Only Hyperuricemia with Crystalluria, but not Asymptomatic Hyperuricemia, Drives Progression of Chronic Kidney Disease

Does elevated uric acid blood levels without symptoms of gout affect the progression of kidney disease?

A new study tried to answer this question. Previous data suggested that elevated asymptomatic uric acid could be a risk factor for the progression of CKD. However, a recent study published in NEJM last year 6/2020) found no benefit from lowering uric acid using allopurinol to slow the progression of CKD.

This new study found that it is not about the level of uric acid in the blood but about the presence of uric acid (UA) crystals in the urine. UA crystallizes in the kidney. UA crystals contribute to CKD progression because UA crystals trigger M1-like macrophage-related interstitial inflammation and fibrosis. 

This study points to the limitation of conventional research that doesn’t look into the individual characteristics of each patient and point to the importance of using the simple and inexpensive urinalysis to help guide risk assessment and approach to managing uric acid in CKD.

https://jasn.asnjournals.org/content/31/12/2773

Association Between Midlife Physical Activity and Incident Kidney Disease: The Atherosclerosis Risk in Communities (ARIC) Study

Fresh from January’s American Journal of Kidney Disease:

Physical activity decreases the incidence of kidney disease… not surprisingly 

Making lifestyle changes can be challenging, but are an important part of the fight against kidney disease. It can be a challenging process but understanding the brain’s efficacy and patterns can help individuals make the changes needed to lead a healthier lifestyle. Read more on our blog.

https://pubmed.ncbi.nlm.nih.gov/32971191/

Effect of Kidney Function on Relationships between Lifestyle Behaviors and Mortality or Cardiovascular Outcomes: A Pooled Cohort Analysis

In this study, investigators found that lifestyle modifications can reduce the risk of cardiovascular disease in patients with kidney function. They looked at smoking cessation, maintaining normal BMI, physical activity, healthy diet and moderate consumption of alcohol individually and in combination. Beside smoking cessation and physical activity, other individual lifestyle modifications were not sufficient alone according to this study. This emphasizes the importance of an integrative approach to kidney health and disease.

https://jasn.asnjournals.org/content/early/2021/02/04/ASN.2020040394

Laxative Use and Risk of Dyskalemia in Patients with Advanced CKD Transitioning to Dialysis

In this article, researchers found that using laxatives alone can help maintain potassium balance in patients with advanced kidney disease. The colon can actually play an important role in potassium excretion. That is one of the many reasons why a diet high in fiber is essential for kidney patients.

https://jasn.asnjournals.org/content/early/2021/02/04/ASN.2020081120

In the wake of the current pandemic, we felt that we should share what we know about COVID-19  as it impacts kidney patients. There is a lot of misinformation out there so please be mindful of your sources. In this blog, we will focus specifically on the impact of coronavirus (COVID-19) on kidney patients and attempt to clarify best practices to prevent infection.

This is a novel virus so there is a lot we don’t know yet. We will do our best to continue to update this blog regularly as we learn new information.

What we do know for sure is that kidney disease, dialysis and transplant patients are one of the highest risk patients. So please, take it seriously. At the same time, let’s follow common sense measures to slow the spread of disease and work with public health officials to reduce hysteria. 

What is COVID-19 (Coronavirus)

Coronaviruses is part of a larger family of viruses which are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). COVID-19 is the most recently discovered coronavirus (Coronavirus Disease 2019).

We’re still learning more about the spread of the virus, but what the research shows is that the disease is primarily spread the same way as other respiratory viruses like influenza and the common cold. The spread is from person-to-person via droplets from the nose or mouth of someone who has COVID-19 who might be coughing or sneezing. These droplets land on objects and surfaces and around another person who can breathe the virus in, or through a contaminated surface then touch their face. 

The Most Common Symptoms

There are many symptoms associated with the infection and the percentage varies from report to report but here are the most common symptoms as of the last update of this blog:

1. Fever, 88%.
2. Dry cough, 68%.
3. Fatigue 38%.
4. Sputum production, 34%.
5. Shortness of breath, 18.6%

Less common/rare symptoms include: Aches/pains, nasal congestion, runny nose, sore throat, diarrhea. 

It’s important to be able to recognize these symptoms early to reduce risk of spreading to others. The majority of people who get infected – over 80% – will not have mild presentation and will not require medical attention or hospitalization. Also, children, while they might help spread the virus, very rarely display symptoms themselves.

What can you do?

The best course of action will always be prevention. There are a few steps you can take to protect yourself and others:

• Wash hands for at least 20 seconds, frequently. Sing happy birthday twice. Don’t forget the back of your hands, thumbs, and wrists. We cannot stress this enough since the virus can last a long time on surfaces.

• Handwashing with soap and water remains the best way to reduce germs. If for some reason they are not available, alcohol-based hand sanitizers that contain at least 60% alcohol can help to reduce the spread of infection.

• Clean surfaces thoroughly using disinfectant solution. That includes countertops, handles, cell phones and touch screens, keyboards, and remotes. Use a paper towel or elbow to open doors whenever possible.  
• Don’t touch your face. This is how the virus can spread to and from surfaces.
•  When you cough or sneeze, always cough into your elbow. Then wash elbow or clothing. 
• Practice social distancing. Avoid crowded areas, public transportation, or social situations where you can’t maintain a distance of 6 feet (2 meters) from individuals).
• Stay away from sick people with any respiratory symptoms. COVID-19 transmission can occur via large droplet transmission (with a risk limited to ~6 feet from the patient). 

Supporting your Immune System

There are some basic lifestyle and dietary practices that are more important now than ever to help support improves immune function:

1. Stress reduction. Stress can reduce your immune function, making you more likely to get sick. Practice stress reduction strategies like meditation and breathing exercises to manage stress. In an attempt to educate ourselves about this outbreak, many of us are getting sucked into the news, worried about finances or loved ones. It’s very important to avoid unnecessary stress and find ways to manage our anxiety.
2. Make sure you’re sleeping well. Sleep plays a big role on immune function, so it is essential to get enough sleep. Maintain consistent sleep hours, avoid the news or stressful conversations in the evening, make sure your bedroom is comfortable and cool, quiet, and dark. Consider setting a reminder to help yourself go to bed on time.
3. Get consistent, moderate exercise.  Regular physical activity helps to boost immune system function. Establish and follow an exercise program.
4. Avoid junk food and continue to eat a nutritious diet. With more of us spending time at home to avoid contamination, the urge to snack or indulge in junk food might be higher. Continue to eat brightly colored vegetables and fruits to boost immunity and avoid highly refined, high sugar, and fired foods. 
5. Consider boosting immunity through supplements (talk to your doctor or pharmacist first). Having adequate levels of vitamins C, A, and D, minerals including zinc and selenium can help support improved immune response. Herbs like elderberry, garlic extract, as well as probiotics can also help boost immune function. 

Although these can be helpful, they’re not specific to the treatment of COVID-19 and should not replace recommendations of your healthcare provider. 

Should you see your doctor?

The healthcare system is experiencing a higher-than-usual pressure right now which makes it more challenging to have capacity to handle the expected risk in cases of COVID infection. If you are stable and have a regular follow-up appointment with your provider, it is ok to cancel and reschedule in 4-6 weeks. It’s a good idea to call your doctor to ask if there is anything they want you to do or if a virtual visit may be sufficient.

Should you stop some medications?

As we mention above, there is a lot we still don’t know. At this time, we know that the virus S spike binds to ACE2 receptor on lung cells. Some medications such as NSAIDs (naproxen, ibuprofen, aspirin, celecoxib, meloxicam) were found to upregulate ACE2. As you know, we already don’t recommend these medications for kidney patients for many reasons, this is another important reason to avoid NSAIDs.

There is some controversy at this time whether the class of antihypertensive medications called ACE inhibitors and ARBs can affect the risk and severity of the infection. At this time, it is believed that the risk of discontinuing these medications is too high. Do not discontinue your medication without speaking to your physician. 

There is also possible genetic predisposition for an increased risk of coronavirus infection, which might be due to ACE2 SNPs that have been linked to diabetes mellitus, and high blood pressure, specifically in Asian populations. We’re still learning more on how this might impact recommendations. 

What About Transplant Patients?

Kidney transplant patients (and those taking immunosuppressive agents for glomerulonephritis) should wear surgical masks when visiting a health provider’s offices. These patients are the most vulnerable and should stick to social distancing.

Some transplant centers are currently halting kidney transplant until the pandemic is controlled. Please check with your provider before discontinuing any medications.

If You Are Sick

If you start to have any symptoms, including dry cough, fever, fatigue:

1. Please CALL your provider’s office before going there.
2. Don’t bring your family members unless essential.
3. Many provider’s offices don’t have the testing available. So, call your state COVID-19 hotline or local health department to get some guidance on local procedure. 
4. DON’T go to the emergency department. Hospitals and Clinics have special procedures for coronavirus, and it will help if you work with the healthcare team to follow them. Make sure you CALL before you go.
5. Please don’t visit people in the hospital!
6. Make sure you have a thermometer that works. Do not take ibuprofen, instead have acetaminophen, guaifenesin, and tissues on hand. Remember, the majority (over 80%) of people will only have mild symptoms they can self-treat; they don’t need hospitalization; and stay home! 

What about Dialysis patients?

The recommendations for dialysis patients are similar to what we mentioned above. We must keep in mind that dialysis centers are healthcare facilities, however since dialysis patients cannot miss visits, we’ve adopted the following recommendations from Center for Medicare & Medicaid Service (CMS) recent guidelines:

1. Facilities should identify patients with signs and symptoms of respiratory infections BEFORE they enter the treatment area in order to take actions to prevent contagion of virus.
2. If you have a fever or respiratory symptoms, CALL ahead to the facility so they can be prepared for your arrival or triage you more appropriately as needed (for example, if they need to go to an acute care hospital).
3. Patients who present with any symptoms of a respiratory infection should wear a facemask (surgical mask) at check-in and keep it on throughout their visit and until they leave the facility. The facility should provide face masks.
4. Patients should inform staff of fever or respiratory symptoms immediately upon arrival at the facility at registration.

Stay healthy everyone!

This article was written with contributions from Dr. Lara Zakaria.

* The intention of this document is to educate. It is not meant to replace the recommendations of your physician of healthcare provider. Always consult your physician or healthcare provider prior to using any of these modalities. For up-to-date information on COVID-19, please consult the Centers for Disease Control and Prevention at www.cdc.gov.