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Does Consumption Of Red Meat Contribute To Reduction In GFR?

Posted on Sat, 2 Jan 2016

Question: hello doctor...I have had ckd for over 10 years... I have been seeing a nephrologist/internist regularly every 4 to 6 months for about 20 years... for hypertension, hyperlipidemia, kidney stones, and ckd... my bp and cholesterol have been well controlled by medications...from 11/11 to 11/14 my gfr went from 80 to 60 based on a 24 hr urine... creatine was 1.59... my doctor thought the change may have been due to the 80 value in 11/11 being skewed high from the 24hr urine... nothing was recommended in regards to diet or change in any of my medications... 4/15 my creatine was 1.77 from blood test but no 24hr urine was recommended nor anything else.... 7/15 I had exam but no blood tests done... my most recent exam on 11/5/15 showed creatinine at 2.15 bun 48... my doctor recommended another 24hr urine which I will do shortly... the calculated value of gfr from blood test is 32!... it has never been this high before... my doctor said that the calculated value of gfr from only blood test can be much lower than the 24hr urine collection since it is more accurate...he expected it to be in the 50s and said I was probably "dry" at the time of the blood test... I have seen this before a few years ago when gfr from blood test showed 55 and from 24hr urine done shortly after showed 70...needless to say I am extremely shocked and dismayed at my most recent test and especially the rapid rate of decline... I am very hopeful that the values from the 24hr urine will significantly increase... although he has not recommended anything yet... he wants to see the results... I have now decided to eliminate all meat from my diet except for some fish occasionally and watch my protein intake... prior to this I was a generous meat eater... i have stopped or significantly reduced my alcohol consumption... I consume more than the recommended daily intake... perhaps 3 cocktails/day every other day... although my liver enzymes are and have always been wnl... and I started drinking more water about 64oz to 80oz per day...my meds are atenolol 100mg/day hygroton 50mg/day, dyrenium 100 mg/day, Avapro 150 mg/day, Lipitor 40 mg/day, potassium 20meq/day, allopurinol 300 mg/day, Cymbalta 60 mg/day... there has been no change in my general health otherwise ... all my other lab values are wnl including potassium ... is it possible for my values to decline at such a rapid rate given my otherwise good health and bp under control... usually 110-125/65-70... could my consumption of meat and protein have triggered this decline although I have always eaten about the same quantities of meat and protein for many years... do you know of anything else I should be doing or could you recommend what you would do in my position... possibly second opinion?... also is the level of water I am drinking ok with my most recent values?...although hoping they will improve with 24hr urine... thank you so much for reviewing this long history and for any of your thoughts or recommendations.. XXXXXXX from XXXX XXXXXXX XXXX

Answered by Dr. Rakesh Madhyastha (12 hours later)

Brief Answer:
Retarding the progression of the kidney disease

Detailed Answer:
Hello

Thanks for the query

I shall answer to all your questions one by one so that I dont miss any. However to be in a better position to help you it would be fantastic if you could furnish me your reports. You can attach them easily onto the website.

Now to answer your questions

1. Cosumption of red meat could have lead to decline in GFR. Proteins are known to be nephrotoxic. The situation is slight different now since you have chornic kidney disease. I recommend you to curtail protein intake to just fish and chicken three times a week
2. In order to retard the progression of kidney disease it is important that you are on ACE/ARB. I see that your doctor has already put you on it, Tab Avapro is an ARB, i usually titrate to the highest possible dose in order to get maximum benefits. The other things you could do is, avoid smoking, avoid painkillers ( NSAID group), lose weight and follow a salt restricted diet
3. If you could furnish me your latest serum creatinine then I can let you know the amount of water you can have. I suggest you to drink when you are thirsty and not drink excessively

I must add here that apart from restricting proteins it is also important to avoid high salt diet and exercise daily, especially cardiovascular exercise like walking, cycling. Avoid lifting weights

I hope I was of help, please get back to me for any further queries

Regards

Above answer was peer-reviewed by : Dr. Prasad

Follow up: Dr. Rakesh Madhyastha (30 hours later)

thank you Dr. Madhyastha, here are 4 yrs of my serum creatinine ... 4/4/11 creatinine clearance 80l, creatinine 1.52....... 8/22/11 creatinine 1.60....... 2/8/12 creatinine 1.34....... 8/20/12 creatinine 1.27....... 1/31/13 creatinine 1.51....... 5/23/13 creatinine 1.47....... 3/17/14 creatinine 1.38....... 8/21/14 creatinine 1.78...... 10/27/14 creatinine clearance 61l, creatinine 1.39....... 11/13/14 creatinine clearance 60l, creatinine 1.59....... 4/14/15 creatinine 1.77....... 11/5/15 creatinine 2.15....... My doctor has now recommended another 24hr urine which I will do in the next couple of weeks. He does not appear to be too concerned with this cange however I am very concerned. As recently as a few months ago he mentioned that I will outlive any need for dialysis. Based on these values and the rate of progression, is he incorrect. He said that the 24hr urine results will probably be much better than the calculated serum creatinine. He said that the gfr will probably be in the 50s rather than the serum calculation of 32. Is this possible? Nevertheless, I feel I need to be much more proactive in trying to slow the progression. Based on all this information, do you think that dialysis is in my future and how soon...if you can estimate based on your experience? You also mentioned that you would give me the amount of water I should be drinking per day based on these values. I was under the impression that the more water the better for your kidneys. Thank you so much for your expertise. XXXXXXX

Answered by Dr. Rakesh Madhyastha (24 hours later)

Brief Answer:
Not an alarming change

Detailed Answer:
Hello

Thanks for getting back with the details

From the reports you have furnished it looks like there has been a gradual progression of the kidney disease however it is not very alarming. Maximising the dose of ACE/ARB and regular exercise to lose weight will further retard the progression.
Based on my experience if the patients is following up regularly and following all precautions patients have been on conservative management for over 10 years without dialysis.

More water is better for the kidney only in cases of acute kidney injury seondary to dehydration, not in chronic kidney disease. With your creat I would recommend less than 1.5 litre of fluid per day.

I am sure you have many doubts, please feel free to get back to me

Regards

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. Rakesh Madhyastha (23 hours later)

thank you again Dr. Madhyastha. Your expertise have been very helpful to me. I have some questions regarding my medications. I am currently taking 150mg of Avapro daily, taken in one dose in the morning. I take all my previously mentioned rx meds at once at the same time in the morning. Is this the best way to take them especially the Avapro, dyrenium, hygroton and atenolol or is it better to take them in the evening? Also I have been keeping track of my blood pressure more closely since our discussions began and I am noticing that my values stay about the same for about 21hrs 125-130/62-70 after taking the meds in the morning. Then the values increase up to a XXXXXXX of 145/84 for the last 2-3 hrs of the 24hr period before my next dosage of meds is due. I am concerned about these higher values and am wondering if my 150mg dose of avapro is adequate. I also take 50mg hygroton daily. I used to take 100mg daily for many years and then it was suggested to reduce to 50mg about a year ago. Should I be on a higher dose of avapro perhaps 150mg q12h or 300mg/day taken once daily? I also tend to remember that my doctor told me my systolic should be under 125 for the Avapro to be working properly. What should my bp values be best maintained at? I would rather be somewhat hypotensive if this helps my renal function than have my bp too high. Thank you again for all your help. XXXXXXX

Answered by Dr. Rakesh Madhyastha (18 hours later)

Brief Answer:
Correction of hypertension

Detailed Answer:
Hello

Thanks for getting back. Since there are several questions, I will try and address them one by one so that I dont miss any

1. It is always a good idea to space the antihypertensives. However we dont really advice them to space and take it every one hour because the compliance of the patients falls as it is difficult to remember and take them every one hour or so.
2. I recommend taking Blood pressure medicines in the mornings, while sleeping at night the heart rate and blood pressure anyway falls due to normal physiology
3. It is ok if there is that much of a spike before the next dose, however I recommend increasinf the dose of Avapro further to attain much better blood pressure control. This will help retard the progression of kidney disease
4. dose of avapro should be under strict supervision. It will be difficult for me to adjust the dose through online consultation. Perhaps you can meet your doctor with my suggestion. One has to monitor blood pressure, creat, potassium and protein loss with avapro
5. I recommend blood pressure to be below 125 systolic
5. It is a very bad idea to be hypotensive, it will lead to other side effects like giddiness, reduces attention span,etc. One should try and maintain normotension

Regards

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Rakesh Madhyastha (34 hours later)

Thank you Dr. Madhyastha. Thank you for clarifiying that the systolic should be maintained below 125. However, how much below is ideal for retarding the progression? Is it better to be in a range of 110-115, 115-120, or 120-124 or are these values not significant as long as it is less than 125? I am 5 feet 10 inches and weigh 180 lbs. My goal weight is to be at 165-170 lbs which I have started working on already. I have also reduced my fluid consumption to less than 1.5l daily and started to reduce protein and salt as recommended however I will consult with my doctor regarding working with a dietician. Thank you again for all your advise. XXXXXXX

Answered by Dr. Rakesh Madhyastha (4 hours later)

Brief Answer:
Blood pressure

Detailed Answer:
Hello

I usually try and maintain blood pressure between the range of 116 to 125. I try and balance between the best blood pressure and symptoms of low blood pressure like gidiness, tiredness, etc

I am glad I was of help, please feel free to clarify any doubts with me.

Regards

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. Rakesh Madhyastha (3 days later)

Hi Dr. Madhyastha. I have a question regarding vitamins and supplements. I heard recently that fish oil would be good to take for kidney support, about 2000mg per day. Is this true to your knowledge? Also are there any other vitamins or supplements you would recommend taking at this time to help my kidneys? I don't think I mentioned before that I have chronic low back pain which I have been treating for years. I avoid all nsaids except for an occasional aspirin for headache however I do take 2-3 vicodin 7.5/325 per day to control the pain. Is the acetaminophen ok for me or would you try to reduce if possible? What about 100mg tramadol which I started taking again about 2 months ago? I used to take the tramadol years ago but stopped taking it in early 2012. Thank you again for your advise. XXXXXXX

Answered by Dr. Rakesh Madhyastha (22 hours later)

Brief Answer:
Not in regards to your kidney disease

Detailed Answer:
Hello

Thanks for the query

It is true fish oil, that is omega 3 fatty acids are used to reduce protein loss. This is used only in patients with a biopsy proven IgA nephropathy. When given without actual basis it tends to increase the cholesterol and does more harm than good.

I only recommend the regular over the counter multivitams, but this is only in people who are not feeding well or have lost their appetite. If one is able to follow a normal diet then I wouldn't be giving any additional vitamins

Please avoid NSAIDs, including aspirin. Stick to Tramadol or Paracetamol ( Acetaminophen). The problem with Tradamol is that it has addictive properties. You can take it once in a while. My other suggestion is to use topical applications of diclofenac and hot packs.

I am so happy you are asking me questions. Some patients of my shy away from asking me questions and believe what they find on google, it does more harm than good.

Regards

Above answer was peer-reviewed by : Dr. Arnab Banerjee

Follow up: Dr. Rakesh Madhyastha (4 days later)

Hi Dr. Madhyastha. I sincerely appreciate all your advise you have provided me. Some other questions came to mind. What would you advise me as the range of sodium intake daily and protein intake daily given all our past discussions and my history. As I mentioned before I started to significantly reduce my sodium intake and also reduce my protein intake as well. I basically stopped eating all red meat and significantly reduced most other white meats with the exception of fish which I am trying to have 1-2 times per week. I purchased a high grade kitchen scale to better portion foods by weight. I read that chicken and fish have about 30g of protein per 4oz serving. Is this correct to your knowledge? As I mentioned before I used to eat all meats and especially red meats several times per week without reference to weight and gram amounts of protein. Regarding the protein amount per day, on days that I eat chicken or fish, how should the percentages be divided? As an example if the XXXXXXX protein per day is 40g, can 30g be from animal protein and 10g from fruits and vegetables? Or should the animal protein be less? Also, regarding my diet is it ok to have some low sodium cheese like ricotta occasionally which has 60mg sodium per one quarter cup [62g] and 5g protein? It is the lowest sodium content cheese I could find. I will be doing the 24 hr urine on approximately January 3. I wanted to try and institute all the measures you have suggested to me for at least one month before doing the test with sincere hopes that my gfr will be significantly higher than the blood serum calculated value of 32 from 11/5/15. As I mentioned before my last 24hr urine was 11/14 with gfr 60. This huge drop is what prompted all my discussions with you. Thank you again for all your advise and professionalism. XXXXXXX

Hi Dr. Madhyastha. I would like to list all the medications I currently take and have you review them. I would like to reduce or eliminate any of the medication that is non essential to my health and may be negatively affecting gfr, bun, proteinurea and the overall health of my kidneys. With my new diet of restricting sodium, animal protein and protein in general and watching consumption of fatty foods would reduction or elimination of some medications be possible in your opinion. I am very willing to try this if it may be beneficial to my kidney health. Be assured I will not change any medications you may suggest without consultation with my internist/nephrologist. My medications are: atenolol 100mg/day, dyrenium 100mg/day, hygroton 50mg/day [this was reduced from 100mg/day for many years to 50mg/day about one year ago], bumex 1g/every other day[if ankle edema is an issue], potassium chloride 20meq/day, Avapro 150mg/day, Lipitor 40mg/day, allopurinol 300mg/day[for prevention of kidney stones not gout], Cymbalta 60mg/day[forchronic back pain which I mentioned to you before , vicodin 7.5/325 q6hr prn back pain and acyclovir 800mg/day with Valtrex 500mg/day[for control and prevention of chronic recurrent herpes labialis]. Is it true that hygroton[thiazide diuretics] can further reduce gfr and increase bun in patients with ckd? Should I consider eliminating it? I thought I read somewhere that allopurinol also can have a negative effect. Can I eliminate it if I watch oxalates and calcium? Last blood test 11/5/15 bun 48, creatinine 2.15 as I mentioned before to you. Also I would like to send you this entire lab report but I don't know how to attach it to my correspondence. Thank you. XXXXXXX

Answered by Dr. Rakesh Madhyastha (31 hours later)

Brief Answer:
Keeping it simple

Detailed Answer:
Hello

Thanks for getting back

I am happy that you are taking utmost care of yourself. I would like to make things as simple as possible for all my patients so that the disease does not become a burden. Here is what I do

1. I tell my patients that they should only avoid red meat. They can have sea food, chicken and egg ( white) twice a week. That is 2 days each. This keeps the protein intake in check. Please make sure to eat in moderation ( 1 serving)

2. Restrict salt intake by avoiding processed food and food obviously rich in salt like chips, fast food ( burgers, pizza, pasta), chips, popcorn, etc. Be careful about the serving while cooking. Measure it and make sure not to exceed 1.5g/ day

Medications

I see that you are on many diuretics. If you are going to cut down on your fluid intake you can come down on them. Please speak to your doctor next time on reducing them. I am in no capacity to suggest which diuretic to reduce without examining you

I recommend Febuxostat instead of Allopurinol. Allopurinol has shown some negative effects in CKD.

Thiazides increases BUN and Creatinine only when one is dehydrated otherwise it has no rule in progression of CKD

Please get back to me with the reports, you can attach them or mail it to customer section and they will attach it onto my dashboard (simply mail it to ' YYYY@YYYY ' and put the Subject as ATTN:Dr Rakesh Madhyastha & it'll be send to me).

Regards

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Above answer was peer-reviewed by : Dr. Arnab Banerjee