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Diet, Diabetes & Hypertension

Diet, Diabetes & Hypertension

A DxD Session with Dr Francisco Salcido-Ochoa


Ended on Thu Feb 28 2019
Ended
Have a question to ask?

Get Dr Francisco Salcido-Ochoa's opinions on your questions! Only approved questions are displayed.

Top Answers


Hi,

Not all patients with chronic kidney disease eventually need to undergo dialysis.

Chronic kidney disease encompasses different disorders of the kidney. To mention some: diabetes, high blood pressure, different types of inflammation of the kidneys, allergies, urine flow problems, rare diseases, etc. Many of them can progress to kidney failure with consequent need for dialysis, but others not, especially if we detect them early and we treat them promptly.

Thus, the first step is to identify what is the cause of your chronic kidney disease, so your doctor can suggest further diagnostic and treatment plans, and can advise you more accurately on its prognosis, including your chances of developing kidney failure.

In general, we advise patients to modify any risk factor (i.e. lifestyle habit) involved in disease progression, for example, avoid smoking, getting better control of the underlying disease like diabetes, high blood pressure, etc. This works in some patients, in occasions to halt the progression, in others at least delays the occurrence of kidney failure for as long as possible.

For some diseases, especially the ones related to inflammation or allergy in the kidneys, patients need to undergo special treatments with powerful anti-inflammation drugs, which sometimes successfully can halt the disease, but sometimes the disease is too aggressive or severe damaged has been already caused to the kidneys, that the expectations of recovery and to avoid dialysis are low. 

Also, the status of your kidney problem is important to know your chances to progress into kidney failure. For example, if the disease is detected early and is amenable to modification of habits and medications to protect the kidneys, the chances of disease progression could be low. But if detected late or your percentage of kidney function is already quite low, you will have higher chances as the time passes by.

There are other important factors to determine your chances to develop kidney failure, which vary patient to patient, so I recommend you to address your concerns with and be evaluated by a specialist kidney doctor.

I appreciate how significant this worry can be for you or your family, and for patients in your condition. So, I always do my best to prevent or retard kidney disease progression, and help my patients understanding this process and walk the path hand in hand with them. However, many times despite all the efforts, the kidneys still give up and go into failure.

For patients suffering total kidney failure, dialysis is one of the management options, but some patients can undergo kidney transplantation. I explain this further in a different question on this series.

Finally, for some patients who are very ill or extremely weak, frail and elderly, dialysis might be too taxing (dialysis it is a strong therapy) or even too risk, therefore, dialysis is not an option any longer and the focus of medical care is to continue with medications and to ensure the patient is as comfortable as possible, especially at the end of life.

Dr Francisco, wishing your kidneys hold for as long as possible and you do not need to encounter total kidney failure.

29 Oct 2018

Hi,

Pain is the main concern of patients opting for or considering haemodialysis.

Indeed, the needle insertion can be painful. We can use creams with a painkiller to be applied on the area for needling beforehand to reduce the pain. Once the needle is in place, typically is not painful.

The process of cleaning the blood by the dialysis machine is by itself not painful. Many patients do not feel any major symptoms but others can feel a little weak or drained during the dialysis session or after, which resolves by itself and after some rest. But some patients can feel some aches, for instance in the back, especially in the first dialysis sessions after starting dialysis for the first time, while the body is adjusting to the therapy.

I hope, if you choose haemodialysis, everything goes fine and is as painless as possible. Perhaps, it will be ideal to have a more detailed discussion with your kidney doctor on this matter and on other pros and cons of haemodialysis vs peritoneal dialysis or even kidney transplantation, so you are reassured you have taken the best possible decision regarding the choice of treatment for your kidney failure.

Dr Francisco, wishing you the best possible health and smoother therapy for you.

29 Oct 2018

Hi,

Progressive and severe injury to the kidneys can cause permanent and irreparable damage to the kidneys, leading to total kidney failure. If total kidney failure is confirmed by your doctor, dialysis will be needed for life. Alternatively, a kidney transplant is another option in these circumstances. And dialysis will be for life because, unfortunately, permanent and severe damage cannot be repaired and the kidney function will not recover.

We use different methods to assess the degree of kidney dysfunction and to confirm if the kidney function is low. When an ultrasound shows small (that is scarred) kidneys and when the kidney function progressively decline through prolonged time until the level of total failure, dialysis will be needed for life. Although kidney biopsy is in theory the best method to check the status of the kidney, in this situation it does not help further and can be of higher risk for the patient.

Only when the doctor has the suspicion that the damage is not permanent, a kidney biopsy could be helpful. However, there are so many factors to consider, that only by seeing a nephrologist and undergoing thorough assessment, proper advice can be given regarding your concern as it is a very significant event for a patient who suffers kidney disease.

Finally, there are cases of temporary kidney failure, what doctors call acute kidney failure, where the patient can need dialysis for a variable period of time and later showing recovery and the dialysis can be stopped. However, these patients need to continue on follow up as they have higher risk of developing progressive kidney disease than normal people.

Please check with your doctor if you are suitable for other options such as kidney transplantation.

Dr Francisco, wishing you the best possible health. 

29 Oct 2018

Hi,

Thank you for your question.

Indeed, reaching total kidney failure and needing dialysis is a big event with a significant impact in your life, requiring in occasions huge modifications in your lifestyle. It can get in the middle of your work life (especially if you have a corporate or full-time job, because indeed each session takes half of your day); your social life; your family life; and your personal life, which can affect your mood and overall wellbeing.

This in indeed a challenge but not necessarily has to be a huge or impossible task in your life: by setting your mindset and actions into a positive one, that you can still perform and enjoy life despite dialysis, and with a supportive network and care providers, it is much simpler that it could seems.

You might need to adjust yourself to a new lifestyle but then try to do your activities as normal as possible when you are not on dialysis. If you like to go to the movies, still go. If you like to walk in the park, still do it. If you like sports, still do them, but double check with your doctor what level of activity can be appropriate for you. Many patients can continue practicing sports, just exerting certain cautions. You need to try to continue as healthy as possible, try to follow the “kidney diet”, which might not be as varied and palatable as your previous diet, but the effort pays out well. In my experience, most of my patients that live a more frugal life with diet control and fluid restriction, tend to live a healthier and longer life while on dialysis.

In short, get your treatment done while chatting and interacting with your peers having dialysis together with you (it helps in your mood and makes it more bearable), and after done, try to set your mindset into “back to normal life mode”, and then try to do the things you used to do you. It is not simple, but I trust you can do it. I have seen many patients doing it, especially if getting good social and medical support.

Travelling can be affected, but not necessarily needs to be avoided. You can get your dialysis done in foreign countries, but then patients get worried about getting infected with blood viruses or other infections. I understand their concern, and nothing is ever risk-free, but it is just matter of finding a reputable centre in which they feel comfortable and safe, especially for common travelers. Some patients that travel a lot do this.

Others opt for peritoneal dialysis which can be done manually at home or at the hotel and many of the vendors deliver the dialysis fluids for the therapy to your foreign address or hotel, so you do it yourself without worries of getting an infection in an unfamiliar environment and if you are worried about the quality of the dialysis centre. In short, find the option you feel comfortable with, get it done and continue enjoying your trip abroad.

Dr Francisco, wishing you the best possible health.

29 Oct 2018

Hi,

Thank you for your question.

The fees charged will depend whether you are doing it privately or obtaining government subsidies.

For example, the fees for haemodialysis in the private sector can range from 200-500 dollars per session, depending if it is a satellite basic dialysis centre or a centre inside a private hospital with more comfort and other features and/or more capabilities to respond to emergencies. A centre located inside a private hospital will be more responsive to emergencies, than a centre in the local neighbourhood.

In addition, some centres charges vary depending on whether the patient is Singaporean, foreigner residing in Singapore or a tourist. The fees will be paid out of your pocket minus any total or partial coverage by your insurer or employer’s benefits, if such.

Overall, the typical satellite dialysis centre end up charging patients or insurance companies around 2500 dollars per month; obviously more, in more high end dialysis centres. My practical advice is talk to:

1) your insurance company,

2) your employer, and

3) your chosen or potential dialysis centres, so you can gauge how much coverage you have and how much out of your pocket you need to pay.

The fees you will end up paying if performing haemodialysis by government institutions like in the National Kidney Foundation (NKF) Singapore depending on the degree of subsidies you are eligible to depending on your household income and expenses and different government insurance and benefits. The basic cost of the dialysis is similar, approximately 180 dollars per session, but that will be minus whatever amount your medishield can cover, then minus what the NKF subsidy can cover, which can range from 0-100% subsidy, then minus your medisave and if still something left to pay, it will come out of your pocket.

Dialysis is expensive, but Singapore government and institutions like NKF, the Kidney Dialysis Foundation (KDF) and some charities or donors always try their best to help patients in the need for financial protection, and for many patients dialysis end up to be totally free. But to make that happen there is a lot of kindness behind absorbing the costs from patients. My practical advice is talk to:

1) NKF or KDF directly,

2) dialysis coordinators and medical social workers in the hospital you are on follow up, and

3) any other charity group willing to help you with moral or financial support.

Peritoneal dialysis, which does not involve a specific centre and the use of expensive machines, it is cheaper for patients, and the healthcare budget. The costs goes around 1500-2000 dollars per month, depending on the modality of dialysis you are using (manual or automated-with the aid of a machine-), type of dialysis solutions you are using, the vendor you have chosen and the dose of dialysis your body needs, minus insurance and government subsidies as applicable, in a similar fashion as explained above for haemodialysis. My practical recommendation is, once your doctor gives you a prescription and recommendation of the type of dialysis appropriate for you, to talk to:

1) dialysis coordinators and medical social workers in the hospital you are on follow up,

2) a government agency like NKF to check whether you are eligible for financial support,

3) your insurance company, and

4) the specific peritoneal dialysis vendor of your choice.

I would like to end up by saying that financial matters are important determinant factors for your decision regarding the type the dialysis therapy, but not the only one. You need to choose the therapy you feel comfortable with and blends better with your lifestyle, work life and personality. I expand on this in another of the questions on this series.

Dr Francisco, wishing you the best possible health.

29 Oct 2018

Hi,

Thank you for your question.

Age is one of the factors determining the type of dialysis, but more important than age, in my experience, it is the fitness, fragility, frailty, nutrition and mobility of the patient what matters the most; either due to age or the impact that accompanying medical conditions have like heart problems, arthritis, amputations, lung disease, blindness.

I have met patients over 80 years all which are fitter than even 40 or 50 years old ones, because disease and lifestyle takes a huge toll on people’s health, lifespan and quality of life.

An important factor to consider is heart function as haemodialysis imposes more workload to the heart than peritoneal dialysis, and doctors tend to advise patients with severe heart problems to consider peritoneal dialysis which is softer for the heart, but also brings along other issues. Overall, there is no perfect therapy. You need to consider many factors when choosing a modality of dialysis, including medical, personal, social and economic factors. I advise you to read my answer in relation to this in one of the questions of this series.

So, your uncle might be fit for dialysis or for any modality if he is still in good general condition.

A proper and a thorough assessment by a nephrologist and a cardiologist is typically recommended, and in occasions by many other specialists. 

Dr Francisco, wishing your uncle the best possible health despite kidney failure.

29 Oct 2018

Hi,

Thank you for your question.

Chronic kidney disease includes different types of diseases of the kidneys, like diabetes, high blood pressure, different types of inflammation of the kidneys, allergies, urine flow problems, rare diseases, recurrent infections, etc. So, the treatment will be divided in a) specific treatment to control the original disease, b) to treat other accompanying conditions to minimize further damage to the kidneys, and c) other general strategies to try to prolong the life of the kidneys.

It is not possible to mention all the specific treatments for specific diseases or associated conditions, but the principle is simple: if diabetes is the cause, aim for good sugar control; if blood pressure is the cause or accompanying factor, aim for good blood pressure control; if inflammation is the cause, assess whether disease-targeted or general anti-inflammatory drugs are necessary, etc. And there are many options to achieve those targets, that is, many ways to achieve good diabetic control, for example.

But in what I can expand is on the section related to general measures to protect the kidneys. The following measures are pertinent:

1.Aim for good blood pressure control, reduce salt intake and monitor your blood pressure at home.

2.Quit smoking.

3.Lose weight through diet improvements (reduce sugary, fatty food; ideally with the guidance of a dietician and a weight loss programme if too difficult to do it alone or you have tried and fail).

4.Do exercise (as tolerable, but consult your doctor first) to maintain your weight and improve your health.

5.Control your blood cholesterol, if high, with diet or medications.

6.If you have diabetes, reduce sugary food and sugary drinks and aim for good blood sugar control.

7.If your doctor prescribed certain diet restrictions, consult a dietician (it is simpler and more effective than figuring out on your own). In general, patients with kidney problems benefit from a diet low in sodium, fat and sugar; and in many occasions low in potassium and phosphate (requiring sometimes to take phosphate binders).

8.Protein restriction in the diet can benefit many patients, retarding in some the progression of kidney disease, but please check this with your doctor as it depends greatly in how advanced your disease is, your nutrition status and many other factors.

9.In advanced stages of kidney disease, water restriction might be necessary as progressively it is more difficult for ill kidneys to handle the excess of water and you can develop fluid retention. So, if your doctor prescribed fluid restriction, try to attach to it, otherwise, you can develop fluid overload with leg swelling, breathlessness, tiredness, potentially flooding the lungs and precipitating a heart failure episode. Frequently, patients need to take diuretics (water tablets) to eliminate excess of fluids retained.

10.Attend regularly your appointments and do not miss them, even if you feel ok.Kidney problems in early and moderate stages are typically asymptomatic (ie you do not feel anything wrong), so that can give you false reassurance. By missing appointments, you can miss to discover things on time and miss the chance to intervene opportunely with the aim of delaying progress of your kidney dysfunction.

11.Take all your medications as prescribed. Some patients are on anti-proteinuric medications, as they can protect your kidneys, but some patients might have contraindications and cannot use them. Check this with your doctor.

12.Many patients with high cardiac risk factors can benefit from taking aspirin or special types of blood pressure tablets, so ask your doctor if they are suitable for you as not everyone can take aspirin, for example.

13.If you have anaemia, take your iron supplements and/or administer your erythropoietin injections as prescribed to improve your haemoglobin levels to the recommended range.

14.If your blood is acidic (low serum bicarbonate), take your bicarbonate supplements.

15.If your uric acid is high, take care of your diet and take anti-uric acid medications if prescribed by your doctor

16.Ask your doctor if you need some vitamin supplements.

17.If you have a stressful life, check what can you do to minimise your stress.

18.Check with your doctor if your 25 vitamin levels must be checked, and if low, take supplements. In addition, some patients with advanced kidney disease might need also to take a more special active type of vitamin D or other medications to control the phosphorus and calcium in your body.

19.If you have high blood pressure and/or diabetes, you might need to see an eye doctor to examine the back of your eye.

20.Check what vaccinations are ideal for you. It varies patient to patient but typically,  vaccinations against influenza, pneumococcus vaccination and hepatitis B vaccination are advisable.

21.If you do not drink alcohol, good for you. If you do, do it with moderation.

22.If you have chronic kidney disease and renal cysts, you might need monitoring of the appearance and size of the cysts by ultrasound, performed at different intervals. Consult your doctor to see if this is necessary for you.

23.Inform your doctor immediately after becoming pregnant as you might need to discontinue medications like anti-cholesterol and anti-proteinuric medications or any other special medication given for certain kidney problems (diseases with inflammation in the kidneys) like some immunosuppressants

24.Go back to consult your doctor if you have queries or worries about your health or side effects of therapies, which can be more common in patients with kidney problems, or if you do not respond as both expected to the strategy proposed by your doctor.

Finally, I need to mention there is no magical medication or strategy to make the kidneys recover, so in many patients the aim and expectation is to maintain the kidney function stable for as long as possible or if deteriorating, to deteriorate as slow as possible; that is, the aim is to prolong the life of the kidneys, hopefully for the rest of the lives of the patients.

Since the treatment is complex and needs to be personalized to your condition and wishes after carefully explained the rationale, pros and cons of all options, my practical recommendation is to allow your kidney doctor to explain all that to you, taking into account your personal priorities and preferences.

Dr Francisco, wishing you the best possible health.

29 Oct 2018

Hi,

Peritoneal dialysis is regarded as a self-care therapy, that is, you do it by yourself, after being trained, contrary to haemodialysis, in which typically the nurses do all the procedures and steps for you. 

The fact that you do peritoneal dialysis by yourself gives you certain freedom and independence of timing and place where you perform the peritoneal dialysis therapy, and makes traveling less cumbersome than haemodialysis, because you need to book a centre overseas and plan your trip around that schedule.

But I appreciate that you might be concerned about infections or other mishaps if performing your peritoneal dialysis in an unfamiliar environment.

The vendors of peritoneal dialysis can deliver dialysis fluids and other equipment to your foreign address, so you can perform it in the comfort of your relatives’ house or in your hotel room. If you are using normally the ‘manual technique’ for peritoneal dialysis, this will be easy for you. On the other hand, if you are normally using automated peritoneal dialysis, ‘machine technique’, at home, it is ideal that you get a refresher training session with the nurses in charge of your care on the ‘manual technique’, to build your confidence when overseas and to be sure you follow the steps to minimise risk for bacterial contamination and infection.

You would need to take all the hygienic precautions explained to you by the nurses, ensure the room where you are performing is clean and comfortable and take good care of your exit site. Then, enjoy your trip or take care of your business matters.

Patients with haemodialysis can also travel. I have helped to arrange haemodialysis sessions to some of my foreign patients while traveling to Singapore for leisure or business with no big issues, trying my best to make it stress-free for them.

For those patients traveling overseas having haemodialysis, my advice is to:

  • look for a trustable and affordable dialysis centre (there are published lists of international centres on the web),
  • ask whether your dialysis coordinator, your nurses or your doctor can help you with the preparation, selection of a centre and planning, including giving you a letter with your prescription and recommendations, arranging the pertinent tests to travel with (if they require them beforehand), or if they familiar with the dialysis care in the country that you are visiting you, to give you more specific recommendations.

But do expect that haemodialysis therapies performed one-off in a foreign country can be more expensive than in your country. 

Dr Francisco, wishing you the best possible health and smoother trips abroad.

30 Oct 2018

Hi, 

Choosing between peritoneal dialysis and haemodialysis can be a difficult decision because there are many factors to consider and it is a significant event in patient’s life.

There are patients who have medical contraindications for one therapy or for the other and therefore they do not have much choice, or patients that have certain medical conditions for which the doctors would recommend one therapy over the other one. Said that, most patients do have a choice.

Overall, I advise my patients to choose the therapy they feel more comfortable with and which blends better with their lifestyle and personality or affects their lifestyle to a lesser degree. Just try to visualise how your personal, family, social, sports and work life will be affected after one or the other therapy. Then, the doctor can tune up your decision or reaffirm it. But do not forget that if you are eligible for kidney transplantation, probably you should consider it over any type of dialysis. I expand on the benefits of kidney transplantation in another question in this series.

Please see below a table comparing some characteristics of peritoneal dialysis and haemodialysis, which can help you to take a more informed decision. But please check all your queries with your kidney doctor, as he can personalise his advice to your needs.

 

HAEMODIALYSIS

PERITONEAL DIALYSIS

CLEANING OF BLOOD

Sufficient

Sufficient

INDEPENDENCE

Three times a week only

Do it at home by yourself

DEPENDENCE

Three times a week, on and on, need to plan your life around this schedule

Do it at home every day

CONFIDENCE

Done by professionals

Done by empowered patients

PEER EFFECT vs FAMILY LIFE

Benefit of dialysing together with peers suffering the same struggles

More permissive of family life, more able to take care of duties and shores at home

FLUID RESTRICTION

Needed and stringent

Needed, less restriction

DIET RESTRICTION

Needed and stringent

Needed, less restriction

TRANSPORT

Needed

Not needed

DEXTERITY & VISION

Not needed

Needed (except if a caregiver helps)

PATIENT ECONOMY

More expensive

Cheaper 

HEALTHCARE ECONOMY

More expensive

Cheaper

WORKLIFE

Part-time or flexibility required

Full-time (while on breaks/night-time)

SPORTS

More permissive but case to case basis

Case to case basis but swimming and contact sports are cumbersome

TRAVEL

More difficult -Need to find a dialysis centre overseas

More permissive -Solutions can be supplied overseas

AESTHETICS

Arm bumps

Tube in tummy (need to cover for showering)

COMPLICATIONS

Infections, blockage, hypotension, messy blood pressure

Infections, blockage, hernias, weight gain

COMPATIBILITY WITH DIABETES

Some fluctuations

Usually worsens it

DURATION

More long-lasting

Peritoneal membrane can thicken with time, especially if developing infections

HOUSE RE-ARRANGEMENTS

Not needed

Need space for machine and fluids

 

In regards to sports, that is a tough question. There are doctors who are more conservative. I do not practice sports and I know how important is to continue doing them, and one of the aims of dialysis and transplantation is to allow as much as possible a close to normal life. But it depends on the type of sport, its intensity and its competitivity.

For instance, rugby will be difficult if you have a kidney transplant, which can be at risk of injury, or for peritoneal dialysis, as the catheter can be pulled accidentally by the opponent. The same might apply for soccer and basketball, although the contact is not a heavy as rugby, but also depends how intensive or competitive you are and who you played with or against it.

If just for leisure, no harm in kicking the ball around after the surgical wounds have recovered. Swimming will be difficult in you have a peritoneal dialysis catheter. Noncontact sports will be simpler like badminton or running or cycling, etc. Patients with haemodialysis on a fistula could do those sports, but ideal they rest well after a dialysis session and ideal to do sport with risks of fall or heavy contact in the hours after dialysis as they receive blood thinners in the dialysis treatment, etc.

There are so many sports and exercise types and permutations trying to match them with the different therapies for kidney failure, that my best practical advice is to discuss this further with your kidney doctor, as he/she can advise you more specifically and accurately, as he/she knows your condition better, based on your priorities and preferences, too.

Dr Francisco, wishing you the best possible health and that hopefully you can continue doing all their sports you like, but indeed you might need to modify the intensity or the setting in which you will practice it.

3 Nov 2018

Hi, 

Kidney transplantation can prolong and improve the lives of patients with kidney failure, in comparison to their outlook if remaining on dialysis forever. Kidney transplantation can also give patients a better quality of life by allowing them to regain their freedom to do many of the things that they used to do or they used to enjoy before developing kidney failure and needing dialysis.

Thus, kidney transplantation appears to offer patients the best chances for rehabilitation in many aspects of their lives, including the medical aspect, work life, school, social life and leisure, and gives freedom for traveling, with less dietary and fluid restrictions, even having better fertility; thus increasing the chances for higher degree of personal fulfilment and a happier personal, family, and work life.  

However, kidney transplantation is not free of potential complications or side-effects of the anti-rejection medications, which broadly speaking could be high chances of infections, metabolic problems like diabetes and increase risks for cancers; but this does not happen in all patients.

And despite they are significant side-effects to consider, the majority of patients undergoing a kidney transplant live longer and fuller lives than if remaining on dialysis, which brings by itself many complications, especially cardiovascular, with a shortened lifespan and lesser quality of life.

Obviously, there are always extreme cases, patients who can lose the transplant on the same day of the surgery or have a major surgical complication, or dialysis patients who live for many years, but the majority of kidney transplant patients do better than the majority of dialysis patients.

There are different types of kidney transplants depending on the types of donors, and the outcomes greatly depend on this. For instance, kidney transplantation through life donation, especially from family members, provides more benefits in comparison to transplantation from deceased donors because the degree of organ compatibility is greater in the former; therefore, fewer chances for rejection and higher chances for a more prolonged life of the kidney transplant. A transplant from family members might also need lower doses of the medications to prevent rejection, and less need to use rescue anti-rejection medications, which are more toxic; therefore, fewer chances for side-effects.In living donation, the quality of the donated kidney is higher as it comes from a healthy family member (or a close person), with more chances to function for longer than kidneys from deceased donors.

In addition, in living donation, in contrast to the donation from deceased donors, the kidney transplant can be performed promptly without the need to remain for years on a waiting list for a kidney from a deceased donor.

This is very important as during those years on a waiting list, many complications can occur that can lead to patient's loss of health and loss of fitness to undergo kidney transplantation in the future, or even worse things. 

These benefits can be even greater if kidney transplantation is performed before undergoing dialysis, what is called pre-emptive transplantation, or as soon as possible after starting dialysis; which avoids the side-effects of prolonging the kidney failure status and the side effects of ‘partially effective’ dialytic therapies, as they cannot clean the blood as well as the transplanted kidney.

In addition, the transplanted kidney, as it is a natural kidney, provides to the patient with all the other important functions the kidneys have, which no dialysis machine or therapy can do.

Thus, for patients who can choose between all these options, a pre-emptive kidney transplant for a living family member offers the best outcomes, leaving deceased donor transplantation and dialysis as last resorts.

However, not every patient is suitable for kidney transplantation plus the kidney transplant surgery is bound to cardiac, surgical and anaesthetic risks as any other major surgery. Patients with kidney failure tend to have several co-existing illnesses and some or many medical complications.

If the summation of all the complications together with age and frailty increases the risk of kidney transplantation, doctors might advise patients against transplantation. Similarly, patients with active or recent cancers or infections or other medical contraindications might not be suitable for transplantation. Thus, in some patients dialysis might be safer than kidney transplantation.

Therefore, all decisions must be individualised, so my recommendation is to get yourself assessed by a kidney specialist who can address in more detail and more specifically all your queries, so you can take the best possible decision for your future wellbeing.

There are many other factors involved, for instance financial. Overall, kidney transplantation is cheaper than dialysis, though there is a big bill to pay following the surgery. But dialysis is more costly in the long run, not only for the wallets of the patients but for their health. Many governments have very kind subsidies for dialysis what make the patient pay much less for dialysis than for transplantation, but that does not mean it is cheaper and, as exposed above, eventually their health ends up paying it back.

So, dialysis is a bridge for transplantation or second best option if transplantation is not possible. But there are patients who simply prefer dialysis in comparison to transplantation, even if eligible, which is respectable, or patients who have no available or suitable donor to give them a kidney…it is just matter to accept that reality and take good care of their health so they can live free of complications for as long as possible.

My patients on dialysis who decided to follow the medical recommendations, the diet and fluid restrictions and to live a more frugal life, tend to live longer and better with fewer complications than other patients.

Kidney transplantation is a beautiful experience and the costs are a huge investment in the health of the patients and their wellbeing and the wellbeing of their families, because this is the method that can hold them together for the longest in the fittest and possibly happiest way.

There are still many big and little things to discuss. Visit your nephrologist and bring all your queries to his/her clinic.

Dr Francisco, wishing you the best possible health.

3 Nov 2018

Hi, I am sorry to hear that your grandmother has diabetes and she is at risk of developing diabetic kidney disease (aka diabetic nephropathy); which means diabetes affecting the kidney, damaging it and potentially leading to kidney failure.

In fact, diabetes is the most common cause of total kidney failure worldwide and in Singapore. Around 40% of patients with diabetes develop kidney problems. Many of them can progress to total kidney failure, needing dialysis or kidney transplant to remain alive.

Besides, patients with diabetic kidney disease and even more with total kidney failure are susceptible to many medical complications, including heart attacks, strokes and disabilities, which can affect dramatically the length and quality of life of the patients who suffer them.

My intention is not to scare you but to create awareness of the potential risks, even if at present the disease seems not to be advanced. But we all know that prevention is better than cure. Thus, I concur with your doctor recommending better blood sugar control to prevent the appearance and/or the progression of diabetic kidney disease into total kidney failure. In addition, good blood sugar control can also help minimising the risk of other complications like blindness and amputations; certainly, it will protect the heart and can reduce blood cholesterol and uric acid and help in losing or maintaining weight.

But how does diabetes cause kidney problems?

Persistent high blood levels of sugar (poor diabetic control) progressively damages many organs of the body which are rich in blood vessels like the heart, eyes, brain and kidneys, and affect the circulation to the limbs. Simplistically, the excess of blood sugar kind of “caramelises” inside the blood vessels and tissues and that causes inflammation, damage and scarring.

Specifically, in the kidney, high blood sugar progressively damages the filters of the kidneys (the ones that clean the blood), and patients start leaking proteins in the urine. If poor sugar control remains, it can lead to progressive scarring of the kidneys, losing their capacity to clean the blood and control body water, with consequent elevation of blood creatinine (a marker of kidney disease) and toxins in the blood.

Never is too late to improve her sugar control. It could prevent the occurrence of diabetic kidney disease, or slow its progression or minimise the impact it has in her health. And the protection of her kidneys will be more impactful if any other little problems that she might have can be controlled and optimised like high blood pressure, overweight, high cholesterol, etc. Doctors also can give some medications to protect, at least partially, the kidneys, the so-called “renin-angiotensin-aldosterone blockade”, and occasionally and if necessary advise on a diet low in protein and salt, and recommend avoidance of bad habits like smoking.

Diet plays a crucial role in the management of diabetic patients to obtain better sugar control, even if taking medications. Medications are necessary for many patients with diabetes, but they are not a substitute for diet control: they are complementary. But many patients think that by taking medications their diet does not need to be controlled. On the contrary, medications will work better if eating a healthier diet; and in fact, many patients can control her diabetes with diet only. 

Many patients find difficult to control their diet, as indeed diet and eating are pleasures and social activities, but with good support and advice from doctors and dieticians, it is possible to adopt a healthier diet and improve blood sugar control. And even this can be achieved without excessive restrictions, with a personalised diet; in order to foster the sustainability of the diet regimen and of the blood sugar control.

Dr Francisco, wishing your grandmother the best possible health. 

11 Jan 2019

Hi,

Malnutrition in patients with chronic kidney disease

Patients with chronic kidney disease can suffer from malnutrition, especially when the disease progresses to more advanced stages.

Nutritional status can be worse in patients with:

  1. other conditions like diabetes,
  2. chronic inflammation like when suffering from lupus or other inflammatory glomerulonephritis
  3. large amounts of proteins loss in the urine like in the nephrotic syndrome,
  4. other debilitating diseases like cancer, heart failure or liver failure, or
  5. high nutritional demands (concurrent illnesses and infections)

A healthy and balanced diet is typically recommended to patients with chronic kidney disease in early and intermediate stages (stages 1-3a).

Ideally, you should avoid:

  • high sugary foods and drinks
  • fatty, oily and fried foods
  • salty dishes
  • processed foods.

However, as the disease progresses, more and more diet restrictions are recommended, in particular in:

  1. sodium (ideally should be around 2 g of sodium per day or 5 g of salt per day)
  2. potassium
  3. phosphorus
  4. calcium (both dietary and the one prescribed as supplements) and
  5. protein.

The type and extent of the restrictions need to be individualised to the patient's:

a) stage of the chronic kidney disease (some patients start needing restrictions at stage 3a of chronic kidney disease, but many more from stage 3b),

b) symptoms,

c) nutritional status,

d) accompanying diseases and

e) laboratory parameters

How much protein restriction is necessary?

Typically, a restriction of 0.8 g of protein per kg of body weight per day is recommended in stages 3a/3b and 4 of chronic kidney disease.

The aim of restricting protein is to:

  • slow down the progression of kidney disease
  • to diminish the amount of protein-derived toxins in the blood (and the symptoms derived from them) and
  • to reduce the load of phosphorus contained in proteins and the consequence of its excess.

Occasionally, doctors prescribe a higher degree of protein restriction. If this is necessary, supplementation with special amino acids (keto acids) is recommended

However, taking keto acids when the protein restriction is not high (very restrictive) does not add any significant benefit to the patient, and adds to unnecessary costs.

Malnutrition and the importance of a dietitian

Unfortunately, malnutrition could be one of the down-points of protein and phosphorus restriction, especially as chronic kidney disease progresses.

Hence, advice from a dietician with expertise in renal conditions is very important.

This will enable you to strike the correct balance between obtaining adequate nourishment, and avoiding malnutrition because of excessive restrictions.

There are indeed some oral supplements and shakes that can be taken in chronic kidney disease to enhance nutrition, but a proper assessment by a dietician taking into account all the patient factors described above is necessary.

Vegetarian diets may be helpful

Some doctors and dieticians favour vegetarian diets.

This can help many patients, but not everyone is ready to become a vegetarian.

It's important that the diet you choose is one that you can sustain, as everyone has different preferences and backgrounds at the end of the day. 

Your dietician will be able to advise you on how to adopt a more balanced vegetarian diet, or how to adopt a more mixed diet according to your needs (disease protection, nutrition, palatability and sustainability).

Watching your weight is important!

Avoiding excess weight is also important in patients with chronic kidney disease, as it is an important risk factor for many medical problems.

This helps to address:

  • potential heart problems
  • potential kidney problems. Excess weight and calorie intake will mean that your kidneys have to overwork. With time, they can get “fatigued”, and result in a faster progression to total kidney failure faster.

The recommended energy intake is around 30 to 35 kcal per kg of body weight per day.

Fluid restriction to prevent flooding of the lungs

As the disease progresses, many patients need to undergo water and fluids restriction.

This helps to prevent fluid retention and potential flooding of the lungs, as the kidney can no longer handle excess fluids.

Malnutrition in patients on haemodialysis

Malnutrition can get worse once the patients reach total kidney failure (stage 5 of chronic kidney disease) and starts haemodialysis.

The occurrence of malnutrition is associated with poorer outcomes, due to the so-called protein and energy wastage syndrome.

Protein and energy wastage syndrome is caused by:

  1. poor intake due to poor appetite, nausea or even vomiting accompanying total kidney failure,
  2. overconsumption or wastage of proteins and energy stores because of high toxins in the blood,
  3. the development of chronic inflammation and many accompanying diseases, or
  4. diet restrictions prescribed by doctors and dietitians (which are in turn necessary to avoid other complications).

It is indeed difficult to strike a good balance in many patients on haemodialysis.

How to identify patients with protein wastage?

Many patients with kidney failure can look very thin. However, overweight patients can still suffer from protein wastage.

Hence, the nutritional status of dialysis patients needs to be checked frequently (eg. every 1-3 months) by:

  1. asking about recent or ongoing weight loss, eg. clothing getting looser or people telling them they have lost weight (sometimes it might not be obvious to them)
  2. asking about new complications or accompanying illnesses. Proper treatment helps to reduce the impact on nutrition
  3. asking them about recent admissions to the hospital, as concurrent illness takes a big toll in the protein and energy reserves of patients
  4. checking for symptoms that suggest dialysis inadequacy (i.e. patient not thriving and the dialysis dose needs to be optimised)
  5. assessing whether chronic inflammation can be minimised
  6. asking them about their typical meals, but ideally with a food diary for at least one week,
  7. body measurements like the body mass index (the so-called BMI),
  8. physical examination
  9. questionnaires
  10. laboratory tests like the serum albumin (ideally around or over 40 g/L in the blood)
  11. measurements of the normalised protein catabolic rate (nPCR)/protein nitrogen appearance (PNA) – a complex but useful way to calculate nutrition in the body of dialysis patients
  12. body fat composition scans

The role of dialysis and dietitians

Advice from a renal dietician who has experience in dialysis patients can help to further improve nutritional status.

Typically, patients are recommended to eat around 1.2 g of protein per kg of body weight per day, ideally of high biological value.

In addition, the energy intake should be around 30-35 kcal per kg of body weight per day.

All these calculations might be perplexing to most people, even to doctors.

Dieticians can help “translate” these doctors’ prescriptions into something practical. Eg: what food to buy and how to cook it, and which food to miss or moderate.

In addition, dietitians are the best professionals to help haemodialysis patients strike a good balance between restrictions and nutrition (although this is not very easy).

Many patients can benefit from prescribed oral protein and energy supplements and shakes, prepared especially for dialysis patients.

Dieticians can tell you which supplement is the right one for you, and how to take the right amount in combination with your diet plan.

Rarely, haemodialysis patients will require intravenous nutritional supplements, especially when not thriving on oral supplementation or when malnutrition is very severe.

Malnutrition in patients on peritoneal dialysis

Malnutrition is also common in patients on peritoneal dialysis.

In patients undergoing peritoneal dialysis, malnutrition occurs because of:

  1. increased protein and energy wastage due to high levels of toxins in the blood,
  2. loss of protein and amino acids into the peritoneal fluid with each peritoneal wash (peritoneal exchange), especially if the peritoneal membrane status is very absorptive
  3. patients not feeling hungry because of the sugar load with the peritoneal dialysis washes, or
  4. patients feeling full because of the dialysis fluid inside the tummy

The nutritional status in peritoneal dialysis patients also needs to be monitored frequently (eg every 1-3 months).

This is similar to the monitoring of patients on haemodialysis. The transport status (with the use of the peritoneal equilibration test) needs to be assessed and monitored for changes across time.

Once more, seeing a dietician with experience in peritoneal dialysis patients is crucial.

The protein intake recommendation is similar to the one for haemodialysis patients, at around 1.2 to 1.3 g of protein per kg of body weight per day. It's ideal to adjust the calories intake to the amount of sugar contained in the peritoneal dialysis washes.

Finally, there are commercial peritoneal dialysis solutions with amino acids with the aim of both minimising the load of sugar per day, but to provide the patients with amino acids to build protein in  order to enhance their nutrition.

I hope this information is useful for you. This is a complex and very important matter, so I recommend you to discuss this further with your favourite nephrologist and an experienced dietician. They can assess you properly and decide whether you need a specific diet. 

Dr Francisco, wishing you the best possible health.

18 Jan 2019

Hi,

Please let me define first what chronic kidney disease and renal failure are.

Chronic kidney disease is the consequence of many different disorders and diseases in the kidneys. Chronic kidney disease results in progressive damage, which eventually impairs all the functions of the kidneys.

On the other hand, renal failure is when your kidneys completely stop working as t and this is typically irreversible.

When your kidney function drops below 10%, patients can become very ill, the situation can be life-threatening, and dialysis or a transplant needs to be performed. 

There are five stages of chronic kidney disease, from stage 1 to 5; stage 5 the most advanced.

Kidney failure stage

The 5 stages are classified according to the so-called GFR, which stands for glomerular filtration rate. GFR is a measurement of kidney function, which is an approximate percentage of kidney function.

In stage 1, the GFR is normal. This means that the way your kidneys clean the blood is still normal and sufficient, but there is already detectable damage to the kidneys.

From stages 2, 3, and 4, the damage to the kidneys become progressively worse, and the kidney function starts dropping progressively.

By stage 4, patients probably already need to start preparing for dialysis or for a kidney transplant.

By stage 5, the patient can feel very ill. The situation can be life-threatening, and dialysis needs to be started, or a kidney transplant needs to be performed.

When does one start feeling signs and symptoms of kidney failure?

It is by stage 4, and definitively by stage 5, when the patient starts having symptoms or signs of kidney disease.

In earlier stages, typically the patient has no symptoms or only minor symptoms. Thus, it's common to be unaware that he or she is suffering from kidney problems.

As such, detecting chronic kidney disease early is important. In many instances, the disease's progression can be halted if lifestyle modifications and medications are started in time.

Why is it that most patients don't realise that they have kidney disease?

Unfortunately, chronic kidney disease has no symptoms in the earlier stages, what means that patients might not be aware there is an on-going problem.

Hence, they seek out medical attention late, which allows the kidneys to be progressively damaged.

Early detection is a critical step in the management of people who are at risk of kidney problems.

But from another perspective, having no symptoms in earlier stages can be good as patients can still enjoy life and perform all their activities as normal.

In early stages of kidney disease, patients must focus on protecting the kidneys and minimise disease progression with a better lifestyle and diet, medications and an adequate monitoring strategy.

What are the symptoms of chronic kidney disease?

kidney disease singapore

When the kidneys are ill, they cannot control the water content of the body very well, so the patient starts retaining fluid and becomes breathless and easily fatigued.

The blood pressure of the patient becomes high, and this can give the patient a headache and can silently damage many organs.

The patient can also feel:

  • very weak
  • very lethargic
  • nausea with vomiting,
  • severe itch 
  • be unable to sleep or concentrate because toxins that the kidneys normally clear start to build up
  • anaemic and weak because the kidneys are not producing the hormone erythropoietin to boost the red blood cell count. Hence, the patient will need to have erythropoietin injections.

Patients can also have bone pains, deformities and even fractures because the diseased kidneys are not activating the vitamin D necessary for calcium absorption and to make the bones stronger, and there is also dysregulation with phosphorus and other problems with mineral metabolism.

There can also be an imbalance in the blood levels of potassium, sodium, calcium, phosphorus, magnesium and many other minerals. This can be life-threatening on occasion, especially in advanced untreated stages.

Other organs can also be affected when you have kidney disease

When the kidneys are ill, many other organs are also affected.

For instance, patients with kidney failure are at increased risk of heart attacks, heart failure, or arrhythmias, which are erratic beats of the heart.

The blood pressure can go very high and damage many other organs. This may precipitate a heart attack or stroke. If the potassium levels go too high, it can even make your heart stop.

As I mentioned before, the bones and muscles can also become very weak.

What is uraemia? 

Uraemia is when the patient becomes malnourished due to toxins in the blood.

This may cause patients to bleed from the stomach.

Uraemic blood means that many organs cannot perform their functions, such as the liver and the brain. This can affect mood, intellect and performance. The patient can become more anaemic, requiring very high doses of erythropoietin or maybe blood transfusions. With severe fluid retention, the oxygen levels drop and they can become drowsy.

Finally, there are also another set of symptoms for glomerulonephritis which are different from chronic kidney disease, but that is a separate discussion.  

I hope you find the answer useful. Please do not get too alarmed and worried, although it is good to be aware of potential symptoms and signs especially if are already having kidney problems or relatives who suffer kidney diseases.

If in doubt, you can consult a nephrologist for further advice.

Dr Francisco, wishing you the best possible health.

16 Jan 2019

Hi,

I am sure anyone would be worried after your experience.

First of all, it is possible it was already in the toilet bowl, especially if:

1. you could see it with your naked eye and

2. you have no urinary symptoms

However, it is also possible that the organism could have been "dragged" by the urine from the skin, vagina or anus during the urination process in women.

This is because the urine stream can "washout" the genitals before going into the toilet bowl.

For example, parasites like Trichomonas vaginalis or Enterobius vermicularis, as well as their larvae can contaminate urine in this way.

There other parasites that can infect the urinary bladder, like Schistosoma haematobium, which indeed could be passed directly during urination.

Even larger parasites like Ascaris lumbricoides have been reported to infect the bladder after an abnormal passage way between the intestine and the bladder was formed. This can cause urinary tract obstruction (see picture of an Ascaris worm inside a urine bag taken from the internet).

Ascaris in a urine bag

In addition, Strongyloides stercoralis is a parasite that can infect immunosuppressed patients like transplant patients. This parasite can also be detected in the urine.

These are just the most common examples.

Most likely everything will be ok, so try not to worry and do not jump to any conclusions.

You can consult a general practitioner, nephrologist or urologist to perform some investigations in your urine, like

(1) examination of the urine sediment (cells and debris in the urine) by a lab technician;

(2) urine cytology, which is the examination of the urine sediment under a more powerful microscope and with the help of special dyes by an expert pathologist;

(3) a urine culture; and

(4) whatever other tests your physician deems necessary after asking you questions and examine you.

If indeed a parasite infection is discovered, you might also need to undergo more special investigations and consult an infectious diseases physician.

Many other infestations and unusual infections can be detected in the urine.

For example, although they are not proper parasites, tropical parasite catfishes (very small fishes) can be caught by swimming in fresh water in certain parts of the world like the Amazon, and can actually enter the body through the urinary system. 

Dr Francisco

15 Jan 2019

Hi,

Here's the summarised answer to your concerns:

First and foremost, diabetes is a common cause of protein leaking in the urine, hence, it's important to rule this out as a cause. 

Regarding the exact treatment of protein leaking in the urine, this will depend mainly on the cause and the severity of protein leakage. As there are many possibilities and more permutations, you should seek out a formal consultation with your doctor or nephrologist. 

If you do indeed have persistent leaking of protein in the urine due to kidney dysfunction, you will certainly benefit from better control of the condition or addressing the risk factor(s) that is causing it (eg. medical issues like high blood pressure, diabetes, high BMI or high cholesterol).

This can be done through medications, as well as lifestyle modification and dietary advice. The use of a special type of blood pressure tablets referred to as anti-proteinurics to minimise the leaking of protein in the urine, thus, protecting the kidneys, is recommended in many patients. 

The role of your kidneys

Role of kidneys

The main job of your kidneys is:

1. cleaning your blood and

2. controlling the right amount of water in your body.

How does your kidney clean your blood?

Kidney functions and glomeruli

To clean your blood effectively, each kidney has around 1 million microfilters (the so-called glomeruli).

The size of the pores of these filters:

1. allows small toxins to be removed and

2. prevents larger substances like proteins from being lost in the urine, - to be healthy, we need to "keep" our proteins inside the blood, and not lose them in the urine.

What happens when your kidney is damaged?

When there is damage to the kidney microfilters, either because of

(i) inflammation like in the case of glomerulonephritis or

(ii) because of scarring like in the case of high blood pressure, diabetes or other diseases,

these microfilters get distorted and can even get destroyed.

When this happens, your kidneys:

(1) might not clean the blood properly, leading to an increase in the levels of blood creatinine

(2) might leak red blood cells in the urine, detected as blood in the urine, and

(3) might leak protein in the urine, which can cause bubbles in the urine. If large amounts of proteins are lost, this may cause medical issues such as fluid retention in the form of leg swelling and face swelling

What happens when protein is detected in your urine? 

Urine test

Thus, as protein leakage was detected in your screening by urinalysis, your doctor, first of all:

a) needs to ask you extra questions and examine you in more detailed (including measuring your blood pressure);

b) measure more accurately the amount of protein leaked in the urine;

c) do a more detailed analysis of the cells and debris present in the urine (looking for blood or signs of infection, for example);

d) check the status of your kidney function and order other pertinent blood tests, and

e) ideally refer you to a nephrologist, who will decide what further special tests you need to undergo to be sure your kidneys are working fine, and try to pin down the cause of protein leaking in your urine.

How do doctors determine the amount of protein in your urine?

urinalysis

Source: Verywell Health

Protein leaking in the urine can be identified and roughly measured by urine dipstick and urinalysis, (what you just did).

However, it can be quantified more accurately in the laboratory either by using:

1. a single fresh urine sample (which is very convenient, fairly accurate and widely used) or 

2. after collecting urine for 24 hours in a bottle (which might be inconvenient, but preferred by some doctors and necessary in certain situations).

Thus, seeing a nephrologist might be necessary to propose an investigation plan and, importantly, to rule out glomerulonephritis - inflammation of the kidneys - as this can endanger the wellbeing of your kidneys.

Other causes of protein leakage in your urine

There are other causes of protein leaking; for instance:

1. people leaking some protein after doing intensive exercise or

2. having a fever or a viral infection.

These are regarded as benign because they are intermittent, transient and do not cause significant injury to the kidneys.

However, when the protein leaking in the urine is:

a) persistent,

b) severe,

c) accompanied by blood in the urine,

d) accompanied by your kidneys showing deteriorating function, or

e) accompanied by markers of other diseases that can affect the kidneys, such as like lupus (among others);

the nephrologist might suggest to perform a kidney biopsy, as well as for a pathologist to examine the biopsy samples under a microscope.

Why are kidney biopsies sometimes necessary?

You need to be properly assessed before a kidney biopsy will be recommended.  

Kidney biopsies are important:

(i) first to diagnose a cause for the protein leaking,

(ii) second to check how much damage has occurred (i.e. scarring of the kidneys), and

(iii) third to provide more accurate treatment and prognosis advice. 

To sum up:

There are many diseases that can cause protein leakage in the urine.

Some progress rapidly, while others progress more slowly. It's important to identify the cause behind kidney disease ASAP so that we can treat it and monitor the problem properly. This will prevent total kidney failure. 

At this moment, do not alarm yourself too much. Discuss this again with your doctor and whether you need to be referred to a nephrologist; but you can consult one by yourself if worried, and he/she can reassure you and propose an initial investigative plan.

It might not be something urgent or severe (hopefully something mild and simple), but do not let the time pass by without investigating properly.

I hope this information was useful. Take good care.

Dr Francisco, wishing you the best possible health.

16 Jan 2019

Top Questions


Hi. Male 37 yrs old/Chinese. About 7 weeks ago, I awoke to sharp pains in my lower stomach/groin area. The pain was quite intense and I had cold sweats. After making my way to the polyclinic, the pain started to subside around and the doctor didn't find anything wrong. About 4 weeks ago, I experienced the same pain again. I also observed pink urine (blood in urine). I went back to the polyclinic and the doctor arranged for an ultrasound for my kidneys. The ultrasound nurse noticed a rice sized particle in my right kidney. I am particularly concerned about kidney stones. What should I do next, and what are my treatment options for kidney stones? Kindly advise, thank you. 

I've been told that I have low red blood cells too. What does this mean?

I’ve heard from a friend that by spreading your meals apart you can manage your diabetes better, is it true?

I would like to understand how does this disease suddenly become incurable at a certain point?

I've read that the recommended potassium intake is about 3,500 to 4,700 mg per day. But I can only buy supplements with 100 mg. How am I supposed to ensure a healthy potassium intake?