Transcript: Hot Topics in Kidney Health episode 1x28
Managing fluid intake as a CKD patient
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Welcome to Hot Topics and Kidney Health, brought to you by the National Kidney Foundation. Each episode we highlight the latest in kidney research. Bring you up to date news in kidney care, dispel myths and answer your kidney health questions. It's important that certain individuals with kidney disease limit their fluid intake. But many don't understand why or where to begin.
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On today's episode, we sat down with experts to discuss fluid restriction, such as why it's important, the negative effects of consuming too much, and ways to manage a fluid restricted diet. Welcome, everybody. It is great to be here on the KNXV podcast. I am Anthony Reid. I am a current transplant recipient and a biomedical equipment technician in dialysis.
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We're all talk today about fluid intake. Kathryn, if you would like to introduce yourself. Absolutely. Thank you. I'm so excited to be here today. This is a great topic. I am Kathryn Wells. I'm a nephrology nurse practitioner in Jackson, Mississippi. I've been doing this for a very long time, so I can hopefully share some of the things patients have told me with you.
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If somebody has kidney disease, why would they need to, first of all, limit their fluid intake? And when depending on the stage of kidney disease and we get into that later on, when would they need to start really watching it very closely? I think this is the fundamental piece to talking about fluid. The kidneys actually do a lot of different things.
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We're going to talk only about the fluid aspect today, but we know they fail to filter, but they also fail to get rid of the water that you have in your body. So your body is made for you to put water in, but also to put that water out in your urine. I want to also mention that when we talk about fluid, we also always talk about salt, because wherever salt goes, water goes.
00;01;54;18 - 00;02;19;26
So you'll hear me mention salt a couple of times throughout is podcast. So when your kidneys fail and these folks and start to fail, it's a little different for everyone. So some people that filter portion of their kidney function fails, but they still make a lot of urine. And for some people they lose both. They lose the filtering function and the ability to put water out through their kidneys.
00;02;20;09 - 00;02;39;12
So it's a little bit different for everyone. And so everyone's prescription for how much fluid they should take in should be different because it should be based on how much kidney function you have and how that kidney function is working for you to get rid of fluid. So also, let's talk a little bit about why. So if you don't get rid of salt and fluid, what happens?
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So we all know that you swell and that you can get shortness of breath, you can have a lot of problems, but that's actually sort of a first symptom of a much bigger problem, which is the fluid in your body can start affecting your other organs. We talk most about your heart. It can lead to heart failure, but it also affects your lungs.
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That's why you get shortness of breath. Some people that are very volume overloaded even need help breathing. So you have to think about all of your other organs except for your kidneys. They don't need all of that extra fluid. And also, like I mentioned, you have salt in your body, too. If you have all that fluid in your body, which is also going to hurt your heart function.
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So when we when we talk about that, you know, there's different stages of kidney disease. There's one, two, three, four and five. And what stage should people really start to limit that fluid intake? Are we looking at two, three or are we looking more towards four and five? Looking more towards four and five? Most people that have chronic kidney disease stages one through three still their kidneys, I always say they're kidneys are still doing what they need them to do, including putting out water.
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It can be a little different for some people and it can start a little earlier. But for most people it's actually in those late stages, Stage four and stage five, when you're getting ready to need a renal replacement therapy most often. Right. So as far as renal replacement therapy, we're looking at some of the options out there. Is dialysis possibly a transplant, correct?
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Right. And both dialysis and transplant are very effective at getting rid of fluid. So dialysis, we can clearly remove fluid directly with a transplant. You start putting out that urine again because you have a healthy kidney. So I would say both options are are the treatment for this type of kidney function. Right. Right. You know, if somebody is in stage four and five around how much fluid should they be looking at daily?
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How much intake should they be putting in daily? So my rule is if it's going if it's coming out, you can keep putting it in. So you have to watch your urine output and you can definitely supplement that with diuretics. There are a lot of different ways to help the kidneys put out more urine. Most of these drugs or all of these drugs, whether it works by getting rid of salt and waterfall of salt.
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And so you can supplement that urine output using diuretics to increase the dose as your kidney function gets worse. You can continue those diuretics, by the way, once you start dialysis or usually don't need them. Like I said, if you have a transplant, but the amount that you can get rid of is going to determine the amount that you can put back in.
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So what we're trying to avoid are the things we talked about at the beginning, all of the swelling and the problems breathing and the heart failure. So we want to make sure to keep the fluid off of you, either by convincing your kidneys to do it. So that is my favorite way, right? So convinced the kidneys to get rid of the water so that you can keep drinking water.
00;05;54;08 - 00;06;13;19
But if that isn't working, then that's when you need to start backing off this or it's usually going to be an advanced kidney disease, advanced chronic kidney disease that we start doing this. It's pretty rare for me to have to do that in clinic until we are at the point of starting dialysis. You know, for me, I was a water drinker.
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I mean, back when I was 18, 19 or even before then, I mean, I'd be working in construction, drinking gallon a day, easy, you know, easy because you're losing all that through sweat and everything else. And so now at age 22, when I was diagnosed with end stage renal disease and said, hey, look, you're on dialysis, it's a whole new ballgame, especially when you're using.
00;06;34;18 - 00;06;51;14
So I guess the best way on this one, when you're looking at a individual that's going on dialysis, having to drink all of this, all this fluid and intake and all this fluid, and now you're limited to how much a day, Right. So, yes, it's very common in early stages of CKD that we tell you, drink, drink, drink, drink, lots of water.
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And then we start. Then we suddenly take it away from you. And then so when we get to the point when you're on dialysis, if you're not putting out a lot of fluid, then you're going to need to drink. Always. Almost everyone needs less than two liters a day, and that's total. Some people need less than that. Some people need to drive less than one and a half liters a day.
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So when I say total, let's mention really quick all those hidden sources of fluids. Anthony and I both live in the south. And so one of the biggest things I talk to people about is pot liquor, because if you eat things like greens or a lot of vegetables, there are a lot of people that just don't love that fluid.
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And but remember that kilts towards your two liters a day. So everything you drink and also foods like that, watermelons, another one. We have some of the best watermelons in Mississippi. So it's really tough. That's all water. And so when we talk about two liters a day, it's combined everything combined. Right? Right. And, you know, for those of you in the south, that means sweet tea, too.
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I used to be a sweet drinker. I'm more of a coffee now. You know, it is what? So the one thing is when you're on this and you have this certain amount, you can drink a day. I want to go back to the limitation of salt and fluid. What happened? Was somebody overload on fluid or on salt? What could the possibility be?
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So when someone is overloaded, if there's someone that needs dialysis, then then that fluid is immediately going to start going into your tissues, but also affecting all of your other organs. And if you can't get the fluid out, then everything you drink after that is going to add to it. So if you start getting short of breath, for instance, because you've been drinking too much fluid, that is not going to get better until we get rid of the fluid salt also.
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So remember that where salt is water is. So if you eat a lot of salt, it's going to do a couple of things. First, it's going to make you thirsty because your body wants a little bit more balance. They don't want you to be super salty without having that water to balance it out so you do get thirsty.
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It also happens with sugar mentioning sweet tea. So sugar could also make you really thirsty. And so then we then the goal is we have to not only get rid of water, but get rid of salt so that you feel good. So if you always have a lot of salt, if you're putting out a lot of fluid in salt, and then we're taking a lot off during dialysis, that makes people feel really bad because they're thirsty all the time because of all of the salt.
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They don't feel good because of the fluid, the things that we've mentioned that are from fluid overload. And it's just it's very much a zigzag up and down with your body where things are not stable. And almost exclusively everyone says it makes them feel bad. And I will let Anthony talk about that more because he probably knows more than I do about that.
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And, you know, when I went into dialysis, I was given a certain target weight, which in turn one time a certain type of sub from a certain certain place, certain certain time went in, did great in the last 5 minutes of treatment. And it started it started in my toes and shot straight through my nose. It hit my whole body and I cramped up like this.
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The individuals take care of me, some of which you get into. I didn't eat nothing. I didn't drink to that. I was good. I had a tuna sub from such and such place a little higher in salt. And and that's a kind of it goes back to where I was. So it's a bad season, right? I ate the wrong stuff and the next thing I know I didn't just reap that one bad thing.
00;10;35;26 - 00;11;08;29
I read the whole harvest in one treatment with the last 5 minutes. So right. Absolutely. So we do know a little bit more now about pulling fluid on dialysis. And so what we know is that that we need to keep those fluid removal rates low, that they it makes you feel better, but it's also healthier, faster. And the more fluid we pull over a short period of time, the higher risk that you have of having complications from the fluid and from removing it because it can make your blood pressure drop low.
00;11;09;08 - 00;11;34;08
It can cause a lot of problems. It's cause some people that need to go to the hospital, it's caused a lot of really bad thing, bad outcomes that but most often that what you what you described is exactly what I hear about. Yeah, as far as dialysis, that is definitely something that does happen. It's not joyful, but I write, you know, if you don't work the first time, trust me, the second is going to just be just as bad, if not worse.
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But now let's switch gears just a little bit here. Okay. You know, somebody's been on dialysis for a few years and often they get that call, right? They get that call they've been waiting on for so long. There's so many people out there that's waiting on that call. And next thing you know, the answer the phone and they pick it up and it's their transplant center.
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Or they see somebody and offered to donate to them, whatever it may be. And that time comes. Okay, So now they're in this transition. They get the transplant, they get you know, they get, you know, start getting back to normal with the transplant. But now you have this another switch that you have to make because in dialysis you're told only drink this.
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And now in the transplant, when you transplant it, it's like push, push, push. And so you have to change your habits. Now, what is what would be your piece of advice for somebody that is going from, you know, this restrictive and now they're traveling, now they have to push. What would you say to somebody and, you know, that would say, how would you encourage them to make that switch if they're transplanted and they're doing well?
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Right. So, yes, most transplant and these immediately start putting out urine even in the operating room. Some people there's a delay. Usually after a transplant, you are a very early like the CKD one through three that we were talking about, which means you're putting out your kidney, doing what it should. You're putting out a lot of urine. And like I mentioned, if it comes out, you have to put it back in, right?
00;13;07;17 - 00;13;29;20
So instead of us moving towards the restriction, now we're moving in the opposite direction, which is not getting dehydrated. You mentioned something earlier about sweating. That's a big thing in the cells. So when we talk about not getting dehydrated and how much you should drink, you have to increase as long as your urine output is increasing for a while, that new kidney will put out a lot of urine.
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You have to put that back in. But also, if you sweat, you know, anything that that you do, that you lose fluid. If you have a sickness, if you have diarrhea, if you are throwing up, you need to replace all of those fluids also, because remember now the fluids going out, you're not used to it, but the fluids going out, you have to put it back in.
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Yes. And I can tell you that you never take for granted the output any more. So that's definitely something that I think is a transition for those that have been on dialysis. I know it was for me, you know, going from dialysis, next thing you know, we're into transplant. And now it's like you got to push, push, push, which you like.
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But I'm used to this and I feel so full and all this other stuff. So, you know, definitely wonderful things. So, Mel, now let's go back a little bit. Let's rewind just the hair back because there is a lot of people that are still on dialysis and they may not have the opportunity or the option of a transplant.
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So it's kind of now a way of living or a lifestyle that they have to adapt to. Now, you know, this is this is what they do, thankfully, we have dialysis, correct? I mean, we have the ability to do that. Correct. So one of the things is when you're in this lifestyle for as dialysis, for successfully tracking this, what is some of the things that have worked that you have seen work?
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And then I can bounce off and share a little few of the things that I've done at that word. Right? So at its foundation, dialysis weight management or volume management works off of weights. So most people find it is much easier to get into the habit of weighing themselves every day. Like you mentioned earlier, you knew exactly what your dry weight was.
00;15;15;18 - 00;15;43;03
So you know what weight you should be at. And if you're weighing yourself every day, you can test yourself. If you've gotten into some fluid. Like I said, sometimes it's things that you don't think about, like saucy vegetables and you've got more fluid habits are extremely hard to break and when I talk about habits, think about things like So in the South, we have Sonic and we go to Sonic and we get these huge drinks.
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I think they call them Root 44 and just huge. You have to break the habit of getting that size drink and restart a habit of getting the small and you're going to feel thirsty at first because your body's sensing the change, because you're used to putting all that fluid in. But you also have to you have to think about it in those terms.
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So water for the day, whatever fluid intake for the day is a budget. If I decide I want a really large drink, this may be a liter of my fluid. I've still got pills to take throughout the day, so I know at the very least I've got to drink fluid to swallow this pill. So don't use up your budget first thing in the morning with a large drink.
00;16;24;20 - 00;16;45;18
Get a small drink instead. And so breaking habits is difficult, though, when you if you're one that drinks water a lot at home, ice is another thing that I see people get in trouble with. They don't want to drink water, so they get a cup of ice and try to use that instead. The problem is that a very large cup of ice is still a pretty big cup of water.
00;16;46;07 - 00;17;02;24
Yes, definitely. And that ice can the ice can definitely get you in trouble. Tastes good. Even though it does not have a taste, it feels good. You know, it kind of quenches it a little bit, you know, And it is hard habit to break, but I can't have that much sweet tea. I can't get one of those big ones from the certain fast food place.
00;17;02;24 - 00;17;22;13
Like a saying here, I think creating new habits. You know, let's let's look at the old one. You know, we can break them more. Let's create new habits. Let's go for the small drink. Yeah, that I will say I've met several people who take their diet so very seriously that will just come in crying and they'll be like.
00;17;22;13 - 00;17;37;07
Like there was nothing I could eat at all. You know, It all had salt in it or all I really wanted was a big drink. And I know I can't have that. And it was noon and I'd already had everything that I could have. And so there is a huge emotional aspect to our eating habits, for one thing.
00;17;37;07 - 00;17;57;01
But also we need to be sure we're giving alternatives. So, you know, make sure that we're we're talking up front about, you know, you don't ever get to noon and stop eating for the day and cry because you don't have anything else to eat. Learn upfront to budget and learn that if you mess up once, then that's a lesson, not a failure.
00;17;58;07 - 00;18;14;16
That's the key in the key point, and that's with anything in life we don't learn from within. It is if you learn from it, then it's a lesson and you go on and move on. You know, whether you're you know, if you're tracking your fluids, you know, that's another thing that it can be kind of difficult because it's a daily habit that we did.
00;18;14;16 - 00;18;36;05
Right. Any of us that are out there that don't have kidney disease or transplant or just use that we just, you know, go to the gas station, you know, get a snack and a pop or a bottle of water or something. Go down the road, don't even think about it. And then you have to shift now. And instead of the real big 36 ounces of water now I'm going to go with this this one right here.
00;18;36;05 - 00;19;08;03
And I got to make it last. You know, And one of the things I found out was chewing gum was actually what helped me. And I've heard that a lot, that chewing gum. And I think it's just because it's just it keeps your mouth not as dry. It will not you know, of course, I don't think I'd recommend the hot spicy ones like the cinnamon one that might not Right specific taste or the overly sugary ones which I mean, there are plenty of options now that aren't overtly sugary sugar based because sometimes that'll make you thirsty.
00;19;08;03 - 00;19;27;13
You know that that's very that's dependent on some people. It doesn't bother them. Hmm. That's an interesting concept. I would say hard candy, but there could be people that are diabetic that may not can have the sugar. So there may be other options that, you know, that that would work on that. Right. I always give exactly that advice about hard candy.
00;19;27;14 - 00;19;49;19
Just make sure that, you know, it is sugar almost all the time. There are a few hard candies that are sugar free, but it's bigger and especially if you're diabetic. Be careful. I, I have heard more people say that the gum works better than hard candy. But then some people really some people have had some success with just peppermint.
00;19;49;19 - 00;20;16;22
I don't know why. It must be just the minty feeling. What would you recommend or what would be the recommendation from somebody that's in a place that the weather is constantly a lot warmer than in other locations? Or just say we have a really hot summer would be recommendations usually for you. So I usually recommend that when they drink something and for some reason if you drink it cold, it seems to be more refreshing for most people.
00;20;17;18 - 00;20;45;04
So, you know, try cold drinks. But even that like cold towels on your neck or things like that. So make sure you're not drinking to try to adjust your temperature and the way you're feeling know there are other options other than drinking a big glass of ice water. If you're hot have there are a lot of different sports products out there now, rags that stay cold and things like that that can help if that is what you're drinking.
00;20;46;02 - 00;21;14;19
We also also focus a lot on salt when it's hot because some work because of the diet in in the south, but you don't want an extra source of thirst. So because when it's hot and humid outside and you're sweating, you're going to be thirsty. Now, that said, you can sweat enough if you're not drinking enough to actually get dehydrated if you're on dialysis.
00;21;15;03 - 00;21;37;19
So know people that work outside have to have to be really careful and account when they're replacing their fluid for We're also the sweating losses with that. Yes, definitely. You know of what Katherine said, be be careful with that. You know, you want to be careful, especially in the hot weather. I'd say, you know, I try to stay in the shade as much as possible.
00;21;38;15 - 00;21;59;12
So might be I mean, is that something you would recommend if there is possible to stay a little cooler so you don't get that? So for most people, I recommend that. I recommend a lot of shade. Remember that you still need sunscreen. I know that's off topic, but it's just very much a habit. But if you need the fluid.
00;21;59;12 - 00;22;21;08
So we talked a little bit about if you don't need the fluid, but if you are someone who needs extra fluid when it's hot outside, you're automatically sweating. When you walk outside. So when it is hot, you know, you need to increase your water. You know, you need more fluid intake, things like staying in the shade, staying cool, trying not to spend a lot of time getting excessively sweaty.
00;22;21;08 - 00;22;47;20
Definitely fits this population because you can get dehydrated that way. We have a lot of issues with even heat stroke from severe dehydration and heat. So that's something that you need to pay closer attention to. And I would agree with that. I agree from the patient aspect. So I do have this question. This popped in my mind because one of the clients I'd heard that they had done the dialysis fluid challenge.
00;22;47;20 - 00;23;20;12
Have you ever done a dialysis fluid challenge? So I we've not done that here, but I have seen where a lot of other people have done it. The goal for most of those challenges is to reduce the amount of weight gain between treatments. So CMS is now actually tracking how fast we're removing fluid on dialysis patients because like we mentioned earlier, we're moving too fast is not only just terrible from the perspective of the patient, but there are risks involved there, medical risks.
00;23;20;28 - 00;23;47;04
So the goal being to to do education to everybody all at once. So we're definitely not singling people out, making sure that we're all of these concepts that we've been talking about are talked about. But with the addition of how much weight are you gaining between Dallas treatments and let's keep that down. No, exactly. For you. You can talk to the dialysis nurses.
00;23;47;04 - 00;24;10;14
They can tell you, look, this is how much we can pull off per treatment. You need to be gaining less than that. So if they tell you they can pull two liters off per treatment and I'm just throwing out numbers, then you don't need to drink two liters. You need to drink less than two liters. Gotcha. Gotcha. Definitely some good advice, you know, definitely to take in and to apply to your life and for your dialysis patient.
00;24;10;14 - 00;24;29;10
And if you are someone that doesn't know anything about kidney disease, I know there's many people I talked to. They don't have kidney disease, but they know somebody, a close family, a relative. This is what this is what people go through. And so, you know, it's more than like I said, it's more than just going back, taking them and picking them back up.
00;24;29;17 - 00;24;51;19
There is more that goes into all of this. And fluid is can be a really big thing. It can be a if somebody drinks too much and they're on dialysis, it's got a negative aspect and they drink and drink enough and they have a good treatment, a good a good outcome. It's better for them, you know, encourage them and encourage your family members to stick within the guidelines that are given to them by the medical provider.
00;24;51;20 - 00;25;13;24
So definitely recommend that. So is there anything out there other than maybe a sheet that somebody can make? I know anybody can use a spreadsheet or different forms online to make their own. Well, is there any kind of app or anything that you know of or anything out there that would help track that fluid? There are a lot of fluid tracking apps now.
00;25;14;27 - 00;25;41;26
Most of them are intended to encourage people to drink more water. But any of these apps, you can set your goal and put in what you're drinking so it can track it. So some people do like to do that. They like to keep it electronic on their phone. Some people some people keep their own paper records for themselves at home and make sure that you're weighing yourself every day.
00;25;41;26 - 00;26;03;02
When I say weigh yourself, it should be first thing in the morning, same time every day with the same clothes on, similar to the way we do it in dialysis. We don't want you know, you don't want to see a change in your weight because you have on heavy boots or things like that. But so track your weight every day because that's going to help you see those fluid gains.
00;26;03;12 - 00;26;29;27
However, if the way it's gone up, it's already too late. So the things like the apps or the paper logs, things like that help you upfront. Know where am I today in my budget of fluids. So if I can have only two liters total and you're just basically subtracting from that every time people that drink a very consistent only drinking water can use things like pitchers that are measured.
00;26;30;14 - 00;26;56;10
You know, this is my allocation of water for today. And I know when it's gone, it's gone. Keep that in the refrigerator. I always remind people that two liters a day is a think of a two liter drink. It's not that I want you to drink it. I drink a Coke to clear coke a day. But that's a visual that we that we all know to be able to to see how much fluid that is.
00;26;57;05 - 00;27;18;00
If you can watch it going down throughout the day, it's a little easier to track and everybody's a little different about how they like to track it. So I think it's important to to sit and talk and say, So if you're tracking things in your life, how do you like to track it electronically or on paper, or should we come up with some other tool like a pitcher?
00;27;18;17 - 00;27;37;20
Right. But the tools are only good if someone uses them and for me, I didn't use anything. I just used memory which kind of got me in trouble once or twice. You know? You know, I had this one tool. How much did I have? Well, maybe I better not. Maybe I better drink, you know? Oh, it'll be okay.
00;27;37;20 - 00;27;59;04
It'll be okay until the next treatment thing. You know, it's like, you know, I probably shouldn't have that much. So the worst thing you can do at that moment, which I see people doing sometimes, is they'll say, Well, I did my fluids. Okay, so I'm going to skip this treatment. Don't forget that your kidneys normally work 24 hours a day, seven days a week.
00;27;59;04 - 00;28;16;29
And when you're on dialysis, most often it's three days a week. That that's your opportunity. Now, a lot of people are now doing more or doing daily. Daily dialysis can actually help a lot with that. You know, somebody wants to do something wonderful in their life and they want to run a business or something. They set goals for themselves, right?
00;28;17;15 - 00;28;45;12
Those in dialysis, they want to live a healthy life. So set those goals because if you can set those goals and like I said, then the fluid fluid, the fluid management and making your treatment, that's a wonderful start to enjoying the life that you dreamed up. Absolutely, because dialysis should support that. But then when you get into some of the you know, if you're not being really consistent with some of these things, then then your kidney disease is going to get in the way of your life.
00;28;45;12 - 00;29;05;29
If you're fluid overloaded, I can guarantee you if you stay fluid overloaded, then your kidney disease is going to get in the way of the life you want. But the reason is, had I said no to that tuna, salmon said, let me go with something a little bit more health conscious. I mean, I drink as much water because that tuna made me really, really, really thirsty.
00;29;07;01 - 00;29;35;25
You know, we could have been different. Absolutely. Absolutely. I think that fatigue is something else, that just exhaustion is something else that a lot of people talk about that is definitely associated with either carrying too much fluid or or trying to pull too much off during dialysis. And so keeping everything stable and steady is a great way to keep your energy level up, whether you're on dialysis or in transplant.
00;29;35;25 - 00;30;00;00
Remember, you have a dietician or a nutritionist. You have a social worker, you have nurses, and then you also have nurse practitioners and physicians. So keep asking until you find a way till you're comfortable with those goals. Just keep asking different people to help support you in creating this. And because you may need a little bit of input from everyone.
00;30;00;15 - 00;30;29;09
Katherine, is there any last words that you have that you would like to share with the audience? I think that so we spend a lot of time talking about how horrible it's going to be if you if you gained all of this fluid. I think we should spend more time on the things that you were talking about, setting goals and making sure upfront that, you know how to do things well so that you can feel good because everyone will learn a lot from any dialysis unit and any transplants that are out.
00;30;29;26 - 00;30;55;29
The concept consists of their actions is what you tend to talk about that a lot. But I think that a lot of people spend so much time on consequences that they they do get they get depressed, they can't handle it because they're not focused. Right. So I really like the way that you focus setting goals and making sure that you are not only honest with yourself, but you're encouraging yourself.
00;30;55;29 - 00;31;20;02
Before we in the episode, we want to give a shout out to a patient celebrating a major milestone. Laura from Colorado donated a kidney to her brother Charles in 2021, and they recently celebrated their one year kidney anniversary. Congratulations on being one year kidney strong. Charles and Laura, thank you for listening. Make sure to rate and review us on Apple Podcasts, Stitcher, Spotify, or wherever you listen to podcasts.
00;31;20;17 - 00;31;57;12
You can also email us directly with your comments and suggestions and cave podcast at Kidney Dawg. We hope you'll join us next time. And from all of us at NKF, we wish you good health.