Cool Beans: Journal Watch

by Robin Rose MD

SPRING CLEANING TIME

My pile of reading materials grows - I tear out tid bits from ASN’s KIDNEY NEWS … and decided to share some insights (so I can toss out a pile of scraps) !

INCREASED CREATININE AFTER STARTING ACE inhibitors and Angiotensin receptor blockers CAN INCREASE CARDIORENAL RISK

(BMJ 2017)

🪷Even small increases in creatinine after starting these medications have been shown to cause increased cardio renal events.

🪷 In a study in England with over 122,000 patients - 1.7% had creatinine increases of 30% or more after initiating renin-angiotensin blockade medications. The outcome was increased end stage CKD, heart failure, heart attacks, arrhythmias, peripheral artery disease, and death. Generally these were older people with more layers of comotbidities and medications. Even those with with less than a 30% increased creatinine endured some complications.

🪷It is known that often patients experience at drop in kidney function when starting ACEi/ARBs. This study sought insight into long term consequences.

🪷 They concluded that the cohort with increased creatinine after initiation of these meds is a high risk group that requires closer monitoring.

🪷 RENOLOGY perspective:

proactive awareness at the earliest onset of CKD and truly any time after aims to lower cardiovascular and endothelial risk. This demands strict observance of the low hanging fruit mind set - true constraint and true confession to many wider kidney tree of lifestyle choices. Lower salt and protein while alkalinizing, organic food. exercise, practicing heart healthy joy. and working with a clinician knowledgeable enough to guide supplementation and peptide/bioregulator choices. There is a place for pharmaceutical therapy and then - there’s a strong call for involving nature in achieving the desired goals. That takes intention and true willingness. Mindful observation and proactivity are our allies.

OXALATE EXCRETION & CKD PROGRESSION

(JAMA Intern Med 2019)

🪷In a JAMA study, 3123 patients in stage 2-4 had 24 hour oxalate excretion tests. When results were 18.6mg/24 hours the GFR began to fall. This was associated with proteinuria as well.

🪷 They did long term follow up. High levels of urinary oxalate can cause acute kidney injury. They defined higher levels as an independent risk factor in progression to end stage failure.

🪷 RENOLOGY TAKE HOME:

Oxalates have a negative effect on kidneys even in those who haven’t had calcium oxalate kidney stones. The effect on tubules is described like little razor blades causing damage. And since we do not routinely monitor tubule function - this can result in hazard under the radar.

🪷There is value in monitoring for Oxalates in CKD.

From chat gpt, here is a thumbnail:

☀️In Organic Acids Testing (OAT), the primary markers that suggest oxalate metabolism issues are:

🍃Oxalic Acid (Oxalate)

• Direct marker of oxalate burden.

• Elevated levels can indicate:

  • Endogenous overproduction (e.g. from vitamin C metabolism, glyoxylate pathway issues).

  • Poor oxalate clearance (e.g. in kidney dysfunction).

  • High dietary intake of oxalates.

  • Yeast or fungal overgrowth (especially Candida species)

🍃Glyceric Acid

• Elevated in Primary Hyperoxaluria Type II (PH2).

• A defect in glyoxylate metabolism leading to excess oxalate.

🍃Glycolic Acid

• Elevated in Primary Hyperoxaluria Type I (PH1).

• Suggests dysfunction in the enzyme alanine-glyoxylate aminotransferase (AGT).

🍃Interpretation Considerations:

• Combine with symptoms: kidney stones, joint pain, urinary discomfort, or autism-spectrum behaviors in children.

• Gut health and yeast markers: High oxalate often correlates with markers like arabinose (suggestive of Candida overgrowth).

🪷Supportive labs (outside OAT):

• 24-hour urinary oxalate.

• Plasma oxalate (in advanced kidney disease).

• Genetic testing if primary hyperoxaluria is suspected.

🪷 SELF MOTIVATION: use cronometer.com to track oxalate intake. It’s impressive to realize how much more Oxalate is being ingested than one realizes. Things like carrots and ginger can increase the level. Best to collect your own data!!

Limit oxalate intake to 50-150mg a daily. Add B6 and consider using the herb Chanca Piedra (as supplement or as fresh herb in tea). Stay safe!

NON-DIPPER BLOOD PRESSURE AND CKD

(Am J Kidney Dis 2022)

🪷 Normally blood pressure drops at night. In CKD this may not happen - it’s often missed because BP isn’t generally checked at night.

🪷 The circadian drop (night time to daytime BP) is protective. Those without this benefit may be at marked increased risk without even knowing it. Absence of nocturnal dipping is a risk factor for adverse cardiovascular and renal outcomes.

🪷 Routine night time monitoring is indicated in all CKD cases - defining the actual hypertension burden with a circadian BP profile let’s us define risk stratification for higher risk patients.

🪷 RENOLOGY INSIGHT

Protection is the intention- regular 11pm monitoring can give us the opportunity to protect and prevent. Make this part of your self-loving CKD lifestyle

🪷 MORE TO COME! 🪷