Kidney Support

Background Kidney disease is a major challenge for the world. Although mild kidney dysfunction may often have limited impact on a person’s quality of life, according to the National Kidney Foundation, 1 in 2 people in the US develop some degree of kidney disease at one point in their lifetime. There are many measures we can take to help prevent chronic kidney disease and help reduce risk of progression. Even something basic, such as a person’s water intake, has been shown to affect a person’s risk of kidney disease by 35% according to a 2021 study. (1)

(1) Wang, Hung-Wei, and Ming-Yan Jiang. “Higher volume of water intake is associated with lower risk of albuminuria and chronic kidney disease.” Medicine vol. 100,20 (2021): e26009. doi:10.1097/MD.0000000000026009

Symptoms of Kidney Disease Blood or urine testing is generally required to detect early chronic kidney disease because most people usually do not present with any symptoms. Symptoms usually begin when kidney disease reaches stage 4 or 5. Some of the more common symptoms and signs at these stages are:

• Nausea

• Vomiting

• Loss of appetite

• Fatigue and weakness

• Difficulty sleeping

• Reduced urine output

• Muscle cramps and twitches

• Swelling in the feet and/or ankles

• Itchiness

• Chest pain

• Difficulty breathing

• High blood pressure

Possible Causes Below are some of the causes of kidney disease:

Types of Kidney Disease Glomerulonephritis Glomerulonephritis occurs when the tiny filters in your kidneys that clean blood (glomeruli) are damaged and lose their ability to remove fluid and waste from your blood. Over time, this can lead to kidney failure. There can be many causes, including certain toxins or medicines, viral infections, and autoimmune diseases (a disease where your body's immune system attacks its own tissues). IgA Nephropathy IgA nephropathy occurs when proteins made by the immune system buildup in the kidneys. This leads to damage to the filters that clean your blood (glomeruli). This damage can take several years to develop, and people with IgA nephropathy usually do not know they have it. IgA nephropathy may progress to chronic kidney disease. Therapies aim to slow damage to the kidneys. Lupus Nephritis Lupus nephritis is an autoimmune disease that leads to swelling, pain, and damage to the body, including the kidneys. Polycystic Kidney Disease This is a genetic disorder that causes growths filled with fluid to form on the kidneys and organs. This can lower the kidney's ability to filter fluid and wastes from the blood. Treatments aim to slow progression and reduce symptoms that are causing health problems. Interstitial Nephritis This is a condition that is characterized by high amounts of inflammation within the kidneys. It usually occurs in both kidneys. Inflammation leads to swelling and scarring of the kidneys. It is called 'Interstitial' because the inflammation does not affect the blood vessels or filters in the kidney, but rather is confined to the parts in between them. Acute Kidney Injury This occurs when there is a sudden decrease in the level of kidney function. It is usually defined as a drop of more than one half (50%) in kidney function. Acute kidney injury usually improves in a few days or weeks. This usually occurs from certain ‘stressors’ on the kidneys from problems elsewhere in the body, rather than diseases starting in the kidney. Treatment is aimed at healing the kidneys and reducing risk of any progression to chronic kidney disease. With the correct treatment, overall prognosis is usually good. Henoch-Schönlein Purpura Henoch-Schönlein purpura (HSP) causes inflammation in blood vessels throughout the body, including the vessels of the skin, joints, bowels and kidneys. Membranous Glomerulonephritis This happens when the small blood vessels in the kidney (glomeruli), that filter waste from the blood, become damaged and thickened. This leads to proteins leaking from the damaged blood vessels into the urine (proteinuria). This loss of proteins leads to a collection of signs and symptoms, referred to as nephrotic syndrome. What do the Kidneys Do? Our kidneys are very important because they are involved in so many bodily processes. Here’s just a handful of some of their many functions:

• Removal of waste from the body

• Removal of drugs from the body

• Balancing body fluids

• Release of hormones to regulate blood pressure

• Production of activated vitamin D, that helps to promote healthy bones

• Control of the production of red blood cells

The kidneys filter around 150 liters of blood every day. The kidneys are very complex and when damaged, this may lead to:

• Leaking of a variety of important nutrients

• Reduced disposal of toxic waste products and compound

• Reduced ability to balance minerals and electrolytes

Naturopathic Approach to Kidney Support

Given the complexity of the kidneys, the goals for each case vary greatly depending on a person’s blood work, the type and stage of the kidney disease or kidney disorder. For example, a person may lose the ability to effectively expel excess potassium and phosphorus from the body into the urine, leading to elevated levels of these electrolytes. On the other hand, an electrolyte like calcium may be reduced because the kidneys activate our vitamin D, which is used by the intestines to help absorb calcium into the body. Without active vitamin D, calcium levels can drop. Diet can get very complicated and overwhelming quickly as patients may be told to then increase calcium intake, and reduce phosphorus and potassium. Some of the main goals of naturopathic kidney support are as follows:

1. Determine and/or treat reversible causes of kidney disease through diet, lifestyle, and other natural therapies

2. Preserve kidney function and health by managing nutrients and electrolyte balance

3. Address risk factors associated with progression of kidney disease

4. Reduce risk of complications, such as cardiovascular disease, by helping the kidneys clear waste products that may predispose individuals

5. Improve overall nutritional status, as evidence suggests this is associated with improved prognosis

6. Reduce overall inflammation as research has indicated that reduced inflammatory markers (CRP, IL-6) are associated with improved prognosis

7. Reduce excessive loss of protein from the body to the urine, because greater loss in protein negatively impacts functional capacity, quality of life, and overall prognosis.

8. Utilize natural therapies to help reduce side effects of commonly medications used in kidney diseases and disorders.

Naturopathic Therapies There is a vast amount of information that could be discussed here as there are over 130 studies on natural therapies that have been completed in the context of various stages of kidney disease. Here we will stick to some dietary strategies, but will not delve into specific therapies as every treatment plan is unique to your state of health and depends on blood work values as well as the stage of kidney disease. Furthermore, if these therapies are given in the wrong context or wrong dosage they could cause adverse effects. Below we will discuss some of the causes and complications of kidney disease that can be addressed to significantly affect overall prognosis, quality of life and kidney function.

Addressing Blood Sugar (as a cause of kidney disease) About 40% of chronic kidney disease cases are due to elevated levels of blood sugar (diabetes). (2) If blood sugar appears to be an underlying cause, then there are two components of blood sugar that are worth addressing: the level of blood sugar and the amount of variability (fluctuation) in blood sugar. Blood sugar variability refers to how high the highs are and low the blood sugar crashes go. Both variability and the overall level of blood sugar have been shown to affect kidney disease progression. (3) They appear to damage blood vessels - this is important because the kidney filtration system is made up of many small blood vessels. (4) Data suggests that by properly managing blood sugar through natural therapies, kidney function can be preserved and risk of injury to the kidneys can be reduced. Below is a list of general interventions that can be considered and their relative impact on measure of blood sugar (HbA1c). Studies generally find that the average person with diabetes needs to drop their blood sugar by about a third to achieve remission from diabetes. (5) As shown below, a single therapy is unlikely to drop blood sugar by a third, however in combination we often see more significant results. (2) Vaidya SR, Aeddula NR. Chronic Renal Failure. [Updated 2021 Oct 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535404/https://www.ncbi.nlm.nih.gov/books/NBK535404/ (3) Wiyono, Lowilius & Siregar, Parlindungan. (2021). The Use of HbA1C Value as Prognostic Factor of Chronic Kidney Disease in Diabetes Mellitus Patients: A Meta-Analysis. Link (4) MacIsaac, Richard J et al. “Effects of glycaemic management on diabetic kidney disease.” World journal of diabetes vol. 8,5 (2017): 172-186. doi:10.4239/wjd.v8.i5.172 (5) DeFronzo, R A et al. “Relationship of baseline HbA1c and efficacy of current glucose-lowering therapies: a meta-analysis of randomized clinical trials.” Diabetic medicine : a journal of the British Diabetic Association vol. 27,3 (2010): 309-17. doi:10.1111/j.1464-5491.2010.02941.x

Addressing Protein Loss Certain stages and forms of kidney disease may also be characterized by proteinuria - this is when damage to a part of the kidney called the glomerulus occurs, leading to protein loss from the body. The glomerulus is like a mesh that acts as a strainer, it allows some substances to move out while keeping larger substances, such as proteins inside the body. If it is damaged, then proteins leak through and travel to the bladder and then are lost from the body through the urine. There are several therapies that have been shown in research to help reduce protein loss from the kidneys. This is important because if too much protein is lost then the body does not have enough protein for muscles and essential processes, leading to malnutrition and possibly cachexia. Cachexia is an extreme form of malnutrition with significant loss of muscle and bone. Cachexia has been shown to significantly affect the overall prognosis of kidney disease. (6) At our clinic, we use a bioimpedance machine to screen for malnutrition by measuring the amount of muscle mass and protein content within the body. If cachexia occurs, there are a number of nutritional and supplemental therapies that have been shown to help reduce cachexia.

Addressing High Phosphorus Contrary to how protein tends to decline in kidney disease, phosphorus sometimes tends to rise. High phosphorus levels are important to address because some research suggests it may lead to worsening progression of kidney disease. (7) If levels of phosphorus are elevated, it is often recommended to restrict dietary phosphorus intake. However, dietary restriction is not always straightforward. Foods such as nuts and legumes appear to have moderately high levels of phosphorus content, but the phosphorus tends to be poorly absorbed by the gut into the body. (8) Similarly, eggs tend to have low phosphorus content, but the form of phosphorus in eggs tends to be very well absorbed in the body. An optimal diet depends on both the phosphorus content and the degree of absorbability from the food.

Addressing High Potassium The National Kidney Foundation & several large organizations recommend a low-potassium diet for those who have high serum potassium levels. (9) Similar to phosphorus, some research suggests that potassium intakes may impact overall prognosis and survival in those with elevated potassium (specifically those who are stage 3, 4 or 5 kidney disease). (10) Unfortunately, many of the healthiest foods tend to have high levels of potassium in them. However, studies have shown that over half of the potassium content from vegetables (11) and almost all of the potassium content in legumes can be easily removed by soaking them in water before cooking. (12) Here are some step-by-step instructions for reducing potassium content:

1. Peel vegetables with a skin (eg, potatoes, carrots, beets, rutabagas)

2. Cut into thin slices before soaking

3. Rinse the cut vegetables in warm water

4. Soak >2hrs or overnight in large amount of unsalted warm water (eg. 10:1 water to vegetables)

5. Change water every four hours if possible

6. After soaking, drain water

Potassium also varies in absorbability in that the body absorbs higher or lower amounts of potassium from certain foods. If dietary changes are indicated for your case, a list of foods to either increase or avoid will be included in your plan. (6) Cravedi, Paolo, and Giuseppe Remuzzi. “Pathophysiology of proteinuria and its value as an outcome measure in chronic kidney disease.” British journal of clinical pharmacology vol. 76,4 (2013): 516-23. doi:10.1111/bcp.12104 (7) Nadkarni, Girish N, and Jaime Uribarri. “Phosphorus and the kidney: What is known and what is needed.” Advances in nutrition (Bethesda, Md.) vol. 5,1 98-103. 1 Jan. 2014, doi:10.3945/an.113.004655 (8) Mark F McCarty, Lower bioavailability of plant-derived phosphorus, The American Journal of Clinical Nutrition, Volume 99, Issue 4, April 2014, Page 966, https://doi.org/10.3945/ajcn.113.081612 (9) Potassium and Your CKD Diet. https://www.kidney.org/atoz/content/potassium (10) Morris, A., Krishnan, N., Kimani, P. K., & Lycett, D. (2020). Effect of Dietary Potassium Restriction on Serum Potassium, Disease Progression, and Mortality in Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation, 30(4), 276–285. (11) Cupisti, A., Kovesdy, C. P., D'Alessandro, C., & Kalantar-Zadeh, K. (2018). Dietary Approach to Recurrent or Chronic Hyperkalaemia in Patients with Decreased Kidney Function. Nutrients, 10(3), 261. https://doi.org/10.3390/nu10030261 (12) Martínez-Pineda M, Yagüe-Ruiz C, Caverni-Muñoz A, Vercet-Tormo A. Cooking Legumes: A Way for Their Inclusion in the Renal Patient Diet. J Ren Nutr. 2019 Mar;29(2):118-125. doi: 10.1053/j.jrn.2018.08.001. Epub 2018 Oct 12. PMID: 30322788.

Addressing Inflammation There are many factors that can lead to increased inflammatory levels in kidney disease, such as: (13)

• Increased production of inflammatory substances (cytokines)

• Infections

• Increased acidity of the blood (acidosis)

• Imbalance of bacteria within the intestines (intestinal microbiota dysbiosis).

There are several tests we can do to check for levels of inflammation in the body. Three of these tests (IL-6, CRP, ferritin) have been shown to relate specifically to kidney health and people with decreased levels of these tend to have improved prognosis. (14) We can address inflammation using natural anti-inflammatories as well as by including foods and dietary patterns that have been shown to reduce inflammation. In particular, the mediterranean style diet has been shown to decrease two of the markers (IL-6 and CRP), but some modification and caution may be necessary given that many of the foods in the diet are high in both potassium and phosphorus. (15)

Addressing Medication Side Effects Another goal of Naturopathic kidney support is to integrate with conventional medicine and help improve quality of life and reduce side effects. Here are some of the medications that may be used in cases of kidney dysfunction:

• Co-Trimoxazole

• Isoniazid

• Azathioprine

• Prednisolone

• Rituximab

• Cyclophosphamide

• Ciclosporin

• Mycophenolate

• Sirolimus

• Tacrolimus

• Valganciclovir

• Calcium Channel Blockers

• Beta Blockers, Alpha Blockers

• Ace Inhibitors, Diuretics

• Phosphate Binders

Each of these medications are used in various contexts - cyclophosphamide is often used for kidney dysfunction due to autoimmune causes (vasculitis, lupus or nephrotic syndrome). Ace inhibitors and calcium channel blockers are often used for controlling blood pressure. Prednisolone, tacrolimus and rituximab are used for nephrotic syndrome. (16) A number of these medications may have unwanted side effects. There are several studies that have found a number of natural therapies that are associated with reduced side effects, improved quality of life and improved kidney disease remission rates. (17) (13) Mihai, Simona et al. “Inflammation-Related Mechanisms in Chronic Kidney Disease Prediction, Progression, and Outcome.” Journal of immunology research vol. 2018 2180373. 6 Sep. 2018, doi:10.1155/2018/2180373 (14) Inflammation in renal insufficiency. Authors:Csaba P Kovesdy, MD, FASNJoel D Kopple, MDKamyar Kalantar-Zadeh, MD, MPH, PhD (15) Schwingshackl, L, and G Hoffmann. “Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials.” Nutrition, metabolism, and cardiovascular diseases : NMCD vol. 24,9 (2014): 929-39. doi:10.1016/j.numecd.2014.03.003 (16) COMMONLY PRESCRIBED DRUGS FOR KIDNEY DISEASE. National Kidney Federation. https://www.kidney.org.uk/commonly-prescribed-drugs-for-kidney-failure (17) National Library of Medicine https://pubmed.ncbi.nlm.nih.gov/?term=%28%28tacrolimus%29+OR+%28cyclophosphamide%29+OR+%28rituximab%29%29+complementary+therapies&filter=pubt.clinicaltrial&sort=date&size=200

Final Remarks There are dozens of potential causes of kidney diseases and disorders. This article only just scratches the surface of supportive management of kidney disease. There are many other causative factors that have not been discussed in detail, such as elevated blood pressure, cholesterol, autoimmune disease and others. Each of these take special consideration and need to be addressed with a comprehensive plan. The best approach to kidney disease involves creating a plan based on careful consideration of all factors involved - underlying causes, personal risk factors for progression, family history, common complications, current medications, and lifestyle. Ultimately, our goal is to utilize therapies that have demonstrated the greatest benefit and safety in regards to the context and characteristics of your case.