heart disease in children with kdoqi guidelines on ...have had problems with heart disease, it was...

E M OT I O N S A N D YO U R H E A R T

Check out the lat-est information onMedicare Part D.

—6

HEART DISEASE IN CHILDREN WITH CHRONIC KIDNEY DISEASE

There is a linkbetween emotionsand your physicalhealth, specificallyyour heart health.

—Page 9

Heart diseaseaffects millions,including child-ren, each year.

—Page 3

The New National Kidney Foundation Clinical Practice Guidelinesfor Cardiovascular Disease in Dialysis Patients

By William Henrich, MD

There are many reasons forthis increase in the high rateand severity of heart disease inpeople with CKD. Individualswith CKD often have a longhistory of high blood pressure,and this is a major cause ofearly damage to the heart andto the blood vessels, which sup-ply the heart with blood.Problems of too much fluid,abnormal blood fat concentra-tions (cholesterol), calcium

deposits in blood vessels due toabnormal levels of calcium andphosphate in the blood and thebuildup of substances normallyremoved by the kidney, whichhave bad effects on blood ves-sels, all add to blood vesselinjury and later damage to theheart and other organs. Itshould be noted that kidneyfailure causes changes in bloodvessels not just in the heartbut in the legs, arms and brain

as well. So it is not surprisingthat less blood flow to theseparts of the body may also bepresent in people on dialysis. Adecrease in blood flow to thelegs could result in pain withexercise, whereas circulatoryproblems to the brain cancause either temporary or per-manent damage. Finally, it isalso well-known that the lead-ing cause of kidney failure inthe United States is diabetes,

This publication is a part of the National Kidney Foundation’s Kidney Learning System (KLS)™

and is made possible through an educational grant from .

Inside this issue:

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K D O Q I G U I D E L I N E S O N C A R D I O V A S C U L A R D I S E A S E

M E D I C A R E P A R T D U P D AT E

A publication of the National Kidney

Foundation

Vol 14, No 4Fall 2005

NEXT ISSUE15th Anniversary Issue

Continued on page 2

HEART DISEASE IS A MAJORPUBLIC HEALTH PROBLEMIN THE GENERAL POPULA-

TION, but it occurs in a much higherpercentage and much earlier in life forpeople on dialysis. Although it has beenwell-known that individuals on dialysis

have had problems with heart disease,it was only recently realized that heartdisease and related health problems arethe cause of death for about half of allpeople on dialysis. In fact, heart diseaseis the leading cause of death in peoplewith chronic kidney disease (CKD).

The NKF has writ-ten and published atotal of 16 guide-lines on a variety ofmedical issues relat-ed to chronic kidneydisease, includingcardiovascular dis-ease. Here, NadineFerguson of ourPrograms Divisiondiscusses the KDOQIGuidelines at arecent annualClinical Meetings.

MANY PEOPLE MAYNOT KNOW THAT

THERE IS A STRONG RELA-TIONSHIP between cardiovas-cular disease (CVD) andchronic kidney disease (CKD)and that those with CKD maybe at higher risk for develop-ing CVD. This issue of FamilyFocus not only hopes to edu-cate you about CVD and whythose with CKD need to knowabout it, but also what you cando to be “heart healthy.”

This issue marks the last onefor the 2005 Family FocusEditorial Board. A great deal ofthought, planning, time andeffort goes into making eachissue of this newspaper thebest we believe it can be.

Family Focuswould not bepossible with-out the greatefforts of theNationalKidneyFoundationstaff and thevolunteerswho make upthe EditorialBoard. As theeditor of Family Focus, I wantto acknowledge and thankeach of them. This year we arelosing several dedicated indi-viduals who have graciouslydonated their time and expert-ise to Family Focus over thepast several years. PedroRecalde, Fitness Editor,

BobbieKnotek,NursingEditor, andRobertaBachelder,End StageKidneyDiseaseNetwork rep-resentative,will be leav-ing us. They

and their contributions will begreatly missed.

By the time you receive thisissue of Family Focus, the newEditorial Board will have metto plan the next four issues for2006. I can assure you that

while it may be a new yearand the Editorial Board mayhave some new faces, somethings will remain unchanged.We will continue to strive tobring you what we believe tobe the most relevant andimportant information youwill need to be an informedconsumer and effective advo-cate for your own health care.We also want Family Focusto remain YOUR newspaper.To help us accomplish this, it is important that you con-tinue to allow us to hear from you.

Karren King, MSW, ACSW, LCSW

For the Editorial Board

2 FAMILY FOCUS • Volume 14, Number 4

F R O M T H E E D I T O R

Karren King

Clinical Practice Guidelines…Continued from page 1

and diabetes is a disease which, over time, leads to blood vesseldamage and can cause heart disease even without kidney fail-ure. In fact, having both kidney failure and diabetes is a majorreason why there is so much vessel damage in people who arebeginning dialysis treatment.

Because of the very common, severe blood vessel disease in peo-ple on dialysis, the National Kidney Foundation (NKF) recentlystarted a project to give doctors and other health care providersclinical practice guidelines for the treatment of cardiovascular(heart and blood vessel) disease in people on dialysis. The NKFhas written and published a total of 16 guidelines on a variety ofmedical issues related to CKD, including cardiovascular disease(CVD). Each of these 16 guidelines follows a specific format:they are the result of a complete review of the medical literatureon each subject, followed by a discussion among kidney diseaseand other experts on the best way to diagnose and treat eachspecific medical problem. The guidelines on cardiovascular dis-ease were written by 19 kidney care and other experts fromaround the world, and were published in the April 2005 supple-ment of the American Journal of Kidney Diseases.

It is hoped that the cardiovascular disease guidelines will givedoctors and other health care providers a practical, up-to-datesummary of the best treatment for people on dialysis. Fromtheir review of the literature that exists, the experts learnedthat there is a great need for more research and studies in thearea of the care and treatment of people on dialysis.

For more information on the guidelines, visit www.kdoqi.org.

William Henrich, MD is Chairman of Medicine at the Universityof Maryland School of Medicine. Dr. Henrich and Dr. Alfred K.Cheung, MD were co-chairs of the NKF Clinical PracticeGuidelines for Cardiovascular Disease in Dialysis Patients.

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NKF Family Focus is published quarterlyby the National Kidney Foundation.

Opinions expressed in this newspaper donot necessarily represent the position of

the National Kidney Foundation.

FAMILY FOCUS • Volume 14, Number 4 3

Y O U R C H I L D A N D Y O U

HEART DISEASE AFFECTS MIL-

LIONS IN THEUNITED STATESEACH YEAR. Commonin older adults, heartdisease especially affectsthose with many risk fac-tors such as obesity, highblood pressure and dia-betes. We are used to theidea that our grandpar-ents may have heart disease, but not our chil-dren. It has now beenshown, however, thatchildren can also haveheart disease, especiallythose with chronic kid-ney disease (CKD).Research shows that thenumber of children withCKD admitted to thehospital for heart failureis rising in the U.S.[1].Also, children, adoles-cents and young adultswith CKD may have ashorter life span due toheart disease[2].

Heart disease can pres-ent itself in children inmany different ways,such as hardening of thearteries, heart failure orabnormal heartrhythms[3]. Childrenwith CKD who are atthe highest risk fordeveloping heart diseaseare those on dialysiscompared to transplantrecipients, and AfricanAmerican children more than Caucasianchildren[2].

The most common car-diac risk factors whichcan lead to heart diseasein children with CKDinclude hypertension(high blood pressure),high cholesterol, obesityand too much fluid in thebody[3]. These cardiacrisk factors are very com-mon and hypertensioncan occur in over 75 per-cent of children with kid-ney disease[3]. In

addition, calcium andphosphorus, which areregulated by diet anddialysis, may build up inthe body and contributeto hardening of the arter-ies, especially for thosechildren on dialysis.Inflammation, infectionand malnutrition arealso cardiac risk factorsamong people with CKDand could speed up theprogression of heart dis-ease. However, moreresearch is needed tounderstand how thesecontribute to cardiovas-cular disease in children.

In order to manage car-diac risk factors andcheck for early signs ofheart disease, it isimportant for children tobe screened early andoften during their timeon dialysis and aftertransplantation. In chil-dren with CKD, the goalshould be to prevent theonset of heart disease.The National KidneyFoundation's KDOQIGuidelines recommendscreening children withkidney disease for heartdisease not less than

once a year(see tablebelow) [4].Risk fac-tors suchas bloodpressureand weightshould becheckedclosely on

a regularbasis at clin-ic visits. Foradolescents

on dialysis or with atransplant (Stage 5CKD), a lipid (choles-terol) panel should bedone during the firstvisit with a doctor, at twoto three months after achange in treatmentsuch as going from dialy-sis to transplant or fromhemodialysis to peri-toneal dialysis and atleast once a year[4]. Acholesterol panel checksthe blood for levels ofgood or bad cholesterol.It is usually done after aperiod of fasting of atleast eight hours; in chil-dren, however, screeningcholesterol panels do nothave to be done whilefasting. Imaging theheart by echocardiog-raphy for damagerelated to high bloodpressure or fluidoverload is also rec-ommended once ayear in children withhigh blood pressure[5]. Echocardiogra-phy is a non-invasivetest which usesultrasound to studythe heart. As manyas 70 percent of chil-

dren starting dialysishave some thickenedheart muscle, which maybe due to uncontrolledhigh blood pressure andtoo much fluid.Electrocardiograms(ECGs) are not done reg-ularly in children sincethese tests are not sensi-tive enough to see thethickened heart muscle[6, 7]. Other methods ofdetecting hardening ofthe arteries in childrenare not usually availableat this time.

Children with CKD areat risk for heart disease.It is important that par-ents and children under-stand the long-term riskand work with theirnephrologists (kidneydoctors) to prevent it.

1. Chavers, B.M., et al.,Cardiovascular disease in pediatric chronic dial-ysis patients. Kidney International, 2002.62(2): p. 648-53.

2. Parekh, R.S., et al.,Cardiovascular mortalityin children and youngadults with end-stage

kidney disease. Journalof Pediatrics, 2002.141(2): p. 191-7.

3. Parekh, R.S. and S.S.Gidding, Cardiovascularcomplications in pedi-atric end-stage renal disease. PediatricNephrology, 2005. 20(2):p. 125-31.

4. National KidneyFoundation: KDOQIClinical Practice Guide-lines for ManagingDyslipidemias inChronic Kidney Disease.Am J Kidney Dis, 2003.41((suppl 3)): p. S1-S92.

5. KDOQI Clinical PracticeGuidelines for Cardio-vascular Disease inDialysis Patients. Am JKidney Dis, 2005. 45(4Suppl 3): p. S1-153.

6. Mitsnefes, M.M., et al.,Changes in left ventricu-lar mass in children andadolescents duringchronic dialysis.Pediatric Nephrology,2001. 16(4): p. 318-23.

7. Mitsnefes, M.M., et al.,Severe left ventricularhypertrophy in pediatricdialysis: prevalence andpredictors. PediatricNephrology, 2000. 14(10-11): p. 898-902.

Rulan Parekh, MD, MSis an Assistant Professorof Pediatrics andInternal Medicine atJohns HopkinsUniversity. She is cur-rently a member of the National KidneyFoundation KDOQIAdvisory Board.

Heart Disease in Children With Chronic Kidney Disease

By Rulan Parekh, MD, MS

Like adults, children with CKD are also at risk for developing heart disease.

It has now been shown… that children can also have heart disease, especially those with chronic kidney

disease (CKD).

RISK FACTORS ASSESSMENT THERAPY

BLOOD PRESSURE

Clinic blood pres-sure measurement

Medications Annual echocardiagramAchieving dry

weight if applicable

CHOLESTEROLFasting lipid profile

yearly

Diet modificationExerciseMedications

TOBACCO USE History of use in older children

Smoking cessation programs

OBESITY

Clinic weight and height

Calculate Body Mass Index (kg/m2)

Diet modificationExerciseWeight loss programs

FAMILY HISTORYEarly heart

attack/stroke less than age 50

Monitor cardiovas-cular risk factors closely


T R A N S P L A N T A T I O N

GETTING A KIDNEYTRANSPLANT CAN

GREATLY IMPROVE THEQUALITY OF LIFE FOR PEO-PLE WITH KIDNEY FAIL-URE. However, it is importantthat any problems with thecardiovascular system befound and treated before a kidney transplant operation.The operation is demandingand can place stress on theheart and blood vessels (car-diovascular system).

Many people ask, “What kindof cardiovascular check-up isnecessary before I receive mykidney?” The process startswhen you have your kidneytransplant evaluation. You willmeet with the transplant doc-tor for a medical history andphysical examination. As partof the complete history takingprocess, the transplant doctorwill ask questions about yourexercise abilities, such aswalking or climbing stairs.During the examination, thedoctor will feel for a pulse indifferent parts of your bodyand listen to your heart. Ifabnormalities are found, addi-tional tests may be needed.

More advanced cardiovasculartests are often done before getting approval for a kidney

transplant. These tests focuson either the heart or theblood vessels.

The heart, a muscular organwhich pumps blood to theentire body, can be tested in avariety of ways. The strengthof the heart muscle and thefunction of the heart valvescan be seen with ultrasound(called an echocardiogram).Several methods can be usedto study the blood flow to theheart, which is importantbecause blood delivers the oxy-gen and nutrients the heartneeds to pump effectively. Apopular method called amyocardial perfusion scan usesa radioactive dye that canshow if blood flows normally tothe entire heart and gets intothe muscle cells. Another way,called a cardiac angiogram,involves the direct injection ofdye into the arteries supplyingthe heart and watching if theblood flows well to all the right areas.

A kidney transplant must beconnected directly to one of themajor blood vessels in the bodyin order to function. It is there-fore very important to makesure that your blood vesselsare healthy before the opera-tion. Like the blood vessels tothe heart, the blood vessels tothe body can be tested in avariety of ways. The simplestway is through ultrasound, inwhich the blood flow to thearms and legs can be seendirectly. More advanced testsinvolve the use of special dyesand imaging equipment, suchas a CT angiogram or MRangiogram. These specialimaging examinations willhelp the transplant teamdetermine how healthy yourblood vessels are prior to atransplant.

Typically, most people willneed several cardiovasculartests before receiving approvalfor a kidney transplant. People

with a history of cardiovascu-lar disease, such as prior heartattack or bypass operation,will usually need the mosttesting.

A common question is: “Canthe cardiovascular tests dis-qualify me from getting a kid-ney transplant?” The answer isyes, because of the demandingnature of the kidney trans-plant operation. The trans-plant center is responsible forensuring the safety of all indi-viduals receiving a kidneytransplant. In some peoplewith severe cardiovascular dis-ease, a kidney transplant oper-ation may seem too risky.

The risk of developing cardio-vascular disease after a kidneytransplant is higher than inthe general population.However, compared with peo-ple on dialysis, the risk islower. It is very important tokeep good exercise habits, con-trol blood pressure and avoidsmoking after transplantation.

Dr. Benjamin Fritz, M.D. is atransplant nephrologist at theNorthern California KidneyTransplant Center in SantaRosa, California.

KIDNEY TRANSPLANTATION:A Matter of the Heart

By Benjamin Fritz, MD

Good heart health is important when planning for a transplant.

THE NATIONAL KIDNEY FOUNDATION (NKF) UNVEILED A NEW BRAND IDENTITY in August designed tounify the organization's signature programs and communications with one single, strong image. This new identityhighlights the National Kidney Foundation's role as a leader in promoting kidney health while communicating the

interconnectedness of our programs, our Affiliates, our volunteers and our staff. The new logo createsa consistent brand family, which will build greater awareness and recognition among patients, profes-sionals and the public of the mission and vision of the NKF.

The new logo's main graphic, a series of interlocking kidneys, immediately communicates theFoundation's dominant purpose, kidney health, as well as the interdependence of the

various NKF components. The logo's red and orange color scheme connotes a dynamic organizationfilled with vitality, life and warmth.

With this new brand identity, the NKF will increase the recognition of all its sub-branded pro-grams, such as the Kidney Walk, Kidney Cars, Kidney Early Evaluation Program (KEEP), KidneyLearning System (KLS) and Kidney Disease Outcomes Quality Initiative (KDOQI), which areinstrumental in helping achieve the NKF's mission and improve outcomes for the 20 million adultsin the United States with chronic kidney disease.

NKF LAUNCHES NEW BRANDING SYSTEM


N K F R E S E A R C H

MANY PEOPLE WITH KIDNEY FAILURE WHO

ARE ON DIALYSIS HAVE AHIGHER RISK OF HEART ANDBLOOD VESSEL (cardiovascu-lar) disease than the generalpopulation. The recipient of anNational Kidney FoundationYoung Investigator Grant,Kamyar Kalantar-Zadeh, MD,PhD, MPH, has been studyingthe risk factors for cardiovascular diseasein people on dialysis in order to find moreeffective ways to improve outcomes inthese individuals.

In the general population, the risk factorsfor cardiovascular disease include smok-ing, diabetes, high serum cholesterol, highblood pressure and obesity. Some of theserisk factors are common in people on dial-ysis. However, according to Dr Kalantar-Zadeh, many studies have failed to findany link between these risk factors andthe higher risk of dying for people on dial-ysis. For example, a recent study (calledthe 4D Study) did not show any survivalbenefit of lowering cholesterol in 1,200people with diabetes who were on dialysisand received a medication that effectivelylowered their serum cholesterol for up tofive years.

“Many observational studies of dialysispatients have reported findings that differfrom those in the general population,” Dr.Kalantar-Zadeh says. For example, peopleon dialysis who are obese appear to livelonger than those who are underweight.Similarly, those on dialysis with lowserum cholesterol levels appear to have ahigher risk of death. More surprising arestudies that have shown greater survivalin people on hemodialysis with higher

blood pressure values, Dr. Kalantar-Zadeh adds. Similar contradictory rela-tionships or those that disagree with eachother, have also been seen in individualswith heart failure, cancer or AIDS. Someresearchers have referred to these rela-tionships, that contradict each other as

“reverse epidemiology,” since they havebeen reported mostly in epidemiologic(observational) studies, he points out.

Seeing such contradictory relationshipsbetween known cardiovascular risk fac-tors and survival in people on dialysis hascaused confusion among both doctors andpatients. However, Dr. Kalantar-Zadehsays that these findings do not necessarilymean that raising blood pressure orserum cholesterol would improve survivalin those on dialysis.

Dr. Kalantar-Zadeh has been studying thepatient database of a large dialysis chainacross the nation to look at the causesand effects of reverse epidemiology. “By

doing so,” he says, “we hope to learn thecauses of the high death rate in people ondialysis, so that better treatments can bedeveloped to improve survival.

“We think nutritional factors or inflam-mation may play an important role in cre-ating these unusual conflicts in

individuals on dialysis,” Dr.Kalantar-Zadeh adds. Manystudies have shown that in peo-ple on dialysis, other factors helpto predict poor survival, such asanemia, high serum phosphorusor calcium levels, malnutritionand inflammation. Fortunately,some of these risk factors, such as

anemia or high phosphorus and calcium,can be effectively treated.

“More studies are needed to find ways toimprove nutritional status or to correctinflammation and to study whether suchinterventions can improve survival in peo-ple on dialysis,” says Dr. Kalantar-Zadeh.

Dr. Kamyar Kalantar-Zadeh is the recipi-ent of an NKF Young Investigator Grant.He is an associate professor of medicine inthe Division of Nephrology and Hyperten-sion at Harbor-UCLA Medical Center inTorrance, CA, and also directs theirDialysis Expansion Program andEpidemiology.

NKF Young Investigator Seeks Better Understanding

By Kamyar Kalantar-Zadeh, MD, PhD, MPH

A young doctor continues his search for risk factors for heart disease in

people on dialysis.

“In the general population, the risk factors for cardiovas-cular disease include smoking, diabetes, high serum

cholesterol, high blood pressure and obesity.”

Kamyar Kalantar-Zadeh, MD


T A K E T H II S Q U I Z !

1. True or False: Part of your heart lies under the flat breastbone inthe middle of your chest.

2. The adult heart is about the size of a fist and weighs: (choose one)a) less than a poundb) about two and a half poundsc) five poundsd) eight pounds

3. At rest, how much blood does the heart pump through the body?(choose one)

a) two cups of blood every minuteb) five quarts of blood every minutec) 12 quarts of blood every minuted) 20 quarts of blood every hour

4. Did you know your heart is a muscle? It is called the: (choose one)a) quadriceps muscleb) myocardiumc) triceps muscled) biceps muscle

5. Your heart muscle is different than other muscles in the bodybecause it: (choose one)

a) has to have a constant supply of oxygen to stay healthyb) is the only muscle that can go without oxygen for

short periods of timec) gets a new supply of oxygen every five minutesd) does not need oxygen

6. The heart pumps blood around the body through small tubescalled: (choose one)

a) lymph nodesb) arteries and veinsc) spinal fluidd) the peritoneal cavity

7. Which blood vessels deliver oxygen rich blood to the heart muscle?:(choose one)

a) carotid arteriesb) femoral veinsc) coronary arteriesd) pulmonary arteries

8. The inside of your heart is divided into _______ spaces calledchambers. These chambers, separated by tissue walls, keep lowoxygen blood (from your body) and high oxygen blood (from yourlungs) from mixing. (choose one)

a) twob) threec) fourd) five

11. True or False: The heart pumps blood to your spleen where it “picks up” fresh oxygen for your body.

12. True or False: The large blood vessels that send oxygen-filled bloodto your heart muscle are called carotid arteries.

13. When the blood vessels carrying blood to the heart muscle getpartly or completely blocked off, the heart gives these “warningsigns” that it is not getting enough oxygen: (choose one)

a) chest pain (also called angina)b) pain that moves up the neck to the headc) left arm paind) all of the above

14. When a blood vessel that carries blood to the heart musclebecomes totally blocked, that section of heart muscle tissue “dies.”When heart muscle tissue “dies,” this is called a: (choose one)

a) strokeb) seizurec) heart attacke) pulmonary embolism

15. Your blood moves through the heart's chambers through four one-way “doors,” called ____________. These one-way doors controlwhere and when the blood can go as it moves through the chambers of the heart. (choose one)

a) capillariesb) valvesc) arteriesd) veins

16. True or False: A small, electric current passes through specialnerves and tissue in the heart every few seconds “telling” theheart when to contract (beat).

17. Coronary heart disease (also called coronary artery disease, CADand coronary atherosclerosis) happens when: (choose one)

a) cholesterol and fats “clog up” the arteries of the heartb) the blood gets too thinc) the heart beats too fastd) the heart beats too slow

18. True or False: Nearly 13 million people in the United States havesome form of coronary artery disease.

19. True or False: People who smoke are three times more likely to getheart disease and 3,000 times more likely to get lung cancer.

20. Heart attacks are dangerous because they can: (choose one)a) damage muscles that keep one-way doors (valves) between

the heart's chambers closedb) make the heart too weak to effectively pump blood to

the bodyc) “short circuit” the heart's electrical system, causing random,

out-of-pattern heart beatsd) all of the above

ARE

YOU HEART

SMART?

By Bobbie Knotek, RN, BSN

ALTHOUGH THE HEART IS ONE OF THE MOST IMPORTANTorgans in the body, many of us take our heart for granted. We smoke, eat the wrong foods and feel we are too busy to exer-

cise. Often, it takes chest pain, shortness of breath or a heart attack tomake us start taking better care of the only heart we will ever have.

Do not be one of those people who waits for heart problems to begin.Start taking better care of your heart today! You can start by takingthe quiz listed below. Then read the other articles in this newspaperfor ideas on how you can take better care of your heart.

See answers on page 15


G E T T I N G T H E W O R D O U T

THE CENTERS FORDISEASE CONTROLAND PREVENTION

(CDC) HAS MADE CARDIO-VASCULAR DISEASE (CVD)ONE OF ITS PUBLIC EDUCA-TION PRIORITIES. The CDChas targeted CVD, commonlycalled heart disease, as one ofthe nation's leading “killers” in2005. An alarming one fourth(70 million) of all Americanslive with CVD. In addition, theCDC reports that the two great-est causes of CVD are uncon-trolled high blood pressure anduncontrolled high blood choles-terol, or too much cholesterol inyour blood. Did you know that:

People with chronic kidney dis-ease (CKD) are among thehighest risk groups for heartdisease due to the fact thathigh blood pressure, diabetesand high blood cholesterol arecommon in that population.There may be other lifestylerisk factors in some of theCKD population such as smok-ing, physical inactivity, obesityand poor nutrition.

Here is what people with CKDcan do to lower their risks foradvanced heart disease and thepossibility of stroke according tothe CDC guidelines:

The National Institutes forHealth (NIH) has a quickchecklist of the signs that aheart attack may be coming.Knowing the signs andsymptoms of a heart attackcan help save a life.

✓ CHEST DISCOMFORT.Most heart attacks involvediscomfort in the center ofthe chest that lasts for morethan a few minutes, or goesaway and comes back. Thediscomfort can feel likeuncomfortable pressure,squeezing, fullness or pain.

✓ DISCOMFORT IN OTHERAREAS of the upper body.This can include pain or discomfort in one or botharms, the back, neck, jaw orstomach.

✓ SHORTNESS OF BREATH.This often comes along withchest discomfort. But it alsocan occur before chest dis-comfort.

✓ OTHER SYMPTOMS. Thesemay include breaking out in a cold sweat, nausea orlightheadedness.

For more information aboutprevention of CVD, heart dis-ease and stroke you can visitthese Web sites:

■ National Kidney Foundation www.kidney.org

■ National Institutes of Health www.nhlbi.nih.gov

■ Centers for Disease Control www.cdc.gov

■ Forum of ESRD (End-Stage Renal Disease) Networks www.esrdnetworks.org

Centers for Disease Control Takes AimAt Cardiovascular Disease

By Roberta Bachelder, MA

The CDC educates the public on cardiovasculardisease, its signs and symptoms.

More than 30 percent of adults in the UnitedStates have high bloodpressure.

■

More that 31 percentof adults in the U.S.have pre-high blood pressure (or whenone's blood pressuremeasures 120/80 to139/89).

■

Lowering high blood pressure by 12–13 points can reduce the risk of heart attack, stroke and death.

■

80 percent of people diagnosed with highblood cholesterol do not control it through diet and medicine.

■

People can lower theirrisk for CVD by controlling high blood pressure and high blood cholesterol levels.

■

A class of drugs calledstatins can lower deaths from heart disease by reducing cholesterol levels; medications that lower blood pressure levels can reduce the risk for strokes, heart disease and other heart problems such as heart attacks.

■

People with CKD may take beta blockers. Beta blockers are medications that slow down the nerve impulses that travel through the heart. As a result, the resting heart rate is lower, the heart does not have to work as hard and the heart requires less blood and oxygen. If a beta blocker is taken within days or weeks of a heart attack, people have a better chance of survival.

People need to learn about the signs and symptoms of heart attacks and stroke and the importance of calling 911 quickly.

■

■

Family Focus is available on the Web.

To find this issue or back issues of the newspaper go to

www.readfamilyfocus.org

People can lower

their risk for CVD

by controlling high

blood pressure and

high blood

cholesterol levels.


P A T I E N T A N D F A M I L Y C O R N E R

Continued on page 11

THE MANY HEALTHCHALLENGES THATWE ALL FACE DUR-

ING OUR LIFETIMES CANBE EVEN MORE SERIOUSFOR PEOPLE WITHCHRONIC KIDNEY DIS-EASE (CKD). In the general

population, people age 60, onaverage, live an additional21.9 years. People on dialysisbetween the ages of 60-64live, on average, an additional4.3 years; and transplantrecipients ages 60-64 canexpect to live, on average, anadditional 11.8 years. [1]These are only averages, andif you are reading this, youare not likely to be “average.” Some form of heart disease,such as heart attacks orstrokes, is the major cause ofdeath in the United States forthose with normal kidneyfunction. But heart disease isalso the major cause of deathamong those with CKD, espe-cially people who are on dial-ysis. Individuals with CKDhave heart failure and heartattacks more often than thosewith normal kidney function.For example, according to theUnited States Renal DataSystem (USRDS) 2004Annual Data Report, about 10percent of people who haveMedicare may experienceheart failure, compared with40 percent of those with CKD,and about 70 percent of indi-viduals on dialysis (seven

times more thanindividuals withMedicare who do nothave CKD!) [2]Therefore, the risksof dying from heartdisease are not onlygreater for peoplewith CKD, but deathusually comes atmuch younger ages,when compared withpeople who havenormal working kid-neys.[1]

The major risks of heart dis-ease for anyone are well-known:

� high blood pressure � excessive weight (obesity) � smoking � no regular physical

exercise � stress

People on dialysis have added risks:

� gaining too much weightfrom fluids between dialysistreatments (causing theheart to work harder topump more fluid) has beenshown to raise the risk ofdeath by 12 percent [3]

� taking off too much fluidweight during the firsthemodialysis treatment ofeach week (quickly loweringthe volume the heart hasbeen pumping) has beenlinked with some reporteddeaths on Mondays andTuesdays. [4]

� high blood levels of potassi-um from eating or drinkingtoo many high potassiumfoods and/or liquids (highblood levels of potassium

cause severe muscle weak-ness, and the heart is onebig muscle)

� high blood sodium levelsfrom eating too many highsodium or salty foodsincreases thirst and bloodpressure

This is not news. All of usknow high blood pressure,smoking, weighing too much,lack of regular exercise andstress are huge risk factorsfor heart disease—but all ofus do not necessarily do any-thing on a regular basis tolower those risks. Some of uswho began hemodialysis inthe 1960s, 70s and 80s want-ed to feel stronger and count-er the challenges to the heartthat go along with CKD. Ournephrologists (kidney doctors)gave us referrals for Medicarecovered physical therapyevaluations to begin regularexercise for heart condition-ing, muscle strengthening

and stretching; in some cases,we meditated for relaxationand to lower stress levels.Some of us tried yoga, TaiChi, gardening, walking, ten-nis and swimming—whateverwe enjoyed, with a doctor'sapproval. We had “forwardthinking” kidney dietitianswho suggested we work onlimiting potassium and sodi-um intake. We expect andhope many others who begandialysis since 1990 have expe-rienced good heart healthynutritional counseling fromdietitians and physical thera-py referrals from nephrolo-gists, and have tried many ofthese activities to lower risksof heart disease.

Think of the many lifestylechanges you have madeadjusting to and coping withkidney failure. Now you haveto deal with the added newsof the high risk of heart dis-ease. However, you have thechance to begin (or continuewith) a heart healthylifestyle, which includesweight loss, no smoking, bet-ter food and fluid monitoring,low saturated fat intake, reg-ular exercise and stress relieftechniques—all under yourdoctor's guidance.

You Can Lower Your Risk of Heart Disease

By John M. Newmann, PhD, MPH

Adopting a heart healthy lifestyle is good for the heart and the kidneys.


“Individuals with CKDhave heart failure andheart attacks moreoften than those

with normal kid-ney func-

tion.”

You have the chance to begin a heart healthylifestyle, which includes regular exercise and

stress relief techniques.


T H E B O D Y A N D T H E M I N D

IT IS NOT UNUSUALFOR PEOPLE WITHCHRONIC KIDNEY DIS-

EASE (CKD) TO EXPERI-ENCE VARIOUS MOODSWHEN DEALING WITHTHEIR ILLNESS. Researchshows that 30 to 50 percent ofthe dialysis population experi-ences depression. [1] Onestudy found that 1/4 of theirdialysis population had symp-toms of depression and 50percent of those individualswere experiencing depressionthat was clinically significant,meaning it was severe enoughto affect such things as sleep-ing and eating habits.[2]Although everyone becomesdepressed at times, those ondialysis have been shown tohave more depression thanpeople who are not on dialysis.[3]

People on dialysis also have ahigher rate of anxiety thanindividuals not on dialysis.[3]Almost half of the people ondialysis in one study had anx-iety. [2] Research has alsoshown that people on dialysisnot only experience hostilitybut, once again, also experi-ence it more often than thosewho are not on dialysis.[4, 5]

So what does all of this have todo with cardiovascular disease(CVD)? Although there is noresearch linking these emo-tions with CVD in the dialysispopulation, there is ample evi-dence showing a positive rela-tionship between each of theseemotions and CVD in the gen-eral population.

Research has shown thatwhen people experiencedepression they are not onlyat higher risk for developingCVD, but if they already havecardiac disease they are morelikely to have cardiac compli-cations such as a heart attackor needing coronary arterybypass surgery. [6, 7, 8]People who were depressed

were also much more likely todie from CVD.[8] There havebeen similar findings for anxi-ety and hostility. Researchdocuments that anxiety notonly contributes to the devel-

opment of CVD but as anxietylevels rise, symptoms of car-diac disease may worsen.[7, 9]If individuals have bothdepression and anxiety theircardiac risk is even higherthan if they experienced onlyone of these moods.[7]Hostility has been shown notonly to contribute to develop-ing CVD but also to increasethe likelihood of dying fromcardiac causes.[10, 8]

There are a variety of reasonsthat depression, anxiety orhostility may be associatedwith CVD. It is possible thatpeople who experience thesemoods may be more likely notto follow their dialysis ordietary prescriptions andthat, in turn, may negativelyaffect their cardiovascular(CV) functioning. People mayalso be more likely to engage

in high-risk behaviors, suchas smoking, if they are experi-encing these emotions, andsuch behaviors may have anegative impact on CV health.However, there are also manyphysiological effects whichcould have an impact on CVhealth when experiencingthese emotions.[6, 7, 8]

The good news is that if youare feeling depressed, anxiousor hostile there are thingsthat can help. The first is toassess whether you arereceiving enough dialysis andif your anemia is under con-trol, as both of these canaffect your quality of life and,

consequently, your mood.Also, ask your physician toevaluate your physical healthand review your medicationsto assure that neither is con-tributing to how you feel.

Assuring there is supportfrom family or friends canlower your risk of depressionas well as having cardiac dis-ease.[7] If this support is lack-ing, talk to your social workerto explore other ways toimprove your support net-work. Group counseling thatfocuses on ways to decreasehostility has been found to besuccessful not only in actuallyreducing that emotion butalso in reducing cardiacdeaths.[7] Therapy focusingon one's thoughts and behav-iors has been shown to beeffective in lowering depres-sion and anxiety, as well ashigh blood pressure, which

can contribute to death fromCVD.[11] Relaxation tech-niques, including biofeedback,controlled breathing and sim-ple relaxation exercises, havebeen found to have positiveeffects on CV health.[12, 7, 13]People with chronic kidney dis-ease (CKD) who were educatedabout their illness prior tobeginning dialysis were foundto have improved moods, andthese positive effects remainedfor the first six months afterdialysis began.[14] If dialysis isin your future, this is yetanother reason to make sureyou learn about CKD!Medication to treat depressionor anxiety may also be consid-ered, especially if you have notresponded to other types oftreatment. Research hasshown that those with CKDcan benefit psychologicallyfrom medication treatment.[15]

Remember that while experi-encing depression, anxiety or

hostility may be normal, theseemotions can have harmfuleffects on your physicalhealth in addition to makingyou feel bad emotionally.There is help available to you.Do not be afraid to look for it.

REFERENCES:

1. Kimmel PL, Weihs K, PetersonRA: Survival in hemodialysispatients: the role of depression.J Am Soc Nephrol 4:12-27, 1993.

2. Kutner NG, Fair PL, KutnerMH: Assessing depression andanxiety in chronic dialysispatients. J Psychom Res 29:23-31, 1985.

3. Livesley WJ: Symptoms of anxi-ety and depression in patientsundergoing chronic haemodialy-sis. J Psychom Res 26:581-584,1982.

4. Fava M, Serafini E, DeBesi L,Adami A, Mastrogiacomo I:Hyperproilactinemia and psy-chological distress in womenundergoing chronic hemodialy-sis. Psychother Psychosom49L6-9, 1988.

Em☺ti�ns and Your He��rt:Is There a Connection?By Karren King, MSW, ACSW, LCSW

Research has shown there is a link betweenthe physical body and one’s emotions.

“Assuring there is support from family or friends can loweryour risk of depression as well as having cardiac disease.”



AS YOU LEARNED FROM OTHER ARTICLES IN

THIS ISSUE of Family Focus,people with chronic kidney dis-ease (CKD) are prone to heartand blood vessel problems,including high blood pressure.This might have something todo with unhealthy personalhabits such as tobacco use andphysical inactivity, which havebeen linked with these illnessesin the past, or there might besome unique things about peo-ple with CKD that makes themmore at risk for cardiovasculardisease.

The federal government is fund-ing research through theNational Institute of Diabetesand Digestive Diseases(NIDDK) to help us betterunderstand the relationshipbetween CKD and heart dis-ease. A description of a few ofthese studies follows:

NIDDK started theChronic Renal

Insufficiency Cohort (CRIC)Study to find out about risk fac-tors for a decline in kidney func-tion and the development ofcardiovascular disease. TheCRIC study involves 3,000 peo-ple, ages 21 to 74, with mild tomoderate CKD. Participants arebeing selected so that the groupwill be racially and ethnicallydiverse (40 percent white/Caucasian, 40 percent AfricanAmerican and 20 percent fromother ethnicities), and abouthalf of the study participantswill have diabetes. CRIC willtake seven years to complete,during which changes in thehealth of the participants willbe monitored. The study willlook at the genetic, environmen-tal, behavioral and nutritionalfactors in these populations. Itwill also look at health careissues and quality of life. Thefollowing tools will be utilized toassess quality of life: BeckDepression Inventory, KidneyDisease and QOL (Quality ofLife), Mini Mental State Examand Symptoms List.

All study participants will havea cardiogram at year one andyear four of follow-up to docu-ment changes in heart function.The study began in April 2003at seven clinical centers:University of Pennsylvania,Philadelphia; University of

Maryland-Johns Hopkins,Baltimore; University of Illinoisat Chicago Clinical Centers;University of Michigan, AnnArbor; Kaiser Permanente ofNorthern California/Universityof California, San Francisco;Tulane University, NewOrleans; and Case WesternReserve University, Cleveland.The data-coordinating center isat the University ofPennsylvania.

The Folic Acid forVascular Outcome

Reduction in Transplantation(FAVORIT) project began inAugust 2001 and will endJanuary 31, 2006. This NIDDKstudy will explore whether ahigh-dose combination of folicacid, vitamin B12 and vitaminB6 will lower the rate of cardio-vascular disease among stablekidney transplant recipients. Inaddition to giving insights toimprove care for transplantrecipients, it is hoped that allpeople with CKD will benefitfrom this research since kidney

transplant recipients havemany of the same traits as peo-ple with cardiovascular diseaseand CKD. Recruitment forFAVORIT began in July 2002.Ultimately, 4,000 kidney trans-plant recipients will participatein the study.

Participating institutions areRhode Island Hospital;University of Iowa; AlbanyMedical Center; Cedars SinaiHealth System; DukeUniversity Medical Center;Hennepin County MedicalCenter (Minneapolis); IndianaUniversity; London (Ontario,Canada) Health SciencesCenter; Medical College ofWisconsin; Ohio StateUniversity; Oregon HealthSciences University; SUNYDownstate Medical Center;University of Alabama atBirmingham; University ofCalifornia at Los Angeles;University of California at San Francisco; University ofMaryland Medical Center;University of MichiganMedical Center; University of Toronto; University ofWisconsin; and WashingtonUniversity. The data-coordinat-ing center is at the Universityof North Carolina.

Continuation of the African

American Study of theKidney (AASK) In 1990, the NIDDK began astudy to learn about ways toslow the progression of CKDcaused by high blood pressurein African Americans. In 2001,as a result of the AASK study,an important discovery wasmade, namely that certain

types of medicines that controlhigh blood pressure are moreeffective than others for slowingkidney disease in AfricanAmericans. The main goal incontinuing the AASK Study isto study the environmental,social, economic, genetic, physi-ologic and other factors thataffect the progression of CKDrelated to high blood pressurein African Americans. For more information aboutthese studies and otherresearch supported by NIDDKthat could improve the healthand well-being of people withCKD, check the Internet atwww.clinicaltrials.gov.

A large amount of tax dollarsgoes into these studies, with thegoal of improving the healthand well-being of people withCKD. The cost of the researchdescribed in this article is $15million per year. That level ofsupport is especially significantin this era of budget tightening.Members of Congress need toknow how much the kidneycommunity appreciates thisresearch funding so that theywill continue to make resourcesavailable to study kidney dis-ease in the future.

Therefore, we encourage you towrite letters of thanks to yourmembers of Congress for theirsupport. Through the NationalKidney Foundation's PeopleLike Us patient empowermentinitiative, we are strengtheningthe voices of people with chronickidney disease and encouragingtheir involvement on public pol-icy and other issues affectingtheir health. In learning tobecome effective, proactivepatient advocates, People LikeUs members have begun to reg-ularly communicate and meetwith their elected officials. Formore information on contactingyour members of Congress, or tolearn more about People LikeUs patient advocacy activities,please e-mail [email protected].

The Federal Government Funds Studies on Heart Disease

and Chronic Kidney DiseaseBy Dolph Chianchiano, JD, MPH

In their ongoing support of those with CKD, the federal government tackles the

relationship between heart disease and CKD.

L E G I S L A T I V E U P D A T E

Dolph Chianchiano, JD, MPH1

2

3

THE NATIONAL KIDNEYFOUNDATION KDOQICLINICAL PRACTICEGUIDELINES FOR CARDIO-VASCULAR DISEASE (CVD)IN DIALYSIS PATIENTS werepublished in April 2005. TheGuidelines are just that—guidelines—and are recommen-dations for management of cer-tain conditions. They are notrequirements, but are consid-ered the best practice based onresearch evidence.

Guideline number 14 is entitled“Smoking, Physical Activity andPsychological Factors.” It iswell-known that traditional riskfactors for getting CVD, such asdiabetes, hypertension (highblood pressure) and high choles-terol are very common in peopleon dialysis and should be lookedat often and treated accordingto current recommendations. Inaddition to these usual medicalrisk factors, there are lifestylefactors, too, that are known toplay an important role in get-ting cardiovascular disease—specifically smoking, physicalinactivity and psychological fac-tors such as depression, anxietyand hostility. This article willfocus on the physical activityand smoking part of thisKDOQI Guideline and whatpeople on dialysis can do to

lower their lifestyle risk factorsto cut their overall cardiovascu-lar risk.

Cigarette smoking is known tobe a risk factor for CVD, andsmoking should be discouragedin people with CKD. This rec-ommendation is even moreimportant due to the relation-ship between smoking and pooroutcomes in people on dialysisand those with a transplant.

If you smoke, you need to stopsmoking. This is not easy to doand you may need extra helpwith it. If your smoking is nottalked about by your healthcare team, be sure to ask themfor information. If there is noinformation available from yourdialysis providers, then thereare many avenues to take.Make a commitment toyourself and your health toquit smoking. Then: 1)Contact your local office of theAmerican Lung Association orthe American Heart Associationand ask for information about

quitting smoking. These organi-zations have educational mate-rials and information aboutlocal smoking cessation pro-grams that may be helpful. 2)Enroll in a smoking cessationprogram. These programs pro-vide tips to help motivate andencourage you to quit smoking.There are many ways to quitand these programs can helpyou find the one that works bestfor you. 3) Talk to your doctorabout using over-the-counternicotine replacements such asnicotine patches, gum orlozenges. A nicotine nasal spray

or inhaler is also available byprescription. A non-nicotineoption is buprorion, which is anantidepressant medication thathas been shown to help peoplequit smoking.

Keep in mind that your doctormay be reluctant to

suggest these med-ications becausethere is very littleresearch availableabout the effects forpeople on dialysis.Nicotine may buildup in your systemwhen using the nico-tine replacementtherapies, so you mayneed to keep a care-ful eye on these lev-els. However, there

are people on dialysis who usethese medications and havebeen able to quit smoking.

Since you see your health careteam in the dialysis unit on aregular basis, you should nothesitate to ask them for supportin your efforts to quit smoking.Also, ask your family andfriends for support. If others inthe home are smokers, askthem to stop smoking in thehouse or in your presence—or ask them to quit with you.


HEALTHY LIFESTYLES: Important for Everyone

By Patricia Painter, PhD

Quitting smoking is part of adopting a heart healthy lifestyle.

K E E P I N G F I T

It is up to each of you to decide which sideof the statistics you want to be on: thelong-term survivors, who actively and con-sistently spend time and effort daily tolower heart disease risks; or the otherside, where individuals are not sure thatit makes a difference, or do not have thedrive to make new life saving/life enhanc-ing changes to their usual routines.Research has shown that heart healthychanges can improve your health status(for example, blood pressure, cholesteroland lipid lab tests), how you feel, your

strength, endurance and overall mood. Itis not too late to start now, no matterwhat your age!

REFERENCES:1. U.S. Renal Data System, USRDS 2004 Annual

Data Report, National Institutes of Health,National Institute of Diabetes and Digestiveand Kidney Diseases, Bethesda, MD, 2004;Figure 6.a: Expected remaining lifetimes(years) of the general U.S. population, 2001; ofprevalent dialysis patients, 2002; of prevalenttransplant patients, 2002. Interpreted by theauthor.

2. Ibid. Figure 9.1 Rates of heart failure, AMI, &cardiac arrest. Interpreted by the author.

3. Saran R, Bragg-Gresham J, Rayner H, et al:Nonadherence in Hemodialysis: Associationswith Mortality, Hospitalization, and PracticePatterns in the DOPPS, Kidney International64: 254-262, 2003.

4. Bleyer JB, Russell B, Satko SG: Sudden andcardiac death rates in hemodialysis patients.Kidney International 55:1553-1559, 1999.

John Newmann has had kidney diseasesince 1971 and received a transplant fromhis daughter in 1993, which he continuesto enjoy.

You Can Lower Your Risk…Continued from page 8

Make a commitment to yourself andyour health to quit smoking.



E A T I N G R I G H T

THE NATIONALKIDNEYFOUNDATION'S

KDOQI CLINICAL PRACTICEGUIDELINES FOR CARDIO-VASCULAR DISEASE INDIALYSIS PATIENTS are nowavailable for review. They werepublished in the April 2005Supplement to the AmericanJournal of Kidney Diseases [1].

These guidelines give informa-tion about evaluating andtreating cardiovascular (heart)diseases such as acute coro-nary syndromes, valvularheart disease and cardiomy-opathy. Guidelines for manag-ing cardiovascular risk factorssuch as smoking, physicalactivity and psychological fac-tors are also discussed.

Nutrition matters for peoplewith heart disease are complexand many sided. Recommen-dations for treating high bloodlipids (fats) and high bloodpressure are discussed in theNational Kidney Foundation

KDOQI Guidelines for dyslipi-demia [2] and hypertension. [3]Therefore, the new Clinical Practice Guidelines forCardiovascular Disease focusedon two key issues that had notbeen addressed: omega-3 fattyacids and an amino acid calledhomocysteine. Because expertsdisagree about how omega-3fatty acids or homocysteineaffect people with kidney fail-ure (CKD Stage 5), the infor-mation is more of a discussionrather than an actual guide-line or recommendation.

Fish oil is known to be asource of omega-3 fatty acidsand is recognized for its ability

to reduce inflammation and fora fat in the blood called triglyc-erides, which are often higherin people receiving dialysistreatment. Food sources foromega-3 fatty acids includeflaxseed oil, canola oil, walnuts and some leafy greens.

It is not known for sure if peo-ple with CKD Stage 5 benefitfrom having omega-3 fattyacids in their diets. However,because there is a largeamount of proof of the positiveeffect of omega-3 fatty acids onheart health, it is importantfor people on dialysis to beaware of the possible advan-tages of adding omega-3 fatty

acids to their diets. Be sure todiscuss your interest and con-cerns with your kidney dieti-tian and doctor. A sampling offood sources and content of theEPA and DHA fatty acids isshown in Table 1..

HOMOCYSTEINE ANDFOLIC ACIDHomocysteine is an amino acid.When homocysteine levels inthe blood are too high (called hyperhomocysteinemia), it hasbeen found to be a risk factorfor heart disease in the generalpopulation. Whether this is truefor people on dialysis isunknown. What has beenshown is that high levels ofhomocysteine can be lowered byfolic acid, a B vitamin. Whilehigh levels of homocysteine canbe lowered, they do not alwaysreturn to the normal range. It isnot clear if the decrease inhomocysteine blood levels thatoccurs by folic acid lowers therisk of heart disease.

Heart-Healthy Nutrition for Adults on Dialysis

By Jordi Goldstein-Fuchs, DSc, RD

Foods that are heart healthy for people withCKD include, among others, oil from many

kinds of fish.

AHA Guidelines for Omega-3Fatty Acids

Considerations for DialysisPatients

Patients without documentedCHD (Coronary Heart Disease):

Eat a variety of (preferably oily)fish at least twice per week. Includeoils and foods rich in alpha-linolenicacid (flaxseed, canola and soybeanoils; flaxseed and walnuts)

Patients with documented CHD:Consume approx. 1 gm EPA+DHAper day, preferably from oily fish.EPA+DHA supplements could beconsidered in consultation with thephysician.

Patients needing triglyceridelowering: Two to four grams ofEPA+DHA per day provided as cap-sules under a physician's care.

While the fish and oils can beincluded in the diet, the use of nuts,seeds and grains that are high inpotassium such as flaxseed and wal-nuts (see Table 2) will need to beavoided or used on a case by casebasis under supervision by an RDand MD. Patients who dislike fishcan consider taking a low dose ofeicosapentaenoic acid (EPA) anddocosahexanenoic acid (DHA) sup-plement, providing less than 1 gramper day. EPA and DHA are theomega-3 fatty acids that provideanti-inflammatory and lipid lower-ing properties.

Clinical bleeding is unusual indoses less than 2 grams. However,patient's bleeding times should bemonitored, especially if the patientis receiving anticoagulation therapy.

Bleeding times will need to be moni-tored as above. The patient'srequirement for antioxidants maybe increased and omega-3.

Table 2. EPA and DHA content of selected cold water fish. [1]

EPA+DHAContent, g/3-oz ServingFish (EdiblePortion) org/g Oil

AmountRequired toProvide≈1 gof EPA+DHAper Day, oz(Fish) or g(Oil)

FISHTuna

Light, canned in water, drainedWhite, canned in water, drainedFreshSardines

SalmonChumSockeyePinkChinookAtlantic, farmedAtlantic, wildMackerel

HerringPacificAtlantic

Trout, rainbowFarmedWildHalibut

CodPacificAtlanticHaddock

CatfishFarmedWildFlounder/Sole

0.260.730.24-1.280.98-1.70

0.680.681.091.481.09-1.830.9-1.560.34-1.57

1.811.71

0.980.840.4-1.0

0.130.240.2

0.150.20.42

1242.5-122-3

4.54.52.521.5-2.52-3.52-8.5

1.52

33.53-7.5

2312.515

20157


Table 1. American Heart Association Guidelines for theAmerican Population with Modifications for Considerationfor Individuals Receiving Kidney Replacement Therapy.


Heart Healthy Nutrition…Continued from page 12

Table 2. EPA and DHA content of selected cold waterfisH[1] Cont’d

EPA+DHAContent, g/3-oz ServingFish (EdiblePortion) org/g Oil

AmountRequired toProvide≈1 gof EPA+DHAper Day, oz(Fish) or g(Oil)

OysterPacificEasternFarmed

LobsterCrab, Alaskan KingShrimp, mixed speciesClamScallop

1.170.470.37

0.07-0.410.350.270.240.17

2.56.58

7.5-42.58.51112.517.5

Modified from: Kris-Etherton P, Harris W, Appel L: Fish consumption, fish oil,omega-3 fatty acids and cardiovascular disease. Circulation: 2002:106:2747-2757. NOTE: The intakes of fish given above are very rough estimates becauseoil content can vary markedly (>300%) with species, season, diet and packag-ing and cooking methods.

It is clear, however, that notenough folic acid in the diet—riboflavin (B2) pyridoxine (B6)and cobalamin (vitamin B12)—can raise homocysteine levels.Therefore, it is very importantthat people with CKD Stage 5take a vitamin supplement thatgives the recommended dietaryallowances (RDA) for each ofthese three nutrients. There aremany vitamin supplementsavailable for people with CKDthat have the nutrients youneed and leaves out those thatyou do not want to take, suchas fat soluble vitamin A. Askyour kidney dietitian and doc-tor which vitamin is best foryour overall health. This sup-plement should have at least 1mg of folic acid.

This is a complicated topic! Ifyou are interested in learningmore about omega-3 fatty acidsand homocysteine, be sure to

speak with your registered die-titian and nephrologist. Theycan best determine how toincorporate this informationinto your diet.

REFERENCES1. National Kidney Foundation. KDOQI

Clinical Practice Guidelines forCardiovascular Disease in DialysisPatients. Am J Kidney Dis 45:S1-S154, 2005 (suppl 3).

2. National Kidney Foundation KDOQIClinical Practice Guidelines forManaging Dyslipidemias in ChronicKidney Disease (2003a). Am J KidneyDis 41;s1-s91 (suppl 3).

3. National Kidney Foundation. KDOQIClinical Practice Guidelines onHypertension and AntihypertensiveAgents in Chronic Kidney Disease. AmJ Kidney Dis 43:5, 2004, suppl 1.

Jordi Goldstein-Fuchs, DSc, RDhas worked in the specialty areaof kidney nutrition as both aresearcher and RegisteredDietitian for many years. Shecontinues to work in thesecapacities in Reno, NV, and isEditor of the Journal of RenalNutrition.

5. White Y, Grenyer BF: The biopsychosocial impact of end-stagerenal disease: the experience of dialysis patients and their part-ners. J Adv Nurs 30:1312-1320, 1999.

6. Musselman DL, Evans DL, Nemeroff CB: The relationship ofdepression to cardiovascular disease: epidemiology, biology andtreatment. Arch Gen Psychiat 55:580-592, 1998.

7. Rozanski A, Blumenthal JA, Kaplan J: Impact of psychologicalfactors on the pathogenesis of cardiovascular disease and implica-tions for therapy. Circulation 99:2192-2217, 1999.

8. Sirois BC, Burg MM: Negative emotion and coronary heart dis-ease: a review. Behav Modif 27:83-102, 2003.

9. Medalie JH, Goldbourt U: Angina pectoris among 10,000 men. IIPsychosocial and other risk factors as evidenced by a multivariateanalysis of a five year incidence study. Am J Med 60:910-921,1976.

10. Booth-Kewley S, Friedman HS: Psychological predictors of heartdisease: a quantitative review. Psychological Bulletin 101:343-362, 1987.

11. Suinn RM: The terrible twos—anger and anxiety. Hazardous toyour health. Am Psychol 56:27-36, 2001.

12. Mayne TJ, Ambrose TK: Research review on anger in psy-chotherapy. J Clin Psychol 55:353-363, 1999.

13. Alacron RD, Jenkins CS, Heestand DE, Scott LK, Cantor L: Theeffectiveness of progressive relaxation in chronic hemodialysispatients. J Chronic Dis 35:797-802, 1982.

14. Klang B, Bjorvell H, Berglund J, Sundstedt C, Clyne N:Predialysis patient education: effects on functioning and well-being in uraemic patients. J Adv Nurs 28:36-44, 1998.

15. Kimmel PL: Depression as a mortality risk factor in hemodialysispatients. Int J Artif Organs 15:696-700, 1992.

Emotions and Your Heart…Continued from page 9

Hurricane Relief AidTHOUSANDS OF VICTIMS OF HURRICANESKATRINA, RITA and WILMA face homelessness anddevastation, but kidney patients without access to dialy-sis treatment face life-threatening danger in addition toloss of property.

To help people with chronic kidney disease (CKD) inthe affected areas get the services they need, the NKFhas created a relief resource network posted onwww.kidney.org, offering dialysis locations andtreatment information, other direct patient assistanceand information for health care professionals interest-ed in volunteering for the effort.

"We are very gratified by the terrific cooperation wehave seen by everyone involved in helping patients deal with this disaster. National Kidney FoundationAffiliates, other kidney organizations, the large dialysisorganizations and the kidney-related industries have allworked hard and closely together on behalf of the peoplewho are suffering," stated John Davis, CEO of the NKF.

To contribute to the Foundation's Patients HurricaneRelief Fund, visit www.kidney.org or mail checks tothe National Kidney Foundation Patients’ HurricaneRelief Fund, 30 E. 33rd Street, New York, NY 10016.One hundred percent of funds contributed to the ReliefFund will go directly towards patient assistance.


F A M I L Y F O C U S V O I C E S

CHRONIC KIDNEY DIS-EASE (CKD) AND

HEART DISEASE ARECLOSELY LINKED. AS ARESULT, THIS ISSUE'SFAMILY FOCUS VOICESQUESTION EXPLORED HOWREADERS ATTEMPT TOREMAIN “HEARTHEALTHY.”

THE RESPONSES SHOWEDCOMMON THEMES. Eighteenof the 27 respondents do sometype of exercise. Many do whatwe think of as traditionalforms of exercise like walking,running or biking. Othersengage in sports such as golf.One person even shared howtaking up competitive ballroomdancing one year ago impactedher life. Her blood pressureand cholesterol have lowered,she lost 80 pounds and herstrength and energy haveimproved. Still others saythey do household chores orgardening for physical exer-cise. Several shared that theydo strength training in addi-tion to aerobic exercise. Someexercise independently whileothers go to a gym. There areall levels of exercisers. Oneindividual has run five miles aday, five days each week, forthe past 36 years! Everyonewho exercises, whatever form,has every right to feel proud.The key is to exercise evenwhen it may not be easy. Onewoman said that regardless ofhow she feels she tries to“make” herself do some form ofexercise. While she says it maybe a struggle to get started,once she “gets going” she findsshe has more energy. Onerespondent urges all who haveCKD to find some form ofphysical activity they enjoyand not think of it as an exer-cise program but rather as amajor part of their lifestyle.She has taken her own advice,and in her words, “I wouldnever go back to my inactivestate again!”

MANY RESPONDENTS SAYTHEY EAT “HEARTHEALTHY.” They eat freshfruits and vegetables that areallowed on their diet, wholegrains, chicken and fish suchas salmon. They also followdiets which are low in saturat-ed fat and use olive or canolaoils when cooking. Avoidingsalt and substituting herbsand other seasonings is howseveral respondents aid theirhearts. The importance ofkeeping an eye on monthlylaboratory reports and focus-ing on potassium and choles-terol levels was also stressed.They select foods carefullywhen eating out. Some reportthat it is easier to control theirdiets when they prepare “homecooked” meals and do not usepackaged foods. One personpointed out that with some-thing new and interestingalways on her table it does notfeel like a diet. An individualwho has been on dialysis for 24years stressed that “diet is abig thing” with kidney failurein general and following dietary recommendations now

will make a BIG difference inhow one feels later in life. Itwould seem this person couldqualify as an expert in thisarea after 24 years on dialysis!

LIFESTYLE CHOICES MAYAFFECT ONE'S HEART.Several pointed out that they donot smoke or drink, althoughone person did share that shethinks of drinking a smallquantity of red wine as some-thing she does to help herheart. The importance ofkeeping body weight undercontrol was also mentioned byseveral people. Keeping lowlevels of stress was the goal ofseveral, with an individualreporting that yoga is helpfulin achieving this.

TAKING SUPPLEMENTSSUCH AS FISH OIL and othermedications to aid in control-ling cholesterol and blood pres-sure was mentioned by severalpeople as something they do to help maintain a healthy heart. Some shared

that it was important to haveregular examinations by theirdoctor. While it is important toremember that there is anentire health care team avail-able to help you stay hearthealthy and that it is impor-tant to always check with yourdoctor before starting any newtreatment, the importance ofbeing your own health advo-cate was stressed. One respon-dent urged those with CKD tolearn about their medical con-dition, ask questions aboutthings not understood andtake an active role in theirown health care.

THE RESPONDENTSSHOWED GREAT WISDOMIN THEIR WORDS. One point-ed out that “having a healthylifestyle and making healthychoices are major factors inempowering a person to havecontrol over his or her health.”Another shared that while“there are no guarantees inthis world, there are medica-tions, behaviors and healthpractices that can prolong lifeand make it very enjoyable.”Ask yourself what you canbegin to do today that mayhelp you have a long andenjoyable life. You are definitely worth it.

A HEALTHY HEART: What Can You Do About It?

By Karren King, MSW, ACSW, LCSW

Family Focus VOICESWE LOVE TO HEAR FROM OUR READERS,so every issue of Family Focus includes a special question.

Read the question below, also posted online at www.familyfocusvoices.org, and let us know what you think.

With all you have to do in your life, including dialysis, how do you maintain a balance?

You may visit the Web site above to share your thoughts, or send your response in writing to:

Family Focus Voices30 East 33rd StreetNew York, NY 10016

One respondent urges allwho have CKD to find some formof physical activity they enjoy andnot think of it as an exercise pro-gram but rather as a major part

of their lifestyle.


Few dialysis centers actuallyoffer the opportunity to exerciseand all nephrologists (kidneydoctors) do not regularlyencourage patients to be physi-cally active. So starting an exer-cise plan may be entirely up toyou. If you have difficulty walk-ing or are unable to walk, haveproblems of muscle weakness,have nerve problems (reducedfeeling) in your feet or hands orother bone or joint problems,you can ask for a referral to aphysical therapist for treat-ment. Once you are treated forthese problems you may be bet-ter able to do more physicalactivity. Physical therapy is cov-ered under Medicare Part B—you just need a doctor's referraland a physical therapist whocan help you with your specificproblems.

If you live with or have sufferedfrom CVD-related conditions,such as a heart attack, bypasssurgery, chest pain or angina,you qualify in most states for cardiac rehabilitation.Unfortunately, many people on dialysis who have CVD arenot referred for rehabilitationbecause they are on dialysis.This is not acceptable. Checkwith your cardiologist (heartdoctor) and ask for a referral forcardiac rehabilitation. The car-diac rehabilitation program willonly be covered by insurancefor a short time (usually threemonths), during which timeyou should pay close attentionand learn as much as you canabout continuing the programon your own when insurance

coverage stops. This includesunderstanding symptoms, howto progress with your exercise,when you should not exerciseand when to contact your doctorif you have certain symptoms.Once you complete a cardiacrehabilitation program, youshould be able to continue onyour own at home or in a gymor club setting.

It is safe for people on dialysisto join an exercise program thatstarts slowly and progressesgradually. There are manybenefits to regular exercise.While you must make a com-mitment of time and effort, thebenefits are well worth it interms of improved strengthand ability to “keep going”(which is endurance), overallfunctioning and quality of life.The commitment is up to you.You do not have to wait foryour dialysis provider to start aprogram in the clinic.Checking your physical func-tioning should be done to be

sure your ability to walk, getaround and do the things youneed to do are not gettingworse. If your doctor or someonein the dialysis clinic is notchecking this on a regular basis,you can test yourself to keeptrack of your condition. Hereare a few ways:

1) Keep a diary of your physi-cal activity and review itoften. Bring this to your doc-tor or go over it with yournurse, dietitian or socialworker at the dialysis clinic.Look back every month or soto see what you were doingbefore to compare your cur-rent levels of activity.

2) You can do specific tests,like how long it takes towalk a certain distance nearyour house or around atrack. Do this on a regularbasis to be sure you arestaying at the same level offunctioning and evenimproving after you start aregular program of physicalactivity. The importantthing is not to get used tolow levels of functioning andnot to think that this is “justthe way it is” now that youare on dialysis.[1]

The bottom line is that thelifestyle choices each of usmake can be the differencebetween a normal level of func-tioning and overall health ornot. Making changes towardspositive health attitudes andbehaviors requires a commit-ment by each of us. Make acommitment to yourself, your

health and your well-being andwork towards quitting smoking(if you smoke) and towards regular physical activity. Yourbody will be grateful and appre-ciate your efforts, and you willlower your risk of having prob-lems with CVD in the future.

REFERENCES1. Painter P: Exercise for the Dialysis

Patient: A Comprehensive Program.University of California at SanFrancisco, 2000.

Patricia Painter is an exercisephysiologist and is adjunct asso-ciate professor in the Depart-ment of Physiological Nursingat the University of Californiaat San Francisco.

Healthy Lifestyles…Continued from page 11

K E E P I N G F I T

Answers to Are You Heart Smart on page 6

1. True 6. b 11. False - oxygen is picked up in the lungs 16. True2. a 7. a 12. False - they are called the coronary arteries 17. a3. b 8. a 13. d 18. True4. b 9. c 14. c 19. True 5. a 10. b 15. b 20. d

THE NKF HAS A BOOKLET

ON FITNESS,

Staying Fit With Kidney

Disease, which is available

for order by calling 800-622-

9010. Also available is the

Life Options Educational

Booklet entitled Exercise for

the Dialysis Patient: A

Comprehensive Program,

which is available at

www.lifeoptions.org.

It is safe for people ondialysis to join an exercise pro-

gram that starts slowly andprogresses gradually.

16 FAMILY FOCUS • Volume 14, Number 4 01-65-1404

MEDICARE PRESCRIPTION DRUG COVERAGE (PART D)

Visit www.kidneydrugcoverage.org to find out more.

ON JANUARY 1, 2006, MEDICARESTARTS HELPING YOU PAY FORTHE DRUGS you need. Anyone withMedicare can get this benefit. It is notfree. You must join a plan to get it. Youcan join as soon as November 15, 2005.Most must join by May 15, 2006 to paythe lowest premium.

Private companies sell Medicare-approved prescription drug plans. Eachplan has a list of covered drugs andwhere you can get them. Go towww.medicare.gov to compare plans.Medicare Part D will replace Medicaidfor drugs starting on January 1, 2006.Everyone needs to choose a plan byDecember 31, 2005 or Medicare willassign you to one.

If you have low income and assets, youmay be able to get extra help. Youcould pay as little as $1 to $3 for eachdrug. To find out more about the low-income subsidy, call 800-772-1213 orvisit www.socialsecurity.gov.

PHASE 1: AWARENESS Kidney Medicare Drugs Awareness and Education Initiative

Unless you have limited income and assets and get “extra help,” if you joina standard Medicare Part D plan in 2006 YOU WILL PAY:

■ A monthly premium that averages $32.20 ($386.40) nationally but maybe more or less in your area

■ The first $250 of the cost of your covered drugs

■ From $251 to $2,250 you pay 25 percent of the cost of your covered drugs and the plan pays 75 percent

■ From $2,251 to $5,100 you pay 100 percent. That is called a “coverage gap.”

To this point, you would have paid $3,600 and the plan would have paid $1,500.

■ 5 percent or $2 for generic or $5 for brand name drugs, whichever ismore, if your drugs cost more than $5,100.

Standard plans sold by different companies may vary from this design aslong as the benefit they pay is the same as this overall. You may save moreif you pay more to join an “enhanced plan” that covers more of your drugsor pays a larger share of your drug costs.

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