RENAL DISEASE - Beaumont Hospital, Dublinrenal disease. Over the last 20 years the technology around, and treatment of, Renal Disease, has changed radically. As a result we have produced

BEAUMONT HOSPITAL

RENAL DISEASEProf. Peter J. Conlon, FRCPI

Helen Dunne, CNMPetrina Donnelly, CNM

www.transplantireland.ie

The Beaumont Transplant Foundation was founded in 1988 with the purpose of providingpatient care education and research in the field of kidney transplantation in Ireland. Sincethat time the Beaumont Transplant Foundation has allowed many new developments totake place and has assisted in several education and research programmes in the area ofRenal Transplantation.These programmes have been made possible through hard work andgreat support from individuals, companies and sporting organisations throughout Ireland.This support and generosity has facilitated many groundbreaking programmes and enabledthe Transplant Unit at Beaumont to become a world leader in its field.

Since 1992 the Transplant Unit has been performing life saving simultaneous kidney andpancreatic transplants on young diabetic patients.At present, the Beaumont Transplant Unitis the only facility in the 32 counties that can perform this surgery concurrently. Thebenefits of this surgery are inestimable. As a centre for excellence in the field oftransplantation the Beaumont transplant unit has also developed a living related donorprogramme.

In 2004 the Beaumont Transplant Foundation celebrated 40 years of kidney transplantation.Over the past 40 years 3,000 people in Ireland have received the gift of life through kidneytransplantation, with patient outcomes improving all of the time.

To develop these programmes, by providing patient care education and researchprogrammes, that will improve patient outcomes, the Beaumont Transplant Foundation willcontinue to organise fund-raising events on an ongoing basis. If you or your family orfriends are interested in participating in any of these events we would love to hear fromyou, and would appreciate your support no matter how big or small.Whether you wouldlike to become a fundraiser or a sponsor, your efforts are warmly appreciated.

The Beaumont Transplant FoundationBeaumont Hospital

PO Box 1297Beaumont Road

Dublin 9

R E N A L D I S E A S E – A G U I D E F O R PAT I E N T S 1

In 1983 Dr Michael Carmody wrote the firstedition of Living with Renal Failure. For more than20 years this book was used as the major patienteducation booklet for patients experiencingrenal disease. Over the last 20 years the

technology around, and treatment of, Renal Disease,has changed radically. As a result we have producedthis series of books to assist patients and their familieswhen diagnosed with renal disease.

This book is the first in a series of three, aimed athelping patients with kidney disease learn more abouttheir illness. This edition, deals with the functions ofthe kidney, types of kidney diseases, diagnostic testsand medicines used to treat kidney conditions.

Book 2 deals with Haemodialysis and PeritonealDialysis and Book 3 covers Kidney Transplantation inmore depth. Please use these books as a guide andreference tool but any worries or issues you haveshould be discussed with your team.The text includescontributions from many members of the BeaumontHospital Renal Unit and has been supported by theBeaumont Transplant Foundation.

We hope you find it helpful.

Prof. Peter J Conlon FRCPIHelen Dunne CNM

Petrina Donnelly CNMJuly 2007

Preface

ContentsCHAPTER 1 The Urinary System

CHAPTER 2 What is Kidney Failure?Causes of Kidney FailureSymptoms of Kidney Failure

CHAPTER 3 Diagnostic Testing for Kidney Failure

CHAPTER 4 Dietary Advice for Renal Patients

CHAPTER 5 Medications

CHAPTER 6 Infection and Vaccination

CHAPTER 7 Practical and Social Support

CHAPTER 8 Reproductive Matters

CHAPTER 9 Your Kidney Healthcare Team

CHAPTER 10 Staying Healthy

APPENDIX Contact NumbersOther Sources of Useful InformationGlossary of TermsContributors

3

8

18

28

32

38

43

50

52

55

R E N A L D I S E A S E – A G U I D E F O R PAT I E N T S2

58

The information contained within this book is correct at time ofgoing to press.This book essentially pertains to the practices atBeaumont Hospital. Other Renal Units may use differentpractices.This book should be used as a guide and reference tool.

©Save where otherwise specified the content of all pages arecopyright to The Beaumont Transplant Foundation and nomatter may be reproduced or stored in any way without thewritten consent of the Editors.


The urinary system is one of the body systems which helps us to dispose of the wasteproducts naturally produced within the body.The main structures in this system are asfollows:

Two kidneys – which lie behind the other major organs in the lower back area.They are bean-shaped organs and measure about 11cm long, 6cm wide and 3cm deep.They have 5 main functions,which will be discussed at a later stage.

Two ureters – (tube like features) which run from the kidneys to the bladder carrying urine.

One bladder – which collects urine from the kidneys, via the ureters, and stores it temporarily.

One urethra – through which the urine is excreted out of the body, allowing the bladder toempty and dispose of the waste.

Chapter 1THE URINARY SYSTEM

Des Hickey


HOW THE KIDNEYS WORK:As blood flows through the body it picks up waste and

carries this to the kidneys using the renal arteries.The waste inyour blood comes from the normal breakdown of active tissuesand from the food you eat.Your body uses food for energy andself-repair. After the body has taken what it needs from thefood the waste is sent to the blood.The kidneys filter out thewaste products and excess fluids from the body, and dispose ofthem in the form of urine via the bladder.The clean blood flowsback to the other parts of the body. If your kidneys did notremove this waste it would build up in the blood and causedamage to your body.

The actual filtering occurs in tiny units inside your kidneyscalled nephrons. Every kidney contains about a million of thesenephrons. In the nephron, a glomerulus (which is a tiny bloodvessel or capillary) intertwines with a urine collecting tubecalled tubules.A complicated chemical exchange takes place, aswaste materials and water in your blood enter your urinarysystem.

WHAT THE KIDNEYS DO:The kidneys…● Filter and remove the waste products of the body.

● Remove excess water from the body.

● Help in the production of red blood cells, which are used to carryoxygen around the body.

● Help maintain healthy bones

❖ Help regulate blood pressure in the body


SOME EXAMPLES OF WASTEPRODUCTS INCLUDE:Urea – Blood carries protein from your dietto the cells to fight disease and repair muscle.Whatever protein is not used is put back intothe bloodstream in the form of urea forexcretion. Too much urea in the blood isknown as uraemia.Potassium – is a mineral absorbed into thebloodstream from many fruits and vegetablessuch as oranges, bananas and potatoes.Potassium regulates the heart rate. Healthykidneys remove excess potassium from theblood stream as a waste product.Creatinine – is a waste product in the bloodcreated by the breakdown of muscle cellsduring activity.The levels vary according to thesize of the individual ie. the muscle mass of theperson.Sodium – is a chemical absorbed in the bloodstream from food containing salts. Excesssodium in the blood may cause a rise in bloodpressure as it plays a vital role in regulating theamount of fluid in the blood.Chloride – like sodium, helpsmaintain a balance of fluid in thebody. It is also absorbed fromsalted foods and is absorbedin the bloodstream in thebowel.

In addition to removingwaste we mentioned someother functions of thekidneys. These are carriedout with the help of threehormones, which are released inthe kidneys.Erythropoietin (eh-rith-ro-poy-eh-tin) orEpo – a hormone which is secreted by yourkidneys and stimulates the bone marrow toproduce red blood cells, which carry oxygen inthe blood to the cells in the body.Renin (ren-in) – a hormone secreted by thekidneys which helps regulate the bloodpressure through a chemical process withinthe blood stream.Calcitriol (kal-suh-try-ul) – the active form ofVitamin D secreted in the kidneys, which helps

maintain healthy bones by maintaining achemical balance between calcium andphosphate in the blood.

HOW DOES KIDNEY DISEASEAFFECT YOUR BODY?

Kidney disease can affect you in a numberof different ways.These include :● Proteinuria (protein in the urine)● Haematuria (blood in the urine)● Hypertension (high blood pressure)● Elevated Serum Creatinine (kidney failure)● Kidney Stones● Recurrent Urine Infections

ProteinuriaProteinuria or protein in the urine is

commonly the earliest symptom of kidneydisease. You will have read in the previoussection on how the kidney works that thekidney has about a million filters. When thekidney is healthy it allows very little proteininto the urine. If these filters become leaky

small amounts of protein will leak into theurine.This is frequently an early sign

of kidney trouble long before thekidney function itself begins to

deteriorate.Doctors very frequently

test the urine of patientsfor blood or protein in theurine to try to detect itearly.There are many causes

of protein in the urineincluding diabetes and

glomerulonephritis. While yourdoctor will do a number of special

blood tests to try to determine theunderlying cause, it may be necessary to havea kidney biopsy, (see Chapter on DiagnosticTests), to find out the exact cause of theprotein.

Patients who have very large amounts ofprotein in the urine (greater than 3 grams) aredescribed as having nephrotic syndrome.Patients with nephrotic syndrome commonlyhave swollen legs.

“Proteinuriaor protein in the

urine is commonlythe earliestsymptom of

kidney disease”

creatinine may be elevated as aearly sign of kidney disease long

before there are anysymptoms of kidney disease(see section under kidneyfailure, chapter 2). Bloodtests identifying elevatedserum creatinine arecommonly done as a

routine during an annualphysical medical examination. If

serum creatinine is elevated itmay be as a result of any of the kidney

disease discussed below.

Kidney StonesKidney stones occur when a tiny fragment

of crystal develops within the kidney or thetube coming from the kidney called the ureter.A kidney stone commonly produces verysevere colicky pain.The pain of a kidney stoneis described as being worse than labour pains.The treatment of a kidney stone will consist ofpain medication, most commonly, initially, as aninjection.

HaematuriaBlood in the urine can either

be present in amounts thatyou can see (macrascopic)or in amounts that youcannot see (microscopic)in which it is only detectedwith urine testing. Blood inthe urine may not appearred but more like strong teacoloured.

Blood in the urine isfrequently an alarming symptom andit should never be ignored. However it onlytakes a few drops of blood for the urine toturn red.There are a large number of potentialcauses of blood in the urine including: urineinfection, kidney stones, kidney or bladdertumours and inflammation in the kidney calledglomerulonephritis (GN).

If you have haematuria the first thing yourdoctor will do is to make sure you do not ahave a urine infection or bladder or kidneytumour.To do this you will usually need to havea number of scans of the kidney and may wellneed a cystoscopy. A cystoscopy is a test inwhich a camera with a light is inserted into thebladder. If these tests are normal your doctorwill then focus on determining if the blood iscoming from kidney inflammation orglomerulonephritis. This may require furtherspecific blood and urine tests or a kidneybiopsy.

HypertensionHypertension or high blood pressure may

arise as a manifestation of kidney disease. It isimportant however to realise that the vastmajority of people with high blood pressurehave entirely normal kidney function. If youhave high blood pressure it is very importantto treat it as it will help preserve your kidneyfunction and reduce the risk of developing astroke or heart attack.

Elevated Serum CreatinineThe serum creatinine is a blood test that is

used to monitor kidney function. The serum


“Blood in theurine is frequently

an alarmingsymptom and itshould never be

ignored.”

7

Subsequently the doctor/urologist may try toextract the stone. Thismay occur by way of anumber of methodsdepending on the sizeand position of thekidney stone. Theurologist may pass ascope into the bladderand try to grab the stone,he/she may try to bypass thestone temporarily with a sten, or theymay try to smash the stone with a largemachine called a Lithotripsey. Occasionally theurologist may need to do an open operationon the kidney to surgically remove the stone.

Once the stones are removed the team willtry to determine the underlying cause of thekidney stones. Conditions associated withrecurrent kidney stones include:● Not drinking enough water. If you have

kidney stones you need to drink 3 litres ofwater a day.

● High levels of calcium in the urine(hypercalcuria). This condition, in whichsome people pass too much calcium intothe urine, happens for unknown reasons. Ifyou are diagnosed with this your doctorwill probably advise you to eat less calciumin your diet and may put you on a tabletcalled Centyl which reduces the amount ofcalcium in the urine.

● High levels of calcium in the blood(hypercalcemia).This may be as a result of agland in the neck called the parathyroidgland being overactive. If this is the case youmay need to undergo a small operationto remove part of the gland. It mayalso be as a result of eating toomuch calcium in the diet.

● High urinary oxalate(oxalosis). Oxalate is aconstituent of certain foodsand if you are diagnosed ashaving too much oxalate yourdoctor may prescribe a diet high

in calcium as this helps prevent kidneystones in this situation.

● Cystinosis. This is anuncommon cause of kidney stoneswhich is inherited (runs infamilies). This occurs as a resultof the body not being able tohandle the amino acid cysteine.

The treatment for this condition isto drink large amounts of water, in

addition the medications captopril andpenicilamine are sometimes prescribed to

help reduce the frequency of kidney stoneformation.The investigation of patients with kidney

stones will consist of a number of 24 hoururine collections and bloodtests to determinewhich of the aboveconditions isresponsible forthe kidney stones.One of the urinecollection bottlescontains acid and it isimportant that it ishandled with careand kept away fromchildren(see pg19 forinstructions on 24 hour urine collections).

Recurrent Urine InfectionsRecurrent urine infections are a common

kidney complaint particularly among youngwomen. The vast majority of patients with

recurrent urinary infection do not haveany underlying structural kidney

disease. It is important howeverto rule out kidney disease byway of performing kidney x-rays. Sometimes long term(6 months) prophylacticantibiotics are used toeliminate any underlying

infection.

“If you havekidney stones

you need to drink3 litres of water

a day”

“Recurrent urineinfections are acommon kidney

complaint,particularly amongyoung women.”

R E N A L D I S E A S E – A G U I D E F O R PAT I E N T S


Kidney failure is a condition in which thekidneys cannot perform their normalfunctions (as listed on page ??). When

your kidneys lose the majority of their filteringability, fluid and waste accumulate in your body,this condition is known as kidney (renal)failure.

When kidney failure happens suddenly, it isknown as ACUTE RENAL FAILURE. Themost common causes of acute damage to thekidneys are:● Decreased blood flow to the kidney:

this may occur when there is extremelylow blood pressure caused by trauma,complicated surgery, septic shock,haemorrhage, burns, associated dehydr-ation or other severe or complicatedillnesses.

● Over-exposure to metals, solvents, x-raydye, certain antibiotics and othermedications or substances.

● Acute Tubular Necrosis (ATN) –may occur when the tissues arenot getting enough oxygen.

Short term treatmentmay be needed for acutekidney failure, but thekidneys usually recover ontheir own. However if thecause of the acute kidneyfailure persists there can bepermanent damage to thekidney which would lead tochronic renal failure.

Chapter 2CHRONIC RENAL FAILURE. Usually

develops slowly, with few signs or symptoms inthe early stages.You may still be passing normalamounts of urine, but it will have poor quality,and waste products which should normally befiltered out will remain in the body. Manypeople with chronic kidney failure do notrealise they have a problem until their kidneyfunction has decreased to less than 25 percentof normal. This damage usually occurs slowly,and is not reversible.

The rate of deterioration of kidneyfunction is variable, ranging from more thanten years to only a few months. If, as oftenhappens, a person only becomes aware ofkidney disease in the late stage of thecondition, the nephrologist (renal doctor) canonly guess as to when it started.

Eventually, the kidneys can only function atless than 10 percent of normal capacity. Thekidneys have almost stopped working at thisstage and treatment in the form of dialysis or

a kidney transplant is required to takeover the work of the kidneys and

maintain life.This is commonly known as

END STAGE RENALFAILURE (ESRF). In otherwords, kidney damage whichis irreversible and cannot becontrolled by conservativemanagement alone. When

kidneys reach 'end-stage', theyvery rarely get better. Once

someone develops ESRF, they willalways have it.

WHAT IS KIDNEY FAILURE?

“Short termtreatment may beneeded for acute

kidney failure,but the kidneysusually recoveron their own”


There are hundreds of different diseasesthat can cause chronic renal failure.Commonly, the condition is due to one

of the following:

Diabetes MellitusDiabetes is a disease in which patients

cannot control the amount of glucose in theblood stream. It is caused either by an inabilityto produce the substance called INSULINwhich controls glucose in the body (Type 1Diabetes) or if the body is unable to respondto the insulin that is produced (Type 2Diabetes). Whether diabetes is treated byinsulin, tablets or diet it can cause renal failure.

Apart from raised levels of blood sugar, animportant feature of this disease is the damagethat occurs to small blood vessels.The kidneyscontain many small blood vessels and whendamaged by high blood sugar levels in theblood they are replaced with scar tissue andbecome blocked.Diabetes can also damage thenerves in many parts of the body. When thebladder is affected, it is more difficult to passurine, resulting in a build-up in pressure on thekidneys, causing further damage.

The urine of people with diabetes has ahigh sugar content, which encourages thegrowth of bacteria, and as a result kidneyinfections may occur. Poor sugar controlcombined with high blood pressure canincrease your risk of making kidney diseaseworse.

High Blood PressureHypertension means high blood pressure.

SYSTOLIC blood pressure is consistentlyover 140 (systolic is the “top” number of yourblood pressure measurement, whichrepresents the pressure generated when theheart beats).

DIASTOLIC blood pressure isconsistently over 90 (diastolic is the “bottom”number of your blood pressure measurementswhich represents the pressure in the vesselswhen the heart is at rest). Either or both ofthese numbers may be too high. Severely highblood pressure can on its own cause kidneyfailure or high blood pressure can make othercauses of kidney failure worse.

In any person with high blood pressure,blood vessels (especially small blood vessels)become damaged. Roughly speaking the higherand the longer blood pressure has been raisedthe more blood vessel damage is likely to haveoccurred.

Many patients need medications to controlhigh blood pressure - known as anti-hypertensives.There is a lot that can be doneto control blood pressure including changes inlifestyle, weight loss, exercise, and avoiding saltin the diet.

High blood pressure will commonly requiremedication to keep blood pressure within thenormal range.

CAUSES OF KIDNEY DISEASE


NephritisThe term nephritis covers a group of

conditions in which there is long-terminflammation of the kidneys ('neph-' meanskidney, and '-itis' means inflammation).Sometimes the condition is described morespecifically as glomerulonephritis or GN('glomerulo-' refers to the glomerulus, which ispart of the kidneys' filtration unit).

When a glomerulus is damaged, substancesnot normally filtered out of the blood streamsuch as proteins, red blood cells and whiteblood cells, can pass through the glomerulusand enter the fluid that becomes urine.Progressive damage to the glomeruli can causeurine production to fall and waste products tobuild-up in the blood, leading to renal failure.There are many types of glomerulonephritis.These may be grouped as primary andsecondary.

In primary GN, only the kidneys areaffected. In secondary GN, the kidneys aredamaged as part of a more generalised diseasethat can affect other parts of the body. Theexact diagnosis can usually only be diagnosedfor certain by a kidney biopsy. Types of GNinclude:

FSGS – is scarring within the kidneyswhich can only be seen clearly under the

microscope. Therefore it is normally onlydiagnosed after a biopsy test of the kidney.The name FSGS comes about in the followingway:F – FOCAL means that some glomeruli are

affected but others may not be.S – SEGMENTAL affecting only a segment of

each glomerulus that is involved.G – GLOMERULO of the glomeruli.S – SCLEROSIS meaning scarring.

It seems that the general cause of FSGS isimmunological. That is, the antibodies andwhite blood cells that usually fight off infectioncause damage to the body by mistake. Thiscondition commonly results in severe swellingof the legs and high blood pressure. Thiscondition may reoccur after kidneytransplantation and cause the failure of akidney transplant. A number of drugtreatments are used to try to stop the damageto the kidney that this condition causes.Thesedrugs include steroids, cyclosporin,cyclophosphamide and cellcept.

IgA Nephropathy This is the commonest form of

glomerulonephritis found in the developedcountries of the world. IgA is short forImmunoglobulin A, an antibody which usually

Blood Pressure Equipment


helps the body to fight infections and toxinsencountered in the gut and lungs. In IgAnephropathy, IgA is deposited in theglomerulus, where they cause inflammationand scarring. In one third of cases it goes on tocause progressive severe damage to thekidneys. IgA nephropathy tends to be slowlyprogressive and so the process of the kidneyfailure can take 10 to 30 years.

Multisystem Diseases Affecting TheKidney

The kidney may be affected in many ways bydiseases which are not directly associated withrenal function. This is mainly due to the factthat the kidneys have a rich blood supply andas a result come into close contact with allelements of the blood.

SLE (Systemic Lupus Erythematosus) A chronic auto-immune inflammatory

disease which affects joints, blood vessels, skinand the nervous system, as well as the kidneys.Inflammation of the glomeruli within thekidneys may result in protein and blood loss inthe urine and high blood pressure. Kidneyinvolvement often occurs within 3 years ofdiagnosis of SLE.

AmyloidosisAmyloidosis is the term given to a group of

chronic infiltrative disorders characterised bythe presence of deposits of an abnormalprotein called amyloid. This is a systemicdisease which can affect the heart, nervoussystem, liver and kidneys. Within the kidneys,the amyloid is usually deposited in the walls ofthe renal arteries and the glomeruli's bloodvessels. This may result in abnormally highlevels of protein in urine and can lead toprogressive renal failure.

Multiple MyelomaThis is a type of cancer of a group of cells

in the bone marrow called plasma cells. Plasmacells are a type of white blood cell present inyour bone marrow. Multiple myeloma maycause kidney problems including kidney failurein approximately 50% of patients at some stagein their disease. Higher calcium levels in theblood due to damage to the bones caused bythe myeloma, can interfere with the kidneysability to filter your bloods waste.The proteins

produced by the myeloma cells can causesimilar problems, especially if you becomedehydrated.

VasculitisRefers to a group of diseases characterised

by inflammation of the blood vessels.Vasculitiscauses changes in the walls of the bloodvessels resulting in thickening, weakening,narrowing and scarring. It may be caused byinfection of the blood vessel walls or animmune/allergic reaction in the blood vesselwalls. This is the more common cause.Vasculitis may affect blood vessels of any type,size or location and therefore may causedysfunction in any organ system, including thekidneys, lungs, skin and joints. Some of thetypes of vasculitis which can cause kidneydysfunction include:● Henoch Schonlein Purpura

● Microscopic Polyangitis

● Polyarteritis Nodosa

● Wegeners Granulomatosis

A blood test called ANCA is commonlypositive in vasculitis and is used to monitor theactivity of this disease. Vasculitis can be verysuccessfully treated, particularly if diagnosedearly and treated with powerful immuno-suppressive medications.

These medications include high doses ofsteroids, cyclophosphamide, cellcept, andimuran.

Polycystic Kidney Disease (PCKD) A genetic disorder characterised by the

growth of numerous cysts within the kidney.These cysts are non-cancerous round sacs ofwater-like fluid. PCKD cysts can slowly replacemuch of the mass of the kidney, reducingkidney function and leading to kidney failure.People with PCKD may also have similar cystsin their liver, and there is also sometimes anassociation with a weakness of some of theblood vessels in the brain. PCKD is the mostcommon inherited kidney disease, and childrenof parents with PCKD have a 50% chance ofbeing affected by it. PCKD commonly causeskidney failure in patients in their 50’s. PCKD isdiagnosed by a ultrasound scan of the kidneys.Apart from control of blood pressure there isno “cure” to stop the development of kidneyfailure.


VASCULAR DISEASES OF THEKIDNEYRenal Artery Stenosis – a narrowingof the lining of the main artery (bloodvessel) which supplies the kidneys. Theresulting restriction of blood flow to thekidneys may lead to reduced kidneyfunction and high blood pressure.

This type of hypertension is known asrenovascular hypertension and accountsfor approximately 5% of patients withhypertension.

Renovascular hyper-tension occurswhen the artery to one of the kidneys isnarrowed (unilateral stenosis). Renalfailure occurs when the arteries to bothkidneys are narrowed (bilateral stenosis).The decreased blood flow to bothkidneys increasingly impairs renalfunction.This condition may be amenableto treatment with a balloon to open theblocked artery.

Obstructive Disorders of the KidneyObstructive Nephropathy – is a renal

disease caused by a blockage to urine flowthrough the urinary tract. There are manythings that can block urine flow. Some of themore common causes include:● Kidney Stones

● Enlarged Prostate Gland or ProstateCancer (males)

● Bladder Problems

● Bladder Cancer

Obstruction of the urinary tract results inincreased back pressure on the kidneys andincreased frequency of urinary tract infections.Both of these factors cause recurrent episodesof renal inflammation, scarring and the kidneysmay shrink in size (atrophy). If the blockage isonly for a short time, the kidney can usuallyrecover completely when the blockage isrelieved. However, if the blockage is there for along time (for many days or weeks) it cancause permanent kidney damage.

Pyelonephritis – is a bacterial infection ofone or both kidneys. Chronic pyelonephritis isrenal damage caused by recurrent orpersistent kidney infections. Chronicpyelonephritis is associated with progressivescarring of the kidneys, which can lead to

kidney failure. It occurs mainly in patients whohave malformations within the urinary tract.

PROGRESSION OF CHRONICKIDNEY DISEASE

It is true to say that once somebody hassome degree of kidney disease it frequentlyprogresses over time.The rate of progressioncan be very variable. The stage of chronickidney disease (CKD) can be thought of interms ranging from 1 to 5.

In CKD stage 1 the patient has normalfiltering function as measured by theGlomerular Filtration Rate (GFR) of about 120mls/min. Other levels of CKD are outlinedbelow:

The GFR can be calculated by doing a 24hour urine collection. Once the GFR is belowabout 70 it frequently continues to decline. Ifthe GFR declines by one ml per year it will take80 years to progress from CKD Level 1 toCKD Level 5 requiring dialysis or a kidneytransplant. However if GFR declines by 10mlsper year it will only take 8 years to go fromCKD Level 1 to CKD Level 5.

CKD 1 GFR greater than 90mls/minCKD 2 GFR 60 to 89CKD 3 GFR 30 to 59CKD 4 GFR 15 to 29CKD 5 GFR less than 15mls min

Renal Artery Stenosis

Blood pressure control is one of thefactors we can have the biggest influence on inslowing the progression of kidney failure.Thetarget blood pressure for any patient withrenal disease should be around 120/80 mmhg.The use of blood pressure medicines called

angiotensin converting enzyme inhibitors orangiotension II blocking inhibitors has aconsiderable benefit in slowing progression ofkidney disease.

Examples of these medicines wouldinclude:


There are are many factors that can affect the rate of decline in renal function.THESE INCLUDE:● Underlying cause of kidney disease● Blood pressure control● Use of certain anti-hypertensive drugs such as ACE inhibitors● In patients with diabetes the success of their blood glucose control● Control of cholesterol level

● Captopril ● Quinapril ● Enalapril ● Valsartan ● Losartin


Many people who have chronic kidney disease do not know itbecause the early signs can be very subtle. It can take many yearsto go from chronic kidney disease (CKD) to end stage renal

failure (ESRF). Some people with CKD live out their lives without everreaching kidney failure.

In fact the majority of people with kidney disease have no symptomswhen first diagnosed and are diagnosed on the basis of blood or urinetests.

However, for people at any stage of kidney disease, knowledge is power.Knowing the symptoms of kidney disease can help you get the treatmentyou need to feel your best.

SYMPTOMS OF KIDNEY DISEASE

SYMPTOM 1:CHANGES IN URINATION

Kidneys make urine, so when thekidneys are failing, the urinemay change. How? You mayhave to get up often atnight to urinate. Urine

may be foamy orbubbly. You mayurinate more often, or

in greater amounts thanusual, with pale urine.Youmay urinate less often, or in

smaller amounts than usualwith dark coloured urine. Your

urine may contain blood.You may feelpressure or have difficulty urinating.

WHATPATIENTS SAY:“My urine is what Istarted noticing first.I would frequently want to go to the bathroom and when I got there I could only pass a few

drops.”

SYMPTOM 2:SWELLINGFailing kidneys don't remove extra fluid, whichbuilds up in your body causing swelling in thelegs, ankles, feet, face and/or hands.

WHAT

PATIENTS SAY:

“I had a lot of swelling

in my ankles.

My ankles were so big

I couldn’t get my

shoes on.” Your tests reveal thatyou are retaining fluids!

© 2007 Jazz C

omm

unications Limited


SYMPTOM 3:FATIGUE

Healthy kidneys make a hormone called erythropoieyin (a-rith'-ro-po'-uh-tin) that tells your body to make oxygen-

carrying red blood cells.As the kidneys fail, they make less erythropoietin.

With fewer red blood cells to carry oxygen, your musclesand brain become tired very quickly.This condition is called

anaemia, and it can be treated.

WHATPATIENTS SAY:“I was constantlyexhausted. It’s just likewhen you’reextremely tiredall the time.”

WHAT

PATIENTS SAY:

“I would sleep a lot.

I’d come home

from work and get

straight

into bed.”

WHATPATIENTS SAY:“Fatigued, and you’rejust drained,even if you didn’tdo anything.”

SYMPTOM 4:SKIN RASH/ITCHINGKidneys remove wastefrom the blood stream.When the kidneys fail,the build-up of wasteproducts in your bloodcan cause severeitching.

WHATPATIENTS SAY:“It’s not really a skin itch or anything, it’s justright down to the bone.I was itching and scratching a lot.”


WHATPATIENTS SAY:“You don’t havethe appetiteyou used to

have.”

SYMPTOM 5:METALLIC TASTE INMOUTH/AMMONIABREATHA build-up of waste products inthe blood (called uraemia) canmake food taste different andcause bad breath. You may alsonotice that you stop liking to eatmeat, or that you are losing weightbecause you don't feel like eating.

WHAT

PATIENTS SAY:

“Foul taste in

your mouth.Almost

like you’re

drinking iron.”

SYMPTOM 6:NAUSEA ANDVOMITINGThe severe build-upof wastes in theblood (uraemia)can also causenausea andvomiting. Loss ofappetite can lead toweight loss.

WHATPATIENTS SAY:

“I was nauseatedand getting sick all thetime. I couldn’t keep

anything in mystomach.”

WHATPATIENTS SAY:“When I got the nausea,I couldn’t eat and Ifound it difficult toswallowmy tablets.”

WHATPATIENTS SAY:“I couldn’t sleep atnight because when

I lay down flat, I couldn’t catchmy breath.”

SYMPTOM 7:SHORTNESS OFBREATHTrouble catching your breathcan be related to the kidneysin two ways. Firstly, extra fluidin the body can build up inthe lungs.And secondly,anaemia (a shortage ofoxygen-carrying red cells) canleave your body oxygen-starved and short of breath.

WHAT

PATIENTS SAY:

“You go up a set of stairs

and you’re out of breath,

or you do work and

you get tired and you

have to

stop.”


SYMPTOM 10:FLANK PAINSome people with kidney problems may have pain in the back or side related to the affectedkidney. Most patients with kidney disease do not experience any pain.

WHATPATIENTS SAY:“I noticedsometimes I getreally cold,like chills.”

SYMPTOM 8:FEELING COLDAnaemia can make youfeel cold all the time,even in a warmenvironment.

WHATPATIENTS SAY:

“My memory disimproved

a lot - I couldn’t remember

what I did last week or maybe

2 days ago. I couldn’t

really concentrate on my

crossword puzzles

or reading.:”

SYMPTOM 9:DIZZINESS AND TROUBLECONCENTRATINGAnaemia related to kidney failure means that your brainis not getting enough oxygen. This combined withuraemia can lead to memory problems, trouble withconcentrating, and dizziness.


Chapter 3DIAGNOSTIC TESTING

WHAT ARE DIAGNOSTIC TESTS?

Diagnostic tests are used by doctors inorder to better assess your healthsituation.These tests can be used to

help establish your initial diagnosis, assess theeffectiveness of the treatment you arereceiving and/or detect potentialcomplications. Some tests are simple, so simplethat often you are unaware that they arehappening, like a dipstick analysis of a urinesample. Other diagnostic tests are obviousenough for you to be aware of – like havingyour blood pressure, temperature and pulsechecked.There is another group of diagnostictests that are considered to be low risk andnon-invasive such as having an x-ray or anultrasound scan.

As soon as the requirements of a specifictest involves entry of a needle or a probe intoyour body they are considered to be ‘invasive’.These tests include procedures such as bloodtests, kidney biopsy or x-rays that require aninjection of a dye.

WHY ARE DIAGNOSTIC TESTSIMPORTANT?

Diagnostic tests are often an importantpart of establishing what your health problemis so that your doctor and nurse can deliverthe treatment and care that will best suit yourhealth care needs. The doctor can use otherassessment skills to assist in this problemsolving process. These skills involve drawingconclusions from a persons medical history

and performing a physical examination.However, a diagnostic test is often required toestablish a diagnosis, to plan an intervention, orto monitor progress.

URINE TESTS

What does a dipstick urine test show?A dipstick urine test, also known as a

urinalysis, is a very simple test that iscommonly done in clinics or when admitted tothe hospital.You will be supplied with a sterilecontainer and asked to carefully pass urineinto the container so as to avoid the samplebeing contaminated. A nurse will insert aspecial strip into the urine sample which candetect protein, blood, white blood cells andglucose in the urine according to the changingcolour of the strip.

Dipstickurine test


Protein – this is an important buildingblock in the body. When your kidneys aredamaged, protein leaks into your urine(proteinuria). Persistent protein in the urinesuggests damage to your kidneys.

Blood – The sample will be examined forcolour and clearness. If blood is present theurine may look red or the colour of cola.Thismay indicate an infection.

White Blood Cells – When present inurine is an indication of infection

Glucose (sugar) – If present in urine it maybe an indication of Diabetes

What is Urine Culture and Sensitivity?A 'mid-stream' urine sample (don't collect

the first or last part of the urine that you pass,which may contain bacteria or cells normallyfound on the skin) is sent to the laboratory tobe looked at under a microscope which canhelp diagnose some kidney diseases. Manythings can be seen - like red blood cells - thiscan be a sign of kidney disease that damage thefiltering units of the kidney, allowing blood cellsto leak into the urine. It may also indicateother problems like kidney stones. Whiteblood cells, crystals, and bacteria can also bedetected if there are bacteria or white bloodcells this may suggest urine infection. Toconfirm this, bacteria are allowed to grow onspecial plates overnight (culture). This allowsthe doctor to prescribe the most effectivetreatment for you.

24 hour urine collectionKidney function is most precisely

measured by calculating theGlomerular Filtration Rate.This is a precise estimateof the level of kidneyfunction and can predictthe time of when renalreplacement therapy islikely to be needed. GFRcan be determined bydoing a 24 hour urinecollection and a blood test.

You may be asked to complete the urinecollection at home or when admitted tohospital.

You will be given 1-2 large urine bottles andasked to collect your urine over 24 hours. It isimportant to discard the first urine sample ofthe day into the toilet and then collect all urinefor the next 24 hours into the bottle(s). Onthe second day the first sample of urine shouldbe collected and then the collection iscomplete.A blood test is taken when the urinecollection is completed. It is important that the

test is accurately carried out or results willbe wrong.

BLOOD TESTSBlood tests are regularly

carried out to measure howwell your kidneys are working.

The table on the next pageoutlines some of the blood tests

that will be performed and whatthey mean.

24 hoururine

collectionbottle

“Blood tests areregularly carriedout to measurehow well yourkidneys areworking”


Blood Sample Normal levels Why it is being measured

Urea (Ur) 2.5-8.5 mmol/L A waste product produced in the liver and excreted by the kidneys. High values may mean the kidneys are not working as well as they should.

Creatinine (Cr) 50-120mmol/L A waste product produced largely from muscle breakdown. High levels especially with high Urea levels indicate problems with the kidneys.

Sodium (Na) 135-145mmol/L The balance of salt and water in the body.

Potassium (K+) 3.2-5.2mmol/L Important for proper functioning of nerves and muscles, particularly the heart. High and low levels require medical evaluation. Potassium comes from food especially fruit vegetables and nuts.

Calcium (Ca) 2.12-2.62mmol/L Excreted by the kidney. Important for muscle contraction, cardiac function and blood clotting.

Phosphate (P04) 0.7-1.5mmol/L Excreted by the kidneys. Necessary for strong bones, teeth, normal functioning of muscle and blood clotting.

Albumin 30-50g/L Protein in the blood made in the liver. Low levels may indicate that protein is leaking into thekidneys or if someone is malnourished.

RisksCholesterol 0.00-5.00mmol/L Measures how much cholesterol and lipids are

present in your blood.

Triglyceride 0.000-1.90mmol/L

Urate 140-420 umol/L

Parathyroid 15-65 pglm Concerned with the regulation of extra-cellular Hormone calcium levels.

Iron Studies Ferrithin 18-240 nglml Main stored iron found in all tissues.

Complete Blood 13.0-16.0gm/dl Complete blood count is the red protein in blood. ItCount (CBC) carries oxygen around the body. One of the kidneys

function is to produce erythropoietin (EPO) which stimulates the bone marrow to produce red blood cells.When kidneys fail it may be necessary to give EPO in the form of an injection.

White Cell Count 4-11 10 ^g/l White blood cells fight infection in the body.(WCC) Raised/low levels may indicate infection.

Hepatitis B+C Positive/Negative Checks for the presence of hepatitis infection.


PLAIN ABDOMINAL X-RAYA plain abdominal x-ray is used to show the

kidneys, urethra and bladder (KUB). It alsoindicates the size, shape, position and thepresence or absence of one or both kidneys.

What preparation is required?There is no preparation required for this

test.

RENAL ULTRASOUND SCANThis is a non-invasive procedure where a

transducer (sonar probe) is moved in closecontact over the skin over the area ofinvestigation and it can be repeated frequentlyif necessary. Ultrasound is used to determinethe size and shape of the kidneys, to checkboth kidneys are present, location of kidneysand is useful in detecting cysts.

What preparation is required?You will be asked to wear a hospital gown.

Depending on the area of ultrasound you maybe asked to fast prior to the procedure.Yourdoctor/nurse will inform you if this isnecessary.

There is no risks attached to thisprocedure.

COMPUTERISED TEMOGRAPHY(CT SCAN)

A CT Scan also known as a CAT scan is aspecialised x-ray which provides clear picturesof the inside of your body. In particular, it cangive good pictures of soft tissues of the bodywhich do not show on ordinary x-ray pictures.

What preparation is required?You will be provided with a hospital gown

to wear during the procedure. Any jewellerywill need to be removed and depending onwhat area is being scanned you may need tofast prior to the procedure.Your doctor/nursecan inform you of this if it is necessary.Also itmay be necessary to drink special fluids priorto the procedure. This is needed if you arehaving an abdominal/pelvic scan. This drinkhelps to show up the stomach and bowel moreclearly. Sometimes a dye (contrast medium) isinjected into the bloodstream via a needlewhich is inserted into your vein.The dye maygive you a flushing feeling and an odd taste inyour mouth for a short time. Your doctorwill prescribe a course of medication(n-acetylcystine) to take on the day before thescan, the day of the scan, and the day after.Thismedication protects your kidneys from

Renal Ultrasound Scan


becoming damaged from the contrast dye thatis used during this procedure.

The scan is painless however it may take alittle time to obtain the necessary pictures.

INTRAVENOUS PYELOGRAM (IVP)An IVP is a type of x-ray examination

specifically designed to study the kidneys,bladder and ureters (the tubes that carry urinefrom the kidneys to the bladder).The kidneysare responsible for removing contrast dyefrom the blood and collecting it into the urine.Contrast dye is injected into a vein via a needlethat the doctor will insert.You will be asked tochange positions throughout the procedure sothat a number of images is taken, at timedintervals, to see how well the kidneys areworking.

You will need to inform the doctor if ● you are, or think that you may be pregnant;● if you are allergic to contrast dye;● if you have any drug allergies.

What preparation is required?You will be asked to fast prior to having the

procedure. Prior to signing a consent form thedoctor will discuss what the procedure entails

and the risks attached to having thisprocedure. It may be necessary to give you alaxative on the evening before and themorning of the procedure in order to removeintestinal gas and faeces to ensure a clear viewof the kidneys.You should remove all jewelleryprior to the procedure and it is necessary towear a hospital gown. It is important to emptyyour bladder before attending for the test.

What will the procedure feel like?When the contrast dye is injected into your

vein you may feel a flushing sensation in thearm and body. Some people experience ametallic taste in their mouth.These symptomsshould disappear in a short period of time. Onrare occasions some patients may becomeshort of breath or experience swelling in thethroat or other parts of the body, these can besigns of an allergic reaction to the contrast dyethat will be treated promptly.

What will happen after the procedure?You will need to drink plenty of fluids for

the following 24 hours providing you are noton fluid restriction. This will help to flush thedye from your system.

Computerised Temography(CT SCAN)

ECHOCARDIOGRAMAn echocardiogram is an ultrasound scan of

your heart.The scan can give clear pictures ofthe heart muscle, heart chambers andstructures within the heart such as the valves.Electrodes will be placed on your chest toallow for a tracing of your heartbeat duringthe procedure. Some cold gel will be spread onyour chest and a transducer is placed on yourribs near your breastbone and directedtowards your heart. The transducer will pickup the echos of the sound waves whichtransmit them as electrical impulses. Theechocardiography machine converts theseimpulses into moving pictures of the heart.During the procedure you may be asked tobreathe in a certain way and change yourposition.

What preparation is required?There is no risks attached to having this

procedure performed and after the test iscompleted you continue on normally.

ANGIOGRAMAn Angiogram is a test using dye and x-ray

to see if there are any problems in the arteries,

valves or chambers of the heart.This test maybe performed if you experience tightness orpain in the chest, jaw or arm. A catheter isinserted via the femoral vein (top of the leg)and fed into the bigger artery.The contrast dyeis injected and a number of x-rays is taken.Youcan have an angiogram of your coronary(heart) or renal (kidney) arteries.This test canidentify tumours, trauma and stenosis of thevessels. Complications of this test includebleeding and a formation of a haematoma atthe catheter site, or occasionally furtherdeterioration of kidney function.

What preparation is required?Your doctor will explain the procedure to

you and will ask you to sign a consent form tostate that you understand the procedure andpossible complications. Some complicationsmay include irregular heart rhythms, chestpain, allergic reaction to the dye, bleeding atthe groin site and very rarely heart attack orstroke.

You will be asked to remove your jewelleryand be provided with a hospital gown to wear.It will be necessary to take some bloodsamples which will be sent to the laboratory


Angiogram


to ensure it is safe to perform this procedure.Your doctor will also place a needle into yourvein (cannula) which is required for theprocedure. It may be necessary for you to takemedication (n-acetylcystine) prior to this testin order to protect your kidneys from the dyethat is required for the test.

What will happen after the procedure?After the procedure you will be asked to

remain on bedrest for 6 hours to allow thepuncture site to heal completely.You will needto drink plenty of fluids for the following 24hours providing you are not on fluid

restriction.This will help to flush the dye fromyour system.A bedpan/urinal will be provided ifrequired. It is very important that you do notbend your leg or sit up before your rest time isover. The nurse will be checking your bloodpressure, pulse and the site where theprocedure was carried out. Inform the staff ifyou have pain or discomfort as pain medicationcan be given.

Your doctor will discuss your results withyou before you leave the hospital or at yournext appointment. It may be necessary to startsome medication or go for further testsdepending on your results.

ANGIOPLASTYAngioplasty will be

required if your angiogramshows that there isatherosclerotic plaques(fatty deposits) in yourcoronary or kidneyarteries as this can reduceblood flow.Angioplasty isused to unblock thesearteries in order to returngood blood flow back tothe heart or kidney.

In general angioplasty isa safe procedure but youshould discuss the risks ofthis procedure with yourdoctor as occasionally theangioplasty may cause arupture of the arteryrequiring emergencysurgery.This happens lessthan 5% of the time.

What preparation isneeded?

Your doctor willexplain this procedure toyou and will ask you tosign a consent form tostate that you understandthe procedure and

possible complications.You will beasked to remove your jewellery andprovided with a hospital gown towear. It will be necessary to takesome blood samples which will besent to the laboratory to ensure itis safe to proceed with thisprocedure.Your doctor will alsoinsert a needle into your vein(cannula) which is required for theprocedure. It may be necessary foryou to take medication (n-acetylcystine) prior to this test inorder to protect your kidneys fromthe dye that is required for the test.Your doctor may also give youaspirin and/or plavix which aremedications that help to thin theblood prior to the test.

What will the procedure feel like?Instead of just injecting dye into

the arteries the doctor will pass atiny wire into the narrowed orblocked artery.An angioplastycatheter will be placed over thewire and when it is correctlypositioned the balloon at the endof the catheter will be inflated.Youmay feel symptoms of chest, jaw orarm pain. If this occurs you will beencouraged to inform the doctorimmediately.The balloon may beinflated and deflated several timesin order to flatten the plaqueagainst the walls of the artery andwiden the vessel. Dye is theninserted to ensure the vessel issufficiently widened.

It may be necessary to havestents inserted (stainless steel meshor coil) into the artery for furtheropening.

What will happen after theprocedure?

See instructions for renal angiogram.


Coronary Angioplasty

Renal Angioplasty


RENAL BIOSPYA renal biopsy is an important test to either find out why the kidneys have stopped working

properly or to confirm a diagnosis of rejection in transplant patients.

What preparation is needed?You are admitted to the ward the day before or the morning of your biopsy.You will be asked

to fast from 12 midnight the night before the procedure.Your blood pressure will be checked anda blood sample taken to ensure that it is safe to proceed.

The doctors will discussthe complications to youand obtain a writtenconsent.The doctor willinstruct you on anymedications that need to bestopped prior to theprocedure e.g.Warfarin.

How is the procedureperformed?

A renal/kidney biopsy iscarried out in the x-raydepartment. Mild sedationmay be given prior to theprocedure.If the biopsy is ofyour native kidney, you willbe asked to lie on yourtummy.

Renal Biopsy

If the biopsy is of your transplant kidneyyou will be asked to lie on your back.Thisallows the doctor easier access to the kidneys.The skin will be cleaned with antisepticsolution and a local anaesthetic will be given tonumb the area. A special biopsy needle isintroduced through the skin into the kidney totake the sample.Two or three samples may berequired.

What happens after the biopsy?Following the biopsy you will be asked to

stay in bed for 24 hours.This is to allowthe puncture site time to stopbleeding. You will be allowed tomobilise to the toilet only after6 hours. Your blood pressureand pulse will be monitoredregularly and the biopsy sitedressing checked. Each time youpass urine it should be given tothe nurse who will then test it tosee if there is any bleeding. Painkillerswill be prescribed if you need them.

You will be able to eat and encouraged todrink plenty of fluids (providing you are not onfluid restriction). Following the 24-hour period

of bedrest, you may be discharged if no otherprocedure/treatment is scheduled for you.

It is advisable to avoid any strenuousexercise for a week after the biopsy to reducethe risk of bleeding.After this there should beno reason why normal activities cannot beresumed.

If you experience severe pain over thebiopsy area or notice blood in your urine, youshould report back to your doctor.

What are the possible complicationsduring a renal biopsy?

Any medical or surgicalprocedure carries risks. Patients

are asked to undergoprocedures because it is feltthat the benefits outweigh therisks. Complications of renalbiopsy are very rare.The most

important is bleeding, and youare closely monitored after the

biopsy to detect bleeding.You may have pain or discomfort after the

biopsy. Painkillers can be taken to reduce anydiscomfort. If you experience severe pain afterthe biopsy you should contact the renal unit.

Other possible complications of renalbiopsy include:● Bleeding into the kidney which can result in

loss of the kidney;

● Persistent haematuria (blood in your urine)

● Biopsy of an organ other than the kidney

● Rupture of the kidney;

● Death (extremely rare)

When do I get the results?It takes up to 48 working hours for the

laboratory to give a preliminary report andabout a week to ten days to get a full writtenreport.Your doctor will discuss the results ofthe biopsy with you and discuss appropriatetreatments if required.

27R E N A L D I S E A S E – A G U I D E F O R PAT I E N T S

“Followingthe biopsy youwill be asked tostay in bed for

24 hours.”


Dietary treatment is an importantaspect of care for all patients withrenal disease. It is necessary to meet

with your dietitian to discuss individual needsfor your renal diet.

The following information will give you anoverview of a renal diet prior to dialysis andalso what to expect when you commencedialysis.

Chapter 4DIETARY ADVICE

FOR RENAL PATIENTSA healthy balanced diet contains correct

amounts of protein, carbohydrate, fat, vitaminsand minerals. It is important that your diet isbalanced and varied to keep you in optimumhealth.

Some of the main functions of the kidneythat relate to the diet include:● Excretion of waste products● Control of fluid volume in the body● Control of blood pressure

Healthy balanced diet

When food and drinks are consumed, ourbodies use what is needed and the rest isturned into waste products which can beexcreted as urine.When your kidneys are notworking properly these waste products canbuild-up in your blood and causecomplications which will be discussed in thefollowing sections.

SALTSalt is an important aspect of dietary

treatment at all stages of your kidney disease.High intake of salt from the diet can causeproblems with blood pressure control, fluidretention and drainage of fluid on dialysis. It isadvised to avoid adding any salt to meals andalso to reduce the intake of very salty foodssuch as processed meats, bacon, sausages, soupand packet sauces in the diet.Your dietitian willadvise you on suitable alternatives to using saltin the diet.

PROTEINProtein intake from the diet is important

during the progression of chronic kidneydisease and also when you commencedialysis.The protein we eat is used for tissuerepair and growth. Any unused protein isbroken down into waste products includingurea and creatinine.As your kidneys are unableto excrete urea and creatinine properly theybuild up in your blood and cause symptomssuch as nausea and loss of appetite.

By eating large amounts of protein foodse.g. meat, fish, chicken, eggs, cheese, milk andyoghurt before commencing dialysis you willaffect the build-up of urea and creatinine inyour blood. An appropriate daily intake ofprotein should be advised by your dietitian.

However once dialysis treatment hasstarted it is important to make sure that yourbody is getting enough protein to preventmalnutrition. Some of your stores of proteinare lost during the haemodialysis and CAPDsessions.

How much protein you need depends onyour body size and is specific to eachindividual.


Foods to avoid

POTASSIUMPotassium is a mineral found in many foods,

mainly fruits, vegetables and potatoes. It isnecessary for muscle contractions but a veryhigh level in the blood can be dangerous as itmay cause irregular heart rythym. If yourpotassium levels increase above normal youwill need to avoid certain foods that are highin potassium as advised by your dietitian. Highsources of potassium in the diet includebananas, dried fruit, peas, beans, spinach andpotato products such as chips and crisps.

The dialysis diet provides enoughpotassium to meet the needs of your body,while preventing accumulation betweendialysis sessions.

PHOSPHATEPhosphate is another mineral found in

many foods, mainly dairy products such asmilk, cheese, yoghurts, and also bran and nuts.Calcium and phosphate work together to keepyour bones, teeth and blood vessels healthy.When phosphate and calcium levels areelevated or out of balance in kidney disease,the extra calcium and phosphate join togetherto form hard deposits in your body. This isknown as calcification.These deposits can formin the heart, lungs, blood vessels, joints andother soft tissue. High phosphate levels alsoaffect your bones, causing renal bone disease.Over time bones become brittle, weak andpainful and liable to fracture easily.

As with potassium an elevated phosphatelevel will require you to reduce the intake ofphosphate from your diet. It may also benecessary to take phosphate bindingsubstances with your food which reduce theabsorption of phosphate from the gut.

FLUIDSIf you are treated with haemodialysis or

peritoneal dialysis you may need to limit yourfluid intake. The amount of fluid you will beallowed depends on the amount of urine youproduce. You can reduce your fluid intake byusing small cups/glasses, and spacing out yourdrinks throughout the day. You can also helpprevent thirst by limiting the amount of saltand salty foods that you eat.

Each person with renal disease is verydifferent and so are their needs andrequirements.The dietary advice you are givendepends on a number of factors including thestage of renal disease, the type of treatmentyou are on, your blood results, your bodyweight, and the presence of other medicalconditions e.g. diabetes mellitus, highcholesterol levels. The dietitian will thereforeprovide you with information that is designedfor you as an individual to suit your ownspecific needs.


We’re a little concernedabout your potassium levels

Pepper, herbs, garlic, mustard, lemon Salt, stock cupes, soupHome-made stock Salted snacksChicken, lamb, pork, beef, eggs Bacon, sausage, black & white puddingFish (excluding smoked fish) Processed meats

Foods to ENJOY Foods to AVOID

The following tables can be used as a guide of suitable foodsto use within your renal diet:

© 2007 Jazz C

omm

unications Limited


Apples, pears, plums, mandarins, grapes Banana, dried fruit, prunes, apricot,Kiwi, peach, grapefruit rhubarbCauliflower, peppers, carrots, broccoli, Peas, baked beans, mushrooms, spinach,Cabbage, green beans, turnip Salt substitutesBoiled/mashed potato, rice, pasta Jacket/chipped/roast potatoSpirits, white wine, boiled sweets Beer, stout, red wine, chocolate, coffee

Foods Lower in Potassium Foods High in Potassium

Ask your dietitian about milk alternatives Milk, yoghurt, cheesePorridge,Weetabix, Cornflakes, tea Bran cereals, peas, beans, corn, nutsMarshmallows, jellies, boiled sweets Toffee, cola

Foods lower in Phosphate Foods high in Phosphate

BREAKFASTBoiled/poached/fried eggs Bacon, sausage, black & white puddingPlain omelette, bagel, English muffin Salt substitutesCroissant, french toast, porridge, Bran cereals, muesliCereals (excluding bran cereal & muesli)

SALADSLettuce, carrots, cauliflower, peppers Raw spinach, olives, pickles,Celery, onions, cucumber, coleslaw Mushroom, kidney beansMacaroni salad, cottage cheese Seeds, nuts, potato salad

MAIN COURSEAsk for sauces/gravy to be served Casseroles, cured or salted meatson the side and use sparinglyRoast/grilled pork/lamb/beefChicken/turkey, fish

SIDE ORDERSGreen beans, cabbage, asparagus Spinach, mushrooms, peas, cornCarrots, cauliflower, broccoli Chipped/jacket potatoPlain rice/pasta/noodles

DESSERTCanned peaches, pears, fruit cocktail Dried fruit, fresh fruit cocktail, melonFresh grapes, fresh & canned pineapple Banana, orangeJelly, pain & cream cakes Desserts with chocolate, nuts, dried fruit,Sherbet, sorbet, plain biscuits Coconut, milk pudding, ice cream

CHOOSE AVOID

Guide of suitable foods to use within your renal diet:


People with renal failurewill find themselves on avariety of medications.

These medications can beclassified according to whatthey do and include thefollowing:

● Phosphate binders● Antihypertensive

medications● Diuretics● Erythropoietin (EPO)● Oral and intravenous iron

These are just examples of some of thedrugs available. Medications have differentbrand names so it is important to realise thatdifferent coloured medication may be givenwhile in hospital.

PHOSPHATE MEDICATIONSMany of the foods you eat contain an

element called phosphate. Foods particularlyhigh in phosphate include all dairy productssuch as milk, and also chocolate, pizza andbread. When kidneys fail they are not able toget rid of phosphate and it will build up in yourbody. It is necessary to take medications called‘phosphate binders’. There are a number ofdifferent phosphate binders available. They allwork in the same way in that they bindphosphate in your stomach which prevents the

phosphate being absorbed into yourcirculation. All phosphate binders aretaken with meals. This is the only way thesetablets work and are of no benefit at any othertime

The available phosphate binders include:Calcium containing compounds. These

calcium tablets are effective at bindingphosphate but sometimes can cause thecalcium level in the blood to go too high.Thesetablets may cause constipation or gas.They arechewed and taken with meals

Sevelamer (Renagel). This tablet isswallowed and not chewed. Frequently youmay have to take as many as 3 tablets, 3 timesa day. This tablet may also cause someconstipation or abdominal discomfort. It hasthe advantage over other phosphate binders inthat it does not contain calcium.

Chapter 5MEDICATIONS

BLOOD PRESSURE MEDICATIONSIt is very important to control blood

pressure aiming to keep blood pressure asclose to normal as possible. There are manyapproaches to control blood pressureincluding weight loss, salt avoidance, exerciseand reduction in alcohol intake. Many patientswill however also need to take blood pressuretablets. There are many different classes ofblood pressure tablets including:● Betablockers● Calcium channel blockers● Angiotensin converting enzyme inhibitors

(ACE)● Angiotensin receptor blockers (ARB)● Alpha blockers

BETABLOCKERS(e.g.Atenolol, Metoprolol, Bisoprolol)

Betablockers are among the mostcommonly prescribed anti-hypertensivemedications examples would include Atenololand Metoprolol.These tablets are used to treatcardiac conditions in addition to high bloodpressure. Betablockers work by blocking theeffect of adrenaline on blood vessels and theheart. Consequently they will slow the heart alittle. People with severe asthma need to becareful with these medications as they maymake asthma worse and they may alsooccasionally make your hands feel cold.Occasionally betablockers may give younightmares.

CALCIUM CHANNEL BLOCKERS(e.g. Istin, Dilzem)

Calcium channel blockers work by directlymaking blood vessels relax by blocking calciumgoing into muscles around the blood vessels.The commonest side-effect of thesemedications is swelling of the legs. They mayalso occasionally cause redness of the skin.

ANGIOTENSIN CONVERTINGENZYME INHIBITORS (ACE) ANDANGIOTENSIN RECEPTORBLOCKERS (ARB)

One of the important hormones in thebody that controls blood pressure in the bodyis called angiotensin. ACE inhibitors work byblocking the production of this hormone andARB work by stopping the effect ofangiotensin. These drugs are used to treatblood pressure and heart failure.They are alsoeffective at slowing the decline in kidneyfunction.ACE inhibitors may sometimes causea persisting cough which resolves when theACE is stopped. These medications may alsocause the potassium levels to rise too high.Your bloods will carefully monitor for this.

DIURETICS(e.g. Lasix, Burinex)

Diuretics are medications that make youpass more urine. These medications are usedto treat swelling of the legs, heart failure andare also commonly used to treat high blood



pressure. Diuretics can also be prescribed forpatients who are on dialysis which helpsproduce more urine and gain less weightbetween dialysis treatments.

These medications will work for up to sixhours after they are taken. Side-effects ofdiuretics include dehydration if they make youpass too much urine.

VITAMINSWhen you have kidney disease you will

have lower levels of vitamins in your body thanyou need, so you may need to take a numberof different vitamins including:● Multivitamins● Folic acid● Vitamin D

MULTIVITAMINSPatients who are on dialysis commonly lose

much of the water soluble vitamins through

the dialysis machine. It is important that youdo not take just any multivitamins as some ofthese preparations may contain too much ofthe fat soluble vitamins.

Folic acid is important for many of themetabolic functions of the body.They also havebeneficial effects in reducing momocysteinelevels which are elevated in patients withkidney disease which in the long-term cancause hardening of the arteries.

VITAMIN DThe kidney is responsible for converting

the vitamin D that is in your body into theactive form of vitamin D. People with kidneydisease lack the ability to produce the activeform of vitamin D.Vitamin D is important forthe absorption of calcium and for bone healthwhich is important to prevent the parathyroidglands becoming overactive. The parathyroid(PTH) glands are small glands in your neck that


the skin. EPO can be administered either once,twice or three times a week or sometimesevery second week or even only once a monthdepending on your blood. Patients will feelmuch better on EPO as they will acquire moreenergy with a higher haemoglobin.

EPO is prescribed on a high-techprescription.Your chemist will give you 4 or 5vials which you will need to keep in the fridge(not the freezer).Your renal nurse will eitherteach you how to administer the medicationyourself or arrange a district nurse or your GPpractice nurse to administer it. It is alsopossible to have your injection when youattend for dialysis.

It is important to stay on this medicationuntil your doctor indicates otherwise.You willneed frequent blood tests to monitor theeffectiveness of the EPO as too much EPOmay cause your blood to go too high or youmay need to increase the dose if you are notgetting enough benefit. It is important that youbring your medication with you on admissionto hospital or for each dialysis treatment ifrequired.

control calcium levels in your body. Peoplewith kidney disease can have PTH levels thatare too high. One of the major functions ofVitamin D is to lower PTH levels. Too muchvitamin D may cause the calcium in your bloodto go too high so your doctors and nurses willbe carefully monitoring calcium levels byobtaining regular blood samples.

ALPHA BLOCKERSAlpha blockers work by blocking the

function of adrenaline on blood vessels.Occasionally these medications may cause youto become dizzy when you stand up.

ERYTHROPOEITIN (EPO)Patients with renal failure commonly have a

low blood count. Under normal circumstancesthe kidney produces a substance callederythropoietin (EPO). EPO works on the bonemarrow cells to make more blood cells. EPOneeds to be administered by way of aninjection. It cannot be taken as a tablet. Theinjection may be given as an injection directlyinto the dialysis machine or as injection into


ORAL OR INTRAVENOUS IRON EPO is extremely effective at increasing

your blood count. However in order for theEPO to work effectively your body needs tohave enough iron. It is difficult for your body totake in enough iron through regular diet forthe EPO to reach full effect.Your doctor mayprescribe oral iron. Iron tablets can be a littleunpleasant to take as they may make yourstomach upset or cause you constipation. Irontablets will also make your bowel movementblack and tarry.

If you cannot tolerate iron tablets or yourdoctor determines by blood test that you arestill low on iron intravenous iron calledVenofer may be prescribed. If you are onhaemodialysis you will be given Venoferdirectly into the dialysis circuit. You mayreceive this by way of 5 injections of 200mgsover a period of time. If you are on homedialysis or not on dialysis you will need tocome to Hamilton Day Ward for infusions ofiron treatment. Intravenous iron is a safe drugbut there is an occasional occurrence of anallergic reaction. So, before you get the firstdose, you will generally receive a test dose(small dose).

PARATHYROID DRUGSAs we discussed under Vitamin D your

parathyroid glands are four small glands inyour neck that control the level of calcium inyour blood. In kidney failure parathroid (PTH)hormone tends to increase. When thishappens it can have a number of effectsincluding weakening of your bones and causingpain in your bones and joints. In the firstinstance your doctor may give you vitamintablets (Rocaltrol or One Alpha), however, ifthese do not work it may be necessary toreceive Vitamin D intravenously (Zemplar)directly into the dialysis machine. If thesestrategies are not adequate your doctor mayadvise you to take another drug calledCinacalcit (Mimpara). This drug is extremelyeffective at lowering PTH level.The main sideeffect of Cinacalcit is that it may cause a littlenausea after it is taken. This generally settlesdown after a few days.

Occasionally if these drugs are noteffective in controlling your PTH level yourdoctor may recommend an operation toremove part of your parathyroid glands (aparathyroidectomy).

Reco-pen

Aranesp


DRUGS TO AVOID● Ponstan● Neurofen● Ibuprofen● Advil● Difene● Volterol, etc.

CAUTION WITH COMMONLY USED DRUGSWhen you have kidney disease you need to be very careful with all

your medications.You need to make sure your doctor knows that youhave kidney disease before he prescribes you any new medications oralters your dose. Only take medication that is prescribed for you.Please inform your doctor or chemist if you plan to take herbalmedication as some of these may interact with your regularmedication. Similarly you need to be very cautious of many ‘over-the-counter’ medications which are easily available. Some of these include:● NSAIDS or anti-inflammatories should be avoided. Examples of

these would include: Ponstan, Neurofen, Ibuprofen, Advil, Difene,Volterol, etc.

For pain controlyou should takesimple analgesicssuch as Panadol orSolpadeine. If youneed somethingstronger speak withyour doctor.

It is veryimportant thatyou know yourmedication andhow it works.Your healthcareteam will workalongside you toachieve this.


CAUSES OF INFECTIONSThe common causes of Infections in Irelandare:● Bacteria (e.g. salmonella,TB, E.Coli)● Viruses (e.g. common cold, flu, winter

vomiting bug)● Fungi (e.g. thrush, athletes foot)

Infections are spread by:● Air (e.g.TB, chicken pox)

● Droplet, sneezing & coughing (e.g. mumps,rubella, common cold)

● Direct contact (e.g. salmonella from eatinguncooked chicken and sexually transmitteddiseases such as syphilis)

● Indirect contact (e.g. salmonella from asandwich made by the unwashed hands of aperson infected with salmonella)

● Vectors - e.g. mosquitoes spreadingmalaria

Chapter 6INFECTION AND VACCINATION


PREVENTING INFECTIONThe human body has developed general and

specific defences against infection. Generaldefences protect the body against all infectionsand examples include skin, secretions such astears, cilia (tiny hairs) which filter air enteringthe lungs and body washings such as flow ofurine from the bladder, which washes awaybacteria with the urine.

Specific defences develop when the body'simmune system produces antibodies againstcertain diseases. These antibodies developafter an infection (e.g. chicken pox) or aftervaccination (e.g. whooping cough, rubella) andensure that infection or re-infectionvery rarely occur.

People with kidney diseasehave an immune system thatdoes not work as efficiently asnormal. In addition somecomplications of commonillness such as pneumonia afterflu can be dangerous for peoplewith kidney disease. Howevereveryone can assist his or her naturalimmune system preventing infection by:● Eating a well balanced diet and taking

regular exercise ● Good general hygiene will help keep the

skin in good condition● Regular hand washing especially before

eating and after using the toilet ● Attending for regular check-ups with your

kidney specialist and GP will ensure thatyour kidney function and general health aremaintained

● Attending your GP or the renal unitpromptly if you are not feeling well

INFECTIONS AND KIDNEY DISEASEPeople with kidney disease are vulnerable

to all the infections that the general populationis such as flu, measles, mumps etc, howeverthey are more vulnerable to certain infectionsdue to the treatments used (haemodialysis,peritoneal dialysis and transplantation) anddue to regular hospital admissions (MRSA,VRE, and C.Difficle).

Infection complications associated withhaemodialysis

Haemodialysis treatment is known to be arisk for:1. Bacterial infections associated with access,

i.e. catheters, fistulas and grafts.2. Blood borne viral infections (hepatitis B, C

and very rarely HIV)

Access infectionsSee chapter 4 for detailed information on

infection associated with access

Blood borne infections associated withhaemodialysis (HD)

Outbreaks of viral bloodinfections (Hepatitis B and C)

have happened in haemo-dialysis units. As a result ourunit takes infection controlvery seriously indeed andevery effort to reduce the risk

to an absolute minimum.

The measures include the following:● All patients are screened on admission and

routinely for hepatitis B & C & HIV● All staff are vaccinated against hepatitis B● All patients are strongly recommended to

be vaccinated against hepatitis B● Patients with known infections are treated

in single rooms on special machinesAll equipment used on each patient is

either disposed of after each use or cleanedand disinfected after every use.

Infection complications associated withPeritoneal Dialysis

See chapter 5 for detailed information oninfection associated with Peritoneal Dialysis

Infection complications associated withTransplantation

See chapter 4 for information on infectionassociated with transplantation and theinformation book ‘Kidney Transplantation – AGuide for Patients’.

“People with kidney disease havea immune system

that does not workas efficientlyas normal.”


MRSA,VRE AND C.DIFFICLEPeople who have regular hospital

admissions such as renal patients are atincreased risk of acquiring MRSA, VRE andC.Difficle.

MRSAWhat is MRSA?

MRSA is the shortened term used whenreferring to Meticillin ResistantStaphylococcus Aureus. Staphylococcusaureus (S. aureus) is the name of the bacteria.The sensitive strain is found in the nose andskin of 20-30% of healthy people.The resistantstrain (MRSA) means that it cannot be treatedwith antibiotics normally used to treat thesensitive strain.

Where is MRSA found?MRSA is most often found in hospitals or

nursing homes where antibiotics are usedfrequently therefore encouraging thedevelopment of resistant strains of bacteria.

How does a person acquire it?MRSA is transferred from one person to

another by human contact.The main method is

on hands, during patient care. Patients, who arecarriers, may pass it on to other patients ifthey are in close contact

Does MRSA make a patient more ill? Some patients are colonised with MRSA

and others have infections caused by MRSA.A patient is colonised with MRSA when he/shehas no signs or symptoms of infection. It doesnot alter their treatment and is not a reason tostay in hospital.

MRSA infection, like other infections, variesfrom mild to severe and depends on otherfactors such as where the infection is and thepatient age and underlying conditions. Aperson found to be colonised or infected withMRSA will be nursed separately from otherpatients in a single room (isolation) or in aroom with others who also have MRSA (co-horted).

What is the treatment for MRSA?A patient colonised with MRSA is treated

with special washes and ointments.A patient infected with MRSA is treated

with antibiotics, in tablet or by a drip into avein.

Good handwashing practiceis essential to avoid the

spread of infections


VREWhat is VRE?

VRE is the short-term used when referringto Vancomycin Resistant Enterococci.Enterococci are bacteria found in the faeces ofhumans. Most of the time enterococci are partof the normal bacteria of the bowel and do notcause disease. A strain of enterococci hasdeveloped resistance to vancomycin, which isan antibiotic used to treat serious infectionsincluding MRSA infections.

Where is VRE found?VRE is found in hospitals where patients are

very unwell, such as intensive care, renal andtransplantation wards. Enterococci can surviveon surfaces, ledges and floors.

How does a person acquire VRE?VRE may be transferred from one person

to another by direct contact particularly fromhands during patient care.

Does VRE make a person more ill?This varies from patient to patient. The

majority of patients are colonised, while someare infected. Colonised means that the VRE isnot causing infection. The presence of VREcolonisation does not alter their treatmentand is not a reason to stay in hospital. VREinfections can vary from mild to severe anddepends on factors such as the site of theinfection and the patients overall condition.

Patients with VRE in a wound or in a urinespecimen or those having diarrhoea need tobe nursed in a single room (isolation) ornursed in a roomwith other patientswith VRE

(co-horted).What is the treatment for VRE?

Infection with VRE is treated withantibiotics usually given in a drip in a vein.Colonisation with VRE does not require anyspecial treatment.

C.DIFFICLE (CLOSTRIDIUMDIFFICLE)What is Clostridium difficle (C. Diff)?

C.Diff. is a bacteria that causes diarrhoeaand may cause intestinal conditions such ascolitis. It is a common infection in hospitals andlong-term facilities.

The use of antibiotics alters the normalbacterial content of the bowel and therebyincreases the risk developing C. Diff. diarrhoea.

Where is C. Diff found?C. Diff is found in the bowel of some

people and can also survive for a long time onsurfaces.

How do people get C. Diff?Healthy people are not at risk from getting

C.Diff. People who have other illnesses orconditions requiring prolonged use ofantibiotics and the elderly are at risk ofinfection. They can become infected if theytouch items that are contaminated and thentouch their mouth.

Does C.Diff make a person more ill?In most patients the symptoms are mild

and discontinuing treatment with antibioticsand fluid replacement results in rapid


improvement. Sometimes it is necessary togive a specific antibiotic by mouth for thecondition. Unfortunately 20-30% of patientsrelapse and need further courses ofantibiotics.

Patients need to be nursed in a single room(isolation) or in a room with other patientswith C.Diff (cohorted) until bowel movementhas returned to normal.

VACCINATIONS RECOMMENDEDFOR PEOPLE WITH CHRONICKIDNEY DISEASE

As prevention is always better than cure,the Department of Heath and Children advisethat certain vaccinations be given to peoplewith kidney disease.Your kidney doctor or GPwill advise you when you need to start gettingvaccinated but in general once a diagnosis ofchronic kidney disease is confirmed thevaccinations listed below should be given:● Pneumococcus - This bacterium can

cause serious infection in the lungs(pneumonia), the blood (bacteraemia) andcovering of the brain (meningitis).Vaccination consists of a single infectionfollowed by a once-off booster dose5 years later

● Influenza (flu) - an annual flu vaccine isadvised as infection can be complicated bypneumonia which is dangerous for peoplewith chronic illness

● Hepatitis B - Hepatitis B is a seriousillness and as haemodialysis is a recognisedrisk for acquiring hepatitis B.Vaccination isadvised. The vaccination course variesdepending on the manufacture used but itis usually 3 or more injections over a 6-month period with a follow-up blood testto check if immunity has developed. Somepeople need an additional injection (boost)or a repeat course to develop immunity. Inaddition people on haemodialysis orperitoneal dialysis have a blood test yearlyand depending on the result may need aboost.

● Varicella (chicken pox) vaccine forpatients not immune and planning to

receive a transplantPeople should not get the vaccines if they

ever had a life-threatening allergic reaction toyeast (hepatitis B), eggs (flu) and/or to aprevious dose (all vaccines). Pregnant womenshould discuss vaccination with their doctorand people who are ill should defervaccination until feeling better.

While a vaccine, like all medicines, iscapable of causing a serious problem such assevere allergic reaction, the risk ofvaccinations causing serious harm, or death isextremely small. Getting the vaccinations ismuch safer than getting the disease

PREVENTING THE SPREAD OF ALLINFECTIONS IN HOSPITALS

This hospital along with all hospitals in thecountry is working hard to reduce the spreadof all infections in hospitals by;● Improving hygiene throughout the hospital● Improving hand hygiene of staff and patients● Implementing antibiotic policies● Education of staff, patients and visitors● Increasing space between beds and number

of single rooms especially as new wards arebuilt

WHAT CAN PATIENTS DO TO HELPREDUCE THE SPREAD OFINFECTIONS IN HOSPITALS?

Patients can help reduce the risk of allinfections spreading by:● Washing hands or using alcohol gel after

using the toilet and before meals● Reminding staff to wash their hands, or use

alcohol gel before they care for you● Advising visitors who are feeling unwell not

to visit● Advising visitors to wash their hands

before and after visiting and to avoid goingfrom one ward to another during visitingtime

● Seeking advice from ward staff if youngchildren wish to visit

● Complaining to the ward sister/Consultantor any staff member if the general wardhygiene is not satisfactory or if staff are not


The Renal Patient Care Co-ordinators atBeaumont Hospital will provide youwith practical and social support and

advice, and will liaise with you and your familyregarding any particular difficulties which yourillness presents, and will advise youaccordingly.This encompasses a wide range oftopics, from the different treatment options topractical help with housing, medical cards etc.

Once you have been diagnosed with EndStage Renal Failure (ESRF), you will be referredto one of the Patient Care Co-ordinatorseither through the ward, the out-patientsdepartment, or your Consultant. Yourallocated co-ordinator will then provideinformation on education, support, practicaladvice and any other assistance possible tohelp you in the transition to renal replacementtherapy (RRT).

EDUCATIONThe Patient Care Co-ordinators, in

conjunction with other members of the renalteam, run education sessions from time totime. These are specifically aimed at patientswho are approaching end stage renal failureand aim to answer the many questions thatyou will have at this time. They includeinformation on the different treatmentsavailable for renal failure; e.g. haemodialysis,peritoneal dialysis or transplantation, andexplain the options available to you at thistime. If you are unable to attend one of these

sessions, or if there is no session planned atthe time of your diagnosis, the Patient CareCo-ordinator will provide all the necessaryinformation on a one-to-one basis.

PRACTICAL ADVICEWhen you or someone in your family is

diagnosed with a chronic illness such as renalfailure, the resulting financial burden canfurther complicate the stress involved and it isimportant to know about the variousassistance schemes available from theDepartment of Social & Family Affairs, the HSEand Local Authorities.

Not everyone isautomatically entitledto financial assistanceand some schemesare means tested.Specific individualcircumstances arealso taken intoaccount, therefore oneperson may qualify forassistance while another with the same illnessmay not. You can only find out about yourposition by actually making an application andproviding all the details required so that therelevant authority can determine youreligibility.Your Patient Care Co-ordinator cangive you advice on your entitlements and,where applicable, provide a letter of supportto accompany your application.

Chapter 7PRACTICAL AND SOCIAL SUPPORT

“Not everyoneis automatically

entitled tofinancial assistanceand some schemes

are meanstested”

The area of grants/ allowances/benefits is awide-ranging one which cannot be covered indetail in this publication. Below is an overviewof what financial assistance may be availableand included at the end is a list of the relevantorganisations to which you can apply forfurther information.

BENEFITS AND ENTITLEMENTSThere are three categories of eligibility

for health services: medical cardholders, GP visit card holders, non-medical card holders.

Medical card holders areentitled to free hospitalisation,GP services, most prescribeddrugs and a range of otherhealth services.A medical card ismeans tested, based on theapplicants weekly income less PRSI.

All people aged 70 or over are entitled to amedical card without a means test.

Further information and a medical cardapplication form can be obtained from yourlocal health centre or can be downloaded fromwww.citizensinformation.ie

Hardship cases are dealt with on merit andspecial circumstances such as chronic illnesscan be taken into account. In cases of financialhardship, medical card holders may apply totheir local health board for assistance with thecost of on-going prescribed medical items notavailable under the Medical Card Scheme. Ifyou feel you need a medical card, apply forone.A supporting letter may be obtained fromyour attending hospital on request.

GP visit card holders are entitled to freevisits to their GP.This card is issued based onspecific income guidelines. In some cases,where a person may have a chronic illnesswhich involves regular GP visits, the HSE maygrant the GP visit card even where theirincome is greater than the guidelines. Largelythe HSE will only consider these applicationswhere an ongoing medical condition is causingor likely to cause undue financial hardship

Non-medical card holders are liable fora Government Levy for in-patient stays. Non-

medical card holders can avail of the DrugsPayment Scheme through their local pharmacy.Under this scheme families (patients, theirpartners and dependant children) pay a fixedamount per month for prescribed medicine.

TAX RELIEF ON MEDICALEXPENSES

Medical expenses of the entire familyqualify for tax relief. Further information

contained in Leaflet IT 6 Tax which isavailable from the Revenue

Commissioner, tel. 01-8736100or visit their website atwww.revenue.ie

Additional tax relief isavailable for renal patients on

expenditures such as travel,telephone, electricity. Further

information may be obtained from theIrish Kidney Association, Ph: 01-6205306.

DISABILITY ENTITLEMENTSPatients who were employed pre-dialysis

are fully encouraged to continue in theirwork/full-time education/training. However,there are cases where this is not an option andthere is a range of entitlements to assist thosewho find themselves on a reduced income dueto illness.

Illness Benefit is a short-term paymentpaid to insured people who are unfit for workdue to illness.You will qualify if you:● are under 66;● are unfit for work due to illness;● satisfy the PRSI contribution conditions.

Invalidity Pension is payable instead ofIllness Benefit.To qualify you must be incapableof working for at least a further 12 months andsatisfy the PRSI conditions.

Disability Allowance is a long-termweekly allowance paid to people with adisability aged between 16 and 66. Yourdisability must be expected to last for at leastone year and the allowance is subject to bothmedical suitability, means test and habitualresidency test.

Both Invalidity Pension & Disability


“All peopleaged 70 or overare entitled toa medical card

without a meanstest”


Allowance entitle you to free travel pass andyou may qualify for companion free pass if unfitto travel alone.

Working and Claiming a DisabilityPayment. In certain circumstances it may bepossible to get a disability payment and work,provided the work is certified as being of arehabilitative nature. People on DisabilityBenefit or Invalidity Pension may be allowed toretain their social welfare payment whileworking part-time (certain conditions apply).Written approval must be obtained from theDept. of Social, Community & Family Affairs(DSCFA).This may result in the withdrawal ofa medical card.

People on Disability Allowance and BlindPerson’s Pension may be allowed to work inrehabilitative type employment/self-employ-ment without it affecting their allowance,provided it has been approved by the DSCFA.However, this may result in the withdrawal ofa medical card.

Carer’s Allowance is a payment forcarers who look after a loved one in need offull-time care and attention. This payment ismeans tested. If a carer looks after more thanone person they may also be eligible for anadditional payment of 50%. A carer may workoutside the home for a small number of hoursper week provided this has first been clearedwith the DSCFA. Any money earned howeverwill be assessed as means in deciding theamount of allowance due.

There are other allowances available withthe Carer’s Allowance such as:-● Benefits in kind● Free travel● Household benefit package● Medical card● A Respite Grant paid annually to all carers.

Carer’s Benefit: Those who leave theworkforce to care for a person in need of full-time care and attention may be entitled toCarer’s Benefit which is based on PRSIcontribution.

If you already receive a Social WelfarePayment you are not eligible for CarersAllowance or Carer Benefit. You may claim

either in place of your Social Welfare Payment.

HEALTH SERVICE EXECUTIVE (HSE)PAYMENTS

Supplementary Welfare Allowance isan emergency payment for people withoutPRSI contributions. It is a basic minimumincome to help bridge the gap while socialwelfare payments applications are beingprocessed.

This payment is available from the localCommunity Welfare Officer and covers areassuch as:● Rent Allowance● Mortgage Interest Payments● Special Diet Allowance● Heating Allowance● Exceptional Needs Payment,

e.g. help towards expenses incurredduring hospitalisation such as travel,clothing etc.

Other HSE payments include:-● Mobility Allowance● Respite Care Grant (as mentioned above)● Blind Welfare Supplementary Allowance

Once-off Payments● Motorised Transport Grant for persons

with disabilities who need to purchase oradapt a car for their needs

● Back-to-School Clothing and FootwearSchemeThese payments may be obtained by

applying to your local HSE with supportingdocumentation.

COMMUNITY WELFARE OFFICER(CWO)

Patients who need financial aid outside ofthe Social Welfare system may be entitled toassistance from the Community WelfareOfficer (CWO), who is based at your localHealth Centre.

As a renal patient, you may apply for variousallowances such as Diet Supplement orHeating Allowance. Your Co-ordinator willadvise on the relevant allowances for you and

will write to your local CWO to support yourapplication as required.

LOCAL AUTHORITY GRANTSDisabled Person’s Grant: Local

Authorities will accept applications frompersons seeking a grant for necessaryadaptations or reconstruction work. Theamount varies according to the work beingcarried out but will not exceed 90% of theapproved cost.

Home Improvement Scheme forOlder Persons

The purpose of this scheme is to improvethe living conditions of older persons living inunsafe or unsanitary private accommodationby carrying out minor essential repairs to theirhomes. These include repairs to floors, doorsand ceilings, minor repairs to windows,

electrical repairs, water supply and carpentryand providing a grant for central heating.

SECURITY FOR THE ELDERLYLocal community groups sometimes have

funding to provide security aids such aspersonal alarms, security lighting, mobility andsafety aids.Your local Citizen’s Advice Bureaumay know if such schemes exist in your areaor you may apply to the HSE Local Authorityor the Gardai.

For free information on your rights andentitlements contact:

CITIZENS INFORMATION. Tel: 1890-77721. Email: [email protected] check the Golden Pages for your localCitizens Information Centre.


HEAD OFFICES REGIONAL HEALTH SERVICE EXECUTIVEHSE EASTERN REGION Northern Area Tel: 01-813 1800

East Coast Area Tel: 01-201 4200South West Area Tel: 045-876 001

HSE MIDLAND Laois Tel: 0502-21135Longford Tel: 043-46211Offaly Tel: 0506-41301Westmeath Tel: 044-40221

HSE MID-WESTERN Clare Tel: 065-682 825Limerick Tel: 061-326 677Tipperary North Tel: 067-31212

HSE NORTH EASTERN Cavan/Monaghan Tel: 049-436 1822Louth Tel: 042-933 2287Meath Tel: 046-902 1595

HSE NORTH WESTERN Donegal Tel: 074-31391Leitrim Tel: 071-962 0308Sligo Tel: 071-915 5100

HSE SOUTH EASTERN Carlow/Kilkenny Tel: 056-778 4600Tipperary South Tel: 052-770 000Waterford Tel: 051-842 800 Wexford Tel: 053-23522

HSE SOUTHERN Cork Tel: 021-965 511Kerry Tel: 066-712 1566

HSE WESTERN Galway Tel: 091-523 122Mayo Tel: 094-902 2333Roscommon Tel: 0906-626 518


COMHAIRLE, Hume House, Ballsbridge,Dublin 4. Tel: 01 604 9000. Email:[email protected]

For information on Social Welfare Payments(Disability Benefit/Allowance, InvalidityPension, etc. contact: Department of Social,Community and Family Affairs, Aras MhicDiarmada, Dublin 1. Tel: 01-7043000 orGovernment Buildings, Ballinlee Road,Longford. Tel: 043-45211. Website:www.welfare.ie

Local Authority payments, e.g. DisabledPersons Grants, Essential Repairs, etc. Contactyour local City or County Council (telephonenumber available in the State Directorysection of your local directory).

Health Board Payments. eg. SupplementaryWelfare, Once-off Grants, Mobility Allowance,etc.Apply to your local Health Centre. If youare unsure as to the location/telephone ofyour nearest health centre, listed below arethe Head Offices of the regional HealthService Executive.

FOLLOWING DISCHARGEThe transition to renal replacement

therapy and/or transplantation is eased by theconstant presence of medical and nursing staffwhile you remain in hospital. Once discharged,it is now time for you to adjust to this new wayof life within the context of your own homeand family life. There are many different waysthat illness can affect your life; maybe you aretoo unwell to do housework and needsome home help; or perhaps you need

meals-on-wheels. Whatever your require-ments, your Patient Care Co-ordinator willliaise with the relevant community services toensure you have the appropriate support afteryour hospital stay.

PUBLIC HEALTH NURSE (PHN)If you require any nursing care following

your discharge you will be referred by thehospital to your Public Health Nurse, who isbased in your local Health Centre.The PatientCare Co-ordinator will ensure the PHN has allthe necessary information required and willliaise with them with regard to your care.

CARE ATTENDANTCare Attendants provide personal care

assistance to patients in the homes and theywork in liaison with the Public Health Nurse.

HOME HELP SERVICEHome Helps provide general assistance

with shopping, cleaning, cooking etc. Onceyou have been referred by the Patient CareCo-Ordinator, the local Home Help Organiserwill assess you and approve the provision of aHome Help as appropriate. You will berequired to make a small financial contributiontowards the cost of this service. A shortage ofHome Helps in some areas means there cansometimes be a waiting list for this service.There is now a Home Care Package availablefrom the HSE, application forms are availablefrom your Patient Care Co-Ordinator.,

Home Care Package is a plan of your carerequirements assessed by your Patient CareCo-Ordinator, Ward Nursing Staff andDoctors.Your support needs are assessed andan application made to the Community Serviceto provide this support for you.

MEALS-ON-WHEELSThese are organised on a voluntary basis

and, again, a financial contribution may berequired. Your Patient Care Co-ordinator orPHN will be able to ascertain if this service isavailable in your area and, if so, will make thenecessary arrangements.

“Once discharged,it is now time

for you to adjustto this new way

of life within thecontext of yourown home and

family life.”

DISTRICT CARE UNIT (DCU)This is a rehabilitative service for patients

over 65 years of age. If you require this service,and are accepted by the DCU team, it canfacilitate an earlier discharge from hospital.TheDCU team consists of a nurse, physiotherapist,occupational therapist and a care attendant.You will be considered for this programme if itis accepted that you will rehabilitatesufficiently over a 12 week period to enableyou to live independently with the normalcommunity support.

DAY CENTRESDay Centres are usually run on a voluntary

basis and provide a social outlet for peoplewho may otherwise feel isolated at home.Theyoften provide lunch, and some centres willtransport you to and from home.

COMMUNITY REHABILITATIONSERVICES

Where appropriate, a referral will be madeon discharge to the Community Physio-therapist, Occupational Therapist or Speechand Language Therapist.

CONVALESCENCEYou may need a week or two of

convalescent care before returning home andthis can be organised through the Patient CareCo-Ordinator. Most convalescent homes arecovered to some extent by private healthinsurance, with the shortfall being paid for byyou. If you feel you would benefit from this,please ask your Co-Ordinator for advice.

NURSING HOMESYou may require more assistance than that

which can be provided by community servicesand/or family members. In the event that longstay accommodation in a nursing home isrequired, your Patient Care Co-Ordinator willassist in making the necessary arrangements.Your Co-Ordinator will also assist in applyingfor Nursing Home Subvention to assist withthe cost of private care.

It is proposed to introduce a newsystem for January 2008. This system iscalled “The Fair Deal on Nursing HomeCare”. Full details of this new schemeare not yet available. It will requirelegislation.


IRISH KIDNEY ASSOCIATION (IKA)The Irish Kidney Association offer support for all patients with renaldisorders. Through its local branches, patients can meet other renalpatients and share experiences, problems and, most importantly,solutions.

On a national and local level the IKArun many functions to raiseawareness of kidney disease in

Ireland, not least of these being their Organ Donor AwarenessWeek.

The IKA also provide holidays every year for renal patientswho are either on dialysis or are transplanted.They also run aSupport Centre in the grounds of Beaumont Hospital, whichoffers a place of refuge for families of renal patients, and short-term accommodation for the families of seriously ill patientsfrom outside the Dublin area.

Your Patient Care Co-ordinator can give you information on allthese services or you can contact the IKA directly at Donor House, ParkWest, Dublin 12 or Tel: 01-6205306.


TEAM IRELANDThe 2004 European Dialysis & Transplant

Team with Miriam Bryan, NationalChairman, IKA and ?????

BLOCK CAPITAL LETTERS PLEASE: (Photocopy will suffice)

Mr. Mrs. Ms. FIRST NAME: INITIAL:

SURNAME:

ADDRESS:

PHONE: MOBILE NO: EMAIL:

ARE YOU A RENAL PATIENT: YES NO

IF YES, PLEASE INDICATE YOUR PRE DIALYSIS

CURRENT PATIENT STATUS HAEMODIALYSIS

Please update our records when / if APD

Status changes. CAPD

TRANSPLANT

HOSPITAL YOU ARE ATTENDING:

IF YOU ARE NOT A PATIENT, PLEASE INDICATE INTEREST IN MEMBERSHIP

RELATIVE OF PATIENT: FRIEND OF PATIENT: GENERAL INTEREST:

I AM OVER 16 YEARS OF AGE: YES NO

I AM UNDER 35 YEARS OF AGE: YES NO

AS A MEMBER YOU WILL AUTOMATICALLY RECEIVE OUR “SUPPORT MAGAZINE”. ARETHERE ANY OTHER ASSOCIATION MEMBERS AT YOUR ADDRESS?

YES NO

WOULD YOU LIKE CORRESPONDENCE FROM THE BRANCH WITHIN YOUR LOCAL AREA?

YES NO

WOULD YOU LIKE CORRESPONDENCE FROM THE YOUTH SECTION OF THE IKA

YES NO

TO BECOME A VOTING MEMBER OF THE ASSOCIATION YOU MUST SUBSCRIBE TO THEMEMORANDUM & ARTICLES (Rules & Regulations) OF THE ASSOCIATION (COPY AVAILABLEON REQUEST).

I SUBSCRIBE TO (SIGNED UP TO AND ACCEPT) THE MEMORANDUM & ARTICLES OF THE IRISHKIDNEY ASSOCIATION LIMITED.

SIGNATURE: DATE:

Please return the completed, signed form to the Irish Kidney Association, Donor House, Block 43A, Park West, Dublin 12.

THERE IS NO SUBSCRIPTION CHARGE.

IRISH KIDNEY ASSOCIATIONMEMBERSHIP APPLICATION FORM


SEXUAL ISSUES

Sexual problems are common for menand women who suffer from kidneydisease. Not only are emotional

problems likely to occur as a result of thestress of the disease, but there are also anumber of medical problems that can affectsexual function and fertility, both in men andwomen.

Emotional problems are common. Patientsmay find themselves going through a grievingprocess due to loss of renal function, whichmay affect their independence, their job, andtheir role in the family. Some patientsexperience a change in body image. Dialysis

can lead to lowered self-esteem, coupled withanger and depression, which can affect sexualfunction. The balance in the relationship mayhave changed – one seeing themselves as thecarer and the other in a sick role. Couplesneed to communicate to one another theirfeelings and fears. Counselling can facilitate theexploration of these feelings.

Contraception is important for people withkidney disease. Do not assume that becauseyou have kidney failure, you cannot have achild. Most methods of contraception aresuitable. Barrier methods such as condomsand diaphragms can be used. The coil cansometimes cause infection and heavy periods.

Chapter 8REPRODUCTIVE MATTERS


The contraceptive pill has a tendency to raiseblood pressure, sometimes one of thecombined forms of oestrogen andprogesterone are prescribed. The morningafter pill may be used in the usual manner.

Fertility levels vary during different stagesof renal failure.Women of childbearing age donot often get pregnant while on renalreplacement therapy as the treatment onlyreplaces a small percentage of kidney function,which in turn can interfere with eggproduction.

For female patients whosemenstrual cycle remains,however irregular, it ispossible to conceive.Although pregnancy isuncommon, some womenhave given birth. Due to risksto the mother and thehigh rate of spontaneousabortion, patients arenormally advised to takeprecautions againstpregnancy. Some womendecide to delay pregnancyuntil they have received atransplant.

Men with kidney disease mayhave a reduced spermcount and mayexperience difficultiesin fathering a child. After successfultransplantation, sperm numbers generally rise.Men with renal failure can have a variety ofsexual problems. These include loss of libidoand ejaculatory problems. However the mostworrying and most common is impotence.

Impotence often has physical causes and isusually a combination of factors.● Poor blood supply occurs as part of the

natural ageing process and is common inolder men. It is particularly common in menwith diabetes and renal failure.

● The testicles may produce less of the malehormone, testosterone.

● Some drug treatments can contribute to

impotency, the biggest culprits being ‘beta-blockers’ such as atenolol, propanol,metoprolol and bisoprolon.

● Tiredness can affect sexual performance.This can be caused by anaemia, under-dialysis or other medical problems ie. heartproblems.

● Psychological or relationship issues.Treatment for impotence is commenced

by checking out general health.Anaemia ifpresent is corrected, treatment time may

need to be extended, drugtreatment may be changed.

Viagra is commonlyprescribed.Trials show that

about 8 out of 10 menbenefit with improvement in

erectile performance.Patients with angina orheart problems should

not take Viagra. It isadvisable to consultyour unit doctor to

ensure that it is a safe optionin your case.

There are many otherinterventions which are

performed by specialist doctors ie.urologists.A referral is sent from the

unit doctor.Counselling is

recommended for emotionalproblems relating to impotence.

Many men who have had difficulty fatheringa child while undergoing renal replacementtherapy have been successful in doing sofollowing transplantation.

Communication is the most importantfactor in any relationship.Wherever there is aproblem share your feelings and fears withyour partner. Nursing and medical staffrecognise that patients can have difficulties insexual relationships and will gladly talk to youand your partner. Professional guidance canhelp – all that may be needed is a littlereassurance.


Your kidney health care team has manyyears of experience treating peoplewith kidney disease. If you have a

question or are looking for information, askany member of your healthcare team. If theycan’t help, they will refer you to someone whocan. Don’t hesitate to ask.

Because your kidney healthcare team isimportant to you, we describe below the rolesand skills of each team member.This may help

you to decide which people you might want totalk to.

NEPHROLOGISTA Nephrologist (or Consultant) is a doctor

who specialises in kidney disease and whotogether with you and the other members ofthe healthcare team, plans the best treatmentfor you.

The Nephrologists in a teaching hospital

Chapter 9YOUR KIDNEY HEALTH CARE TEAM

Professor Peter Conlon (left) and his team

see medical students if you are not feeling upto it.

NEPHROLOGY NURSENephrology nurses work closely with you,

your family and other team members.They willteach you and your family about your kidneydisease and its treatment, and support youin the lifestyle changes that you may need tomake. In some units Clinical Nurse Specialists,Nurse Clinicians or Nurse Practitioners mayalso be part of the team. On each ward aClinical Nurse Manager will be responsible forthe day-to-day management of the unit.

Sr. Maureen McNulty, CNM2,St. Peter’s Ward

(L-R): Eileen Collins,Student Nurse, Martin

Ferguson, Pharmacist andPetrina Donnelly, CNM2,Clinical Practice Support

Nurse.

will typically have a team of non-consultant hospital doctors assistinghim or her in your care.

These doctors include thefollowing:

RENAL REGISTRARA renal registrar will have

completed at least 3 years of post-graduate medical education. He willbe responsible for the supervisionof the Senior House Officers andinterns. A registrar will typically beparticipating in a 4 to 5 year trainingprogramme on kidney diseases.

SENIOR HOUSE OFFICERThe senior house officer will be at least 1

year post-graduation from medical school andis training in the general aspects of hospitalmedicine.

INTERNIn the first year after graduation from

medical school all medical student must spenda year of training in the hospital to learn thefundamentals of hospital medicine

MEDICAL STUDENTSTraining hospitals will have many medical

students.These students will talk to you abouthow the disease has affectedyou.They will also ask you forpermission to examine you.This is how they become adoctor themselves one day.On ward rounds commonlythe registrar or Consultantwill ask the medical student topresent their findings aboutyou and your condition to theteam. It is your choice not to


48 R E N A L D I S E A S E – A G U I D E F O R PAT I E N T S

STUDENT NURSESCurrently it takes four years at university to

become a registered nurse. Student nursesspend a lot of this time rotating into differentareas within the hospital. Student nurses willhave different levels of experience accordingto what year they are in university.

DIETITIANThe dietitian will instruct you on the

proper food choices you may need to make aspart of your treatment. Together with yourdoctor and you, the dietitian will prepare adaily eating plan.

RENAL NURSE COUNSELLORMany renal units in Ireland have access to a

counsellor who has specific experience inlooking after patients with chronic renalinsufficiency. Being diagnosed with renal failurecan be very difficult for you, your partner andyour family. The renal counsellor will workclosely with you and your family to help adjustto this new lifestyle.

PATIENT CARE CO-ORDINATOR(PCC)

Your Patient Care Co-Ordinator is availableto provide supportive counselling to you andyour family. You may benefit from discussingemotional, financial, family or other concernswith your Patient Care Co-Ordinator as youtry to understand and adjust to the changesthat result from having kidney disease. Theycan also assist you with information aboutcommunity resources and financial aidprograms.

SURGEONA surgeon is a doctor specially trained in

surgery.A surgeon will perform the operationto establish access for dialysis, or to transplanta kidney.

TRANSPLANT CO-ORDINATOR The transplant coordinator assists in

coordinating the necessary tests, studies, andother activities to determine your suitabilityfor a transplant.

YOUR FAMILY DOCTOR (GP)It is important that you continue to see

your family doctor. He or she knows you andyour family best.Your kidney healthcare teamwill take excellent care of any problemassociated with your kidney disease. However,your family doctor is best suited to providepreventative healthcare check-ups, such as papsmears and prostate examinations, and to lookafter any other healthcare needs. The kidneyhealthcare team will communicate with yourGP on a regular basis.

CARE ATTENDANTSWork closely with nursing staff in providing

your nursing care.

PHARMACISTWorks closely with members of the kidney

healthcare team. They provide you withinformation surrounding your medications toensure you have full understanding of yourtreatment.

HOUSEHOLD OPERATIVESResponsible for household activities at

ward level. They assit with stocking ofequipment and supplies.

PORTERING STAFFAssist by tranporting patients to, and from

procedures.

DOMESTIC STAFFResponsible for ward cleaning to ensure

hygience standards are maintained.

CATERING STAFFEnsure that the food you receive is of a high

standard.Also they will order any special dietsthat your dietitian has ordered for you.

WARD CLERKSWill ensure that the correct information is

gathered in relation to:

● Medical Card Number● Health Cover


Taking part in pleasant leisure activitiesand maintaining a well-balanced lifestylecan go a long way toward helping you

stay healthy. And have fun! It is important totake part in social activities, sports andrecreation events, and other past-times thatyou, and other members of your family andfriends enjoy. You may need to make a fewadjustments, but they will be well worth it.

EXERCISE AND SPORTSExercise is vitally important to both your

physical and mental health. Staying physicallyfit will give you more energy.With moreenergy, you’ll feel like doing more thingswhich will improve your outlook andspeed your return to your usual lifestyle.Talk to your healthcare team about asuitable exercise or sports program beforeyou begin (or resume) these activities.

There are many benefits to be enjoyedfrom exercise and these include:● Improved physical

functioning● Better blood

pressure● Improved muscle

strength● Lower level of blood fats● Better sleep● Better control of body weight● Reduced risk of heart disease● Development of stronger bones

● Reduced stress and depression● Meeting people● Having fun.

If you’re interested in getting and staying fit,then remember the F.I.T.T principle. Studieshave shown that for it to be effective you mustexercise:● Frequently● Reach a minimum Intensity● Continue for a minimum length of Time● Do an appropriate Type of exercise

FrequencyTo ensure that you get a positive

effect, exercise at least three timea week. Unless you exercise thisoften, your physical conditioning

will not improve. Spread theexercise over the week. Don’t

do it all on consecutivedays. This gives your body

time to recover and buildup your muscles andenergy for the next

time.

IntensityUnless you exercise hard

enough, you’re not going to getmuch benefit from it. There are

different ways to measure intensity. One of themost common is by measuring your heart rateas you exercise. Talk to your doctor or

Chapter 10STAYING HEALTHY


someone who specialises in physical conditioning.Time

The exercise must last at least 15 minutesto be effective. Any less, and your physicalconditioning won’t change. If you’re not ableto exercise continuously for that long, trydoing it a little less vigorously, or pause fora couple of minutes to catch your breath,then keep going.The longer you keep itup, the more good it will do you.

TypeSome exercises are better than others.

Some of the best are walking, swimming, andriding a bicycle. They get most of yourmuscles working and increase your heart rate toa healthy level.You can also adjust the intensityto suit your level of fitness. Best of all, they’refun to do.

Before you start a vigorous exercise program, check with your healthcare team-they can adviseyou on which exercises are best for you, and which ones, if any, you should avoid.

GENERAL HEALTH ADVICENUTRITION

Eat a healthy diet, this means eating a widevariety of foods in the correct amounts to ensuregood health. Important points:● Eat three main meals a day● Avoid fried and fatty foods● Eat more fruit and vegetables● Eat more fibre rich foods● Reduce sugary foods and sweetened drinks● Avoid adding salt to foods● Adhere to diet restrictions such as low salt,

low cholesterol and diabetic diets accordingto doctors or dietitians instructions

● Fluid restrictions may be necessary tomaintain, please follow your doctors adviceregarding same.

WEIGHT CONTROL/EXERCISEExercise has a positive affect on blood

pressure, cholesterol levels and the functioning ofthe heart and lungs even if you do not loseweight.

Adopt a regular exercise pattern if one doesnot exist in your life.This is essential to maintaina healthy body weight and decrease the risk ofobesity.


CLINIC APPOINTMENTSPlease attend all Out-Patient or other clinic appointments to ensure a continuous record of

medical history.If you are unable to attend any scheduled appointments, please inform the department for

further available dates.

MEDICATIONSPlease keep a list of your current medications with you on all

health visits as it is important to have an up-to-date record ofthis. Medications not prescribed by your doctor should not betaken.

Avoid herbal remedies without seeking medicaladvice as some may interact with specific

medications.

STRESSDecreasing stress will improve your

psychological health which is essential to general health and well-being.

Further help may be sought from the renal nurse counsellor ortherapist.

ALCOHOL INTAKEAlcohol is high in sugars and calories. Excess alcohol can increase

your triglyceride level and promote weight gain.Use sugar free mixers such as diet minerals or slimline tonic.Have 2-3 alcohol free days per week and when taking alcohol do not

exceed the recommended limits:(A) Men: 21 units p.w.

(B) Women: 14 units per week

SMOKING AND DRUGSIf you are currently smoking try firstly to cut back and over

a period of time to cease.Smoking damages the lungs and puts you at risk of lung

cancer.Smoking tobacco, marijuana

or other drug use is harmful toeveryone.

Any form of “recreationaldrugs”, such as ectasy, speedor cocaine have a seriouseffect on your body andmind. These drugs may alsointeract with your medications.

“Please keep

a list of your current

medications with you

on all health visits

as it is important to

have an up-to-date

record of this.”

Any form of ‘recreational drugs’

such as ectasy, speed or cocaine have a serious effect on your body and

mind.

58 R E N A L D I S E A S E – A G U I D E F O R PAT I E N T S

Beaumont Hospital 01-809 3000

Hamilton Ward 01-809 2323/2327

St Peter’s Ward 01-809 2290/2285

St Damien’s Ward 01-809 2292/2293

Renal Day Care 01-809 3144

Patient Care Co-Ordinators 01-809 2727

Renal Nurse Counsellor 01-809 2751

Ambulatory Nurse Specialist 01-809 3144

Prof Conlon Secretary 01-809 2747

Dr Donohoe Secretary 01-809 3080

Prof Walshe Secretary 01-809 2567

Contact Numbers


Other sources of useful information

BEAUMONT TRANSPLANT FOUNDATIONwww.transplantireland.ie

IRISH KIDNEY ASSOCIATIONwww.ika.ie

DIALYSIS PATIENTS GUIDEwww.kidneydoctor.com

AMERICAN KIDNEY PATIENTS ASSOCIATIONwww.aakp.org

IRISH HEALTH WEBSITEwww.irishhealth.com

KIDNEY DIRECTIONSwww.www.renalinfo.com

NATIONAL KIDNEY FOUNDATION USAwww.www.kidney.org

TRANSPLANTATION AND DONATIONwww.transweb.org


GLOSSARY OF TERMS

TERM DEFINITIONARF – Acute renal failure A sudden loss of kidney function that is often reversible

AVF – Anteriovenous fistula Vascular access for dialysis, Joining an artery and veintogether.

Anaemia A shortage of red blood cells in the blood. One of thefunctions of the kidneys includes EPO (erythropoietin)production.When the kidneys fail EPO is not made whichleads to anaemia.

ANCA – (Anti-neutrophil This is a type of antibody that is associated with vasculitis cytoplasmic antibody) conditions.

APD – Automated Also known as CCPD.This is a form of peritoneal dialysis peritoneal dialysis which is carried out overnight.

Arteries Blood vessels that carry blood from the heart to the rest ofthe body.

Blood Tests A blood test that is used to measure many substances in thebody to ensure they are within normal/safe range.

Blood Pressure (B/P) The pressure that the blood exerts against the walls of thearteries as it flows through them.

CAPD – Continuous Infusion of fluid into the peritoneum, prolonged dwell period ambulatory peritoneal dialysis and then drainage.

Central Venous Catheter (CVC) Also known as permcath.A catheter with two ports insertedinto a major central vein for the purpose of haemodialysis.

Creatinine A waste substance produced by the muscles when they areused.The higher the blood creatinine level the greater theindication of kidney failure.

Chronic Renal Failure (CRF) Slow onset of renal failure which is irreversible.

Dehydration Not sufficient water in the body to maintain normal function.

Dialysis (HD) An artificial process which removes chemical substances andwater from the blood by passing it through an artificial kidney.

End Stage Renal Failure (ESRF) Advanced Renal failure.

Erythropoietin (EPO) Hormone involved in production of Red Blood Cells.

Fluid Overload The body contains excess water.This occurs in renal failure asone of the functions of the kidney is to remove excess waste.

Haematuria Blood in the urine.


GLOSSARY OF TERMS

TERM DEFINITIONHepatitis An infection of the liver. Can be passed on by blood contact.

Kidneys Two bean shaped body organs where urine is produced.Functions of the kidney include removal of toxic waste,removal of excess fluid, controls blood pressure helps toproduce red blood cells and helps to keep bones strong andhealthy.

Nephron Small filtering unit in the kidney, made up of blood vessels andtubules.

Oedema A build up of fluid causing swelling, especially ankles and thelungs.

Oliguric Passing low levels of urine.

Potassium A mineral that is normally present in the blood.Too much ortoo little can cause complications.

Transplantation The replacement of an organ that is not working in the bodywith another donor organ.


We would like to extend special thanks to the followingmembers of the renal team at Beaumont for theircontribution to this book.

Prof. Peter J. Conlon Consultant Nephrologist

Helen Dunne Patient Care Co-Ordinator

Petrina Donnelly Clinical Practice Support Nurse

Irene Reynolds Ambulatory Care

Ciara White Renal Course Co-Ordinator

Louise Kelly Renal Day Care

Bernice Curtice Renal Dietitian

Margaret Hanna Renal Nurse Counsellor

Sheila Donlon Renal Virology Co-Ordinator

M.T. Murphy Patient Care Co-Ordinator

Marion O’Farrell Patient Care Co-Ordinator

Dr. Darren Pachaippan Dialysis Registrar (Photography)

Cartoons and Illustrations

Des Hickey (deceased), KegKartoonz (Noel Kelly),

Jazz Communications Ltd., and www.netterimages.com

Also, to the patients and staff who took timeto contribute to editing this book.

Contributors


NotesUSE THIS PAGE TO RECORD ANY QUESTIONS

YOU MAY HAVE FOR YOUR DOCTOR,OR ANY MEMBER OF THE TEAM.


NotesUSE THIS PAGE TO RECORD ANY QUESTIONS

YOU MAY HAVE FOR YOUR DOCTOR,OR ANY MEMBER OF THE TEAM.

Bea

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The Beaumont Transplant Foundation,Beaumont Hospital,

PO Box 1297, Beaumont Road, Dublin 9.Tel: 01-2850021.Email: [email protected] Web: www.transplantireland.ie

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