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Nephrology/follow-up question to my mother's kidney problem

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Dear Sir
Regarding to your queries to my previous question, here are the details:
# My mother had high blood-pressure and due to it gradually her kidneys had shrunk (approx size of both kidneys=70 mm x 27 mm)and thus her kidney disease is chronic.
# She has no gynae disease,a gynaecologist had properly examined all such possibilities.
# She has no obstruction to urine, she urinates frequently, more so in night.
# For 2 years, her creatinine level was between 3-4 and urea 60-100, with Hemoglobin=6.5-7.5 ,but due to sudden heavy menstrual bleeding past week, and accompanied UTI with fever and vomiting (and acidosis) her levels became creatinine/urea/Hb= 7.0/162/4.9.
# Now, main problem is anemia, she had blood-transfusion with 2 units of blood, but nothing happened, 2 days ago she was given 3x ferric-carboxymaltose 500mg infusions with normal saline (100ml)8 hourly followed by Erythropoeitin 4000 IU injections biweekly.
# She is not vomiting, but in pain and severe weakness, unable to even  sit and eat.
# Regarding doctor not giving her dialysis, I don't know the exact cause, but it may be due to poor facility in comparison to no. of patients in the govt hospital where she is undergoing treatment.

Hence, I would ask you that what can I do to help her.
yours sincerely
mohit

Answer
Good morning, Mohit,

Thank you for the additional information.

It seems clear that your Mother's kidney disease is chronic and, likely, been present for many years.  The fact that she has small kidneys means that she has lost much functional renal tissue and, unfortunately, also means that her condition will persist and progress.

One of the characteristics of kidney failure (symptomatic kidney failure is called UREMIA) is a bleeding tendency.  If your Mom's excess menstrual bleeding is not due to gynecological disease, which the gyn doctor feels it is not, then, it is probably due to her uremia and is an indication for the institution of chronic dialysis.  So is her weakness and lack of sense of well being. It think it is important to confront the nephrologist (it is important that she be followed closely by an experienced nephrologist) and ask him just exactly why your Mother is not receiving dialysis and/or transplantation as there may be a rational reason....like concurrent infection, etc.

There are some NONdialytic interventions that can be used to treat uremia although these interventions are usually temporary while one awaits the institution of dialysis.  She is receiving some of them already, such as epogen therapy for her anemia, as well as appropriate blood transfusions.

The primary nondialytic treatment for chronic kidney failure is the implementation of a low protein diet. If she is of average size, she would likely benefit from a 20 to 30 gram high biologic protein diet.  The protein should be of high biologic value (such as eggs and animal meats, as opposed to plant protein, which is metabolized to the toxins that cause the uremic symptoms). This diet is complex and NOT without risks, because, if the protein intake is less than the minimum amount required, she would become malnourished and sicker.  This diet requires the supervision of both an experienced dietician as well as nephrologist. The diet was shown in the 1940's to improve the symptoms of uremia and in the 1980's, to actually slow the progression of kidney failure and prolong life.  But, as I said, it is complicated and has measurable risks.

A class of medications called ACE inhibitors have also been used to slow the progression of chronic renal failure but should not be used if the patients creatinine is above 2. This would preclude using them to treat your Mother.

Getting her on such a diet is something that you could do, but I think it is important for you to "hold the doctor's feet to the fire" and demand a reason for her being deprived of the benefit of dialysis and/or kidney transplantation.

I'm sorry that you and she are having such difficulties and I hope the above is of some use to you.

Please, feel free to follow up id necessary.

Sincerely,

Dr Falkinburg  

Nephrology

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Newell R. Falkinburg, M.D., FACP

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I am a board certified nephrologist and emeritus professor of medicine at a major medical school and past Director of Nephrology & Hypertension at a university affiliated hospital. I have expertise in all areas of clinical nephrology, dialysis, transplantation and plasmapheresis.

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