HemoDoc, From Doctor to Patient

Star fruit: The Death Fruit for Dialysis Patients

By Peter Laird, MD

Dialysis patients limit potassium, phosphorus and salt and are advised to eat several servings of fruits and vegetables, but their is one fruit that should never find its way onto your menus. The star fruit is a popular fruit especially in the Philippines and the south Pacific and it is now becoming a popular fruit in America as well. However, for dialysis patients, the star fruit could be deadly.

Intoxication by star fruit (Averrhoa carambola) in 32 ueaemic patients:

Background. Clinical symptoms and outcomes of uraemic patients ingesting star fruit are quite variable and may progress to death. The purpose of the present report was to discuss the neurotoxic effects of star fruit intoxication in uraemic patients and to present the efficacy of different therapeutic approaches.

Results. The most common symptoms were persistent and intractable hiccups in 30 patients (93.75%), vomiting in 22 (68.7%), variable degrees of disturbed consciousness (mental confusion, psychomotor agitation) in 21 (65.6%), decreased muscle power, limb numbness, paresis, insomnia and paresthesias in 13 (40.6%) and seizures in seven (21.8%). Patients who were promptly treated with haemodialysis, including those with severe intoxication, recovered without sequelae. Patients with severe intoxication who were not treated or treated with peritoneal dialysis did not survive.

Conclusions. Haemodialysis, especially on a daily basis, is the ideal treatment for star fruit intoxication. In severe cases, continuous methods of replacement therapy may provide a superior initial procedure, since rebound effects are a common event. Peritoneal dialysis is of no use as a treatment, especially when consciousness disorders ensue.

Daily hemodialysis is the only effective treatment for star fruit intoxication, but the best treatment alternative for this neurotoxic fruit is to simply avoid it completely. My Filipino wife enjoys this fruit but won't bring it into the house at all since it is a potentially deadly toxin to me. Just one small price we pay for extending our lives with dialysis. The star fruit is one fruit to scratch from your diet and not temp yourself at any time. Testing the limits of this neurotoxic fruit is not advisable if you are on dialysis or have chronic kidney disease. Fortunately, I wasn't that adventuresome when I visited the Philippines several years ago before I was aware of the deadly consequences. For once, my simple tastes turned out to be my best friend.

Walking in the Shoes of Your Patients

By Peter Laird, MD

I came across two recent articles on experiencing direct patient care to raise the level of empathy among health care professionals. The first article in MedScape is written by a practicing physician who had several suggestions for medical students to experience before they ever laid hands on any patients:

What Should Medical Students Experience Before They are Allowed to Touch Patients?

The object of this exercise would be to help students develop the sensitivity and compassion appropriate to carrying for patients well. So I'll start of the list of what med students should be required to experience, both men and women, before they are allowed to go near patients, in no particular order: 

1. Placement of an NG tube. 

2. Rectal exam done in the same bent-over position that we ask men to assume for their prostate exams, for both men and women. 

3. Pelvic exam done in the lithotomy position for both men and women. 

4. Venipuncture with drawing of at least 8 tubes of blood. 

5. Upper and lower GI. 

6. BG monitoring at least twice daily for, say, a month. 

7. Urinary catheterization. 

8. Hospital stay of at least 3-4 days as a "mystery patient" with a contrived diagnosis, including access to hospital food only, strict I&O, daily AM fasting labs, multiple dosing of placebos, ordered with specifications around mealtimes, sleep etc. At least one day of strict bedrest. This experience must take place in a teaching hospital under the care of a team not alerted to the identity of the patient. 

I must confess I don't know what medical students experience in school any longer, but we used each other to practice several of these tasks such as NG tubes and blood draws.  It was rather comical to see an NG tube coming up and out the mouth on the first nervous attempts instead of going correctly down into the stomach. Unfortunately, throughout my training there were many examples of fellow students with serious illnesses. I was one of those in medical school who suffered such an example with a testicular cancer in my third year of medical school. After I healed from the operation, I underwent daily radiation treatments and then went to my OB/GYN rotation seeing "real" patients right after the radiation. I learned to appreciate Lomotil which saw me through those three weeks.

Dr Belding Scribner often stated to be a good physician, you first must be a patient. Being able to identify with individual fears and suffering tempers the grandiosity also associated with being a doctor, especially in the early years of a career. However, other than venopuncture and NG tube placement which we did on each other, I could not recommend the other procedures on the this list because they are associated with side effects and risks of complications that precludes this sort of unnecessary torment. 

When I was nineteen, I worked as an orderly covering the shifts for three other orderlies on their days off. That meant I worked all three different shifts each week since the other three orderlies all had set work times. During the night shift, I worked in the Emergency Room and the majority of the time, I did the initial triage evaluations on patients seen during those late hours. I would take vitals and briefly interview the patient about their symptoms and concerns. I would then wake up the doctor asleep in his call room and stay and assist him during his examination. The most notable patients were trauma patients who came in covered in blood. It was my job to clean up their bloody wounds before the doctor placed sutures.

Invariably, every single time I saw someone in pain and bleeding, I had a visceral reaction with chills running up and down my spine. Fortunately, I have never experienced that type of trauma and I hope to never in the future, but I didn't need to experience directly those injuries to understand the impact it was having on the patients laying before me.  This reaction never prevented me from doing what I needed to do, but I would hope most people are uncomfortable when they see other people in pain and suffering. When we graduated, my medical school class chose the Oath of Maimonides instead of th Hippocratic Oath. Today, I believe it expresses well the necessary temperament needed of physicians to view patients as fellow creatures in need:

The Oath of Maimonides

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily decieve me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have aquired, always to extendits domain; for knowledge is immense and the spirit of man can extend indefintely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

The second example of sampling the life of their patients was among renal dietitians who took their own advice for five days by experiencing a renal diet.

The "Walk the Talk" challenge at St. Michael's Hospital

It's my last day on the renal diet....I MADE IT!! (barely!)  It was not an easy week...and I have to admit that I cheated today and had whole wheat bread.  My colon was begging me for some fibre!   

I also went out for dinner last night for a friend's birthday, and the birthday girl decided on Chinese food.  Since I have been depriving myself of fluid and feel quite dehydrated, I had an extremely difficult time controlling my thirst after our salt-laden Asian meal.  Actually, I went home must have drank a litre of water!  I'm positive that if I were a dialysis patient, I would be fluid overloaded right now!

This week has been an eye-opener.  My colleagues and I realized just how difficult it is to change life-long habits, and we only changed one small aspect of our lives.  Our patients on dialysis have so many more changes they have to face - being on a machine 4 times a week, taking an abundance of medications at different times of the day, limiting their favourite foods, not travelling as they please, not being able to work....the list could go on and on. 

I do applaud those that participated in this renal diet challenge, but as some commentators on IHD noted, the renal diet as restrictive as it is still affords a broad enough selection to eat well. I tell people that I do have a restriced diet, but I am not deprived especially since starting on daily home hemodialysis. I eat oranges, bananas, spaghetti, potatoes, tomatoes, ice cream  and pizza, all in moderation of course.  Sodium is the worst contender along with phosphate preservatives and additives. While it is difficult to find food items acceptable to a renal diet, anyone that has tried Zach's famous chunky chile would tell the renal diet challenge folks to lighten up and use their imaginations a bit more to make the renal diet much more palatable. (here)

When I first started on dialysis, my renal dietitian recommended a book called: Cooking for David. The devoted wife of a dialysis patient spent years developing and cataloging renal friendly foods that her husband enjoyed. My wife and tried several of the recipes and I used to enjoy her Pita Pizza recipe on a regular basis. My life was restored from the first day of home hemodialysis training with potatoes, oranges and bananas for the first time in two years.

Yes, by all means consider methods of teaching health care professional empathy for their patients, but I would avoid first of all avoid advocating for any test that care potential risks which eliminates nearly all of the list above and secondly, use a bit of imagination to not only survive a renal diet, but also to thrive. After all, day and day out, the renal diet is one of the most important aspects of remaining healthy on dialysis and life is too short to not enjoy a pot of spaghetti from time to time. All things in moderation gives me little I can't eat if only to get what I call a taste of taste. We are all one of God's creatures and healthy or not, all of us have had our share of pain and suffering. Perhaps that is the prerequisite needed to be a doctor or other health care professional.  Yes, Dr. Scribner is absolutely correct that to be a good doctor you need to be a patient first, but short of that, perhaps all that is needed is to simply have a heart.

The Japanese Dialysis Survival Debate: Ignoring the Evidence

By Peter Laird, MD

The survival differences between Japan and the United States are well documented and extensively researched with the preponderance of the evidence focusing on dialysis practice difference.  I have written on this issue several times in the past three years. (here, here and here) Many have wrongly in my opinion put forth the low incidence of renal transplant in Japan and alleged exclusion criteria coupled with lower co-morbid conditions that have not withstood the light of day as the explanation of these differences. Dr. A.K. Singh entered this debate a few days ago on his Kidney Doctor Blog:

Global Nephrology: Better Cars in Japan Maybe, but also Better Dialysis? The bottom-line?

There are a number of differences in dialysis practice that alone or together could explain the difference in mortality. While the very low transplantation rate in Japan, i.e. selection bias, might be a part of the explanation, it does not explain the two-fold higher mortality rate in the US. In Japan, like the US, there is a highly prevalent diabetic population on dialysis with an average age in the 60s that similarly dialyzes 3 times a week in center. It's either better dialysis or some other factor, but not just differences in transplant rates, nor is it because the Japanese are very selective in who they treat on dialysis.

The underlying untold story line to the great Japanese dialysis survival debate is the allegation that we could never take a group of patients in America and duplicate the Japanese survival outcomes with only a change in dialysis practice due to alleged higher co-morbidities, alleged lower incidence of diabetes, and alleged selection bias. I would urge all to consider that we actually have these answers already starting first of all historically when home dialysis patients and in-center dialysis patients had outcomes as equal or better than the current Japanese survival data. Dr. Lowrie boasted of a mortality rate as low as 7% in 1972:

Survival of Patients Undergoing Chronic Hemodialysis and Renal
Transplantation

Over an eight-year period 172 patients received an allograft from a living, related donor, 112 receivedcadaveric transplants, and 125 were placed on home dialysis. In a period of three years, 287 patients passed through our center dialysis program. Analysis of survival curves shows that patient survival was significantly better in recipients of transplants from living, related donors and in dialysis patients than in those receiving a cadaver graft. One-year patient survival rates for recipients of parental, sibling and cadaver allografts were 84.2, 89.5 and 68.7 per cent respectively. Survival rates at one and two years for home-dialysis patients were 88.5 and 77.8 per cent, and similar values for center patients were 92.9 and 86.1 per cent. These probabilities should be considered in the choice of which form of therapy to employ in a given patient, and illustrate the need for continued investigation into the prevention of allograft rejection and cadaver-recipient selection, (N Engl J Med 288:863–867, 1973)

Presented in part at the Fifth International Congress of Nephrology, Mexico City, Mexico, October 8–13, 1972.

Many would state that the dialysis patient of 1972 was younger and diabetics were excluded explaining the historical data by selection bias and exclusion criteria. I won't debate the merits or lack of merit of that type of argument at this point, but let us move on to the real issue; if we changed dialysis practices here in America, could we duplicate the Japanese survival data with a large cohort of American dialysis patients. The answer to that question is yes with 5000 dialysis patients in a CMS demonstration project by Fresenius  which recorded a 9.3% annual mortality rate on thrice weekly in-center dialysis:

The first three years of the demonstration (2006 through 2008) were evaluated and the case-mix adjusted results indicate the following for Fresenius Medical Care (FMC) patients enrolled in the demonstration:

• A significantly larger percentage of patients in the FMC program survived to the one year and two year time points.
  • Patient survival at the one year time point for FMC was 90.7% vs 85.4% for the comparison group. Patient survival at the two year time point for FMC was 80.1% vs 73.9% for the comparison group. This equates to mortality improvement for FMC versus the comparison group of 36.3% at the one year time point (9.3% vs 14.6%) and 23.8% at the two year time point (19.9% vs 26.1%).
• A significantly lower percentage of patients in the FMC program were hospitalized for the first time by one year and two years.
  • Improvement for FMC versus the comparison group in first hospitalizations for “all causes” at one year of 13.6% (51.1% vs 59.1%) and at two years 20.5% (60.5% vs 76.1%).
• A significantly lower percentage of patients in the FMC program were hospitalized for cardiovascular disease for the first time by one year and two years.
  • Improvement for FMC versus the comparison group in first hospitalizations for “cardiovascular disease” at one year of 14.1% (50.0% vs 58.2%) and at two years 20.7% (59.7% vs 75.2%).

This project utilizing the Medicare Advantage allocation which has no wall between Part A and Part B in a capitated system allowing Fresenius to eliminate the extra profit centers in fee for service practice at the hospital and other points of care that standard Medicare cannot eliminate. This study has not received broad attention especially given that this was with standard 3.5 hours thrice weekly dialysis in-center. What is also not published nor recognized widely is that Fresenius accomplished similar outcomes in their joint Kaiser/FMC ventures in Southern California which I was able to observe firsthand for two years as a patient. Changing practices by first of all aligning cost incentives to prevent hospitalization and outside medical utilization results in cost containment and improved survival. The principle investigator for Fresenius offered detailed analysis of why they were able to achieve these results in an interview with Medscape:

Battling ESRD With Nutrition and Monitoring: Fresenius Project: the Interview

Mr. Farrell: We really think this is right in the sweet spot of where CMS wants to take health reform. One point about our demonstration program was that this was individual enrollment of patients, so at any given dialysis clinic you might have a handful of patients who choose to enroll in this program. This presents an opportunity when you move to a broader accountable care structure. What we have proposed with CMS is the concept of the integrated care health home, with the nephrologist as the principal care physician for these patients and the dialysis clinic provider and our integrated care program providing the data systems and care program infrastructure of the medical home. We'd like to see CMS give us an opportunity to deploy this kind of a model on a full clinic basis rather than individual patient enrollment. This would give us the opportunity to operationalize this model in a more integrated and efficient manner with our clinics and nephrologists in support of our patients. We're very encouraged by the results we were able to achieve in this demonstration project, even in this individual enrollment environment, but see a huge opportunity for ESRD patients if we are able to deploy this model on a larger scale.

If this model sounds familiar, it is because it is the integrated medical care system that Kaiser pioneered over fifty years ago which allows the provider to capitalize on economies of scale and to capture the health care savings by preventing illness and undo utilization of resources. In addition, I have reported on the benefits of nutritional supplementation in the dialysis unit nearly three years ago on DSEN:

Food Insecurity: The Shameful Secret Affecting Dialysis Patients

In the vacuum left by Medicare, some nephrologists have taken matters into their own hands. One exceptional example is Dr. Phillip Tuso, a nephrologist with Kaiser Permanente who created FIRN in response to the high number of his own patients with food insecurity that were dying at an alarming rate from malnutrition. Dr. Tuso started this non profit organization dedicated to relieving food insecurity within his dialysis population which has succeeded greatly in reducing mortality among his dialysis patients. Hospitalizations are likewise over 50% lower than before he began this intervention in 2004 saving Kaiser Permanente millions of dollars from one dialysis unit alone.

One nephrologist who was motivated by the knowledge of a simple and cost effective intervention with nutritional supplements serves as a outstanding model for how America could once again regain the threshold of humane care of those at risk of food insecurity in our dialysis population. It is time for America to save both lives and money with a simple intervention with oral nutritional supplements. The best medicine is once again the cheapest medicine.

I believe the Japanese survival debate is a false debate clouded by a lack of evaluation of known data and by ignoring extensive studies revealing that the cause of our different outcomes is our different dialysis practices. The American dialysis patient is not the cause of our terrible outcomes as many academic American nephrologists would like all of us to believe. In addition,  Japan also has a different payment system where nephrologists are paid per hour of dialysis not per session of dialysis. I have spoken to many leaders in the dialysis industry in the last three years and many place the blame of our outcomes squarely on our perverse payment system that does not reward dialysis providers for keeping patients out of the hospital and avoiding complications.

I believe it is time to go beyond vacuous debates that fail to examine all of the evidence and instead to move forward with concrete practice changes already demonstrated in Europe, Japan, Australia and even right here in America that I have witnessed firsthand. Practice patterns will change when CMS creates incentives for outcomes instead of processes or biochemical profiles. Practice patterns differences are the reason for the excellent Japanese survival on dialysis and I believe that we can not only duplicate but surpass their survival rates by combining the practice changes that Fresenius utilized in an integrated care system with standard thrice weekly in-center dialysis and nutrition and holistic support and then surpassing that model by incorporating daily dialysis. That is the experiment and the direction that we need to take and stop endless and useless debates long since settled by the preponderance of the evidence.

The Brave New World of the Renal Bundle

By Peter Laird, MD

We are now a year into the social experiment we call the renal bundle where payments for all dialysis services are bundled into a single payment with disease modifiers and QIP matrices for quality care tied to the final payment. There is no doubt that the abuses of EPO and other separately billable items under the old payment system suffered from an extreme profit motive pushing EPO dosages higher and higher with no clinical benefit and indeed, many would rightly argue, great clinical harm to those at the high dosage end with elevated Hb levels over 12.0. 

CMS.gov: ESRD Payment

Medicare payment to ESRD facilities for outpatient maintenance dialysis services furnished to Medicare beneficiaries with End-Stage Renal Disease (ESRD) is based on a prospective payment system known as the basic case-mix adjusted composite payment system.  The base composite rate covers the costs of the dialysis treatment and certain routine drugs, laboratory tests, and supplies furnished at home or in a facility.  Other items and services, particularly injectable drugs (for example, erythropoietin (EPO), iron sucrose, vitamin D), and non-routine laboratory tests are not included in the composite rate and are billed separately to Medicare.  Separately billable services represent about 40 percent of total Medicare payments per dialysis treatment.  The base composite rate is adjusted by a drug add-on payment to account for changes in the drug pricing methodology that occurred in 2005 and by case-mix factors, that is, age, body size, and a special adjustment for pediatric patients.

Since the implementation of the prospective payment system, several reports are sending a mixed message of this "brave new world" we now know as the bundle. EPO utilization is dropping dramatically as are patients average Hb levels. The biggest news of the renal bundle in 2011 was the decision by CMS to drop the lower Hb target level of 10.0 leaving the door open for providers to adopt the pre-EPO modality of iron supplementation and rescue transfusions. The literature is repleat with the dangers of patients having Hb levels lower than 10.0. PTH levels are rising and uncontrolled secondary hypoparathyroid disease will result in a net increase in the need for parathyroidectomies to control this new epidemic. DOPPS has published an interim report on the effects of the bundle and continue to monitor it effects.

DOPPS reports early trends in dialysis care after the implementation of the ESRD bundle

Anemia management

Trends in all patients: From Aug. 2010 to April 2011, average hemoglobin levels fell slightly (0.10 g/dL). The percentage of patients with hemoglobin >12 g/dL declined from 31.4% to 28.0%. The percentage with hemoglobin <10 g/dL rose from 8.5% to 10.0%, and the percentage with hemoglobin <9 g/dL was stable at ~2.7%. The average prescribed epoetin dose fell by ~3% and the average administered dose fell by 6%-7%, with a notable drop in the higher epoetin dose range. The percentage of patients prescribed injectable iron per month rose from 57% to 78%.

Mineral and bone disorder management 

Trends in all patients: Overall, the average PTH level rose sharply from 337 to 435 pg/mL from August 2010 to April 2011, an increase of 29%. No substantial changes were seen in serum phosphorus or calcium values. The reasons for the rise in PTH are being investigated; large changes in use of injectable vitamin D or oral medications are not yet apparent.

The safety net of the bundle is an ongoing and developing quality indicator payment reduction system for failing to reach the minimum quality standards. Many are now decrying the fact that just measuring the indicators is enough to qualify for payment without actually addressing some of the measured indicators. 

What to Expect from the ESRD Quality Incentive Program

By Steven Fishbane, MD

The Centers for Medicare & Medicaid Services (CMS) published the final rule for the End-Stage Renal Disease Prospective Payment System and Quality Incentive Program (QIP) on Nov. 1. This follows the proposed rule that had been published in the Federal Register on July 8, 2011.

In this article, the focus will be on the ESRD QIP. There were 88 public comments received on the QIP, and the final QIP rule reflects important changes relative to the proposed rule. The greatest changes in the QIP will be for payment year 2014. It is critically important for providers to understand the 2014 QIP because, 1) it contains major changes from previous years and 2) the performance period begins very soon: Jan. 1, 2012. This posting is a summary of the major components of the final QIP rule, with changes from the proposed rule highlighted in italics.

Despite the alleged oversight through the QIP, a distressing essay written by a leading dietitian and posted by Gary Peterson in RenalWeb today depicts the desperate plight that the ESRD bundle is having on the dietitian profession who are admittedly one of the most important clinical partners in preventing complications of dialysis care. It is not only a call to arms for dietitians, but for all concerned about the care of dialysis patients in America. It is most importantly, a call to arms so to speak for all dialysis patients here in this nation as we see many of the improvements of the last three decades in pharmaceutical care slip through the bottomless pit of the ESRD bundle with QIP indices for Hb for instance with no minimum safety zone. Instead, for Hb, the patient is now at the mercy of their provider to consider what is their "healthiest" Hb levels without any guideline to say when low is too low.

Call to Arms

MY FELLOW RENAL dietitian, if ever there was a time to stand up, make noise, and be heard, it is now. We as renal healthcare professionals can no longer sit by in the wings as Medicare and dialysis units make policies that negatively impact our patients’ lives and outcomes. I am outraged by the changes that I have seen in the past year. I am disappointed that policies are made and implemented without thinking about how they will affect those that we serve. I am disheartened that one day, I, a family member, or a friend will have to submit to the suboptimal care that these policies have created. We, as a profession, knew that there would be changes in how we treat our patients when the bundled reimbursement plan came into effect last year. I could never imagine the turn that it would take. . .

Finally, this summer, Medicare released its proposed QIP measures for 2013, which addresses bone mineral management. With the inclusion of phosphate binders into the bundled rate beginning in 2014, Medicare is proposing that units attest whether or not they are following disease markers. There is no proposal at this time on whether the unit is treating the disease. There is no mention of disease marker goal ranges, either minimums or maximums. There is no mention of accountability that medications to treat the disease are being used. I concede that we do not yet know the “ideal” ranges for calcium, phosphorus, and parathyroid hormone, but there is enough evidence to determine levels that we should not exceed without increasing morbidity and mortality in our patients.

Yes, we are entering a brave new world we call the ESRD bundle and to date, the data is not comforting. Prior to the final ESRD bundle rule, CMS had many open meetings and vast input from patients, physicians, health care providers and dialysis patient groups. The QIP was the safety net proposed by CMS to address the concerns of all involved and as congress sat idly by aloof to the outcry by many to intervene for patient safety, instead we entered quietly into this brave new world. If the latest report by the renal dietitians is any indication of where we are heading, then this brave new world may in fact be nothing more than a return to the dark ages of dialysis prior to when advances in pharmaceuticals ended many patients suffering. There is a dark cloud hanging over this nation in our dialysis centers and the QIP blindly measures the faltering indices but has no power to evoke change. A call to arms is our only choice at this point in time. It is no longer a time for complacency among dialysis patients or allied health care professionals. 

What is Your Favorite Dialysis Friendly Restaurant

By Peter Laird, MD

In the day and age of fast food and instant meals, choosing a renal friendly dinner especially while traveling can become a difficult chore for many. Most fast food restaurants at the highway exists are filled with fats, salt and high phosphorus content. Fortunately there are options. My favorite since before and after starting dialysis is the Cracker Barrel Old Country Store and Restaurant. The first time I encountered this unique restaurant in 1998 while traveling cross country with my family, we stopped in a location in Indiana, and I dived into a home style plate of pot roast with all the fixins. My wife and I have been hooked on the Cracker Barrel ever since.

We soon discovered that every meal at Cracker Barrel is an experience right out of grandma's kitchen. To my greatest pleasure, Cracker Barrel is spreading across the entire United States except for a few states to date such as California which already has another company with the same name. After I started dialysis, to my great surprise, I found that it is the best place for me to keep my renal diet in check while on the road. They do not use high sodium in their foods and they also serve good wholesome fruits and vegetables as routine side dishes.

Breakfast in these old country restaurants is something to behold and it is probably a good thing that they are not within easy driving distance to our house.  The closest to us now is a good 7 hours away. Driving back and forth between our home and our kids home in Idaho, there is an entire string of these restaurants that we most often can have breakfast, lunch and dinner exclusively at the Cracker Barrel all in the same day. Thankfully, they have very consistent quality between all of their stores. In addition, we have stopped and refreshed ourself with a meal in as little as 20 minutes making this a unique fast food restaurant when you must keep a schedule that is likewise friendly to your wallet.

As you can tell, I am quite a fan of this restaurant and I believe you will enjoy them as well. If anyone has a favorite must stop place for dining out, I would like to hear about it, but for my wife and I, we are already looking forward to our next road trip and eating out in our favorite dialysis friendly restuarant.

Vitamin Supplements: The Dialysis Paradox

By Peter Laird, MD

Vitamin supplements are a favorite of health advocates who help generate the demand in this billion dollar industry, yet recent studies point to the paradox of adverse outcomes from these same supplements in high dosages.   The difficulty of defining the proper role that vitamin supplements play is especially unsettled in dialysis patients who suffer the opposite extreme of documented vitamin deficits as a result of washing out water soluble vitamins during dialysis. Unfortunately, in some instances, the data on supplementing these deficiencies comes at a risk as well.

Vitamin C levels are especially low in dialysis patients according to a recent study looking at dialysis patients undergoing usual in-center schedules compared to extended hours dialysis protocols. Despite the low vitamin C level which borders on the development of scurvy, supplementation of vitamin C also increases oxalate levels even at low dosages of vitamin C which can build up in dialysis patients causing severe effects:

Water-soluble vitamin levels in extended hours hemodialysis

The major finding of this study was the high prevalence of vitamin C deficiency in extended hours hemodialysis patients compared with conventional dialysis patients. This is not unexpected as ascorbic acid is the smallest molecule (MW 176 g/mol) of the vitamins we assayed, and is readily removed by dialysis.²⁴ As the prevalence of more frequent and longer hours (quotidian) dialysis is increasing, the importance of the assessment and supplementation of vitamin C in this patient group is demonstrated.

Traditionally, vitamin C has been used sparingly in patients with end-stage renal failure, as its metabolism generates oxalate. Increased levels of oxalate can cause deposition of calcium oxalate crystals in tissues (oxalosis), with cardiac, renal, and bone manifestations reported historically.²⁷ The appropriate dose of vitamin C for patients with renal failure, as well as the impact of vitamin C dose on oxalate levels has been the subject of much debate. The European Best Practice Guidelines recommends 75 to 90 mg/day;¹⁸ however, this dose may not be sufficient to correct vitamin C deficiency in either extended or CHD patients. For example, a study of 18 conventional patients on 100 mg vitamin C daily found 5 patients had ascorbate levels in the range of deficiency (<0.30 mg/dL).¹⁵ The dose was increased to 500 mg/day for 2 weeks, which corrected the deficiency, and increased the mean plasma ascorbate from 0.69 to 1.82 mg/dL (39–103.5 μmol/L). However, because of a median increase in oxalate levels of 17%, the authors advised against high-dose vitamin C.

The balance between vitamin C levels too high or too low in extended hours dialysis remains a subject of debate with few studies available to guide the individual patient on what is the optimal strategy, truly leading to a vitamin supplement paradox between deficiency or harm from producing excessive oxalate levels with enough supplement to correct the deficiency. This is one area of study that demands a quick resolution since both extremes can cause harm to the patient.  As of yet, there is no consensus on how to proceed.

Vitamin D likewise defies definition of optimal dosage at both ends of the spectrum as well. Low levels of vitamin D can precipitate rickets and is suspected to increase the risk of cancer as well as increasing the risk of death from cardiovascular disease, it brings on cognitive impairment, and may be an important factor in the prevention of diabetes and other health related conditions. Paradoxically, several studies in the female population at risk of osteoporosis showed a tendency to induce vascular calcification with vitamin D supplementation which is likewise demonstrated in dialysis patients as well.

Dialysis patients are especially at risk of vascular calcifications and mineral bone disorders due to the loss of enzymes that activate vitamin D synthesized in the skin by exposure to sunlight.   A recent study suggested that vitamin D supplementation increases vascular calcifications in dialysis patients when phosphorus levels run high:

The dualistic role of vitamin D in vascular calcifications

The current treatment approach of providing vitamin D analogs to patients with CKD often poses a dilemma, as studies linked vitamin D treatment to subsequent vascular calcification. Recent genetic studies, however, have shown that vascular calcification can be prevented by reducing serum phosphate levels, even in the presence of extremely high serum 1,25-dihydroxyvitamin D and calcium levels. This article will briefly summarize the dual effects of vitamin D in vascular calcification and will provide evidence of vitamin D-dependent and -independent vascular calcification.

Certainly dietary guidelines for dialysis patients include eating several servings of fruits and vegetables every day which contain many of these vitamins as well as taking a daily vitamin specifically designed for dialysis patients.  Data on the efficacy of this recommendation remains scant. Vitamin D is an important element in improving anemia as is Vitamin C, but at what cost. The balance between deficiency and too many vitamin supplements remains for future studies. In the mean time, for those taking vitamin D or its analogs, one key noted in the study above is keeping phosphorus levels in check.  Likewise, there is hope that extended dialysis schedules may be able to remove the excess oxalate from increased vitamin C supplements but this remains unproven to date.

Until we have the studies available, discuss the risks and benefits with your medical team of vitamin supplementation which in the case of dialysis patients is mandatory to avoid the known consequences of severe deficiencies, control your phosphorus, eat a diet complemented with fruits and vegetables, exercise regularly which is perhaps the best "vitamin" we have, and do all things in moderation including vitamin supplements. Sometimes too much of a good thing is actually harmful. 

Six Large Food Companies Pledge to Reduce Salt

By Peter Laird, MD

The recent news release that six major food companies will begin to reduce salt levels is good news for all consumers, especially people with chronic illnesses such as diabetes, HTN, CHF and certainly for all renal patients who already have limited food choices. An article from the Atlantic gives more details:

Six major companies are uniting with the NSRI, including Hostess (committing to reduce salt in its bread products), the supermarket group Delhaize (pledging to cut sodium in 22 categories of packaged foods such as frozen pizza, cereal, and butter), and the seasonally appropriate Butterball, a manufacturer of many meat products but best known for turkey. These companies have set varying goals, with staggered timelines focusing on 2012 and 2014 as benchmarks. The NSRI is already working with food companies such as Subway, Heinz, Starbucks, Kraft, and Mars. The six new partners bring the number of participating food companies to 22.