Online Health Chat with Dr. Michael Lioudis

March 16, 2012

Introduction

A number of diseases, including diabetes and high blood pressure, can prevent your kidneys from functioning at their best. When kidney function steadily worsens waste builds up in the blood. This condition is referred to as chronic kidney disease or CKD. Patients with CKD can become anemic and develop weak and brittle bones. CKD also increases the risk of stroke and atrial fibrillation. CKD is managed as long as possible with medications and a special diet. As the disease progresses, however, patients may require a kidney transplant or dialysis. Early detection and appropriate treatment are important in slowing the disease process, with the goal of preventing or delaying kidney failure.

Dr. Michael Lioudis joined the Glickman Urological & Kidney Institute in 2011 and is located at the Twinsburg Family Health & Surgery Center. He specializes in the treatment of chronic kidney disease and hypertension.

If you would like to make an appointment with Dr. Lioudis or any of our other nephrologists in the Glickman Urological & Kidney Institute, please call 800.223.2273 x46771 or request an appointment online by visiting clevelandclinic.org/appointments.

Cleveland_Clinic_Host: A number of diseases, including diabetes and high blood pressure, can prevent your kidneys from functioning at their best. When kidney function steadily worsens, waste builds up in the blood. This condition is referred to as chronic kidney disease or CKD. Patients with CKD can become anemic and develop weak and brittle bones. CKD also increases the risk of stroke and atrial fibrillation. CKD is managed as long as possible with medications and a special diet. As the disease progresses, however, patients may require a kidney transplant or dialysis. Early detection and appropriate treatment are important in slowing the disease process, with the goal of preventing or delaying kidney failure.

Dr. Michael Lioudis joined the Glickman Urological & Kidney Institute in 2011 and is located at the Twinsburg Family Health & Surgery Center. He specializes in the treatment of chronic kidney disease and hypertension.

If you would like to make an appointment with Dr. Lioudis or any of our other nephrologists in the Glickman Urological & Kidney Institute, please call 800.223.2273 x46771 or request an appointment online by visiting www.clevelandclinic.org/appointments. Thank you!

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Michael Lioudis. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Medication Interactions

Francois: For a psychiatric disease, I take the prolonged-release injection Risperdal Consta® 25 mg that releases the medication for three weeks. Only during the first week there is a marked decrease in the volume of urine upon waking in the morning. For the rest of the day, any volume decrease is not noticeable. Also, during this first week my weight increases by a pound or two that is subsequently lost. Am I at risk of developing kidney problems with this medication? During my three years on this medication, my annual blood and urine kidney tests have been normal. I am male, 74, and suffer from significant episodic (not sustained) hypertension. Otherwise, I am healthy.

Dr__Lioudis: As with any medication, there are risks and benefits that must be discussed at patient visits. Resources should include both your physician and pharmacist. Risperal Consta®, or risperidone, should be dosed based on your renal function. However, there may be effects from other medications you are taking that should also be considered. Make sure your prescribing doctor has an active medication list for you (including any herbal supplements or over-the-counter medications you are taking). Your pharmacist can also assist in checking for medication interactions.

java_hut: I have stage 4 kidney failure. At this stage, is it possible for Zoloft® (I take 100mg a day every morning) to not work as well?

Dr__Lioudis: Zoloft® does not appear to be affected by kidney function. If you feel that it is not working as well for you, please talk with your prescriber.


Kidney and Renal Artery Changes

Becca: Does a significantly smaller kidney continue to function at reduced capacity? Will the kidney keep shrinking?

Dr__Lioudis: There is typically some variation between the left and right kidney. Significant differences are usually reflective of some underlying problem affecting the smaller kidney.

Becca: What can cause renal artery narrowing seen on an angiogram disappear several months later? Can renal stenosis reverse itself? If so, does it happen often?

Dr__Lioudis: Typically, renal artery narrowing is not reversible and would not necessarily disappear. Its appearance, or lack thereof, can depend on the type of study used.

nancy: Do patients who have coronary artery disease have damage to renal artery as well?

Dr__Lioudis: Atherosclerosis can occur throughout the body in all vessels. However, having coronary artery disease does not mean that it will lead to noticeable kidney problems. Regardless, it will be important to reduce your risk factors, such as smoking, and have your cholesterol levels monitored.


Fluid Retention

Becca: Does the effectiveness of diuretics decline with kidney function? What impact would this have on an already significant fluid retention?

Dr__Lioudis: The choice of diuretic, based on an individual's kidney function, is an important consideration for your doctor. There is often a delicate balance that must be achieved between diuretics and fluid retention. This is because diuretics are also very effective blood pressure medications too, and could lead to very low blood pressures, which could further compromise kidney function.

Becca: Can damaged kidneys cause fluid retention in the legs, abdomen, hands and lungs all at the same time? Is fluid in the lungs always detectable on a lung x-ray if it comes and goes? Is it common in CKD to see considerable abdominal fluid retention? What is the most effective and permanent way to treat edema?

Dr__Lioudis: Edema can be caused by a variety of medical problems. The key is to identify and treat the underlying cause. Fluid retention or edema that is significant and generalized is often referred to as anasarca and should prompt immediate medical attention. Fluid in the lungs is not always detectable by a plain chest ray and often depends on the amount present.

Becca: Besides affecting the legs, feet and hands, can significant fluid retention extend to the abdominal area and the lungs? Can severe fluid retention cause shortness of breath?

Dr__Lioudis: Fluid retention or edema can extend to the abdomen or even the lungs, resulting in shortness of breath. This is a very serious condition that can be life-threatening. Again, if someone is experiencing shortness of breath, they should seek immediate medical attention.


Tests

locally_owned: My brother was recently diagnosed with Stage 3 chronic kidney disease. He had a rapid decline in eGFRd. His renal ultrasound indicate "bilateral renal cortical thinning" with worse cortical thinning on the right. There are focal areas of scarring on right mid pole. What does it mean? I am not looking at a diagnosis from you, just an explanation of what all these terms are and what they mean for my brother. His last blood results indicate a low anion gap. What does this mean and what causes it?

Dr__Lioudis: The ultrasound helps to provide a non-invasive picture of the kidneys. It can help to rule out obstruction (such as a kidney stone blocking urine flow) and give an indication of the kidney's structure and size. "Cortical thinning" represents a change to the kidneys. However, it does not tell us what the underlying cause was. It will be important for your brother's doctor to obtain a detailed history and medication list (including over the counter medications and herbal supplements). Lab workup will likely include a urinalysis and monitoring blood work. An anion gap is only one lab component and can be affected by multiple things, including protein level and medications.

mkz: I was diagnosed over 10 years ago with hydronephrosis on left kidney. I have little pain on the left side. The x-ray did not find any stone or UTI. What test should I do it? What can I do to prevent the discomfort episodes every few years? (I am a 45-year-old woman, generally healthy. I had martial valve repair done 8 months ago.

Dr__Lioudis: The key to hydronephrosis is whether it is a functional obstruction or not. For example, is it actually blocking urine from freely flowing? Is there true blocking of urine flow or are you experiencing discomfort as a result of the hydronephrosis? You should consider being evaluated by a urologist.

Becca: Which test is used to determine how the kidney functions of each kidney? When would such a test be indicated?

Dr__Lioudis: Testing often depends on what is available at your particular institution and the degree of suspicion that a problem exists. The most readily available test is a blood test that looks at the creatinine level. This will give you a collective view of your kidneys and not an individual evaluation of each kidney's function. Other tests could include a diuretic renogram.


Risk Factors

nancy: Is there a genetic contribution to chronic kidney disease?

Dr__Lioudis: Yes, there are congenital (seen at birth) or inherited forms of kidney disease that can be passed on to future generations. It is important to discuss with your doctor whether or not a kidney problem falls into one of these categories.

livin: Are there any particular foods that I should avoid with CKD?

Dr__Lioudis: This will depend upon any lab abnormalities that have been discovered and whether you have high blood pressure. For example, some patients may need to modify their potassium intake based on whether their potassium is high or low. Others may need to watch the amount of sodium in their diet if they have high blood pressure. In general, I recommend a well-balanced diet to my patients.


General Questions

Becca: Can fibromuscular dysplasia in renal arteries damage the kidneys enough to cause chronic kidney disease? Does fibromuscular dysplasia in renal arteries accelerate CKD progression?

Dr__Lioudis: Fibromuscular dysplasia (or FMD) can result in a narrowing or stenosis of the renal arteries. In some instances, this can lead to a phenomenon called renovascular hypertension. Chronic kidney disease can then occur as a result of uncontrolled hypertension or progressive narrowing of the vessel. Typically, evaluating the carotid arteries is also performed in patients with renal artery FMD.

Becca: What is your advice on keeping the kidney function stable for as long as possible?

Dr__Lioudis: Referral to a nephrologist can be an important part of preserving kidney function that has been compromised. Recommendations by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative can be viewed at www.kidney.org.

Becca: What is the microalbumin/creatinine ratio? What does a consistently high (58.1 - 67.5mg/mmol) (normal 0.0 - 2.8) ratio mean?

Dr__Lioudis: Increased protein excretion can be an early sign of kidney disease. The microalbumin to creatinine ratio helps to reduce the variability of a urine sample based on volume of the urine sample (for example if you drink a lot of fluid your urine will be less concentrated). Values 30 to 300 mg/g of creatinine (or 3.4 to 34 mg/mmol of creatinine) indicate that the albumin excretion is 30 and 300 mg/day. This would be referred to as microalbuminuria. Values greater than 300 mg/g (or 34 mg/mmol) would indicate microalbuminuria.

Becca: What are the typical causes of renal infarcts? Can they cause the kidney to atrophy?

Dr__Lioudis: Renal infarcts are very serious and require immediate attention. There can be many conditions that lead to a renal infarct including problems with the heart (atrial fibrillation or valve vegetations), atherosclerotic renovascular disease, disruption of plaque buildup, or even FMD.

pkr: If my husband eventually has to get a kidney transplant, how long can we reasonably expect the new kidney to last?

Dr__Lioudis: There are multiple factors that can affect the lifespan of a kidney transplant. This can include whether it is from a living donor (related or unrelated) or a deceased donor. Also, the amount and type of immune suppression used can also affect long term function. In general a transplant can last between 7 to 10 years, though there are many patients that have enjoyed good kidney function for over 20 years.

Becca: What process is responsible for shortness of breath in CKD?

Dr__Lioudis: Shortness of breath of breath can be caused by many different medical problems. If someone is experiencing shortness of breath, they should seek immediate medical attention.

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr. Michael Lioudis is now over. Thank you for taking the time to answer our questions today about Chronic Kidney Disease.

Dr__Lioudis: Thank you everyone for your wonderful questions!


More Information

If you would like to make an appointment with Dr. Lioudis or any of our other nephrologists in the Glickman Urological & Kidney Institute, please call 800.223.2273 x46771 or request an appointment online by visiting clevelandclinic.org/appointments.

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