 The show for people who care about their health and the health of our planet on the think tech live streaming network series. I'm your host Dr. Grace O'Neill joining with today is Dr. Sheenam Joshi, a nephrologist. Today we are going to talk about kidney health. So let's get into it. So, why don't you tell us what the kidneys do for those people who don't know. Yeah, the kidneys do a lot. They are these wonderful organs. They're about the size of the fist. We have two of them in our flank area in the back on both sides. And they help keep everything in line. They help keep your sodium levels in check. They regulate all the electrolytes. They help us with the amount of fluid in our body. And we see all of that as urine and we, you know, we kind of take it for granted every time we go to the bathroom and urinate. But for people who have kidney problems and can't do this or have failing kidneys. All of this just accumulates in the body. So imagine if you couldn't urinate and all that urine just sat in your body and you know that wouldn't feel good. And yeah, that's not good. No, that is definitely not good. And a lot of people have kidney disease in the United States. Can you tell us about what percentage or how many people are suffering from kidney disease in the United States. Yeah, like 16 or 17% of people have kidney disease. A good portion of them don't know they have kidney disease. But as you develop health problems like high blood pressure and diabetes that percentage does increase. So, for people that have high blood pressure it's about one in five and for people who have diabetes it goes up to one in three. You know, that's really, really bad for diabetes is, you know, sometimes I've seen actually in because I work somewhere where I see a lot of younger patients and, you know, they have an elevation in their creatinine and is it ever okay to have an elevation one of my, one of the residents said that he was told by his physician that because he had, you know, a high body mass, I mean a high muscle mass and because he was on a keto diet it was okay for his creatinine to be elevated is it ever okay. I guess you know, you couldn't explain what a creatinine is it's something that kind of used to measure kidney function but is it ever okay for that to be high. Yeah, exactly. So, so creatinine is this blood test it's a compound in the blood we measure it as that number goes higher. That actually translates into a lower percent kidney function which often shows up as a GFR or estimated GFR which stands for glomerular filtration rate, and that roughly correlates to percent kidney function. And going back to your question. Some people do have a high creatinine because they do have a lot of muscle muscle mass amount of muscle you have in your body does affect that number. And conversely some people have a very low creatinine. And as you would expect people who don't have a lot of muscle mass, like older women often have a very low creatinine serotics often have a very low creatinine they don't have a lot of muscle mass. So looking at that number alone can be misleading so it's good to look at that e GFR number and see what number that's giving you. And sometimes that can be off because you might have more muscle mass than expected. So if you're still in doubt, a kidney doctor or even your primary care doctor can order another test called a size that and see your sister and see. And that test can also tell you what your GFR is and then that might be able to give a better representation kidney function. How about supplements? Do supplements affect the creatinine? I mean if some of these younger patients are taking a lot of supplements like creatine, is that something that would affect your creatinine? Yeah, absolutely. Taking a ton of creatine will definitely get metabolized into creatinine. And that could affect kidney function. I've seen that before. Eating a lot of meat can do that because that's muscle. It's not your own muscle. It's another being's muscle and you ingest that and then you can develop, you can increase your creatinine that way. So if in doubt, you can repeat the test without having a T bone steak or something like that and without having all that creatine powder right before the blood test. And you may get a different result or like I said you can do a sister and see or you can even do 24 hour urine collection to really be accurate. So do you recommend that people stay away from those supplements? If they are increasing the creatine, can that do long term damage to your kidney if you are on those supplements? The creatine supplement I don't think will do long term damage. I think it just messes up how we assess for things. It just makes it harder for us to test. So if you're in that situation and if you're going in for tests and maybe you've had kidney problems in the past or you have a little bit of kidney disease, probably not a good idea to take that supplement right before you be tested because then your doctor will be confused and you may get more or less treatment depending on the result. But I think I haven't read anything that these supplements cause harm again. It's not encouraged to take more supplements than you need because you don't know really what's in there. These are not well regulated. There could be contaminants. But what I find frequently is people do a lot of protein and then that's really controversial with the protein, whether to do protein or not to do protein. Yeah, so I mean, are those protein supplements? Could they be possibly harming the kidneys if they are from animal protein, for instance? Yes. Yeah, so there's some observational literature that suggests that eating more animal protein can be detrimental to the kidney. People have increased risk of developing kidney disease or kidney failure. Granted, these aren't your ideal experimental trials. This is just looking at people and noting associations. But that whole question, does eating a lot of protein in general cause problems to the kidneys? There's a lot of evidence for and against and I've written papers on this and tweeted about this. But what we do know, or at least what we're fairly confident of is that eating a lot of protein if you already have kidney disease is not a good idea. And actually, the guidelines in our societies recommend restricting amount of protein as being consumed so that you're not overdoing. You don't want to take out the proteins. Obviously protein is important for health. You want to make sure you get enough protein so you're not becoming malnourished, but you want to not overdo it. So the ideal amount is getting it right in the normal range, which is around 0.6 to 0.8 grams per kilogram of ideal body weight. How about vegetable protein? Can people with kidney disease have vegetable protein? Does that seem to cause the same harm as animal protein? Vegetable protein is thought to actually be a little bit easier on the kidneys. There's a couple studies to suggest this, that vegetable protein may be helpful for the kidneys. And it may cause less of a burden to the kidneys and they may have some added benefits for the kidney. And people previously used to avoid vegetable proteins because of this concern with the potassium and phosphorus. But what we're learning now after having a few more decades of research, we're realizing that actually this may not really be as big an issue as we previously thought. We think actually these foods may not cause problems with phosphorus or potassium. It actually may be really healthy and helpful for patients to eat. So how much, if you already have a little bit of kidney disease, how would you gauge how much of that plants and plant foods can you have if you're already kind of afraid that you might have too much phosphorus or potassium in your diet? How would you gauge that? Yeah, so if you already have kidney disease, it can be a little tricky because there's a few things that you have to monitor. But so for all patients with kidneys, I recommend seeing a dietitian who's skilled or specifically a renal dietitian or dietitian that manages kidney disease to help guide you in the situation. But what I tell my patients is I tell them to eat a healthy plant-based diet to make to incorporate a lot of healthy fruits and vegetables, cut out the process, fast food, fried food, added sugars, sodas, things like that. Because those healthy foods, fruits, vegetables, whole grains, legumes, nuts and seeds, really are some of the healthiest foods on the planet. And people who have health problems need to be eating those foods so they don't develop more health problems. I mean, can you explain the concept of hyperfiltration and how the protein is related to hyperfiltration and the kidney where the kidney works? Yeah, so people think that there might be a benefit to this, like there's a reason why this hyperfiltration process happens. So hyperfiltration means you have more blood being filtered by the kidney. It is what it sounds like. And this happens in certain states. So when women become pregnant, hyperfiltration is happening because there's more blood flowing in the body. This also happens when people eat more protein. And the reason for this is that protein, some of those metabolites need to be excreted in the urine. And so the way that this is done to prevent it from accumulating in the blood is that the kidneys receive more blood during that period of time. And those toxins are ultimately filtered out, those metabolites come out in the urine. This also happens in pathologic states like diabetes. So there's hyperfiltration happening in diabetes. This can also happen in certain kidney disease states as certain portions of the kidneys start to decline in kidney function or some parts of the kidney stop working. The other parts of the kidney kind of pick up the slack. So a good example is when someone donates kidney or loses a kidney, the other kidney picks up the remaining work and it goes into this hyperfiltration state. This can be bad if the kidneys are already struggling. So if the kidneys are struggling and they go into this hyperfiltration state, it's kind of like making a card that really is kind of old and beat up. And that's putting it like on the Daytona 500. You know, it's not a good setup. You know, after a while it's going to start to burn out. And that's kind of what happens in kidneys that aren't working so well when people do things that taxers or even without their intention just happens normally. So could you maybe decrease the protein in your diet to kind of decrease, you know, the amount that the kidney needs to filter with that make less impact on your kidney, theoretically. Yeah, yeah, absolutely. So we frequently tell our patients to avoid eating too much protein. So the idea is not to restrict protein entirely or to cut protein out because like I said earlier you need protein for survival. But the idea is to avoid overdoing protein. So you don't want to eat protein protein protein. So what we say is 0.6 to 0.8 grams per kilogram per day somewhere in that area. You don't want to be eating two grams of protein per day. That's, you know, two grams per kilogram, I should say that's just too much protein. And that could put your kidney into trouble that that all that protein causes hyper filtration. And the idea is the medications we get to treat people who have kidney disease is actually to undo the hyper filtration. So, what would you say, have you ever seen somebody go on a plant based diet or any kind of diet and be able to reverse or kind of slow down at least their kidney disease. Yeah, definitely. I have seen people go on plant based diets. There are definitely stories. I mean, you could even go with some people have had a remarkable response with plant based diets. Other folks have gone on plant based ice and have slowed down the progression of the kidney disease. Other folks have had improvements in their diabetes or high blood pressure. That has was contributing to the kidney disease and they've been able to improve these other health problems that were affecting the kidneys. Other folks have had improvements in some of the complications of kidney disease, and thereby have been able to take less medications like less sodium bicarbonate to neutralize the acid and die less phosphate binders. So I've seen a lot of results with this. I mean, what if you already have kidney failure, and you're on dialysis, is it worth it for these people to go on a plant based diet, would you say like suppose you're already getting progenial dialysis or you know, hemo dialysis. Yeah, I think it's still worth it for a lot of reasons. Yeah. We, we recently wrote a paper on this and the potential benefits of folks eating a plant based diet while on dialysis. And, you know, there's the fiber aspect, a lot of people on dialysis have constipation more than 50% of people. So the fiber can help with that fiber can help control potassium levels. It can reduce blood pressure can help reduce phosphate and acid levels. And then the other thing is, if you're on dialysis, the healthier you are while on dialysis the better it is because if you ultimately apply for kidney transplant, or on the waiting list. And dairy everyone that's on dialysis should be evaluated for kidney transplant so potentially all these people, you know the healthier you are the better, the better it could ultimately be for when you go on, get a transplant. Yeah, that's a good point and I mean also just being on a plant based diet decreases your risk of so much. So many other diseases, you know, diabetes, you know heart disease of course. So that's definitely a good point. Now, I'm going to shift gears and start asking you about kidney stones because a lot of people they don't necessarily have kidney failure but they suffer from kidney stones. So, you know, the most common kind of stone is a calcium stone calcium oxalate stones. And what can people do to kind of decrease their recurrence of having a stone if they've already had one, or if they don't want to ever get stones I guess, what can they do with their diet. So kidney stones are pretty common. People get them and as you mentioned the most common was calcium oxalate. And a lot of my patients think that because they had a calcium oxalate stone they need to cut back on calcium. And for most people that's actually not true and there's been studies on this and we've talked about this in a couple of presentations and we're working on a paper at the moment on it. But at any rate, the main things to remember and anyone has had a calcium oxalate stone is to one drink more water. Water helps dilute the urine, concentrated urine helps form crystals and stones. So drinking more water turns that, you know, those potential crystals and precursors to stone formation into more soluble compounds that prevents their aggregation. So water is important. I counsel patients to get at least two liters so in order to get two liters you should be drinking two and a half, maybe even three liters of water per day. And it's helpful to carry a little reusable water container with you and you can fill up at work at home on the go. And that and you know you can keep track how many, you know, times have you filled it up throughout the day and that kind of helps to go so that's number one. Number two is to cut back on salt. Salt, the more salt you eat, the more salt you have to melt your pee out in your urine. And for reasons that we don't fully understand. For every time you pee out salt, you're actually peeing out calcium and you don't want calcium in your urine, because calcium is a important element ultimately used to form calcium based on so you don't want calcium in your urine and the way to do that is to reduce the amount of sodium that you're taking in your diet. And a lot of people don't know that the third thing is animal protein animal protein acidifies the year and promote stone formation, specifically calcium oxalate stone formation. So it's been recommended time and time again to actually avoid all animal protein. And this includes red meat, chicken, fish, seafood, pork, eggs, all these proteins that come from animal based sources acidify the urine, help promote stone formation so I help patients all the time to reduce their animal protein intake actually get plant protein which actually alkalinizes urine we think of alkaline water, but actually plant foods are alkaline foods they're even better than alkaline water. And then, and then eating a lot of fruits and vegetables can help neutralize on some of the stones that are being formed it can help prevent stones. So there are those are the big things. And for this is just not necessarily for kidney stone patients but how much fluid would you recommend somebody get per day because I know there's some crazy diets now that they're recommending you know people have like a, a lot of water which is not harmful I'm supposing if you're, you know, your body can filter that water and everything but how much do you recommend like, you know, like, is it to, is it how much you weigh, you know, an ounces that you get or what is your recommendation for people. Yeah, maintain their kidney health, you know. Yeah, so you definitely want to drink to thirst, unless you have heart chronic heart liver kidney issues. You know that it just you know to have a glasses of water day. I think that was later, not found to really be evidence based, but you know the idea is to drink to thirst, make sure your urine is not getting too concentrated because that could lead to forming a stone. So why are you're into be on, you know, light yellow kind of like a light lemonade to on the clear side unless you have a pre existing health or more or less your doctors told you otherwise but most people should drink on specifically water and not something else that's actually probably an equally important point is what people are drinking and then when you do drink water try to not try to avoid getting too thirsty. And just giving back to the topic again of the stones. I did have a patient that had been on a plant based diet for a long time, and, you know, was very healthy otherwise but he kept getting the calcium oxalate stones because you know a lot of the leafy green vegetables have them. So is there anything you would recommend for those patients that are already on a plant based diet they're eating pretty healthy and they just don't know what else they can do. I mean, I know there's a vegetable like or rock that's supposed to be quite nice you can grow in your garden but not everybody has the resources right so I don't know if you have any extra recommendations for those kind of people. Yeah, so some high oxalate containing foods can cause problems with some people. There's this oxalate issue is, is a big topic and probably bigger more complex than we have time for but if you, if, first, if we know it's always important to know that you are that is being affected by this is the only way to know this is to do a 24 hour urine collection to know how much oxalate truly is in your urine and if you are one of those few people that have a lot of oxalate urine. You definitely want to see a kidney doctor there are some ways to reduce the oxalate I have done this with some of my own patients. Some great ways to do this are to cut back on eating high oxalate containing plant foods so this includes some nuts and seeds chocolate rhubarb star fruit cashews, these types of things you kind of want to avoid they're really high there's list of oxalate yeah. And then you can also try to eat calcium containing foods at the same time or some people you need a calcium supplement, antibiotic exposure believe it or not can increase oxalate absorption so there's a whole a lot of a bunch of things that go into it. But if you follow to this category definitely see a kidney doctor. Yeah. I mean, another thing this is another question. If somebody has kidney disease and they're trying the plant based diet. And they're losing a lot of weight. Is there something you could recommend for those people. Yeah, so, so if, if you are. Regardless of you have kidney disease or not and you are on a plant based diet, and you are losing weight. Always, you know, it doesn't hurt to see a dietitian. But if you're unable to don't have access, some ways to increase your calories is, you know, eating more food that's fairly intuitive. But one way to do that is to actually eat more more food that is higher in calories so a good way to do this nuts and seeds, peanut butter tahini almond butter. These things are high in calories. Some people we plant based eat a lot of raw on completely on processed food, eating a slightly more processed food than complete raw will help you gain more calories. And then smoothies smoothies are a great way to add calories to your day on that category. Yeah, so we're going to have to wrap it up soon so I just want to let you have the opportunity to tell our listeners where they can find you if they, you know, want to get in touch with you or they're interested in what you have to say. I know you have a nice blog so if you can let them know about your blog and your website and I don't know Eric if you're able to show the website that I put on the form. Yeah, so if if anyone out there has questions you're more welcome to email me my email is on my website. I'm on Instagram and Twitter as Joshi and D that's S J O S H I M D for both of those Instagram and Twitter. I'm more active on Twitter I'll say, and then my website is afternoon rounds calm I have a whole webpage on resources links to free papers I have lists of dietitians I have videos of lectures I have a lot of resources for patients for anyone interested. Thank you so much Dr. Joshi so we're out of time we're going to wrap it up now. I'm Dr. Grace O'Neill this is healthy planet on the think tech live streaming network series. We've been talking to Dr. she from Joshi nephrologist. Thanks to all of you for being here and thanks to Eric, our broadcast engineer and the rest of the crew at think tech for hosting our show. And thanks to you are listeners for listening. I'll see you on June 9 for more of healthy planet on think tech, the show for people who care about their health and the health of our planet. Our next show will be about coral health with coral biologist Wendy cover. If you have ideas for the show, please contact me at healthy planet think tech at gmail.com. Check out my website at grace and Hawaii.com for more information on my projects and future show guests. I'm Dr. Grace O'Neill Aloha everyone. Thank you so much for watching think tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram, Twitter and LinkedIn and donate to us at thinktechhawaii.com. Mahalo.