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Wednesday, August 21, 2013

Rock On: The Kidney Stones!

DIETETIC INTERNSHIP: Weeks 18 & 19 (of 41)
Renal (Kidney) Disease

The renal world (i.e. kidneys) poses a lot of complications for patients in many arenas, from medication management, coordination of many healthcare specialists, and very importantly, drastic nutrition alterations.  Unless you develop some form of kidney troubles, most people have no idea what the kidneys do, where they are located, or how many we have?...  (Psst!  In general, your two kidneys are located in the back of the abdomen (see a picture here), working hard all day long to filter blood (remove waste products, create urine), maintain fluid and electrolyte balance, and secrete hormones to control blood pressure!)  Everything you know about healthy eating recommendations is (nearly) reversed in kidney disease.  Let me explain...

Standard healthy eating advice:
Eat whole grains, buy wheat bread instead of white, brown rice, not white!  Eat more fruits and vegetables!  Consume low-fat dairy 3 times per day!  Limit your sodium intake!

Oh wait, you have chronic kidney disease (CKD) and/or on dialysis?  Screeeeeech!  Cancel nearly ALL of those recommendations! 
For the patient, and for the dietitian/dietetic intern, it is a reversed modality of thought.  Adjustment of thought is an understatement.  With the exception of sodium restriction, revoke ALL of those recommendations, plus add a whole lot more. Limited dairy, limited acceptable fruits and vegetables, no legumes, fluid restrictions...; let's just agree that it is extremely difficult for the patient and the practitioner. (If you are curious, the CKD/dialysis diet focuses on limiting foods high in phosphorus, potassium, and sodium, and depending on the CKD Stage, protein intake needs drastically fluctuate.) 

As a fun project this week, I am eating as if I am on dialysis 3 times per week…  My normal diet consists of lots of fruit, vegetables, beans, and whole grains; I am very much a flexitarian eater.  Two weeks of diet change have been a drastic amendment to instinctual recommendations and choices.  The average dialysis patient also takes phosphate binders with every meal, usually 2-4 massive pills.  I’m also taking binders, but mine are in the form of peanut halves; 2 peanut halves with every single meal, 1 with snacks.

Dialysis patients must be seen once per month by a registered dietitian as diet intake is the #1 method of controlling symptoms at this stage, in addition to thrice weekly dialysis.  This week I reviewed laboratory results with many dialysis patients, and individually counseled each on dietary intake...

--While assessing one patient’s monthly lab values with an older gentleman (84 yo), I couldn’t help but smile.  He has had a double nephrectomy (i.e. both kidneys GONE!), has been on dialysis for several years, and has consistently had the most positive, smiling attitude of anyone in the unit.  We laughed heartily until I had tears in my eyes on two different occasions.

--Contrary to popular banana thought, potatoes have more potassium than any other food.  Potatoes in any form are consequently a rather terrible choice for anyone on dialysis.  As I explained this to one patient, he suddenly "got it" and exclaimed, "Potatoes?  Those things are fatal!"  Yes, fatal potatoes.  We laughed and laughed at his outburst!

--Another patient, whom I had counseled two days prior while he consistently flirted with me, told me as I walked by, “You just got my battery running again!” as he mock-fluttered his heart.  Two days later as I walked by and his blood pressure monitor began beeping due to high BP, he blamed it on me: “You’ve got my ‘pressure’ racing up every time you walk by!”

Not everyone has such a jovial attitude, but I choose not to incorporate those sentiments into my long-term memory bank.

Avoid kidney disease by:  Maintaining a healthy body weight (BMI <25); Managing diabetes (if you have it, A1c <7%); and Managing blood pressure within normal limits (<120/80).  (Two of the top three reasons for end-stage kidney disease and consequently, dialysis.)

Attitude is a little thing that makes a big difference.  Winston Churchill

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