What is Alport Syndrome?

Alport syndrome is the second most common inherited cause of kidney failure. It usually affects young men, but it can affect older people and women.

What happens in Alport syndrome?

In each of the one million tiny filtering units (glomeruli) in each kidney, blood is filtered across the glomerular basement membrane (GBM). In Alport syndrome, type IV collagen, one of the proteins that makes up the GBM, is absent or abnormal. Although the GBM looks normal in childhood, it deteriorates with time because it lacks the special type IV collagen that should be there. As well as in the kidney, this special basement membrane collagen can also be found in some other parts of the body – most importantly in the inner ear and in parts of the eye.

What trouble does Alport syndrome cause?

In each of the one million tiny filtering units (glomeruli) in each kidney, blood is filtered across the glomerular basement membrane (GBM). In Alport syndrome, type IV collagen, one of the proteins that makes up the GBM, is absent or abnormal. Although the GBM looks normal in childhood, it deteriorates with time because it lacks the special type IV collagen that should be there. As well as in the kidney, this special basement membrane collagen can also be found in some other parts of the body – most importantly in the inner ear and in parts of the eye.

How is it inherited?

Alport syndrome is much more common in boys and men because the gene that usually causes it (called COL4A5) is on the X chromosome. Women have two X chromosomes (XX), so they usually have a normal copy as well as an abnormal copy of the gene. Men have only one X chromosome (XY), so if they have a problem with the COL4A5 gene, that is their only copy. Boys who inherit the disease in this way must inherit it from their mother (as the mother contributes the X chromosome and the father the Y). Women who carry the disease on one of their X chromosomes may have minor kidney trouble, such as blood or protein in the urine with high blood pressure, but occasionally get severe disease and develop kidney failure. In other families the gene involved (COL4A3 and COL4A4) is on another chromosome. In this case, men and women are equally affected, but otherwise the disease seems the same.

How is the diagnosis made in the patient and their family?

The diagnosis is usually made after kidney biopsy and from the eye and hearing changes. If someone in the family has been shown to have Alport syndrome, it is not usually necessary for everyone to go through all the tests. Sometimes doing a special test that involves looking at a sample of skin under the microscope can help, but this is a test which can only be done in some centres.

Can I have genetic testing?

There is no simple blood test for Alport syndrome. Trying to find the problem in the gene is very difficult, and it is not likely that a simple test will become available in the near future. Genetic testing is possible in a few families, where the problem has already been sorted out.

Can it be cured?

No. Complications of kidney failure can be prevented (see chronic renal failure and its progression), but the underlying problem cannot be cured.

What if kidney failure develops?

People with Alport syndrome are usually otherwise healthy and do very well on dialysis, and even better after a successful kidney transplant. Very occasionally (in less than 1 in 20 Alport transplants) kidney transplants meet with a unique problem. Because the transplanted kidney has normal type IV collagen, the immune system may see it as ‘foreign’ and attack it. This causes Alport anti-GBM disease, which is very similar to the kidney disease seen in Goodpasture’s disease. Unfortunately it usually destroys the transplant.

Please be aware that while we have made all effort to ensure that this information is accurate, we cannot guarantee that there are no mistakes. Also that the best management for individual patients may differ from that outlined here. Only the doctors caring for the patient will be able to advise on this.

Anaemia

Symptoms of Anaemia include the following:

• Tiredness
• Lethargy
• Loss of appetite
• Less able to excercise
• Possible breathlessness

Anaemia is diagnosed by measuring the haemoglobin content of your blood. Your red blood cells are partly made up of haemoglobin which contains iron. If your body isn’t making enough red blood cells your haemoglobin level will be low and your iron level will also be low.

Causes of Anaemia

Normal, healthy kidneys produce plenty of erythropoietin (EPO) which continually triggers the bone marrow to make red blood cells. With kidney failure the production of red blood cells is reduced. As a result you become anaemic.

Other Causes of Anaemia can include :

• Blood loss during haemodialysis
• Iron deficiency
• Lifespan of red blood cells shorter than normal
• Gastritis

In the short term Anaemia can be treated by giving a blood transfusion but the beneficial effect is not long lasting.

The best long term solution is in giving Human EPO (Recombinant Human Erythropoietin). EPO will gradually bring your haemoglobin levels up and once the desired level has been achieved it will be kept there.

Human EPO does the same job as your own kidneys and triggers the bone marrow to make red blood cells. Your consultant at the Renal Unit will decide if you need EPO. Your haemoglobin level and general health will be taken into account. A full blood count is carried out before embarking on EPO.

EPO is given by injection and you will be taught by a nurse how to inject yourself. It is a simple procedure and patients will be supplied with EPO in ready made up syringes with the exact dose worked out for you.

Blood Pressure and kidney Disease

High blood pressure

Blood pressure is measured often because it has important effects on the heart and circulation, and because nowadays high blood pressure (also called hypertension ) can be easily treated. The kidneys have a major influence on blood pressure and it is particularly important to monitor blood pressure whenever kidney disease is suspected.

There are three reasons for this:

• Many kidney diseases cause high blood pressure – high blood pressure is very common in people with kidney diseases
• High blood pressure can cause further damage to diseased kidneys
• People with kidney disease are at high risk of developing heart disease and circulation problems

What trouble does it cause?

High blood pressure rarely produces any symptoms at all, unless it is very high. However people with high blood pressure have more strokes and heart attacks than people with normal blood pressures, and it may damage kidneys. How often high blood pressure damages normal kidneys is uncertain, but it is probably quite rare compared to the heart disease and strokes that it causes. Kidney damage caused by blood pressure seems to be more common in some races, particularly in black people.

What causes high blood pressure?

Very often the cause of high blood pressure is not known – this is called essential hypertension , and it is the most common kind. The next most common cause is kidney disease . Diseases within the kidney itself can cause high blood pressure, and so also can disease of the artery that carries blood to the kidney. After that there is a long list of rare causes, but in fact many of these also work through the kidney. High blood pressure with one of the less common causes is more likely in young people, and in people with particularly severe blood pressure trouble.

Do I have to take tablets?

Some simple things can improve blood pressure without taking drugs. If blood pressure is only moderately raised, these may be enough on their own. They may also make that blood pressure that requires tablets easier to treat.

Salt – reducing the amount of salt that you eat can have an important effect. Most of us in Western nations eat far more than we need and it may be harmful. It is difficult to lower it a lot if you eat a lot of fast food, which is often very high in salt.

Weight – blood pressure falls if obese people lose weight

Exercise – although your blood pressure rises during exercise, regular exercise reduces average blood pressure, and is good for you in other ways as well.

Not smoking – smoking raises blood pressure, but even more importantly, the combination of smoking and high blood pressure increases the risk of getting serious problems with the arteries to the heart and elsewhere. Generally having a healthy lifestyle (exercise, diet, etc) will reduce the risk of complications from high blood pressure, as well as reducing the blood pressure itself.

What if I need tablets?

Treatments for high blood pressure have improved hugely in the last 20 years. The table shows the major types of drugs used – but these are only examples. For each type of drug, there are many alternatives, and there are some additional types of drug not mentioned in this short list of commonly used drugs.

Type of drug	Examples	Comments
Diuretics	Bendrofluazide (bendroflumethazide)	Cause the kidneys to lose more salt and water. Simple and usually cause few or no side effects
Beta-blockers	Atenolol	Cannot be used in asthmatics, or in those with very poor circulation, but well tested and proved
ACE inhibitors	Ramipril, enalapril	Particularly effective in kidney diseases, especially if there is much protein in the urine, e.g. diabetes. Cause high potassium and worsening kidney function in some people; blood tests needed. Sometimes cause cough but very few other side effects
AIIR antagonists	Irbesartan	Similar to ACE inhibitors; can be used if ACE inhibitors cause side effects (e.g. cough) but also require blood tests
Calcium channel blockers	Diltiazem, nifedipine	In kidney disease these are usually added to other therapy when the pressure is still not low enough
Alpha-blockers	Doxasosin	Again useful as a second or third drug when blood pressure is difficult. Also used in prostate enlargement
Centrally acting drugs	Methyldopa, moxonidine	Methyldopa is used less nowadays because it sometimes has side effects, but it is known to be safe in pregnancy

How low should my blood pressure be?

As the years have gone by, it has been found that lower and lower blood pressures are better for preventing some complications of high blood pressure. In kidney disease this is particularly true. Really low blood pressures seem to protect the kidney from further damage in many diseases. Unfortunately this often requires more than one drug to achieve it – sometimes up to four or even more.

For people with poor kidney function , or at risk of developing it, a currently recommended MAXIMUM blood pressure is 130/80 . If there is a heavy protein leak from the kidney, this should be lowered to a maximum of 125/75 .

All patients are different though, and the type of kidney disease, or the presence of other diseases, or age may lead to recommendation of different target blood pressures – either upwards or downwards from the figures mentioned.

What if I get side effects?

No effective medicine can be completely free of side effects. However drugs nowadays are much better, and the number of different types of treatment available means that almost everyone can find something that suits them well. Sometimes it may be worth tolerating mild side effects if the benefit is worth it.

Most packs of blood pressure medication now come with a frightening list of possible side effects. Mostly these will be rare side effects that you are unlikely to get. However you should discuss any problems that you think could be caused by treatment with your doctor. Often these will not be related to the treatment, but sometimes it is difficult to know.

Can I stop the tablets?

Usually you will need to remain on treatment ‘for ever’. It is important therefore to find treatment that suits you as well as possible. However there are a few kidney diseases where treatment of the disease may improve the blood pressure so that you can stop some drugs. Things often change with time, and you may need more or less treatment, or different drugs. If your kidneys fail completely and you start dialysis, you may need less treatment , because dialysis alone may control the blood pressure. Most people would prefer to prevent their kidneys getting this bad, if they could.

Cystitis and Urine Infections (UTIs)

Urinary Tract Infections ( UTI ) are infections in the urine, anywhere from the kidneys to the bladder. They are very common.

DefinitionsCystitis is infection of urine in the bladder. Most people pass small amounts of urine much more frequently than usual, and painfully (‘burning’). There may be lower abdominal pain and sometimes other symptoms too. Urine may be cloudy and smelly. In young children it may be difficult to spot though, and they may just have a fever and be unwell.Pyelonephritis is infection in the kidney. This is a much more serious infection, which causes fevers, pain in the loin (the low back, on either side of the middle), and usually (but not always) there are symptoms of cystitis as well.

Why am I getting urine infections?

Women are much more likely to get cystitis and other urine infections than men. This is usually blamed on the shorter distance to the bladder in women. However some women get lots of infections, while others get hardly any at all. Cystitis is very common. About 1 in 3 women have a urine infection at some time in their life, and it is common to have many.

Things making urine infections more likely

• Females – see above
• Infancy – boys and girls under 1 year get more urine infections
• Sexual intercourse – makes urine infections more common in women
• Pregnancy – makes urine infection even more common in women
• Reflux – when urine travels up the ureter towards the kidney – further information
• diabetes – because sugar in the urine helps bacteria to grow
• tubes, stones, or anything ‘foreign’ in the bladder or urinary tract
• abnormal urinary tract – congenital or other abnormalities
• incomplete bladder emptying – because bacteria aren’t ’emptied out’ properly – eg with prostate gland enlargement in men

What tests should I have?

Before you receive antibiotics, a urine sample should be sent to prove infection and identify the bugs responsible for it. This is collected as an MSU , which stands for Mid-stream Sample of Urine . For these to be reliable, they should be collected properly. Other tests are usually only worthwhile if the infections occur unexpectedly (eg in young men), or are particularly frequent or severe. These tests will be to look for any of the things that make urine infection more likely (see above).

What is the treatment?

Antibiotic tablets usually cure cystitis very quickly, and should be taken for several days to reduce the risk of the infection coming straight back again. Infection in the kidney, or if there are other complicating factors, requires longer treatment. You should continue to drink plenty of liquid (enough to keep the urine light coloured) during and after the infection.

It is necessary to send a urine sample (MSU, see above) to be certain that you are receiving an antibiotic that will kill the bugs responsible for the infection. Different bacteria need different antibiotics.

What can I do to prevent them?

Women Many things are recommended for women who have frequent infections, and some of these are sensible.

The most important things are probably:

• Keep plenty of fluid going through to ‘wash out’ the system – drink plenty
• Empty your bladder last thing at night, and after sex

Beyond these simple things, the best evidence for a ‘non-medical’ treatment is for cranberry juice. Something in cranberry juice (if you drink some every day) helps to reduce the number of infections. Reflux If you have reflux , ‘double emptying’ is sometimes recommended. This means that after emptying your bladder, you should go again 10-15 minutes later to empty the tiny extra amount that has collected. Antibiotics If other measures don’t work, a single night-time dose of an antibiotic is often helpful. However it is best to avoid this unless really necessary.

Should all urine infections be treated with antibiotics?

Not necessarily. Some people find that the early symptoms of cystitis disappear if they drink a lot, and if they do, then that is OK. Some people have bugs in their urine without having any symptoms, or coming to any harm. Antibiotics are then often unnecessary, although there are some exceptions, for example:

• in pregnancy
• in some patients with abnormalities in their urinary tract

I get symptoms of cystitis but the samples don’t show infection. This can have a number of explanations.

Here are some:

• antibiotics have prevented the sample from coming out positive
• it is an ‘ordinary’ type of infection, but a problem with urine sampling or delivery of the sample to the lab has led to it being missed.
• the infection is caused by an unusual bug that the lab can’t grow using ordinary methods (there will usually be other signs of infection in the sample though; white blood cells, for instance)
• it isn’t infection, but irritation of the bladder or urethra (the tube from bladder to the outside) caused by something else. In women this may be caused by soap or shampoo or other causes of irritation or inflammation.

In most cases where samples don’t show infection, antibiotics will not help.

Please be aware that while we have made all effort to ensure that this brief information is accurate, we cannot guarantee that there are no mistakes. Also that the best management for individual patients may differ from that outlined here. Only the doctors caring for the patient will be able to advise on this.

Diabetic Nephropathy

What is diabetic Nephropathy?

Diabetic nephropathy is the kidney disease that occurs as a result of diabetes. It is a leading cause of kidney failure in Europe and the USA. After many years of diabetes the delicate filtering system in the kidney becomes destroyed, initially becoming leaky to large blood proteins such as albumin which are then lost in urine. This is more likely to occur if the blood sugar is poorly controlled.

1 . It begins with a tiny amount of protein appearing in the urine – this is called microalbuminuria
2 . Over 10-15 years proteinuria increases, and nephrotic syndrome may develop
3 . With the development of proteinuria, the kidneys’ ability to remove poisons from the blood deteriorates such that 5-10 years later the kidneys are almost completely unable to remove these poisons from the blood.
4 . This is called ” e nd- s tage r enal d isease” ( ESRD ), and, unless treated, the poisons can build up to fatal levels.

Do all diabetics develop nephropathy?

The overall risk of developing diabetic nephropathy varies between about 10% of type II diabetics (diabetes of late onset) to about 30% of type I diabetics (diabetes of early onset). There are many factors, some known and others not, that affect the individual risk of developing diabetic nephropathy. Some of the factors that are known to increase the likelihood of getting diabetic nephropathy include:

• Indo-Asian or Afro-Carribean background
• Male
• Relatives have had kidney disease or high blood pressure
• Diabetes began in teens
• Blood sugar control is poor
• High blood pressure
• Smoking

Will I need a kidney biopsy?

Given the relatively predictable nature of diabetic nephropathy , a kidney biopsy is usually not needed. You will be evaluated by history, examination, as well as blood and urine tests and a kidney ultrasound examination. If there are unusual features, then further investigations may be needed to define the kidney condition, and this may well involve a biopsy.

Does diabetic nephropathy have any other effects?

High blood pressure almost always develops or worsens in diabetic nephropathy, and can be the first abnormality to develop. Diabetic nephropathy is also a sign of worsening blood vessel disease throughout the body. Diabetic eye disease is usually present by this stage indicating damage to smaller blood vessels. Larger blood vessels (arteries) are almost always affected leading to heart attacks, strokes, and circulatory disease occurring more often and at a younger age than usual. Commonly diabetes will have also resulted in damage to small nerves causing “diabetic peripheral nephropathy” and “autonomic neuropathy”.

What can be done to reduce the risk of problems?

Blood glucose control: Good blood glucose control can prevent the development and slow the progression of diabetic nephropathy, as well as preventing the other complications of diabetes, even if kidney failure has developed. This can not be achieved by tablets and/or insulin alone, but requires a good diet too. Achieving these things will involve discussion with doctors, nurses and dieticians.

Blood pressure control: The recommended target blood pressure is 125/75 mmHg in diabetic patients. This usually requires more than one type of tablet to achieve. If you are overweight, losing weight will help too.

Using ACE inhibitors and AT II antagonists: Two classes of drug used to control blood pressure deserve special mention. These are the A ngiotensin- C onverting E nzyme ( ACE ) inhibitors and a ngio t ensin II ( AT II ) receptor antagonists. Many studies have documented the greater potency of ACE inhibitors at reducing proteinuria and the progression of kidney disease compared to other classes of drug. These drugs not only reduce blood pressure in the large blood vessels, but also directly in the kidneys’ filtering system (called glomeruli). Although these drugs tend to be preferentially used, they need to be monitored as they may have a detrimental effect on some people. It is thought that AT II receptor antagonists will have a similar effect, and these are often used in those unable to tolerate ACE inhibitors.

Diet: A modest reduction in dietary protein intake may be of benefit in those who already have kidney impairment. However this is a controversial and uncertain area, because the effect may be small if other things are well controlled, and low protein diets can be hazardous. Many (eg the American Diabetic Association) recommend moderate restriction of dietary protein. Other aspects of diet (including energy, calcium and phosphate intake) are important in renal failure, and the assistance of a renal dietitian is usually required.

Controlling blood lipids and cholesterol: Although the role of lipid-lowering is unclear in the course of diabetic nephropathy, it helps to prevent heart disease and possibly strokes. Lowering blood lipids requires both dietary and drug treatment, with the current available data pointing towards a target cholesterol of 5.2mmol/l.

Smoking: You really shouldn’t smoke, not only for the sake of your kidneys, but also for the sake of your heart and brain blood vessels. Smokers die earlier than non-smokers, but diabetic smokers die much earlier and often develop serious circulation problems at a young age.

What is the treatment?

 

Stage	Assessment	Treatment
No proteinuria	Monitor blood pressure (BP) Monitor blood glucose Screen for microalbuminuria if type I diabetic for over 5yrs, or type II diabetic	Aim under 130/85mmHg Aim HbA1c under 7% Dietary advice for sugar and fat STOP SMOKING
Microalbuminuria	Close monitoring of blood pressure, blood glucose, and blood lipids. Monitor urinary protein and 24 hour creatinine clearance (measure of kidney function)	Add further blood pressure lowering drugs if needed Aim total cholesterol under 5.2mmol/l Add ACE inhibitor if possible
Proteinuria	Close monitoring of blood pressure, blood glucose, and blood lipids. Monitor urinary protein and 24hr creatinine clearance	Aim BP <125/75mmHg Low protein diet
Declining kidney function	–	Prepare for dialysis and/or transplantation

Key Points

• Diabetic nephropathy does not occur in all diabetics.
• The risk of diabetic nephropathy is greater when the control of blood glucose is poor, as well as in those diabetic patients who have high blood pressure and are smokers.
• Diabetic nephropathy is a sign of worsening blood vessel disease throughout the body, and is associated with an increased risk of heart attack, stroke and circulatory problems.
• The risk and effect of diabetic nephropathy can be reduced by controlling blood sugar, blood pressure and cholesterol levels ¬ this can be achieved with a combination of good dietary control as well as medication
• Smoking shortens life. It is vital to stop!

Please be aware that while we have made all effort to ensure that this information is accurate, we cannot guarantee that there are no mistakes. Also that the best management for individual patients may differ from that outlined here. Only the doctors caring for the patient will be able to advise on this.

Diet in Renal Failure

This page deals with What’s In Food. To learn about diet at different stages of renal disease.

What’s in food?

• Kidney function is essential in dealing with the waste material from ingested food – urea is made from dietary protein and is excreted by the kidneys along with other substances such as sodium, potassium and phosphate.
• Impaired renal function can lead to a build-up of these substances in the body.
• Dietary restriction can modify this accumulation and its effects.

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Protein

Excessive intake of protein must be avoided, and sometimes protein restriction is advised for patients with renal failure. Here are the reasons:

• lowering protein intake may slow down the rate at which the kidneys get worse
• it reduces the phosphate load (important to prevent bone and other problems in the future)
• it helps to control the acid level in the blood – if the blood is too acid it can lead to loss of muscle and to a high potassium level in the blood
• in advanced (stages 4 and 5) kidney disease it can relieve symptoms such as nausea and vomiting

It is recomended to most patients that a protein restriction is not imposed as it can interfere with eating a healthy diet.

On haemodialysis protein restriction is not generally required once patients are established and patients should eat a normal protein intake of 1 g/kg ideal body weight, about 70g each day.

In CAPD a higher protein intake is recommended due to a small loss of protein from the drained fluid (dialysate) which adds up to 5-10g over the day. It has been suggested that as much as 1.5g/kg of protein daily should be consumed but this is very difficult to achieve. An intake of 1.1-1.2g/kg ideal body weight is more realistic.

• A typical daily intake in the UK is 60 – 80g.
• Normal requirement is only 45-55g
• The richest sources are: Animal protein – meat, fish, cheese, eggs and milk
• Vegetable protein – nuts,beans, pulses,soya milk

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Sodium

Common salt is sodium chloride. Very low sodium diets, with food being cooked salt-free, are never recommended in renal failure. The existence of excess fluid in the body (eg swollen ankles) and high blood pressure should be managed by some sodium restriction to 100mmol per day. This allows for salt to be used in cooking, but means avoidance of very salty foods, and avoiding the addition of salt to food after it has been cooked. Many blood pressure tablets only work properly if combined with a reduced salt intake.

On haemodialysis, restriction in the form of “No Added Salt” diet is necessary since a greater intake will result in poorly controlled blood pressure.

On CAPD, there is a “no added salt” restriction for the same reasons.

On dialysis too much salt leads to excessive thirst, difficulty in adhering to the fluid restriction and risk of excess fluid and high blood pressure. A number of salt substitutes are available but they consist mainly of potassium chloride and therefore salt substitutes are not usually suitable for patients with renal failure.

A typical daily intake in the UK is 150 – 200mmol (9-12g of salt, or 3-5g of sodium)

Only around 10% of this is found in fresh food, the remainder is added as sodium chloride or sodium bicarbonate in cooking and food processing, and as table salt which may be sprinkled on the food after cooking.

Sodium rich foods: cheese, bacon, ham, sausages, tinned meat eg.corned beef, meat + fish paste
Oxo, Bovril, Marmite, salted butter & margarine, tinned vegetables, tinned & packet soups salted nuts & crisps, salty biscuits eg TUC, Cheddars

Other sources of sodium: Effervescent pain-killers – may contain up to 20mmol sodium per tablet!
Antacids and some other medicines

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Potassium

Potassium is not restricted routinely in patients on conservative treatment of renal failure. Too much potassium in the blood (hyperkalaemia), often occurs for reasons other than dietary excess like too much acid in the blood. Sometimes dietary potassium may have to be restricted for instance in diabetics and those on ACE inhibitors, drugs with a name ending …pril for control of high blood pressure.

On haemodialysis , potassium is reduced during each dialysis treatment then usually rises between treatments. It is felt that a pre-dialysis potassium of up to 6mmol/L is safe. Patients must be aware of all foods which are rich in potassium but no food needs to be avoided completely due to its high potassium content.

On CAPD , it is more common to have a low level of potassium in the blood (hypokalaemic) and require a high potassium intake. One of the main differences between the diets for haemodialysis and CAPD is the recommended intake of potassium. The continuous uptake of glucose from the dialysis fluid may influence potassium balance. Some patients still require potassium restriction in the same way as those on haemodialysis.

A typical daily intake in the UK can vary from 50 to 150mmol

Potassium is always found in association with protein and therefore all the protein-rich foods, especially milk, contribute significantly to the daily intake of potassium

Other rich sources of potassium are: Potatoes – especially baked, chips & crisps (boiling leaches out a lot of potassium); bananas, grapes, rhubarb, fresh grapefruit, fresh pineapple, Kiwi fruit,dried fruit eg currants, sultanas, dates, pure fruit juice including apple juice (even though fresh apples are low in potassium) tomatoes, butter beans, sweetcorn, mushrooms, beetroot, sprouts, leeks chocolate (plain contains less than milk) liquorice, fruit gums, coffee. Coca-Cola & diluting fruit squash contain negligible amounts of potassium.

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Fluid Intake

All drinks contain mostly water. Fluids refer to all drinks taken per day. Until the kidneys fail and dialysis is required, a fluid intake of 2 litres is encouraged – it is important to avoid dehydration as this can affect the kidney function.

On haemodialysis the fluid allowance for each patient needs to be quite strictly controlled.

The optimum fluid allowance when on CAPD is more difficult to calculate. The amount of fluid removed varies from person to person and sometimes CAPD is not suitable, due to poor fluid removal (ultrafiltration). A typical fluid allowance on CAPD is 1 litre per day.

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Phosphate

Too much phosphate in the blood (hyperphosphataemia), is usually only a problem in the later stages of renal failure although phosphate retention occurs long before it shows up in raised blood levels. The renal diet is automatically low in phosphate due to the protein restriction and if the phosphate rises above the upper limit of the normal range it can only be treated by using phosphate binding medication before meals. This medication works by binding phosphate in the gut and it is therefore important that it is taken just before food.

The commonest binders are calcium acetate (Phosex) or calcium carbonate (Calcium 500 or Calcichew), or sevelamer (Renagel). Renagel is a modern alternative but it is expensive and requires a lot of tablets.

On dialysis phosphate is controlled to a certain extent by diet. Phosphate binders are used in the same way as prior to dialysis with the aim of acheiving a pre-dialysis level of 1.5-2mmol/L.

A typical daily intake of phosphorus in the UK is 35-40mmol

Phosphate, like potassium, is found in association with protein, especially in milk and cheese. Only a few other foods which contain phosphate like wholegrain cereals (wholemeal flour and bread, oatcakes). Other sources are convenience foods which have phosphates added by the food manufacturers.

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Energy

It is essential that patients on a protein restriction take a high energy diet. Too few calories lead to the breakdown of muscle to provide energy. This results in an increase in the blood urea and a debilitated patient.

A high calorie diet should be achieved through high energy foods such as sugar, jam, marmalade etc. but in some cases it is necessary to provide specialised products which are produced commercially.

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Fibre

The intake of fibre is encouraged to avoid constipation. This can be important in CAPD as constipation can cause problems with the catheter position and result in poor drainage of dialysate.

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Diet after Transplantation

A successful transplant allows dietary freedom, but in particular freedom to drink. A healthy diet is encouraged with avoidance of excessive use of salt or sugar along with high fibre and low fat – the latter is important due to the high cholesterol and other lipids frequently found in blood testing of transplant patients. It is also important to maintain a healthy weight.

Haematuria

What is haematuria?

Haematuria means the appearance of blood in the urine. Haematuria is most commonly present in very small quantities (microscopic haematuria) and is only detected by a simple dipstick test. Less often visible blood may appear in the urine as a brown discolouration or red.

What causes haematuria?

Blood should not normally appear in the urine, red blood cells are kept in the blood stream by the filtering units of the blood, the glomeruli. Any part of the urinary tract from the kidneys to the bladder and urethra may be a cause of haematuria.

Causes of haematuria

Haematuria can originate from the kidney itself due to inflammation in the kidney, eg glomerulonephritis affecting the filtering units (glomeruli). When this is the cause of haematuria there are often other signs of kidney disease such as

• protein in the urine ( proteinuria )
• high blood pressure
• abnormal blood tests of kidney function

Kidney cysts, tumours or kidney stones can also cause haematuria. Blockages or stones in the tube to the bladder (ureter) may cause haematuria. The bladder may also be the cause of haematuria, in cystitis (bladder infection), stones, or tumours in the bladder. Diseases of the prostate gland may also cause haematuria

Haematuria is more common when taking medication to thin the blood ( eg Warfarin). However it is still possible that a separate problem may be causing the haematuria and other tests are still needed. Haematuria may sometimes be found in sickle cell anaemia (or even sickle cell trait).

Is haematuria always a bad thing?

Haematuria may not be a important, if any of the following can explain it:

• Haematuria can be detected in the urine during a menstrual period.
• When it occurs only during a urine infection.
• Sometimes some medicines and foods can colour the urine red. This is not the same as passing blood.
• When it only occurs following strenuous exercise.

What tests are needed?

Blood tests are done to check for a low blood count (anaemia) and that the kidney is working normally. The urine will be checked for protein and for infection.

An ultrasound scan looks at the kidneys for cysts or tumours. Sometimes, an X-Ray with a dye injection (IVU or IVP) is done.

A special test called a cystoscopy is often needed. This test uses a camera at the end of a flexible tube to examine the bladder wall. It is possible to do this test under local anaesthetic.

If after all these tests it seems that the bleeding is coming from the kidney, then a kidney biopsy may be suggested. This test involves taking a very small piece of kidney tissue and examining it under the microscope.

Things that suggest that diseases of the kidney may be the cause of the bleeding include:

• protein in the urine ( proteinuria )
• high blood pressure
• abnormal blood tests of kidney function

What is the treatment?

Haematuria is usually small in amount and in itself doesn’t require any treatment. The main reason for tests is to look for any definite cause of the haematuria which may require treatment.

What if no cause is found?

Sometimes no definite cause for the bleeding is found. Usually this means that the risk of there being a serious cause for the bleeding is very low. Where there are no signs of serious disease, occasional (every 6-24 months) monitoring of the urine, blood tests and blood pressure is usually all that is required. This is to detect the rare cases where the haematuria is an early sign of an important condition that develops later in life.

Please be aware that while we have made all effort to ensure that this information is accurate, we cannot guarantee that there are no mistakes. Also that the best management for individual patients may differ from that outlined here. Only the doctors caring for the patient will be able to advise on this.

Haemodialysis

How does it work?

During haemodialysis the blood is treated by passing it through an artificial kidney. Plastic tubes connect you to the dialysis machine and, in order to provide a good blood flow, a fistula, or neckline, or other device will be necessary. Most patients will have a fistula constructed in the arm and this will require a brief admission to hospital. It is not usually a major procedure. It will be done under a general or local anaesthetic and the staff will explain the procedure to you.

Whilst your fistula is developing, it may be necessary to place a temporary plastic tube in one of the blood vessels in your neck. This temporary measure will allow you to have dialysis until your fistula is ready for use. These tubes are not as good as a fistula because they may become blocked or infected.

Where, when, how long?

Most patients require three sessions a week with each session lasting between three and five hours, depending on your needs. Dialysis itself is relatively painless, although initially you may feel a bit light-headed at the end of each session. For this reason we ask you not to drive during the first few weeks after coming off treatment.

Are problems common?

In general, most patients feel physically better after two or three weeks of treatment but haemodialysis may cause side effects. Generally speaking, your energy levels may drop a bit as haemodialysis can be a bit tiring, particularly the day after treatment. Take this into account and try not to over-stretch yourself. It is also important to note that people with kidney failure are more prone to infection. Any sign of infection such as sore throats, boils or fever, should be reported to the Unit staff. Simple measures such as maintaining good personal hygiene and eating sensibly within the guidelines go a long way to helping you feel well. On the whole, once you are established on treatment, you should feel quite an improvement in your overall health.

What about my diet on haemodialysis?

Haemodialysis treatment only takes place for an average 12 hours in the week, leaving many hours when you have little or no kidney function. It is therefore important to control your diet to avoid excessive accumulation of fluid and the waste products from food.

It is, however, possible to have a normal protein intake but you will have to restrict salt, potassium (particularly in potatoes, chocolate and fruits) and to take phosphate binders (eg Phosex, Calcichew or Calcium 500) before your meals.

The amount of fluid you will be able to drink depends entirely on the amount of urine you pass and this may diminish once treatment starts.

The fluid allowance is 500 mls plus an amount equal to the urine volume passed.

Please also see our article on diet for more information.

Local information

St Helier Patients lnitially you will be dialysed at St Helier Hospital and, if you wish, you will be encouraged to become involved in the treatment process. This helps to maintain your independence. Patients are encouraged to make their own arrangements for transport to the dialysis unit but, if necessary, the staff can arrange for you to be brought in by ambulance or ambulance car.

You may be transferred to the satellite units which greatly reduces your travelling time. Whatever your treatment, help is available from the Renal Unit at St Helier at all times, day and night, by our fully trained and qualified staff.

You will be advised whether to attend in the morning, afternoon or evening shift. Every effort will be made to give you a time and to complete your treatment promptly but please remember that delays are sometimes unavoidable, for example when an emergency arises, technical problems crop up or transport difficulties develop. We will try to accommodate you on the shift most suited to you but we would emphasise that the late evening shift is usually reserved for patients who have been stabilised on treatment and this can take a few months.

After a spell, consideration may be given to a home dialysis installation which also increases your independence. Should this be decided upon, the hospital make all the arrangements and meet the costs. A “helper”, usually a spouse, partner or relative, will be taught how to assist you.

Satellite Units

• Crawly
• Woking
• Farnham
• Mayday
• Kingston

Immunosuppressive Drugs

Treatment with Immunosuppression in Renal Disease

Some types of kidney damage occur through activation of the immune system causing inflammmation. Lupus ( SLE ) affecting the kidney, vasculitis , and Goodpasture’s disease are all diseases in which kidney damage is caused by inflammation. Immunosuppressive drugs and drugs that reduce inflammation are used to treat these diseases. Immunosuppressive drugs are essential in kidney transplants to dampen the immune system and prevent rejection. Some other kidney diseases are slower but also respond to treatment of this type, for example some causes of nephrotic syndrome .

Steroids

Steroids, for example prednisolone and methyl prednisolone, are useful and are the most commonly prescribed immunosuppressive drugs. Their full description is corticosteroids . Large doses of these drugs over a long period of time can, however, result in a long and well-known list of side-effects including:

• Weight gain, fluid retention and raised blood pressure
• Diabetes, in some patients
• Thinning of bones – osteoporosis
• Thinning of skin and easy bruising
• Risk of serious infections

Doses are reduced as soon as possible but no alternative agent has yet been developed that can completely replace the use of steroids.

If steroids are taken for a long time, the body stops producing its own steroid hormone. Suddenly stopping steroid treatment after it has been taken for a long time can then be dangerous, as the sudden shortage of steroid hormones causes an Addisonian crisis . Therefore steroid treatment is often reduced slowly to allow the adrenal glands to recover. However in the six months after you have stopped steroid treatment, an infection or other illness may increase the body’s need for steroids, and you may need to start treatment with steroids again. It is recommended that anyone who is taking steroids should carry a STEROID CARD so that medical staff will know about your steroid treatment if you have any other health problems. You should continue to carry it for at least six months after stopping treatment, too.

Here are some ways to counteract the bone thinning effects of steroid therapy:

• Bone loss during steroid treatment may be offset by using calcium and Vitamin D
• Hormone replacement therapy (HRT) may help in women, after the menopause
• Other treatments may be required if osteoporosis is already proven or in some other circumstances.
• Bisphosphonates are the most commonly used of these (eg Didronel)

Cyclophosphamide

This is a powerful drug that attacks white blood cells. It has proven to be especially effective in several types of vasculitis that were often fatal in the past, and in SLE and in other conditions. However the drug has some serious side-effects:

• Serious infections and bleeding – blood count must be checked regularly
• Bladder irritation may cause cystitis and bleeding
• It may lead to infertility in men through toxic effects of the drug on sperm, (usually following prolonged treatment over more than 3 months of daily treatment). Sperm can be collected before the treatment starts if time permits.
• In women it may cause infertility and premature menopause through toxic effects on the ovaries (usually after prolonged treatment ) It is toxic to unborn babies
• There is a slightly increased risk of bladder cancer in later life
• There is a slightly increased risk of leukemia in later life

Keeping the courses short (three months) reduces the risk of toxic effects from cyclophosphamide. Administering it in the form of an injection every two to four weeks, rather than as a daily dose by mouth, can also keep the total dose down. However this may not be as effective in all circumstances.

Azathioprine

This drug has similar side-effects to cyclophosphamide but is less powerful and generally safer. It does not affect fertility or the bladder, and has been used safely in pregnancy. Azathioprine must be monitored with blood counts and has an increased risk of infection. It is often used after a course of cyclophosphamide in severe vasculitis, or at the outset in milder vasculitis or milder SLE. Azathioprine is also used to prevent rejection in kidney transplants and can be used in some kinds of glomerulonephritis. There is an important side effect for people who are taking azathioprine for a long time:

• People on azathioprine for a long time are at risk of developing some skin tumours. It is important to avoid sunbathing and to use sun blocking creams.

Mycophenolate mofetil (MMF)

This is a newer drug which works in a similar way to azathioprine. It is more powerful, but may carry extra risks. It is used in transplantation to prevent rejection, but has also been used in vasculitis and SLE, mainly to stop the disease from returning after an initial course of treatment with cyclophosphamide. Trials of MMF as a first treatment are under way, but its use in this way is relatively new. It is also being used in some other kidney diseases. MMF is usually used with steroids. Most of its serious side effects are similar to other drugs of this type. Side effects include:

• Stomach upset, including diarrhoea and vomiting. Improves with dose reduction.
• Risk of serious infections
• Risk of bleeding and easy bruising
• Risk of some cancers with long term treatment
• Risk to baby in pregnancy

Methotrexate

Methotrexate is used to treat some cancers. It can be used to treat inflammation in some types of arthritis and sometimes in vasculitis. In vasculitis and arthritis it is usually given once a week, with folic acid (a vitamin) being given 1-3 days later. Regular tests for blood count and liver function are required. It should not be used in pregnancy. Side effects can include:

• Hair loss
• Mouth ulcers and diarrhoea
• Liver damage (rare)
• Lung damage causing shortness of breath and cough (rare)
• Risk of infections and bleeding

Cotrimoxazole

Cotrimoxazole is an antibiotic combination (also known as Septrin, Bactrim) which can sometimes be used in some types of vasculitis, particularly Wegener’s disease (Wegener’s granulomatosis). Some patients have an improvement in vasculitis affecting the nose, sinuses and throat. It is probably less useful in kidney and lung vasculitis. The main side effects are gastric upset and occasional allergic reactions.

The same antibiotic is often used to prevent ‘Pneumocystis’ pneumonia in patients who are heavily immunosuppressed (e.g. receiving high doses or several of the drugs on this page). Pneumocystis pneumonia can be a problem in people with a weakened immune system.

Cyclosporin (ciclosporin) and Tacrolimus

Cyclosporin (now officially spelled ciclosporin) and tacrolimus are powerful drugs to dampen the immune response. They are mainly used in transplantation, but occasionally are used in kidney diseases, especially in nephrotic syndrome . Side-effects may be troublesome. Cyclosporin can sometimes cause tremor, and excessive hair growth, especially on the face, and gum swelling. There are some other rarer side effects. Tacrolimus may also cause tremor, and can cause upset sleep or headaches. Occasionally it causes feeling sick, and pins and needles in the arms and legs. Both of them can cause kidney damage themselves.

Both medications work in a similar way and may make infections worse. Being on these tablets over a long time can increase the risk of some tumours and it is recommended to avoid sunbathing and always wear sunblock in sunny weather to protect against skin cancer. You should watch out for the development of lumps and bumps on the skin and report these to your doctor if they occur. Women should have regular cervical smears.

Plasma Exchange

This is a treatment in which a volume of plasma is removed and discarded and replaced by a plasma substitute taken from blood donors. It involves pumping blood through a machine for between one and two hours, and is usually given every day and then perhaps on alternate days for a short period. It is most useful during severe disease before other treatments have had time to work, and is not usually effective on its own. Usually the patient’s plasma is replaced with a very pure protein called albumin. However it may be necessary to use frozen plasma or other proteins from plasma. These carry similar risks to blood transfusions. There is some risk of causing or worsening bleeding, because clotting factors are removed, and thinning of the blood is required to allow the machine to work.

Immunoadsorption is a treatment in which antibodies are removed without removing plasma. Less replacement is therefore required, and the treatment may be more efficient at removing antibodies. However the treatment is complex and long, and the machines required (and skilled operators) are not widely available. For some diseases it may not be as good as plasma exchange, but if antibody removal is very important it may be more effective.

Other treatments

Other drugs that are occasionally used include anti white cell antibodies such as antihuman thymocyte globulin ( ATG ) or Campath 1H. IVIG (intravenous immunoglobulin) is an injection of mixed antibodies collected from blood donors. It is only of proven benefit in Kawasaki disease (a type of vasculitis that usually occurs in children), although it helps in a number of autoimmune conditions where antibodies attack parts of the body. Anti-TNF antibodies and other similar treatments are under investigation in a number of aggressive types of kidney inflammation.

Please be aware that while we have made all effort to ensure that this information is accurate, we cannot guarantee that there are no mistakes. Also that the best management for individual patients may differ from that outlined here. Only the doctors caring for the patient will be able to advise on this.

Kidney Tests

This page describes some blood tests that are commonly used in patients with kidney diseases, or to measure kidney function in people who may have kidney disease.

Tests for how well are my kidneys working?

Creatinine – Creatinine is the best routine blood test for measuring how well kidneys are working. It is produced by muscles and put out through the kidneys. This means that ‘normal’ levels depend on how much muscle you have, and this can cause some problems in spotting kidney disease.

Creatinine comes from muscle. The little girl has normal kidney function and a creatinine level less than 60. The body-builder has normal kidney function and a creatinine of 120. For the girl, a creatinine of 120 would be very poor kidney function.

Big changes in creatinine are likely to be important, whatever the creatinine level. Although different labs may give significantly different results for the same creatinine sample, because there are different ways of doing the test.

Normal blood creatinine is 60-120 micromol/litre (0.7-1.4mg/dl) – In many people, ‘normal’ creatinine can sometimes conceal 50% loss of kidney function.

Urea – Urea is a small molecule that is produced in the liver from protein that you have eaten. It is normally put out by the kidneys, so blood levels rise as kidneys fail. However other things change the level of urea in your blood too, so that it is not a simple guide to kidney function. Here are some of the things:

• Fluid – if you are short of fluid (e.g. drinking very little), your kidneys keep more urea in the blood
• How much protein you have eaten
• Liver disease can stop urea being produced normally

Urea is still a very useful test when used together with creatinine. It can also be used to measure how efficient dialysis is. Normal blood urea is 3.5-6.5 mmol/litre (20-30mg/dl)

Creatinine clearance

You can get round many of the problems of blood creatinine measurements by collecting urine for 24 hours and measuring how much creatinine is in the urine at the same time as finding out how much is in the blood. This is called creatinine clearance . If any urine is not collected during the 24 hours, the result will not be accurate.

Normal creatinine clearance is about 100mls/minute.

Glomerular filtration rate(GFR) and estimated GFR (eGFR)

This is a test of how much the kidneys are filtering. It is normally about 100 mls/minute. This means that the kidneys are removing all the creatinine found in 100mls of blood every minute – almost 150 litres per day! Most of this is treated, and then absorbed back into the body, so that only 1-2% of the filtrate appears as urine. Creatinine clearance (see above) gives quite a good measure of GFR, but requires a 24 hour urine collection for measurement. Two other ways of measuring GFR are:

• Injecting a tiny amount of a radioactive substance and measuring how quickly it disappears from the blood, or appears in the urine.
• Using blood tests, age, sex, and sometimes other information to estimate the GFR (eGFR). This isn’t as good as measuring it, but is much simpler as it requires just one blood test. It is being used increasingly to spot kidney disease earlier than previously, and earlier than would be possible using just creatinine measurements.

Normal GFR is about 100mls/minute/1.73m2

Tests of other things the kidney puts out

Sodium (Na) – Sodium comes from salt, which is sodium chloride. Although there is often too much of it in your body when your kidneys don’t work properly, its level in the blood does not change much. This is probably because sodium makes you thirsty, so you drink more until the level is normal again. Having too much sodium in the body causes high blood pressure, oedema (swelling), and eventually severe problems such as heart failure and fluid on the lungs (pulmonary oedema). Removing sodium is an important part of dialysis treatment. Diuretic drugs (e.g. furosemide) increase the sodium put out by the kidney. Most people with kidney disease need to keep down the amount of salt in their food.

Normal blood sodium levels are 135 – 145 mmol/litre

Potassium (K) – Potassium comes from food, especially fruit, vegetables and nuts. Extra potassium you eat is normally put out in urine, so its levels in blood may rise in kidney failure. Blood potassium is normally precisely controlled and important. High levels can be very dangerous as they can cause serious heart rhythm abnormalities, including cardiac arrest, even before you have any other symptoms from it.

Normal blood potassium levels are 3.5 – 5.0 mmol/litre

How high is dangerous?

There isn’t a simple danger level, but levels above 5.5 usually cause concern, and levels much above 6.0 may be dangerous. Levels above 7.0 are certainly dangerous.

• Diet is the most important way of controlling potassium levels in renal failure.
• Potassium is lowered by dialysis, but in patients treated by haemodialysis it rises between treatments, so it is important to be careful what you eat.
• Some medicines make blood potassium higher. This is more of a problem when kidneys don’t work properly.
• Sometimes high potassium levels may not be accurate, for instance because of delays in getting the sample to the lab.

Treatments for dangerously high potassium may include giving sugar (glucose) and insulin, and some other measures. If it is very high and kidney function is poor, dialysis may also be necessary.

Calcium (Ca) – The body’s calcium is mostly in bones, but in kidney failure there are problems with calcium and bones. Low levels of calcium may lead to thinning of bones, very low levels lead to weakness, tingling, and other problems. High levels cause sickness. It is measured regularly in patients with kidney diseases because:

• Blood calcium may be low in renal failure, without treatment.
• Special types of vitamin D (calcitriol, alfacalcidol) are given to prevent renal bone disease and to raise blood calcium.
• Medicines (phosphate binders) given to keep blood phosphate low may also raise blood calcium.
• After years of kidney failure, parathyroid hormone levels often rise, causing high blood calcium levels
• Normal blood calcium levels are 2.3 – 2.5 mmol/litre (8.4-10.4 mg/dl).
• Changes in blood proteins (albumin) may change these normal ranges though.

Phosphate (PO4) – Phosphate levels are high in kidney failure. If not controlled, this causes

• bone disease to be worse
• itching
• calcium deposits to form in blood vessels and in other parts of the body – these may cause serious disease.
• Normal blood phosphate levels are 0.9 – 1.3 mmol/litre (2.5-4.3mg/dl).
• In renal failure the aim is to keep levels at or below 1.8 by controlling the amount of phosphate in diet and by using phosphate binding drugs.

Parathyroid hormone (PTH) – Parathyroid hormone is measured from time to time in patients with kidney diseases to prevent renal bone disease (renal osteodystrophy) After years of kidney failure, PTH levels often rise, causing calcium to be removed from bone and blood calcium levels to be high. The parathyroid glands may need to be removed if this cannot be controlled, an operation called parathyroidectomy . The glands are in the neck, behind the thyroid gland. Normal levels of PTH are different when measured in different labs. In kidney disease it may not be best to keep PTH levels completely normal – some guidelines suggest just keeping it less than 2 or 3 times the normal level.

Other blood tests

Haemoglobin (Hb) – The stuff in red blood cells that carries oxygen. Too little is anaemia.

• Normal haemoglobin levels are approximately 130-180 grams/litre in men and 115-165 g/l in women. (Many labs use grams/decilitre, g/dl, for which normal values are 11-18 rather than 110-180)
•  Erythropoietin (EPO) and other treatments aim to get dialysis patients close to normal (usually over 110 g/l)

White blood cell count (wbc) – White blood cells fight infection. Levels are often high during infections, but may be made low by some drugs, and sometimes also by infections. If the numbers are very low there is an increased risk of serious infection. Different kinds of white blood cell are added together to get the wbc. Neutrophils are the type that is most important for fighting common infections, and they are particularly likely to be affected by drugs.

• Normal wbc is approximately 4-11 thousand million per litre .
• Different kinds of white blood cell are added up to give the total wbc.

Platelets (plats) – Platelets are needed to form blood clots. If the numbers are very low (below 50) the risk of serious bleeding increases. Patients with kidney disease quite often have slightly low platelet counts, but other diseases, and drugs, may cause low platelet counts.

• Normal platelet count is approximately 150-350 thousand million per litre.

Albumin (Alb) – Albumin is a blood protein. It usually makes up more than half of the protein in blood. Some things that may cause low levels include:

• Leakage into urine
• Poor diet and starvation
• Infections or other causes of inflammation
• Liver disease
• Normal albumin levels are 35-45g/litre .

In dialysis patients it has been found that low albumin levels can be a marker for not doing well on dialysis. Unfortunately different methods used to measure albumin mean that different labs can get quite different results for the same samples from patients with kidney diseases.

Is my dialysis good enough?

Urea Reduction Ratio (URR) – This is a measure of how much the urea has been changed by one haemodialysis treatment. It is used to check that enough haemodialysis is being given. If it is too low more than once, you should find out why.

• URR should usually be over 70% if you are dialysed three times each week and have little or no remaining kidney function.

Kt/V – This is a more complicated test of how good dialysis is. URR is a simpler test. Kt/V includes more than just the change in urea. If it is too low more than once, you should find out why.

• Kt/V should be over 1.2 for each dialysis if you are dialysed three times each week and have little or no remaining kidney function.

Drug levels

Ciclosporin, Tacrolimus and Sirolimus are drugs that are used to prevent your immune system from rejecting your transplant. They all need blood tests to make sure that you are taking enough, but not too much. Too much may cause serious side effects, while too little may not prevent rejection. The exact levels you are aiming for depend on a number of things, for instance:

• How long ago your transplant was
• The other medicines you are taking
• The risk of rejection in your own case

– so we have not given a target range here. If you want to know, you should ask your transplant team what your target levels are.

Please be aware that while we have made all effort to ensure that this brief information is accurate, we cannot guarantee that there are no mistakes. Also that the best management for individual patients may differ from that outlined here. Only the doctors caring for the patient will be able to advise on this.