Two Masters

A friend of mine, the one I mentioned when I wrote about renal sally ports, recently has had a relapse. Yep, he neglected to take his medications at the proper times. That can cause havoc for mental illness, especially bipolar disorder. It got me to thinking. What if my friend had Chronic Kidney Disease AND bipolar disease? How could he handle both diagnoses at the same time?

Let’s start at the beginning. There are certain drugs I take in the hopes of delaying dialysis as long as possible. One of those is the ACE Inhibitor I’d been taking for hypertension for about two decades before I was even diagnosed with CKD. Here’s the definition from What Is It and How Did I Get It? Early Stage Chronic Kidney Disease: “ACE Inhibitor: A blood pressure medication that lowers protein in the urine if you have CKD.”

It works by both relaxing the blood vessels and reducing the blood volume. This, in turn, lowers your blood pressure which, in turn, lowers your heart’s oxygen needs. And the problem for my friend would be? Well, maybe just remembering to take the medication each day.

However, according to MedicineNet.com at http://www.medicinenet.com/ace_inhibitors/page2.htm,
The most common side effects are:
• Cough
• Elevated blood potassium levels
• Low blood pressure
• Dizziness
• Headache
• Drowsiness
• Weakness
• Abnormal taste (metallic or salty taste)
• Rash
• Chest pain
• Increased uric acid levels
• Sun sensitivity
• Increased BUN and creatinine levels

Did you notice increased uric acid levels, and increased BUN and creatinine levels? This could be a dicey medication for CKD patients if they did not heed their doctor’s advice once (s)he has evaluated the patient’s labs. That’s the problem here: not having the ability to be a compliant patient during a bipolar episode.

I was also prescribed a drug for cholesterol, a statin. This drug inhibits (the word of the day) an enzyme in the liver that produces lipids. As reported in The Book of Blogs: Moderate Stage Chronic Kidney Disease, Part 1:
According to Dr. Dr. Robert Provenzano, chief of nephrology at St. John Hospital and Medical Center in Detroit, “…LDL, bad cholesterol, directly impacts acceleration of Chronic Kidney Disease.” One of the possible side effects is of this drug is Type 2 Diabetes. All I can say about that is thank goodness these side effects are not the norm.

Here’s the problem: statins have to be taken at night. That’s when the body produces cholesterol. Again, can my friend be compliant during an episode? What about the drugs he already takes? Are they going to somehow interfere with these common drugs for CKD?

Lithium is the usual drug for him. This is from The Book of Blogs: Moderate Stage Chronic Kidney Disease, Part 2:
“There were two Plenary Sessions I attended at the Southwest Nephrology Conference I attended last weekend. It was at the second one, ‘Psychiatric issues in kidney patients’ that I suddenly sprang to attention. What was this man saying? Something about lithium doubling the risk for Chronic Kidney Disease? And I was off… how many psychiatric patients knew that fact? How many of their caretakers knew that just in case the patient was not responsible at the time of treatment? What about children? Did their parents know? Was a screening for CKD performed BEFORE lithium was prescribed?”

Kidney.org at https://www.kidney.org/atoz/content/lithium has me downright frightened for my friend:

“What is lithium?
Lithium is a common medicine used to help calm mood for treating people with mental disorders. Since such disorders need lifelong treatment, long-term use of lithium may be harmful to organs, such as the kidneys.

How does lithium cause kidney damage?
Lithium may cause problems with kidney health. Kidney damage due to lithium may include acute (sudden) or chronic (long-term) kidney disease and kidney cysts. The amount of kidney damage depends on how long you have been taking lithium. It is possible to reverse kidney damage caused by lithium early in treatment, but the damage may become permanent over time.

What is nephrogenic diabetes insipidus?
The most common problem from taking lithium is a form of diabetes due to kidney damage called nephrogenic diabetes insipidus. This type of diabetes is different than diabetes mellitus caused by high blood sugar. In nephrogenic diabetes insipidus, the kidneys cannot respond to anti-diuretic hormone (ADH), a chemical messenger that controls fluid balance. This results in greater than normal urine out-put and excessive thirst. It can be hard to treat nephrogenic diabetes insipidus.”

I keep reminding myself that the word “may” appears over and over again. Yet, since my friend either wasn’t taking his medication at all or not taking it as prescribed, it wasn’t working…and he is still at risk for CKD.

I found this tidbit on Drugs.com at https://www.drugs.com/interactions-check.php?drug_list=1477-0,1489-0, ACE Inhibitors: “…may increase the blood levels and effects of lithium. You may need a dose adjustment or more frequent monitoring by your doctor to safely use both medications.” Wait. So you need an ACE Inhibitor if you have CKD, but it can interfere with the lithium you take if you’re bi-polar. And statins? While I couldn’t find any interactions, I did find the caution that there may be some and to check with your doctor. I am aware he takes an anti-depressant, but in researching, have discovered there are many that are safe to take with CKD.

My friend usually goes to his medical appointments, but he neglects to mention certain symptoms and sometimes has trouble telling reality from non-reality. Does he know whether his doctor has warned him about the higher risk of CKD or not? Does he know that he may develop a form of diabetes from long term use of lithium? Does he know that if even one of his parents has CKD, his risk is doubled yet again?

Tomorrow is July 4th, the day the United States celebrates its independence from the tyranny of England. Where is my friend’s independence from the tyranny of his mental illness? The English and the United States have learned to peacefully share our existences (right, English readers?). Here’s hoping my friend can learn to peacefully share his existence with bipolar disorder… and CKD should he develop it. Heaven forbid.

Until next week,
Keep living your life!

Dr. Rich Synder DO – Guest Blog

Nothing like being post blood draw for feeling relieved and ready to work.  By the way, that picture frame on the right side of the table contains a list of my numbers.  Make sure you know your own so you can deal intelligently with your body and your doctors.

I keep my eye out for any Chronic Kidney Disease publications after the release date of my own book.  One day, to my surprise since it had been a futile attempt until then, I discovered What You Must Know About Kidney Disease. I figured it was going to be about another kind of kidney disease just like all the others I’d looked at since last May, but it wasn’t. I bought it, read it, and is my wont, contacted the author to both congratulate him on an informative book and ask him whatever questions I had.  It turned out Dr. Synder reads the blog and to quote him, “Concerning your blog, I love your blog!”  Where’s that feather that keeps knocking me over?

You’ll find his blog on my blogroll to the right below the calendar after the categories.  I should be on his blogroll, too, by now or will be soon.  This is one busy person.

Below are the answers to some of the questions I asked him:

Let me a clarify: probiotics and alkalinized water are for everyone.

My approach: I am looking at the kidney as part of and working with your total body. It is a different approach than the way I was taught in fellowship. If the heart and the blood vessels and the cells are not working well, your kidneys are not going to work well.I am using a more holistic approach.

Probiotics in general: While decreasing total body inflammation, they help to normalize the immune system as well as help bowel irregularity. The kidney based probiotic is still a probiotic; it just also helps to also clear the intestine of the uremic toxins that can build up in advanced CKD. They have the lactobacillus and bifidobacterium species present in other probiotics.

Concerning water: Do you know how many people I see with early stage CKD who have a benign urine and no proteinuria? Why do they have early CKD ? Maybe part of it is what we ingest and what we are exposed to every day. An article in The New England Journal of Medicine talked about water and low level lead exposure and how it can be a cause of CKD over the years. This encompasses the pesticides in the water, not to mention the cellular effect of an acidic Western diet. I did a show entitled “Are Colas Killing Your Kidneys?” in which I talked about the fact that twenty years of phosphoric acid are likely to have an effect on your kidneys.

Ongoing studies of how to treat glomerular disease and proteinuria: These look at protocols: what can I give – steroids or chemo or both? I am not going to say I have  not used them or medications when necessary. I would be a hypocrite if I did. But….why, why, why do my patients have kidney disease and what can one do about it? The prevention is what we do each and every day of our lives.

Here are some suggestions:
1) Alkaline/anti-inflammatory based diet: Some say,”Eat for your blood type.” But, what is the DASH diet for hypertension? It is not just a low salt diet. It is also full of anti-oxidants and anti-inflammatory.

2) Water: I have taken alkaline water myself and I notice a difference in how I feel. Our bodies are sixty percent water. Why would I not want to put the best type of water into it? Mineralized water helps with bone health.  In alkalinized water, the hydroxyl ions produced from the reaction of the bicarbonate and the gastric acid with a low pH produce more hydroxyl ions which help buffer the acidity we produce on a daily basis. Where are these buffers? In the bones and in the cells, as well as some extracellular buffers. You are helping lower the total body acidity and decreasing the inflammation brought on by it. You do this early on so that you don’t have a problem with advanced acidosis later. Why wait until you are acidotic before doing something?

3) Decreasing total body inflammation and raising anti-oxidant support:  Why is the heart the most common organ affected by kidney disease and dialysis? It’s due to inflammation and vascular calcification. If a person is diabetic and obese, they may also have a fatty liver. Altered liver hemodynamics are also going to play  a role in kidney function. I see the end aspect of this everyday in the hospital. I look at these things too.

4) Standard care for someone with diabetes and kidney disease: This is the use of an ACE inhibitor. This is right and I use it with anyone I can. What happens if the person is on the ACE inhibitor and is still spilling tons of protein? What happens if they can’t take the ACE inhibitor because of high potassium problems?  I look for other answers.

Your kidney doctors are not wrong  at all in what they are telling you. I  just look at things from an additional perspective. Do I bat 1,000? No way. Have I had better results than before? Absolutely, yes. Do I need to learn a lot more? Heck, yes….I keep looking at things from a different perspective and asking why.

Many thanks to Dr. Synder for guest blogging to answer my questions today. Listen in at 8pm EST (that’s 6pm in Az.) to hear him interview me on Improve Your Kidney Health tonight: www.voiceamerica/show/1843/improve-your-kidney-health.

Until next week,

Keep living your life!