Saturday, April 25, 2015

The Renal Report - Living Well with Kidney Disease

Meat-Heavy, High-Acid Diet Poses Risk for Those With Kidney Disease: Switching to regimen higher in fruits, veggies might help stave off organ failure, experts say
FRIDAY, Feb. 13, 2015 (HealthDay News) -- Patients struggling with chronic kidney disease who routinely consume meat-rich, highly acidic diets may boost their risk for kidney failure, a new study suggests.
Tanushree Banerjee’s team (University of California, San Francisco) conducted a nutritional analysis of nearly 1,500 kidney disease patients over a roughly 14-year period.
As reported Feb. 12 in the Journal of the American Society of Nephrology, those who consumed high-acid diets appeared to face triple the risk of kidney failure compared with those who consumed low-acid diets. “ The high costs and suboptimal quality of life that dialysis treatments bring may be avoided by adopting a more healthy diet that is rich in fruits and vegetables.”

Some of you learned - only shortly after me - that I was the proud owner of a single and very unhappy kidney. Its discovery is called an “incidental finding” in medicine, found accidentally or coincidentally during testing for something else.
“Absent left kidney” the CT report read, “correlate clinically.” The report was no surprise as I’d scrolled through the actual CT on the computer and noticed the absent kidney bean on the right side of the screen. Whoa! Where’s my kidney? 
I’d been given IV CT contrast dye prior to the test and had the IV remained, we would have infused another liter of normal saline - to flush my kidney. CT dye is hard on kidneys, they have to process it, turning it into urine to be excreted from the body. Impaired kidneys (called insufficient) are overwhelmed and may be damaged by CT dye. They sat me down in the Radiology Dept and would not let me leave until I gulped down a liter of water. “Drink lots of water for the rest of the day,” they instructed.
The nephron is the working unit of the kidney; a kidney doctor is called a Nephrologist. I inquired about seeing one. “Your creatinine looks okay,” my primary care doc (PCP) said, “You’re okay.” That was 2002. I had a bad feeling about it and began research on the internet. 
I did a drive-by-curbside-consult with my favorite Nephrologist, the one who followed our patients on the open heart surgery team. “These kidney tend to fail,” he said, “You need to be followed. I’d be happy to see you.” When my medical benefits returned to Kaiser, I pleaded my case for a Nephrology consult to my new PCP. “Your creatinine looks okay,” she said, “I don’t think you have a problem. But if your nephrologist friend said you should be seen, I’ll send a referral.” That was 2005.
Dr. Patel was the chief of Nephrology and I had to wait an extra month for an appointment on his schedule. My physician friends promised he was worth the wait. Dr. Patel is, to this day, a very lean and soft-spoken man. His medical assistant called and sent me to the lab, where they drew more tubes of blood than I can ever remember having drawn at once.
“I have reviewed your CAT scan,” Dr. Patel said pointing to the picture on his computer screen. “Your kidney is a little larger than normal; we expect that when there is only one because its doing the work of two. Your renal (kidney) artery comes off the aorta four centimeters lower than it should. This affects renal blood flow. Your kidney will be very sensitive to changes in blood pressure. Its important that you keep your blood pressure low. If your blood pressure goes up to 110, we will put you on medication.” His eyes scanned me from head to toe, “I wouldn’t gain any more weight.”
“People can lose a kidney," he continued, "And because kidneys are redundant, they can live well with only one kidney. Kidneys like yours are not perfect, their tubules are not perfectly formed and smooth, they have structural defects and over time, they tend to fail. The way to make kidneys last is to lighten their work. How you do that is by what you eat.” 
We reviewed my lab work - it was whacky. “I’m sending you to the Taking Care of your Kidneys Class. If you follow the diet, over time your lab work will improve. Just one more thing,” he held up one finger, “No NSAIDS (Motrin, Aleve, etc.), no sodas,” he raised a second finger, “No salt,” … third finger, “No chocolate,” …four, “Very little meat,” five.
“No problem,” I said calmly, “I’ve already given up all of that.”
“Why?” he was wide-eyed and clearly stunned.
“Believe it or not doc, I have, at times, said out loud - These things are bad for your kidneys; I’m not doing them.”
A month later, I sat in the very last row of Kaiser's Taking Care of your Kidneys Class - tears streaking my cheeks. “No Cheetos, no gatorade, no artificial orange coloring,” she said. This is so unfair; I don’t belong here. I was initially distraught and I didn’t even know why. My life hadn’t changed one iota except for a new label - renal insufficiency and chronic kidney disease. F them, I thought in a defiant moment later that day while consuming Cheetos and orange Gatorade.
Some think the Renal Diet is too restrictive and difficult to follow. It is comparatively low in protein - my allocation is 45 grams/day - I’m a little person after all. “You can bump that up for backpacking trips if needed,” my dietician said. In truth, my diet changed very little. I discovered that I already followed a renal diet, that I had naturally gravitated in that direction because I felt better when I ate a diet high in raw fruits and vegetables with little or no meat. I learned to count protein grams before consuming them. Cheetos and Gatorade were banned in short order. 
My blood work improved over time and after two years, looked almost normal. Good blood work = happy kidney bean.
Bill, me, John
“I think this kidney will last until you are about 70 years old,” Dr. Patel said three years ago. “But if you want to hike in Nepal; that kind of remote hiking? You should do that sooner than later.” 
I took his warning seriously and began weighing the items of my bucket list. Last fall, I hiked in the Swiss Alps with two of my best buddies. Big CHECK off the bucket list.

I saw Dr. Patel on Monday. “Your lab work is very good; your kidney is very stable. They key to renal longevity is a diet high in vegetables and raw food. If you continue with what you are doing, I can see this kidney lasting another two decades.” Yippeeeeeeeeee!
Its been ten years and I have been the poster child for making the renal diet work. Dr. Patel just doubled my renal prognosis. I am thankful because its doubtful I will ever consent to dialysis (peritoneal or hemo) or transplant. I’ve had a decade to ponder the matter and am unconvinced that life is always worth living at any cost.

But I do want to address how one can live well and thrive with renal insufficiency and chronic kidney disease. Diabetes is epidemic in all western countries and the leading cause of both renal insufficiency and failure. "Chronic kidney disease represents an underestimated public health hazard, affecting at least 26 million Americans," said Dr. Ernesto Molmenti, surgical director at North Shore University Hospital Transplant Center in Manhasset, N.Y. The new study (the one that headlines this blog) "provides us with a nutritional intervention that can be instituted in all people at all levels of society."
Maintaining renal function is directly related to diet and the science is in - in the majority of cases, diabetes type 2 is reversible and renal insufficiency (heart disease, heart attack, stroke) AVOIDABLE. As one who is more interested in life’s quality than quantity, I am acutely interested in avoiding diseases that will curtail my activities or stop me with pain.
So the first things I had to give up were the thoughts: I should be able to eat whatever I want, whenever I want, in any quantity I want.” Second, I had to give up that FDA recommendations and the traditional American diet had any relevance to my current situation. Third, I had to give up that I should be able to eat more than 1100-1200 calories/day. Give it up! It is not serving you.
Fourth, I set up my environment to support me. What does that mean? I purged my home of foods that were not on the renal diet. At the time, I considered Cheetos and popcorn a major food group in and of themselves; they were my binge foods and were summarily banned from my pantry. I could eat Cheetos - but I had to go buy them when the mood struck and I was not allowed to bring them home. Setting up a supportive environment is key. Why? Because "will power" is a limited commodity for us all that wanes with the day. None of us can long withstand the siren's song of chips or ice cream or cookies or popcorn or Cheetos or _____ (insert your favorite snacky food’s name here).

In what other ways do I set up my environment to support me? I ALWAYS bring something that I can eat to potlucks. I ALWAYS travel with food bars. I ALWAYS pack a lunch. I ALWAYS have healthy foods stashed at my desk. In fact, the largest drawer of my office file cabinet is filled with a variety of teas, food bars and low/no salt crackers. One would think I was a foodie and I’ll admit, I do think about food a lot. I am very proactive about meals and am never subject to convenience or fast foods.
“Sounds boring,” one of my friends said. Au contraire! Fresh and raw foods taste amazing once you wean yourself from the salt and sauces hiding their subtle flavors. Over time, my diet has transitioned to include more raw foods just for convenience. Big-box stores like Costco, who sell large bags of super-greens, make it easy.

The kidney makes epoetin (Epogen, you’ve seen the cancer commercials) - an essential building block for red blood cell production. When kidneys are insufficient, they make less epoetin and anemia ensues. A strict vegetarian diet can make keeping up with anemia difficult for those with kidney disease. 
“I wish you would eat a little more meat,” Dr. Patel said after a few years. “Its easier for your body to extract what it needs to make blood from meat than plants.” 
But in the world of restricting all protein (all animal products - yes, even poultry and fish, dairy, beans, and nuts) to 45 grams/day, meat is expensive. 
I made a deal with him, I would eat meat when I dined out. That seems to work. I might have 3-4 oz of meat no more frequently twice/month. With that, I corrected my anemia. I continue to keep it at bay with figs, dark leafy greens and infrequent medallions of meat. It also makes life easier when dining  out and avoids crazy-making for the wait-staff burdened by my peculiar requests.
I’ve learned that protein and fat consumption stave off hunger; that if my foods are strictly rabbit-ish - I am always hungry. So adding a little protein and fat - say a cheese stick, peanut butter, almonds or a little yogurt to breakfast - will hold me until lunch. The formula that seems to work is approximately 10 grams of protein at breakfast and lunch. That translates into feta cheese, nuts or half an avocado on my salad or a black bean burger for lunch. That leaves 20 grams of protein for dinner.

Kidney patients can be very salt sensitive. If we eat too much salt and retain water, we do not efficiently process that water into urine for excretion. Remember, in insufficiency, kidney function is low and slow so water stays in the body to accumulate in the tissues of the feet, ankles, lower legs and lungs until it can be processed and excreted.
I learned this the hard way at Rubios one day. I stopped in for two blackened, mahimahi tacos and (easily less than) 30 salty, tortilla chips. Overnight, I gained eight pounds of retained water. It accumulated around my feet and ankles where the skin was stretched so tight, I ached and itched. My feet could not be stuffed into shoes and I literally felt water “slosh” around my ankles with each step. Auwe! I took a diuretic and learned that flogging a failing kidney with diuretics is like whipping a horse with a broken leg to run faster - it doesn’t work. Over time, I’ve learned that my Bean can process about one pound of excess water/day - that it takes eight days to clear eight pounds of retained fluid.
“No ham, no pastrami, no pepperoni, no corned beef, no preserved meats, no sausage, no salted pork or fish,” Dr. Patel said. I understand and avoid them, unwilling to live with my lower extremities bloated like sausages stuffed in their epithelial casings. Its just not worth it.

Let food be thy medicine and medicine be thy food. Hippocrates 

The human body has tremendous capacity to heal itself. We now know that  type 2 diabetes and heart disease are reversible conditions for many. Some have gone so far as to label those diseases food borne illnesses. As a society, we are suffering the diseases of excess.
Studies show dietary links to autoimmune diseases and autistic spectrum disorders, not as causal agents but in decreasing overall inflammation and the abatement of symptoms and stabilization of disease progression.

Next year, I’ll turn 60 years young. I intend to throw a party. My friends have threatened to speak at that party. YIKES! I’ve started to announce my age more readily just to watch eyes protrude, jaws drop, and dentures shatter when they fall. I am easily one of the oldest members at my yoga studio. I love hanging out with the lithe and lovely bodies that frequent my classes and am inspired by their ease of movement.
“If you continue with what you are doing,” Dr. Patel said on Monday, “I can see this kidney lasting another two decades.” That’s good - coz I have plans. I’d like to see every National Park, maybe even work as a seasonal park ranger in my favorites. I’d like to live in Europe for half a year and experience it from my bicycle. I’d like to do more hiking abroad. I might want to tackle the Pacific Crest Trail in sections. I can’t do any of it from a dialysis chair.
Some say we are spiritual beings having a physical/earthly experience. Spiritual beliefs aside, our bodies are the vehicle through which we experience this life. I desire rich experiences requiring high-performance physicality. I’m not ready to limit myself to paved, flat surfaces. I am unwilling to tolerate one day of avoidable pain and discomfort. For me, the dietary trade-offs are a no brainer.

Tools, Tips and Strategies:
   If you are trying to manage weight, hypertension, diabetes, limit salt or caloric intake, have an autoimmune disease and want to decrease pro-inflammatory foods, these tools, tips and strategies may be helpful.
The first step in managing food is tracking it. This can bring a modicum of consciousness to eating. My favorite food app is one called My Fitness Pal. Their food library is extensive. This allows me to check protein, salt and calories before I eat. It can be found online and is available for mobile devices.
   Start with Meatless Mondays and Fish Fridays. There is a learning curve to increasing plant-based eating and Meatless Mondays and Fish Fridays are an easy way to start.
Cleanse the pantry. Rid your home of tempting foods that derail and are not on your food plan. Its not that I can never have them - I can’t have them in my home. I keep snacks in my home that can’t hurt me = seasonal fruit. “But I can’t …” Excuses keep you stuck.
Ya gotta move. Last year, Kaiser Permanente (Sacramento region) gave every employee who registered, a FitBit. Its a glorified pedometer and my workmates were shocked at their levels of inactivity. Everyone started moving - walks at lunch and more. “But I can’t …” Excuses keep you stuck. There are ways to move, even for those in wheelchairs. Ask me how.
We are the company we keep. Deep-dive into supportive communities. Attend support groups and surround yourself with the like-minded. When dining with others, I make requests. I rarely agree to steak houses (where the menu will offer little I can eat) or places known for gargantuan portions (where my companions and I will be tempted to negate an entire week of stellar food choices in a single meal).
Have go-to strategies. Someone wants to meet for dinner? Couple meals with activity. Take a walk before dinner; a bike ride before brunch.
More on chronic kidney disease at the National Kidney Foundation.

Its not hard; its different. 

Think different ~ Steve Jobs