Plant Based Kidney Health Episode 4: GFR, Fistula, Kidney Vitamins and Calcium Supplements

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In this episode of Plant Based Kidney Health, we answer your questions on when a fistula should be placed, which vitamins are needed in kidney disease, what is the role of calcium supplements, and how much calcium do you need?

Transcript

Sean Hashmi, MD, MS, FASN

All right. Welcome, everyone, to Plant Based Kidney Health. And I can’t believe, is this really our episode number four?

Michele Crosmer, RD, CSR

It’s already episode number four.

Sean Hashmi, MD, MS, FASN

Wow. Well, guys, thank you so much. I have to tell you, this is so amazing. We’re getting so much feedback from people. We’ve been getting questions after each episode. So what we try to do on this show, really, guys, is we are focused on trying to answer all of your questions. So as you hear us, send your questions in our email is Plantbased Kidneyhealth at gmail. Com. If you don’t know who we are, I’m Sean Hashmi. I’m a board certified nephrologist and obesity medicine specialist, and this is my partner.

Michele Crosmer, RD, CSR

Hi, everyone. I’m Michele Crosmer, and I’m a registered dietitian and certified specialist in renal nutrition.

Sean Hashmi, MD, MS, FASN

So, Michelle, where do you want to start today? What questions do we get this time?

Michele Crosmer, RD, CSR

Okay. So I think one of the first ones that we have on the list for today is definitely for you, but the person asked at what GFR should someone have officially placed or a permanent access place for dialysis?

Sean Hashmi, MD, MS, FASN

This is a really important question, guys. And I’ll tell you why it’s so critical. The reason that this makes such a big difference is because imagine if you will, you have four lifelines PD being the fifth one. But let’s put PD out of it for a second and just talk about Hemo or blood dialysis. You have four lifelines, two right up here, which is your neck area and two, which is your growing area. If you lose those four access, then we basically have no way to be able to DIALIZE you.

Sean Hashmi, MD, MS, FASN

Now, what does that have to do with fishilla placement? Fishuleas, they need time to mature. So if you’re somebody who is well controlled in all your numbers, your fistula may mature very well in anywhere between six weeks to eight weeks, sometimes longer. But some people can take three months to six months for the fistula to get ready. Some people need revision surgery. So in general, what we have done is my rule is what I call the 15 2025 rule or the 25 2015 rule. Basically, what it means is if your kidney function is at 25 of a GFR number, we jokingly say percent, but it’s not really percent, but just think of it in that regard.

Sean Hashmi, MD, MS, FASN

So when you’re at around 25%, what we want to do is the nephrologist or dietitians and our social workers, all of us. We want to educate you on dialysis. We want you to know what your options are, what transplant means, all of that. And the reason for that is because there’s a little bit of shell shock. People think dialysis is very scary, and we need to get them over that, and we need to guide them through it. So it takes time when they get below 20.

Sean Hashmi, MD, MS, FASN

We say it’s time to get ready, and that means putting the fishula in if they’re going the route of hemodialysis, because what we don’t know is how long it will take you to get ready. If you have substantial amount of protein you’re spilling in the urine, you may decline very, very fast. So once you’re less than 20, it’s time. Then when you get to less than 15, we say you’re in dialysis territory where you start dialysis is a joint decision between your nephrologist and you. It could be because at less than 15, you have so much swelling, we can’t control it.

Sean Hashmi, MD, MS, FASN

That dialysis is the best option, or it may be that you get below ten. You have no symptoms. You’re doing really well. We don’t have to start it. We sometimes make a compromise where we start patients on sort of a modified dialysis regimen instead of three days a week. We do two days a week so that they can get dialysis yet at the same time, they don’t have to have the full burden of it. So that’s a long winded answer to essentially say is when you get less than 20, it’s really around the time.

Sean Hashmi, MD, MS, FASN

We want to put an official for you.

Michele Crosmer, RD, CSR

So my question for you is with that, I think a lot of times people what I’ve heard people say is that they think the FIshelA is placed and it’s just okay. And when it matures, you’re automatically starting dialysis. So can someone have a fish yellow place as like, okay. We want to prevent emergency dialysis from an emergency access from being needed. But can someone have officially replaced and potentially not need it for months to years, depending on their state that they’re in and symptoms and all that?

Sean Hashmi, MD, MS, FASN

Absolutely. And in fact, I’ve seen that happen. I’ve had some patients where we put Africula in, but they’ve taken such control of their lives. They’ve done everything that we talk about on this channel. They’re sleeping, they’re moving more. They’re working on reducing the stress. And they’re eating a plant based diet that’s whole food, not just processed foods. So as a result, their A one C’s are better. Their blood pressure is better, they’re maintaining a healthy weight. And so all of those things together slow down the decline.

Sean Hashmi, MD, MS, FASN

And even though we put in the Fisher, they haven’t needed it. So the fish loss can stay in. And if you don’t use them, that’s fine. Every once in a while. It turns out, especially people who’ve had kidney transplants. Where the fishula you can hear the sound sometimes when it grows really big and we can tie that off. But bottom line there is you don’t want to delay the fishola, because if you end up getting catheters, they can cause scarring. They can cause stenosis. And remember, they’re going in your four lifelines.

Sean Hashmi, MD, MS, FASN

If you lose those four lifelines, we don’t have anything left. And this is why we make such a big deal about making sure that we do optimal starts or get the access in a timely fashion.

Michele Crosmer, RD, CSR

Yes. And I love that you say that because it’s not necessarily that it’s this like sentence to dialysis or to something. It’s really to protect you and prevent you from needing that emergency catheter access or using one of those lifelines, and you can have the fish and not need it if you’re at that lower GFR like you’ve seen, I have a current client I’ve been working with over a year, maybe close to a year and a half. Now, that had official place at the beginning of us working together, and her GFR is stable.

Michele Crosmer, RD, CSR

She doesn’t have any symptoms. Potassium is controlled, and she feels good and it’s there if she needs it, if and when she needs it. But for now, she’s thriving, not on dialysis. So everyone’s case is different. But I think it’s important to hear you explain that as far as when someone might need to have that place.

Sean Hashmi, MD, MS, FASN

And it’s kind of like insurance, you don’t get insurance because, you know, your house is going to burn down. You’re getting insurance in case something happens to the house. You know, you’re covered in an emergency situation. If you see the trend of the kidneys getting worse, the Fisher is there so we can start you. And the other reason why it’s such a big deal if we have to put a catheter, usually we have to admit you to the hospital. If we can just go ahead and start outpatient with the fishula, we save you a hospitalization.

Sean Hashmi, MD, MS, FASN

We save you a lot of stress and mental anguish as you go through this.

Yes.

Sean Hashmi, MD, MS, FASN

All right. Let’s change topics. Now, this was a question that we received, and it’s a question that I get asked a lot, and I always defer to our exceptional dietitians. But now I have you. So I don’t need to ask anybody else. So here’s my question. What vitamins and supplements should someone with kidney disease take?

Michele Crosmer, RD, CSR

Okay. So I also get asked this all the time, and I wish it was a very simple, easy, straightforward answer. But of course, it’s not the thing with vitamins and supplements that is important with kidney disease and kidney health is we need to be cautious. Our kidneys are filtering our blood, removing waste and toxins. And for some vitamins and minerals, they play a role in preventing toxic levels of vitamins in our blood. And so what it ultimately comes down to is. And what I recommend is that we don’t want to be oversupplying.

Michele Crosmer, RD, CSR

We want to supplement things that we either are deficient in. That blood work has told us we’re low in or deficient in or supplements that we simply cannot get enough in our diet or supplements that are not harmful to the kidneys. And that might be helping us in some way. And so when we think of it in that sense, then I like to give some examples of things. But vitamin D, that’s a vitamin that the general population, it’s more common to be deficient in and especially in the kidney disease population.

Michele Crosmer, RD, CSR

But even knowing that it’s so important to have your blood levels checked so that your physician and renal dietitian can recommend a dose. Do you need a higher dose for a short period of time, or do you need a lower maintenance dose that you take on a daily basis? And so it’s important to still individualize that and know how your blood looks. And then there are other things that we know. Like, for example, vitamin C, high doses of vitamin C supplementation, especially taken on a daily basis, is not good for people with kidney disease.

Michele Crosmer, RD, CSR

It can even increase the risk of developing kidney stones. And so that’s something where vitamin C is something that is in a lot of supplements or supplement blends, and oftentimes in very high amounts. And so that’s where it becomes really tricky. So usually what I say with that is across the board. If we can get it from food, then that is going to be the best, because it’s usually an amount that our body can tolerate and our kidneys can handle. And then we supplement things that were deficient in or that we can’t get enough in the diet.

Michele Crosmer, RD, CSR

So I know that’s kind of a roundabout answer with that. But I think and again, some of the more common ones would be again, vitamin D is more common to be low, and someone who can eat disease, vitamin B twelve needs to be supplemented, and someone who is on a plantbased diet or a vegetarian or vegan diet. And so that’s something to keep in mind. And then there are kidney specific vitamins. So they’re called renal vitamins. And usually those are going to contain B vitamins that people might have lower levels of when they have kidney disease and a very small amount, usually only about 60 to 90 milligrams of vitamin C to make sure that you get the adequate amount in the not getting this really high excessive amount.

Michele Crosmer, RD, CSR

So those are always an option. Otherwise it would be doing things kind of supplementing what you need on its own instead of just doing so. I usually don’t recommend that people with kidney disease just take a standard over the counter multivitamin, especially if you’re in later stages of kidney disease.

Sean Hashmi, MD, MS, FASN

I think that’s absolutely true. And when it comes to especially vitamins like B vitamins, when we’re doing dialysis on patients, that becomes really important. But prior to that, we really emphasize foods. And I think there’s a lot of misconceptions about potassium. So as a result, people are afraid of fruits. People are afraid of vegetables. And we’ve talked about this on previous episodes. We are able as nephrologist as dietitians and essentially as healthcare providers to help you control your potassium. This is not where you would rather put down the strawberries and go have the hamburger.

Sean Hashmi, MD, MS, FASN

What we’re saying is if you are having an issue with fruits, let us help you if it’s vegetables, let us help you. And keeping that in mind, that the best source of all of these vitamins really is food.

Michele Crosmer, RD, CSR

Yes. Exactly. And the thing, too, is that it’s important to think about is we know about certain vitamins and minerals because we’ve studied populations of people who consume diets that are usually higher in this. And so some of these miracle things like taking turmeric supplements or ginger supplements. And we know that those are anti inflammatory, high antioxidant vitamins and supplements because we found in populations of people that consume them regularly that, you know, it’s beneficial. And then what we like to do is just concentrate and put it in this really high dose pill form and say, take this where now what was that spice used on?

Michele Crosmer, RD, CSR

What type of food was that spice used in? And that’s likely where, again, that synergistic, effective food and vitamins and minerals all work together. Whereas if you change absolutely nothing with your diet and you just start taking a supplement, well, you’re not going to see the same effect as if you change up your diet and add more whole plant foods and potentially use some of these spices instead of just taking them in supplement or capsule forms, which, again, can potentially be in very high quantities. That potentially could be dangerous.

Michele Crosmer, RD, CSR

There’s a big difference there. So I usually recommend that people be cautious if you have kidney disease with overdoing vitamins and supplements, and ideally talk with your renal dietitian or your doctor about what you actually need or what might benefit you or help you versus just taking things across the board, especially if you just read it in a forum or online.

Sean Hashmi, MD, MS, FASN

Yes, indeed. All right. What’s our next question?

Michele Crosmer, RD, CSR

Okay. And this is actually a good segue because it’s about a specific mineral. But someone was asking specifically about calcium and about calcium supplements taking calcium supplements. But I think it’s important, especially with calcium, if you can explain just the role of calcium supplements, potentially on kidney health or heart health. And if that’s something that people should or shouldn’t be taking, oh, gosh.

Sean Hashmi, MD, MS, FASN

You know, calcium is probably one of the most controversial topics to address. And it’s funny, because even if we go back and we look at the very first data that we had around calcium in terms of how the recommendations came out, it turned out that they had a really small study was less than 100 people that they tested it on. And what they figured out was what was essentially a neutral calcium balance. What that meant is the amount you took calcium in and the amount that left the body.

Sean Hashmi, MD, MS, FASN

And this is unhealthy people. And so they figured that’s how much calcium you need to be eating. But that data had nothing to do with does that amount of calcium impact factor risk and all sorts of other outcomes. So there was nothing studied on outcomes. So I’ve always been wary about these recommendations on calcium because the original data that they based it on was only looking at a neutral balance. Now let’s get into kidney disease. So what’s interesting is if you look at the National Kidney Foundation, what they basically say is that the total calcium intake, that means food plus supplements, and people with renal disease really should not be greater than 2000 mg per day.

Sean Hashmi, MD, MS, FASN

That’s the total. Now what’s the evidence? Well, there was a really elegant study that was done, and essentially, they were looking at two arms. The first arm was going to be 800 mg of calcium per day, and then the other one was going to be 2000. And more. So when they gave these people 800 milligrams, they found that essentially their calcium balance was negative to neutral. What that meant was that the amount of calcium coming out of their body was essentially more than what was going in.

Sean Hashmi, MD, MS, FASN

So the idea is that you want to balance out the calcium needs. So your bones take in the calcium. All the other places where calcium is needed gets taken up, and then what’s leftover gets filtered out. That’s considered neutral. So at 800, this was total at 800 total. It looked like it was negative to getting close to neutral. But when they put in 2000, something very interesting happened. So they put in 2000. Then they measured what was going on in the stool, and they found that the amount that was going on inside the stool going on, it actually didn’t change at all.

Sean Hashmi, MD, MS, FASN

Okay, so then that means that 2000 was getting absorbed. Fine. But we already knew that they didn’t really need that 2000. So we expected some of that 2000 to come out into the urine. They checked the urine. No increase going on in the urine either. Then if that’s the case and you put extra calcium in your body, you expect your blood level calcium to rise. If it didn’t come out in the stool, it didn’t come out in the urine. It should be in the blood. So they checked the blood level.

Sean Hashmi, MD, MS, FASN

It didn’t rise. So here’s the million dollar question. Where did the calcium go? And the answer for everybody who’s listening or watching is it went inside the tissues. So what happens with calcium is as you take more than what your body needs, it will precipitate out, which means it will combine with things like phosphorus. And this is why in dialysis patients, sometimes when we do X rays, like a chest X ray, you can literally see every single one of their blood vessels on the chest Xray, it’s lighting up so much because of the fact that they have such bad calcifications going on.

Sean Hashmi, MD, MS, FASN

So somewhere between the 800 Mark and the 2000 Mark lies the truth with NKF, what their recommendation is to stay under 2000. So in terms of trying to supplement, I don’t think patients on kidney disease need to supplement calcium. There’s lots of good sources. It’s interesting when we talk about things like kidney stones, what do we tell people is to eat a diet rich in calcium, not to take calcium supplements because the Dietrich in calcium, the calcium in food will go in their gut and will bind the oxalate and prevent the oxalate from entering inside their body.

Sean Hashmi, MD, MS, FASN

So it’s paradoxical in that you get calcium oxalate stones as the number one thing to prevent calcium oxalate stones. We want you to increase calcium in your diet. So here when we talk about kidney disease, what we know is that if you start taking supplements, that calcium has to go somewhere and if it ends up in your tissues and gets calcified, one of the markers for early death is how flexible your blood vessels are, the less flexible the harder they become, meaning they’re all calcified and hardened.

Sean Hashmi, MD, MS, FASN

The more likely you are to see issues with your blood pressure. You are to have all these complications. One of the things that we see in patients that are all the way at the end stages of kidney disease is they have a very large difference between their systolic blood pressure and their diastolic blood pressure. So what that means is their vessels have gotten stiff and it can’t expand and contract anymore. And that’s a marker for early death. So bottom line here is when it comes to calcium and kidney disease, more is definitely not better.

Sean Hashmi, MD, MS, FASN

We still think going with food is still one of the best things going on.

Michele Crosmer, RD, CSR

That explains a lot. And I have a follow up question too. So then let’s say someone is taking or not taking a calcium supplement or they’re looking just simply at how many milligrams they’re consuming in their diet. And I think I know the answer to this. But ultimately, how would their blood like, could their blood work? Calcium blood levels still be within a normal range, and they could still be consuming or supplementing too much calcium in the diet where that calcification is going on?

Sean Hashmi, MD, MS, FASN

Absolutely. And this is why this study that I was talking about it was done in 2014 with Spiegel and colleagues. The reason it was so important and so elucidating is calcium in your blood is being regulated by your bones. It’s being regulated by your kidneys. It’s being regulated by the absorption of calcium in the gut. So your serum levels won’t necessarily rise. That extra calcium will go somewhere. And if the kidneys can’t handle it, there’s only one place left and that’s going into your tissues. So in other words, if you’re consuming too much calcium, it’s going to end up somewhere.

Sean Hashmi, MD, MS, FASN

And you want to be aware of that. And this is why just because something is good, too much of it doesn’t mean it’s great.

Michele Crosmer, RD, CSR

Yes. Exactly. And the person who had asked this question and this is an important thing to remember, too, with calcium is they were asking almost specifically about tongues. And so that’s something to keep in mind, too, is that sometimes these antacids or these medications over the counter meds that someone might be taking for heartburn. Those are calcium based, and they’re providing calcium. And so that is something to keep in mind is that that does count as supplemental calcium and is adding to your diet. So you want to be mindful of that and talk about what you’re taking with your doctor and again with a renal dietitian.

Sean Hashmi, MD, MS, FASN

Excellent. Well, let me ask you then, since we’re on the subject of calcium supplements and just calcium in general, how much calcium can be absorbed at once.

Michele Crosmer, RD, CSR

So typically you want it to be less than 600 milligrams. So usually what they’ll say is about 500 milligrams of the calcium can be absorbed at one time. So if someone does need calcium supplementation and they need let’s say 1000 milligrams, then splitting that up maybe into 250 or even 500. Let’s say it’s 500 milligrams in the morning and the evening. But the other thing that’s important with calcium is that calcium can and taking calcium supplements can reduce or inhibit the absorption of some other minerals and specifically things like iron.

Michele Crosmer, RD, CSR

And so usually we can eat disease anemia or something. And we are trying to increase the absorption of iron. And so if someone is taking a calcium supplement, then ideally taking it away from their iron rich meal so that they’re not reducing or inhibiting absorption of iron.

Sean Hashmi, MD, MS, FASN

No, I think that’s really helpful and important to understand. So let’s say that I’m trying to plan out my day in terms of taking calcium. What would be some tips in terms of how to space it out and kind of think about it in those terms.

Michele Crosmer, RD, CSR

So I think kind of with everything else is best spaced out. This comes into play. Even with things like potassium, we don’t want this bank of protein or potassium or calcium where we just save it all up for one giant meal of the day, because that’s really our bodies and our kidneys are meant to utilize food and nutrients throughout the day. So I think it’s best calcium and everything else is spreading out throughout the day. Whether that’s two or three meals plus one or two snacks, then that’s going to be the best way to do that.

Michele Crosmer, RD, CSR

And some plant sources of the calcium or leafy Greens are going to be great sources of calcium. Certain beans and legumes, and then sometimes like fortified foods, might have calcium added to them. But ultimately, again, it’s spreading it out throughout the day. You don’t want it to be okay. Well, I’m going to have this one super high calcium meal or super high potassium meal, but then not eat anything else the rest of the day. We really want it to be spread out. And again, that could be different from person to person in general, two to three meals, one to two snacks depending on your lifestyle and what fits into your day of eating.

Sean Hashmi, MD, MS, FASN

I love that. So that’s really practical advice as far as calcium is concerned. All right. So coming back and trying to sum up some of the main points for today, at least from my perspective, what I hope that the folks listening to this will get out of this is when it comes to calcium supplementation. Don’t get caught up in the hype. Same thing with vitamins and everything else that we talk about is, at least from my perspective, you don’t want to get caught up in that more is necessarily better, right?

Sean Hashmi, MD, MS, FASN

There is an optimal range where too little, maybe bad for you, but the same way is too much, maybe bad. So I think that was really important for me to make sure our readers and listeners kind of get that. What would you say are some of your take homes.

Michele Crosmer, RD, CSR

I think aside from that, that’s important is what you had talked about earlier with the fistula and with dialysis is looking at if your doctor is addressing or even bringing up dialysis, too. It’s looking at it through the lens of they’re not trying to force you into dialysis. Or I think a lot of times people think they just like, oh, I just want to put you on dialysis. It’s easier to manage you that way. And it’s really just to give you options and to protect you from having this emergency situation where you have to use one of those lifelines.

Michele Crosmer, RD, CSR

And it doesn’t mean that it’s this definite sentence of being on dialysis. I think that’s the thing, too. And we could probably have other episodes. Dialysis is a life sustaining treatment, right. And it’s needed for some people. It’s not needed for others. But that’s where the power of food and lifestyle comes in. Is that regardless of what stage of kidney disease you’re at, whether you’re on dialysis or you’re not or you’re, like, close and your doctor’s talking about it with you. You can make changes to your diet and to your lifestyle that help your kidneys, but also protect your heart, prevent cardiovascular outcomes.

Michele Crosmer, RD, CSR

And so there’s always at any stage. There are things that you can be doing, and there is hope at any stage that you can make a difference. And I think that we probably talk about that almost in every episode as well. But I think it’s so important because it’s easy for us to just look at one thing and one route. But we really do have options, and it’s just important to talk with your doctor and dietician and your other healthcare providers about what those options are.

Michele Crosmer, RD, CSR

But make sure that you’re still, like you said, have that insurance policy or that you’re being saved and you’re aware of all of the potential options or outcomes.

Sean Hashmi, MD, MS, FASN

Wow. That’s excellent. Well, guys, I want to thank every single person for checking us out we would love to have your questions. We are really curious to see what questions you guys have, and both Michelle and I, what we’re trying to do is make this so that this really helps you guys out. This is about you guys getting healthier, about you being able to have good conversations with your doctors, being able to go home and make better choices about what you eat. So we’re very grateful. Michelle, I got to tell you our little podcast YouTube thing.

Sean Hashmi, MD, MS, FASN

This is really amazing. The feedback we’re getting has been just wonderful.

Michele Crosmer, RD, CSR

Yes, I agree. I’ve even had other renal dietitians reach out and say, oh, I’m showing my patients this or I’m telling my colleagues about this because again, and I said this in the first episode. I think it’s something that’s really been lacking in the kidney community and the opportunity for people to ask questions and then get both the nutrition side and the medical side and just have a discussion around things and explain things in a way where again, if you don’t have a lot of time at your doctor’s office or even with your dietitian, at least hopefully we can explain things a little bit longer and more drawn out or in more detail.

Michele Crosmer, RD, CSR

That way, it prompts you to ask those questions of okay, well, how do I make this relevant or specific to me when you do go back to your doctor?

Sean Hashmi, MD, MS, FASN

I couldn’t agree more. So, guys, thank you so much for joining us. Thank you so much for checking out another episode, and we look forward to your questions. And other than that, then I think we will see you guys next week.

Michele Crosmer, RD, CSR

Yeah, we’ll see you guys next week, and you can submit your questions. Plantbasedkidneyhealth@gmail.com and we’ll answer them on future episodes.

Sean Hashmi, MD, MS, FASN

Perfect. And that’s plantbased Kidneyhealth@gmail.com. Thanks, everybody. Take care of yourselves. You got this one body right. And don’t forget, as long as you’re taking care of yourself. One other thing you can also do is express gratitude and be kind to others. This is a small world. We have just a short amount of time in this world, and being kind to others is not goes really a long way. So with that. Thanks, everybody. See you guys next time.

Michele Crosmer, RD, CSR

See you guys next week.

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