Chronic Renal Insufficiency

What is renal insufficiency? Renal insufficiency, also called renal failure, is when your kidneys no longer have enough kidney function to maintain a normal state of health. Note that the term renal failure is beginning to be replaced by renal insufficiency when in the context of chronic kidney disease. There are two kinds. Acute renal failure (ARF). This is kidney failure that happens rather suddenly, where something has caused the kidneys to shutdown. This may be due to infection, drugs (prescription, over-the-counter, recreational), traumatic injury, major surgery, nephrotoxic poisons, etc. Emergency dialysis may be needed until the situation resolves and the kidneys begin functioning again (this might take a short time, or months, or it might be permanent). While more acute episodes are possible in the case of IgAN (we often refer to them as "flare-ups"), IgA nephropathy is a condition that mainly causes chronic renal insufficiency (CRI), not usually acute renal failure (ARF). However, some people may experience spontaneously-reversing acute renal failure as well. The latter are cases where serum creatinine goes up dramatically but later returns to a more normal baseline. In such cases, dialysis may be needed until the condition improves. ARF in the context of IgAN is usually more associated with the person developing a flare-up of HSP. Chronic renal insufficiency (CRI). This is when a disease such as IgA nephropathy slowly and gradually destroys the filtering capacity of the kidneys. It is sometimes referred to as progressive renal insufficiency, chronic kidney disease or chronic renal failure (CRF). This kind of damage cannot currently be repaired, and as such, it is irreversible. A person may have chronic renal failure for many years, even decades, before dialysis or a kidney transplant become necessary. Chronic renal insufficiency does not, by itself, mean complete shutdown of the kidneys, and a person with chronic renal insufficiency may still pass urine normally, and may have more than enough kidney function left for normal functioning of the body. Note that you cannot judge the efficiency of your kidneys by the amount of urine you produce. People with quite advanced renal insufficiency, and even people on dialysis may still produce a fair amount of urine. But this does not mean that the kidneys are filtering waste nor regulating serum electrolyte levels efficiently. Chronic renal insufficiency itself causes more loss of kidney function. One important aspect of kidney disease is that, once a kidney is damaged by it to a certain degree, it continues to deteriorate even if the underlying kidney disease can or could be cured. This is commonly referred to as the point of no return (PNR).What happens is that the chronic renal insufficiency (CRI) continues to progress on its own, scarring of the glomeruli continues, and kidney function continues to gradually decline. It's possible that controlling blood pressure with an ACE inhibitor like ramipril, or an angiotensin II receptor blocker like Cozaar or Avapro may slow this progression of chronic renal

insufficiency. There is also beginning to be some evidence that the class of anticholesterol drugs called "statins" (like Lipitor, for example) may help slow progression of CRI. The point of no return is generally considered to be when serum creatinine reaches 2.0 mg/dl in U.S. measurements, or about 175 umol/L in international SI measurement. End-stage renal disease. As chronic renal insufficiency continues and progresses, the person may eventually reach the point where it is considered to be end-stage renal disease (ESRD), which is the subject of a different section on this website (see main menu). Stages and Symptoms of Renal Insufficiency Your nephrologist may use a classification system to describe what stage of chronic kidney disease you are at (such as Stage I, Stage II, etc.). Although these are not universally-used, a common example of this is given below. It is based on clinical practice guidelines on chronic kidney disease published in 2002 by the National Kidney Foundation (NKF) in the U.S., as part of its Kidney Disease Outcome Quality Initiative (K/DOQI). Stages of Chronic Kidney Disease These guidelines are adapted from the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) Stage Description GFR* 1 Signs of mild kidney disease but with normal or better GFR greater than 90% 2 Mild kidney disease with reduced GFR 60-89% 3 Moderate chronic renal insufficiency 30-59% 4 Severe chronic renal insufficiency 15-29% 5 End-stage renal failure less than 15% *GFR is given in ml/min/1.73 m2 More information about GFR Because there is considerable unpredictability and overlap as to when various symptoms of chronic renal insufficiency might start appearing, rather than limiting ourselves to these specific stages, we will instead look at 3 broad categories as follows. Please note that if you happen to have heavy proteinuria, even if your IgAN is at a very mild stage in terms of chronic renal insufficiency, you may begin to experience symptoms of what is called nephrotic syndrome. These symptoms are due to the heavy loss of protein, and are not strictly-speaking symptoms of "renal failure". Early chronic renal insufficiency (Stages 1 to 2) Physical symptoms. Usually few or no physical symptoms that you can feel (other than those you may experience if you have heavy proteinuria). Blood work. Blood work results will show abnormalities - mainly a slightly elevated serum creatinine. Note that there is often a time lag between elevations of serum creatinine, and some progression of the IgAN. By the time serum creatinine is elevated,

the person may already have lost 50% of kidney function. Urinalysis. Urine will show abnormalities. Urine can be checked by dipstick in the doctor's office (as an initial check), and followed up with a more complete urinalysis. The main urine abnormality that will suggest a kidney disease is the presence of protein and/or blood. Either will usually trigger further investigation. However, blood and/or protein in the urine doesn't say anything about actual kidney function. Treatment. Treatment may involve some mild dietary changes (a lower protein diet may in some cases be recommended), and a blood pressure medication may be prescribed (usually of the ACE inhibitor class, the angiotensin II receptor class, or both, even if blood pressure is not really elevated much). Blood pressure. Some people start having high blood pressure even in early chronic renal failure. IgAN is one kidney disease that can do this. Anemia. Anemia may rarely occur at this stage. In this case, it is most often caused by having heavy proteinuria rather than actual chronic renal insufficiency. Advanced chronic renal insufficiency (Stages 3 to 4) Physical symptoms You may still feel completely normal at this stage, or you may begin to experience one or more of the following symptoms: Serum creatinine. Serum creatinine will be higher (indicating less than 30% kidney function) Tiredness or fatigue Puffiness or swelling (obvious in the hands or feet and ankles, but the puffiness will often first be seen around the eyes). Back pain. Usually felt as a dull ache anywhere in the mid-to-lower portion of the back, on one side or the other - this is sometimes referred to as flank pain, or loin pain) Appetite. Changes in appetite or eating pattern. Foods may start tasting "funny". Urine. Changes in urination (amount, colour, frequency). Urine may in fact look exceptionally clear at this point, rather than abnormal. This is because little is actually being filtered into it by your kidneys. Previously high proteinuria and/or hematuria may actually improve. Blood pressure. High blood pressure (also referred to as hypertension) Digestion. Poor digestion (varying degrees of gastroparesis, which means that digestion is slowed). Treatment Diet. Dietary changes may be ordered (renal diet: low protein, low potassium, low phosphorus, low sodium, higher calorie) Medication High blood pressure medications. It's common to need more than one at this stage, and often 3 or more. Other drugs/supplements. May be prescribed if needed, such as vitamin D analog (calcitriol is a common one), renal vitamins (not a regular multi-vitamin, as these contain too much vitamin A for the typical advanced renal insufficiency patient). Drugs for controlling heavy proteinuria if necessary (note that heavier proteinuria does not automatically follow with more advanced chronic renal insufficiency). Phosphorus binder. You may be asked to begin taking a calcium supplement with meals

as a phosphorus binder (or a medication may be prescribed instead of or in addition to calcium). End-stage renal failure (or late chronic renal insufficiency) The terms end-stage renal failure and end-stage renal disease are used interchangeably, and the abbreviation ESRD is commonly used. Typically, patients will have kidney function in the area of 10-15% or so. These are the common symptoms you may experience at this stage (and some people may start experiencing some of these earlier): Symptoms anemia (may begin earlier than this) easy bleeding and bruising headache fatigue and drowsy feeling (more than normal or usual for you) weakness mental symptoms such as lowered mental alertness, trouble concentrating, confusion, seizures nausea, vomiting, and generally less desire to eat thirst muscle cramps, muscle twitching nocturia (night-time urination) numb sensation in the extremities diarrhea itchy skin, itchy eyes skin colour changes (grayish complexion, sometimes yellowish-brownish tone) swelling and puffiness (more than you had while in advanced renal failure, and most likely in the feet and/or ankles) difficulty breathing (due to fluid in the lungs, anemia) high blood pressure (with IgAN, you may already have had this since the early stages) decreased sexual interest changes in menstrual cycle (and difficulty getting pregnant) decreased urine output (however, you should be aware that some people with ESRD will continue to get rid of water as urine, but not wastes - therefore, the urine may be very clear and normal-looking, and some may have increased urine output rather than decreased). poor digestion (varying degrees of gastroparesis). Treatment The exact time that dialysis starts will vary slightly depending on various factors. Consult your nephrologist. Dialysis Kidney transplant What happens when you approach ESRD? It is at this stage that you are on the threshold of needing renal replacement therapy (any form of dialysis, or a kidney transplant). When this actually happens will depend on your

symptoms and lab results, but it will occur as you get close to 10% kidney function (by which time the special renal diet and medications will no longer be enough to keep you healthy). You will be considered to be approaching ESRD when you are under 30% kidney function (as measured by Glomerular Filtration Rate), and more actively as you approach 20% kidney function. Sequence of events when you approach ESRD Some localities, such as many major urban centers, may have a very complete "system" that patients come under or have access to as they approach or reach ESRD. Other areas might not. The sequence of events given below is typical, but it's possible that some of the items listed might not be available where you live, or your nephrologist may vary it slightly. It is provided as a guide, so that you will know what to expect, and what to discuss with your nephrologist. 35 to 30% kidney function (or thereabouts) Refer for Renal Replacement Therapy classes, also referred to as pre-dialysis classes. This is where patients should be introduced to the concept of the renal diet, and have the renal replacement options explained to them, ie. hemodialysis, peritoneal dialysis, and kidney transplant. This allows patients to make an informed choice of treatment method when the time comes, in consultation with their nephrologist and family. In some areas, handouts may be used in place of actual classes. Classes are usually about 6 to 8 hours spread over a couple of days on alternate weeks, or during evenings. Around this time, you will probably also be told to start taking calcium with meals as a phosphorus binder, if you haven't already (don't do this on your own). 30 to 25% kidney function (or thereabouts) Choose dialysis method. Sometime during this timeframe, your nephrologist will want you to choose a dialysis method, so that the dialysis access to your body can be arranged. He or she may also ask if you have any potential kidney donors. Arterio-veinous fistula (for hemodialysis). Called AV fistula for short, or just fistula. This is considered the best way of performing hemodialysis. A fistula is really just a vein near the surface of your lower or upper arm, that has been connected to an artery by a vascular surgeon. It requires surgery in your arm (usually in your non-dominant arm, in a day surgery setting). Because a fistula needs time to develop and to be exercised before it can be used, fistula surgery should usually be scheduled a good 6 months before the date dialysis is expected to be needed. It's not too early to have it done a year before expected dialysis. That way, if you have to start dialysis earlier than expected (as often happens), your fistula will be ready for use by the time you need it, and you won't have to start dialysis via a catheter inserted in your chest. If it turns out you don't need to start dialysis that soon, it doesn't hurt to have that fistula ready and waiting. Graft or shunt (for hemodialysis). This is similar to an AV fistula, but whereas the fistula uses a natural vein in your arm, a graft is an artificial piece of tubing that is implanted in your arm to serve the same purpose. People who choose hemodialysis but who don't have suitable veins for fistula surgery may need to have a graft instead of a

fistula. Most IgAN patients are able to develop a fistula. The word shunt is often used, but it is an obsolete term in this context. Some health professionals in dialysis may even refer to a fistula as a shunt. Abdominal catheter (for peritoneal dialysis). If you choose peritoneal dialysis (PD), a surgeon will have to insert a plastic tube in your abdomen, through which you will perform your dialysate fluid exchanges. This does not need as much lead time as a fistula for hemodialysis, but it's still preferable to have it ready when the time comes, so, like the fistula, ideally, the catheter is inserted during the 6 months to a year preceding the time of expected dialysis. Shortly before you later need to actually start PD, the catheter already inside your abdomen is brought out for use. Potential kidney donors (for pre-emptive transplant). Some people may want to consider having a kidney transplant when they reach ESRD rather than having to go on dialysis. This is called a pre-emptive transplant. Obviously, this requires having a suitable and pre-qualified donor lined up. As both the patient's pre-evaluation as a potential kidney transplant recipient, and the donor's pre-evaluation as a potential kidney donor can take some time (weeks or months in some cases), this is best performed well-ahead of time (ie. the year leading up to anticipated ESRD). There can be many medical or psychological/social reasons that a potential kidney donor is rejected, and, unfortunately, it's not unheard of for a qualified kidney donor to back out of it very late in the process. Or sometimes, an illness will make it impossible to get the transplant at the time it's needed. For that reason, many nephrologists will suggest that you also choose a method of dialysis just in case it's needed (given the lead time that is required for the access surgery). Therefore, even a patient with a donor all pre-qualified for an expected preemptive transplant might still have fistula surgery performed, or a PD catheter inserted. Kidney transplant waiting list. If you do not plan to have a pre-emptive kidney transplant, it's still a good idea to go through your evaluation as a potential kidney transplant recipient before you start dialysis. That way, you will be on the waiting list and able to receive a kidney if one should come along soon after you start dialysis. Otherwise, you could miss out if your evaluation is only started once you are on dialysis. Some important information about getting listed: Getting on the waiting list does not happen automatically. Make sure your nephrologist knows you want a transplant, and that however it happens, you do actually get referred to a kidney transplant center. Once this happens, you will need to go through a potential kidney transplant recipient evaluation, which usually includes a complete medical evaluation, medical tests (such as various heart tests), a psychological and/or social worker evaluation, interviews with a transplant nephrologist and a transplant surgeon. This evaluation can easily take a number of months. It usually can be completed before you actually reach the point of needing dialysis. In Canada, you can be evaluated while you are pre-dialysis, but the exact rules which govern may vary from Province to Province, and from region to region within each province. Using the Province of Ontario as an example, no matter when you complete the

evaluation, before or after having started dialysis, your time on the waiting list begins the exact date that you start dialysis, not before (it is retroactive if you completed the evaluation after having started dialysis). If you have a potential live donor, you will be put on hold from the waiting list while that person is being evaluated. This is done because a kidney from a live donor is considered to be superior to one from the waiting list. The reasoning behind starting everyone's time on the waiting list as of the date of first dialysis is that evidence has shown that the longer a person is on dialysis, the more overall health declines. Therefore, it is believed to be more fair to everyone that time on the list begins on the date of first dialysis. Some people may have completed their evaluation before dialysis, some after. Some may have been on hold one or more times because of other illnesses, etc., but nobody is penalized for having had delays in their potential recipient evaluation or for having had other illnesses during the course of dialysis. In the United States, you can usually be evaluated as a potential kidney transplant recipient within the 2-3 year period before you would be expected to start dialysis. If you have done so, credit for waiting time on the waiting list begins when you have reached 20% kidney function (more precisely, a GFR of less than 20, as per a rule change implemented by UNOS in 1998). Since dialysis is typically started when GFR is about 10%, it is therefore possible to obtain a cadaveric kidney transplant before having actually started dialysis. 15 to 10% kidney function (more or less) It will vary based on a patient's symptoms, but this is the timeframe when dialysis is started. A person who is diabetic will often be started at 15% kidney function, while most IgAN patients would start at about 10%. It's common practice these days to start dialysis in a planned manner, rather than waiting until it becomes an emergency situation (thankfully!). Most people will either start dialysis or have the pre-emptive kidney transplant done when or slightly before they reach 10% kidney function. Some people may reach 10% without experiencing any major symptoms, but, generally, dialysis will be started at this point, if not slightly before, in a planned fashion, even if the patient doesn't feel any significant symptoms. Since there is still about 10% kidney function at this point, it may be possible to continue quite some time without dialysis, but starting dialysis early increases chances of an easier transition, and it allows time to initiate dialysis in a way that minimizes stress on the body. Contrary to popular misconception, there is no advantage to being able to delay dialysis even if no symptoms of renal failure are felt once kidney function (glomerular flitration rate) reaches about 10%, and there may in fact be significant disadvantages for the patient in terms of mortality and morbidity.

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Diet for Kidney Disease

Alternate Names : Renal Diet Overview & Description | Functions and Sources | Pictures and Images Attribution Ads by Google Kidney Diet? Know Which Foods Boost Kidney Function... And Which Ones Harm. www.TheKidneyDiseaseSolution.com NICOM Fluid Optimization World Leading NonInvasive Hemodynamic, Cardiac Output Monitor Cheetah-Medical.COM Bathing Suit Body Diet SALE today - 30% OFF Award-Winning 17-Day Bathing Suit Body Diet www.StephenCabral.com Fat Absorb for Weightloss 100% Natural and Safe to use. Eat what you Like. Order now! www.FatAbsorbIndia.com Diabetic Diet & Meals Free Diabetic Recipes > Breakfast, Lunch - Snack - Dinner - Dessert. www.diabetesinfocenter.org Advertise on this site There are two types of diets for kidney disease. One type of diet is specifically for people who have progressive chronic renal failure, or kidney failure, but are not on dialysis yet. Along with medicine, a low-protein diet may slow the worsening of kidney failure. The other more restrictive type of diet is for people on dialysis whose kidneys have totally failed and are no longer working at all. This is called end stage renal disease, or ESRD.
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The kidneys also make hormones needed by the body. These include hormones that help make bones and blood cells. The kidneys also help control blood pressure by limiting the amount of fluid and salt in the bloodstream. People with kidney disease are at risk for

vitamin deficiencies. Their bodies may not be able to make certain blood cells, which can lead to anemia. Their kidneys also prevent the body from maintaining bones as usual. The extra fluid and sodium in the bloodstream that can accumulate as a result of kidney failure can lead to high blood pressure. Hormonal changes can cause cholesterol and other fats in the blood to be high. The buildup of toxic substances can make a person with kidney disease feel ill. In children, all of these conditions may prevent normal growth and development. PRE-DIALYSIS DIET Eating a low-protein diet before starting dialysis may help preserve kidney function. Protein restriction can delay the start of dialysis. The healthcare provider will determine whether a low-protein diet would be useful. A registered dietitian should be consulted to help plan the diet. This diet limits the amount of protein in the diet to about 40g to 50g per day. The protein eaten should be of high quality. Lean meat, fish, poultry, and eggs are good sources of high quality protein. Other nutrients many be low in this type of diet, so a multiple vitamin including folic acid is usually recommended. It is important that people following this type of diet get adequate calories from carbohydrates and fats. This keeps the body from using protein calories for energy. Sodium, including table salt, may also be restricted. It is also important to speak to the healthcare provider before using any salt substitutes. Individuals should consult with a registered dietitian to ensure that this diet is adequate in all nutrients. DIET FOR PEOPLE ON DIALYSIS People who have ESRD must undergo dialysis or receive a kidney transplant. Dialysis is a process that filters the blood to remove toxic substances. There are two types of dialysis. They are hemodialysis and peritoneal dialysis. In hemodialysis, the person's blood is filtered through an artificial kidney machine. This machine removes waste products, as well as extra fluid and salt, from the blood just as the person's kidneys would if they were still working. In peritoneal dialysis, the blood is cleaned inside the body using the abdominal cavity. Fluid is placed into the patient's abdominal cavity. The waste products from the blood pass into the fluid. The fluid and waste products are then drained from the abdominal cavity through a tube. The diet for people on dialysis may limit the following nutrients: fluid phosphorus potassium protein sodium

Protein may or may not be restricted for people with ESRD. The decision depends on remaining kidney function and other factors. A nephrologist, a physician who specialized in kidney diseases, and a registered dietitian can provide guidance on optimal protein intake. Sodium The amount of sodium is restricted in this diet. The following foods are usually limited: canned foods convenience foods processed foods table salt

Salt substitutes should not be used because they contain potassium. Acceptable alternatives to salt include the following: garlic powder herbs onion spices that don't contain salt vinegar

Fluids Fluid restrictions vary, depending on how much liquid the person's kidneys are able to remove. Any food that is liquid at room temperature contains water. Foods that have a high fluid content are as follows: apples gelatin grapes ice cream and sherbet lettuce and celery melons oranges soup tomatoes

All of these foods add to a person's fluid intake. Fluid can build up between dialysis sessions, causing swelling and weight gain. The extra fluid affects the blood pressure and can make the heart work harder. This can cause serious heart trouble. Potassium

Potassium is a mineral that affects how steadily the heart beats. Healthy kidneys keep the right amount of potassium in the blood to keep the heart beating at a steady pace. Potassium levels can rise between dialysis sessions and affect the heartbeat. Eating too much potassium can be very dangerous to the heart. It may even cause death. Potassium is found in many foods, including dairy products, meats, and dried beans. There are certain fruits that are especially high in potassium, such as: apricots avocados bananas cantaloupes, honeydew, and other melons dates and other dried fruits grapefruit and grapefruit juice kiwifruit mangoes and papayas nectarines and peaches oranges and orange juice pears prunes and prune juice rhubarb

Vegetables that are high in potassium include the following: artichokes brussels sprouts dried beans and lentils fresh tomatoes, tomato paste and puree, and tomato juice lima beans and succotash potatoes pumpkins and squash spinach and Swiss chard vegetable juice

Phosphorus The kidneys play an important role in balancing the phosphorus and calcium in the body. When a person has kidney disease, the phosphorus from food may build up in the blood. Too much phosphorus in the blood pulls calcium from the bones. Losing calcium makes the bones weak and more likely to break. Also, too much phosphorus may make the skin itch. The following foods are high in phosphorus and need to be restricted: cola drinks milk and cheese nuts and peanut butter peas

Most people on dialysis also need to take a phosphate binder to control the phosphorus in their blood between dialysis sessions. These medications act like sponges to soak up, or bind, phosphorus while it is in the stomach. Once it is bound, the phosphorus does not get into the blood. Instead, it is passed out of the body in the stool. Diets for kidney disease must include sufficient calories to prevent weight loss and the use of protein for energy. Due to the many food restrictions, people who have kidney disease usually need supplements of vitamins, iron, and calcium. A diet for kidney disease takes a lot of planning. It is a very personalized diet. How much each nutrient needs to be restricted varies from individual to individual. Kidney disease usually requires frequent visits to the healthcare provider. A registered dietitian can help plan individualized meals. The dietitian can also instruct the patient on his or her special diet. Frequent blood tests show which nutrients need to be limited. Any new or worsening symptoms should be reported to the healthcare provider.