- Briefing#4

Dialysis and Diet:

The double act that keeps you healthy without kidneys
Our kidneys are pretty remarkable organs. Most people know about their main role, but in fact they perform a double act. Act One is waste removal, where they filter excess minerals and the wastes and toxins that build up in our blood after we have digested the food we eat and drink. Then they combine all this waste with any fluid (water) we dont need into urine and pass it to the bladder for disposal. Removing the wastes and toxins keeps us healthy; removing the extra fluid helps control or blood pressure. Act Two is more a behind-thescenes performance, where they regulate the mix of electrolytes (sodium, potassium, chloride, and bicarbonate) for a healthy heart and central nervous system; and the calcium and phosphate levels in our bodies in conjunction with our parathyroid glands to keep our bones strong and our blood haemoglobin levels healthy. With all this going on, replacing our kidneys when they fail is the original hard act to follow. But, fortunately we live in a time of medical and biotech wonder that has done just that, also as double act: Act One: Dialysis to remove waste and control excess fluid Act Two: Diet to minimise salt and potassium and phosphate-rich foods; supplements to manage our calcium, phosphate, red blood cell, iron and ferritin levels.

Together they form a new double act that keeps us healthy long after our kidneys have left the building.

Act One: Dialysis

Dialysis removes waste and controls fluid by passing our blood through a dialyser that filters out most wastes and excess water and returns clean blood back to our body. There are two ways to dialyse: Haemodialysis (HD) and Peritoneal Dialysis (PD).

Haemodialysis
Haemodialysis is done by machine. Two needles are inserted into an enlarged vein in your forearm, called a fistula (created surgically a few months before you begin dialysis). Blood is pumped from your arm via the first needle and tubing to a dialyser on the dialysis machine. The dialyser filters the blood and extracts wastes and water, which are discharged into a drain. The amount of water to be removed can be varied, depending on how the machine is set up. The freshly cleaned blood is returned to the body via the second needle. This is done continuously for as long as the machine pump operates. At any one time only about a cupful of blood is outside the body. During each session, the equivalent of all the blood in your body will be filtered several times. The more blood that passes through the dialyser, the more effective the dialysis, so the keys to good dialysis are the speed of the pump (typically 300 350 mL/min), the size of the needles (the larger the better) and the time spent on the machine (most people dialyse for 3-4 hours each time, about three times per week).
.

Peritoneal Dialysis
Peritoneal Dialysis uses a natural membrane inside your abdomen to remove waste products. A small, soft plastic tube is sewn into your solar plexus (a 15-30 min surgical procedure). The tube is used to add special dialysis fluid into abdominal cavity. Waste products are absorbed by the dialysis fluid, which is then drained out again. Depending on the type of PD you choose, this can be done either by hand four times a day (called Continuous Ambulatory Peritoneal Dialysis CAPD) by a machine overnight (called Automated Peritoneal Dialysis APD).

Act Two: Diet

The bad news is that once we lose kidney function, just about everything we eat has the potential to kick us off the straight and narrow. Our fluids and electrolytes are finely balanced. Any one mineral or chemical has the potential not just to cause its own problems, but to set a clutch of other dominoes falling with it. Take salt: alone, too much makes us THIRSTY. VERY THIRSTY; so we drink too much and with nowhere to go that lovely fluid pools around our body; our blood pressure goes through the roof; fluid sitting on our lungs makes it hard to breathe; ankles and legs swell; and on it goes. Sadly there is no pill to neutralise a salt overdose. We have to program ourselves and others not to cook with salt and to remember to tell people not to add salt to your food. We soon come to learn that ideally, we should only drink about a litre a day. Its the same with potassium, which controls nerve and muscle function. In particular it keeps our heart in rhythm. High levels can cause nausea, weakness, numbness or tingling, slow pulse, irregular heartbeat and heart failure. Potassium is in nearly everything, so we shouldnt eat too much meat, poultry or fish, apricots, avocado, bananas, melons, kiwi fruit, lima beans, milk and cheese, oranges and orange juice, potatoes, prunes, spinach, tomatoes, even vegetable juice. Phosphate packs a double whammy. Too much results in long term problems like weak and brittle bones, and calcium deposits throughout the body. But the immediate impact is also dire: Olympic level skin itching, joint pain and eye irritation and sometimes unstable heart rhythms and even heart failure. Again, phosphate is in nearly every food, but especially so in foods like pastries, whole grain bread, cola drinks, coffee, chocolate, dairy products, mayonnaise, margarine, egg yolks, peas, lentils, nuts, puddings and gravies, processed meats and too many more. You cant eliminate phosphate from your meals, but you can stay away from or minimise foods with lots in it. You can also control phosphate levels with phosphate binders (like Caltrate, Renagel, Alutabs or Fosrenol). These work pretty simply: you take at least one just before you have food or drink. The pill sits in your stomach and dissolves into a paste. As the phosphaterich food arrives, the phosphate binds with the paste. The bound molecules are then carried through the gut, into the bowel and out into the cold hard world. At first glance, this new diet routine may seem onerous and it can be if you let it take over. The key is moderation, not abstinence. It will take some time to find the combination of foods that work for you (most of the time your body will tell you when you have strayed too far). But you will find it. The right diet does require some self-control, but not an iron will. Supplements like calcium, Calcitriol, Erythropoietin or Darbepoetin alfa, iron, and ferritin also form a key part of most BigD-ers lives, keeping our bones strong and our blood red and healthy. With supplements we need less self-control to stay well; their use is usually managed by our kidney specialist, and our only role is to take them as prescribed. Over the years youve come to know and love many quality double acts: Oliver and Hardy, Abbot and Costello, Pete and Dud, Jekyll and Hyde, but none so life changing as Dialysis and Diet the latest duo in your life. Get to know them!

FOR MORE INFORMATION, HELP, ADVICE AND SUPPORT GO TO http://bigdandme.wordpress.com.

Except where otherwise noted, content on this document is licensed under a Creative Commons Attribution 3.0 License.