Chronic Kidney Disease Stage 4 (Polycystic Kidney Disease)

Chronic Kidney Disease Stage 4 (Polycystic Kidney Disease) and lots more in 52 yo M


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mychael_seubert1974
Message 1 of 3 , Feb 15
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Hi Natchatters,

This is my first posting for help on a case and appreciate and help you can provide.  I had a complicated case on Friday and this is a long posting.  I am in an unlicensed state (NY), but have an MD that will run pretty much whatever labs I recommend in this case.

A 52 yo Caucasian Male (Greek) presented with a CC of Chronic Kidney Disease (Stage 4 Polycystic Kidney Disease) and his main symptoms he suffers from are fatigue, light twinges in his lower back, and erectile dysfunction/low testosterone.  Kidney dysfunction was first discovered about 8 – 9 years ago.  He states he has also been diagnosed with bipolar disorder since 1979. He sees a psychiatrist every 4-5 months, has been told he is stable, and has not been hospitalized in 16 years.  Other diagnoses include per the patient include:  Hypertension (currently runs 130/83 pretty much every day – started 20 years ago), gout, “an enlarged prostate” , GERD, a cough for 1-2 years (using a PPI has helped it a “good deal”, a lump on his groin (I advised him to have it checked by an MD ASAP), and anemia for 1 to 2 years (hematologist has said “let’s watch this”).

He sees the following MDs:  PCP, Nephrologist (as he was leaving he said his PCP and Nephrologist are the same doctor), Endo, Hematologist, and Psychiatrist.  He has basically been told he will need dialysis or a transplant in 1 to 2 years, to eat a low sodium diet, not to eat red meat, not to have more than 4 oz of protein every 4 hours, and that he should see a nutritionist.  He has not been given any other restrictions or advice.  A friend advised him to see a naturopath and his MD said absolutely not to and that the AMA does not approve of us.  Oh and he said to “watch out for those herbs.”   His response was that “you have told me I only have 1 to 2 years until my kidneys fail and they have just gotten worse so what do I have to lose.”  I’ve told him that the chances of reversing this are very, very, very unlikely and that just being able to keep it from progressing at this stage might be the best we can do, but that I make absolutely no guarantees.  He said he would be happy if he could just delay it.  Like all patients, he also understands that I can only make recommendations that he must get approved by an MD.

He seems like a very intelligent man (he also has a Phd and has his act together.  However, he does not have a lot of information on his overall health – the docs have not said much to him.

I can give more info about his basics if needed. But the quick version is he is laid back but has a lot of stress due to illness as well as his mother being in the hospital.  He says staying busy with his two jobs of helping the disabled get employment and starting up an online MBA program keep him  “healthy mentally.”  He has a lot of fatigue all day and wakes particularly tired.  Sleeps 9 hours and solid except when he wakes 2-3 times to go to the bathroom and it takes him 15 minutes to get back to sleep.  Exercise is very infrequent – he swims occasionally  and will try to increase to 3-5 times per week for 20-30 minutes, but will not push it.  Diet (will be filling out diet diary) is: B:  Cheerios or Eggs, L: Sandwich with mayo and chicken or a sandwich from a deli – varies but no red meat, D: no typical dinner and it varies a lot, but he tries to get a serving of veggies.  Snacks on nuts and yogurt .. occasionally he has a cookie.   GI health – GERD as mentioned above that is improved a good deal but not completely with PPI, no other symptoms  and he has one well-formed BM daily and perhaps a few times a month he goes a day without one.

He can still urinate, it is not dark, and he has slight foaming.  No blood or pain, but urgency and he can slightly urinate himself some mornings when he wakes.

He is scheduled to have an operation in the next few weeks to “have a stent placed for dialysis” and is “being worked up for a possible transplant.
”
His current medications and supplements include:
Depakote 500mg BID
Risperidone 3mg QD
Lamotrigine 100mg QD
Amlodipine Besylate 10mg QD
Losartan Potassium 25mg QD
Tamsulosin 0.4 mg QD
Uloric 40mg QD
Pantoproazole 40 mg QD (but he forgets here and there)
AndroGel 1.62% 2 pumps
Vit D3: 2000 IU QD

His recent labs from Jan 8th 2015:
Lipid Panel
TC   189
HDL  33 L
LDL 102
TG 270 H

Hepatic Fx
Total Protein 6.5  (6.1 – 8.1)
Albumin  4.2  (3.6 – 5.1)
Billirubin, AST, ALT, Alk Phos all low side normal.

Renal Function
Fasting Glucose   77  (88 in Sept 2014)
Sodium  141
Potassium 4.6  (3.5 – 5.3)  It was 4.4 in Dec and 4.6 prior to that
Chloride  109 (98-110) It was 111 on two occasions prior to this
CO2  22  (19-30)  It was 21 in Dec and 18 prior to that
BUN  61 H   (It was 45 in Sept 2014 then 63 and then 58 prior to this)
Creatinine   3.85 H  (It was 3.43 in Sept, then 3.77, and then 3.41 prior to this
Phosphorous   4.6 H ( 2.5 – 4.5)   prior to this in Dec it was 4.1 N
Calcium 9.6  (8.6 to 10.3) 9.7 prior to this
eGFR  17 L   (it was 19  in Sept 2014, then 17, and then 20 in Dec)


CBC
WBC 4.8
RBC  3.82 L
HGB  11.1 L
HCT 34.0 L
MCV 89
MCH  29.1
MCHC 32.7
RDW  16.3 H
Platelets  139 L  (140 – 400)
MPV   8.1
Everything else “normal”

Other labs in Dec 2014
Uric Acid 6.4  (5.4 in Sept 2014)
Magnesium  2.6 H  (1.5 – 2.5)   It was 2.1 N in Sept 2014
Vitamin D 25 OH was run but I only see pending.

Other labs in Sept 2014:
GGT  19 (3-95)
LDH 199  (120 – 250)
Iron  88
TIBC  250
% Sat  35
Ferritin  416 H

Ok, if you are still reading, this is what I am thinking of recommending, but I would appreciate any/all advice:
Exercise as mentioned above, as for diet I was wondering if 0.75g per kg of his ideal body weight is appropriate (http://www.renal.org/guidelines/modules/nutrition-in-ckd#sthash.H7ZjITvq.dpbs)  ?   I would recommend 3oz servings of grass fed/free rage red meat or chicken as well as hemp protein (to help prevent secondary heart disease) as the basics to eat.  As for vegetables  is it ok to push it to about a handful of them at each meal of lower phosphorous/potassium ones?  I was thinking about recommending the following fruits and veggies:  apples, pears, green peas, onions, Romaine lettuce, endive.   I would avoid dairy and I guess he should avoid the nuts.  I’m curious about a reasonable go to snack food that fits.  I’d recommend brown rice as his main carb and to try to use brown rice flour.  Coconut oil as a good fat.  He drinks at LEAST 10 glasses of water each day and is very thirsty.  He says his MDs have not restricted fluid consumption at all.  Is this ok for now.  I’m thinking of having him substitute a few cup of organic green tea.

As for supplements that I would recommend, I was thinking:
Hawthorn – dried encapsulated, high dose for now
Melatonin 10mg (interesting studies on animals on protecting kidneys, HBP,  GERD (yes dose tested I believe is 5-6mg, and possibly to help with sleep).
Turmeric and Ground Flax to help with cysts
Dr Yarnell’s/Heron  Two Treasures Tincture  1 to 1.5 tsp TID
Renadyl Probiotic 2-4 per day for elevated BUN and GI issues
Are there others more important at this point?  Would Niacinamide 250mg with each meal for lower phosphorous absorption be critical, L Carnitine, CoQ10, or B Complex?  Angelica sinensis for anemia.  Cordyceps?  I’ll be trying to have him check his zinc and selenium (among other things).

As for labs, would it be best to run any of the ones most recently run again or wait? I was going to ask to add in a 24 hour urine creatinine and microalbumin, UA, Vit D both 25 OH and 1,25, Cystatin C.  Should I check his Phos/potassium weekly in the beginning?  I’d like know his testosterone, estradiol, zinc, selenium, homocysteine, and EPO levels as well and inflammatory markers.  A celiac panel (tTG, IgG, Anti-deamidated Gliadin IgG, Anti Reticulin IgG, and total IgG) would be on my wish list as well.

Any and all feedback (even on how to better lay out a case ) is greatly appreciated!  Thanks  so much in advance for your help.

Mychael Seubert, ND
New York (all over Long Island)
SCNM Dec 2012


Eric Yarnell
Message 2 of 3 , Feb 16
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Treating the cause (PKD): I have probably posted about this in the past so you may want to search archives but the take-home bullets are:
	1. You are right, it is probably too late to really do much about the cysts at this point with this degree of renal failure, but what does he have to lose?
	2. Phytolacca, Fouquieria, Ceanothus equal parts 0.5 tsp tid to actually try to shrink or delay cyst growth (have seen this helping patients in CKD 1 with PKD).
	3. Glutamine 10 g tid
	4. Avoid all caffeine like the plague, it stimulates cyst growth.
	5. Animal-study level evidence says curcumin may slow cyst growth (as you note). Dose unknown of course. I would probably try Meriva 1-2 g tid. Definitely go with the flax for the same reason.
	6. There is promising evidence that high water intake is helpful for slowing cyst growth. Takes 3 L/d in the average adult to achieve this. Goal is urine osmolarity of 285 ± 45 mosm/L.Wang CJ, Creed C, Winklhofer FT, Grantham JJ (2010) "Water prescription in autosomal dominant polycystic kidney disease: A pilot study" Clin J Am Soc Nephrol 6(1):192--197.

It is highly unlikely you'll do anything but buy him another couple of years at best before he ends up with dialysis and/or transplant, which is great but just to be realistic here. We don't know how to completely stop the cysts (yet).

Treat the BPH, that is almost certainly going to become a problem in the future for his kidneys if not already. How large is it? If >50 g then finasteride or surgery is probably a better bet. If not then you could continue with the tamsulosin (or switch to spasmolytic herbs like Ammi visnaga). The testosterone could well be stimulating prostate growth. That's kind of unclear at this point in general but concerning in this individual patient.

Treating the symptoms (CKD 4): I have discussed this at length and you are basically correct in your approach below (Crataegus, Two Treasures, etc.).
	1. Start the niacinamide now for sure!! Don't wait until his phosphorous is totally out of control. What's his iPTH?
	2. Beef + gout = bad situation. I would not give him red meat because of that, not because of protein restriction issues, which are highly dubious anyway.

"The efficacy of a 2- to 3-year intervention of dietary protein restriction on progression of nondiabetic kidney disease remains inconclusive."
Levey AS, Greene T, Sarnak MJ, et al. (2006) "Effect of dietary protein restriction on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease (MDRD) Study" Am J Kidney Dis 2006;48(6):879-88.

	3. Potassium: you can give him a modest level of veggie intake and just keep monitoring his serum potassiums. If they rise, you'll have to back off. If they don't, you're fine. Also give him lots of Glycyrrhiza to help maintain normal potassium (while monitoring serum potassium again to make sure they don't go low, but this is almost impossible). Also having him sweat regularly can help get rid of potassium.
	4. Have they discussed non-hemodialysis options with him? What about peritoneal dialysis? This might make it easier for him to stay at work. Is there a home hemodialysis option in his area? I would suggest he make excuses to delay the AV graft placement surgery while you see how your interventions work. If they aren't working, so what he almost certainly will not get into trouble in 3-6 mon.

Cheers,

Eric Yarnell, ND, RH(AHG)
Seattle, WA
Natural Approach to Gastroenterology 2nd ed (healingmtn.com)
Northwest Naturopathic Urology (urologynd.com)


mychael_seubert1974
Message 3 of 3 , Feb 16
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Thank you so much for the time and help (and citations!)  Dr Yarnell.

He has no idea of the size of his prostate and cannot even recall having a DRE.  I will refer him to a urologist that will do that, and inform him his options.

His docs have not run an iPTH, but we will be getting it done _ i forgot to include that in my list.

They have not discussed any of these options with him.  They did not tell him much of anything other than that he will need dialysis in about a year or two.  I'm pretty sure he has a home hemodialysis option in his area, but I will make sure.  I will also have him schedule an appt with his nephrologist to discuss these options.

I tried searching the docs before posting on CKD Stage 4 - I'll dig some more to see what I missed.

Thanks again so much!