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!

It Is Not All In Your Mind; It’s In Your Organs, Too.

It’s National Kidney Month and National Kidney Day on March 13th is coming up fast, so – naturally – the Southwest Nephrology Conference was this past weekend.  It was the usual   Az. Kid Walk pleasure to see Dr. James Ivie, Director of Patient Services at The National Kidney Foundation of Arizona.  The man is wonderfully generous and will be distributing business cards for the book and blog at the Arizona Kidney Walk on April 7th at Chase Field as he allowed Dr. Jamal Atalla from Arizona Kidney Disease and Hypertension Center (AKDHC) to do at the last KEEP (Kidney Early Evaluation Program) event here.

I am up to my elbows in wedding preparations and had to push to make the time to attend the conference and, other than the non-renal diet food (geared to nephrology related practitioners, not patients), I was glad I did.

So much of the material was right up my alley, even though I’m what’s called ‘Allied Health’ rather than medical practitioner. True, I couldn’t quite understand the very technical medical issues, but what I did understand is worth sharing here.

There’s so much to share that I wasn’t sure what to concentrate on this week… until I spoke with Nima. We went from discussing my great-niece’s first birthday party to Nima’s god-mother’s youngest granddaughter’s Bat Mitzvah to lithium. That part of that family has a number of male members who have taken lithium for extended periods for bipolar disorder years ago.

According to Wikipedia, “Trace amounts of lithium are present in all organisms. The element serves no apparent vital biological function, since animals and plants survive in good health without it. Nonvital functions have not been ruled out. The lithium ion Li+ administered as any of several lithium salts has proved to be useful as a mood-stabilizing drug in the treatment of bipolar disorder, due to neurological effects of the ion in the human body.” The operant word in this definition is SALTS.  You can read more about lithium at:   http://en.wikipedia.org/wiki/Lithium.

There were two Plenary Sessions.  It was at the second one, “Psychiatric issues in kidney patients” presented by Dr. Christian Cornelius from Phoenix’s own Banner Good Samaritan Medical Center (where two of Cheryl’s grandchildren were born and also where she was diagnosed with the colorectal cancer that ended her life) that I suddenly sprang into attention again.

Hey, it had been a long morning and lunch was coming up soon.  I hadn’t been able to eat the mid-morning snack of cookies, soda, or coffee. I was tired from getting up at 5:30 to get to the conference down in Chandler in time. Tired and hungry – not the greatest combination.

cookiesWhat 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?

26 million Americans have kidney disease that is not yet diagnosed.  What if one of these psychiatric patients belongs to that group?  What if they all do?  Currently, kidney disease is the ninth leading cause of death in the United States.  Ninth!!!  Are these undiagnosed psychiatric patients moving it to the eighth?  And what about the 73 million at risk for kidney disease due to high blood pressure, diabetes, or family history?  Are they being given lithium without screening?  (You can read more facts about kidney disease at: http://www.kidney.org/news/newsroom/factsheets/FastFacts.cfm.)

I decided to dig deeper, as I often do.  Again and again on different sites about side effects of different psychiatric drugs, I found warnings that patients need to have a complete medical exam before starting the drug and then periodical exams to check whether or not the patient has developed some damage from taking the drug.  Here’s my question: do these exams include kidney screening?lithum

First I looked at my Twitter feed and found this at: http://www.winnipegfreepress.com/local/screening-for-kidney-disease-on-first-nations-193767521.html

“The $1.6-million federally funded project — First Nations Community Based Screening to Improve Kidney Health and Dialysis — will launch in March.

The project, co-led by Manitoba First Nations’ Diabetes Integration Project and Manitoba Health’s Manitoba Renal Program, provides early detection and treatment to several First Nations communities.

Detection of the disease in people as young as eight can take less than 15 minutes.”

The article deals with a KEEP type program for some Canadian First Nations and is included here to demonstrate the growing awareness of the need to screen for kidney disease, not to infer that First Nations have psychiatric disorders.

Other than that article, there is nothing about screening for kidney disease.  If medical practitioners aren’t aware of the prevalence of CKD – and, obviously, I am not referring to the entire medical professions – how can psychiatric practitioners be expected to know to do this?

I am not a psychiatric patient, not even for minor psychiatric issues, so I don’t know what the screening process is first hand.  However, I do know people who have confided in me (no names for privacy’s sake) that they are taking drugs for some psychiatric condition.  Big mouth here always asks what effect that drug might have on their kidneys… or liver for that matter since such drugs may hit the liver negatively.

That is not enough.  We need a lot more big mouths to ask the right question about drugs: How will this affect my kidneys?

I’m asking for one, no two, wedding presents from each and every one of you.

  1. Have yourself tested for kidney disease
  2.  Before you take any drug for any reason, ask how it will affect your kidneys.

Wow!  You have it in your power to make me a happy bride.  Please do it for your sake and mine.  wedding dress

Until next week,

Keep living your life!