Chronic Use Of Aspirin/Paracetamol Containing Drugs and Chronic KidneyDisease.

Analgesic nephropathy (Photo credit: Wikipedia)

Chronic use of over the counter pain killers have previously been cited as something to avoid if you have kidney disease. There is well established evidence that mixed analgesics have negative effects on kidney function.
So much so that a specific disorder chronic analgesic nephropathy has been described. It has been defined as the renal damage that occurs when two analgesics and caffeine or another drug is taken routinely over years. You may ask yourself who would take such medication on a chronic basis? However many people with chronic disease particularly painful conditions for which there is no definitive therapy such as chronic osteoarthritis or nerve damage take these drugs for relief of chronic pain. Problems occur with dependence induced because of ingredients such as caffiene codiene or barbiturates.

Drugs that have been implicated here include

• Aspirin


• Paracetamol


• Pyrozolones


• Phenacitin

in combination with,

• caffeine


• codiene


• or barbiturates.

A few weeks in Vietnam 310 (Photo credit: JaulaDeArdilla)

The disease itself is slowly progressive over many years and is associated with findings of scarring of the kidney with shrinking of the cortex (the place where a lot of the work of filtration is done), and over time there is a chance of transformation to transitional cell cancer of the kidney ureter or bladder.

Some Points to take home about Analgesic Induced Kidney Disease.

• The use of CT-SCAN has recently been validated as a method of detecting analgesic nephropathy in patients with stage 3 and 4 CKD. The CT scan is done without contrast and hence is safe.

• Analgesic induced kidney disease is invariably caused by compound analgesic mixtures regardless of the presence or absence of phenacetin as one of the active ingredients. Phenacetin was once thought to be the primary cause of analgesic induced nephropathy, this has proven to be false as the disease can occur with any of the drugs listed above.

• Healthy individuals who occasional take the above drugs are not at risk of renal disease.

• Paracetamol is frequently prescribed instead of aspirin like compounds because of the known association of kidney disease with aspirin however paracetamol is also a cause of analgesic induced kidney disease although the risk is described as modest.

• Analgesics may cause acute renal failure. The renal failure however is not always reversible when the drug is withdrawn.

• Once kidney disease occurs continued use of the offending drug worsens the chances of recovery and increases the rate of progression to end stage.

• In patients with stage 3 to 4 CKD the dug of choice should be the drug with the least chance of producing acute renal failure and it should be used for as short a time as possible. hence short courses of paracetamol is indicated for pain.

• Despite the toxicity of the ingredients, it is the addictive nature of the habit forming co ingredients which creates the chronic dependence which can lead to ESRD.

Kidney Cancer Treatment-Medical therapy of Renal Cell Cancer.

Gross appearance of the cut surface of a nephrectomy specimen containing a large renal cell carcinoma (the large yellowish tumour in the upper half of the kidney). (Photo credit: Wikipedia)

Non surgical therapy for renal cell carcinoma is offered when the cancer has already spread to other organs or when the cancer has advanced to nearby tissues in the vicinity of the kidney. Under these circumstances treatment of the cancer is not expected to result in a cure.

Chemotherapy
Depending on the type of renal cell carcinoma you have the rate of response to chemotherapy varies. Individuals may also differ in terms of there genetic make up and hence their response to chemotherapy.
On the average the response rate to chemotherapy is low.


Immunomodulatory Therapies

These are therapies aimed at modifying components of the immune system to alter the growth of cancer cells by forcing the body to destroy the cells. There are reports of remissions which may occur spontaneously using these types of therapies.
The include such methods as

• Stem cell transplantation


• Vaccination against tumors.


• Interferon therapy

Interferon is a substance produced by cells of the immune system. Its function is to tell other cells to resist viral infection. A small percentage of a subtype of renal cell cancer will respond to interferon alone.However interferon therapy is associated with significant side effects.

Interferon signalling (Photo credit: AJC1)

Interleukin-2 is considered standard therapy for renal cell carcinoma that is advanced. Patients do very well when there is a complete response to the drug.
Research is ongoing in this area and there is the hope that patients who are likely to have a good response will one day be identified by blood test.

The Future

The identification of the major gene that underlies renal cell cancer has allowed for theoretical constructs with which to drive research.
Research is advanced in the area of exploiting bone marrow transplantation and the use of vaccines. New drug types that inhibit the growth of blood vessels within the tumour are also
in development as adjunctive or "add on" therapy that will further add to the possibility of producing a durable remission.

Until then a combination of therapy surgical and medical may be the best approach to the treatment of Renal cell Carcinoma that is locally advanced or with distant spread. The use of interferon after surgical resection was shown to be superior to interferon alone for this patient group.

Phosphate, PTH and Kidney Disease

What is Phosphate?

image courtesy of wikipedia.

Phosphate is an inorganic ion which is present in many foods and preservatives of food. Here is a list of foods that are high in phosphate.

What are the Disorders of Phosphate Metabolism.

1. Hyperphosphatemia

2. Hypophosphatemia.

1. Hyperphosphatemia.




Elevated levels of phosphate are common in patients with kidney disease due to the disturbance of the bodies natural method of controlling phosphate levels, the kidney.
The kidney is responsible for eliminating phosphate from the body based on the concentration of phosphate in the blood and the concentration of a hormone known as parathyroid hormone.



When the kidney is unable to get rid of the phosphate within the body the levels of phosphate begin to rise and this stimulates the parathyroid glands, these glands are located in the neck behind the thyroid. The contain special sensors that inform the gland about the levels of calcium, vitamin d and phosphate within the blood.

In response to increased levels of phosphate parathyroid hormone or PTH is secreted. This hormone stimulates bone to take up calcium and phosphate when vitamin d is present in sufficient quantities thus decreasing the blood level of phosphate. It also stimulates the kidney to increase excretion of phosphate in the urine. The combination of bone uptake and urine excretion will regulate phosphate.

If the kidney is unable to secrete phosphate despite the stimulation of PTH the result will be persistently elevated levels of both phosphate and PTH.

2. Hypophosphatemia.




Hypophosphatemia is much less common than hyperphosphatemia.

Causes include:-

• In patients with malnutrition levels of phosphate may be low. They may go even lower when patients are subsequently fed.

• When the blood becomes alkalotic a state that can occur with intoxication of certain drugs or in sever illness phosphate levels in the blood fall.

• Alcohol impairs phosphate absorption. Alcoholics are also malnourished with regard to minerals.

• Abnormalities of the gut which prevent the absorption of phosphate.

• Defects of the kidney or its regulation that leads to excessive excretion of phosphate in the urine.

Why are High Phosphate Levels so Bad?

• Studies have shown that high phosphate levels are linked to increased risk of death from cardiovascular disease.

• It has also been shown that increased levels of phosphate is associated with deposition of calcium phosphate crystals in the skin a condition known as uremic calciphylaxis. This is a debilitating process that leads to loss of skin, it is very difficult to treat and has a high rate of mortality once diagnosed. Prevention here is much better than cure.

• High phosphate levels occur with increased levels of PTH this results in continuous activation of bone metabolism this leads to a disease of the bone known as renal osteodystrophy. Where the bones can become painful and brittle prone to having fractures.

• High PTH levels as a result of phosphate will also affect the marrow of the bone causing worsening of anemia. Anemia in CKD is usually treated by prescribing EPO. If PTH levels are high for long enough the bone marrow may be damaged and not be able to respond to EPO.



Structure of the PTH protein. Based on PyMOL rendering of PDB 1bwx. (Photo credit: Wikipedia)

• High phosphate levels are associated with more pain in general in ESRD and a lower quality of life.

What is the Treatment for High Phosphate Levels.

Decrease the amount of phosphate entering the body and increase the amount of phosphate leaving the body.

• Decrease the phosphate by having a low phosphate renal diet.

• Decrease the phosphate entering the body by binding it in the gut thus preventing absorption by using.

Phosphate binders such as:-

• TUMS (calcium carbonate)

• PHOSLO (calcium acetate)

• RENAGEL (sevelamer).

photo credit: trekkyandy

Increase the amount of phosphate leaving the body.

• This can be accomplished via dialysis, however conventional dialysis is notoriously poor for removing phosphate. The removal of phosphate is linked to length of time spent on dialysis therefore longer treatment is more effective for phosphate removal.

• Some of the effects of high phosphate are believed to be due to elevated levels of PTH. Therefore as a means to improving outcomes in patients with high phosphate and high PTH, one or more parathyroid glands may be removed to reduce the total amount of PTH circulating in the blood.

• An alternative to surgical removal of the gland is a drug known as cinacalcet which directly turns of PTH production by the parathyoid.

• Such drastic measures maybe necessary in patients that have persistently elevated levels of both phosphate calcium and PTH despite other therapies.

Herbal Preparations to Dissolve Kidney Stones.

Herbs (Photo credit: KatieTT)

There is an ongoing study investigating the effectiveness and safety of 9 east indian herbs regarding their ability to dissolve kidney stones.

The herbal preparation being studied is known as Cystone. The components of Cystone are as follows.

Didymocarpus pedicellata

Based on the data obtained this herb has been used by traditional herbal practitioners. It is mainly indicated for the treatment of renal afflictions in general. One study has shown that it possesses powerful antioxidant effects which are capable of preventing damage to the kidney in the presence of specific toxins in an experimental fashion. This herb was also found to have an antiproliferative effect.

The Present data available suggests this herb is primarily an antioxidant. Another herbal antioxidant has previously been shown in similar laboratory settings to prevent stone formation. A vital step not shown in the study with Didymocarpus.

Bergenia ligulata

This is a widely used plant in South Asia, mainly India and Pakistan, as a traditional medicine for treatment of Kidney Stones.

One study available in the pubmed database has shown that extracts of this herb prevented calcium salt deposition in renal tubules. The treatment was associated with increased urine output as if due to a diuretic effect of the herb as well as an increase in urinary magnesium along with antioxidant effects.

Muitiple kidney stones composed of uric acid and a small amount of calcium oxalate. (Photo credit: Wikipedia)

This study supported a possible role of the use of this herb in preventing stone formation. But the diuretic effect may need to be accounted for as this could interact with other common medication to cause dehydration or predispose for acute renal failure in certain circumstances. Safety data was not available for human subjects.

Rubia cordifolia

Reportedly a herb used since ancient times. It is also known as Manjistha. It is used as a "detoxifier" in traditional medicine. The herb was found to be useful as an antibiotic agent active against at least 2 common species of bacteria. The exact dose is unknown.

Antibiotics are useful for the treatment of kidney stones only when infection is suspected. The antibacterial property of this herb may be of use however its exact spectrum of activity and interactions in humans remain unknown. It is believed that given the long history of use it is at least safe. However the more effective it is the more likely that care needs to be taken in terms of interaction with other mainstream drugs.

Cyperus scariosus

This herb has one study dating back to 1972 which showed anti-inflammatory activity as well as antioxidant activitiy


Achyranthes aspera

A. aspera has been cited in 27 studies within the pubmed database. It has been found to have anti parasitic effect, an antifertility effect and cardiac toxicity, inreases levels of thyroid function and antiinflammatory effects.

aspera study 1
aspera study 2
aspera study 3
aspera study 4

Onosma bracteatum

One study published in 1957 was a study of the phytochemical and pharmacological study of this herb is unavailable currently. However it is like that the herb has medicinal effects hence the reason for the study initially.

Kidney stone (Photo credit: Wikipedia)

No more useful evidence based information was available.

Vernonia cinerea

Was found to have potent antioxidant effects like many of the other herbal extracts.
Antimalaria effects as well as anti-inflammatory, antipyretic and analgesic effect.

In other words this maybe effective for treatment of pain and fever associated with stone passage.

Like most herbal preparations cystone is a mixed bag of herbs with multiple effects on multiple systems. THis herbal preparation seems somewhat more focused than some others in the areas of anti-inflammatory and antioxidant activity. The current ongoing trial is likely to show some positive effect. We of course would await the results of this trial to recommend such a product. As with most herbal products drug interaction will be of concern.

New and Upcoming Treatments for Polycystic Kidney Disease.

ID#: 861 Description: Gross pathology of polycystic kidneys. Gross pathology of polycystic kidneys. Ureters are visible. Content Providers(s): CDC/Dr. Edwin P. Ewing, Jr. Creation Date: 1972 Copyright Restrictions: None - This image is in the public domain and thus free of any copyright restrictions. As a matter of courtesy we request that the content provider be credited and notified in any public or private usage of this image. (Photo credit: Wikipedia)

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic disease of the kidney. For many years the treatment of this condition has been at a relative standstill when compared to the advances in therapy in other kidney diseases. However exciting new developments are currently in the research pipeline. These may finally allow specific therapies aimed at reducing the progression of the underlying problem, which has always been the unrestricted almost exponential growth of cysts within the kidney leading to kidney failure.

The main approach to the treatment of autosomal dominant polycystic kidney disease has been good control of blood pressure. This has been shown to reduce the rate of progression of the disease to end stage. Patients with ADPKD have been shown to have elevated levels of a hormone known as renin. Renin is important in regulating the balance of fluid and salts within the body and under normal circumstances renin signals the kidney to retain salt and water in order to maintain a normal volume of blood within the body. In ADPKD renin levels are increased, this may be due to the compression of sensitive areas within the kidney by enlarging cysts, compression of these areas may stimulate the production of renin. Renin and other substances directly produced because of high levels of renin result in increased cyst growth in ADPKD. This produces a viscous cycle of events that leads to ESRD.

Aliskerin is a novel drug which is now available, it functions as an inhibitor of renin. This drug has been shown to significantly lower the levels of renin in patients with ADPKD as well as providing better control of hypertension. This may be become a mainstay of the treatment of hypertension in ADPKD and should definitely be a drug to watch.

A very old drug that has been hypothesized to have a preventative role in ADPKD is colchicine. It is better known for its role in the management of gout. It is a potent anti inflammatory agent and has effects which may be useful in delaying cyst growth.

Cyst growth in ADPKD is based on the accumulation of fluids within the cyst by the action of a complex pump known as CFTR which is the same protein which is abnormal in cystic fibrosis. Inhibtors of CFTR have been available for some time. Recently they have been shown to be of efficacy in reducing cyst growth in mouse models of APKD.

The drug sirolimus which has been used for many years for immunosuppression post renal transplant has been shown in mammalian models of ADPKD to reduce the growth of cysts and is now the target of a study which will determine its role in the treatment of ADPKD in humans. The results of this study will be available in 2010.

Deutsch: Schema der beiden Proteine PKD1 und PKD2. Nach einer Vorlage von http://www.bio.davidson.edu/Courses/Molbio/MolStudents/spring2003/MaloneyH/Polycystins.html (Photo credit: Wikipedia)

The focus thus far has been on possible therapies aimed at reducing the growth of cysts in order to reduce progression to ESRD. However other new therapies are available currently for the treatment of symptoms associated with ADPKD such as recurrent hematuria and pain.

Techniques aimed at reducing the number of existing cysts in the kidney have been shown to reduce symptoms. Options for this kind of therapy range from open surgery with direct decompression and decortication of cysts, laparoscopic procedures to reduce cyst volume and more recently ultrasound guided techniques where substances that destroy the structure of the cysts are injected under guidance. All these techniques have been proved beneficial in terms of symptom relief but have not been shown to delay progression of the kidney disease.

That  particular goal remains elusive but we are closer now than ever before.


photo credit: euthman

Anemia in Kidney Disease & EPO too

Red Blood Cells (Photo credit: Wikipedia)

Anemia for the normal population is defined as having less than the normal quantity of red blood cells within the blood. Each individual red cell contains within it the substance hemoglobin. This substance carries oxygen within the cell and releases it in organs where it is needed most. Oxygen is derived from the lung and the process of taking up oxygen into the red cell from the lung is known as oxygenation. Patients with chronic kidney disease are usually anemic for various reasons some of which are specific to kidney disease.


Patients with anemia have symptoms such as weakness and general lethargy, poor appetite, decreased capacity to exercise and usually describe themselves as generally unwell. The hormone responsible for the production of red blood cells is erythropoietin or epo. It is produced by the kidney, it then travels to the bone marrow where it stimulates the cells there to change into red blood cells and enter the circulation.

Major proteins in the erythrocyte (red blood cell) membrane. (Photo credit: Wikipedia)

Patients with kidney disease may have anemia because the damaged kidney is unable to produce epo. The presence of toxins which accumulate in kidney disease also have a negative impact on the bone marrow to produce cells. Because of the depressed appetite present in patients with kidney disease there may be inadequate intake of the nutrients required to form the building blocks for the production of red blood cells. Patients with kidney disease are also deficient in iron due to slow leaks of iron from the gut due to the build up of toxins within the blood. When on dialysis there is blood lost in the dialysis tubing that further compounds this iron deficiency. Because of decreased levels of vitamin D there maybe elevated levels of another hormone known as PTH which can lead to damage of the bone marrow and decreased ability to produce red blood cells.

Treatment of anemia in kidney disease therefore relies on first determining the cause of the anemia. In addition to the usual causes detailed above, patients may also have anemia due to the preexisting diseases that cause anemia of which there are many. The evaluation to determine the cause never assumes that the anemia is only due to kidney disease.

If it is established that anemia is entirely due to kidney disease then treatment may commence by replacing the nutrients required for generation of red blood cells, iron and vitamins usually. Provision of adequate dialysis where necessary and the administration injectable of synthetic epo.

Figure 2 - Schematic of Maxwell model using one dash-pot and one spring connected in series (Photo credit: Wikipedia)

Epo is administered in such a manner as to maintain your blood count in the region of 11 to 12 grams of hemoglobin (Hb). Any higher and there is a risk of adverse events such as stroke or heart attack any lower and the benefits in terms of well being may be less than ideal.

Recently studies have suggested that there may be benefits of higher doses of epo. The authors of one study found that targeting a higher Hb around 12 g/dl was more beneficial than targeting conventional Hb in terms of reduction of the size of the heart and quality of life. Enlargement of the heart is a very serious complication of hypertension and anemia which can lead to early death in patients on dialysis. The fact that epo at higher doses may reduce the occurrence of this is exciting. In fact epo has recently been found to have a possible regulatory role in the function of the heart where studies have shown that administration of epo has direct effects on the muscle cells of the heart improving their function this study suggests that erythropoietin may have a direct positive effect on the heart and brain unrelated to correction of the anemia by reducing cell death and by increasing new blood vessel growth, both of which could prevent tissue damage. This could have profound therapeutic implications not only in heart failure but in the future treatment of myocardial infarction, coronary heart disease, strokes, and renal failure. These effects are independent of the effect of epo on the bone marrow.

However the current guidelines are based on very well done studies which have demonstrated increased mortality in patients with hemoglobin levels of greater than 12 g/dl. Other authors however are of the opinion that the increased mortality may not be due to the actual level of the hemoglobin but the dose of epo and iron required to get you there. These same authors are usually of the opinion that slowly increasing the levels of Hb over a longer period of time may be beneficial.

Erythropoietin currently is the best therapy available for anemia of chronic kidney disease. The exact dose and rate of increase in hemoglobin is likely to be revealed in upcoming studies.

Colon Cleanse and The Kidney....to cleanse or not to cleanse?

photo credit: DoctorWho

The notion that the normal operation of the Gut results in pounds of un-excreted toxic materials, that accumulate over the lifetime of a human being is the basis of the colon cleansing industry that has sprung up nearly simultaneosusly world wide.

The theory behind colon cleansing hails back to the era of the greek and egyptian schools of medicine. Where autointoxication was believed to be responsible for all causes of disease. Autointoxication refers to an ancient theory that food enters the digestive system and rots giving rise to pus which enters the blood stream and causes all manner of ills. By 1919 the idea of autointoxication had run its course being debunked in the professional literature of the time. However despite the fact that there is no evidence of any benefit derived from the process, colon cleansing is still vigorously advertised as a mainstay alternative medicine treatment.

The claims below are derived from a popular website.

Toxins from the colon are supposedly able to:-

• Go to the brain and disturb mental function


• Go to the joints and cause pain and stiffness


• Weaken and stress the heart


• Go to the skin and cause blemishes, paleness, psoriasis, liver spots, wrinkles


• Irritate the lungs and cause foul breath


• Go to the muscles and cause weakness and terrible fatigue


• Rob you of your youth and ruin your health



Colon Cleanse Dietary Supplement (Photo credit: SpecialKRB)

While Colon Cleansing has the following positive effects.

• Controls your weight


• Increases your energy level


• Prevent constipation and disease of the colon


• Eliminates waste such as fatty tissue, cholesterol, cellulite, toxins, mucus, hardened fecal matter, harmful drug residue


• For the glow of health inside and out that shows with clear skin, bright eyes, and shiny hair

Those are some wonderful claims that would tempt anyone. But what is not mentioned are some of the dangers particularly if you have kidney disease. Oral phosphate preparations used for the purpose of cleansing the colon have recently been shown to cause sudden worsening of kidney function a state known as acute renal failure. This reduction in function tends to occur in two patterns based on the timing of onset of kidney failure after ingestion of the cleansing compound.

If symptoms begin to occur within 24 hours of ingestion (lethargy, confusion, seizure and sever muscular spasms) the course of the illness can be particularly stormy and even death may occur. On the other hand the patient may be fine after taking the cleansing compound for days to months after, however during this time an insidious process of calcification occurs within the kidney where much of the framework of the delicate tissues of the kidney are converted to a bone like substance. Death with this second pattern is unusual but patients go on to have chronic kidney disease.

Many proponents of colon cleansing will be quick to point out that they are aware of this problem with phosphate containing cleansers and would never use them for the purpose of cleansing the colon. They will then insist that proven herbal methods are available which are far more gentle and safer. They may also claim that by performing an enema using nothing but water the effect of the cleansing is guaranteed to be safe.

Unfortunately its still not as simple as that. Even irrigation with water has been shown to be dangerous, in fact perforation of the sigmoid colon has been documented to occur in patients with chronic renal failure who underwent irrigation enema's. Also instilling large volumes of dilute fluid into the colon of patients with kidney disease may not be a good idea. Dilution of the electrolytes ( important minerals within the blood) can result in abnormalities of cardiac function muscle spasm and abnormal brian function even seizures all of this for no proven benefit. Cleansing tends to lead to excessive excretion of fluid particularly if carried out regularly and this results in dehydration. Dehydration can give rise to acute renal failure as well.

I urge you to find some other way to find that glow of health inside that shows clear skin, bright eyes and shiny hair...please.

Kidney Cancer and Cysts Information

photo credit: euthman
Renal masses and cysts are a cause of anxiety for many patients that automatically assume any mass or cyst of the kidney must be due to cancer. However the vast majority of these cysts are benign simple cysts of the kidney. They are predominantly seen in patients over the age of 50 years. They are usually asymptomatic and are an incidental finding in the majority of cases. No one really knows why simple cysts occur but the fact that they are usually seen in older persons may imply that this is one of the effects of normal aging of the kidney.

A simple renal cyst has a characteristic appearance on ultrasound that differentiates it from cysts which may be suspicious for cancer. This method of testing has all but replaced older methods that relied on imaging the blood vessels of the kidney and examining the picture for any disturbance of the normal pattern, which may imply a mass or cyst splaying the blood vessels apart. With the advent of CT and MRI the mass or cyst can be directly visualized and a determination made as to how likely it is to be due to cancer.


There are some genetic conditions that predispose to the formation of cysts in the kidney. The most common such condition is known as Autosomal Dominant Polycystic Kidney Disease or ADPK for short. This disease is associated with development of cysts in the kidney which progressively destroys the substance of the kidney decreasing its ability to filter blood and form urine. MRI, Ultrasound and CT scan are both able to make a possible diagnosis of polycystic kidney disease by examining the distribution of the cysts their number and the individual characteristics of the cysts. True polycystic kidney disease is not associated with transformation to cancer.

A very similar pattern of cysts may be seen in individuals who are on dialysis who do not have ADPK. The cysts in these patients tend to increase in number and volume as the number of years on dialysis increases. These cysts are usually present in small shrunken kidneys unlike ADPK where the kidney is quite massively enlarged in most cases. These cysts have to be monitored very carefully as the have a chance of transforming to cancer. As such patients on dialysis are routinely monitored for the development of cysts with yearly ultrasound after 3 to 4 years on dialysis.

The combination of kidney cysts and stones is seen in medullary cystic disease of the kidney. In this condition the tiny tubes that carry urine from the individual filter in the kidney tissue are supposed to join together like tributaries of a great river ultimately leading into the bladder through the ureter. In this disease the smaller tributaries develop cystic dilations which pool the fluid which will become urine. These pools of fluid have low flow and sediments eventually settle which form concretions and ultimately stones in the tissue of the kidney. Therefore many small stones tend to be present within the kidney. This condition develops due to a problem with formation of the kidney and is not transmitted genetically.

As has been shown the causes of cysts on the kidney are diverse and this was not a complete list. There exists very well established means of determining the danger of cancer in any situation where cysts are found on the kidney. A detailed history and family history as well as a routine examination and blood tests with the required imaging tests will lead to speedy diagnosis with relief of anxiety or rapid and timely treatment should the diagnosis be cancer.

Vitamin D in Kidney Disease

Chemical structure of cholecalciferol, aka vitamin D3. (Photo credit: Wikipedia)

photo credit: aluzano

The authors of a recent study in the clinical journal of the american society of nephrology has suggested that vitamin d may have a role in reducing proteinuria in chronic kidney disease. Previously the main stay of therapy for protein in the urine or proteinuria has been the use of a class of drugs known as A.C.E inhibitors (ACEI). This newly discovered effect of vitamin D occurs in addition to the effect of ACEI on proteinuria. This implies that vitamin D supplementation may be a possible adjunctive therapeutic option in patients with kidney disease and proteinuria. Vitamin D may also reduce the loss of a vital class of cell within the kidney, the ever more important podocyte. This cell class is involved multiple diseases affecting the kidneys ability to retain protein in the blood. Dysfunction of the podocyte has been cited as being responsible for some types of inherited causes of kidney failure. In addition blood pressure, the sensitivity of the body to insulin as well as inflammation are all improved by vitamin D.

The authors note that although only few studies exist, the data suggests that this is an area worthy of further research, with previous studies in pre-dialysis patients showing similar findings as above. The decrease in proteinuria due to vitamin D has also been shown to occur in patients with IgA nephropathy in one study of 10 patients, it was also accompanied by decreased levels of chemicals responsible for the development of scarring in the kidney. The development of fibrosis or scarring occurs as a final pathway of injury in many diseases that affect the kidney including diabetic kidney disease. Diabetic kidney disease is perhaps the most common cause of kidney failure requiring dialysis. As such if vitamin D supplementation should be able to have even a small impact on the survival of kidneys of patients with diabetic kidney disease the resultant decrease in spending on dialysis would save millions of US dollars each year.

Several mechanisms have been suggested for the positive action of vitamin D in kidney disease. Chief among these is the notion that the vitamin acts as a hormone at the level of specific tissues and organs of the body where it influences immunity, vascular function cardiac function and muscle function. It also acts on the immune system to turn off inflammation. These are all effects that would benefit patients with kidney disease.

These are truly interesting times for Vitamin D.

Vitamin D in Health and Kidney Disease.

Overview of calcium regulation (See Wikipedia:Calcium in biology). To discuss image, please see Talk:Human body diagrams References Page 1094 (The Parathyroid Glands and Vitamin D) in: Walter F., PhD. Boron (2003). Medical Physiology: A Cellular And Molecular Approaoch, 1300, Elsevier/Saunders. (Photo credit: Wikipedia)

photo credit: photofarmer

Vitamin D is an essential hormone in both health and disease, it is obtained from both dietary sources as well as direct sunlight via a process that occurs in the skin involving ultraviolet radiation. Foods that are high in vitamin D include oily fish, the ingestion of which is capable of preventing vitamin D deficiency. Measurement of vitamin D levels to determine if you have adequate amounts of the vitamin within your body is difficult as there is no consensus on the amount of vitamin D that is appropriate for all individuals. Broad guidelines that are capable of identifying very low levels as insufficient and very high levels as toxic are probably inadequate moving forward and will likely be revised when a more narrow and useful band is obtained.

Vitamin D is related to parathyroid hormone which controls the formation of bone and is now thought to be responsible for vascular health via mechanisms that are still to be worked out. Vitamin D either by direct methods or through its effect on parathyroid hormone should therefore play a role in cardiovascular disease.

Abnormalities in both vitamin D and parathyroid hormone have been cited in the press as being responsible for abnormalities that include cognitive dysfunction, muscle and bone abnormalities and cardiovascular effects. The bulk of the research into vitamin D and parathyroid hormone is obtained from the nephrology literature where its role in metabolic bone disease is well established and its emerging role in cardiovascular disease is being investigated in the dialysis and Chronic Kidney Disease population. It is intriguing that vitamin D's important in the normal population may have been overlooked for so long.

For years the general population has had an increasing incidence of cardiovascular disease diabetes and metabolic syndrome, which has largely been driven by obesity as well as increasing rates of some cancers. Some researchers now speculate that the finding of abnormally low vitamin D in these groups may be more important than previously thought and may imply a causative role of vitamin D. This would place the vitamin at the center of multiple processes that do not seem related on the surface, implying a deeper level of complexity in terms of its involvement with metabolic processes that was unsuspected.


photo credit: aresauburn™.

One author speculates that many of the findings in the normal population have been under our noses the entire time in CKD patients

The findings of cardiovascular disease increased cancer and metabolic syndrome in some part may be considered a part of the aging process with the body becoming progressively more unable to heal entirely with time. The previosuly mentioned problems of cardiovascular disease and metabolic syndrome are prevalent among patients with chronic kidney disease, this was previously thought to be due to the presence of toxins that are not adequately excreted by the failing kidney. But if we think of CKD as a process of accelerated aging and compare vitamin D levels between the normal population and CKD population then the hypothesis that vitamin D may play a central role in the aging process and hence affect multiple systems simulataneously becomes more plausible.

Studying this moving forward will be challenging due to the fact that we are still in the relative infancy of vitamin D research. What does one measure to determine the effect of vitamin D ? which one of the vitamin D's do you measure (of which there are several), what is the normal range for these measurements? Which one of the vitamin D's do you supplement with and how does that affect levels of the other vitamin D's.

However, research is ongoing, studies have demonstrated that positive effects can be obtained by supplementing greater than 700 iu per day, with some reduction in cancer risk and fracture rates. Supplementation with an activated form of vitamin D has also been shown to decrease protein excretion in patients with CKD this may translate into more years off of dialysis for patients with progressive nephropathy something everyone would like to see.



UPDATE: 12/4/12
Related articles

• Vitamin D treatment not found to reduce cardiovascular abnormalities in kidney disease patients (eurekalert.org)
• Vitamin D treatment not found to reduce cardiovascular abnormalities in kidney disease patients (medicalxpress.com)

Impotence in kidney disease

Dialysis USA 3-2007 004 (Photo credit: jimforest)

Approximately 50% of uremic men complain of impotence or erectile dysfunction. An even larger proportion of patients also complain of decreased desire for sex as a result of kidney disease, this is particularly so among patients in stage 5 chronic kidney disease on dialysis.

The reason for this high incidence is related to the associated diseases that are frequently present in patients on dialysis as well as the physiologic alterations that occur because of chronic kidney disease on a vascular and hormonal level. Diabetes mellitus and hypertension are the two most common predisposing causes for chronic kidney disease. Both disease conditions are associated with dysfunction of the blood vessels with an impairment of the ability to relax when needed. This affects the blood vessels within the penis as well resulting in decreased blood flow in this organ due to impaired relaxation in response to appropriate sexual stimulus.

Chronic kidney disease results in several co-morbidities, in my opinion the two most important of these are cardiovascular disease and anemia. They are both related to CKD as well as to each other. The presence of cardiovascular disease in CKD is due in part to the extreme inflammatory state that occurs in patients with kidney disease as well as due to in the increased workload carried by the heart due to retention of fluid in the presence of a decreased supply of oxygenated blood due to anemia. Anemia on the other hand is due to decreased production of erythropoietin by the kidney. This hormone is essential for the the stimulation of bone marrow to produce red blood cells which are the primary constituent of blood.

The desire for sex in men on hemodialysis increases when anemia is treated, this is caused by increased energy levels and individuals perceive themselves as being more vital and they feel "less sick" when the blood count is elevated to about 10 mg/dl by treatment with drugs such as Epogen or CERA. It has been shown in some studies that testosterone levels may also be linked to the treatment of anemia in CKD with increased levels correlating with higher blood counts.

The evaluation of this complex disorder must also include psychological testing. However the efficacy of psychotherapy which essentially is talking about the problem and working through any issues which may be preventing performance is unknown. The use of antidepressant medication for this indication in dialysis patients is not well studied and there are significant possibilities of negative drug to drug interactions along with nebulous required dose adjustments due to renal failure and dialysis to complicate matters. The use of various other methods such as direct injection of the penis with drugs to increase blood flow to the area or surgical prosthesis is certainly possible but may not be socially acceptable as many men find injection of the penis or any surgery in that area distasteful.

The real success story of the treatment of erectile dysfunction in patients with chronic kidney disease is Viagra. Sildenafil the active ingredient in viagra increases nitric oxide levels which result in powerful vasodilation. The drug specifically targets nitric oxide production in penile blood vessels thus preventing systemic vasodilation and resulting severe hypotension (low blood pressure).

Since one of the primary causes of erectile dysfunction in chronic kidney disease is decreased relaxation this treats the cause directly in the majority of patients with good effect.



photo credit: Felixe

So an approach centered around ensuring the patient is well enough for sex, treating anemia hence improving libido, adequate dialysis if on dialysis with counselling aimed at identifying and removing psychological factors which may impair performance. And if necessary prescription of Viagra or Equivalent sildenafil like compound, will be likely to produce very good results.

Diabetes Symptoms! act early to Prevent Kidney Disease

Diabetes symptoms are more serious than you think!

It's important for you to know the symptoms as a first line indication as to whether you or your children have contracted it? If you are aware that you have any of these symptoms then you need to take action right away. Diabetes is a highly debilitating illness which often ends in death and it needs to be taken seriously.

Overview of the most significant possible symptoms of diabetes. See Wikipedia:Diabetes#Signs_and_symptoms for references. Model: Mikael Häggström. To discuss image, please see Template talk:Häggström diagrams (Photo credit: Wikipedia)

Alkaline water has been discovered to be very effective in alleviating the symptoms of diabetes and assisting sufferers get off their prescriptions... but before you do anything else,it is very critical to seek professional medical consultation first and foremost.

In Type 1 diabetes, the symptoms can often come on suddenly and dramatically. It mostly shows up in childhood or early teens often after an illness, virus or injury. The extra stress can cause diabetic ketoacidosis. Without treatment, ketoacidosis can lead to coma and death.

Symptoms of Type 2 diabetes are often not obvious and you may think they are due to aging or obesity. It's possible to have Diabetes 2 for many years without being aware that you have it. Steroids and stress can be big factors in the onset of Diabetes 2. It's important to take this illness seriously; it can lead to unpleasant outcomes like blindness, kidney failure, heart disease, and nerve damage.

Here are some common symptoms of diabetes 1 and diabetes 2

Excessive and Unusual Tiredness:

When you contract diabetes the body is mostly unable to use glucose for fuel. It begins instead to metabolize fat to get the extra fuel it needs. This process is not very efficient. You have less energy than before and you feel tired.

Weight Loss You Just Can't Explain:

Because you can't metabolize sugar, much of the fuel in your food is excreted in your urine via the kidneys. You may find yourself eating way more food than normal and still losing weight. You become dehydrated and lose even more weight.

Excessive thirst:

The high concentration of sugar in your bloodstream overcomes your normal kidney function. Instead of being re-absorbed for future use the sugar is passed out in your urine. The brain senses a need to dilute the blood and you experience this as thirst. As a result you find yourself drinking more water as the body tries to correct this sugar imbalance.

Increased Urination:

The body tries to excrete the excess sugar via the kidneys. As a result you pass more water and feel thirsty.

Overeating:

The body will try to increase its levels of insulin production to reduce the excess blood sugar. Insulin is the key that opens the muscles and lean tissue to receive the sugar. But in Type 2 Diabetes you become insulin resistant. Your muscles refuse to take up the sugar.

One of the other jobs of insulin is to make you hungry... it isn't possible for you to absorb this extra insulin so your forced to eat more.

Wounds Refuse to Heal:

If your blood sugar levels are high then your white blood cells are not able to do their respected job. As a result to this your wounds heal slower than normal and your more susceptible to infection.

Thickening of the Arteries

SEELOW, BRANDENBURG - AUGUST 08: Country doctor Dieter Baermann measures the blood sugar level of an elderly patient in the patient's home on August 8, 2011 in Sachsendorf near Seelow, Germany. Baermann works in the state of Brandenburg in eastern Germany, a region that is struggling with a shortage of doctors in rural areas. Critics charge that current laws actually discourage doctors from taking up posts in rural areas, and the German government is debating a new law intended to reverse the trend. Many doctors across Germany complain about a legal system that they claim burdens them with too many costs and hampers their ability to provide the best care. (Image credit: Getty Images via @daylife)

Long term diabetes can cause your arteries to thicken, reducing blood flow.

You catch more Infections:

Because your immune system is no longer functioning as well as it should you'll often find you are contracting skin and yeast infections as well as urinary tract infections.

Mood Swings:

You may very well find yourself incapable of concentrating, irritated, or agitated- all are symptoms of very high blood sugar levels

Impaired Vision: You may find you have difficulty focusing and things appear blurry.

Don`t give up! There are herbal methods available .

Education: High Blood Pressure Prevention.

Main complications of persistent high blood pressure. Sources are found in main article: Wikipedia:Hypertension#Complications. To discuss image, please see Template_talk:Häggström diagrams. To edit, please use the svg version, convert to png and update both versions online. (Photo credit: Wikipedia)

Most of people with hypertension do not know they have it. In fact it has been estimated that about 50 percent are not aware of it. It is estimated by the year of 2025, one and half billion of people will live with High Blood Pressure.

High blood pressure can be caused by a malfunctioning kidney and adrenal gland dysfunction; yet, about ninety to ninety five percent of all cases have an unknown nature.

Even though, medicine is still searching for the right answers for cure of the silent disease, it is up to the patients to find remedies and cures to keep up their health. There are several ways to reduce your blood pressure. This article will focus on how to lower your blood pressure by losing weight.

Losing weight can be very challenging because it involves change in the lifestyle. However, once the individual is able to make few changes in the lifestyle losing weight becomes automatic.

Based on review from to British Hypertension Society, low intensity aerobic exercise can aid in lowering your blood pressure drastically. A low intensity aerobic exercise can be 20-30 min walk to a park or grocery store, slow movement yoga class, cardio workout class. It is important to maintain the routine and to exercise minimum three times a week.

The results do not show for the first 2 weeks. However, drastic results can be seen after one month. Losing weight happens in stages and an individual should be patient with him/herself. Even if the person will not see instant results in weight loss, the hypertension will be treated from the first day of exercise. Even low intensity activity will increase blood flow and improve cardiovascular system by flushing the bad cholesterol out of the body.

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Find more Ways to treat High Blood Pressure

Eating the right type of foods is just as essential as the exercising. It is critical to eat everything in moderation and to avoid cravings. Many fitness instructors recommend taking small meals up to 6 times a day. When picking groceries chose chicken breast over a thigh or drumstick, very soon it will becomes natural picking the foods that are lower in cholesterol and a lot healthier for the body.

Consuming high amounts of water stimulates detoxification of body and helps healing processes to take place faster. By avoiding pops, fast food, processed foods one can eliminate about 30% of empty calorie intake.

While there is no precise explanation on the onset of hypertension, there are ways available to control and to prevent this disease. Maintaining a healthy weight by exercising and eating the right foods is one of many ways to battle high blood pressure.

While there is no perfet explanation to Hypertension, there are natural ways available to control and prevent this disease. Keeping a healthy weight by exercising and eating right is one of many ways to combat hypertension.

Dialysis and Death the Double D's and DOPPS.

dialysis - session 4 (Photo credit: wj gibson (Archie Goodwin))

Hemodialysis is a life saving therapy for patients with severe kidney disease. The therapy is well established and is the most readily available form of renal replacement therapy in the United States. Improving survival on dialysis is the aim of several ongoing studies. The largest of these studies is the Dialysis Outcomes and Practice Patterns study or (DOPPS). The investigators sought to determine detailed information about the association of various co-morbid and clinical characteristics of patients which may shed light on the causes of death and ultimately how to increase length and quality of life on dialysis.

Data from the DOPPS study suggests that patients are at the highest risk of death within 120 days after starting dialysis. This increased risk of death is believed to be based on patient specific factors such as age, race and the presence of various co-morbidities. Previous studies that have attempted to isolate the predictors of early death in patients starting dialysis have revealed death rates as high as 12% for the first 90 days.

The DOPPS study has revealed that death within 120 days was more likely in patients that were.

• Elderly


• White


• Diagnosed with heart failure.


• Utilized a catheter for first dialysis.


• Diagnosed with cancer


• Diagnosed with lung disease


• Diagnosed with neurologic disease


• Diagnosed with psychiatric disorder


• Were referred late to a specialist.



Simplified hemodialysis circuit. (Photo credit: Wikipedia)

Although some of these risk factors are admittedly unchangeable and expected. Two risk factors are particularly note worthy. Late referrals and the use of a catheter at first dialysis session. These two factors are a more direct index of the degree of health care that the patients received during their follow up prior to needing dialysis. Any death due to these two factors within the first 120 days of starting dialysis are directly preventable by simply following the established protocols. Patients should be referred to a specialist in a timely manner such that interventions are possibly that will improve the prognosis of the patient.

Catheters are a form of dialysis access that are grossly inferior to other methods of accessing the blood stream for the purposes of dialysis. The use of catheters at first dialysis are associated with increased risk of life threatening infection and decreased dialysis adequacy and thus decreased survival and quality of life. The choice to place a catheter as a form of first access should only be made when no other access is possible. However discussing the types of possible access and the pros and cons in a manner that allows the patient an educated choice will take time hence the need for early referral.

Late referral to a nephrologist almost always results in the use of a catheter. The quality of life of patients may therefore be significantly improved by referring patients to a nephrologist in a timely manner to allow for a more appropriate choice of access such as a natural AV fistula.

In summary while some factors are unmodifiable such as age and race, we must strive to maximize the benefit of other factors that are well within our ability to modify by simply improving basic patient care in the pre dialysis period.

Related articles

• Most women on dialysis may experience sexual problems (medicalxpress.com)
• New Dialysis Catheter Reduces Thrombus Accumulation (prweb.com)
• Muscle Cramps In Dialysis Treated By Vitamin E (allkidney.com)
• Cannulation Technique may Improve Fistula Survival (allkidney.com)
• Older Dialysis Patients May Not Derive Benefit from Dialysis (allkidney.com)