Chronic kidney disease affects the bones in the following ways:

• A change occurs in the balance between two important minerals in your body-- calcium and phosphorus--leading to loss of calcium from your bones.

• Four small glands (parathyroid glands), which help to regulate calcium in your body, become too active.

• Not enough vitamin D is changed to an active form that can be used by the body.

Your doctor will examine you and do certain blood tests and, in some cases, a bone biopsy. These tests help the doctor decide what type of bone disease you have and what treatment is best for you. 

• Phosphorus is in most foods you eat and whatever is not needed in the body is usually removed by your kidneys. When your kidneys have stopped working normally, phosphorus may build up in your blood. Too much phosphorus in your blood leads to loss of calcium from your bones, which weakens them over time.

            Eating foods that are low in phosphorus can help to prevent phosphorus from building up in your blood. (See information on diet.) You may also need to             take a medicine called a phosphorus binder which keeps phosphate from being absorbed from your food.

• As phosphorus stays in your body when your kidneys can no longer remove it, calcium levels of the blood tend to drop. This causes four small glands in your neck (parathyroid glands) to become too active. When this happens, calcium is removed from your bones over a long period of time, causing them to weaken.

            This problem can also be helped through changes in your dialysis treatments, a low phosphorus diet and by taking certain medicines such as calcium and             vitamin D. Sometimes, surgery is necessary to remove some of these glands

• Vitamin D is an important vitamin that affects your calcium balance. Normally, vitamin D from the food you eat, from vitamin and mineral supplements and exposure to sunlight is changed by the kidneys into an "active" form that can be used by the body. If your kidneys have failed, they can no longer do this important job. Fortunately, the active form of vitamin D is available as a medicine that can be ordered for you by your doctor if needed.

• In general, over-the-counter vitamin D supplements should be avoided by people with kidney disease. Check with your doctor about the right supplements for you. The amount of vitamin D found in the foods you eat is not a problem.

By reducing phosphorus in your diet, you can help to prevent the amount of phosphorus in your blood from becoming too high. Foods high in phosphorus include: dairy products such as milk and cheese, dried beans and peas, nuts and peanut butter, and beverages such as cocoa, colas and beer. Using non-dairy creamers and recommended milk substitutes is a good way to reduce the amount of phosphorus you eat.

Your treatment may include one or more of the following:

• Reducing phosphorus in your diet

• Taking a medicine called a phosphate binder

• Taking medicine with a form of vitamin D

• Taking calcium supplements

• Changes in your dialysis treatment

• An exercise program approved by your doctor

• An operation to remove some of the parathyroid glands

A successful kidney transplant may help your bones to heal from the damage that might have occurred during the time that you had kidney failure. However, the cortisone-like medicine taken by kidney transplant patients can be a serious problem.

Updated: 05/12/04

Cholesterol is a fat-like substance found in your blood. Your body can make cholesterol as well as get it from eating meats and other animal food products.

Too much cholesterol can build up in your blood vessels. This build up can narrow vessels and lead to a blockage, preventing blood from getting to a certain area of your body. When this occurs in your heart vessels, it is called coronary heart disease and can cause a heart attack.

In people with chronic kidney disease (CKD), heart disease is very common. It is suggested that people with CKD have cholesterol labs drawn at least yearly. Your doctor may want to do them more frequently if something has changed with your health.

Low density lipoprotein (LDL) cholesterol, also known as bad cholesterol, is the primary cholesterol test used to screen for heart disease. Other lab tests usually drawn are high density lipoprotein (HDL) cholesterol, also known as good cholesterol, triglycerides, and total cholesterol.

Since these tests are affected by food, it is recommended that you should not eat nine to 12 hours before the lab tests are drawn.

Cholesterol lab values are different for adults and children. The lab ranges stated below are for adults and should not be used for children. People with good LDL cholesterol, high HDL cholesterol, and normal triglycerides are less likely to have heart disease.

	LDLCholesterol	HDLCholesterol	TotalCholesterol	Triglycerides
	Optimal <100mg/dL	>60mg/dL F >55mg/dL M	Desirable <200mg/dL	Normal <150mg/dL
Near Optimal	100-129mg/dL
Borderline High	130-159mg/dL		200-239mg/dL	150-199mg/dL
High	160-189mg/dL	<40mg/dL*	>240mg/dL	200-499mg/dL
Very High	>190mg/dL			>500mg/dL

Aside from high LDL cholesterol levels, the risk for heart disease increases with the following risk factors:

• cigarette smoking

• obesity

• high blood glucose

• low HDL cholesterol

• age (men > 45 years old; women > 55 years old)

• high blood pressure or on antihypertensive medications

• diabetes mellitus

• family history of early heart disease

• other forms of vessel narrowing diseases.

People with CKD may have some added risk factors that lead to heart disease:

• large calcium intake from diet or medication

• high blood phosphorus levels

• high parathyroid hormone levels

• high homocysteine levels

• whole body inflammation.

People who are physically inactive or who eat foods that are high in saturated fat and cholesterol are also at risk for developing heart disease.

Lifestyle Changes:

• Increase physical activity to 30 minutes every day at a moderate level. This will help:

• • raise HDL cholesterol

  • lower LDL cholesterol in some people

  • lower blood pressure

  • improve diabetic control

  • improve heart function.

• Obtain and maintain a healthy weight

• Talk to your doctor and dietitian

• Do not smoke.

• Do not drink alcohol excessively. (Limit alcohol to 1 drink a day with physician approval.)

Diet Changes:

• Choose foods that are low in saturated fat and cholesterol. See "Tips to reduce fat and cholesterol in your diet."

• Decrease use of trans fatty acids since they can raise LDL cholesterol.

• Use plant stanols and sterols found in regular or "light" specially formulated margarine-like spreads. Increase soluble fiber. (Fruits and vegetables and grains are good sources of fiber.)

• Talk with your dietitian for assistance with safely and gradually increasing fiber in your diet.

Treatment of Other Risk Factors:

• Control hypertension and diabetes.

• Treatment for these diseases can include medications, diet changes and increased physical activity.

• Your doctor and dietitian can help you with lifestyle changes to best treat these diseases.

Medications are available for lowering LDL cholesterol and triglycerides, but heart disease medications work the best when diet and life style changes have already been made. 

• Your doctor can talk to you about how best to treat your risk for heart disease.

• A pharmacist can answer questions you might have about any medications the doctor has prescribed for you.

• A dietitian can help you in making healthy food changes to your diet.

1.  Choose lean meats, poultry and fish. The loin and round cuts of meat tend to be leaner than rib cuts and organ meats.

2.  Trim all visible fat from meat and remove skin from poultry.

3.  Steam, broil, roast or bake meat, poultry and fish. Place the food on a rack to allow the fat to drain away from the food. Do not fry foods.

4.  Choose fresh fruits and vegetables. Steam, boil, bake or microwave vegetables. Do not fry foods.

5.  Use nonstick pans or vegetable sprays for sautéing.

6.  Use herbs and spices to season foods instead of sauces, butter or margarine.

7.  Try wine, lemon juice, or flavored vinegar to give flavor with limited fat and calories.

8.  Use jelly, jam, honey or syrup instead of butter or margarine on toast, waffles, pancakes or muffins.

9.  Use fat free or reduced fat versions of high-fat foods. For example, use fat-free sour cream in place of regular sour cream or use 1% or skim milk in allowed amounts.

10.  Limit hydrogenated and partially hydrogenated fats. These can be found in some margarines, peanut butters, packaged baked goods and snacks, and fried foods. Try baked crackers instead of fried crackers. Buy grilled or baked items when eating out.

11.  Use two grams of plant stanols or sterols per day. These are sold as specially formulated margarine-like spreads. Your dietitian can assist you with finding these products.

12.  Limit products made with coconut, palm kernel, palm oil, lard, shortening, bacon fat and cocoa butter.

13.  Use canola or olive oils instead of shortening, butter or other oils when cooking. These monounsaturated fats will not lower your HDL level.

14.  Try sherbet or ice milk instead of ice cream.

15.  Read food labels on the foods you buy. Do not be misled by foods that are cholesterol free but contain large amounts of saturated fat that your body will turn into cholesterol.

The most common ones are Type 1 and Type 2. Type 1 diabetes usually occurs in children. It is also called juvenile onset diabetes mellitus or insulin-dependent diabetes mellitus. In this type, your pancreas does not make enough insulin and you have to take insulin injections for the rest of your life.

Type 2 diabetes, which is more common, usually occurs in people over 40 and is called adult onset diabetes mellitus. It is also called non insulin-dependent diabetes mellitus. In Type 2, your pancreas makes insulin, but your body does not use it properly. The high blood sugar level often can be controlled by following a diet and/or taking medication, although some patients must take insulin. Type 2 diabetes is particularly prevalent among African Americans, American Indians, Latin Americans and Asian Americans.

With diabetes, the small blood vessels in the body are injured. When the blood vessels in the kidneys are injured, your kidneys cannot clean your blood properly. Your body will retain more water and salt than it should, which can result in weight gain and ankle swelling. You may have protein in your urine. Also, waste materials will build up in your blood.

Diabetes also may cause damage to nerves in your body. This can cause difficulty in emptying your bladder. The pressure resulting from your full bladder can back up and injure the kidneys. Also, if urine remains in your bladder for a long time, you can develop an infection from the rapid growth of bacteria in urine that has a high sugar level.

About 30 percent of patients with Type 1 (juvenile onset) diabetes and 10 to 40 percent of those with Type 2 (adult onset) diabetes eventually will suffer from kidney failure.

The earliest sign of diabetic kidney disease is an increased excretion of albumin in the urine. This is present long before the usual tests done in your doctor's office show evidence of kidney disease, so it is important for you to have this test on a yearly basis. Weight gain and ankle swelling may occur. You will use the bathroom more at night. Your blood pressure may get too high. As a person with diabetes, you should have your blood, urine and blood pressure checked at least once a year. This will lead to better control of your disease and early treatment of high blood pressure and kidney disease. Maintaining control of your diabetes can lower your risk of developing severe kidney disease.

As your kidneys fail, your blood urea nitrogen (BUN) levels will rise as well as the level of creatinine in your blood. You may also experience nausea, vomiting, a loss of appetite, weakness, increasing fatigue, itching, muscle cramps (especially in your legs) and anemia (a low blood count). You may find you need less insulin. This is because diseased kidneys cause less breakdown of insulin. If you develop any of these signs, call your doctor.

Table 1

Signs of Kidney Disease in Patients with Diabetes

1. Albumin/protein in the urine

2. High blood pressure

3. Ankle and leg swelling, leg cramps

4. Going to the bathroom more often at night

5. High levels of BUN and creatinine in blood

6. Less need for insulin or antidiabetic medications

7. Morning sickness, nausea and vomiting

8. Weakness, paleness and anemia

9. Itching

First, the doctor needs to find out if your diabetes has caused the injury. Other diseases can cause kidney damage. Your kidneys will work better and last longer if you:

• Control your diabetes

• Control high blood pressure

• Get treatment for urinary tract infections

• Correct any problems in your urinary system

• Avoid any medicines that may damage the kidneys (especially over-the-counter pain medications)

If no other problems are found, your doctor will try to keep your kidneys working as long as possible. The use of high blood pressure medicines called angiotensin converting enzyme (ACE) inhibitors has been shown to help slow the loss of kidney function.

The kidney doctor, called a nephrologist, will plan your treatment with you, your family and your dietitian. Two things to keep in mind for keeping your kidneys healthy are controlling high blood pressure in conjunction with an ACE inhibitor and following your renal diabetic diet. Restricting protein in your diet also might be helpful. You and your dietitian can plan your diet together.

End stage renal failure , or kidney failure, occurs when your kidneys are no longer able to support you in a reasonably healthy state, and dialysis or transplantation is needed. This happens when your kidneys function at only 10 to 15 percent. The usual span of time between the onset of diabetic kidney injury and kidney failure is about five to seven years.

Three types of treatment can be used once your kidneys have failed: kidney transplantation, hemodialysis and peritoneal dialysis.

Yes. Once you get a new kidney, you may need a higher dose of insulin. Your appetite will improve so your new kidney will break down insulin better than your injured one. You will use steroids to keep your body from rejecting your new kidney. If your new kidney fails, dialysis treatment can be started while you wait for another kidney.

Sometimes it is possible to perform a pancreas transplant along with a kidney transplant. Your doctor can advise you about this possibility.

Research suggests that a low-protein diet can slow the advance of kidney damage.

Today, more and more research dollars are spent on diabetes research. Hopefully, the prevention and cure of diabetes is in our future. In the meantime, you can manage your diabetes better with:

• home monitoring of your blood glucose levels

• maintaining an awareness of controlling your blood pressure, and possibly monitoring your pressure at home

• following your special diet.

Updated: 05/18/05

This means that your kidneys are not doing as good a job as they should to help keep you healthy. Your kidneys normally remove waste products and extra fluid from your blood. These waste products and fluids come from the foods you eat and liquids you drink. If you have early kidney failure, some of the waste products and extra fluid remain in your blood. Sometimes, early kidney failure may progress to total kidney failure. However, if you follow your doctor's orders carefully, you may be able to slow down this process. 

A special diet can help to control the buildup of waste products and fluid in your blood and to decrease the workload of your kidneys. This diet may also help to slow down the loss of kidney function. The main goal of the diet is to keep you healthy. Your doctor may recommend a special diet, depending on the stage of your disease. If and when this diet is ordered for you, your doctor may want you to see a renal dietitian, who has special training in diet for kidney disease.

In general, the diet used for the early stages of kidney disease controls the amount of protein and phosphorus you eat. Usually, sodium is also controlled. Getting enough calories to maintain a healthy weight is very important at this time. The following information tells you where these nutrients are found in foods.

Your body needs protein every day for growth, building muscles and repairing tissue. After your body uses the protein in the foods you eat, a waste product called urea is made. If you have lost kidney function, your kidneys may not be able to get rid of this urea normally. You may need to reduce the amount of protein you eat to avoid buildup of urea in your body. Protein is found in two types of foods:

Your body needs protein every day for growth, building muscles and repairing tissue. After your body uses the protein in the foods you eat, a waste product called urea is made. If you have lost kidney function, your kidneys may not be able to get rid of this urea normally. You may need to reduce the amount of protein you eat to avoid buildup of urea in your body. Protein is found in two types of foods:

• in large amounts in foods from animal sources such as poultry, meat, seafood, eggs, milk, cheese and other dairy products.

• in smaller amounts in foods from plant sources such as breads, cereals, other starches and grains, and vegetables and fruits

While you may need to limit the amount of protein you eat, it is important that you eat the right amount of protein. This helps to keep your body healthy.

Your kidneys may not be able to remove phosphorus from your blood. This causes the level of phosphorus in your blood to become too high. A high blood phosphorus level may cause you to lose calcium from your bones. This may weaken your bones and cause them to break easily.

To help control the phosphorus in your blood, you should eat fewer foods that are high in phosphorus. Phosphorus is found in many foods but is especially high in the following foods:

• dairy products such as milk, cheese, pudding, yogurt and ice cream

• dried beans and peas such as kidney beans, split peas and lentils

• nuts and peanut butter

• beverages such as cocoa, beer and cola soft drinks

Using non-dairy creamers and recommended milk substitutes instead of milk is a good way to lower the amount of phosphorus you eat.

You may need to limit the amount of sodium in your diet. This is because high blood pressure, kidney disease and sodium are often related. Learning to read labels can help you make lower sodium choices. Sodium is found in many foods, but is especially high in the following:

• table salt and foods with added salt such as snack foods, soups and processed cheese

• some canned foods, prepared foods and "fast foods"

• foods pickled in brine such as pickles, olives and sauerkraut

• smoked and cured foods such as ham, bacon and luncheon meats

You may need to limit the amount of sodium in your diet. This is because high blood pressure, kidney disease and sodium are often related. Learning to read labels can help you make lower sodium choices. Sodium is found in many foods, but is especially high in the following:

• table salt and foods with added salt such as snack foods, soups and processed cheese

• some canned foods, prepared foods and "fast foods"

• foods pickled in brine such as pickles, olives and sauerkraut

• smoked and cured foods such as ham, bacon and luncheon meats

Calories give you energy. Because you are getting fewer calories from protein, you will need to get more calories from other foods. Your dietitian may recommend that you get these extra calories from sugar and vegetable fats to help you get the right amount of calories.

Avoid losing too much weight because it can cause malnutrition and lead to illness.

Some ways to increase calories are as follows:

• Increase unsaturated fats such as vegetable oils (made with corn, cottonseed, safflower, soybean or sunflower oils), olive oil and mayonnaise type salad dressings.

• Use sugar or sweets such as hard candy, gum drops, jelly beans, marshmallows, honey, jam and jelly.

• Use canned or frozen fruits in heavy syrup.

If you are diabetic or overweight, talk with your renal dietitian about the best way for you to get the right amount of calories for your needs.

In general, you do not need to limit potassium or fluids in the early stages of your disease. However, it is best to avoid salt-substitutes that contain potassium. These can cause the level of potassium in your blood to become too high. Instead, try using spice blends to enhance the flavor of foods. Also, try adding a dash of hot pepper sauce or a squeeze of lemon juice to add flavor.

Your new diet may have more fats and carbohydrates (starches and sweets) than you are used to eating. These are added to help maintain weight and protect your muscle tissue.

Your special diet may help to slow the loss of kidney function and to protect you from malnutrition. In later stages of kidney disease, the diet may also help you control the amount of waste products in your blood. If these waste products build up to very high levels, they may cause nausea, vomiting, hiccups, tiredness, weakness, sleepiness and other disorders.

Your diet may change as your kidney function changes. In the early stages of your kidney disease, your diet may be reduced in protein. If dialysis or a kidney transplant is needed, your diet will change based on the treatment option you choose.

Vitamins and minerals come from a variety of foods you eat each day. If your diet is limited, you may need to take special vitamins or minerals. Take only the vitamins and minerals your doctor orders for you. Certain vitamins may be harmful to people with kidney disease.

In some cases, you may need to make only a few changes in your diabetic diet to fit your needs as a kidney patient. If your doctor suggests that you eat less protein, you must be sure to get enough calories from other sources.

If you are a vegetarian, it becomes very important to get good nutrition advice from a renal dietitian. Vegetarian diets by nature are high in potassium and phosphorus because of all the vegetables, whole grains and fruits that make up the diet. A vegetarian diet that includes eggs and milk is easier to work into the renal diet. The goal is to eat the right combinations of plant proteins while keeping potassium and phosphorus under control.

Yes. Calcium and phosphorus are two minerals important for healthy bones. Diseased kidneys are unable to remove phosphorus from the blood as well as they should. Too much phosphorus in your blood may lead to loss of calcium from your bones. This may cause your bones to become weak and to break easily.

As mentioned earlier, phosphorus comes from many foods in your diet. By eating fewer high phosphorus foods, you reduce the amount of phosphorus in your blood, which reduces calcium loss from your bones. Your doctor may order a medicine called a phosphorus binder to keep your body from absorbing phosphorus from foods. This medicine should be taken with your meals and snacks as your doctor orders.

Unfortunately, the best food sources of calcium are also high in phosphorus. The best way to avoid losing calcium from your bones is to limit high phosphorus foods, which lead to the calcium and phosphorus imbalance in your blood. In addition, your doctor may have you take medications to help raise the levels of calcium in your blood. As with all medication, it is important to follow your doctor's instructions very carefully.

Usually not. Most female dialysis patients do not have regular periods. The use of erythropoietin (EPO) has improved some women's overall health, which can result in a greater chance of pregnancy. If a patient becomes pregnant, she usually has a miscarriage. Only rarely has a dialysis patient been able to have a baby, and then only after increasing treatments, changes in diet and medications, and more frequent doctor visits. Pregnancy adds stress to the healthy body and can put the dialysis patient and the unborn child at greater risk. Being unable to have a baby can cause feelings of loss. Since people in our society expect married couples to have children, a childless woman may question her role. She may feel incomplete or unfulfilled in her role as a woman, which may lead to feeling negative about herself and her sexuality. As a way of coping, she should talk openly about her feelings and needs with her partner and/or health care staff. Other options, such as adoption or becoming a foster parent, may also be available.

Yes. Men who are on dialysis or who have received a kidney transplant can father children. A couple should seek professional help if they have tried for at least a year to have a child without success. A man can have a routine fertility checkup.

Yes. A woman who has had a kidney transplant usually has more regular periods and better general health. Therefore, it is easier for her to get pregnant and have a child. However, pregnancy is not recommended for at least one year after the transplant, even with stable kidney function. In some cases, pregnancy is not recommended because of risk to the mother's life or possible loss of the transplant.

The amount of anti-rejection medicines is important. In the early period after a transplant, patients are on higher doses of these medicines. Once the medicines are reduced to maintenance levels, they do not seem to have negative effects on a developing baby. However, long-term side effects are still unknown. A woman transplant patient who is considering pregnancy should discuss any possible risks with her doctor.

Dialysis patients who have periods or who could become pregnant should use birth control to guard against pregnancy. The doctor can recommend the type of birth control that should be used. Generally, women who have high blood pressure should not use the pill since it can raise blood pressure. Transplant patients should not use an IUD. These patients are more likely to get an infection from an IUD because the anti-rejection drugs they must take also lower the body's ability to fight infection. The diaphragm, sponge and condom are good means of birth control, especially when used with spermicidal creams, foams or jellies.

Updated: 06/03/04