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Home , Kidney failure, Uremia

Failure: What to Expect

How does affect a word “renal” refers to the kidneys. Even people who have treatments person’s health? may experience some of the problems of idney failure can affect a person’s if they skip treatments or eat foods health in several ways. Some not recommended for people on dialysis. Kpeople experience , some lose their appetite, and some have leg . These problems are caused by Can uremia be avoided? waste products that build up in the blood, People with kidney failure can avoid a condition known as uremia. Healthy most of the problems of uremia by having kidneys remove waste products from the regular dialysis treatments and limiting blood. When the kidneys stop working, foods that contain , , uremia occurs. and phosphorus. People who have CKD should see a kidney specialist—called a The kidneys also make hormones and nephrologist—regularly to track the pro- balance the minerals in the blood. When gression of the disease so they can begin the kidneys stop working, most people appropriate treatment before uremia develop conditions that affect the blood, occurs. bones, nerves, and . In addition to fatigue, loss of appetite, and leg cramps, Even though health care providers can some of the more common problems treat most of the complications of CKD caused by kidney failure are itching, sleep and ESRD, people with these conditions problems, restless legs, weak bones, joint should know what to expect when their problems, and depression. kidneys fail.

When is uremia likely to occur? What problems can occur during Uremia is likely to occur when a person ? reaches the final stages of chronic kidney During the first few weeks of disease (CKD). People with CKD often hemodialysis—a type of dialysis that uses feel no symptoms until the kidneys are a machine to circulate blood through a severely damaged. Usually when people filter outside of the body—many people develop symptoms, their kidney failure find that rapid changes in the body’s has progressed to the point where they water and mineral balance can cause prob- must have regular blood-filtering treat- lems. Muscle cramps and —a ments called dialysis or receive a kidney sudden drop in —are two transplant to stay alive. Kidney failure common side effects. Hypotension can treated by dialysis or transplant is called make people feel weak, dizzy, or sick to end-stage renal disease (ESRD). The their stomach.

National Kidney and Urologic Diseases Information Clearinghouse Many people need a few months to adjust to How does kidney failure affect the hemodialysis. Side effects can often be treated quickly and easily, so people should always report appetite? problems to their health care provider and dialysis People who have uremia often lose their appe- staff. Many side effects of hemodialysis treatments tite. Some people find that food tastes different. can be avoided by following a diet tailored for Some no longer like foods they once craved. In hemodialysis patients, limiting liquid intake, and fact, many people feel sick to their stomach at the taking medications as directed. thought of eating. But getting enough protein and calories is important for staying healthy. People with kidney failure should talk with the renal dieti- How does kidney failure affect the tian at their dialysis clinic or transplant center to blood? find foods that are appealing and provide needed In addition to uremia, kidney failure can also cause nutrients. , a condition in which the red blood cells are fewer or smaller than normal, which means How does kidney failure affect the skin? less oxygen is carried to the body’s cells. Anemia Many people treated with hemodialysis complain can cause extreme fatigue and can worsen existing of itchy skin, usually on the back, chest, head, or heart problems. limbs. The itching is often worse during or just Anemia is common in people with CKD, as well after dialysis treatment due to the waste prod- as those on dialysis, because the damaged kidneys ucts that are not removed from the blood during slow the production of the hormone erythropoie- dialysis. tin (EPO), which helps the make red The problem can also be due to the damaged kid- blood cells. Less EPO means the body has fewer neys’ inability to balance the levels of the minerals red blood cells, resulting in anemia. A synthetic and phosphorus in the blood. The result- form of EPO is commonly prescribed for people ing low levels of blood calcium trigger four pea- on dialysis. sized glands in the neck, called the parathyroid glands, to release , which How does kidney failure affect the draws calcium from the bones back into the blood. heart and blood vessels? The high levels of parathyroid hormone can cause itching. Some people feel much better after having People with kidney failure, particularly dialysis most of their four parathyroid glands removed. patients, have far higher rates of heart and blood As long as one parathyroid gland remains, it can vessel problems than people without kidney regulate the calcium and phosphorus balance in problems. Heart attacks are the leading cause of the blood. hospitalization and death among dialysis patients. Kidney failure also raises the risk of other cardio- Damaged kidneys cause phosphorus to build up vascular problems such as blockage of blood to the in the blood, which can also cause itching. Often, heart and congestive . People who medications called binders—such have kidney failure need to monitor their cardio- as (Tums), calcium acetate vascular health, take all prescribed medications, (PhosLo), sevelamer hydrochloride (Renagel), or and follow their health care provider’s instructions lanthanum carbonate (Fosrenol)—are prescribed for diet and exercise. with meals and snacks to bind phosphorus in the bowel, decreasing its absorption into the blood. The resulting lower blood phosphorus levels seem to ease the itching for some people. Reducing the dietary intake of phosphorus can also help.

2 Other people find relief after exposure to ultravio- How does kidney failure affect the let light. Ultraviolet light can be absorbed simply by spending time in sunlight or near a light box, joints? a therapeutic device that uses several fluorescent Kidney failure can cause pain, stiffness, and fluid lights. Still others improve with EPO shots. A few in the joints, the points where two or more bones antihistamines, such as diphenhydramine (Benad- come together. These symptoms result from amy- ryl) and hydroxyzine (Atarax, Vistaril), have been loidosis, a condition in which an abnormal protein found to help. People should consult their health in the blood called amyloid is deposited in tissues care provider before starting any therapy that and organs, including the joints and tendons—the includes over-the-counter medications. tough bands of tissue that connect muscles to bones. Healthy kidneys filter amyloid protein out A cure for itching that works for everyone has of the blood, but dialysis filters are not as efficient not been found. In some situations, a health care as the kidneys in removing amyloid. Dialysis- provider may refer people to a dermatologist, a related amyloidosis is common in people who doctor who treats people with skin problems. have been on dialysis for more than 5 years. No treatment to reverse amyloidosis has been found, How does kidney failure affect the although a successful kidney transplant may stop the disease from progressing. Health care provid- bones? ers can advise people on the best ways to relieve Kidney failure weakens the bones due to a condi- their pain. tion called chronic -mineral and bone disorder. As discussed in the previous sec- tion, kidney failure can throw off the balance of How does kidney failure affect sleep? calcium and phosphorus in the blood, causing the People who have kidney failure often have parathyroid glands to produce too much para- —trouble getting to sleep and staying thyroid hormone. The high level of parathyroid asleep. Insomnia and other sleep disorders can hormone draws calcium from the bones into the worsen a person’s quality of life. People with blood, leaving the bones without enough cal- kidney failure should discuss these problems with cium. -mineral and bone their health care provider. disorder describes the imbalance of calcium and Some people suffer from sleep apnea syndrome, phosphorus and how this imbalance weakens the which may be related to the effects of advanced bones. The condition affects 90 percent of dialysis kidney failure on breathing. Episodes of apnea are patients, both children and adults, causing bones breaks in breathing during sleep. Over time, these to become thin, weak, or malformed. Symptoms sleep disturbances can lead to day-night reversal— can be seen in growing children with kidney dis- insomnia at night, sleepiness during the day. This ease even before they start dialysis. Older patients condition can cause , depression, and and women who have gone through menopause fatigue. Some treatments may work with people are at greater risk for this disorder. Controlling who have sleep apnea, whether they have kidney parathyroid hormone levels prevents damage to failure or not. These treatments include losing bones. Usually, overactive parathyroid glands are weight, changing sleeping position, and wearing controllable with an adjustment in dialysis treat- a mask connected to a small machine that gently ment, medications, or changes in diet. In some pumps air continuously through a hose into the cases, removal of most of the parathyroid glands nostrils—nasal continuous positive airway pres- may be useful. Reducing dietary intake of phos- sure, commonly known as CPAP. phorus can also help prevent bone disease.

3 Many people on dialysis have trouble sleeping at Eating, Diet, and night because of aching, uncomfortable, jittery, or For people who are on dialysis or approaching total restless legs. They may feel a strong impulse to kidney failure, adequate nutrition is important for kick or thrash their legs. Kicking may disturb a maintaining energy, strength, healthy sleep pat- bed partner throughout the night. Theories about terns, bone health, heart health, and good mental the causes of this syndrome include nerve damage health. A person’s treatment will dictate the type and mineral imbalances. of diet that should be followed: Moderate exercise during the day may help, but n People on hemodialysis must watch how much exercising a few hours before bedtime can make fluid they drink and avoid eating foods with too restless legs worse. People with restless legs syn- much sodium, potassium, and phosphorus. drome should reduce or avoid caffeine, alcohol, and tobacco. Some people also find relief through n In contrast, people on —a type massages or warm baths. Health care provid- of dialysis that uses the lining of the abdomen, ers may prescribe medications called benzodiaz- or belly, to filter the blood inside the body—may epines, often used to treat insomnia or anxiety, for be able to eat more potassium-rich foods because relief of . Benzodiazepines peritoneal dialysis removes potassium from the include clonazepam (Klonopin), chlordiazepox- body more efficiently than hemodialysis. ide (Librium), diazepam (Valium), and n Both hemodialysis and peritoneal dialysis can (Halcion). A newer and sometimes more effective remove proteins from the body, so anyone on medication therapy is levodopa (Sinemet), which is either form of dialysis should eat protein-rich also used to treat Parkinson’s disease. foods such as meat, fish, and eggs. How does kidney failure affect mental All dialysis centers and transplant clinics have a renal dietitian who specializes in helping people health? with kidney failure. People who are on dialysis Many people feel depressed when starting dialysis, or have a kidney transplant should talk with their or after several months of treatment. Adjusting clinic’s renal dietitian to develop a meal plan that to the effects of kidney failure and the time spent will enhance the effectiveness of their treatment. on dialysis can be difficult. People on dialysis also For more information about nutrition for people have less energy. They need to make changes in with advanced CKD or who are on dialysis, their work or home life, giving up some activities see Nutrition for Advanced Chronic Kidney and responsibilities. Keeping to a schedule can Disease in Adults or Eat Right to Feel Right on be difficult when kidneys fail. Accepting this new Hemodialysis from the National Kidney and situation can be hard. A mental health counselor Urologic Diseases Information Clearinghouse at or renal social worker can help people who are approaching total kidney failure and those start- www.kidney.niddk.nih.gov. ing dialysis. People who have kidney failure and depression should not keep their depression to Points to Remember themselves or assume they can handle their prob- n Kidney failure can affect a person’s health in lems on their own. They should tell their health several ways. care provider because depression can often be treated with adjustments to the diet and dialy- n When the kidneys stop working, waste products sis dose, medications, and counseling. Scientists build up in the blood, a condition known as are also studying the use of cognitive behavioral uremia. therapy—a way of correcting harmful thought and n People with kidney failure can avoid most of the behavior patterns—to treat depression in people problems of uremia by having regular dialysis with total kidney failure. treatments and limiting foods that contain sodium, potassium, and phosphorus.

4 n Anemia is common in people with chronic kid- Hope through Research ney disease (CKD), as well as those on dialysis, The National Institute of and Digestive and because the damaged kidneys slow the produc- Kidney Diseases (NIDDK) is devoted to improving tion of the hormone (EPO), the lives of people with kidney disease. Its Division which helps the bone marrow make red blood of Kidney, Urologic, and Hematologic Diseases sup- cells. ports several kidney programs and studies. These n People with kidney failure, particularly dialysis focus on improving treatment for patients with patients, have far higher rates of heart and kidney disease. The End-Stage Renal Disease Pro- blood vessel problems than people without gram promotes research for patients on dialysis or kidney problems. with a kidney transplant. The research is designed to reduce medical problems in kidney failure. These n People who have uremia often lose their include bone, blood, nervous system, intestinal, appetite. heart, and endocrine problems. The program is also n Many people treated with hemodialysis com- designed to improve the effectiveness of dialysis and plain of itchy skin. transplantation. Current efforts focus on home dial- ysis options and alternative dialysis schedules. They n Kidney failure weakens the bones due to a con- include short daily sessions or long nightly sessions. dition called chronic kidney disease-mineral and bone disorder. Participants in clinical trials can play a more active role in their own health care, gain access to new n Kidney failure can cause pain, stiffness, and research treatments before they are widely avail- fluid in the joints. These symptoms result from able, and help others by contributing to medical amyloidosis, a condition in which an abnormal research. For information about current studies, protein in the blood called amyloid is deposited visit www.ClinicalTrials.gov. in tissues and organs, including the joints and tendons. For More Information n People on dialysis often have insomnia, sleep apnea syndrome, and restless legs syndrome. American Association of Kidney Patients 3505 East Frontage Road, Suite 315 n People who have kidney failure and depression Tampa, FL 33607 should tell their health care provider because Phone: 1–800–749–2257 depression can often be treated with adjust- Fax: 813–636–8122 ments to the diet and dialysis dose, medications, Email: [email protected] counseling, and cognitive behavioral therapy. Internet: www.aakp.org n For people who are on dialysis or approaching American Kidney Fund total kidney failure, adequate nutrition is impor- 6110 Executive Boulevard, Suite 1010 tant for maintaining energy, strength, healthy Rockville, MD 20852 sleep patterns, bone health, heart health, and Phone: 1–800–638–8299 good mental health. Fax: 301–881–0898 Email: [email protected] n All dialysis centers and transplant clinics have a Internet: www.kidneyfund.org renal dietitian who specializes in helping people with kidney failure. People who are on dialysis National Kidney Foundation or have a kidney transplant should talk with 30 East 33rd Street their clinic’s renal dietitian to develop a meal New York, NY 10016 plan that will enhance the effectiveness of their Phone: 1–800–622–9010 or treatment. 212–889–2210 Fax: 212–689–9261 Internet: www.kidney.org

5 Renal Support Network National Kidney and Urologic 1311 North Maryland Avenue Glendale, CA 91207 Diseases Information Clearinghouse Phone: 1–866–903–1728 or 3 Information Way 818–543–0896 Bethesda, MD 20892–3580 Fax: 818–244–9540 Phone: 1–800–891–5390 Internet: www.rsnhope.org TTY: 1–866–569–1162 Fax: 703–738–4929 Email: [email protected] Acknowledgments Internet: www.kidney.niddk.nih.gov Publications produced by the Clearing- house are carefully reviewed by both The National Kidney and Urologic Diseases NIDDK scientists and outside experts. Information Clearinghouse (NKUDIC) is a This fact sheet was originally reviewed service of the National Institute of Diabetes by Keith Norris, M.D., Charles R. Drew and Digestive and Kidney Diseases (NIDDK). University of and Science, Los The NIDDK is part of the National Institutes Angeles. of Health of the U.S. Department of Health and Human Services. Established in 1987, the Clearinghouse provides information National Kidney Disease about diseases of the kidneys and urologic Education Program system to people with kidney and urologic disorders and to their families, health care 3 Kidney Information Way professionals, and the public. The NKUDIC Bethesda, MD 20892 answers inquiries, develops and distributes Phone: 1–866–4–KIDNEY publications, and works closely with profes- (1–866–454–3639) sional and patient organizations and Govern- TTY: 1–866–569–1162 ment agencies to coordinate resources about Fax: 301–402–8182 kidney and urologic diseases. Email: [email protected] Internet: www.nkdep.nih.gov The National Kidney Disease Educa- This publication is not copyrighted. The Clearing- house encourages users of this publication to dupli- tion Program (NKDEP) is an initiative cate and distribute as many copies as desired. of the National Institute of Diabetes and This publication is available at Digestive and Kidney Diseases, National www.kidney.niddk.nih.gov. Institutes of Health, U.S. Department of Health and Human Services. The NKDEP aims to raise awareness of the The U.S. Government does not endorse or favor any seriousness of kidney disease, the impor- specific commercial product or company. rade,T tance of testing those at high risk, and proprietary, or company names appearing in this document are used only because they are considered the availability of treatment to prevent or necessary in the context of the information provided. slow kidney disease. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.

You may also find additional information about this topic by visiting MedlinePlus at www.medlineplus.gov. This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your health care provider for more information. NIH Publication No. 12–6059 December 2011

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