Dear Poubis
It can be difficult to give individualized answers at a site like this as, even though you have told me some of the information about your husband, there is much I do not know.
For example, you have not given me his ‘diagnosis’.
While hypertension is commonly associated with CKD, it is not very often the sole cause … perhaps with the exception of renovascular disease (as a diagnosis). But, renovascular hypertension is a state more commonly seen - as a diagnosis - in older patients and not in 35 year old men with an onset of CKD well before his 30th birthday – as would seem to be the sequence in your husbands’ case.
From a distance, and not knowing all the facts – an elevated blood pressure in a young man with proteinuria and CKD seems more likely to be a secondary rather than a primary feature.
Has he has a renal biopsy?
I would be awfully suspicious, from his story, that his underlying disease might actually be glomerular disease: eg. FSGS … and that his elevated blood pressure is simply an outward expression of an underlying glomerular lesion.
As for protein restriction … and this is a question (or my answer) that you may want to copy into Lee-Ann Smith’s ‘expert’ site for her to comment … I am not such a fan!
Let me tell you why.
In the 40’s and 50’s of the 20th century, Giordano and Giovannetti popularized severe protein restriction to levels like 0.3 gm/kg/day to delay death from CKD. It worked – to a point. Remember: this was the days BEFORE dialysis was possible. The theory was that if you restricted protein, the production of nitrogenous waste ( the end-result of protein metabolism) would be less, and the symptoms of ‘uraemia’ would also lessen. Also, to a point, that happened.
But, this was a huge cost. This level of protein restriction led to gross negative protein (nitrogen) balance with wasting and malnutrition … so, while in the pre-dialysis days, patients lived a little longer and with less symptoms of uraemia, the trade-off was that they developed gross muscle wasting and weakness.
Then along came dialysis. This led to a rapid move away from the draconian protein restriction diets of G&G and towards earlier dialytic support. It was though better allow a patient to get to dialysis a little bit earlier but in positive nitrogen, protein, nutritional and muscle balance and to avoid the profound wasting of protein denial.
Most nephrologists, I think, would still support that attitude.
Negative nitrogen balance can be a mean and insidious beast. Personally, I don’t ascribe to it. I like my patients to be well nourished – even if they do come to dialysis a wee bit earlier than if I had wielded the draconian dietary axe!
When I was training in the early 70s, we had an easy-recall dietary prescription: 60/60/60! That was 60 gm protein, 60 gram sodium, 60 gram potassium. Note: there was no reference to body weight! Things were simplistic then … perhaps too simplistic. And … I think 60/60/60, too, was wrong. Yet that is what I learned to use.
Now, we use /kg body weight as the yard-stick. This recognizes that a 45 kg elderly lady is a very different organism, with different dietary and metabolic requirements, when compared to a 300 lb line-backer (US) or a front-row rugby league player (Aust).
My rule of thumb … but note, I an NOT a dietitian and I am more than prepared to be rolled on this by Lee-Ann Smith (please ask her) … is that even 0.6 gm/kg body weight/day protein intake (used by some) cuts it too fine and that, broadly, 0.75 gm/kg body weight/day sustains normal protein (and nitrogen) balance and yet is still a marked reduction on the average protein intake of western diets, which can be close to double that level!
So … I am a 0.75 gm/kg/body weight per day protein intake guy.
That is enough protein to maintain +ve balance but is still a significant reduction on the ambient dietary protein habits of a western society.
As for salt … yes, salt restriction will help to control blood pressure. I do think that, in most circumstances, 2 grams a day is a bit harsh – but it is doable – and it is hard to comment more without knowing the difficulties (or otherwise) of his blood pressure control.
3-4 gm/day is a kinder goal … and is still way, way less salt than is common for most western diets. But, I’d need to know much more to be proscriptive.
Re using diuretics ‘to decrease the amount of protein he was spilling’ … I wonder if this might have been an error in your interpretation of what was said. To be honest, I really don’t think that most diuretics actually – of themselves – have any impact on protein excretion …. OTHER THAN through the reduction of the blood pressure itself. Certainly, lowering blood pressure will help to abrogate (diminish) proteinuria - no question about that - so, it is not so much the diuretic itself that has any effect on the protein leak, but the reduction in proteinuria is end result of better blood pressure control.
Some blood pressure agents DO reduce proteinuria in their own right … ACE inhibitors and ARB agents both do this. Sometimes, a variety of thiazide diuretic derivatives are added to ACEI and ARBs (often in a combined pill) to help control blood pressure… and it may be here that you misinterpreted or misunderstood a little. Don’t worry – it’s a complex area.
ACEI and ARB agents are commonly used to delay the progression of CKD – and they are very good at this. There was a fashion for using both together for an additive effect but a recent trial (called the On-Target trial) brought that practice into question. Hmm … am I absolutely convinced that they are bad as a combination? … to be truthful, I am not. What is clear is that they should not be used together in advanced CKD. Earlier on in the early phases of CKD and/or in diabetics who hyperfilter, despite the On-Target trial, my own view here is that the jury is and should remain out.
As regards creatinine and diet - the actual title of your post - there is little in diet that impacts creatinine other than some of the high protein supplements that body builders use and which ar so high in creatine that this can have an adverse effect on renal function. Creatinine, itself, is still more a marker of GFR.
Your question re diuretics impacting on volume and thus on renal perfusion can be relevant … but usually only when an intercurrent illness perturbs the overall volume status. I’d usually not be anxious - in a stable CKD patient - about this as a practical issue.
While some diuretics - you didn’t say which he is taking - like spironolactone, act differently to the loop (eg: frusemide) and thiazide agents, these can be regarded similarly from the volume aspect. Potassium can be an issue - especially in diabetics, the elderly or those on concurrent ACEI or ARB agents … but i doubt that is a factor in your husband’s case.
As for encouraging his exercise – absolutely!
I think I have dealt with most of your questions. I would suggest you ask Lee-Ann about her responses, as a dietitian. Ask her to read my answer here, too … and ask her to be critical of my response too. Nephrologists tend to shove diet off to the dieticians … mainly ‘cos we don’t have a clue!
Hope that’s helped.