Kidney Disease No More

Beat Kidney Disease

The ebook teaches you how to beat kidney disease in a way that no big pharm company wants you to know. The biggest companies make their money when people like you, with kidney disease come in and wonder if there is any way that they can be cured. The medical industry profits off of these sorts of people, because most people do not know that there is a way around the mass-produced medical industry. With the information in this ebook guide you will be able to restore your help without using drugs that end up hurting your kidneys even more. You will be able to avoid surgery, or having to use dialysis just to survive. You can also improve your quality of life if you are already on dialysis or end stage renal failure. This book was born of years of research from Duncan Capicchiano, ND. All of his research, findings, and suggestions are available to you! Continue reading...

The Kidney Disease Solution Overview

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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,...

Extra Corporeal Dialysis

Other than Peritoneal Dialysis, electrolytic chloroxidizer is used as well in extra-corporeal dialysis. Because of the fact that the dialytic circuit is considered an extension of the blood circuit of the patient, it is imperative to adopt universal precautions in order to avoid potential transmission of infections. In chemical disinfection, the requirements for dialysis monitors disinfections are being easily recognizable for positive presence or for residual presence before any single use of the dialysis monitor It seems to us that the electrolytic chloroxidizer, better that any other agent, positively answer to these requirements (in particular if used after a descaling agent such as citric acid, oxalic acid or acetic acid). Furthermore, the other advantages described earlier are not satisfied by other industrial hypochlorites. In fact, because of the 1998 European new regulations concerning all medical devices, a disinfectant for dialysis apparatus must be 'CE marked'. All other...

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...

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...

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.)...

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...

Desalting And Buffer Exchange By Dialysis Through Regenerated Cellulose Tubing

When sample volume is < 200 ml, dialysis can be accomplished by placing the sample in standard dialysis tubing immersed in a buffer of the desired ionic strength and continuously stirring the buffer. For larger volumes, multiple dialysis bags may be used, but desalting or buffer exchange on a large scale is more rapidly achieved by tangential-flow diafiltration (see Alternate Protocol 1). Because the exposure time of the sample to the buffer is relatively long, the composition, pH, and ionic strength of the buffer should be dictated by considerations of protein stability when large volumes are involved, buffer price may be a factor as well.

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),...

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...

Factors that influence the development of nephropathy

Whether nephropathy ever develops and how rapidly it progresses vary immensely from patient to patient. For some, the risk of kidney damage increases with the duration of diabetes, but the risk does fall when the diabetes is continuously well controlled. For others, however, hereditary factors are also important. Even among those who have high blood sugar levels for years, there are some people who never develop nephropathy. On the other hand, there are people with fairly good diabetes control who nevertheless develop kidney damage. We know that children from families with diabetes in which one member already has a renal problem have a much higher risk, from the onset, of developing nephropathy. Unfortunately, there is as yet no definite known marker in the blood or the urine that can predict the risk of developing nephropathy for an individual patient. This would naturally be a great help, as patients at higher risk could then be managed much more intensively.

External Disinfection of Dialysis Monitors

Disinfection of the hydraulic circuits of the dialysis monitors is not the sole procedure capable of guaranteeing maximum security it is also necessary to carry out a thorough cleansing and disinfection of the external parts of the equipment before starting another dialysis session. A correct procedure includes the operators (clothing, maneuvers, instruments) and the environment (from the dialysis room to the furnishing). Having a correctly disinfected monitor in its internal components, but operating in a contaminated environment is paradoxical. Disinfection of connectors with Amuchine 25 for 10-15 min at the end of each dialysis treatment followed by a generous rinse could be very useful 64 (table 1). In table 1, we report a list of the most important incompatibilities and of the dangerous associations between chemical, disinfecting, descaling, detergent normally utilized in the dialysis centers ( 65 modified). We also report their characteristics and possible toxic effects 66-68 ....

Purification Of Map System By Dialysis

The chemistry of solid-phase peptide synthesis has been significantly improved since it was first introduced in 1963. Now synthesis of peptides of 100 or more residues with satisfactory yield and purity is possible. In general, crude synthetic MAP systems (after the cleavage step) are pure enough for many purposes (e.g., for production of antisera). When highly purified MAP systems are required (e.g., for vaccines for humans), the crude synthetic product must be purified to near homogeneity. MAP systems can be purified by dialysis, gel-filtration chromatography, RP-HPLC (unit 9.2), and high-performance gelfiltration chromatography (see Support Protocol 3). This protocol details the special procedure required for the sequential dialysis of MAP systems.

Sample Preparation by Microdialysis

Spectra Por dialysis membrane (Spectrum Medical), rehydrated If the sample contains a high concentration of salt (e.g., 2 to 8 M urea or 6 M guanidine), apply < 100 l in order to leave room for volume expansion during dialysis. 3. Cut open a small piece of rehydrated Spectra Por dialysis membrane of appropriate exclusion limit. Cover the cap and sample with a single layer of membrane and secure with the top piece of the cut tube.

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...

Synovitis in Renal Transplantation and Prolonged Hemodialysis

Articular Capsule The Hip

The pinhole scan features are similar to those seen in other types of synovitis, although they are mild unless complicated by an infection. Once infection is present, pyarthrosis manifests as extremely intense tracer uptake with a narrowed joint, which looks like a joint in flame (Fig. 8.7C). Interestingly, whole-body bone scintigraphy, a necessary imaging in bone scanning, demonstrates systemic low skeletal uptake with the absence of kidney uptake, denoting osteoarthropathy secondary to chronic renal failure (Fig. 8.7D).

Chronic Renal Failure Introduction

Chronic renal failure (CRF) is the progressive deterioration of kidney function that reaches 50 or more loss or a creatinine level of less than 2 mg dl. Causes include congenital kidney and urinary tract abnormalities in children less than 5 years of age, and glomerular and hereditary kidney disorders in children 5 to 15 years of age. The disease involves all body systems as abnormalities include water, Na+, Ca++ losses, K+, HPO2-4, Mg++ increases, and reduced Hgb and Hct that result in metabolic acidosis, anemia, growth retardation, hypertension, and bone demineralization. Eventually, if untreated, uremic syndrome develops as the kidneys are not able to maintain fluid and electrolyte balance. End stage renal disease (ESRD) is defined as loss of kidney function at 90 or greater. ESRD is the term applied when the kidneys are no longer able to clear wastes from the body. Eventually the disease terminates in death unless kidney transplantation or dialysis is performed.

Biofilm and Disinfection in Dialysis

Hypochlorite Sodium Biofilm

Disinfection enters the quality assurance program in dialysis and represents part of the various anti-inflammatory treatment strategies adopted to improve outcome in these patients. Fig. 1. Subsequent phases of biofilm formation with bacterial deposition (a), attachment (b), growing (c) up to a mature biofilm (d) onto a silicone tube from a dialysis monitor hydraulic circuit. Fig. 1. Subsequent phases of biofilm formation with bacterial deposition (a), attachment (b), growing (c) up to a mature biofilm (d) onto a silicone tube from a dialysis monitor hydraulic circuit. Fig. 2. Biofilm presence on a peritoneal dialysis catheter removed because of peritonitis caused by colonization. Fig. 2. Biofilm presence on a peritoneal dialysis catheter removed because of peritonitis caused by colonization. Today, as a matter of fact, disinfectants in dialysis are considered as class II devices and therefore regulated by FDA in the US and CE mark application directives in Europe. Therefore...

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.

Dialysis deferral 4 years

GFR fell progressively, and in 1995 he was started on a very-low-protein diet supplemented by essential amino acids, despite the absence of symptoms. Progression continued. In 1996, 200 mg per day of keto-conazole, and 2.5 mg per day of prednisone were added. At that time his GFR was 33.8 ml per min. Seven years later, it is only slightly lower (29.5 ml per min on July 18, 2003). Thus progression of his kidney disease has stopped. Between July 1999 and June 2000, he had problems with high blood potassium, owing to the ACE inhibitor and the reluctance of his primary physician to discontinue it. When it was finally discontinued (June 2000), urinary protein excretion initially increased but has now fallen again to 384 mg per day. He has no symptoms of renal failure and swims every day for 40 minutes. Dialysis deferral 7 years so far Ketoconazole also has a number of lesser side effects that often disappear with continued administration. These include fatigue, headache, light sensitivity,...

How blood pressure affects the development of kidney damage

This is most important for people with Type 2 diabetes because, in their case, the blood pressure is often already high when the diabetes is diagnosed. A large trial has recently shown a significant relationship between the value of the systolic blood pressure and the onset of kidney disease the lower the systolic pressure, the less frequent is the occurrence of kidney disease (Figure 4.7). But, as with blood sugar, there is no threshold for blood pressure below which one is definitely protected from kidney failure.

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.

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....

Purification Of IgM By Dialysis And Sizeexclusion Chromatography

The protocol involves centrifugation of ascites fluid or monoclonal antibody supernatant, followed by simple dialysis against water. IgM is separated from contaminating proteins (such as normal mouse proteins or proteins from fetal bovine serum) by use of size-exclusion (SE) chromatography. The purity of IgM is checked by SDS-PAGE and the pure IgM is stored in borate buffer. Sorvall centrifuge and SS-34 rotor (or equivalent) Dialysis tubing (appendix 3h) Additional reagents and equipment for purification of immunoglobulin G (unit2.7), protein dialysis (appendix3h), size-exclusion chromatography (appendix 3i), and SDS-PAGE (unit 8.4) 2. Transfer clarified ascites fluid or MAb supernatant to dialysis tubing and dialyze (appendix3h) against > 10 times the sample volume of distilled water for 24 hr at 4 C.

When nephropathy already exists

The more developed the kidney disease is, the more relevant is the degree of high blood pressure for the progression of the disease. If appropriate treatment can keep the blood pressure in the normal range at the stage of micro- or macroalbuminuria, the chances are good that the kidney damage will not proceed or will at least be delayed. This has been demonstrated in several studies. Figure 4.8 shows, as an example, the course of kidney disease in a patient who already had macroalbuminuria as a sign of advanced kidney damage and in whom the blood pressure was at first not well managed. At this time, the kidney function deteriorated fairly rapidly. However, it was possible, through good management of the blood pressure, to arrest the downwards trend after several months and to stabilize kidney function at a lower level. Management of high blood pressure stabilizes kidney function Management of high blood pressure stabilizes kidney function Figure 4.8 The course of kidney failure in a...

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.

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...

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...

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...

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...

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.

Clinical presentation of acute renal failure

Oliguria is a common indicator of acute renal failure, and it is marked by a decrease in urine output to less than 30 mL h. Acute renal failure may be oliguric (< 500 L day) or nonoliguric (> 30 mL h). Anuria (< 100 mL day) does not usually occur in renal failure, and its presence suggests obstruction or a vascular cause. B. Acute renal failure may also be manifest by encephalopathy, volume overload, pericarditis, bleeding, anemia, hyperkalemia, hyperphos-phatemia, hypocalcemia, and metabolic acidemia.

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...

Clinical evaluation of acute renal failure

Initial evaluation of renal failure should determine whether the cause is decreased renal perfusion, obstructed urine flow, or disorders of the renal parenchyma. Volume status (orthostatic pulse, blood pressure, fluid intake and output, daily weights, hemodynamic parameters), nephrotoxic medications, and pattern of urine output should be assessed. aminoglycoside use, or vascular catheterization. Interstitial nephritis may be implicated by a history of medication rash, fever, or arthralgias. E. Chronic renal failure is suggested by diabetes mellitus, normochromic normocytic anemia, hypercalcemia, and hyperphosphatemia. D. Skin rash suggests drug-induced interstitial nephritis palpable purpura suggests vasculitis nonpalpable purpura suggests thrombotic thrombocytopenic purpura or hemolytic-uremic syndrome. 5. White cell casts and eosinophilic casts indicate interstitial nephritis. VI. Management of acute renal failure E. Hyperkalemia is the most immediately life-threatening...

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...

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 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.

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.

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.

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. p.cm. 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...

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 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.

Animal Models of IgA Nephropathy

IgA nephropathy (IgAN) is a form of immune complex glomerulonephritis that occurs spontaneously in humans. The disease is characterized by accumulation of noncovalent macromolecular aggregates within glomeruli, and is distinguished from other forms of immune complex glomerulonephritis by virtue of the predominance of IgA as the major class of Ig within the aggregates. Although IgAN is the most common form of glomerulonephritis throughout the world, its clinical expression is highly variable and may include either occult or visible blood in the urine (hematuria), abnormally high urinary protein excretion (proteinuria), and or retention of nitrogenous wastes (renal failure) in any combination. Rarely, there is retention of salt and water as well. Likewise, pathologic expression of disease is varied and ranges from histologically normal kidneys to florid proliferative or even necrotizing endocapillary glomerulonephritis. Patients with this disease are unified by virtue of the...

Urinary Tract Infection Acute Pyelonephritis

Sequela of pyelonephritis includes changes of reflux nephropathy. These changes include renal scarring and calyceal blunting due to reflux of urine through the ducts of Bellini, resulting in parenchymal scarring. Changes of reflux nephropathy include broad-based scars centered over clubbed calyces, predominately occurring in the poles of the kidneys. Overall renal function of the affected kidney is best evaluated with radionuclide renography. AIDS Nephropathy Autoimmune deficiency syndrome (HIV AIDS) nephropathy constitutes a variety of renal pathologies. Findings are generally nonspecific, but patients with an HIV infection, renal failure, and hyperechoic nephromegaly likely have AIDS nephropathy. These sonographic findings in an AIDS patient usually indicate that the patient will develop irreversible renal failure.

Selection and Preparation of Dialysis Membrane

Dialysis membranes are available in a number of thicknesses and pore sizes. Thicker membranes are tougher, but restrict solute flow and reach equilibrium more slowly. Pore size is defined by molecular weight cutoff (MWCO) i.e., the size of the smallest particle that cannot penetrate the membrane. The MWCO designation should be used only as a very rough guide if accurate MWCO information is required, it should be determined empirically (see Craig, 1967, for a discussion of parameters affecting MWCO). Knowledge of the precise MWCO is usually not required however, it is necessary only to use a membrane with a pore size that is much smaller than the macromolecule of interest. For most plasmid and protein dialyses, a MWCO of 12,000 to 14,000 is appropriate, whereas a MWCO of 3500, 2000, or even 1000 is appropriate for peptides. Most dialysis membranes are made of derivatives of cellulose. They come in a wide variety of MWCO values, ranging from 500 to 500,000, and also vary in cleanliness,...

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...

How failing kidney function affects diabetes management

To achieve good blood sugar control in the presence of failing kidney function is a difficult task for patient and doctor. There are various reasons for this. Someone who has advanced nephropathy often also suffers from other complications of diabetes. These may include damage to the nerves that regulate the gastrointestinal tract. Then food is no longer digested and absorbed properly. Typical signs are bloating, feeling full, irregular bowel movements, diarrhoea, nausea and vomiting. The irregular absorption of food can cause the blood sugar levels to swing violently. Additionally, remember that many drugs, including those that reduce blood pressure, are excreted via the kidneys. If kidney function deteriorates and excretion does not occur properly, these drugs may persist in the circulation. This means that their effects are heightened and prolonged, which can lead to hypoglycaemia or other complications. Therefore, not all drugs are suitable for the treatment of people with...

How is kidney function measured

Blood, for example, creatine and urea accumulate. Creatine is a waste product of muscle metabolism that is normally excreted through the kidneys. Healthy people (Table 2.1) have a creatine serum concentration of between 0.6 and 1.2 mg 100 ml. The normal value in an individual depends on the muscle mass. In someone with less muscle, it is lower in 'muscle men', it is higher. If kidney function fails, the creatine concentration in the blood gradually rises. Generally, though, mild kidney impairment does not lead to a noticeable change in serum creatine concentration. It rises only when kidney function has decreased by more than half. In people with little musculature, the low starting point for the creatine concentration can mean that it stays within the normal range for a long time, even when kidney function is seriously compromised. A more exact picture of kidney function is given by the so-called creatine clearance rate. To measure this, the urine must be collected for 24 hours or...

Gel Dialysis Of Protein Samples

This protocol describes a simple method for dialyzing small interfering molecules and salts away from protein samples using an agarose or polyacrylamide gel (see Fig. 3.4.5 Freifelder and Better, 1982). Somewhat dense, well cross-linked gels are used to keep proteins from penetrating the gel while unwanted salts and low-molecular-weight compounds diffuse (are dialyzed away) into the gel. This is a micro to semimicro method, an alternative to conventional dialysis (Craig, 1967), and to the use of small pressure-membrane disposable kits or microcentrifuge filtration units with MWCO values of 5,000 to 10,000. Figure 3.4.5 Dialysis by out-diffusion of low-molecular-weight compounds into gels cast in small cavities (Beyer, 1983). Figure 3.4.5 Dialysis by out-diffusion of low-molecular-weight compounds into gels cast in small cavities (Beyer, 1983). If the wells have a diameter > 5 mm, dialyze for 1 to 2 hr or longer. The rate of dialysis is temperature dependent, so dialysis should be...

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...

Selective Precipitation By Isoionic Precipitation Dialysis Method

One of the older means of rendering proteins salt-free or nearly salt-free (i.e., isoionic) is dialysis (also see unit 4.4 & appendix 3b). However, two problems frequently arise with conventional dialysis (1) when appreciable amounts of protein are present, osmotic effects result in swelling of dialysis bags as salt diffuses outward and (2) often it is quite uncertain where the isoionic point is, even if it is feasible to deionize by dialysis against a buffer. The resin deionization method (see Basic Protocol 2), sometimes called Dintzis' method (Edsall and Wyman, 1958), automatically adjusts a protein precisely to its isoionic pH without prior knowledge of it. Proteins that precipitate immediately when deionized are troublesome in the column method described in Basic Protocol 2 and Figure 4.5.4. Precipitates plug the column and pose the problem of separating precipitated protein from resin beads. P-lactoglobulin and a number of other proteins behave in this way they have...

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...

With nephropathy is there a point of no return

Another important question is whether there is any benefit of good blood sugar control once the signs of kidney failure, either micro- or even macroalbuminuria, have appeared. This was disputed for a long time. The opinion was that there was a point of no return, after which there could be no reversing the course of the disease - it would progress inexorably until dialysis was necessary, regardless of how well controlled the blood sugar level was. But the studies of recent years have shown clearly that good blood sugar control brings benefits, even at this stage. The progression of the nephropathy can be prevented, or at least delayed, by good management. This is true for both Type 1 and Type 2 diabetes.

Various Applications in Dialysis

Ronco C, Mishkin GJ (eds) Disinfection by Sodium Hypochlorite Dialysis Applications. Contrib Nephrol. Basel, Karger, 2007, vol 154, pp 139-144 Amuchina 10 Solution, Safe Antiseptic for Preventing Infections of Exit-Site of Tenckhoff Catheters, in the Pediatric Population of a Dialysis Program

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...

Disinfection of Disposable Dialysis Tubing

The rate of continuous cycler PD use in the hospital setting is increasing. Using a cycler frees up the nurse's time. Instead of performing 4-8 manual exchanges per day, the nurse can put up enough dialysate for a day with one connection to initiate the cycle and one disconnection to terminate the cycle. Infection rate decreases due to fewer connect disconnect procedures where touch contamination is possible. The patient can be disconnected for procedures and then reconnected to the same line. Despite these advantages, there is increased cost of continuous cycler PD. The costs are related to the cycler, cycler tubing sets, cycler drain line bag and dialysate solutions. The patient must be able to disconnect and reconnect to the cycler either in between or during PD treatments as needed either in dwell or at the end of drain. Thus the concept of disinfection of disposable dialysis tubes for multiple use 19 .

Internal Disinfection of the Dialysis Monitors

Disinfection of the monitors for dialysis, whichever method and agent used, is not a single operation but consists of a series of operations in succession which should comprise primarily a procedure of post-dialysis rinsing and pre-disinfection, then cleansing, descaling, thorough disinfection and a final post-disinfection rinse so that the machine is in perfect condition for the successive dialysis sessions. Post-Dialysis Pre-Disinfection Rinse This is done with the aim of removing all residue of the dialysis solution from the hydraulic circuit of the machine, and if correctly carried out for a sufficient time with adequate flux it makes a valid contribution to the removal of organic substances such as hematic traces coming from an intradialytic rupture of the filter. It is particularly important for the removal of glucose residue which, if not completely eliminated, 'caramelizes' when heat-disinfection is used and represents an ideal pabulum for germs. The aim is to act on the...

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....

Diabetic Nephropathy

The prevalence of diabetic nephropathy has increased dramatically and is now the first cause of end-stage renal disease requiring renal replacement therapy worldwide (72). Although the genetic background is important in determining susceptibility to diabetic nephropathy, exposure to chronic hyperglycemia leading to the subsequent activation of multiple pathogenic pathways appears to be the main initiating factor (2,3,4-6,41). Diabetic nephropathy occurs in up to 30 -40 of diabetic patients. The initial abnormalities include glomerular hyperfiltration and hyperperfusion resulting in microalbu-minuria, increased glomerular basement membrane thickening, and mesangial ECM deposition. These processes are followed by mesangial hypertrophy, diffuse and nodular glomerulosclerosis, tubulointerstitial fibrosis, and eventually progressive renal failure (73). Immunohistochemical studies of kidneys from normal and diabetic rats show that glomerular basement membrane, mesangium, podocytes, and...

Dialysis

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....

Biofilm and Dialysis

Several medical devices could be used. Intravascular or urinary catheters represent the most frequent cause of medical device related pathologies, but it is during the phase of chronic kidney replacement therapy that uremic patients are at higher risk. During chronic hemodialysis infections, with related inflammatory events activation, may take place not only from vascular access but also from dialysis apparatus 12 . Even in the absence of standardized collection methods, biofilm has been detected in the hydraulic circuits of hemodialysis machines particularly in low-flux sections, loops and ultrafilters. In this biofilm, the concentrations of bacteria and endotoxins can range from 1.0 X 103 to 1.0 X 106 cells cm2 and 1-10EU cm2, respectively. Several constituents of cell wall of viable or not viable microorganisms can be released into the dialysate, including high molecular weight substances (> 100,000 Da) as well as low molecular weight ones (< 1,000 Da) or DNA fragments 13 ....

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

Largevolume Dialysis

Dialysis of samples in large, easily handled volumes, typically 0.1 to 500 ml. Dialysis membrane (see Support Protocol) Clamps (Spectrapor Closures, Spectrum, or equivalent) Macromolecule-containing sample to be dialyzed Appropriate dialysis buffer 1. Remove dialysis membrane from ethanol storage solution and rinse with distilled water. Secure clamp to one end of the membrane or knot one end with double-knots. Always use gloves to handle the dialysis membrane because the membrane is susceptible to cellulolytic microorganisms. 3. Replace the water or buffer in dialysis membrane with the macromolecule-containing sample and clamp the open end. Again, squeeze to check the integrity of the membrane and clamps. 4. Immerse dialysis membrane in a beaker or flask containing a large volume (relative to the sample) of the desired buffer. Dialyze at least 3 hr at the desired temperature with gentle stirring of the buffer. Dialysis rates are dependent on membrane pore size, sample viscosity, and...

Large Volume Dialysis

This protocol describes the use of membranes, prepared using the support protocol, for dialysis of samples in large, easily handled volumes, typically 0.1 to 500 ml. Dialysis membrane (see Support Protocol) Clamps (Spectra Por Closures, Spectrum, or equivalent) Macromolecule-containing sample to be dialyzed Appropriate dialysis buffer 1. Remove dialysis membrane from ethanol storage solution and rinse with distilled water. Secure clamp to one end of the membrane or knot one end with double-knots. Always use gloves to handle the dialysis membrane because the membrane is susceptible to cellulolytic microorganisms. 3. Replace the water or buffer in dialysis membrane with the macromolecule-containing sample and clamp the open end. Again, squeeze to check the integrity of the membrane and clamps.

Small Volume Dialysis

For solution volumes less than 100 l, the use of dialysis membrane as described above can result in unacceptable sample loss. The method described below can easily dialyze volumes as small as 10 l. The sample is held in a 0.5-ml microcentrifuge tube, with dialysis membrane covering the open end of the tube. 1. Puncture the lid of each microcentrifuge tube using a heated glass Pasteur pipet (wide end heated) or cork borer to completely remove the center part of the lid (see Fig. A.3H.1). Open lid and place a single layer of dialysis tubing over top of tube, then close lid to hold dialysis tubing in place. Alternatively, some researchers use a microcentrifuge tube without a cap. The sample is placed in the microcentrifuge tube, a dialysis membrane is placed over the top of the tube, and the membrane is secured with a rubber band. With this method, however, there is a risk that a small sample e.g., 10 to 20 pl may be lost around the edge of the tube. 2. Turn tube upside down and shake...

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.

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...

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,...

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. 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...

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.

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...

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....

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.

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)...

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.

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.

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...

Taking Supplements with Your Diet

Cium, because very-low-protein diets usually contain inadequate amounts of these substances. Almost any multivitamin suffices, unless it contains added phosphate. However, vitamin requirements for those with advanced kidney failure are different. Specially formulated multivitamin preparations are available. (See Appendix 1.)

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...

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...

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.

Water Deficit without Salt Deficit

The same time, the brain releases a hormone called vasopressin or antidiuretic hormone that makes the kidney conserve water. But if there isn't much kidney function left, the organ can't respond to the hormone's chemical message. So although people with reduced kidney function can act on their thirst, they can't produce much concentrated urine.

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.

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...

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...

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.

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.

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...

Treatment of Calcium and Phosphate Problems

I have rarely seen excess calcium levels in patients taking calcium carbonate, which is effective even though it is poorly absorbed. Calcium acetate (PhosLo) is better absorbed but may lead to high readings. This may not be a serious problem in dialysis patients, but in predialysis patients, glomerular filtration rate may decrease sharply and may not recover. Calcium carbonate is the much safer option, in my experience. Serum phosphate in patients on the supplemented very-low-protein diet is usually within normal limits, except in a few patients with very severe renal failure. This is because a low-protein diet is almost always a low-phosphate diet, too dietary phosphate is highest in foods high in protein. (See chapter 7.) Some nephrologists have recommended the use of the activated form of vitamin D, calcitriol, in all patients, at a dose of about 0.25 mcg daily. I have used this in a few patients with low serum calcium levels (corrected for albumin) but not otherwise. A recent...

Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers

Constriction of small blood vessels, leading to a rise in blood pressure and therefore in the pressure of blood within the glomerular capillaries in the kidneys. Lowering this pressure may well be the mechanism by which these drugs tend to slow progression of kidney failure. The effects of ACEIs differ from those of ARBs in several important respects. It is even conceivable that taking drugs from both classes is more effective than taking just one or the other alone. Unfortunately, side-to-side comparisons of these two classes of drugs have not been performed, because the drug industry has no interest in such trials. These drugs are also effective in reducing urinary protein excretion in the nephrotic syndrome, and they also slow progression of chronic renal failure even when added to a low-protein diet. Many clinical trials have demonstrated slowed progression with ACEIs, and more recently with ARBs, particularly in patients who have large amounts of urinary protein. Yet...

Finding Your Glomerular Filtration Rate

Final concentration to obtain GFR in ml per minute. There is no need to collect urine. Curiously, this technique, although known for decades, has been employed in the evaluation of chronic renal failure only in the last few years. It is particularly useful in children, in whom it is more difficult to obtain timed samples of urine, but a good case can be made that it also should be used in adults. There are four disadvantages 2. When kidney function is severely impaired, the steady state is reached only after a day or two of infusion, which is inconvenient to say the least. In a modification of the constant infusion technique that is very widely used, a GFR substance is injected intravenously, and its disappearance from the body is measured by several blood samples obtained during the ensuing hours. Many different formulas have been proposed for calculating GFR from timed blood samples. No urine samples are required, but this technique suffers from the same disadvantage as the constant...

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.

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...

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...

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...

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.

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.

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