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Patients who have being on dialysis for a long time may develop one or two of the following health problems. The most common once include
- Heart disease and blood vessel disease
- Bone disease
- Nerve damage
Heart disease ( sub link under long term effect of dialysi)
Patients on dialysis are much more likely to develop heart and blood vessel disease than ordinary people not on dialysis. This increased risk is related to kidney disease and other health problems like diabetes and high blood pressure. When you take steps to protect your heart you improve your chances of living long and living well on dialysis
Are there different kinds of heart and blood vessel disease?
Some of the most common ones are:
- Left ventricular hypertrophy (LVF) – The muscle on the left side of the heart becomes thicker and does not working as well.
- Stroke – Lack of blood flow to the brain. A stroke may be caused by a blood clot or bleeding in the brain from a broken blood vessel.
- Coronary artery disease – The most common form of heart disease. It affects blood vessels of the heart and causes angina (chest pain) and heart attacks.
- Heart failure – The heart is not able to pump blood around the body as well as it should. Heart failure develops slowly over time. It can have a large impact on ability to perform daily activities.
Dialysis patients should have their heart tested for heart and blood disease
To check how well your heart is working, you should have:
- An electrocardiogram (ECG) when you first start dialysis and then once a year after that.
- A stress echocardiogram (a type of echocardiogram that includes exercise, usually on a treadmill) or a nuclear imaging test. These are done to check for a blocked artery.
- An angiogram (an x-ray of the heart or arteries) to locate a blocked area and help plan treatment.
- Echocardiograms (echo) this will show the size of your left ventricles and how well it works.
- 24-hour blood pressure (BP) tells your doctor much more than a single check. If your blood pressure is high all the time or does not drop at night you need to take steps to lower it.
- Bio impedance analysis ( BIA) checks for fluid overload by looking for fluid in and outside of your cells
- C-reactive protein (CRP) A CRP blood test measures inflammation, which has been linked to heart damage in people on dialysis
What dialysis patients can do to help prevent heart and blood vessel disease?
If test results shows you have any of the above heart disease, you and your care term must take steps to prevent further damage or progression of the condition by controlling health problems that can lead to heart and blood vessel disease, especially diabetes and high blood pressure.
Here are some steps that can help prevent heart and blood vessel disease
Following a healthy diet and lifestyle, exercise regularly will help prevent heart disease. Members of your health care team will work with you to develop a care plan that meets your needs.
Eating a healthy diet containing enough protein: Research have shown that low serum (albumin), protein levels can make LVF get worse faster. Not been able to eat enough protein because of poor appetite is an indication you may not be having enough dialysis treatment. You can speak to your health term about increasing your treatment which can improve your heart.
Stop smoking: Smoking tobacco is known to be one of the leading causes of lung and kidney disease, also recently this habit is found to increase your risk of developing LVF by up to 42%. Quitting smoking can help prevent and protect your heart from further damage.
Blood pressure control: It is important to follow your treatment plan for your blood pressure control. Some blood pressure control drugs are usually preferred in people with chronic kidney disease. This includes angiotensin receptor blockers (ARBs), angiotensin converting enzyme (ACE) inhibitors are known to help protect your heart.
Control your Fluid and sodium (salt) intake: Maintain your fluid allowance and salt intake to keep fluid from building up in your body and increasing your blood pressure. Ask your health care team about other steps to help prevent this happening.
The target blood pressure for dialysis patients before a dialysis treatment is less than 140/90. The target blood pressure after a dialysis treatment is less than 130/80. Ask your doctor or nurse if your blood pressure readings are on target. If you check your own blood pressure at home, keep a record of your daily blood pressures and show this to your doctor at each visit. If your blood pressure readings are not on target, ask your doctor what can be done to improve them.
Control blood sugar if you are diabetes
Check your blood sugar as often as your doctor tells you to. Follow your treatment plan of medications, diet and exercise. We will discuss this more under diabetic nephropathy.
Reduce high cholesterol levels
High blood levels of fats like cholesterol increase your chance of developing heart and blood vessel problems. You will have blood tests to check for total cholesterol and other fats in your blood. If your levels are too high, you may need to follow a low-fat diet and exercise more. Some patients may also need to take pills (such as a Statin) to help lower cholesterol.
Follow a heart-healthy diet
Your diet should have the right amount of protein and calories to maintain a healthy weight. Your doctor and dietician may also ask you to:
- Reduce foods that are high in saturated fats and cholesterol like eggs, whole milk, cheese and fried foods. (See NB: How Lipids Can Affect Your Heart”) for more information.
- Eat more foods that are rich in heart-healthy omega-3 fatty acids. These include cold water fish like salmon, albacore tuna, lake trout and sardines, and other foods like, canola oil and walnuts.
- If you are on a protein or potassium modified diet, speak to your doctor and dietician before making any changes in your diet.
Increase physical activity
Be sure to ask your doctor about an exercise program that is right for you. Regular exercise helps you:
- Lower high cholesterol levels
- Control blood sugar levels if you have diabetes
- Reduce high blood pressure
- Lose excess weight
- Improve the fitness of your heart and lungs
- Increase your energy level
- Improve emotional well-being.
Treat anaemia if present
Anaemia-a low red blood cell count is common in patients with CKD. This makes you feel tired and can lead to a heart problem called left ventricular hypertrophy (LVF). This is a thickening of the muscle on the left side of the heart.
Steps can be taken to prevent and treat anaemia. A hormone called erythropoietin (EPO) and extra iron can be used to prevent anaemia. Correcting anaemia helps to keep your heart healthy.
Keep important mineral level in cheek and balance
Here are some of the steps that can be followed
Calcium and phosphorus: Are some of the important minerals that are likely to get out of balance when you have CKD.
Resulting in bones loosing calcium and weaken over time. Some calcium may end up your heart and blood vessels. This causes stiffing and narrowing of your blood vessels. When this happens, you are more likely to have a heart attack or stroke. The following measures can be followed to prevent this happing:
- Diet low in high-phosphorus foods like cola drinks, dairy foods, dried beans and peas and nuts and seeds. Discuss this diet with a registered dietician.
- Take medications called phosphate binders. These help to keep your blood phosphorus level in a healthy range.
- Take an active form of vitamin D if your doctor orders it for you.
- Taking aspirin can prevent you having a heart attack, speak to you doctor before taking this drug as it may cause bleeding.
- Folic acid, vitamin B6 and vitamin B12 are known to help maintain homocysteine( amino acid made in your body) levels in the blood. High levels of homocysteine in your blood can increase the risk of heart attack. Taking enough of this vitamin when you have kidney failure will help prevent heart disease.
Maintain emotional well-being
Living and coping with CKD can be very stressful for the patients and their relatives. This can lead to feeling of anger and depression which often reduces your chance of coping with your disease and following treatment plan that can improve your health in general. In turn known complainant and high stress levels can increase your chance of developing heart disease if you are feeling you are having these feeling speak to one of your care team who can arrange for you to see a counsellor who will help you through this difficulty times. Your doctor may also prescribe you some medication to treat your depression.
Renal bone disease (Osteodystrophy ) (sub link under long term effect of dialysis)
Renal osteodystrophy is bone disease due to kidney failure. Patients on dialysis are commonly affected by this disease. Symptoms may include joint pain, bone pain and fractures. Healthy kidneys help ensure healthy bones by keeping the bone-building minerals, calcium and phosphorus in balance in your blood.
Calcium, phosphorus and kidney disease
Calcium: is the most common mineral in your body. It helps to maintain muscles function, aids clotting of your blood in times of injury, maintains the nervous system and control fluid balance in your cells. Calcium is stored in your bones for when your body needs it for remodelling of your bones. Calcium can be found in the food you eat. For example dairy foods like milk, cheese are good source of calcium. In CKD extra calcium remains in your blood. Guide line for patients on dialysis say your blood calcium level should be at the lower range of the normal limits. This means from 8.4 to 10.0 mg/dl and not higher than 10.2mg/dl.
Phosphorus: Is one of the common minerals your body formed in your bones. Like calcium a small amount of phosphorus is let out during remodelling.
Phosphorus is needed for building healthy strong bones, as well as keeping other parts of your body healthy.
It’s found in whole grains, dried beans, dairy products, chocolate, cola drinks and meats.
Normal working kidneys can remove extra phosphorus in your blood. When you have Chronic Kidney Disease (CKD) your kidneys cannot remove phosphorus very well. High phosphorus levels can cause damage to your body.
A normal phosphorus level is 3.5 to 5.5 mg/dl
Effect of excess calcium and phosphorus in your body.
When you have Chronic Kidney Disease (CKD) your kidneys cannot remove phosphorus very well. High phosphorus levels can cause damage to your body.
Extra phosphorus causes body changes that pull calcium out of your bones, making them weak. High phosphorus and calcium levels also lead to dangerous calcium deposits in blood vessels, lungs, eyes, and heart. In CKD extra phosphorus can bind with calcium to create sharp calcium phosphate crystals. These crystals can form in arteries and veins making them calcify turning them like stone. Calcification of the heart valves reduces the normal function of the blood vessels which can lead to heart failure. This can happen in your eyes, lungs and other organ. It may show up in your knobs or lumps, on top of bones, in joints or on tendons. Sometimes the crystals can harm blood vessel and cut off blood supply to a finger, tissue or a whole limb. This condition is called calciphylaxis, it can be painful and fatal. It is known that his affects about 4% of people on haemodialysis. Particularly diabetic patients are affected by this condition. It starts as red or purple skin marks (often on both legs in the same spots) they may look like bruises. The marks soon turns black as the skin dies, and turns into ulcers that grows larger and difficult to heal.
Your kidneys produces an hormone called calcitriol (Vitamin D) that helps your gut absorb calcium from the food you eat. When your kidneys fail it produces less calcitriol. This means you have less calcium than your body needs even when you eat foods that contain calcium. If your blood calcium level drops, your body will automatically pull calcium from your bone reserve. After sometime your bones become weak and feeble.
Reduced calcium in your bones and body can affect other organs in your body. One of such organs is the parathyroid glands
The parathyroid glands are four bean shaped glands situated at the back of your neck, behind your thyroid. They produce hormone called the parathyroid hormones (PTH). Its function is to help absorb calcium from your bone during remodelling of the bones. In CKD the level of calcium in your blood may drop so often due the reduce cacitriol production as mention before. When this happens your parathyroid glands kicks in over and over again to produce PTH. After a long period of time the glands become larger (hypertrophy). They can get so big that they cannot shut off. A too high level of PTH in your blood means too much calcium been withdrawn from your bone. This leads to a condition called secondary hyperthyroidism ( sHPTH ). This condition can make your bones weak and prone them to breaking at any time.
This type of bone disease caused by sHPTH is called renal osteodystrophy.
How is renal bone disease diagnosed?
Patients who are regularly on dialysis should work with their care team to test and check for signs symptoms of bone disease. Patients can report any signs of bone disease they are feeling to their doctor or nurse so it can be investigated promptly. Here are some the test your doctor may do to diagnose the disease
- X ray, ultrasound, CTscan or electron beam tomograghy (EBT) of your blood vessels to measure the amount of calcification you already have.
- An echocardiogram (echo) to see how well your heart pumps can also help.
- Your doctor will take history from you and carry out a medical examination on you
How you can control renal bone disease ( osteodystrophy)
For patients to control renal bone disease in partnership with your care team you must understand the causes of the different disease. Phosphorus and calcium is the main mineral in the body. As already mention keeping in- balance the levels of these minerals in your blood will help prevent renal bone disease. It is known that following low phosphorus and calcium diet and maintaining a healthy lifestyle by taking regular prescribed exercise will help maintain your bones for a longer period and also prevent some of the complications associated with bone disease.
Here are some of the control measures that you can follow:
- Following low phosphate diet and taking phosphate binders: This will help pull extra phosphate out of the blood. Food high in phosphate includes, chocolate and cocoa products, nuts/ peanut butter ( unless is part of protein allowance) malted drinks eg Horlicks, ovaltine, fish and edible bones eg sardines, supplement drinks like complain and nutriment. This list is not exhaustive; please speak to your renal dietician for further guidance. Some high protein foods tent to be high in phosphate. By keeping to a moderate amount of protein foods you can keep control of blood phosphate. In particular milk and milk product and cheese.
- In calcification of blood vessels doing more dialysis may help shrink the deposits. Also osteoporosis drugs like bisphosponates are known to help treat this condition. Getting more dialysis will remove more phosphate so you will need fewer binders and you can more normal diet.
- Taking gentle prescribed exercise regularly will help maintain and improve your general health and bone healthy.
- Having a kidney transplant: A new kidney will remove more excess calcium and phosphate from your blood.
Treatment of renal bone disease ( osteodystrophy )
Your doctor will work with you to treat specific bone disease once a diagnosis is made
- To treat excess phosphate and calcium in your blood your doctor will prescribe some phosphate binders. Research has found that phosphate binders based on calcium can further increase calcium to too high levels which can make your condition worse and even cause the disease to happen. Sure drugs should be avoided by your doctor. Non calcium based binders like Renagel is now commonly used.
- Active vitamin D—taken by mouth or through the vein
- Surgery called parathyroidectomy can be performed to remove most of the parathyroid glands will change the balance of calcium and phosphate in the body.
- Sodium thiosoulfate: This drug helps to pull calcium out of the body. This is usually given by injection but can also be given into to the peritoneum.
- In advanced bone damage when the limb is not healing an amputation may be done to save life.
- Antibiotic can be used to prevent infection in skin ulcers
- Kidney transplant: A new kidney will help remove excess calcium and phosphate from the blood.
Amyloidosis and kidney disease (sub link under long term effect of dialysis)
What is amyloidosis?
Is one of the long term complications of dialysis treatment that affects your bones, joint and tendons.
Proteins are important in forming and maintaining many parts of your body including muscles, bones, hair, and nails. Proteins circulate throughout the body in the blood and are normally harmless. Occasionally, cells produce abnormal proteins that can settle in body tissue, forming deposits and causing disease.
Research shows there are different kinds of proteins that can form amyloid deposits and have identified several types of amyloidosis. Two of these types are closely related to kidney disease. First is primary amyloidosis. This abnormal protein production occurs as a first step and can lead to kidney disease. Dialysis-related amyloidosis (DRA), on the other hand, is a result of kidney disease.
Primary amyloidosis occurs when the body’s antibody-producing cells do not function properly and produce abnormal protein fibres made of antibody fragments. Some people with primary amyloidosis have a condition called multiple myeloma. The antibody fragments come together to form amyloidf deposits in different organs, including the kidneys, where they cause serious damage. Injured kidneys can’t function effectively and may be unable to remove urea and other wastes from the blood. Elevated levels of these protein fibres can also damage the heart, lungs, brain, and digestive system.
Signs and symptoms include high levels of protein in the urine a condition known as proteinuria.
- Healthy kidneys prevent protein from entering the urine, so the presence of protein may be a sign that the kidneys aren’t working properly. A physician who finds large amounts of protein in the urine may also perform a biopsy—take a small sample of tissue for examination with a microscope—to confirm amyloidosis.
Current treatments are aimed at slowing the progression of amyloid build-up. Combination drug therapy with melphalan, a cancer drug, and prednisone, an anti-inflammatory steroid drug, may improve organ function and survival rates by interrupting the growth of the abnormal cells that produce amyloid protein. These are the same drugs used in chemotherapy to treat certain cancers, such as multiple myeloma, and they may have serious side effects, such as nausea and vomiting, hair loss, and fatigue.
Treating amyloidosis by transplanting the patient’s own blood stem cells to replace diseased or damaged bone marrow is a long term solution to this problem. The therapy also requires high doses of melphalan, so side effects can be serious. Patients with heart problems may not be considered for this treatment.
Normal healthy kidneys filter and remove excess small proteins including the beta-2-microglobulin (B2m ) from the blood, thus keeping blood levels normal. When the kidneys don’t work properly, as in patients receiving dialysis, one type of small protein calle beta-2-microglobulin builds up in the blood. When this occurs, beta-2-microglobulin molecules may join together, like the links of a chain, forming a few very large molecules from many smaller ones. These large molecules can form hard waxy substance and eventually gets deposited in the surrounding tissues like joints, bones, and tendons where they harm tissue and cause great discomfort. This condition is called dialysis-related amyloidosis (DRA).
DRA is relatively common in patients who have been on haemodialysis for more than 5 years. In the past haemodialysis membranes that have been used for many years don’t effectively remove the large, complex beta-2-microglobulin proteins from the bloodstream. Newer haemodialysis membranes, as well as peritoneal dialysis, remove beta-2-microglobulin more effectively, but not enough to keep blood levels normal. As a result, blood levels remain elevated, and deposits form in bone, joints, and tendons (the tissue that connects the muscle to the bone). DRA is may cause the following
- Arthritis-like pain, stiffness, and fluid in the joints.
- Joint damage
- Bone cysts that can lead to fracture
- Carpal tunnel syndrome ( wrist pain, numbness, and tingling sensations)
- Rarely DRA can also cause enlarge tongue
- Heart problems
- Cystic or soft tissue tumours
- Inflamed colon
How you can reduce the chance of you getting DRA
Two main steps can be taken to reduce the chance of harmful build of amyloidosis in your body
1) Your care team will assist you to choose a form of dialysis treatment that remove more medium and large B2m. Using newer HD membranes will help more B2m to be removed by doing daily and nocturnal HD treatment.
Getting a kidney transplant before you ever start dialysis (pre-emptive transplant) is the best option of treatment that will remove more B2m than any other form of treatment.
2) Using ultrapure water for dialysis will reduce the chance of the inflammation process that seems to make DRA occur faster. Ultrapure water for dialysis though more expensive is known to contain less endotoxin (toxic pieces of the cell walls of dead bacteria.
Other treatment options includes using steroid injection to reduce inflammation
NSAID can be used to help relief pain, care should be taken in its use as it can further reduce kidney function and cause stomach bleeding.
Having physiotherapy care help increase mobility.
New research breakthrough is on their way to improve the prevention, treatment and management of DRA. If you have amyloidosis you might want to join in the clinical trial (see www.clinicaltrials.gov )
Neuropathy (sub link under long term effect of dialysis)
Your nerves are like phone cables; they take signals to and from your body’s surface to your spinal cord (your central switchboard). When someone strokes your hand, that signal is carried by a nerve to your spinal cord. If someone pokes your hand with a tack, you feel this in a different way—and your nerves allow you to tell which is which.
Neuropathy is nerve damage. On dialysis, this most often affects peripheral nerves—in the hands and feet. Nerves can be harmed by:
- Squeezing them through a too-tight space – e.g., in carpal tunnel syndrome, nerves to the hand are compressed at the wrist
- Immune disease – that attacks the nerves
- Poor blood flow – this is more likely in the legs and feet
- Infection – such as Shingles
- Diabetes – half of people with diabetes have some degree of nerve damage
- Poisons – like lead or mercury
Besides burning, numbness, and tingling, neuropathy can cause:
- Muscle wasting in the hands and feet
- Erectile dysfunction
- Muscle weakness
Nerve damage can change sensation, so soft fur might feel prickly to you. Or, you may have nerve damage without any symptoms. It can take years to feel the damage.
Dialysis and nerves
Neuropathy in people on dialysis is quite common—from 60 to 100% may have it. In one study, a greater number of active nerves were found right after an HD treatment. It is believed that toxins that build up in the blood may poison the nerves.2
We don’t yet know which toxins are the culprits. Studies have found that high levels of potassium reduce the nerves’ ability to act; this may cause part of the problem. A middle molecule called TNF alpha has also been found in higher levels in people on peritoneal dialysis (PD) who have neuropathy than in those who don’t. So this may also be a clue.
Symptoms of neuropathy
- you may have pins and needle in your hand and/or feet
- Stabbing or shooting pains in your hands and/or feet
- Burning sensation on your hands
- Your feet very sensitive to touch
- Pains in your feet at night
Numbness or weakness:
- Numbness in your feet
- Lose of pain sensation in your feet
- Weakness of muscles in your feet and legs
- Wasting of muscles in your hands or feet
- Foot drop( having problems lifting toes when you walk )
- Unsteady on feet standing or walk
Other symptoms may include
- Open sore in your feet and legs that heal slowly
- Changes in the muscles and bones in your feet
- Men may have trouble getting an erection
If patients on dialysis have any of the above symptoms they should speak to a member of their care team about them so further investigations are carried out to allow your doctor to rule out other disease, as other condition can cause your symptoms.
Surely, the best defence is a good offense. You are best off if you can avoid neuropathy. Research has found that neuropathy mainly happens when the GFR (the amount of filtering) is less than 12 ml/min. Recent research found that neuropathy was more likely the longer someone was on standard HD—and the lower the dose of treatment. Men were more likely to have problems than women.
These findings mean that you may be able to prevent nerve damage by getting your blood cleaner with:
- Two dialyzers in sequence
- Daily HD
- Nocturnal HD
If you have diabetes, keeping your blood sugar in the target range can also help you prevent nerve damage. Ask your doctor to refer you to a nurse educator and/or dietician if you need help to manage your disease.
Once nerve damage occurs, you may need to try a number of things to get relief from the pain and numbness. Some options include:
- Get more dialysis – even if you have no nerve damage symptoms, getting your blood cleaner may help keep them from getting worse. And, it may even help them to get a bit better.
- Relieve pressure – if you have carpal tunnel syndrome, a nerve problem, you may need surgery to free up space in your wrists for your nerves to fit.
- Treat vitamin deficiencies – dialysis removes vitamin B6. Taking B6 supplements helped relieve nerve pain in people on PD and on HD. If you don’t take a renal vitamin, ask your nephrologists to suggest one.
- Treat mineral deficiencies – dialysis also removes zinc. In one random, double-blind, crossover study, adding zinc to the dialysis bath helped nerve function—and sense of taste. Before you take any kind of supplement, talk with your nephrologists and your dietician.
Pain control for neuropathy
A number of kinds of drugs have been used to treat nerve pain. As with any drug, these can have side effects; it can take time to find one that best helps you. Here are some drugs suggested:
- Over-the-counter pain pills – if your symptoms are mild, acetaminophen (e.g., Tylenol®) or an NSAID (e.g., Motrin®, Aleve®, Advil®) may help. NSAIDs can reduce your remaining kidney function.
- Capsaicin cream – products based on the ingredient that gives chili peppers their heat can help nerve pain. You rub them on the skin (and keep the cream away from your eyes).
- Antidepressants – low doses of some tricyclic or SSRI antidepressants can help pain (and sleep problems) along with depression.
- Lidocaine patch – if your pain is mostly in one place, a skin patch with a topical anaesthetics may help. You may need to use a new patch up to three times per day.
- Anti-seizure drugs – some drugs in this class, such as Neurontin® (gabapentin), Tegretol® (carbamazepine), Dilantin® (phenytoin), and Lyrica® (pregabalin) may help relieve some nerve pain. These drugs are very strong and have many side effects.
- Other drugs – a heart rhythm drug called Mexitil® (mexiletine HCl) may help burning pain. This drug can worsen heart failure.
- Prescription pain pills – opiate drugs like codeine, morphine, or oxycontin may relieve pain, but can cause addiction.
Non-drug options for nerve pain
If you have tried drugs—or you don’t want to—here are some suggestions and other options:11
- Acupuncture – very thin needles are used to stimulate vital energy in the body. You may need a few treatments, and they can be costly.
- Hypnosis – while you are in a light trance, you are given suggestions to help you feel less pain.
- Relaxation – tensing your muscles can make your pain worse. A gentle form of Yoga, Tai Chi, meditation, or guided imagery may help you learn to relax.
- TENS – a small machine sends electrical pulses to help block the path of nerve pain through your skin. It is safe and painless and may help.
Neuropathy is common in dialysis, but you can take steps to prevent it or to treat it once it happens. If you are not doing longer or more frequent HD, you may want to think about trying one of these treatments.
If you have neuropathy, it may take some time to find your way to a treatment that helps you, but there are a number of options you can try. Talk with your doctor to be sure you are doing all you can to keep your nerves healthy.