12 Golden Rules of Kidney Care

No. 1 Kidney Support Services
No. 2 Kidney facts
No. 3 Kidney function
No. 4 Diagnosing CKD
No. 5 Monitoring CKD
No. 6 Causes of CKD
No. 7 Diet
No. 8 Anemia
No. 9 High Blood Pressure
No. 10 Bone Disease
No. 11 Acidosis
No. 12 Cardiovascular Disease
No. 1
CKD Clinic
An intensive personalized approach to kidney care.
Program goals:
√ Improve & preserve kidney function
√ Slows loss of function.
√ Reduce medical complications associated with disease
√ Preparation for dialysis or  transplantation
Meet your CKD team:
Your nephrologist
KSS nurse practitioner
Registered dietician
Medical assistant
Your coordinator
No. 2
The Kidneys
Kidney Facts:
Weigh about 4 ounces each 
Each is approximately the size of a fist
Each contains about 1 million nephrons and 140 miles of tubules
The filtering unit of the kidney is called the nephron. Within the nephron, blood is filtered & cleaned through a network of vessels called the glomerulus. Inside the nephron are tubules where waste becomes urine. Urine then travels from the kidney down the ureter to the bladder where it is stored until eliminated.
No. 3
What the Kidneys Do
√ Filter blood, removing waste
√ Balance body fluid
√ Produce erythropoietin (EPO), a hormone needed to make red blood cells
√ Produce renin, an enzyme to help control blood pressure
√  Activate vitamin D to maintain healthy bones
The kidneys are like ‘worker bees’ & they do much more than just produce urine. Kidneys filter & clean all of your blood every 5 minutes. About 200 quarts of fluid are filtered & returned to the body every 24 hours. Only about 2 quarts are eliminated as urine.
When They Don’t Work
X Changes in urination: urinating at night, less often, in smaller amounts, darker in color, foamy, blood in urine or difficulty producing
X Swelling in legs, ankles, feet, face or hands
X Bad taste in mouth or food tastes different.
X Fatigue
X Itching
X Nausea & vomiting
X Shortness of breath
X Feeling cold/chilled
X Dizziness & trouble concentrating
No. 4
How Do I Know if My Kidneys Are Working?
Creatinine is a waste product made by muscles, released into your blood & filtered by your kidneys. When kidney function declines so does the ability to filter creatinine correctly. Therefore, creatinine levels measure basic kidney function. The measured outcome is assigned a number known as the estimated glomerular filtration rate (eGFR).
At Risk
High blood pressure
Family history of kidney disease
Advanced age
No. 5
Monitoring CKD
Common Lab Tests
Kidneys are important to the balance of these substances.
Creatinine – A waste product of muscle activity.
Blood Urea Nitrogen (BUN) – A waste product of protein breakdown.
Sodium, Potassium, Chloride & Bicarbonate – Common electrolytes which are essential to life
Hemoglobin & Hematocrit – Red blood cell count used to determine anemia
Calcium, Phosphorus, iPTH & Vitamin D – Important to healthy bones & heart
At each visit report the following:
All medications: prescribed, OTC, vitamins, herbals & supplements
Record of blood pressures & blood sugars
Weakness, dizziness, confusion
Breathing difficulties
Decrease in appetite
Nausea or vomiting
Abnormal bleeding
No. 6
Causes of CKD
(1) Diabetes Mellitus
It causes nearly 40 -50% of new CKD cases each year. The body does not produce enough insulin or use it properly. Insulin is an enzyme needed for cells to convert glucose to energy. Without insulin, sugar remains in the bloodstream, causing damage to blood vessels. Damaged vessels in the kidneys allow protein to be eliminated.
(2) High Blood Pressure
Is the second leading cause of CKD. It causes damage to blood vessels throughout the body. This pressure & stress within the blood vessels in the kidneys can damage the nephrons. This damage activates renin production, resulting in fluid overload, increased blood pressure & nephron loss.
(3) Glomerulonephritis
A disease of the kidneys in which the kidneys’ 
filtering units become 
inflamed. They slowly lose their ability to filter fluid & waste. If not treated this can lead to scarring, loss of kidney function, high blood pressure & kidney failure.
No. 7
Why Diet is Important
Protecting & prolonging kidney function is our goal and yours. Proper diet & nutrition is an important part of kidney care.
Keep a food diary                 
This gives dieticians a snapshot or your eating patterns.
Limit protein
Too much protein can harm your kidneys. Proper balance is essential.
Limit your sodium                
Excess sodium can increase fluid, swell body tissue & elevate blood pressure.
Limit your potassium
It can control smooth muscle, but it can also change muscle function, namely heart muscle.
Maintain a balance of calcium & phosphorus
The correct balance is required for bone health and to prevent calcium deposits in blood vessels.
No. 8
Normal kidneys produce the hormone EPO needed to stimulate bone marrow to make red blood cells. In contrast, unhealthy kidneys cannot make enough EPO. Fewer red blood cells result in anemia.
Untreated, anemia forces the heart to work harder to get needed oxygen to the body. Over time, the heart muscle becomes 
damaged & heart disease develops.
Feeling weak, fatigued or tired
Shortness of breath
Rapid heart rate
Pale skin
Inability to think clearly
Anemia of CKD is treated with synthetic EPO injections and/or oral iron, or infusions of intravenous iron. These injections are administered at the KSS clinic. Blood values are monitored & medication doses adjusted to correct anemia. 
No. 9
High Blood Pressure
American Heart Association Blood Pressure Guidelines
Normal 120/80
Pre-Hypertension 120/139-80/89
Stage 1 140-159/90-99
Stage 2 160/100>
Diabetes keeps blood pressure below 
Angiotensin Converting Enzyme inhibitor (ACEi)
Angiotensin Receptor Blocker (ARB)
These medications both help decrease the pressure in the glomerulus, which reduces protein loss & slows the progression of kidney dysfunction.
Other Contributors              
Smoking–If you smoke, please quit
Sodium–Reduce your intake & monitor
No. 10
Bone Disease
Calcium & Phosphorus
Calcium and phosphorus work closely together to build and maintain strong bones and teeth.
Renal Osteodystrophy 
This form of bone disease is caused by an increase in parathyroid hormone(PTH) & secondary hyperparathyroidism. 
Left untreated:
• Weak, brittle bones
• Joint pain
• Itchy skin
• Major organs (heart, blood vessels) can develop calcifications (hard deposits)                              
• Death
Abundant in foods, dietary adjustments may be required for phosphorus intake & phosphorus binders may be prescribed. Additionally, vitamin D supplements may be required to maintain strong bones & keep the parathyroid functioning normally.
No. 11
Many CKD patients develop metabolic acidosis as a result of a reduced ability to eliminate the hydrogen waste of protein.
Acidosis is connected with worsening bone disease. It can increase the breakdown of skeletal muscles & decrease protein production. This may contribute to a protein malnourished state in people with CKD.
Metabolic Acidosis Symptoms:
√ Headache
√ Lack of energy
√ Sleepiness
√ Rapid, shallow breathing
√ Nausea & vomiting
√ Diarrhea
√ Dehydration
√ Loss of appetite
√ Fruity smelling breath
√ Disorienation
√ Loss of consciousness
Testing & Treatment
A blood bicarbonate level (CO2) <22 mEq/L indicates a need to treat the metabolic acidosis. Treatment begins with sodium bicarbonate or sodium citrate. Because of the sodium in the treatment, a diuretic (water pill) may be added.
No. 12
Cardiovascular Disease
Also called heart disease, cardiovascular disease involves the heart or blood vessels and contributes to heart attack & stroke. CKD patients are more likely to develop CV disease than others & it is the most common cause of death for CKD patients.
Anemia makes the heart work harder to supply oxygen to organs. High blood pressure stresses both heart & blood vessels. Bone disease can lead to hardening of heart & blood vessels. Diabetes can damage the entire body, including the heart.
Additional Complications 
Elevated blood lipids (fats) are common in patients with diabetes, high blood pressure & CKD. These lipids contribute to blood vessel plaque. 
Left ventricular hypertrophy (LVH) can occur due to stress of increased fluid levels, high blood pressure, anemia & narrowed, hardened vessels. 
Enlargement of the lower left chamber of the heart occurs as it pumps blood to the body. Slowing the progression of CKD can reduce CV risk.
Testing & Treatment
Maintain BP <130/80
Maintain hemoglobin >10.0
Reduce protein in the urine
Treat high lipids
Control blood sugar levels