Dialysis Related Care

Dialysis Related Care

LOW POTASSIUM DIET

 

What is potassium?

Potassium is a mineral found in many foods and an important constituent in our body.

What happens in kidney failure?

The healthy kidneys are responsible for maintaining the right amount of potassium in your body. A normal level of potassium keeps the heartbeat regular, helps to maintain fluid balance, and allows the nerves and muscles to function properly. If your kidneys are not healthy, you may need to limit the amount of potassium in your diet. The normal range for potassium is 3.3mmol/L to 4.9mmol/L. Unfortunately, this is a rather narrow range and it is dangerous when blood potassium level goes outside these limits.

High levels of potassium can cause muscle weakness and irregularity of the heart rate. It results from intake of high potassium containing foods or excessive breakdown of body tissue (as in fever, surgery, gastrointestinal bleeding).

Low levels of potassium occur when there is insufficient potassium in the diet, potassium loss through vomiting, diarrhoea, and use of medications such as potassium binding resins and diuretics. Low potassium levels can also cause abnormal heart rhythm.

Not everyone has to restrict potassium. It depends on your blood results and your kidneys’ ability to remove potassium. Do check with your doctor for advice on your diet restriction.

Sources of Potassium

Most dietary potassium comes from fruits and vegetables. Here are some foods you need to avoid if your potassium is high.

High Potassium Foods (Best to Avoid)

Vegetables:
Spinach, Chye Sim, Kailan, Dried Mushroom, Lentil, Potato, Yam, Lotus Root, Beet Root, Carrot(raw), Bamboo Shoot, Broccoli, Tomato, and Green Leafy Vegetables

Fruits:
Durian, Mango, Coconut, Papaya, Avocado, Apricot, Kiwi, Grape, Orange, Pomegranate, Prune, Banana, Jack Fruit and Dried/ Preserved Fruits e.g. Dates, Prune, Plum

Grains:
Wholemeal, Bran, Oat

Drinks:
Prunes Juice, Grapefruit Juice, Milk, Soy Milk and Malted drinks e.g. Milo, Ovaltine, Horlicks

Condiments:
Tomato sauce, Marmite, Stock Cube, Salt Substitutes, Molasses

Others:
Chocolate and Chocolate Products, Chinese Herbs, All Beans and Nuts, Yogurt

What can I eat?

You still can enjoy taking foods containing lesser potassium. However, care must be taken to consume the appropriate portion. Eating more than 1 portion of a low potassium food can cause high potassium. It is recommended to limit to 2 servings of fruits and 2 servings of vegetables a day.
(1 serving size = 1/2 cup or 4 oz)

Low Potassium Foods (Recommended but to limit intake)

Fruits:
Melon, Strawberry, Guava, Watermelon, Apple, Apricot (canned), Blackberry, Blueberry, Fruits Cocktail (drained), Mandarin Orange, Peach, Pear, Pineapple

Vegetables:
Cabbage, Lettuce, Watercress, Cauliflower, Onions, Bean Sprout, Celery, Corn, Cucumber, Eggplant, Mushrooms, Water Chestnut (canned), Asparagus

Grains:
Food prepared with Plain Flour, Pasta, Bread, White Rice, Noodle, Plain Cracker

Drinks:
Tea (<2 cups), Coffee (1 cup), Apple Juice (1 cup)

How do I get rid of the potassium from my favourite vegetables?

A leaching method can be use to remove some potassium from the vegetables by soaking. You may leach the vegetables by cutting them into small pieces and soaking in plain water for a minimum of 2 hours. During this time, change the water used for soaking 2 to 3 times. After soaking, remove the vegetables from the water and bring to boil with fresh plain water. Finally discard the boiled water and cook it as you desired. But remember do not make soup or gravy with the water you used as it contains the removed potassium.

Tips on avoiding potassium

• Do not steam or use a pressure cooker or microwave or stir fry your vegetables. Always boil them in plenty of water so as to remove potassium.
• Root-vegetables with skin such as potato, carrot and beet root contain high potassium. They should be peeled and leached.
• Canned fruits and vegetables are lower in potassium than fresh fruits. Avoid the syrup in the can.
• Salt substitutes contain potassium. It is advisable to read labels carefully for the salt substitute content. When in doubt about the food products, check with your doctor, dietician or nurse whether the products are suitable for you.

High potassium levels do not usually cause noticeable symptoms until the potassium level is very high. The complications are extremely dangerous. So, please monitor blood potassium level regularly and discuss with your doctor, dietician and nurse about your dietary preferences.

You may visit these websites for more information:
http://www.davita.com/
http://www.uptodate.com/patients/index.html

LOW PHOSPHORUS DIET

What is phosphorus?

Phosphorus is a mineral needed by the body in energy producing processes as well as for building healthy strong bones.

What happens in kidney failure?

The normal healthy kidney helps to keep phosphorus in balance by removing extra phosphorus from the body. In early kidney failure, the usual corrective changes are initially successful in correcting the phosphorus level by increasing elimination through the kidneys (urine). This is through signal from parathyroid hormone (PTH). With more severe kidney failure, even with high level of PTH, the kidneys cannot respond. PTH causes minerals to be released from the bone, making the bone structure weak.

High blood phosphorus level lowers the calcium level in the blood and causes calcium to be taken from the bones, which weaken the bones and cause easy fractures. The common symptoms of high phosphorus levels are itch, bone pain and red eyes.

The normal range for phosphorus is 0.77mmol/L to 1.38mmol/L or 2.0mg/dl to 4.0mg/dl. High phosphorus level is detected through a simple blood test.

How can I control my phosphorus level?

You can keep your phosphorus level normal by understanding your diet and what medications can help in phosphorus control.

Your doctor may order phosphate binders, which are medications for you to take with your meals and snacks. Phosphate binder will bind with the phosphorus in your food when you take your meals. Phosphate binders include aluminium hydroxide, calcium carbonate and lanthanum carbonate commonly known as Alutab, Calcichew, Tums and Fosrenol. These medications must be taken with meals; otherwise they will not be effective.

Dialysis can remove some phosphorus from your blood, but its action is limited.

What foods are high in phosphorus?

Phosphorus is mainly found in dairy products, high protein food, and all kinds of nuts and beans. Here are some foods that you need to avoid.

High Phosphorus Foods (Best to Avoid)

Dairy Products:
Milk, Cheese, Yogurt, Ice Cream

Meat, Poultry, Fish and Seafood:
Organ Meat, Marrow, Ikan Bilis, Sardine, Seafood, Shellfish, Beef, Mutton

Nuts and Beans:
Baked Beans, Peas, Lentil, Soya Bean, Pumpkin Seed, Sunflower Seed, Almonds, Cashew, Walnut, Peanut, Pecans, Cocoa

Grains:
Bran, Muesli, Oat, Wheat Germ, Wholemeal Bread, and Foods containing a lot of baking powder and yeast

Yeast and Vegetable Extracts:
Beer, Wine, Bovril, Marmite.

Drinks:
Carbonated Cola, Soy Milk, Beer, Cocoa, Malted drinks e.g. Horlick, Ovaltine, Milo

Others:
Egg Yolk, Bean Curd, Coconut, Coconut Products, Chocolate and Chocolate Products

What can I eat?
You may eat some of the phosphorus foods. Although poultry and fish may be higher in phosphorus, they are acceptable alternatives because they are good sources of protein.

 

Lower Phosphorus Foods

Poultry, Fish:
Fish and Chicken

Grains:
White Rice, Pasta, White Bread, Corn Flakes

Drinks:
Coffee, Tea, Cranberry Juice, Apple Cider

Others:
Egg White, Popcorn, Plain Cracker.

Tips

• Restrict to a minimum amount or avoid food that contains high phosphorus.
• Remember to take phosphate binders with food. Do not stop taking them on your own. If you experience problem or side effects, discuss them with your doctor, dietician or nurse.
• Some foods may also contain a high amount of potassium, so be careful in your selection.
• When in doubt about the food products, check with your doctor, dietician or nurse whether the products are suitable for you.

Take phosphate binding medication as prescribed by your doctor and avoid high phosphorus food can help you control phosphorus levels.

You may visit these websites for more information:
http://www.davita.com/
http://www.kidney.org/atoz/content/phosphorus.cfm

LOW SODIUM DIET

What is sodium?

Sodium is a mineral found naturally in foods and is the major part of table salt. Sodium is needed to help your body in absorption and maintenance of major nutrients and water.

What happens in kidney failure?

Sodium is needed for body water balance. But when kidneys lose the ability to control sodium and water balance, one can be in a high or low sodium and water state. It is more common to encounter problems with excessive sodium and water.

Common problems include:
• thirst
• fluid gain
• high blood pressure

By using less sodium in your diet, these problems can be controlled.

How do I limit my sodium intake?

There are many sources of hidden salt in seasonings and processed foods which should be avoided. The following are some examples of high sodium foods. You may substitute them with other alternatives to enhance the food taste.

High Sodium Foods

Limit the amount of...  Substitute with...


Salt and Salt Seasonings:
Table Salt, Seasoning Salt, Garlic Salt, Onion Salt, Celery Salt, Lemon, Pepper, Meat Tenderizer, Seasoning Cubes, Flavour Enhancers

Fresh Garlic, Fresh Onion, Garlic Powder, Black Pepper, Lemon Juice, Vinegar, Salt-free Seasoning, Allspice, Basil, Bay Leaf, Cardamom, Curry Powder, and Ginger can be used for meat, fish, vegetables

Salty Foods:

High Sodium Sauces:
Barbecue Sauce, Steak Sauce, Soy Sauce, Teriyaki Sauce, Oyster Sauce

Salted Snacks:
Cracker, Potato Chip, Corn Chip, Tortilla Chip, Nut, Popcorn, Sunflower Seeds

Cured Foods:
Ham, Salt Pork, Bacon, Pickle,Olives

Low-Salt Sauces, Salad Dressings, Vinegar, Mustard Powder

Fresh Beef, Veal, Pork, Poultry, Fish Egg

 Luncheon Meats:

Hot Dog, Cold Cut, Deli Meat, Sausage, Corned Beef

 Low-Salt Deli Meat
 

Processed Foods:
Buttermilk, Cheese

Canned:
Soup, Tomato Product, Vegetable Juice, Canned Vegetable

Convenience Foods:
Macaroni & Cheese, Spaghetti, Commercial mix, Frozen prepared food, Fast food

 

Natural cheese (1-2 oz per week)


Homemade or low-sodium soup, canned food without added salt


Homemade casserole without added salt, made with fresh or raw vegetable, fresh meat, rice, pasta, or unsalted canned vegetables

Tips to keep your sodium intake down

• Cook with herbs and spices instead of salt.
• Read food labels and choose those foods that contain low sodium.
• Avoid salt substitutes and low-sodium foods made with salt substitutes because they are high in potassium.
• When eating out, ask for less salt. Request for gravy or sauce on the side, as these may contain large amount of salt.
• Limit use of canned, processed and frozen foods.

Can I use salt substitutes?

Caution! If you are told to limit potassium in your diet, be very cautious about using salt substitutes because most of them contain some form of potassium. Check with your doctor or dietician before using any salt substitute.

You may visit these websites for more information:
http://www.davita.com/
http://www.uptodate.com/patients/index.html

FLUID MANAGEMENT

How much fluid can a person with chronic kidney disease on haemodialysis drink?

Fluid allowance is usually limited to 800ml to 1000ml a day for haemodialysis patients who are no longer able to urinate. Those whose kidneys are still able to remove some fluid, their fluid restriction may be increased. Individual goals for weight gain between dialysis treatments must be determined by the doctor, and may vary based on body size and other considerations. So, do check with your doctor for advice on your daily fluid allowance.

Dialysis patients are also advised to weigh themselves daily to keep track of their weight and fluid balance. This helps to better manage weight gain between dialysis sessions. It is important to control the amount of fluid intake to prevent the body from fluid overload which causes many complications.

Why is it important?

Fluid intake for a haemodialysis patient is limited between dialysis sessions as the kidneys have lost the ability to make urine to remove excess fluid from the body. Excess fluid can cause hypertension, heart problems, and shortness of breath. There may also be build up of water which causes swelling in the face, legs and arms. To prevent these complications, it is important to follow the daily fluid allowance ordered by your doctor.

How do I keep to my fluid allowance?

• Count all fluids you take. Hidden fluid such as, sips of water, ice cube, gravy, soup, gelatine, watermelon, oatmeal and porridge are counted as part of your fluid allowance.
• Measure your favourite cup or mug, so that you will not under or overestimate the amount of fluids you drink. Fluid allowance is usually limited to 800ml to 1000ml a day for haemodialysis patients who are no longer able to urinate.
• Try to reduce salt intake as this will help to reduce thirst. Avoid adding salt and other sauces to your food.
• Keep away from salty foods such as, bacon, ham, salted products, cheese and canned foods and other salty food.
• Substitute salt with garlic, onions, herbs or spices to enhance flavour to your cooking.
• Instead of a few large drinks, divide them out into smaller and frequent portions. You may want to use a smaller cup.
• Sip or use a straw for drinks as this will last longer.
• When you feel thirsty, you can rinse your mouth, clean your teeth or use mouthwash to freshen your mouth and throat.
• Try squeezing some lemon juice into the water or suck on a slice of lemon. This helps to stimulate salivation.
• Some people find that sucking sweets help to quench thirst. Choose sugar-free sweets if you are a diabetic.
• Keep yourself busy. This can distract you from thinking about water.
• Weigh yourself daily to check your weight gain. If you are on haemodialysis, you should not put on more than 1.5 to 2 kg between dialysis.
• When in doubt about your fluid allowance, always discuss it with your renal doctor, dietician and dialysis nurses.

Planning the daily fluid intake

These are a few steps you can take when managing your fluid intake:

1) Fill your water bottle with your prescribed fluid allowance at the beginning of the day.
2) Choose a water bottle with markings for volume or you may measure your water bottle before use. For example if your fluid allowance is 1000ml, the water bottle is 500ml, then you have to fill 2 bottles or fill the same bottle twice.
3) Drink from this water bottle throughout the day.
4) You can still enjoy your favourite drinks or soups. To keep track of your fluid allowance, pour away the amount you just drank from the water bottle.

Common Measure of Fluid

1 can drink 330ml
1 packet drink 250ml
1 full coffee mug 300ml
1 full tea cup 200ml
1 full glass 200ml
1 scoop ice-cream 60ml
1 standard ice cube 30ml
1 tablespoon fluid 15ml

You may visit these websites for more information:
http://www.davita.com/
http://www.uptodate.com/patients/index.html

BLOOD PRESSURE AND DIALYSIS

What is blood pressure?

Blood pressure is the force of blood pushing against the walls of the arteries. The blood pressure reading consists of two numbers. The top number is called the systolic pressure. It measures the maximum pressure of the blood when the heart is pumping. The lower number is the diastolic pressure. It measures the pressure when the heart is at rest in between beats, filling up before pumping again. Blood pressures in dialysis patients may be alternately high or low depending on the situation in which blood pressure is measured.

Why is my blood pressure high?

The cause of high blood pressure in dialysis patients is often related to a state of excessive salt and water. Excess water in the body increases the amount of fluid in the blood vessels and increases the blood pressure. Narrowed or clogged blood vessels can also raise blood pressure. Consumption of food containing large quantities of salt makes one thirsty leading to a higher intake of water. It is common to see blood pressure normalize after a dialysis session when fluid has been dialysed out of the blood space only to go back to high levels after several hours when the blood space is refilled with fluid from other body compartments.

Can high blood pressure harm dialysis patients?

Yes! High blood pressure stresses the heart as the heart needs to work harder to pump against a higher pressure. High pressures in the blood vessels also damage the blood vessel walls. Thus, it is very important that blood pressure is well controlled as high blood pressure can cause heart attack, stroke and even death.

What can I do to control my blood pressure?

If the cause of your high blood pressure is related to consumption of salt and water, then you must control your intake of salt and water.

If you already have high blood pressure, you must take your medicines regularly as prescribed by your doctor. The medicines will control the blood pressure.

However, more often than not, you will need to combine both fluid, salt restriction and medicines in order to have a better control of your blood pressure. A trial of reducing post dialysis body weight concomitant with reduced salt and fluid intake while keeping the ultrafiltration (fluid removal) rate constant is worth a try to normalize blood pressure.

Why is my blood pressure low during dialysis?

There are several reasons why you experience low blood pressure or hypotension during dialysis:

• Too high a fluid removal rate during dialysis has been set. The body is unable to tolerate too rapid a fluid removal rate as the blood compartment cannot refill in time causing the blood pressure to fall. It is therefore important that you keep check of your fluid intake and monitor your weight gain in between dialysis. Higher weight gain between dialysis sessions means more has to be removed during a single session.

• The prescribed dry weight may be too low. If you have gained body weight with higher muscle or fat content, the proportion of fluid would be been reduced if the prescribed dry weight was not increased to keep up with this increase in body weight.

• Elderly and diabetic patients often have reduced response to fluid reduction in the blood space.
A normal response with fluid removal is to increase the pump (heart) rate and the force of pumping thereby maintaining the blood pressure. Blood vessels also narrow temporarily to keep the blood pressure up. This is achieved through messages received by receptors which are passed to the heart and blood vessels by nerves. A nervous system that responds poorly will not be able to pass these messages appropriately and blood pressure can fall easily once fluid removal starts.

• Taking anti-hypertensive medications before dialysis. Many blood pressure medications interfere with the response mechanism as detailed earlier.

• In some instances, eating during dialysis may also cause a drop in blood pressure. This is because blood supply in the body is diverted to the stomach to digest food.

How can I prevent hypotension during dialysis?

• You can prevent hypotensive episodes by limiting your water intake. The doctor will instruct you the amount of fluid you can have daily.

• If you have accumulated fluid over a long time, do not be overzealous in bringing it down to achieve the dry weight. For each person, there is a limit on how much can be withdrawn during each 4 hour session. In general, one should not put on more than 5% of your body weight between dialysis. Depending on each individual, it sometimes takes 4 – 8 weeks to achieve the correct dry weight.

• Adjust the timing of taking anti-hypertensive medication. Check and monitor blood pressure regularly. If you persistently experience low blood pressure, inform your doctor. Your may need adjustment to your medicines.

• If the cause of your low blood pressure is eating during dialysis, than you may want to consider eating less during dialysis.

• If you are unwell, have diarrhoea or vomiting, inform the nurse as she will plan the dialysis treatment to avoid discomfort.

• Inform the nurse or doctor if you have gained flesh weight or have lost weight. The nurse or doctor will adjust your dry weight accordingly.

What are the signs of low blood pressure?

During dialysis, should you experience one or more of these symptoms, you must inform the nurse.
• Feeling faint
• Sweatiness
• Nausea
• Vomiting
• Shortness of breath
• Stomach or leg cramps

Do not suffer in silence! Severe low blood pressure is very dangerous. You can risk losing your fistula or graft function because of severe hypotension.

Remember!
The first step towards good dialysis treatment is to have a well-control blood pressure. This will help avoid any discomfort during your dialysis treatment.

You may visit these websites for more information:
http://www.davita.com/
http://www.uptodate.com/patients/index.html

WHAT IS A VASCULAR ACCESS?

A vascular access is a point of entry into blood vessels so that you can be connected to the dialysis machine.
It is often referred to as your dialysis life line.

There are three types of access:
a) Fistula (arteriovenous fistula)
b) Graft (arteriovenous graft)
c) Catheter

Arteriovenous Fistula (AVF)

This involves a small operation to join a suitable artery (which supplies blood) and a suitable vein together, allowing the arterial blood to flow directly into the vein. This higher pressure enlarges the vein so that it can be used for dialysis. The wrist or upper arm is usually chosen to create the fistula. This makes it easier to insert the needles that are required to withdraw blood and also to return it to the body.

A fistula is the best type of access because:
a) Your veins and arteries are part of your body, so a fistula is less prone to infections or clots than other type of access.
b) Self-healing occurs after each needle stick, so the fistula can last for a much longer time.

It is best to create an access before you need dialysis. Your doctor will decide when you should have it done and which type of access will work best for you.

When can an AVF be used?

Ideally a new fistula should not be used for 3 to 4 months after surgery as it needs time to mature though some can be used after 2 months.

What happens after surgery?

Sometimes your arm may swell for a few days or weeks. When the swelling subsides, you must exercise by squeezing a rubber ball many times a day to increase the blood flow to the fistula arm. This helps the fistula mature faster.

Arteriovenous Graft (AVG)

A graft uses a tube that is either synthetic (man-made) or veins harvested from other parts of the body. This is then used to join a suitable artery and a vein together. It is used when patient’s own blood vessels are too small to create a fistula. This is often necessary for the elderly or diabetic patients.

These can be either straight or looped. The most popular material used for the grafts is in a form of Teflon® (expanded polytetrafluoethylene, ePTFE). Gore-Tex® is another material that is used. Grafts are most commonly placed in the upper arm, lower arm or thigh. It is placed under the skin.

When can an AVG be used?

It takes 3 to 6 weeks before the new graft can be used for dialysis.

What happens after surgery?

Sometimes your arm may swell for a few days or weeks. You must allow adequate healing and sufficient growth of tissue to stabilize the graft before you start needling.

Dialysis Catheter
A catheter is a plastic tube placed into the large veins in the neck or groin. It is mainly for short-term use until a fistula or graft is ready. Some catheters can be tunneled under the skin to allow for stability and protection from infection. Non-tunneled catheters are more easily inserted but more likely to cause infection.

A tunneled catheter (sometimes referred to as “Permcath”) may be placed for patients with very poor veins and arteries but they are still not as good as a fistula. They can clot thus blocking the blood flow, become infected and cause narrowing of the veins in which they are placed.

Care of the Arteriovenous Fistula or Graft

You can take several steps to protect your access:
1) Use your access site only for dialysis.
2) Keep your access clean and dry at all times.
3) Check for the “buzzing” everyday. Inform your nurse or doctor if you cannot feel the buzz. Do not wait until your dialysis day as you will not be able to use it when you need it most.
4) Inform your nurse or doctor if your access is red, warm, has pus or you have a fever.
5) Don’t wear jewellery or tight clothes over your access site.
6) Don’t place heavy objects or put pressure over your access arm. This will close off the flow in the fistula or graft.
7) Don’t allow anyone to put a blood pressure cuff on your access arm.
8) Be careful not to bump or hurt your access.
9) Don’t sleep with your access arm under your head or body.
10) Wear an arm guard to protect the access in sports or doing heavy work.
11) Wash your access arm with antiseptic soap before dialysis.
12) Don’t apply too much pressure on the access punctured site after dialysis. Your nurse will teach you how to apply sufficient pressure to stop bleeding.
13) Remember to tell your nurse to rotate the needling sites to allow healing of the punctured site and to prolong the life span of the access.

You may visit these websites for more information:
http://www.davita.com/
http://www.uptodate.com/patients/index.html

BONE PROBLEMS IN END-STAGE RENAL FAILURE

When the kidney fails, its function dealing with bone mineralization and vitamin metabolism can be affected and result in renal osteodystrophy.

What is renal osteodystrophy?

Renal osteodystrophy is the sum of various bone related effects occurring in a patient with renal failure. There are specific factors relating to kidney failure as well as other factors present in the general population who do not have kidney failure such as aging.

What is osteoporosis?

Osteoporosis means porous bones or thinning of bones. This can be progressive and can lead to increase bone fragility and fractures. This process occurs in normal people as well as kidney failure patients.

Who is more susceptible to osteoporosis?

Bone density increases from birth through childhood and peak around mid 20s to early 30s. From the age of 30-50, bone density declines minimally. However, after the age of 50, in males the rate of bone loss is around 0.2-0.5% per year whereas in females, is around 3-5% per year. This rate of loss however slows down 5-8 years after menopause to 1-2% per year.

Many factors contribute to bone loss these include genetic, nutritional, environmental and hormonal factors. This condition is more common in the elderly and is associated with certain medical conditions such as end stage renal disease (ESRD), Cushing’s syndrome, steroid therapy and long term heparin use.

Why do people with renal failure have increased risk of osteodystrophy?

Patients with ESRD have increased bone loss due to the following reasons:
a) Reduced active Vitamin D production from the kidneys
b) Reduced phosphate excretion
c) Increased bone breakdown with increased parathyroid hormone (PTH) levels

These processes are not present in normal people.

Normal healthy bone formation and maintenance requires the production of Vitamin D by the kidneys to maintain normal serum calcium levels. This is closely monitored in normal renal functions via a feedback mechanism through PTH, a hormone produced by the parathyroid glands situated behind the thyroid glands in the neck. When the serum calcium falls, the parathyroid glands are stimulated to produce PTH and this in turn act on the bones to release calcium so that the serum level can be normalized. While this is a good system for the short term, in ESRD, there is a constant deficiency of Vitamin D leading to reduced calcium levels. The parathyroid glands are being constantly stimulated in an attempt to maintain normal serum calcium level and as a consequence, calcium is perpetually being “stolen” from the bone.

Another stimulus to high PTH release is phosphate excretion. It is crucial to calcium metabolism. The normal kidney responds to high PTH levels by increasing the excretion of phosphate through the kidneys. Unfortunately, in ESRD, there are no “good” kidneys to attend to this “message” and the end result is that calcium is released from the bone instead. In this instance, it is therefore important that the phosphate levels be kept within acceptable range so that PTH is not stimulated.

How can we assess and monitor renal osteodystrophy?

We can do it in the following ways:

a) Blood tests
Regular testing of serum calcium, phosphate and alkaline phosphatase. Higher amounts of the enzyme alkaline phosphatase is formed from bones and released into the blood stream when the bones are stimulated by PTH to increase the rate of bone formation and breakdown. Based on the results, medications are adjusted.

b) Dual-energy X-ray absortiometry (DEXA) scan
This method gives an estimate of bone density in relation to the normal population. Measurements are taken from the vertebral bodies and femoral head. Serial measurement can be done to monitor progression of bone disease at a yearly or 2 yearly interval but is costly.

c) X-Rays
X-ray are generally not good for monitoring bone diseases as they are only able to detect it in the later stage.

What is the consequence of poorly controlled bone disease?

In severe renal failure, the automatic control of serum calcium and phosphate is lost and therefore we rely on medication to normalize these levels and maintain bone density. This leads to:

a) Symptoms such as bone aches, joint pains and itch.
b) Fragile and thin bones. This predisposes to fractures with less trauma than normal bones.
c) The maintenance of normal bone structure and skeletal shape becomes deranged. The patient soon assumes a characteristic posture in time because of changes in shape in the spine and chest cage.
d) When serum calcium and phosphate level exceeds a certain level it will cause deposition of calcium in blood vessels or muscles. Calcification of blood vessels can lead to blockage of smaller blood vessels. The surgeons may find it difficult to get a successful arteriovenous fistula for dialysis because the blood vessels have been hardened or blocked by calcium.

How can it be prevented?

Renal osteodystrophy can be prevented in the following ways:

a) Keeping to strict dietary advice. This will help by reducing phosphate intake and reduce intake of phosphate binders.
b) Do regular weight bearing exercise to stimulate bone growth and maintain bone integrity.
c) Optimization of body weight.
d) Compliance with medication especially phosphate binders and vitamin D supplements.

Prevention is very important because once the parathyroid gland has been stimulated for some time, it becomes very difficult to treat even if the patient is compliant subsequently.

How can it be treated?

Every patient with renal failure will have some degree of bone disease at entry into dialysis. Treatment is aimed at minimizing and retarding the disease’s process.

a) Vitamin D is frequently prescribed to supplement reduced production. This is usually given in the form of 1-alphacalcidol or calcitriol 2-3 times per week. However, this also encourages phosphate absorption in addition to calcium and aggravates the high phosphate level. So it is stopped when phosphate levels are high.

b) Phosphate binders e.g. Calcichew, Calcium Acetate and Alutab. Calcium containing phosphate binders bind phosphate present in food to form calcium phosphate, a compound which is subsequently excreted in the stools. The binders have to be taken with the meal otherwise there is no phosphate in the stomach or intestine to bind. Some patients dislike the taste of
Calcichew and prefer Calcium Acetate which does not require chewing. By weight, Calcium Acetate contains less calcium and is more suited to patients who also have higher calcium levels with the use of calcium containing phophate binders. Both are just as effective. Alutab is also a very effective phosphate binder. However, it contains Aluminium and too much of it can prevent proper bone growth and cause bone thinning by a different mechanism from that previously discussed. Doctors seldom prescribe Alutab continuously and often limit its use to 2 to 4 weeks at a time when needing to stop calcium phosphate binders for a while because of high calcium levels.

c) Parathyroidectomy, the surgery to remove the parathyroid gland is needed when medical treatment has failed to suppress PTH production. As this is a more drastic measure needing hospitalization and general anaesthesia for the operation, only severe cases are sent for surgery.

Prevention is Better than Cure

It is far better to prevent bone disease than to try and treat bone disease when permanent changes have set in. We cannot remodel the skeletal shapes back to the original once severe bone disease has taken root.
Thus, the old adage of “prevention is better than cure” definitely holds true in this case.

You may visit these websites for more information:
http://www.davita.com/
http://www.uptodate.com/patients/index.html

TRAVEL GUIDE FOR HAEMODIALYSIS PATIENTS

Can patients on haemodialysis treatment, travel?

Certainly!
Haemodialysis patients are encouraged to take a break, go for a holiday and spend time with their family and spouse. However, before planning for a trip, the patient should be reasonably healthy and also certified fit by doctor for any trips. Planning for the trip should start four weeks prior to departure date. If it is during peak season you will need to start six weeks prior to departure date.

What are the necessary preparations before the trip?

• Decide on the destination. Eg. Country, Cities
• Decide on the length of the trip. Eg: 3 days, 2 weeks
• How is the holiday organized:
– Tour agency
– Free and easy
• Decide on the type of holiday activities: Fishing, cruise, sightseeing, visiting family and friends, etc. The type of activities carried out may or may not be near a dialysis facility. This must be considered during the planning.

Who to inform?

Doctor in charge:
• You need to consult the doctor on medication and the number of dialysis needed during the trip. This will be according to the number of days planned for the holiday.
• To obtain a medical summary of your current condition. This will give the transient dialysis centers’ charge nurse an idea of your diagnosis, previous medical treatment and current status.

Nurse in charge:
• To help you to reschedule your treatment for your departure date & arrival date.
• To help with the medical summary.

How to find a dialysis facility convenient to the destination?

You can find these information from:
• Doctor in charge
• Nurse in charge of dialysis center
• Medical social worker
• Dialysis journals such as Dialysis & Transplantation (July issue every year)
• Internet

What are the basic information you should give the dialysis facility?

• Nurse in charge to fill up the ‘Patient information data’ which the doctor in charge has to sign.
• The days in which dialysis is needed

How do you get this information to the transient dialysis facility?

• You can fax it to them.
• If the centre does not have a fax machine, you should bring the documents to the dialysis facility when you get there.

What about payment?

• You need to ask the nurse in charge of the transient dialysis facility about the amount to pay for each treatment. Preferably this should be done before you start your trip to help you with your budget. Note that most centers differentiate charges between Hepatitis B positive and negative status.
• Find out how you can pay. E.g.: cash, credit card or travelers check, etc.

Do I need to confirm treatment reservation?

• Yes. Two weeks before the departure, call the facility again to confirm.
• When you arrive at your destination, call the dialysis center again to reconfirm appointment.

What else must I do?

• You might need Resonium for this trip. Remember to take the medication according to the instructions.
• You may visit the dietitian for some advice especially if dialysis treatment is reduced during the trip.

You may visit these websites for more information:
http://www.davita.com/
http://www.uptodate.com/patients/index.html

Disclaimer: The information given here should not be used as a substitute for a consultation or visit with your physician. We would like to remind you that proper medical advice could be obtained only in the context of overall clinical assessment so medical consultation is important for diagnosis of condition.

About Us

The Kidney Dialysis Foundation (KDF) is a non-profit charitable organisation, established in February 1996.

KDF provides subsidised dialysis treatment to needy members of our community so that these patients will not be deprived of treatment.

Get in Touch

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  • 65 6559 2630 (Main Office)

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