The more you know about kidney failure and dialysis, the better you will be able to help take care of yourself.  Education helps you function as a vital member of the treatment team.  Learning about your disease and its treatment helps you to make wise choices in taking care of yourself.  Education helps you understand the why behind your treatment. Those who learn as much as they can about their disease process and treatment needs, who make sure they get enough dialysis, and take the right medications at the right time may avoid health problems later.  Education can help you take control of your treatment and your life.  Even if you have been on dialysis for a long time you can benefit from learning about new techniques, medications, and rehabilitation opportunities.  

Blood Pressure Control	Infection Prevention
Diet	Anemia Management
Fluid Restrictions	Bone Disease
Adequacy	Influenza vaccine
Medications	Pneumococcal Polysaccharide vaccine
Helpful Links	Hepatitis B vaccine

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Normal blood pressure primarily depends on what is normal for a particular person but in general, high blood pressure (hypertension)  is considered to be anything greater than 140/90.  High blood pressure stresses the body over time and can lead to serious conditions such as stroke, congestive heart failure, myocardial infarction (heart attack), or cardiomyopathy.  It is sometimes called the silent killer because it can exist without symptoms until irreparable damage has been caused.

High blood pressure is the second most common cause of kidney failure.  Those who did not have high blood pressure before they developed kidney failure frequently develop high blood pressure after their kidneys have failed because helping to maintain a normal blood pressure is one of the jobs that healthy kidneys perform.

High blood pressure does not always cause symptoms.  You need to check your blood pressure to  know if you have high blood pressure.

Low blood pressure exists when there is not enough pressure to maintain normal circulation of the blood throughout the body.  Symptoms of low blood pressure may include:

• Dizziness
• Fainting
• Vomiting
• Rapid heart beat

You can help control your blood pressure by:

• Restricting the salt that your eat.  Don’t salt your food and avoid foods high in salt.
• Restricting the amount of fluids that you drink.
• Taking your blood pressure medicine as prescribed by your doctor.  You may need to wait some period of time until after your dialysis treatment to take your blood pressure medicine on dialysis days.   

Diet
One of the key things that you can do to stay healthy is to eat a sufficient amount of high biologic protein. Your body uses protein for many purposes including to build and repair muscle and other tissues and to make antibodies to fight disease.  Eating too little protein may cause weight loss, muscle loss, weakness, fatigue, and poor wound healing.  Eating too much protein may cause nausea, vomiting, fatigue, confusion, and increased serum potassium.  The goal is to have an albumin level of 4.0 gm/dl or higher. 

Foods to include that are high in protein include:

red meat poultry fish seafood

pork veal lamb eggs

Dairy foods and beans are high in protein but also are high in phosphorus and should be eaten in sparingly.

Sodium

Sodium should be avoided because it can cause fluid retention which can lead to congestive heart failure.  Sodium also makes you feel thirsty which can make you drink more than you should.  Foods to avoid include:

• table salt
• canned goods
• processed meats
• salted snacks
• soy sauce

Never use salt substitutes because they are high in potassium.   

Phosphorus

Phosphorous is a mineral that is not removed well by dialysis.  A high level of phosphorus in your blood will contribute to bone disease over time.  This may lead to muscle weakness, fractures, pain, itchiness, and calcium/phosphate deposits throughout the body, including the major organs and blood vessels.  Phosphorus can be controlled by restricting foods that are high in phosphorus and by taking binders to prevent the phosphorus you eat from being absorbed from your intestinal system into your blood.  The goal is to have a phosphorus level between 2.5 and 6mg/dL.  All dairy products contain phosphorus and should be eaten sparingly. 

Foods to avoid completely include:

• Colas
• Dried beans
• Nuts and seeds
• Peanut butter
• Whole grain cereals

Potassium

Potassium is the most dangerous mineral commonly found in food for people with renal failure because too much potassium in your blood can cause the heart to suddenly stop beating.  There may be times of blizzard or other disaster when your doctor may prescribe a medication, kayexalate, which can be taken by mouth to reduce the amount of potassium in your blood. 
A potassium level that is too low is also not healthy and may cause muscle weakness and irregular heart rhythms.  The goal is to have a potassium level between 3.5 and 5.5 meq. 

Foods that are high in potassium include:

• Potatoes
• Tomatoes
• Dried beans
• Greens
• Oranges
• Bananas
• Melons
• Dried fruit
• Salt substitute  

Things you can do to help you limit your weight gains include:

• Limit your fluid intake to 1 quart (32 ounces) a day.
• Suck on ice rather than drinking water between meals.
• Remember to count foods that are liquid at room temperature, such as ice cream, and watery foods, such as soups, as part of your fluid intake.
• Remember to include the water you use to take your medication in your daily total fluid allowance.
• Avoid salty foods.

If you gain too much fluid between your dialysis treatments you may notice:

• Swelling in your feet, legs, hands and face
• Shortness of breath
•  Headache

It is not healthy to overload your body with fluid on a regular basis.  Fluid overload is very stressful for your heart.  The dangers from fluid overload include:

Congestive heart failure (too much fluid in your circulatory system causes your heart to enlarge and weaken)

• Pulmonary edema
• High blood pressure 

Your doctor determines your estimated dry weight which is the weight you would be if your kidneys were working normally.  When you are at your dry weight, you feel just right and you are not too dry and not too wet.  Your estimated dry weight is the weight used to calculate how much fluid to remove during each dialysis treatment.  The difference between your pre dialysis weight and your estimated dry weight is your fluid weight.  Your estimated dry weight needs to be adjusted whenever you gain or lose actual body weight.  You will be able to feel changes in your body and should alert your doctor or dialysis staff if you think your estimated dry weight needs adjusting.

Your estimated dry weight should be:

• Lowered - if you reach your dry weight but still any have signs of fluid overload such as high blood pressure congestive heart failure.

Your estimated dry weight will also need to be lowered if you lose muscle mass.

• Raised - if you do not gain too much weight between treatments and develop low blood pressure, dizziness, or cramps during or after your treatment. This will happen if you get stronger and have gained muscle mass. 

Adequacy
Adequate dialysis is necessary to keep you healthy.

Adequate dialysis may help you have energy, sleep well and have a good appetite.

Inadequate dialysis may make you feel weak and tired, feel nauseated and lose your appetite, feel swollen, have a bad taste in your mouth, and to have nerve damage. 

Your monthly blood work is used to check how adequate your dialysis is.  One of the waste products removed by dialysis is urea.  Two blood tests are used to show how well urea is being removed from your body during your dialysis treatments, KT/V and URR.  These are complex formulas which are calculated monthly from your lab tests.  Your KT/V should be 1.2 or higher and your URR should be 65% or higher.  Your albumin level is also measured to show your nutritional state.  It should be 4g/dl or higher. 

When you first start on dialysis, your kidneys may still have residual renal function which means that they are still working a little.  Residual renal function will help to clean wastes from your body.  As your kidney function decreases with time, you may need more dialysis to clean your body adequately.  You doctor may change your dialysis prescription to give you adequate treatments.

Some of these changes could be:

• Increase the size of the dialyzer
• Increase the blood flow or dialysate flow rate during dialysis
• Increase the amount of time you are on the dialysis machine
• Check that your access is working correctly

Having your arterial and venous needles placed too close together can decrease the adequacy of your dialysis treatment.  Your arterial needle and venous needle should be inserted at least two inches apart.  If they are too close together, some of the blood that has just been cleaned and is being returned to your body through the venous needle will be drawn back into the arterial needle and the freshly cleaned blood is passed through the dialyzer again.  This is called recirculation and will make your dialysis treatment less adequate. 

Some things you can do to assure that your have adequate dialysis include:

• Remain on dialysis each treatment for all of the prescribed treatment time. 
• Avoid excessive weight gains between treatments to help prevent low blood pressure and cramps during treatments.  (Low blood pressure and cramps are a frequent reason for cutting treatment times short.)  

Do not eat immediately before or during dialysis because eating can cause low blood pressure and vomiting during your treatment. 

 

•  Lower your blood pressure
• Prevent anemia
• Keep your bones healthy
• Relieve itching or restless legs
• Replace vitamins
• Keep your blood from clotting
• Prevent constipation, indigestion, or gas

It is important to take your medication as prescribed by your doctor.  Do not take over-the-counter medications unless you check with your doctor when you come for dialysis.  Many medications are metabolized, broken down, or excreted by the kidneys and may not be eliminated from the body well when you have kidney failure.  People on dialysis may need to have different doses of medications than those who have normally functioning kidneys.  Some medications may contain substances that can build up to dangerously high levels that can not be removed by dialysis.  Two of the most common ingredients in over the counter medications that may accumulate in dangerous levels for people on dialysis are aluminum and magnesium.  For example, you should not take medications such as Maalox, Milk of Magnesium, or Alutabs without consulting with your nephrologist.  

It is important to bring in your medications to the dialysis unit every month to review them with your doctor and nurse.  This permits an accurate record to be maintained of all the medications that you are taking, especially if you regularly see more than one doctor, have been hospitalized, or had your medications changed for any reason.  Reviewing your medications with your doctor and nurse also makes sure you understand medications, their purpose, and how to take them properly. 
 
Infection Prevention
Patients on dialysis have an altered immune system which means that they can get sick more easily than before.  This means that your body will have a harder time fighting off infection.

You can do several things to help prevent infections:

• Avoid large crowds and stay away from people who are sick with contagious conditions, like colds. Tell your nurse or doctor if you develop any signs of infection such as redness, swelling, drainage, pain, fever or chills so that you can be treated promptly. 
   
• Take good care of your dialysis access.  Wash your access site before dialysis.  Wear a mask during initiation and termination of your treatment if you have a catheter. Wear a glove if you hold your own sites after treatment and remember to wash your hands with antibacterial soap when you are finished.
   
• Take the vaccines that are offered by your dialysis unit.  The flu vaccine is offered every year in the fall. You will be checked for immunity to Hepatitis B and will be offered a series of vaccinations for Hepatitis B if you are not immune. You will also be offered the Pnuemovax vaccine.  Please read the attached Vaccine Information Statements from the Center for Disease Control to learn more about these vaccines.
   
• Check feet daily, especially if you are diabetic, and notify your doctor immediately if there are any sores or signs of infection, loss of feeling, or changes in the shape of your feet. People with diabetes are especially prone to foot problems and should see a podiatrist regularly.
   
• Have an annual dental exam.  Have an annual rectal exam and a colonoscopy every 5 years after you turn 50. Women should have a pelvic exam with pap test and a mammogram every 2 years.

Anemia Management
One of the jobs of healthy kidneys is to secrete a hormone, erythropoietin, which stimulates your bone marrow to make new red blood cells.  When kidneys fail and the production of erythopoietin falls, your bone marrow in your hip and breastbone stop making enough new red blood cells which results in a condition known as anemia.  One of the jobs of red blood cells is to carry oxygen to the tissues and to return carbon dioxide to the lungs to be exhaled.  Without enough of these cells, you are considered anemic.  Symptoms of anemia include feeling:

• Very tired
• Short of breath
• Cold

Your hemoglobin is a measure that indicates the number of red blood cells in your blood.  The goal is to maintain your hemoglobin between 11 and 12 g/dL.  It is important to report any sign of bleeding anywhere in your body to your doctor since bleeding will increase your risk of becoming anemic.

There are two common medications used to control anemia.  The first is Epogen, which is used to replace the erythropoietin that your body needs to stimulate your bone marrow to make blood cells.  Infections anywhere in the body can prevent Epogen from working properly and must be treated promptly.  Epogen can be given either intravenously or by subcutaneous injection during your dialysis treatment.  The second common medication to control anemia is IV iron, which is a necessary part of the red blood cell.  Kidney failure can lead to changes in the gastrointestinal system which makes it difficult to absorb iron from food and supplements.   Iron can be given to you as a prescription to be taken by mouth but it may be poorly absorbed or cause upset stomach or constipation.  To prevent any of this, it can be given to you in the intravenous form during your dialysis treatment. 

Please read the attached information on Epogen provided by manufacturer of this medication. 
 
Bone Disease
The texture of your bones relies on good control of your calcium and phosphorus balance and control of parathyroid gland activity.  When you develop renal failure, phosphorus levels begin to rise because the failing kidney cannot excrete phosphorus.  And, dialysis does not remove phosphorus from your blood well.  A high phosphorus level causes the parathyroid gland in your neck to be stimulated and to produce a higher level of parathyroid hormone (PTH).  A high phosphorus level also causes changes in calcium levels because calcium binds with the extra phosphorus.  This combination of calcium and phosphorus can be deposited in blood vessels and other body tissues which may lead to amputations and death.  It can also cause generalized itching and pain.  Your phosphorus level goes up, calcium level goes down, and PTH goes up.

Often what happens is a vicious cycle of high phosphorus causing a low calcium, both of which cause an increase in the level of PTH.  PTH goes to bone tissue and causes calcium and phosphorus to be removed from bone, mostly in an effort to raise the calcium level.  The loss of these minerals from the bones makes them brittle and likely to break easily.  Unfortunately, since calcium and phosphorus are bound together in the bone, calcium cannot be released without phosphorus.  And so, we go round again. 

There are some drugs, which are primarily IV Vitamin D preparations, which can be very helpful in reducing the levels of PTH.  Unfortunately, these medications cannot be used if the phosphorus level is too high.  If the phosphorus level is too high, calcium binds to it and is deposited in the tissues.  This causes the calcium level to fall and the PTH to increase.  Back into the vicious cycle. 

So, what can you do?  First, find out what your numbers are.  If your PTH level is higher than 200, you may be a candidate for Vitamin D therapy.  Your phosphorus level must be 7.5 or below and your calcium/phosphorus ratio must be 75 or below in order to receive Vitamin D therapy. 

In order to control your phosphorus level you must make educated choices about your diet and avoid foods that are high in phosphorus.  Phosphorus binders are essential with every meal or snack.  Even some soft drinks contain phosphate and binders should be taken with them.  You can increase the effectiveness of the binders by taking them regularly 10 – 15 minutes before eating.  To be effective, binders must be in your stomach as your food starts to digest because they literally “bind” to the phosphorous and prevent it from being absorbed into our blood.  The phosphorous and the binder stay in your intestine and are eliminated with your bowel movement.  It is important to know that phosphorous binders also “bind” with iron.  So, if you are taking an oral iron preparation, you must not take it at meals with your phosphate binder because you will not be able to absorb the iron into you blood. 

In addition to taking your binders regularly, you should limit the foods that are high in phosphorus so that you put less phosphorus into your body in the first place.  Your renal dietitian will review your lab values with you every month and if your phosphorus level is high, will help you identify what you can do to get your phosphorus levels under control.

Bone disease resulting from kidney failure happens slowly over time and often there are no obvious problems until it is well advanced.  It is important to control your phosphorus levels and PTH levels in order to remain healthy as the years on dialysis go by.