Make a Plan to Get Movin’
Anemia and Your Diet
Prescription For Health:
Meds for your Reds (blood cells)
Managing Anemia on Dialysis
From the Director’s Chair
The Importance of Touch: Part of the Goodness of Living Announcements to Chew On!

Make a Plan to Get Movin’
Ann Mader, Dietitian

It’s hard to believe that this is going to be the third year for the exercise program! For those of you who are new or have not participated in the past, here’s your chance to join the WDI exercise team!

WDI will officially launch the Third Annual Exercise Program on June 1, 2006. It’s fun and easy to join in, plus it’s good for you…just ask your kidney Doctor! Each participant will be required to keep a log of his or her progress throughout the summer.

Your dietitians, Ann and Fran will work with you to develop an individualized program that is done on your own and at your own pace. Your exercise could be at home, in a gym, or wherever you feel comfortable. The goal is to get each dialysis patient to experience the positive benefits of exercise.

In each of the last 2 years approximately 30 patients finished the program. WDI honors the participants and celebrates success with an awards banquet each September.

So get ready to reap the benefits of exercise and have fun doing it! Start by making a plan of how you are going to join in and get movin’!

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The best six doctors anywhere
and no one can deny it,
are sunshine, water, rest, and air, exercise and diet.
These six will gladly you attend
if only you are willing.
Your mind they'll ease.
Your will they'll mend,
and charge you not a shilling.

~Nursery rhyme quoted by Wayne Fields, What the River Knows, 1990.

Anemia and Your Diet
Amanda Parks, dietetic intern
Fran Kittell, MS, RD, preceptor

Do you feel tired and run down, experience shortness of breath or have trouble sleeping? You could have anemia. Anemia is associated with many symptoms, so do all you can to prevent or control this common condition.

How can your diet be used to decrease your risk or treat your anemia? Good nutrition is important to maximizing your health and consuming adequate vitamins and minerals will help treat anemia and its symptoms. In particular, iron and vitamin B-6 are required for your body to make hemoglobin, the oxygen-carrying protein in your blood that is reduced in anemia. Although eating foods high in iron is certainly helpful, dietary sources of iron are not usually enough to meet your needs.

In kidney disease, your ability to produce red blood cells is diminished due to a decrease in the hormone erythropoietin. Thus, you are likely taking a weekly medication to replace this hormone as well as receiving iron during hemodialysis (PD patients usually take an iron supplement instead).

Still, diet always plays a role! Vitamin C is known to increase your body’s absorption of dietary iron; therefore it’s a good idea to ensure that your meals are well-rounded so that both of these important nutrients are consumed together. Further, getting enough iron overall is important for erythropoietin to do its job.

So where can Iron, Vitamin C, and Vitamin B-6 be found? There are 2 types of iron: heme iron and non-heme iron. Heme iron is absorbed best. Sources of heme iron are fish, pork, poultry and beef. Sources of non-heme iron are: fortified breakfast cereals (such as shredded wheat, total, cheerios, etc.), whole grains and eggs. Vitamin C ( not high in Potassium) are bell peppers, broccoli, cranberries. Vitamin B-6 sources are fortified cereals, chicken, fish and pork. Talk with your dietitians if you need further help with meal planning.

Additional Tips:
- Eat one iron-rich food for every meal
- Use an iron skillet when cooking – but why Fran?
- Eat cereal fortified with at least 30% RDA of iron
- Take your medications
- Know your hemoglobin level and stay at the goal of 11-13 mg/dL

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The Philosophy of Charles Schultz
(Provided courtesy of Dr. A. Vishnu Moorthy - thanks Dr. Moorthy!)

The following is the philosophy of Charles Schultz, the creator of the "Peanuts" comic strip. You don’t have to actually answer the questions. Just read on and you’ll get the point.

1. Name the five wealthiest people in the world.
2. Name the last five Heisman trophy winners.
3. Name the last five winners of the Miss America pageant.
4. Name ten people who have won the Nobel or Pulitzer Prize.
5. Name the last half dozen Oscar winners for best actor and actress.
6. Name the last decade's worth of World Series winners.

The point is none of us remember all the headliners of yesterday. These are no second-rate achievers. They are the best in their fields, but the appreciation dies. Awards tarnish. Achievements are forgotten. Accolades and certificates are buried with their owners.

Now, here's another quiz. See how you do on this one:

1. List a few teachers who aided your journey through school
2. Name three friends who have helped you through a difficult time
3. Name five people who have taught you something worthwhile.
4. Think of a few people who have made you feel appreciated or special.
5. Think of five people you enjoy spending time with.

The Lesson: The people who make a difference in your life are not the ones with the most credentials, the most money or the most awards. The people who make the biggest difference are the ones that care about you!

Prescription For Health:
Meds for your Reds (blood cells)
Kimberly Holdener, PharmD

Anemia, or low red blood cell count, is very common in people with kidney disease. Red blood cells are important because they carry oxygen to all parts of your body. Some of the common symptoms of anemia are feeling tired, shortness of breath, looking pale, and trouble concentrating. People with kidney disease often have anemia because they stop producing or do not produce enough erythropoietin – a hormone made in your kidneys that tells your body to make red blood cells. At WDI, we check your hemoglobin regularly to monitor for anemia. Hemoglobin, which is measured by a lab test, tells us how many red blood cells you have.

There are two medications to treat anemia for dialysis patients Darbepoetin (Aranesp) and epoetin (Procrit or Epogen). Both of the medications are man-made forms of erythropoietin and both are effective at treating anemia. The main difference between these two medications is that darbepoetin lasts longer in the system than epogen. Therefore, most patients at WDI who need anemia treatment receive darbepoetin once a week during their dialysis treatment. However, people with anemia due to kidney disease, who are not yet on dialysis, usually receive their anemia medication as a subcutaneous (beneath the skin) injection.

Darbepoetin and epoetin work by taking the place of the erythropoietin that is not being produced by your kidneys and telling your body to make more red blood cells.

There is another important part of anemia therapy – iron. No matter how much darbepoetin or epoetin you receive, it will not work if you do not have enough iron in your body. This is because iron is a necessary component of red blood cells. Many dialysis patients are iron deficient (do not have enough iron). At WDI, your iron levels are checked every three months. You may have heard of oral forms of iron such as ferrous sulfate. For some patients on peritoneal dialysis, oral iron is adequate. However, for people on hemodialysis, oral iron supplements are usually not enough to replenish the body’s iron stores. This is why we give intravenous iron to hemodialysis patients who need iron supplementation. The iron product that is used at WDI is called iron sucrose (Venofer). Patients whose iron levels are very low get a “load” of iron. This means that you will get 100mg of iron sucrose for 10 dialysis sessions in row. Patients whose iron levels are moderately low are given “maintenance” iron dosing once a week to keep your iron levels from dropping too low.

The goal for anemia therapy is to get your hemoglobin and iron levels into the goal ranges and keep them there, to reduce the symptoms of anemia, and to help prevent complications that anemia may cause. The lab tests to monitor for anemia are done regularly so that medication doses can be adjusted as needed to meet these goals.

Managing Anemia on Dialysis
Kathleen Bendewald, RN, CNN

What is anemia?
Anemia means you are not producing enough red blood cells. One test which indicates how many red blood cells are present in your body is known as hemoglobin. The National Kidney Foundation has established, per research, that a level of hemoglobin of 11 to 12 is desired for hemodialysis patients. This is also the range WDI uses.

What are the effects of anemia?
Fatigue is certainly one complaint. I had one patient tell me that he would mow one strip of lawn and then sit and rest for 5 minutes. He would then mow another strip and rest and so on. But more seriously, The American Heart Association now considers anemia to be a non-traditional cardiovascular risk factor for patients with chronic kidney disease. Anemia has also been associated with an increased risk of stroke.

Why are patients with chronic kidney disease low on red blood cells?
They lack a hormone which the healthy kidney produces called erythropoietin. Erythropoietin sends a message to the bones to make more red blood cells. But this communication does not happen with a person who suffers from kidney failure, or if it does, the red blood cells that are produced are of poor quality and don’t last long.

What does WDI do to help patients increase their red blood cells?
We give a medication called Aranesp. Those patients familiar with Epogen, which we used to give, may be interested to know that Aranesp is a longer molecule (it has an addition of two N-linked carbohydrate chains to the original molecule). Thus, it is not degraded as fast.

Why would a patient’s levels of hemoglobin vary?
Many factors can interfere with the efficacy of Aranesp. The most common is lack of iron. Iron is a raw material in the manufacture of red blood cells. Most hemodialysis patients require iron as part of their treatment plan. Other causes of low hemoglobin are hospitalization, infection, inadequate dialysis, inflammation, protein malnutrition, vitamin deficiency, co-existing medical conditions and blood loss.

How is anemia managed?
Monitoring your anemia is an important part of your overall health. Therese Crowley and I evaluate each patient’s hemoglobin and we adjust your Aranesp and Venofer doses. If you have any further questions about our role with your hemoglobin and iron, please feel free to speak with us. Therese manages the patients who receive dialysis on the Monday, Wednesday, Friday shift and those at East, while I manage the Tuesday, Thursday, Saturday shift.

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Attention east and Fitchburg patients. See the patient bulletin board in your unit. There will be a new topic every month! Take the monthly quiz and you could win the monthly prize!

From the Director's Chair
Dialysis Adequacy - How do You Know if You’re Dialyzing Too Little or Too Much?
Paul S. Kellerman, MD

How do your WDI caregivers know if you’re getting enough dialysis for optimal health? That is a very good question. Dialysis gets rid of the waste products from your cells that go back into your blood, and also gets rid of salt and water you take in by mouth that your kidneys can no longer excrete.

First of all, we clinically assess you, both by asking you questions and sometimes examining you. Regarding the waste products, if you’re not dialyzing enough, you may have symptoms of “uremia”, which can include itching, nausea, poor appetite, restless legs or pain in your legs (neuropathy). Regarding the salt and water, we look at your fluid gains between dialysis, whether your blood pressure is high, whether you’re having problems breathing, particularly when lying down, and whether you have swelling in your legs. Prior to 1990, a well-dialyzed patient was considered a patient who had none of these problems.

In the 1980’s, dialysis times were shortened due to more efficient dialyzers and both patient and doctor preferences, and more patients started becoming ill. It was realized at that point that a certain amount of dialysis is best for feeling good on dialysis and long life on dialysis. It was also realized that we didn’t really know how to measure how much dialysis a person needs for quality and quantity of life. The question of how much dialysis is enough has been an active area of research over the last 15 years. Is there something we can measure, aside from how you feel, to tell us how much dialysis is best? The answer is that we now have fairly good measures of how much dialysis is best for your health.

Monthly, you receive your report card, which describes your lab tests. On that report card is a “URR”, which stands for urea reduction ratio. This is one measure of whether you are receiving enough dialysis. Another measure is a formula called the Kt/V. Let’s talk about the URR, which you see monthly. Blood tests are drawn at the beginning and end of dialysis, measuring your BUN (blood urea nitrogen), and we calculate what percentage of BUN is removed. Through very large studies, it has been determined that the minimum acceptable reduction is 65%, but we feel that between 70-75% is optimal. How much dialysis you need also depends on your size. If you are a small person, you will need less dialysis than a large person.

The primary way we have to change your URR is the amount of time on dialysis, although we sometimes will first change to a larger artificial kidney to see if that helps.

Know your URR number each month, and if it is under 65%, you and your doctor should be talking about improving your dialysis adequacy, usually by increasing your time. No one likes being on dialysis for longer periods of time, but we only advise this in the interest of you living long and well on dialysis. Conversely, if your number is near 80%, then you may be able to decrease your time on dialysis.

Other conditions can decrease your URR. If you have a narrowing in your fistula or graft, that can cause recirculation (redialyzing the same blood, which is very inefficient). Sometimes, if we see a URR decrease, it makes us look for a narrowing in your fistula. It is also important on lab days that you complete your whole time on dialysis, to get an accurate URR. If you shorten your time that day, it will look like you don’t routinely get enough dialysis.

So look at your URR and tell us if you don’t feel well, so we can work in partnership with you to keep you in the best health possible.

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Never leave that till to-morrow which you can do to-day.
-Benjamin Franklin

The Importance of Touch: Part of the Goodness of Living
Chaplain Penny Andrews

Did you know that the most sensitive areas of your body are your hands, lips, face, neck, tongue, fingertips and feet? There are about 100 touch receptors in each of your fingertips. The least sensitive part of your body is the middle of your back.

Children who are picked up, cuddled, cradled, rocked, petted, and stroked have been shown to gain weight and grow faster and to start crawling, walking, and grabbing earlier. Research has shown that touch may even be as important to a baby's physical, emotional, and cognitive development as eating and sleeping.

In a study of an overcrowded orphanage in Romania, researchers from Harvard Medical School found that babies who lay for hours without physical human contact suffered stunted growth and had abnormal levels of cortisol. Cortisol is an important hormone in the body, secreted by the adrenal glands and involved in the following functions:

• Proper glucose metabolism
• Regulation of blood pressure
• Insulin release for blood sugar maintenance
• Immune function
• Inflammatory response

When we pet an animal both the pets and the human’s blood pressure goes down.

We need to touch and be touched. We are hardwired for it. It changes us—it transforms us. Whether we are children or adults, touch is good for our body, mind and spirit.

The gentle act of holding hands, sharing a hug, exchanging a hand, back or foot rub can take a bad day and brighten it. It can take a good day and make it a great one.

Let yourself be touched by life. It has hidden benefits and they are all part of the Goodness of living.

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"The smile on your face will let me know you need me, there's truth in your heart that says you’ll never leave me, and the touch of your hand says you’ll catch me whenever I fall."
- Melody Beattie

Announcements to Chew On!

• March was a busy month. WDI recognized National Kidney Month with cookies for patients. March was also nutrition and social work month. Special thanks to the WDI dietitians Fran & Ann and social workers Helen & Anastasia.
• April 26th is Secretary’s Day. WDI would like to recognize the awesome secretaries that keep us all in line, up to speed and on task. Merci Beaucoup to Terri, Mary, Kris, Trisha, Easton and Jacqui. We don’t know what we would do without you!
• If you are a recipient of WCRD you will be receiving a packet sometime in the spring to reapply for the program. Please let your social worker know if you need assistance.
• Nurse’s week will be celebrated May 6-12. Recognition of our outstanding nurses will be in the summer Pathways, but until then….we applaud our nursing staff.
• Look for the Pathways Newsletter on line at www.wisconsindialysis.org.