Saturday, April 27, 2019

Exercising on dialysis: an important tool in the quest for a normal life

Everyone on dialysis would like to lead a normal life if given a choice. However, people on dialysis  often have constraints that prevent them from doing things that people with healthy kidneys do. Exercise is one such example.

Exercise is beneficial for everyone irrespective of whether their kidneys are functioning or not. It keeps the body fit and an often ignored benefit is its positive impact on the mind. It is not different for those on dialysis.

The important thing is to talk to your treating nephrologist about what exercise you can safely do. Start small and then slowly increase the duration and intensity. Listen to your body. Don't overdo it. Stop immediately if you feel any signs of discomfort, excessive tiredness, panting, breathlessness and so on. Talk to your doctor and then adjust the duration or intensity.

Here are some ways you can incorporate some physical activity into your life without much ado:

1. Walking

Walking is a very safe form of exercise and suitable for almost everyone. It requires no special equipment or clothes. It can be done anywhere and at any time. Try to walk when the pollution levels are low (early morning, late night). Try to walk in an area which is green and peaceful if possible. If you are not exercising at all, then start with a short, easy, five-minute walk - very slow, very calm. If you feel good about it, continue for a week or so. Then increase it to ten minutes. Watch your body and look for any signs of stress or discomfort. If everything is all right, gradually increase this duration of the walk. You can slowly increase the speed of walking if you wish.

2. Swimming

Swimming is an excellent form of exercise for everyone. It is all the more beneficial for those with any joint pain / weakness and so on. Since the joints feel less pressure while in the water, this is a great way to exercise the body without subjecting the joints to additional stress that is possible while walking. Like with any other form of exercise, make sure you start slow and small and gradually increase the duration and intensity.

3. Yoga

There are several poses in Yoga that help in making the body supple and less stiff. Most dialysis patients are not used to moving their limbs much at all and as a result the joints become stiff and inflexible. This can also result in several pains in the body. The stretching that Yoga poses encourage allows the body to become less rigid and able to withstand any sudden jerks and movements that might result in a sprain or pain. Pranayam in Yoga is very safe for almost everyone and can be done with almost no physical stress and exhaustion. The poses should be done slowly and under the guidance of an expert who knows about your condition and can ensure that you don't hurt yourself. There are various derivatives of Yoga such as Iyengar Yoga that make some poses easier snd less taxing on the body by using props.

4. Sports

The advantage of playing a sport compared to things like walking and swimming is that there is an additional incentive in terms of winning a game and also having company. If your bones and muscles are in good health, you can take up any sport such as cricket, Table Tennis, Badminton etc. This can not only keep your body in good health but also keep your mind competitive and energetic. One thing to be careful about in cricket is your dialysis access. Make sure you take adequate protection and don't let it get injured. Make sure to consult your doctor before starting any sport.

5. Strength Training

After a few years on dialysis, many people find that they begin to lose strength in their legs and hands. Simple tasks like getting up from a chair or climbing a flight of steps becomes a major challenge. This is because the muscles and bones start becoming weak. They start to lose their ability to do some of the most basic tasks we usually take for granted. Strength training for this helps a lot. Several patients have reported a dramatic improvement in these abilities even after a couple of months of strength training. You can either engage with a Physiotherapist or look up exercises on YouTube or the internet for simple exercises that will help you to keep the muscles and bones in your arms and legs healthy and strong. You can read up a little more about this topic here.


Many people believe that once they get onto dialysis, life is going to be compromised. They can no longer do things that healthy people do. Nothing can be farther from the truth. It is all in the mind. If you believe you can do it and genuinely desire to do it, nothing is impossible. Exercise is one such thing.

The physical benefits of exercise are well-known. The benefits on your mind however will amaze you once you begin.

However, like everything else in kidney disease, talk to your doctor before starting anything new. Start small and mild. Make sure you listen to your body closely. Gradually increase the duration and intensity. In case of any discomfort, stop immediately and speak to your doctor.

You can download a copy of this post here.

Sunday, April 21, 2019

The importance of the duration of a Hemodialysis Session

Hemodialysis does two main things - remove excess fluids and remove the built-up toxins in the body. Since the kidneys are not functioning and removal of these toxins and excess fluids is one of the most important tasks of the kidney, dialysis is used to sustain life by removing these two. Uncontrolled build-up of toxins and fluids can kill a person whose kidneys are not functioning.

Most people on dialysis die earlier than the normal life-span of humans because of problems with the heart. The main cause of heart failure and other issues of the heart among dialysis patients is the presence of excess fluid in the body.

An average human adult has about five litres of blood in the body. When the kidneys are functioning, they remove any excess fluid in the form of urine. So at any given time, the body has only the amount  of fluid it really needs. However, when the kidneys don't function, the fluid needs to be removed by dialysis. If there is about 2 litres if excess fluid in the body, there is about 40% excess volume of blood for the heart to pump. This puts enormous strain on the heart. This can be tolerated only for some time. Beyond a point the heart cannot continue to pump this excess volume. It fails after that.

The fluid in the human body can be thought to be present in three 'compartments' as Dr. John Agar, a reputed nephrologist in Australia refers to. The there compartments are

  • blood
  • cells in the body (intracellular fluid)
  • space surrounding the cells (extracellular fluid)

Under normal circumstances, in someone with healthy kidneys, any change in the fluid status of any of these compartments results in fluid moving into or out of the other compartments to ensure that the fluid is well-balanced across all the three compartments. However, there is a limit on the rate at which this movement can happen. This rate is around 400 ml per hour. Any movement into or out of these compartments can happen only at around 400 ml per hour or less.

During dialysis, the access is only to the fluid in the blood. Since blood is being drawn out of the body and passed through the artificial kidney (or the dialyser), fluid can be removed only from this compartment. However, excess fluid that builds up in a dialysis patient is there in all three compartments. 

Let us assume that a dialysis patient came in for dialysis one day with a weight gain of 3 kgs. This 3 kg is equivalent to about 3000 ml of water. This 3000 ml is present across all three compartments - the blood, the cells and the space surrounding the cells. For simplicity let us assume that this water is distributed equally across all three compartments. So it is roughly 1000 ml per compartment. Now when dialysis begins, water starts getting removed from the blood (since the dialyser only has access to the blood). 

Until the 1000 ml gets removed, there is no problem. Since this is anyway excess fluid in the blood. However, the ultrafiltration is set for 3000 ml which means fluid removal goes on beyond 1000 ml. At this point, water is being removed from the blood which is actually a natural part of the blood. So the water starts moving from the other compartments into the blood. 

The fluid is being removed at the rate of 1000 ml/hour. However, the movement of the excess water from the other two compartments into the blood can happen only at around 400 ml per hour. This cause the blood to become deficient in water at the rate of 600 ml per hour. This causes a fall in the Blood Pressure as blood becomes thicker and moves slowly in the body. Similar complications like cramps also happen due to the rapid removal of fluid from the blood.

That is why the ultrafiltration rate should ideally not be more than 400 ml/hour. If you are doing a four hour session, the ultrafiltration should not be more than 1.6 kgs. If you need to remove 3000 ml, you need to set your dialysis duration to 7.5 hours to have a safe, complication-free dialysis session.

Some claims have surfaced recently that you can do three-hour dialysis sessions and achieve the same results. They claim to use high flux dialysers and get equivalent clearances. This claim is true only partially. Only toxins can be removed more efficiently using high flux diayzers. Fluid removal,  unfortunately, is a constraint of the body and not the dialysis machine or the dialyser. The 400 ml/hour limit is something that the body imposes and using any kind of diayser or machine cannot change this. There is a possibility of lesser complications happening during a session by some techniques. However, in the long run, removing fluid at a rate more rapid than 400 ml per hour can result in serious cardiac issues and affect longevity of the patient.

So, please ensure that you try to stay close to the 400 ml/hour limit set by your body. The four hour dialysis session is an arbitrary number that is chosen and should be the bare minimum duration of your dialysis session. In reality, that much is usually not enough for optimal removal of fluids and toxins. So, never even think of reducing that duration. If your centre is dialysing you for less than three hours by making ludicrous claims of doing more efficient dialysis, please insist that you get the full four hours (if not more).

You can download a copy of this post here.

Friday, April 12, 2019

Problems that are not serious but can hamper quality of life on Dialysis

The kidneys are wonder-organs. They do so many different things. They impact so many life-processes. It is impossible for us personally, to realise what all they do unless they stop doing these things. That is why when the kidneys do not function, so many routine aspects of daily life are affected that dealing with these issues (co-morbidities as they are called) becomes as big a challenge as the main kidney failure itself.

Some of these co-morbidities are serious. Problems with the heart, for example, are probably the most serious of them all. There are several smaller problems that may not pose a risk to life itself. These problems however severely impact the quality of life of dialysis patients if left untreated. Sometimes, doctors don’t take them as seriously because they are not clinically significant - they don’t do any harm to the body itself. However, for the person who is suffering, often these problems can dramatically increase the burden of the disease.

The good thing is these problems often have simple solutions. It is just about talking to your doctor, insisting on finding a solution and then sometimes, by trial and error figuring out what works for you. Like everything in medicine, these problems may not have a one-size-fits-all solution. However, it is possible to find a solution to most such problems. 

Here are a few commonly encountered problems which are not life-threatening but can seriously hamper quality of life and some effort should be made to treat them. Remember, never, ever start any medication suggested here without talking to your treating nephrologist. Start any medication only if he or she prescribes it for you. Each individual is different and every medication has side effects that can sometimes be worse than the condition it is treating.

1. Restless Legs Syndrome: Restless Legs Syndrome (RLS) describes the urge to shake or move the legs and extreme restlessness of the legs in the absence of motion. This is a common side effect of those with Kidney Failure. Patients typically have to walk about to get relief from the symptoms. Shaking the legs vigorously also helps. The symptoms usually worsen at night and many patients find it very difficult to sleep. There are some very effective treatments for this syndrome such as Gabapentin, Pregabalin. It is important to talk to your doctor before starting any of these drugs. You can find more information about RLS here.

2. Peripheral Neuropathy: Numbness of the feet and hands. Long term kidney failure affects the nerves. This results in numbness and a feeling of tingling in the hands and feet. Over a period of time, the symptoms can worsen and become painful. While longer, more frequent duration dialysis can help with this, the symptoms are not always completely reversible. However some amount of relief can be achieved by drugs such as Gabapentin and Pregabalin. Read more about Peripheral Neuropathy here.

3. Constipation: Difficulty in passing stools is a very common side effect of kidney failure. A lot of this is due to the change in fluid status of the body. Dialysis patients are sometimes fluid overloaded and then during the dialysis sessions, there is rapid removal of fluid. This results in several problems with the gut and the way it works. This problem is further compounded by the diet restrictions that are a standard part of the dialysis diet. It is difficult to get adequate quantities of fibre in the diet and this can worsen the problem. There are several possible solutions to constipation and you should talk to your doctor about what you can try. Some of the solutions worth discussing are the use of Lactulose Syrup (Duphalac), Psyllium Husk (Isab Gol) and Stool Softeners such as Cremafin. Read this excellent article for more information about Constipation on dialysis.

4. Itching: Also called Uremic Pruritis, many patients have a big problem with itching. There could be multiple causes of itching. The most common is excess Posphate in the body. Since the kidneys do not remove the excess phosphorus in the blood, this can build up and cause itching. There are multiple types of Phosphate binders that you could be prescribed to help with this problem. More efficient and regular dialysis can also help. Another cause for itching is related to the nerves. If your Serum Phosphorus levels are normal, then your nephrologist might recommend a drug that treats disorders of the nerves.

5. Sleep Problems: Called Insomnia in medical parlance, sleep disturbances are very common among dialysis patients. There could be several reasons for this. It is quite difficult to nail down the cause of sleeplessness. Some people find it difficult to sleep because of Restless Legs Syndrome described above. In that case, addressing that could give almost immediate relief from insomnia as well. In several patients, sleeping during the day or not engaging in any physical activity during the day can result in sleeplessness at night. Try doing something to get you tired during the day and see if this improves your sleep at night. Avoid sleeping in the afternoons. In other cases, if it is diffficult to identify the cause, discuss with your doctor about taking a mild sedative. While it is not always the best solution, sometimes the harm to the quality of life due to poor sleep might be worse than the side effects of a sedative. These days there are drugs that are relatively harmless and you should have a conversation with your doctor about this option.

6. Sexual Dysfunction: This is is a common side effect of kidney failure. Most patients on dialysis report some form of sexual dysfunction over a period of time. Typically the symptoms worsen with age with kidney disease. Lack of arousal, erectile dysfunction, fertility problems are typically reported by patients. For some of these problem, there are effective drugs that can be prescribed. For some, there are other solutions. For Sexual Dysfunction, remember the rule: if you don’t use it, you’ll lose it. See this excellent article for more information about Sexual Dysfunction with Kidney Disease.

You can download a copy of this post here.

Sunday, April 7, 2019

Aashayein Hyderabad on 14th April

Aashayein is back in Hyderabad after a gap of seven years. 

Sunday, 14th April, 9 AM

Hotel Manohar, Begumpet