If you have stage 3 CKD, you may want to start paying attention to phosphorus. If you limit processed foods with phosphate additives and eat smaller amounts if foods naturally high in phosphorus, you may keep your bones and heart healthier and live longer.
In early kidney disease as the kidneys slow down and phosphorus rises even a little bit, a protein called FGF-23 (fibroblast growth factor) is released from bone cells. This protein directs the kidneys to get rid of more phosphorus in the urine so blood levels stay normal. FGF-23 also reduces active vitamin D so there is less phosphorus and calcium absorbed from the gi tract.
Parathyroid hormone (PTH) production begins to increase in early kidney disease too.  It is overproduced to keep phosphorus and calcium in the normal range.  As PTH goes up it leaches phosphorus out of your bones.  High phosphorus in the blood causes calcifications in the blood vessels and heart.
Studies show that early dietary phosphorus restriction helps keep PTH lower.  The benefit of controlling PTH by reducing phosphorus intake is phosphorus and calcium will remain in the normal range and your heart and bones will stay healthy longer.

The next time you visit your doctor ask about your phosphorus, calcium and PTH results.

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Patients who dialyzed during the night for a longer time (6 to 8 hours) were shown to have higher albumin levels and phosphorus in the normal range compared to patients on traditional in-center dialysis (usually 4 hour treatment time).

High phosphorus and poor nutrition are two very strong predictors of hospitalization and increased chance of dying if you have kidney disease. Kidney patients are challenged to keep phosphorus levels down while eating enough protein to prevent malnutrition.  Dialysis patients  need more protein that others–1.2 to 1.3 grams/kg compared to 0.8 gm/kg for the average healthy person. For example a healthy person who weighs 150 pounds (68 kg) requires approxiamately 55 grams protein; a person on dialysis requires 82-88 grams of protein.

The dilemma here is that good sources of high quality protein also contain phosphorus; protein and phosphorus go hand in hand. Dietitians often advise patients to limit or avoid high protein foods with the greatest amount of phosphorus–milk, yogurt, milk shakes, legumes, nuts, peanut butter. The recommended high quality protein foods include lean red meats, poultry, fish and seafood, eggs and cottage cheese. Even with these changes phosphorus control may be quite difficult requiring phosphorus binding medicines, a low phosphorus diet and avoiding processed foods containing phosphate additives.

If you are looking for ways to eat better and keep a normal phosphorus learn more about how nocturnal dialysis works and how it can help you be healthier.

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Trick or Treat?

Halloween candy is a treat so you may need some Halloween tips to help you stay in control of your kidney diet when tempted by all those extra sweets. Don’t be tricked into letting your potassium, phosphorus, blood sugar or waistline increase!

Before Halloween Tips

• Purchase candy you know is acceptable on your diet. For example if you suck on hard candies to help control thirst, buy your favorite kind and use leftovers for thirst control.
• Be aware of high potassium and high phosphorus ingredients like chocolate and nuts and avoid candies made with these ingredients.
• Instead of buying candy buy caramel apples or make popcorn balls as a Halloween treat.
• If you have diabetes buy low sugar candy or allow for the extra carbohydrate in your diet. You could save sugar-containing candy for emergency use when you have a low blood sugar episode.
• Purchase Halloween candy you don’t really like—you won’t be as tempted to eat it, especially the leftover candy.
• Try a DaVita.com Halloween recipe
  Glistening Frog Eye Salad
  Halloween Delight Cake
  Hot Apple Cider
  Popcorn Balls
  Spooky Punch

After Halloween Tips

• Package extra candy and drop it off at a homeless shelter or send to a home-bound friend.
• Give away leftover candy—to the neighbors, take some to church or dialysis or anywhere there’s a crowd. You’re sure to get many takers!
• Freeze leftover candy or store it in a container in the pantry. Out of sight, out of mind means less temptation to eat too much leftover candy.
• Take a walk or do some other exercise to match each piece of candy you eat.
• If you have diabetes, check your blood sugar more often. If your results are too high you will be less tempted to eat leftover candy.
• Avoid the candy isle in stores after Halloween—the fantastic sale prices may tempt you to buy unneeded candies.
• For more information, check out the latest DaVita.com article, Kidney-friendly candy for dialysis patients.

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Not everyone has to restrict potassium though. It depends on your lab results and your kidney’s ability to remove potassium. If you still have urine output around 4 cups or more a day (1 liter or more) you may continue to have normal potassium levels without following a low potassium diet. Normal potassium in the blood is 3.5-5.0 mEq/L.  A low potassium diet around 2000 mg a day is usually prescribed if potassium levels are too high.

Some blood pressure medications cause you to retain more potassium. In some cases your doctor may change your blood pressure medicine to help lower potassium levels or prescribe a diuretic that helps remove extra water and potassium.

Here are some tips to help manage potassium if you need to follow a low potassium diet:

• Have a plan. Work with a dietitian who specializes in kidney disease to come up with a meal plan you can use as a guide when planning your meals.
• Include low potassium fruits and vegetables but stick with the portion recommended on your meal plan. Find your favorites on your diet guide and make them a part or your weekly menus.
• Limit high potassium fruits and vegetables. If there is a food you cannot live without, try having a smaller portion and eat it less frequently.
• Boil vegetables instead of microwaving or stir-frying. Potassium from boiled vegetables leaches into the water. Some high potassium vegetables like potatoes can be thinly sliced and boiled in a large amount of water to reduce potassium.
• Each ounce of meat contains around 100 mg potassium. Eat the amount of meat recommended on your meal plan and avoid excessive portions.
• Limit dried beans and peas. A half cup of mature beans ranges from 250 to 600 mg potassium, depending on the type of beans. If you have a meal with beans, leave off the meat. This helps keep potassium lower. Green beans and jelly beans are low in potassium—you can still enjoy these beans.
• Limit milk and yogurt and foods made with milk. One cup has over 350 mg potassium—even more if extra protein or milk solids are added.
• Snack on low sodium crackers or popcorn instead of chocolate and nuts. If you do eat chocolate candy, stick with the snack size as an occasional treat.
• Try new recipes and collect the ones you like. DaVita.com has over 600 kidney-friendly recipes that are low potassium, low sodium and low phosphorus.

If you need a guide with a list of high and low potassium foods, check out this DaVita.com article on potassium: Potassium and chronic kidney disease

Try one of these low potassium recipes this week:

Honey Maple Snack Mix

Zesty Cucumber Salad

BBQ Chicken Pita Pizza

Bowtie Pasta Salad

Almost Mashed Potatoes

No Tomato Salsa

Apple Bars

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The first day I had an introduction to the rolling hills of western Michigan and the serene back roads showcasing farms and produce–lots or corn and soybeans. Along with many DaVita teammates and friends I rode 67 miles today–my longest ride ever.

Michigan corn field

Day 2 Tour DaVita

Day 2 greeted us with light  rain, or as the Backroads crew called it–spritzing (it’s still wet no matter what you call it!).  We stopped by the DaVita Newaygo Dialysis center in Fremont for a rally which included presentations by 2 of the center’s patients–one who had a recent kidney transplant. Their words were inspiring. For many in the crowd this reminder of who we are riding for and why was so motivating–a little rain no longer mattered. The Fremont High band played as we took off for the ride.

Cherry Orchard

The hills on day 2 were challenging to say the least. I admit I walked my bike a few times. I loved the scenery–ran across a pumpkin patch, asparagus fields, more corn fields and fruit orchards–cherry, apple and plum trees. What a beautiful site! Sticking with a low potassium diet must be easier when local grown low potassium fruit choices are so readily available. 45 miles total today.

Day 3 was sunny and not as hilly. Lake Michigan appeared often on this route. I rode with fellow dietitian Christine from Florida and enjoyed great conversation as well as the beauty of the ride. Christine is very passionate about diabetes and teaching patients to manage their glucose. She has first hand experience caring for her husband, who had diabetes and kidney disease requiring dialysis.

Lake Michigan

My personal best today was 54 miles. A high point was greeting the DaVita Village mayor, Kent Thiry as he arrived at the last refreshment stop.

Onward to the finish line where we celebrated and welcomed other riders as they completed the tour. Next year…I have a 166 mile record to break!

The finish line

Many people already on dialysis will agree this is a worthy cause. Many of them were never alerted to risk factors or signs of kidney disease. The chance to know you are at risk or to identify existing kidney disease can make a difference in when and if you need dialysis. If you find out about kidney disease early on, you can work on blood pressure control and/or diabetes control to help delay the progression of kidney failure and dialysis.

Diet changes like limiting sodium, balancing carbohydrate intake for diabetes control, eating healthy fats and moderating protein intake are all important in managing early kidney disease.

Unfortunately too many people find out they have kidney disease when they are in CKD stage 4 or 5–in need of dialysis instead of earlier when they could do things to make a difference.  A routine blood test for creatinine can help you know your glomerular filtration rate (GFR) to determine presence of early kidney disease.

I hope the many miles I peddle this week contributes to at least one person learning about kidney disease risk before they are diagnosed with end stage renal disease. That would make every hill and every peddle well worth the effort! Please help by letting your friends and family know about kidney disease risk factors and that detecting early kidney disease in a very important thing they can do to make a difference.

What kind of noodles do you eat? Growing up my family ate egg noodles and spaghetti.  As an adult, I’ve discovered a whole world of noodles from around the world. A basic noodle recipe calls for flour, water, egg and salt.

Types of flour used in noodles include wheat flour, (white or whole wheat) rice flour and buckwheat. Some noodles are made with starch instead of flour; bean starch, corn starch, potato starch and tapioca starch are used throughout the world. Tofu and seaweed are also used as a noodle base. Some noodles contain additional flavorings or colorings. Given all these ingredient combinations, the plain old noodle I knew as a child has certainly expanded into a vast menu of noodle choices.The next time you feel bored with your kidney diet, consider exploring different noodles to try.

Noodles are often named by their place or origin. Included in the category are Chinese egg noodles, Chinese wheat noodles, Filipino pancit noodles, German paetzle noodles, Hong Kong noodles, Japanese udon and ramen noodles, Korean gook soo noodles, Malaysian hokkien noodles, Shanghai noodles, Thai noodles, and Vietnamese mi chay noodles. The Italians call their noodles pasta—which originates from the word paste or dough. Dried pasta ingredients include durum semolina, durum wheat and water. Fresh pasta includes egg, salt and sometimes olive oil.  Spaghetti, vermicelli, fettuccini and linguine are popular long pastas in the US.

Noodles are inexpensive, healthy and versatile. Most noodles are a great choice for kidney diets because of the low potassium and phosphorus content. Some noodles contain salt, so read labels to make the best choice. Choose kidney-friendly ingredients to dress up your favorite noodles.

High potassium tomato sauce is not the only flavoring for pasta or noodles. Consider adding noodles to homemade soup; create a cold noodle salad; stir up a noodle, meat and veggie stir fry; make spring rolls with a rice noodle and fresh vegetable filling; try deep fried noodles to add crunch to a salad or side dish. Check out the following kidney friendly noodle recipes from DaVita.com:

Chicken Noodle Soup

Fettuccine Alfredo

Holushki Noodles and Cabbage

Linguine with Garlic and Shrimp

Pancit

Rice noodles with Chicken and Oyster Sauce

Sesame Vermicelli

Shrimp and Asparagus Linguine

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If you are currently on Renagel®, your doctor will change you to Renvela® or another phosphate binder once you have depleted your current supply.

Phosphate binders are prescribed to dialysis patients to help control phosphorus in the blood. When kidneys no longer work, the ability to excrete phosphorus is lost and levels build up in the blood and tissues. High phosphorus causes bone and heart problems, itching, calcification and increases risk of hospitalization or death.

Timing is important when taking phosphate binders. The main action occurs in the intestines as food is digested.  It’s important to take binders immediately before eating or during the meal or snack as prescribed by your doctor.

Binders, a low phosphorus diet and adequate dialysis all work together to successfully keep phosphorus in control.

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One of the headliners in this week’s Renal Business Today’s eNewsletter is “Baking Soda Slows Progression of Chronic Kidney Disease”.  The article sites a Royal London Hospital based research study published online in the Journal of the American Society of Nephrology.  A group of patients with advance chronic kidney disease (CKD) were given a daily sodium bicarbonate tablet.  Decline in kidney function for this group was greatly decreased compared to the group who did not receive the sodium bicarbonate.  Additional studies are required before recommending this treatment but there’s hope in knowing this simple treatment may help your kidneys last longer.

In advanced kidney disease, accumulation of waste products such as sulfates, phosphates and uric acid cause an imbalance in the blood pH, resulting in a condition called metabolic acidosis.  Meta what???  It’s a medical term that means there’s too much acid in the blood.  It’s detected by measuring CO2 levels—normal is 22 mmol/L; as levels go lower, acidosis increases.   Normally to restore things to normal you breathe faster to get rid of CO2 and your kidneys clear more acid through the urine while making more bicarbonate.   With kidney failure, this doesn’t happen.  In the above mentioned study, the sodium bicarbonate tablets helped by increasing bicarbonate levels to restore normal blood pH.

There’s a nutritional benefit to correcting metabolic acidosis.  When too much acid builds up in the blood, proteins in the body break down, causing loss of protein stores from muscles, organs and tissues.  Chronic metabolic acidosis can also cause loss of bone minerals and contribute to bone disease.   These problems have been detected and studied in people with CKD stages 3, 4 and 5.

What can you do? Learn more about metabolic acidosis and how it is related to kidney disease.  Your doctor monitors your blood work and can let you know if your CO2 level is normal or if you are at risk for acidosis.   If you are on dialysis, your renal dietitian can also answer questions about your CO2 level.   Self-prescribed treatment with sodium bicarbonate is not recommended as any therapy for kidney patients must be closely monitored.

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What if you don’t eat fish?  You could try fish oil supplements (check with your doctor first).  Studies with prescription grade fish oil supplements have shown reductions in triglycerides and increases in HDL cholesterol (the good one).  Research recently published in the Journal of Renal Nutrition (July 2009, Bowden) studied over-the-counter fish oil supplements to see if taking these has a effect on blood fats.  Participants took fish oil concentrate capsules daily for six months.  The study concluded  that over-the-counter fish oil supplements help lower CVD risk in end stage renal disease patients related to an increase in HDL cholesterol (the good one) and a decrease in LDL particles (the bad one).

Eating fish may be even more beneficial than taking supplements.  Not all fish are created equal.  Herring, mackerel, rainbow trout, salmon and tuna are higher in omega-3 fatty acids compared to many other fish.  Add these to your diet several times a week to make a difference.  It’s easy if you plan fish into your weekly meals— eat a tuna sandwich for lunch or make a snack with low sodium crackers, pan-fry trout fillets, make salmon burgers or try grilled salmon or mackerel.  DaVita.com offers several fish recipes.  Try one this week to help boost your omega-3 level and protect against cardiovascular disease.

Here are some of my favorites:

Baked or Grilled Trout

Honey Spice Rubbed Salmon

Mahi Fish on the Green

Southwest Tuna Salad

Tuna Pasta Salad

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