Hemodialysis.com | Hypertensive Nephropathy | Dietary Acid Reduction & GFR | Dr. Wesson
Author Interview: Donald E. Wesson, M.D.
Vice Dean, Texas A&M College of Medicine
Chief Academic Officer, Scott and White
Publication: Author Interview: Donald E. Wesson, M.D
Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy
Nimrit Goraya, Jan Simoni, Chanhee Jo and Donald E Wesson
Kidney Int advance online publication, August 31, 2011; doi:10.1038/ki.2011.313
What are the main findings of the study?
Our study shows that dietary acid reduction with two interventions, addition of sodium bicarbonate (NaHCO3) or addition of base-inducing fruits, each reduces urine parameters of kidney injury in subjects with chronic kidney disease (CKD) due to hypertensive nephropathy.
These data are consistent with reduced kidney injury in the study subjects who had kidney injury as reflected by their high levels of these urine indicators of kidney injury and their reduced kidney function as measured by reduced glomerular filtration rate (GFR).
These findings complement multiple published animal studies from our and other laboratories showing that reduced dietary acid with alkali or with base-inducing dietary protein reduces kidney injury in animal models of CKD.
Were any of the findings unexpected?
Because our previously-published studies showed that each intervention reduced kidney injury in animal models of CKD, we were not surprised by the main findings described, i.e., that these two interventions reduced urine parameters of kidney injury.
We were surprised, however, by the finding that fruits and vegetables also reduced blood pressure in these hypertensive subjects. By contrast, we saw no blood pressure decrease in the subjects given NaHCO3.
What should clinicians and patients take away from this study?
This is another in a series of human studies showing that dietary acid reduction reduces kidney injury and earlier published studies from our and other laboratories show that this intervention also slows decline of kidney function, as measured by estimated GFR, in subjects with CKD.
To our knowledge, our newly published study is the first to show that dietary acid reduction with fruits and vegetables reduces kidney injury. Clinicians should recognize that dietary acid reduction is an effective adjunct to conventional kidney protection therapy (blood pressure reduction and use of angiotensin converting enzyme inhibitor drugs, both of which were features of the management of all subjects in our study) to reduce kidney injury in patients with CKD.
This recent publication supports that dietary acid reduction effective enough to reduce kidney injury can be accomplished with the addition of dietary fruits and vegetables, as has already been shown to be the case using NaHCO3, the latter shown in previous publications from our and other laboratories.
What recommendations do you have for nephrology health care providers as a result of your study?
Because our subjects all had CKD due to hypertensive nephropathy, our recommendations are best applied to such patients.
Further studies will be needed to determine if such interventions are effective in subjects with CKD due to other causes. Hypertensive nephropathy patients with reduced GFR and urine indices of kidney injury, the latter indicated most commonly by higher-than-normal urine albumin excretion, should be considered candidates for dietary acid reduction as adjunctive therapy to blood pressure control and therapy with anti-angiotensin II pharmacotherapy.
If our findings are confirmed by other laboratories, health care providers can consider using addition of fruits and vegetables as a means by which to achieve this dietary acid reduction. The concomitant blood pressure reduction with fruits and vegetables is an additional attractive feature of using fruits and vegetables because this blood pressure reduction might additionally contribute to reducing the risk of cardiovascular disease (CVD) in these CKD patients who are already at very high CVD risk.
Another potential advantage of using fruits and vegetables rather than NaHCO3 to achieve this needed dietary acid reduction is that using fruits and vegetables avoids the added dietary sodium that can lead to fluid retention and increasing blood pressure in some CKD patients.
Abstract:
The neutralization of dietary acid with sodium bicarbonate decreases kidney injury and slows the decline of the glomerular filtration rate (GFR) in animals and patients with chronic kidney disease.
The sodium intake, however, could be problematic in patients with reduced GFR. As alkali-induced dietary protein decreased kidney injury in animals, we compared the efficacy of alkali-inducing fruits and vegetables with oral sodium bicarbonate to diminish kidney injury in patients with hypertensive nephropathy at stage 1 or 2 estimated GFR.
All patients were evaluated 30 days after no intervention; daily oral sodium bicarbonate; or fruits and vegetables in amounts calculated to reduce dietary acid by half. All patients had 6 months of antihypertensive control by angiotensin-converting enzyme inhibition before and during these studies, and otherwise ate ad lib. Indices of kidney injury were not changed in the stage 1 group. By contrast, each treatment of stage 2 patients decreased urinary albumin, N-acetyl β-D-glucosaminidase, and transforming growth factor β from the controls to a similar extent.
Thus, a reduction in dietary acid decreased kidney injury in patients with moderately reduced eGFR due to hypertensive nephropathy and that with fruits and vegetables was comparable to sodium bicarbonate. Fruits and vegetables appear to be an effective kidney protective adjunct to blood pressure reduction and angiotensin-converting enzyme inhibition in hypertensive and possibly other nephropathies.
Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis:
Help, I Need Dialysis! How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure.
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