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Inflammation and Chronic Kidney Disease

What is inflammation?

Inflammation is an immune response that occurs when the body’s white blood cells and immune-fighting chemicals work to protect it from infective and foreign substances, such as bacteria, viruses and injuries. The white blood cells are carried through the blood stream to the site of infection or injury. The site becomes warm and red, with increased blood flow to the affected area. Inflammation is a normal occurrence that helps keep your body healthy.

There are two types of inflammation: acute and chronic.

Acute inflammation occurs for a short period of time. Acute inflammation can happen at the onset of injury or infection, and last for minutes or days. Once the injury or infection has responded, the inflammation process stops.

Chronic inflammation occurs over a long time and may never go away. Inflammatory chemicals are continuously released throughout the body as a result of the chronic inflammation.

Inflammation is the natural defense the body takes on when it is under attack. But inflammation can also occur when there is nothing to fight or fend off. In this case inflammation “turns on the body” and can lead to diseases such as rheumatoid arthritis, hay fever and atherosclerosis. Some researchers blame inflammation as the cause of Alzheimer’s disease, heart attacks, diabetes and cancer. People with chronic kidney disease (CKD) can experience chronic inflammation that can lead to cardiovascular disease and even an increased rate of death.

What causes inflammation in people with chronic kidney disease?

Inflammation in people who have chronic kidney disease can be caused by:

  • Poor nutriton due to poor appetite
  • Dialysis vascular access infection
  • Gum disease or poor dental health
  • Foot ulcers
  • Anemia
  • Uremia (extra waste in the blood)
  • A transplanted kidney that no longer works

Other causes of inflammation that affect people who do or do not have chronic kidney disease include:

  • Infections that linger
  • Toxins
  • Pollutants
  • Insomnia
  • Lack of exercise
  • Obesity, especially if large amounts of fat are around the stomach

How do I know if I have inflammation?

Symptoms of acute inflammation can resemble flu-like symptoms and include:

  • Redness
  • Fever
  • Chills
  • Swollen joints, warm to the touch
  • Fatigue
  • Muscle stiffness
  • Loss of appetite
  • Headaches

People with chronic kidney disease may not experience all of the symptoms. They may have additional problems like anemia, anorexia, muscle wasting and weakness.

To detect chronic inflammation, doctors look at several lab results. C-reactive protein (CRP) is a protein that increases with inflammation. Levels are normally < 1 mg/dL; higher levels of CRP show inflammation is present. An increase in CRP is associated with coronary artery disease, stroke and heart attack in patients with chronic kidney disease. Studies have shown that dialysis patients who have high CRP and low albumin levels are hospitalized more and are more likely to die.

Serum albumin is a blood protein that decreases with inflammation. This happens because the liver makes less albumin and instead makes other proteins needed for the inflammation response. Normal albumin is 4.0 mg/dL or higher. Lower levels indicate a person may have protein malnutrition or inflammation.

Malnutrition, inflammation and chronic kidney disease

There is a connection between malnutrition and chronic inflammation in people with kidney disease. Eating problems may occur frequently in kidney disease patients, especially for those with end stage renal disease (ESRD) and on dialysis. Poor appetite results in a lack of calorie and protein intake. Over time, a condition called protein energy malnutrition (PEM) occurs. In addition to weight loss, patients experience muscle wasting, because the body must break down muscles to supply protein for vital functions. PEM makes you more proneto infection and illness. Doctors and dietitians check the albumin level to help evaluate the degree of PEM.

Studies show that inflammation also causes muscle wasting, and it interferes with the body’s ability to make new proteins. When a person has inflammation, chemicals called cytokines are released. Normally cytokines are good – they help fight infection. However, cytokines also decrease the appetite and slow down stomach emptying. If chronic inflammation is not treated, muscle wasting and cytokines contribute to chronic low albumin levels. Low albumin is used as a marker of malnutrition and inflammation in kidney disease patients.

A large research study called Nutritional and Inflammatory Evaluation in Dialysis Patients (NIED study) looked at malnutrition and inflammation in dialysis patients over a 5 year period. Patients who reported having a fair or poor appetite were found to have lower albumin levels and higher CRP and cytokines in their blood. In addition, they had lower quality of life, lower hemoglobin, more hospitalizations and a higher death rate than patients who reported a good or very good appetite.

An evaluation tool called the Malnutrition-Inflammation Score was used in the NIED study.  DaVita dietitians use this tool in their dialysis patient initial and annual nutrition assessments to help identify patients with malnutrition and inflammation.

How can I prevent and treat inflammation and CKD?

Inflammation prevention and treatment in people with chronic kidney disease usually begins with a healthy, kidney-friendly diet. To prevent malnutrition, which is connected with inflammation, try to focus on adequate calorie and protein intake and foods that contain antioxidants. Foods that contain high quality protein are:

  • Fish
  • Poultry (chicken breast)
  • Lean red meat
  • Low cholesterol egg products
  • Eggs or egg whites
  • Soy products (sodium, potassium and phosphorus vary greatly - read labels or check with your dietitian)

Some foods that are high in antioxidants include:

  • Fish high in omega-3 fatty acids
  • Olive oil
  • Red bell peppers
  • Cabbage
  • Cauliflower
  • Garlic
  • Onions
  • Apples
  • Cranberries
  • Blueberries
  • Raspberries
  • Strawberries
  • Cherries
  • Red grapes

Eating fish 2-3 times a week helps treat inflammation because of the anti-inflammatory effect of omega-3 fatty acids in fish. Albacore tuna, herring, mackerel, rainbow trout and salmon are among the fish highest in omega 3s. If you do not like fish, ask your doctor about taking fish oil supplements to increase omega 3s.

The kidney diet regulates the amount of potassium, phosphorus and sodium you consume, and contains enough protein to prevent malnutrition. A kidney diet providng a variety of foods listed above may help treat inflammation, too. Talk to your renal dietitian about kidney-friendly foods that may help treat inflammation.

Medicines may be prescribed by your doctor to treat inflammation. While you may read that certain over-the-counter medicines can treat inflammation, it is recommended you talk to your doctor before taking any medicine when you have chronic kidney disease. Medications such as non-steroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, aspirin and naproxen, are not usually recommended for people with kidney disease unless prescribed by their kidney doctor. For those with decreased kidney function, NSAIDs have been associated with acute kidney failure. Only your doctor can determine if NSAIDs are the right medicine for you.

There are other medicines available by prescription that help reduce inflammation; however, many of them require a doctor’s supervision when taken by people with chronic kidney disease. Remember, talk to your doctor about any medications for you may take for inflammation.

Additional treatment for inflammation is to identify the source. Things that cause inflammation can include dialysis access infection, gum disease or dental health problems and chronic upper respiratory infection. In those with diabetes who have chronic kidney disease and inflammation, unhealed sores and foot ulcers should be treated.

Hemodialysis patients who have catheters for their dialysis access are at a greater risk for inflammation. A fistula or graft to replace the catheter is recommended to improve health and lower inflammation risk.

Some additional considerations in treating chronic inflammation include adequate dialysis to remove toxins from the blood, correction of anemia and vitamin D deficiency, and increased exercise. Obesity is known to increase CRP and cytokines. Weight loss in obese people decreases inflammation by decreasing these levels.

Summary

In people with chronic kidney disease and those on dialysis, chronic inflammation can lead to heart disease and even death. It is important that you talk to your doctor and renal dietitian about inflammation and how it can be prevented and treated.

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