usually needed about 5–8 ml/min (1–11/2 teaspoons)
*CKD = chronic kidney disease
The more albumin (the main type of protein) a person has in their urine at any stage, the more at risk they are of worsening chronic kidney disease, sudden temporary kidney damage (acute kidney injury), death from heart disease, and death from any cause. Urine albumin higher than 300 milligrams is more risky than urine albumin between 30 and 300 milligrams. Urine albumin less than 30 milligrams is normal.
How do I prevent chronic kidney disease?
Fortunately, most causes of kidney disease can be prevented. For every three people with chronic kidney disease in the United States, diabetes and high blood pressure are the causes of two of them. While diabetes and high blood pressure tend to run in families, one can lower their own risk by not putting on too much weight, by not drinking too much alcohol, by not eating too much salt, and by not smoking.
Other ways of preventing chronic kidney disease: Don’t use cocaine or heroin. Don’t take nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, Motrin, Aleve, naproxen, Naprosyn, or aspirin (except a baby aspirin for heart protection) regularly for more than a few days. Don’t have unprotected sex with someone who has HIV or hepatitis B. Don’t share a toothbrush or razor with someone who has hepatitis C.
I heard a person could live with just one kidney. How much is each of my kidneys affected?
Unless you have something that is in just one place, such as a blockage of the large artery that funnels blood into the kidney or a big mass or stone, both kidneys are equally affected. Both kidneys are feeling diseases (like diabetes or high blood pressure) that affect the entire body (systemic diseases).
Does alcohol hurt my kidneys?
The liver, not the kidneys, processes alcohol, which is why alcoholics sometimes suffer from liver failure. However, alcohol can indirectly hurt the kidneys if one drinks enough often enough to cause high blood pressure, which can directly cause kidney damage.
Why is there a warning on my deodorant bottle to not use it if you have kidney disease?
Some deodorants contain aluminum, very tiny amounts of which can theoretically be absorbed through the skin into the blood. Toxic levels of aluminum can cause a weakening of bones, anemia (low blood levels) resistant to treatment with iron, and dementia. This used to be a common problem in patients with advanced chronic kidney disease or on hemodialysis until the 1980s when the main sources of aluminum—medications to lower blood phosphorus levels and municipal water sources—were dealt with. Now that aluminum-based binders are rarely used in the United States and strict national and international guidelines for removing aluminum from water supplied to dialysis centers are in place, aluminum toxicity is essentially a thing of the past.
What do I need to eat or drink to make my kidney function come back or keep my kidneys from getting worse?
Unfortunately, there is no food or drink that can fix kidneys. At best, one can slow down the pace at which kidneys worsen by eating a low-carbohydrate diet to help control diabetes or a low-salt diet to help control high blood pressure. A low-protein diet can slow down worsening somewhat in people who lose a lot of protein in their urine, but this often comes at the expense of the person’s overall body nutrition and muscle health.
A kidney or renal diet is about restricting the amount of potassium or phosphorus when the kidneys can no longer control them. Following a low-potassium diet can protect you from dangerously high blood potassium levels that can stop your heart. Following a low-phosphorus diet can help maintain strong bones. But a renal diet does not make the kidneys better or slow down the progression of the disease. And since it involves limiting a lot of really good food, there is no need to follow it unless the person is at a very advanced or end-stage (on dialysis) kidney disease.
How much water should I drink to flush out my kidneys?
While it is important to not allow yourself to become dehydrated, your blood is constantly being filtered through working kidneys. That’s how they remove toxins from the blood. There is no need to flush them. Drink if you’re thirsty.
What medicine do I need to make my kidney function come back or keep it from getting worse?
Unfortunately, with chronic kidney disease, damage to the kidneys is irreversible. One can slow down the rate at which it worsens by controlling things that can hurt the kidneys (like diabetes or high blood pressure) or by avoiding things that can hurt the kidneys (like NSAIDs or too-high doses of certain antibiotics). Certain diseases can be treated with medicines that suppress the immune system. Angiotensin converting enzyme (ACE) inhibitors can slow down worsening by lowering the protein in the urine.
Can cranberry juice protect my kidneys?
Cranberry juice is a weak antibiotic, which means it can partially treat a bladder infection. The problem with treating a bladder infection partially is that it can mask the symptoms (the pain when you pee may lessen) while the infection spreads to the kidneys. Don’t rely on it to adequately treat an infection or to prevent anything. It can’t.
If I have chronic kidney disease, how soon will I need dialysis?
It depends on the cause, how early it’s detected, and how it is treated. Some diseases (particularly those that cause more than 2,000 milligrams of protein in the urine) can cause the kidneys to completely fail within five or ten years. Some causes take so long to worsen to complete kidney failure that the person will die of something else first. Repeated blood and urine tests ar
e critical to getting a better sense of the rate at which your kidneys are declining.
I feel fine and pee fine. Why do I need dialysis?
All pee ain’t good pee. The kidneys do so much more than just pass water. Urine must also contain enough potassium, acid, and toxins for the body to survive.
Most people do feel pretty well until it’s time to start dialysis. When that is depends on the size of the person, because the bigger the person, the more kidney they need. But most people will need dialysis when the estimated glomerular filtration rate (eGFR, how fast blood is being filtered through the kidneys) drops down to near 5 milliliters (1 teaspoon) per minute. But more important than the eGFR is how the person is doing (if there is nausea, vomiting, unintentional weight loss, sleeping more during the day, shortness of breath) or if the potassium level, acid level, or blood pressure can’t be controlled with medications.
What does dialysis do and how will it make me feel?
Dialysis is a kidney replacement; it does many of the jobs the kidneys can no longer do, like removing toxins and excess water, potassium, acid, and phosphorus and replacing calcium. Dialysis doesn’t work nearly as well as normal kidneys do. It really only gives a person the equivalent of severe chronic kidney disease, an eGFR of 20 to 25 milliliters (4 to 5 teaspoons) per minute. And it doesn’t correct the anemia or fully control the phosphorus. Medications can be given to help with these.
Patients on hemodialysis (through the blood) need to follow a low-potassium diet and limit their fluid intake between dialysis treatments (three times a week) because potassium and fluid can only leave the body through dialysis. Most hemodialysis patients stop urinating much at all within several months after starting dialysis. They may feel if their potassium level becomes dangerously high (though most don’t feel high potassium at all) or feel short of breath or have increased leg swelling if they drink too much fluid between treatments. Patients on hemodialysis may feel tired after their treatment. How long depends on their age and their overall health, from a couple of hours to until it’s almost time to go back to dialysis. During dialysis, some get cramping or light-headed if too much fluid is removed. People can also have problems like infection (especially with hemodialysis catheters) and clotting (especially with grafts; more than with fistulas). Grafts are more prone to clotting than fistulas, because a graft is a manmade blood vessel, while a fistula is made from the person’s own blood vessels.
Patients on peritoneal dialysis (through the belly) tend to feel more “even” and don’t have as much fluid restriction and often no potassium restriction since dialysis is being done continually every day. They don’t get cramping or light-headedness, but they may get an infection (peritonitis) if they don’t take good care of their peritoneal catheter site and have excellent technique (wash hands, wear a mask, and be careful when draining or filling the belly). Peritonitis is uncommon and usually can be treated with two to three weeks of antibiotics at home.
If I start dialysis, how long will I need it?
Until you get a transplant. Dialysis is just a kidney replacement. It’s not making the kidneys better.
Why do I have to have dialysis? Can’t I just get a kidney transplant?
Maybe. If you are healthy enough for the transplant surgery and someone is willing to give you one of their kidneys or you are placed on the kidney waiting list when your eGFR is 20 milliliters per minute and your disease worsens slowly, you may get a transplant without ever having to be on dialysis. Unfortunately, many people are not aware they have chronic kidney disease or are not in the care of a nephrologist, so referral for kidney transplant can be delayed. Further, most kidneys for transplant come from deceased donors and many more people need kidney transplants than kidneys are available, so most people will need to spend some time on dialysis before a kidney transplant is available. Finally, paying someone for their kidney is considered unethical.
If I have a kidney transplant, where does it go and do they take out my old kidneys?
Usually the transplanted kidney will be placed in the lower abdomen on the right side. It takes a couple of hours to do the kidney transplant. Taking out the original (native) kidneys would take another three to five hours, so they usually are not removed.
However, the native kidneys may be removed in these cases:
Patients with polycystic kidney disease whose kidneys cause a lot of pain, blood in urine, or infection, or are so big there’s no room for the new kidney
Patients who have a lot of infections because abnormal anatomy cause urine to go the wrong way (reflux)
Patients who are losing very high amounts of protein in their urine (nephrotic range proteinuria, more than 3 grams a day)
Patients who have a small mass in their kidney that might be caused by cancer
Can I travel if I am on dialysis? Work? Exercise?
Yes. I encourage people to work and exercise as much as they feel up to. Arrangements can be made for hemodialysis patients to visit a dialysis center where they are going. Peritoneal dialysis supplies can be shipped. However, travel outside of your state or to some countries may not be possible if you don’t have Medicare or private health insurance or if hemodialysis centers are not available.
When should someone consider not starting dialysis or stopping it?
Dialysis significantly lengthens and improves the quality of life for most people with end-stage kidney disease. However, dialysis may not extend life and may even worsen the quality of life for people who are over age seventy-five and have other serious medical problems such as dementia or ischemic heart disease (blockage of heart blood vessels). Dialysis may prove to be more of a burden. This group may be better cared for with conservative management—which includes symptom management and psychosocial/spiritual support. These patients may live weeks, a few months, or even a couple of years depending on how long their kidney function lasts. In the end, they will become sleepier and sleepier over time. Some may develop nausea, vomiting, or cramping. One patient I cared for had a seizure. There are medications to minimize all of these symptoms.
Stopping or withdrawing dialysis should be considered when things change for the worse. For example, if a person is diagnosed with a new terminal condition or has significant worsening of an existing condition, then stopping should be considered, particularly if dialysis is becoming harder to do and doesn’t seem to be helping the person feel any better. People who have very little or no kidney function and withdraw from dialysis completely will die within a few days or up to two weeks.
How can I support someone who has chronic kidney disease, who is on dialysis, or has a kidney transplant?
Different people have different needs depending on where they are in the course of their illness. And different people have different personalities with varying abilities to ask for or accept support. Some will fear that they are or will be a burden to those around them. Ask. Offer.
For someone just finding out about their diagnosis or that they may soon need dialysis, offer to go with them to see the doctor or to educational sessions. It’s difficult for some people to hear, comprehend, and think of what questions to ask—especially when the news is upsetting. Encourage them to write down questions before appointments. Take notes on what is said.
If you live with someone who has very advanced chronic kidney disease or is on dialysis and needs to follow a low-potassium and/or low-phosphorus diet, understand what their restrictions are and be supportive. For example, if the person needs to follow a low-phosphorus diet, don’t bring liters of Diet Coke or Pepsi home; Diet Sprite and 7UP are preferable for soda drinkers.
Someone who is about to have a kidney transplant will need support in those first few months. They will need rides to and from doctor appointments or the lab. They may need help changing bandages or picking up medications from the pharmacy.
Wherever a person may be in the course of their illness, it is important for the people who care for them to have empathy, not pity, for their situation. To
support their self-sufficiency, not mother them. And, most important, to just be there and not run.
Still more questions? Check out the National Kidney Foundation (www.kidney.org) or American Association for Kidney Patients (www.aakp.org) for additional information.
About the Author
Vanessa Grubbs, MD, is an associate professor of medicine and nephrology at the University of California, San Francisco, and maintains a clinical practice and research program at Zuckerberg San Francisco General Hospital. She received her undergraduate and medical degrees from Duke University and teaches writing for patient advocacy to medical students and practicing physicians. She lives with her husband, teenage son, and two dogs in Oakland, California. This is her first book.