I’ve Been Compromised 

It’s true, and it’s not only me. It’s you, too, if you have Chronic Kidney Disease. ‘What do I mean?’ you ask. It’s your immune system that’s been compromised by your CKD. ‘HOW?’ you demand. That’s what today’s blog is going to explain.

Let’s start the usual way: at the beginning. So, what’s this immune system I mentioned? I turned to Medline Plus, a part of the U.S. National Library of Medicine which, in turn, is a division of the National Institutes of Health at https://medlineplus.gov/immunesystemanddisorders.html

“Your immune system is a complex network of cells, tissues, and organs that work together to defend against germs. It helps your body to recognize these ‘foreign’ invaders. Then its job is to keep them out, or if it can’t, to find and destroy them.”

According to the National Kidney Foundation at https://www.kidney.org/atoz/chronic-kidney-disease-and-pneumococcal-disease-do-you-know-facts,

“…Having kidney disease and kidney failure can weaken your immune system, making it easier for infections to take hold.  In fact, doctors and researchers have found that most infections, …, are worse in people with kidney disease.  People with a kidney transplant also have weakened immune systems.  This is because antirejection medicines (‘immunosuppressants’), which protect the body from rejecting the transplanted kidney, suppress the immune system.”

That makes sense. But exactly how does CKD compromise this system?

According to a British Society for Immunology study published in PubMed [“PubMed Central (PMC) is a free archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health’s National Library of Medicine (NIH/NLM),” as stated on their website. NCBI is The National Center for Biotechnology Information.] at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5904695/:

“The immune system and the kidneys are closely linked. In health the kidneys contribute to immune homeostasis, while components of the immune system mediate many acute forms of renal disease and play a central role in progression of chronic kidney disease. A dysregulated immune system can have either direct or indirect renal effects. Direct immune‐mediated kidney diseases are usually a consequence of autoantibodies directed against a constituent renal antigen, …. Indirect immune‐mediated renal disease often follows systemic autoimmunity with immune complex formation, but can also be due to uncontrolled activation of the complement pathways. Although the range of mechanisms of immune dysregulation leading to renal disease is broad, the pathways leading to injury are similar. Loss of immune homeostasis in renal disease results in perpetual immune cell recruitment and worsening damage to the kidney. Uncoordinated attempts at tissue repair, after immune‐mediated disease or non‐immune mediated injury, result in fibrosis of structures important for renal function, leading eventually to kidney failure.”

Hmmm, it seems my linking function is not working for this URL. No loss, just copy and paste the URL if you’d like to read more about the immune system and the kidneys.

There are a few medical terms in the above paragraph that you may need defined. Thank you, my all-time favorite dictionary, the Merriam-Webster, for helping us out here.

Antibodyany of a large number of proteins of high molecular weight that are produced normally by specialized B cells after stimulation by an antigen and act specifically against the antigen in an immune response, that are produced abnormally by some cancer cells, and that typically consist of four subunits including two heavy chains and two light chains

(https://www.merriam-webster.com/dictionary/antibody)

Antigenany substance (such as an immunogen or a hapten [Gail here: Bing defines this as “a small molecule which, when combined with a larger carrier such as a protein, can elicit the production of antibodies which bind specifically to it (in the free or combined state.]) foreign to the body that evokes an immune response either alone or after forming a complex with a larger molecule (such as a protein) and that is capable of binding with a product (such as an antibody or T cell) of the immune response

(https://www.merriam-webster.com/dictionary/antigen)

Autoantibodiesan antibody active against a tissue constituent of the individual producing it

(https://www.merriam-webster.com/dictionary/autoantibodies)

Fibrosisa condition marked by increase of interstitial fibrous tissue [Gail here: That’s not much help. In a word, fibrosis means scarring.]

(https://www.merriam-webster.com/dictionary/fibrosis)

Renal: of, relating to, involving, or located in the region of the kidneys

(https://www.merriam-webster.com/dictionary/renal)

Oh, boy. Now what? Can we build up our immune system? WebMD’s slide show  at https://www.webmd.com/diet/ss/slideshow-strengthen-immunity offers some ways we can. To summarize this slide show:

  1. Avoid stress.
  2. Have sex more often (I love this one.)
  3. Get a pet.
  4. Be optimistic.
  5. Build your social network
  6. Laugh more.
  7. Eat colorful fruits and vegetables. (Within your kidney diet, of course.)
  8. Consider herbs and supplements. (Check with your nephrologist first.)
  9. Exercise.
  10. Sleep an adequate number of hours.
  11. Cut back on alcohol consumption.
  12. Stop smoking.
  13. Keep washing those hands.

Some doctors, such as  Dr. Suzanne Cassel, an immunologist at Cedars-Sinai, think we need to balance our immune systems rather than strengthen them. ” ‘You actually don’t want your immune system to be stronger, you want it to be balanced,’ Dr. Cassel says. ‘Too much of an immune response is just as bad as too little response.’

Dr. Cassel says most of the things people take to boost their immune system, such as vitamins or supplements, don’t have any effect on your immune response.”

Obviously, all doctors don’t agree. Whether you want to balance your immune system or strengthen it, the suggestions above will be helpful. Notice whether or not we’re in the middle of a pandemic, washing your hands frequently can help your immune system. Most of the suggestions from WebMD may be surprising to you since they are lifestyle changes and/or are the same ones suggested in general for CKD patients. There’s got to be something to them if they can both help with your CKD and your immune system. Why not try the suggestions you’re not already adhering to?

By the way, to the reader who asked why chocolate is not good for CKD patients, it’s loaded with potassium. In addition, many CKD patients also have diabetes. The sugar content in chocolate is not going to do them any good.

Until next week,

Keep living your life!

It’s Time  

Time for what, you ask. Time to talk about Covid-19 and your kidneys. I don’t really want to, and maybe you don’t, either. But this is a pandemic, so we must. Better to know than play ostrich.

By the way, my favorite dictionary, the Merriam Webster at https://www.merriam-webster.com/dictionary/pandemic defines pandemic this way:

pandemic  adjective(Entry 1 of 2)

occurring over a wide geographic area and affecting an exceptionally high proportion of the population 

…..

pandemic noun (Entry 2 of 2)

an outbreak of a disease that occurs over a wide geographic area and affects an exceptionally high proportion of the populationa pandemic outbreak of a disease”

So much is unknown about the current pandemic, but it does look like Covid-19 lends itself to AKI (Acute Kidney Injury).

Let’s go back to this 1918 flu and see if we can find any kidney involvement there. I did, sort of. This study was published by Craig Garthwaite of the Department of Economics at the University of Maryland: The Effect of In-Utero Conditions on Long Term Health: Evidence from the 1918 Spanish Flu Pandemic. It deals with children of mothers who were pregnant during the 1918 Pandemic. You can find it at https://www.kellogg.northwestern.edu/faculty/garthwaite/htm/fetal_stress_garthwaite_053008.pdf.

“Depending on the period of fetal development during which exposure occurred, individuals have a higher probability of developing coronary heart disease, diabetes, kidney disorders, or being in poor health…. When flu exposure is defined using particular quarters of birth, however, there is an approximately 23 percent increase in the probability of developing diabetes for individuals exposed to the flu during the first months of pregnancy.”

Diabetes is the number one cause of Chronic Kidney Disease (CKD). CKD is a kidney disorder.

Did you know that there were three other pandemics between the one in 1918 and today’s? I didn’t. According to the Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html, they are

1957-1958 Pandemic (H2N2 virus) “The estimated number of deaths was 1.1 million worldwide and 116,000 in the United States.”

1968 Pandemic (H3N2 virus) “The estimated number of deaths was 1 million worldwide and about 100,000 in the United States.”

2009 H1N1 Pandemic (H1N1pdm09 virus) “… 12,469 deaths … in the United States…. Additionally, CDC estimated that 151,700-575,400 people worldwide died … during the first year the virus circulated.”

While these may seem like scary numbers, as of this past Saturday (and we know these numbers change daily), the World Health Organization (WHO) posted the following numbers:

“Total (new cases in last 24 hours)

Globally 12 322 395 cases (219 983) 556 335 deaths (5 286)”

You can check more data from WHO at https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200711-covid-19-sitrep-173.pdf?sfvrsn=949920b4_2.

The United States statistics?

“Coronavirus Cases:

3,355,646

Deaths:

137,403”

This is according to Worldometers at https://www.worldometers.info/coronavirus/country/us/.

It’s clear the pandemic is not done with us yet. People speak of the second wave coming. I live in Arizona and believe we are still in the first wave. I have no scientific proof for my belief, but our numbers keep going up without ever having gone down.

The National Kidney Foundation at https://www.kidney.org/coronavirus/covid-19-information#can-covid-19-cause-kidney-failure-otherwise-healthy-adults gives us the insight we need into Covid-19 and our kidneys:

“Initial reports from Wuhan found approximately 3% to 9% of hospitalized patients with confirmed COVID-19 developed an AKI. Incidence rates have now increased to 15% of hospitalized patients and 20% and higher in ICU patients with many requiring dialysis treatments. AKI appears to be a marker of COVID-19 infection severity and the mortality rate is higher for these patients.

Various COVID-19-related effects that are thought to contribute to AKI include kidney tubular injury (acute tubular necrosis) with septic shock, microinflammation, increased blood clotting, and probable direct infection of the kidney. Most patients with COVID-19-related AKI who recover continue to have low kidney function after discharge from the hospital.”

As usual, we need to back up a little here. AKI in not CKD (Here we are back in alphabet city.), although it may lead to CKD. While it may raise the death rate of Covid-19 patients, not all Intensive Care Unit (ICU) patients and those with Covid-19 but not in the ICU develop AKI.

Acute tubular necrosis may be a new term for you. Healthline at https://www.healthline.com/health/acute-tubular-necrosis explains it for lay folks like you and me:

“Inside your kidneys are small tube-shaped structures that remove salt, excess fluids, and waste products from your blood. When these tubules are damaged or destroyed, you develop acute tubular necrosis (ATN), a type of acute kidney injury. The damage may result in acute kidney failure.”

This past weekend I received this invitation from the American Association of Kidney Patients (AAKP) and George Washington University which you may find useful for yourself:

“Over the course of the past three months, you’ve joined AAKP and some of our allied experts in one of our nine COVID-19 webinars.

(Gail here: Go to their webinars. They’re a good way to read more about Covid-19 and your kidneys.)

We’re now pleased to invite you to pre-register to join our 2nd Annual Global Summit entitled, Global Kidney Innovations – Expanding Patient Choices & Outcomes, hosted in partnership with the George Washington University School of Medicine and Health Sciences.

This year’s summit focuses on the impact of COVID-19 on kidneys and kidney patients (Gail again: I purposely italicized that part of this sentence.) as well as key innovations in kidney care. All registration fees have been dropped to allow the broadest possible audience of frontline medical professionals, researchers, and kidney patients.

Join us for immediate access to key insights related to COVID-19 and risks to kidney patients! Beyond COVID-19, the agenda focuses on emerging innovation and research to care for kidney diseases, including diversity in clinical trials; precision medicine; genetic conditions such as APOL1; emerging research in the areas of early disease diagnosis and artificial intelligence; novel therapies in transplantation including wearable and artificial implantable devices; and advancements in home dialysis care.

Virtual Summit Event Dates: July 16-17, 2020

If you’re interested in this timely, free summit to learn more about your kidneys and Covid-19 – and/or for any of the other topics – you can register at https://aakp.org/programs-and-events/2nd-annual-global-summit-global-kidney-innovations-expanding-patient-choices-outcomes/.

Until next week,

Keep living your life!

D’immunity

I can just see your faces now. Huh? What is that? The concept makes sense, but the word doesn’t. Do you remember my mentioning that one of the joys of being a writer is that you make up words? Well, that’s one I made up right after my doctor talked with me about vitamin D and immunity. He was talking about warding off a reoccurrence of cancer, but when I started researching I found that it has to do with all immunity.

Wait a minute. Just as I keep reminding you that I’m not a doctor and never claimed to be one, it’s important you realize that when I use the word ‘research,’ I mean searching the web and whatever journals or texts I have available. I am not a researcher in the true sense of the word. My favorite dictionary, The Merriam-Webster at https://www.merriam-webster.com/dictionary/research can help us out here:

1: careful or diligent search

2: studious inquiry or examination especially investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories or laws in the light of new facts, or practical application of such new or revised theories or laws

3: the collecting of information about a particular subject”

(‘Er’ is a suffix that means ‘one who,’ so a researcher is one who researches.) Most of us think of a researcher as the second definition. I think of myself as the third definition.

Okay, now that’s cleared up let’s get back to the miraculous vitamin D and your immunity. ScienceDaily at https://www.sciencedaily.com/releases/2019/04/190417111440.htm tells us,

“The University of Edinburgh team focused on how vitamin D affects a mechanism in the body’s immune system — dendritic cells’ ability to activate T cells.

In healthy people, T cells play a crucial role in helping to fight infections. In people with autoimmune diseases, however, they can start to attack the body’s own tissues.

By studying cells from mice and people, the researchers found vitamin D caused dendritic cells to produce more of a molecule called CD31 on their surface and that this hindered the activation of T cells.

The team observed how CD31 prevented the two cell types from making a stable contact — an essential part of the activation process — and the resulting immune reaction was far reduced.

Researchers say the findings shed light on how vitamin D deficiency may regulate the immune system and influence susceptibility to autoimmune diseases.

The study, published in Frontiers in Immunology, was funded by the Medical Research Council, Biotechnology and Biological Sciences Research Council, Natural Environment Research Council and Wellcome.”

If you’re like me, you’ll need help with some of these terms.

Dendritic cells are:

“a branching cell of the lymph nodes, blood, and spleen that functions as a network trapping foreign protein,”

according to Dictionary.com at https://www.dictionary.com/browse/dendritic-cell.

Let’s take a look at T cells now. I was comfortable with MedicineNet at https://www.medicinenet.com/script/main/art.asp?articlekey=11300’s definition:

“T cell: A type of white blood cell that is of key importance to the immune system and is at the core of adaptive immunity, the system that tailors the body’s immune response to specific pathogens. The T cells are like soldiers who search out and destroy the targeted invaders.

Immature T cells (termed T-stem cells) migrate to the thymus gland in the neck, where they mature and differentiate into various types of mature T cells and become active in the immune system in response to a hormone called thymosin and other factors. T-cells that are potentially activated against the body’s own tissues are normally killed or changed (“down-regulated”) during this maturational process.”

I’m sure my doctor had been telling me about this during the course of my treatment, but last week – now that I’ve been declared cancer free – immunity became a big issue to me and I finally listened with both ears. Maybe you should, too, since we’re in the middle of the Corona Virus Pandemic.

Let’s get some more information about vitamin D and your immunity. Healthline at https://www.healthline.com/nutrition/vitamin-d-coronavirus#effect-on-immune-health gives us another view of vitamin D and the immune system:

“Vitamin D is necessary for the proper functioning of your immune system, which is your body’s first line of defense against infection and disease.

This vitamin plays a critical role in promoting immune response. It has both anti-inflammatory and immunoregulatory properties and is crucial for the activation of immune system defenses ….

Vitamin D is known to enhance the function of immune cells, including T-cells and macrophages, that protect your body against pathogens….

In fact, the vitamin is so important for immune function that low levels of vitamin D have been associated with an increased susceptibility to infection, disease, and immune-related disorders ….

For example, low vitamin D levels are associated with an increased risk of respiratory diseases, including tuberculosis, asthma, and chronic obstructive pulmonary disease (COPD), as well as viral and bacterial respiratory infections….

What’s more, vitamin D deficiency has been linked to decreased lung function, which may affect your body’s ability to fight respiratory infections….”

I caught a word or two in that explanation that we may need defined.

Vocabulary.com at https://www.vocabulary.com/dictionary/pathogen informs us that a pathogen is,

“… is a tiny living organism, such as a bacterium or virus, that makes people sick. Washing your hands frequently helps you avoid the pathogens that can make you sick.”

How about macrophages? I went to News Medical Life Sciences at for their definition.

“Macrophages are important cells of the immune system that are formed in response to an infection or accumulating damaged or dead cells. Macrophages are large, specialized cells that recognize, engulf and destroy target cells. The term macrophage is formed by the combination of the Greek terms “makro” meaning big and “phagein” meaning eat.”

This must be what my doctor was talking about re cancer.

On another note: I am 73, still undergoing chemotherapy, and have Chronic Kidney Disease. Please be kind to me and others like me by wearing your mask, even if you hate it or think it makes you look weak. You could be saving my life.

Until next week,

Keep living your life!

Saving CKD Lives

Last week, I wrote about Covid-19 and a little about precautions explaining why we – as Chronic Kidney Disease patients – need to take extra care. A reader in Ireland was shocked that this was all we had in the way of protecting ourselves (as much as possible) from contacting the virus here in the United States. The precautions weren’t that much different than the precautions for everyone else.

There are a few things going on here. First is that we have no leadership from Mr. Trump who seems to have decided this is not his responsibility. That leaves us with the governors of each of the fifty United States and, in some cases, the mayors of individual cities in each of these states to lead us. They may have very different ideas.

There is this post I found on Facebook that exemplifies our situation in the U.S. Unfortunately, it is not attributed to anyone. I would love to give credit where credit is due.

“WE ARE NOT IN THE SAME BOAT …

I heard that we are all in the same boat, but it’s not like that. We are in the same storm, but not in the same boat. Your ship could be shipwrecked and mine might not be. Or vice versa.

For some, quarantine is optimal. A moment of reflection, of re-connection, easy in flip flops, with a cocktail or coffee. For others, this is a desperate financial & family crisis.

For some that live alone they’re facing endless loneliness. While for others it is peace, rest & time with their mother, father, sons & daughters.

With the $600 weekly increase in unemployment some are bringing in more money to their households than they were working. Others are working more hours for less money due to pay cuts or loss in sales.

Some families of 4 just received $3400 from the stimulus while other families of 4 saw $0.

Some were concerned about getting a certain candy for Easter while others were concerned if there would be enough bread, milk and eggs for the weekend.

Some want to go back to work because they don’t qualify for unemployment and are running out of money. Others want to kill those who break the quarantine.

Some are home spending 2-3 hours/day helping their child with online schooling while others are spending 2-3 hours/day to educate their children on top of a 10-12 hour workday.

Some have experienced the near death of the virus, some have already lost someone from it and some are not sure if their loved ones are going to make it. Others don’t believe this is a big deal.

Some have faith in God and expect miracles during this 2020. Others say the worst is yet to come.

So, friends, we are not in the same boat. We are going through a time when our perceptions and needs are completely different.

Each of us will emerge, in our own way, from this storm. It is very important to see beyond what is seen at first glance. Not just looking, actually seeing.

We are all on different ships during this storm experiencing a very different journey.”

Let’s take a look at the Chronic Kidney Disease boat to see what I can find out for us. I immediately went to the National Kidney Foundation at https://www.kidney.org/coronavirus/kidney-disease-covid-19. If you’ve read last week’s blog, then you already know we are more vulnerable to Covid-19 and why.

Are there special precautions that someone with kidney disease should take?

Older adults and people with kidney disease or other severe chronic medical conditions seem to be at higher risk for more serious COVID-19 illness. If you are at higher risk of getting very sick from COVID-19, you should:

  • Stock up on supplies
  • Take everyday precautions to keep space between yourself and others
  • When you go out in public, keep away from others who are sick, limit close contact
  • Wash your hands often
  • Avoid crowds as much as possible
  • During an outbreak in your area, stay home as much as possible.

Please remember that if you are on dialysis, you should not miss your treatments. Contact your clinic if you feel sick or have any questions or concerns.

If you have a kidney transplant, it is important to remember to keep taking your anti-rejection medicines, maintain good hygiene and follow the recommendations from your healthcare team. Contact your healthcare team with any questions or concerns….

Should CKD patients wear masks in public?

It is best to stay home, unless you need to attend a dialysis treatment. If you must go out in public, ask your healthcare provider if it is necessary as a CKD patient to wear a face mask since each individual case is different.

The Centers for Disease Control and Prevention (CDC) recommends face masks for those who are infected with COVID-19, have symptoms of COVID-19, or taking care of someone with COVID-19.

The CDC also recommends wearing cloth face coverings to slow the spread of COVID-19 in areas where community-based transmission is significant. These homemade cloth face coverings are not masks and do not replace the President’s Coronavirus Guidelines. (Gail here: As you can see, Trump doesn’t have much more to offer than what we already know. To be fair, this site hasn’t been updated since March 16th, over a month ago. Wait a minute! Why isn’t this site updated daily?)

Tips for using a mask include a snug but comfortable fit covering the bridge of the nose and the entire mouth. Also, be sure to be laundered [sic] the cloth mask after use each outdoor use, ideally without damage to the shape or structure of the mask. … The CDC also recommends coffee filters as an alternative. Use of any mask is in addition to practicing social distancing or at least 6 feet from others to limit coronavirus spread. All patients at high risk, such as immunosuppressed transplant recipients or people receiving dialysis should follow the directions of their clinicians regarding the type of face covering that should be used outside of a clinic setting.

When in public it is important to practice social distancing by staying 6 feet away from other people and to also avoid touching your face. Wash your hands immediately after you have been in public.”

This is still paltry information at best. Emedicine at https://www.emedicinehealth.com/script/main/art.asp?articlekey=228849 gives us just a bit more insight about patients on dialysis according to the CDC:

“The CDC (Centers for Disease Control and Prevention) guidance recommends that for medically stable patients facilities give the option of waiting in a personal vehicle or outside the facility and to be contacted by mobile phone when they are ready to be seen.

  • Dialysis facilities should have space allocated to allow patients who are ill to sit separately from other patients by at least 6 feet.
  • Patients experiencing respiratory symptoms should promptly be taken to appropriate treatment areas to reduce time in waiting areas.
  • For those with symptoms, ideally, dialysis treatment should be provided in a separate room from other patients, with the door closed.
  • If a separate room is not available, the masked patient should be treated at a corner or end-of-row station not near the main traffic flow. A separation of at least 6 feet should be maintained between masked, symptomatic patients and other patients during treatment.
  • Use of hepatitis B isolation rooms should only be considered for patients with respiratory symptoms if the patient has hepatitis B or if no patients treated at the facility have hepatitis B.

Healthcare personnel caring for patients with undiagnosed respiratory infections should further observe standard contact and droplet precautions with eye protection unless a suspected diagnosis such as tuberculosis requires airborne precautions, according to the guidance.

Precautions should include using gloves, facemasks, eye protection, and isolation gowns.”

And transplantees? I am so frustrated by the lack of more concrete information that might be more helpful than that given to non-kidney patients. UNOS (United Network for Organ Sharing) at https://optn.transplant.hrsa.gov/governance/policy-notices/ offers the following information:

COVID-19 Policy Actions Implemented

The table below contains information for actions taken to address OPTN operational issues in the COVID-19 crisis.

Policy Summary Documents & supporting resources Effective date
Policy 1.4.F: Updates to Candidate Data during 2020 COVID-19 Emergency This emergency policy will allow transplant programs to refresh candidate clinical data with data obtained through previous testing in order to maintain current waitlist priority.

This policy prevents candidates who cannot undergo routine testing due to the COVID-19 crisis from being adversely affected on the waitlist.

OPTN Policy Notice March 17, 2020
Policy 3.7.D: Applications for Modifications of Kidney Waiting Time during 2020 COVID-19 Emergency This emergency policy allows transplant programs to submit a waiting time modification application to retroactively initiate waiting time for affected candidates.

This policy prevents potential non-dialysis candidates who meet creatinine clearance or glomerular filtration rate (GFR) criteria from being disadvantaged because they cannot obtain other testing required.

OPTN Policy Notice April 3, 2020
Policy 18.1: Data Submission Requirements
Policy 18.2: Timely Collection of Data
Policy 18.5.A: Reporting Requirements after Living Kidney Donation
Policy 18.5.B: Reporting Requirements after Living Liver Donation
This emergency policy change relaxes requirements for follow-up form submission.

The intent of the policy is to prevent unnecessary exposure risk to transplant recipients and living donors, and also to alleviate data burden for centers in the midst of COVID-19 crisis.

 

Longer blog or not today – and it is much longer – I wish you all would adhere to these conditions. Are they restricting? Possibly. Are they uncomfortable? Could be. Are they lifesaving? It seems they are. Be safe.

Until next week,

Keep living your life!