Black and Blue is Back

I looked in the mirror and what did I see? Black and blue under my eyes staring back at me… and then I realized I’d been seeing them for ages. Hmmm, what could be causing them?

I researched and researched and researched and didn’t really find any answers that relate to me, but did find some that do relate to Chronic Kidney Disease. The biggie was anemia. Let’s go all the way back to What Is It and How Did I Get It? Early Stage Chronic Kidney Disease for the definition:

“Anemia: A blood disease in which the number of healthy red blood cells decreases”

Need some basics? In SlowItDownCKD 2011, it was explained that the red blood cells are the ones that contain the hemoglobin which carries oxygen to your cells. There’s a bit more about hemoglobin in The Book of Blogs: Moderate Stage Chronic Kidney Disease, Part 2. There we learned that it’s a protein and that it is responsible for the red color of your blood.

Well, what’s this got to do with CKD? This explanation from The National Kidney and Urologic Diseases Information Clearinghouse at http://kidney.niddk.nih.gov/kudiseases/pubs/anemia/anemia_508.pdf which appeared in SlowItDownCKD 2015 will explain:

“Healthy kidneys produce a hormone called erythropoietin, or EPO, which stimulates the bone marrow to produce the proper number of red blood cells needed to carry oxygen to vital organs.  Diseased kidneys, however, often don’t make enough EPO. As a result, the bone marrow makes fewer red blood cells.”

A little more about erythropoietin from the Lung Institute at https://lunginstitute.com/blog/oxygen-kidneys/:

Red Blood Cell Regulation: When the kidneys do not receive enough oxygen, they send out a distress signal in the form of erythropoietin, a hormone that stimulates bone marrow to produce more oxygen-carrying red blood cells.”

Uh-oh, what happens if we have fewer red blood cells – or anemia? I popped over to SlowItDownCKD 2016 to find the answer.

“If you have fewer red blood cells, you are carrying less oxygen to your vital organs… which are the following according to livescience at http://www.livescience.com/37009-human-body.html

‘The human brain….The human heart…. The job of the kidneys is to remove waste and extra fluid from the blood. The kidneys take urea out of the blood and combine it with water and other substances to make urine. The liver….The lungs are responsible for removing oxygen from the air we breathe and transferring it to our blood where it can be sent to our cells. The lungs also remove carbon dioxide, which we exhale.’

Okay, so the lungs are responsible for gathering oxygen from the air (for one thing) and healthy kidneys produce red blood cells to carry oxygen to your vital organs (again, for one thing). CKD reduces the oxygen you have since it reduces your red blood cell production….”

Let’s get back to the seeming black and blue under our eyes. While Dr. Mercola is not necessarily my medical hero, I did find an interesting explanation on his website at https://articles.mercola.com/what-causes-dark-circles-under-eyes.aspx:

“Some of the causes believed to contribute to hyperpigmentation around the periorbital area are temporary and resolve after the irritant has been removed. Possible temporary and permanent triggers for periorbital hyperpigmentation include….”

Sun exposure Genetic pigmentation Dermal melanocytosis
Allergic dermatitis Contact dermatitis Edema (swelling)
Drugs Aging Hormones

According to the Merriam-Webster Medical Dictionary, periorbital means “of, relating to, occurring in, or being the tissues surrounding or lining the orbit of the eye, “ and hyperpigmentation is “the production of excess melanin causing dark spots on the skin.” This is not exactly what we were looking for, but notice the last item in the third column: hormones. Erythropoietin is a hormone.

Maybe it has to do with the reduction of red blood cells which means less hemoglobin which means less red color. To my way of thinking, that means your veins would show up as blue. I’m conflicted here. I can’t decide if that’s just plain silly since I’ve never seen a red vein through my skin or if this might be the germ of a thought to be expanded upon.

EyeHealthWeb at https://www.eyehealthweb.com/dark-circles-under-eyes/  lists many possible causes of these black and blue or dark rings under our eyes.

  • Heredity. Dark circles under the eyes can appear in childhood, and are often an inherited trait. Some children will outgrow them, but others will not.
  • Allergies. Nasal congestion can dilate the blood vessels that drain from the area around your eyes, causing them to darken.
  • Sleep deprivation is the most common cause, and the easiest to prevent, but …
  • Oversleeping can also cause dark eye circles.
  • Eczema
  • Stress
  • As we get older, our skin becomes thinner.
  • Iron deficiency can prevent the blood from carrying sufficient oxygen to eye tissues.
  • Minor trauma that causes the appearance of a black eye 

Additional causes for dark circles under your eyes:

  • Crying
  • Lifestyle. Excessive smoking or drinking can contribute to under-eye circles. Also, people who drink too much coffee or who use cocaine or amphetamines may have difficulty getting enough sleep.
  • Fluid retention, as may occur with pregnancy or weight gain.
  • Skin pigmentation abnormalities. The skin around the eyes is thinner, which is why your blood vessels are more readily visible through it.
  • Excessive exposure to the sun. Sun exposure encourages your body to produce more melanin.
  • Age. As we get older, we lose some of the fat and collagen surrounding our eyes. This loss, combined with the thinning of our skin, magnifies the appearance of dark eye circles.
  • Mononucleosis can cause the eyes to appear puffy and swollen. This is due partly to the fatigue that people feel when they are suffering from it, and partly because this illness causes a yellowing of the eyes and the skin around them (this is called jaundice).
  • Periorbital cellulitis. This is a bacterial infection of the eyelid or eyelids. If it is promptly treated with antibiotics, however, it is nothing to worry about.
  • Excess salt in the diet causes fluid retention throughout your body—including underneath your eyes.

Gulp! Iron deficiency (which may be a kind of anemia), excessive smoking or drinking, certain drugs, excess salt. Sound familiar? These are some of the things we’re told to avoid as CKD patients.

Until next week,

Keep living your life!

So Tired, Tired Of Waiting For…

It’s the year of the dragon!  Happy Chinese New Year to those who celebrate.  I have fond memories of the parades in NYC’s Chinatown and wending our way through firecracker wielding crowds to get to our favorite restaurant on something like 19 1/2 Pell Street. Or was it Mott Street?  Crooked streets, a below street level entrance and some of the best food I’ve ever eaten.  That was pre-CKD and I wonder if my taste buds have adapted to the renal diet enough that I wouldn’t appreciate the flavor any more if I ever get back there again.  Oh well, my kids can appreciate the food for me and I’ll appreciate the rest of the experience, my usual attitude toward something that might not be available to me these days.

I’m tired these days with “iron deficiency without anemia” but I clearly remember saying no to Epogen when it was suggested to me in the early days of my CKD.  It just struck me as wrong.  It was a gut feeling: I knew nothing about it at the time.  Since then, it’s been suspected of causing cancer and I’ve written about that in a previous blog.  I’ve also written in the book about how it’s necessary to remember that your kidneys are not functioning as they should which means that medication may stay in your body longer so you’d need less of it.  Has someone heard me?  Or was it just time for the medical community to implicate the cautions I’d been suggesting?

On the 19th of this month, Eurekalert.org ran the following:

New drug labels for kidney disease patients — what do they mean?

Drugs that treat anemia are critical for many who have kidney disease

Highlights

  • More than 20 million adults in the United States have chronic kidney disease.
  • Drugs that treat red blood cell deficiencies are critical for maintaining many chronic kidney disease patients’ health.
  • Experts comment on newly released federal recommendations for these drugs.

Washington, DC (January 19, 2012) — The U.S. Food and Drug Administration (FDA) recently recommended that clinicians be more conservative when they prescribe chronic kidney disease (CKD) patients with drugs that treat red blood cell deficiencies. But the drug label’s recommendations fall short, according to two commentaries appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN).

The new federal recommendations apply to erythropoiesis-stimulating agents (ESAs). Patients with CKD may need these drugs if they lose the ability to make red blood cells and become anemic, which can make them tired, weak, and short of breath. ESAs treat certain types of anemia by stimulating red blood cell production and decreasing the need for blood transfusions. Drugs in the ESA class are epoetin alfa (marketed as Epogen and Procrit) and darbepoetin alfa (marketed as Aranesp).

Clinical trials have shown that ESAs can increase the risk of patients developing heart-related problems such as strokes and heart attacks when used to intentionally increase hemoglobin  (a red blood cell component) above 13 g/dL. Because of this, the new ESA label now states that clinicians should consider starting ESA treatment when a CKD patient’s hemoglobin is less than 10 g/dL, and they should individualize dosing and use the lowest dose of ESA to reduce patients’ need for blood transfusions. In addition, if a dialysis patient’s hemoglobin level approaches or exceeds 11 g/dL (10 g/dL for a CKD patient not on dialysis), clinicians should reduce or hold the dose of ESA. (The drug label previously recommended that ESAs be dosed to achieve and maintain hemoglobin levels within a target range of 10 to 12 g/dL in CKD patients. This target range concept has been removed from the label.)

A commentary by Braden Manns, MD (University of Calgary, in Alberta, Canada) and Marcello Tonelli, MD (University of Alberta, Canada) suggests that the new guidance is not completely consistent with the evidence and that some of the guidance may prove difficult for physicians to apply in practice. “The recent FDA labeling update seems balanced, although more specific guidance to clinicians would have been helpful,” the authors wrote. They suggest that instead of recommending that physicians individualize ESA dosing and reduce it when hemoglobin exceeds 11 g/dL in dialysis patients (10 g/L in non-dialysis CKD patients), perhaps the FDA should simply have recommended targeting hemoglobin ranges of 9 to 11 g/dL in dialysis patients and 9 to 10 g/dL in non-dialysis patients.

In a second commentary, Alan Kliger, MD, Fredric Finkelstein, MD (Hospital of St. Raphael and Yale University), and Steven Fishbane, MD (Hofstra North Shore-LIJ School of Medicine) take a different angle and propose that treatments for anemia should focus on the individual needs of each patient, weighing the risks and benefits in each case. While it is important to minimize patients’ chances of developing heart-related problems, it is also important for patients to feel less tired, have more energy and vitality, and be better able to function physically. “Instead of simply targeting hemoglobin levels, we should be looking at the hemoglobin level in the context of the patients’ perception of their quality of life and use ESAs judiciously to improve these perceptions,” the authors wrote. In other words, at what hemoglobin level do anemia-related symptoms become less burdensome for each individual patient? With this information in hand, physicians and patients will be better able to balance the risks versus the benefits of treatment.

You can find the article at:  http://www.eurekalert.org/pub_releases/2012-01/ason-ndl011312.php

You’ve got to weigh in with your own thoughts on this drug and it’s dosage.  Yes, your doctor is the specialist for your disease, but this is your life.  Take charge of it.

On the book front, possibilities are popping up, but I like to wait until they are certainties before announcing them, so:

Until next week,

Keep living your life!This is what Early Stage Chronic Kidney Disease looked like in August, 2011.  I could swear I had a picture from last week but just can’t find it.  Thank you to my dear friend and her daughter for inviting me to the wedding in Providence, Rhode Island.  (I’d expected to cool off a bit there, but ran right smack dab into a heat wave so it wasn’t just hot as it is here, but hot and humid.  The wedding made up for that!)