Dr. Alok Gupta - 'Low Carb for Renal Patients: My Experience'

Summary

In this health-focused presentation, a nephrologist from Regional Queensland shares his personal journey and professional insights on managing chronic kidney disease (CKD) with a low-carb diet. He details his transformation from pre-diabetes to diabetes and his family's history with the condition. The speaker discusses the prevalence of metabolic syndrome in CKD patients and the benefits of a low-carb diet in managing obesity and diabetes, which are significant risk factors for CKD progression. He also presents a case study of a young woman with severe CKD, highlighting the impact of dietary changes on her health outcomes.

Takeaways

• 👩‍⚕️ The speaker is a nephrologist who began a low-carb diet journey to improve their own health, transitioning from pre-diabetes to diabetes.
• 📈 The speaker's A1C levels improved from 6.7 to 5.5-5.6 after adopting a low-carb diet, reducing medication intake significantly.
• 🔬 A study by Dr. Ludwig's group inspired the speaker, suggesting that a high-fat, moderate-protein, low-carb diet can improve metabolic rate and induce weight loss.
• 👨‍👩‍👧‍👦 The speaker has a strong family history of diabetes and hypertension, which motivated them to address their own health proactively.
• 📉 The speaker experienced a significant reduction in weight and improvement in metabolic health markers after changing their diet.
• 🤰 The case study of a young woman with a history of hypertension and kidney disease during pregnancy highlights the complexity of managing such conditions.
• 🩺 The patient in the case study had severe kidney damage, requiring dialysis, and struggled with metabolic syndrome despite multiple medications.
• 🍚 The patient was advised to modify her diet, reducing carbohydrates and focusing on whole foods, which led to substantial weight loss and health improvements.
• 📊 Metabolic syndrome is prevalent in patients with chronic kidney disease (CKD), often exacerbating the condition and leading to further health complications.
• 🥦 The speaker advocates for a low-carb diet in CKD patients, emphasizing the importance of whole foods and avoiding processed items high in sugar and starch.
• 📚 Current guidelines for CKD patients regarding protein intake vary, and the speaker suggests that a more liberal protein intake may be beneficial for metabolically unhealthy patients.

Q & A

What is the speaker's profession and where is he based?

The speaker is a nephrologist, a specialist in kidney diseases, based in Regional Queensland.

What health condition did the speaker initially struggle with?

The speaker initially struggled with metabolic syndrome, moving from pre-diabetes to diabetes with an A1C between 6 to 7 for about 10 years, and hypertension requiring multiple medications.

What term was introduced to the speaker during his 'Loca Journey'?

The term introduced to the speaker during his 'Loca Journey' was 'tofi', which stands for 'thin outside and fat inside', highlighting the issue of central obesity.

What dietary approach did the speaker adopt to improve his health?

The speaker adopted a low carbohydrate diet, reducing his carbohydrate intake and focusing on a higher fat, moderate protein diet to induce weight loss and improve his metabolic health.

What was the case presented involving a young woman from South India?

The case involved a young woman who migrated from South India to Australia and developed severe health issues, including end-stage kidney disease, hypertension, and metabolic syndrome, after multiple pregnancies and complications.

What was the double pathology found in the young woman's kidney biopsy?

The double pathology found in the young woman's kidney biopsy was glomerulonephritis (inflammation of the glomeruli) and changes indicative of severe hypertension, such as fibrin deposition in the kidney's blood vessels.

Why is metabolic syndrome common in patients with chronic kidney disease (CKD)?

Metabolic syndrome is common in CKD patients because as CKD progresses, patients become more insulin resistant due to postreceptor defects, and if they already have metabolic syndrome, the two conditions exacerbate each other, leading to further health complications.

How does obesity affect kidney function and blood pressure?

Obesity leads to metabolic syndrome, which in turn activates the sympathetic nervous system and the renin-angiotensin system, increasing blood pressure. Excess fat can also compress the kidneys, reducing salt and water loss in urine, leading to increased salt and water absorption, high blood pressure, and ultimately, kidney damage.

What are the potential benefits of a low carbohydrate diet for patients with chronic kidney disease?

A low carbohydrate diet can help control obesity and diabetes, which are root causes of CKD. It can also reduce the risk of developing or put diabetes into remission, and potentially improve metabolic health, which can slow the progression of CKD.

What dietary recommendations did the speaker make for his patients with CKD?

The speaker recommended a low carbohydrate diet with 50 to 100 grams of non-fiber carbohydrates per day, focusing on whole foods, avoiding processed foods and sugars, and having a good mix of healthy fats and proteins. He also emphasized the importance of monitoring electrolytes and GFR, especially in moderate to severe CKD.

Outlines

00:00

👨‍⚕️ Personal Journey with Metabolic Syndrome

The speaker, a nephrologist, introduces himself and his personal health journey, highlighting his struggle with metabolic syndrome. He moved from pre-diabetes to diabetes and experienced hypertension. He shares his initial A1C levels and how they improved through lifestyle changes, particularly diet. The speaker emphasizes the impact of a low-carb diet on his health, leading to a reduction in A1C levels and medication requirements. He also discusses his family history of diabetes and the importance of managing diet to combat metabolic syndrome.

05:00

🏥 Challenging Case of a Young Woman with CKD

The speaker presents a challenging case of a young woman with chronic kidney disease (CKD). She had a history of hypertension and complications during pregnancies, leading to end-stage kidney disease. A kidney biopsy revealed glomerulonephritis and hypertensive changes. Despite multiple medications, her blood pressure remained high. The patient's metabolic syndrome and insulin resistance were significant factors. The speaker discusses the patient's transition to peritoneal dialysis and the challenges of managing her metabolic syndrome while on dialysis, including the high sugar content in dialysis bags.

10:03

🔬 Understanding the Impact of Metabolic Syndrome on CKD

The speaker delves into the relationship between metabolic syndrome and CKD, explaining how obesity and insulin resistance contribute to kidney damage. He discusses the role of the sympathetic nervous system and the renin-angiotensin system in hypertension and kidney function. The speaker also highlights the importance of managing blood pressure and the use of ACE inhibitors and ARBs in CKD patients. He emphasizes the need to address obesity and metabolic syndrome to prevent the progression of CKD.

15:03

🍽️ Exploring the Role of Diet in CKD Management

The speaker contemplates the role of diet, specifically a low-carb diet, in managing CKD. He questions the conventional wisdom of protein restriction and explores the potential benefits of a low-carb diet in reducing obesity and diabetes, which are major risk factors for CKD. He discusses the safety of low-carb diets in patients with different stages of CKD and references studies that suggest protein restriction may not be necessary in early stages of CKD. The speaker also addresses concerns about potential side effects of low-carb diets, such as increased risk of kidney stones or metabolic acidosis.

20:05

🏋️‍♀️ Challenges in Weight Loss for CKD Patients

The speaker discusses the challenges faced by CKD patients, particularly those on dialysis, in losing weight. He mentions conventional weight loss advice and its limitations for patients with low energy levels and other health issues. The speaker explores alternative approaches, such as OIC or GLP-1 agonists and bariatric surgery, but acknowledges their drawbacks and side effects. He emphasizes the need for a personalized approach to diet and weight management in CKD patients, considering their unique health challenges.

25:07

🌱 Implementing a Low-Carb Diet in CKD Practice

The speaker shares his experience implementing a low-carb diet in his clinical practice for patients with different stages of CKD. He provides a detailed dietary plan, focusing on whole foods, avoiding processed foods, and balancing protein and fat intake. The speaker also discusses the importance of monitoring electrolytes, GFR, and adjusting diuretics and insulin doses accordingly. He highlights the benefits of continuous glucose monitoring (CGM) in empowering patients to understand the impact of their diet on blood sugar levels. The speaker concludes by emphasizing the need for careful monitoring and open communication with patients when adopting a low-carb diet, especially in advanced stages of CKD.

Keywords

💡Nephrologist

A nephrologist is a medical specialist who has extensive training in diagnosing and treating kidney diseases. In the video, the speaker is a nephrologist based in Regional Queensland, treating patients with various stages of chronic kidney disease. This term is central to understanding the speaker's authority and expertise on the subject matter discussed in the video.

💡Chronic Kidney Disease (CKD)

Chronic Kidney Disease is a condition characterized by a gradual loss of kidney function over time. The video discusses the impact of CKD on patients and the importance of managing it through lifestyle changes, particularly diet, which is a key theme of the video.

💡Metabolic Syndrome

Metabolic Syndrome is a cluster of conditions that includes increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels. The speaker mentions being a victim of metabolic syndrome, which is directly related to the video's theme of managing health through dietary changes.

💡A1C

A1C, or glycated hemoglobin, is a measure of average blood sugar levels over the past 2 to 3 months. It is an important indicator for diabetes management. The speaker discusses their personal journey of managing A1C levels, which is a critical health metric in the context of diabetes and CKD discussed in the video.

💡Tofi

Tofi is a term used to describe a condition where an individual appears thin on the outside but has a high amount of fat on the inside, often indicated by central obesity. The speaker uses this term to describe their own body composition and to highlight the importance of addressing hidden obesity in the context of metabolic health.

💡Low Carb Diet

A low carb diet is a dietary approach that involves reducing carbohydrate intake to lose weight and improve health. The video emphasizes the benefits of a low carb diet in managing metabolic syndrome and diabetes, which are common in patients with CKD.

💡Peroanal Dialysis

Peritoneal dialysis is a type of dialysis that uses the lining of the abdomen to filter waste and excess fluid from the body. The video discusses the challenges of managing metabolic syndrome in patients undergoing peritoneal dialysis, as the dialysis solution used contains high levels of sugar.

💡Insulin Resistance

Insulin resistance is a condition in which the body's cells do not respond properly to the hormone insulin, leading to high blood sugar levels. The video describes insulin resistance as a common issue in CKD patients and a target for dietary interventions.

💡Hypertension

Hypertension, or high blood pressure, is a condition where the force of the blood against the artery walls is too high. The speaker discusses hypertension as a significant health issue that needs to be managed, especially in patients with CKD.

💡Obesity-Related Glomerulopathy

Obesity-Related Glomerulopathy is a kidney disease associated with obesity, which can affect kidney function. The video mentions this condition to illustrate the direct impact of obesity on kidney health, reinforcing the importance of weight management for CKD patients.

💡CGM Patch

A CGM (Continuous Glucose Monitoring) patch is a device that tracks blood sugar levels continuously. The speaker used a CGM patch to monitor the impact of diet on their blood sugar levels, demonstrating the practical application of technology in managing diabetes.

💡Bicarbonate Supplementation

Bicarbonate supplementation is the act of taking additional bicarbonate to balance the body's acid-base levels. The video discusses the importance of bicarbonate supplementation when following a low carb diet, especially for patients with CKD, to prevent metabolic acidosis.

Highlights

The speaker is a nephrologist who has personally experienced metabolic syndrome and used a low-carb diet to improve his health.

The speaker moved from pre-diabetes to diabetes with an A1C between 6 to 7 for about 10 years before adopting a low-carb diet.

The concept of 'TOFI' (Thin Outside and Fat Inside) was introduced, highlighting the issue of central obesity.

A case study of a young woman with end-stage kidney disease and hypertension was presented, emphasizing the challenges in treating such patients.

The importance of managing metabolic syndrome in chronic kidney disease (CKD) patients was discussed, as it is common and can worsen outcomes.

A low-carb diet was suggested as a potential approach to managing diabetes and obesity in CKD patients.

Protein restriction in CKD patients was discussed, with guidelines suggesting different protein intake levels based on the stage of CKD and diabetes status.

The potential risks and benefits of a low-carb diet in CKD patients were debated, including concerns about kidney overwork and protein intake.

The speaker described a personal approach to implementing a low-carb diet in clinical practice for patients with different stages of kidney disease.

The use of continuous glucose monitoring (CGM) was highlighted as an empowering tool for patients to understand the impact of food on their blood sugar levels.

The impact of a low-carb diet on the speaker's own health transformation was shared, including significant improvements in A1C and weight.

The case study patient's remarkable weight loss and health improvements on a low-carb diet while on peritoneal dialysis were detailed.

The speaker's guidelines for a low-carb diet in CKD patients were shared, focusing on whole foods and avoiding processed items.

The importance of closely monitoring electrolytes and GFR in CKD patients on a low-carb diet was emphasized.

The potential for a low-carb diet to improve metabolic health and be beneficial in CKD, even in advanced stages, was discussed.

The transcript concluded with a summary of the speaker's recommendations and the importance of an open discussion with patients about kidney health management.

Transcripts

[Music]

um good morning everyone and thank you

Ro uh giving me an opportunity to to

speak to such a health conscious and

health aware audience it's it's a

privilege and honor so I'm a nephologist

based in Regional

Queensland um

and I treat all patients with different

stages of chronic kidney disease from

severe to mild to moderate uh chronic

kidney

disease I have no Financial disclosure

related to this presentation but I have

been a victim of metabolic syndrome and

I started my loab joury journey about

three and a half years

ago so the first patient uh who I

treated with Loca was myself

[Music]

so I moved from pre-diabetes to diabetes

with ay between 6 to 7 for about 10

years and current guidelines say if you

have aeny of about six person that's

okay that's a pre-diabetes and you don't

have any problems um but I had um at the

time of diagnosis my A1C was 6.7 I was

age 40 then and it moved to seven and

then I could bring down to 6 person with

more medications

I had hypertension requiring about two

to three drugs on average to bring down

my blood

pressure and I was introduced this term

when I started Loca Journey called tofi

so thin outside and fat inside I did a

body composition for myself and I was

shocked to see what the central obesity

looks like on a

scan so I have Universal positive

history everyone in my family from my

parents to siblings to cousin cousins to

aunts to Uncle everyone has diabetes so

becoming a diabetic and having high

blood pressures is sort of a natural

progression as we age so I took it for

granted um but I came across a paper

from Dr Ludwig's group um that was in

early

2020 and he showed that if you have a

higher fat moderate protein and a low C

approach you can change your basil

metabolic rate and you can induce weight

loss so I was I was always doing regular

exercises maintaining sleep nutrition

but the only thing which I did not

change was my diet during my last 40 50

years of life so I was convinced of that

paper and I tried to bring down my

carbohydrate intake um putting all my

data in the my fitness Paul app and

looking at the macros at the end of the

day and I I wore a CGM patch around the

same time and with eating porridge wheat

bit my wife cooks that porridge and my

sugars went up to 14 from that time I

did not eat any porridge at all and in

fact I stopped doing um breakfast and I

just do fast until lunchtime so it works

very well so given this my A1C is now

sitting 5.5 5.6 on a very minimal

diabetes

medications um now I will present a case

this case was a very challenging case

and I was already into 6 months of my

loab lifestyle and I could see the

benefit of loab this is a young woman

who migrated actually from South India

to Australia somewhere in 2015 with her

husband so when she presented to us in

2019 she was aged um so she currently

aged 33 she was aging about 28 or so um

at that time of presentation to us in

2019 so she had her the first pregnancy

in 2014 Complicated by

hypertension unfortunately resulted in a

still birth the hypertension record in

subsequent two pregnancy 2016 and 18 and

in the second third pregnancy she was

detected to have album in Uria though

she never had any eclampsia or

preclampsia

and she moved from Darwin to tumba in

early

2019 and unfortunately did not see

anyone she was lost to follow up um she

presented at the end of the year at the

emergency with very high blood presses

of

1220 um and creatinine of close to

1,000 So within a year she has

progressed from normal kidney function

to end stage kidney disease

at that time her was 44 with a

weight of 120 kilos so my colleague um

did a kidney biopsy on her which showed

a double pathology so she had a glome

nephritis which is inflammation of the

glomi um these are the heads of the

nephrons which are the kidney units

which is a very common glome nephritis

which car insured one of the patients

but she had a double pathology so she

had changes of very severe blood

pressure in her

kidneys so this is a picture of the

glomerulus on the top which is all

scorose so it's all burned out um and on

down below there is

a picture of a blood small blood vessel

in the kidney and it has this dark pink

material which is as a fibrant

deposition which is a sign of high blood

pressures and pathology we call as from

btic

microangiopathy this this figure shows

those burnt out glomas in dark blue but

there were a lot of area which she had

excessive scarring that these kidneys

were very bad and she would likely need

dialysis so she was very severely

hypertensive so she was on five to six

different blood pressure tablets and yet

her blood pressures were between 180 to

200s during her training for dialysis I

used to get calls every day and she had

multiple trips to emergency and one of

the trips she landed up in IU with

hypertensive en copath and she had

Caesars from very high blood

pressures and she her case was

transferred to me from my colleague who

was looking after her initially so I

looked at certain parameters her

triglycerides were high her fasting

insulins were high Al she was not

labeled as is diabetic uh most of our

CKD patient have some degree of anemia

so their hemoglobin comes down so A1C is

not a very good test for our patients it

could be spuriously

low and we calculated this Homa IR score

which is extremely high so she's

definitely has insulin resistance and

metabolic syndrome though not formally

declared as a

diabetic so she picked up this dialysis

modality um called is peronal dialysis

which you can do at home she has two

young children to care for um and we use

Peroni as a dialysis

membrane um and guess these bags which

we use um to remove the toxin from the

belly are very high in sugar so each bag

of a manual peronal dialysis has at

least 2 to 3 kilog of sugar and that you

keep that for for 4 hours and then you

replace with another bag so she had huge

exposure to she will be having a huge

exposure to glucose in your Peroni

absorbing all that glucose and worsening

your metabolic syndrome it's very well

known if you go on peronal dialysis you

will either worsen or develop new

metabolic syndrome weight gain

triglycerides and and blood pressure and

fluid

changes

now so it's a double v so she has

metabolic syndrome very difficult to

control blood pressures very high weight

and she's going on peronal dialysis so I

was struggling for first few months what

to do with

her so um coming back to a bit of um

literature search um metabolic syndrome

is extremely common in kidney patient

according to one

study up to 70 to 75% patients of CKD

have some component of metabolic

syndrome so it's extremely common uh in

CKD patient and as you develop chronic

kidney disease you become more insulin

resistance due to a postreceptor defect

so insulin resistance from CKD and if

you already have metabolic syndrome they

feed each other and it leads to

disasters um hyperglycemia and insulin

resistance as um Karen already alluded

to um very common in our patients this

is the typical D idemia we see in

CKD high triglycerides and low HDL and

prior to my urea moment with low cab

diet and transformation in my personal

health I used to ignore Tri glyceride

there nothing I can do about them just

don't look at

them and low Edge deal again I can't fix

it um just give them some

statins um and just forget about because

cardiologist and everyone's low LDL low

LDL that's the theme of

recommendations and our patients have

extremely high blood pressures on

average my patients are anywhere between

three to five drugs minimum to keep

their blood pressures under

control most of our CKD patient actually

die of cardiovascular diseases before

they end up on dialysis so they are

extremely high risk so this is a um

picture I took from our one of our um

very reputed Journal called as American

Journal of kidney disease and I will

show you how the Obesity affects your so

the the one the picture on the round is

a blood vessel vascular damage and the

kidney

damage so the in the actual um uh

diagram it says excessive calorie intake

not carbohydrate intake which I

changed I could not show it as excess

calorie intake so it leads to obesity

and metabolic syndrome which in turn

leads to activation of our sympathetic

nervous

system more importantly activation of

our renin andot elderone uh system which

is a system which maintains our blood

pressure and then it leads to so if you

have twoo much fat it can lead to

compression of the kidneys and that

compression of the kidney itself can

redu reduce the salt and water losses in

the urine so you could retain more salt

and water you've got too much fat around

your kidneys or inside your

kidneys so all this leads to increase

absorption or reduced clearance of salt

in the urine which in turn leads to

changes in the kidney and guess what

high blood pressures which is a Hallmark

of kidney

disease and what does lead

to so if you have very high blood

pressures the individual kidney units we

have got 1 million in each kidneys they

overwork and they filter more and more

so that leads to we call as

hyperfiltration and that overwork and

hyperfiltration actually burns them out

very quickly and so they die early so if

some of the Nephron units die they pass

on the work to the remaining nephrons so

the workload of remaining nephron go up

and they die early and that's how the

chronic kidney disease progresses so if

you can reduce the glal hyperfiltration

by drugs like a Inhibitors or ARB and

sg22 inhibitor as Karen mentioned

earlier in her talk you could reduce the

progression of the kidney disease and

blood pressure management is key that's

why Ras Inhibitors like ACE inhibitors

or abs are the drugs of choice to manage

their blood pressures now obesity itself

um so we know that the edipo sites are

very active hormonal uh secretors as

well and they released a lot of

ocin uh which in turns leads to insulin

resistance insulin resistance in turns

worsens the blood pressure and insulin

resistance also causes damage to the

kidneys and the blood vessels so what

happens in the end you get vascular

damage and KY injury so you got chronic

kidney disease as well as vascular

damage affecting entire vascul not only

the

kidneys and once you have chronic kidney

disease then it perpetuates the blood

pressure so it's a double they keep

feeding each other and then the blood

pressure continues to get

worse so in turn we end up with

cardiovascular diseases and reduce

kidney function and Progressive

CKD now we we know that low carbohydrate

diet um

improves obesity reduction in weight we

know that low carbohydr di reduces the

risk of either developing or putting the

diabetes in

remission so these are two beneficial

effects of low carbohydrate diet and we

know that both of these increases the

risk of developing a diabetic or other

CKD chronic kidney diseases

and obesity itself is associated with a

noble condition in the kidney call as

obesity related

glomerulopathy so massive obesity

without um diabetes can directly affect

kidneys in this particular pathology

called as obesity related um glos

sclerosis so my question was um when I

was introspecting shall I put my

patients on low carb approach everyone

talks about protein restriction and

coron disease that's the usual theme so

protein is a very dirty World in our

world but no one talks about this

elephant in the room which is diabetes

and obesity which is accounting for 2/3

of all cases of chronic kidney disease

so my question was can low carbohydrate

diet help with chronic kidney disease by

controlling its root causes which are

diabetes and and

obesity

so again as I said um protein so most of

our guideline restrict proteins for

patients earlier used to be across the

board different stages of CKD from mild

moderate and severe chronic kidney

disease but of late this has changed

slightly I was worried about if I

increase if I reduce the carbohydrate

what should I replace with fats protein

or both and What

proportion so my worri is could I worsen

the kidney over work or

hyperfiltration could I increase the

risk of kidneys stones or um increase

their phosphate levels as well as

metabolic acidoses because animal

protein increases the net acid um load

um on the body once they change their

diet so what's the safety of um low

carbohydrate diets in kidneys but I

would focus more on the protein side of

things this is a landmark paper from Dr

anwin um he showed in his general

practice that if you have normal kidney

function and if you switch to lower

carbohydrate diet with modest to

moderate moderate protein intake this is

was in patients who suffer from diabetes

the actually GFR go up rather than going

down so it's a very safe approach in

someone with Baseline normal kidney

function um this was a um cochine review

and metaanalysis um k and sent me this

article earlier this year which clearly

showed that in patient with Stage 1 2 3

which is mild to moderate chronic kidney

disease protein restriction does not

help so um proteins are pretty safe in

that population so I should not worried

about my mild to moderate chronic kidney

disease but when it comes to stage four

and five which is moderate to severe and

pre-dialysis population

that's a that's a gray area this is one

of our um Peak bodies called as K DOI

and National Kidney Foundation based in

us and they published their nutrition

guidelines for kidney patients in uh

2020 so that's very

fresh and what they showed was um based

on their literature review what the

guidelines suggest that if you have

chronic kidney disease stage 3 to five

so moderate to sever chronic kidney

disease um if you are diabetic then

protein intake of

62.8 G but if you're non-diabetic 0.55

to6 G per kilogram per day which is

pretty low as U compared to um General

uh

population but there is a cavat here

they say um those patients who are

metabolically

healthy should have a low protein intake

but most of our patients are

metabolically

broke so according to their description

further in the guideline they say those

patients who are sick um malnourished or

rapidly losing weight patients in ICU

catabolic poorly controlled diabetes

these patients are not metabolically

stable so these guidelines would not

apply to most of our patients who are

metabolically unhealthy poorly

controlled diabetes obesity inflammation

so I think I can work around these

guidelines for my

patients I wanted to save my job and my

license uh but patients who are not on

dialysis they are more liberal with

protein intake to one to 1.2 G per

kilogram and in peronal dialysis these

patients loot extra protein during their

dialysis exchanges from the

Peroni so the convention approach now

when this patient was in hospital

speaking to different doctors nurses

practitioners everyone said lose weight

okay everyone agreed she should lose

weight she's 120

kilog but no one tells them um how to

lose weight just don't

eat what should I do to lose weight or

eat less move more that should work

she's a dialysis patient she has very

poor energy level levels she has to look

after house household two young

children she has no energy so she can't

do high intensity

exercises um OIC or gp1 Agonist

um could work for these patients to help

them lose weight uh so that they're

eligible to receive a transplant uh down

the track drug is not on um PBS and

these drugs have side effects nausea

vomiting diarrhea and dialysis patient

already suffer from these GI symptoms

and if you put fluid in your belly for

dialysis the symptoms even get worse so

this was not a very good option and it's

an expensive option um bariatric surgery

is another extreme and some of the D

patient actually go and get this surgery

to lose weight so that they can receive

a

transplantation now I said I should take

the matter in my hands um although all

dietitians are my friend and colleagues

but we we had such a difference of

opinion um they ask patients to eat

every few hours and have four pieces of

bread and full grains I said this will

not work for you and she's from south of

India so her plate usual plate has 34

consisting of rice and whatever is left

with her is some Curry and some lentil

and some beans and some form of meat

that's like 1/5 of her 1/4 of her plate

that was her staple diet so rice rice

and rice so I said don't Grace just have

two big meals a day eat to your

satiation uh that will allow your

insulin levels to drop and heal yourself

I tried avoid processed foods um high

sugar um processed uh foods that was my

key homebased food have a good dose of

animal and plant proteins or whatever

she could choose from from fish chicken

seafood meat soy whatever she prefers uh

have eggs um throw them in your diet

have a full fat Dairy um have nuts beans

and

seeds um avoiding root

vegetables um have low sugar fruits like

avocado berries and

coconut um and in we compromise that she

can have a little bit of rice because

most of the family when they have a

dinner or a lunch they have rice that's

their staple diet and I said you can

have a little bit of rice but eat the

rice towards the end of the meal rather

than start of the meal so by the time

she eats everything else she has no

appetite or room left for

Rice so in 3 years despite this very

high glucose exposure over 3 years

um she lost 36 kilos of weight and this

is a dialysis patient so a BMI dropped

from 44 to

30.8 her triglycerides are low5 and HDL

went up to 1.1 and this clearly shows

that she has been managing low carb

approach her fasting glucose insulin and

that calculated H IR score

dropped so she's now left in one blood

pressure tablet and that to a beta

blocker

labetalol and um if I try to put her on

ASM or ARB her actually she crashes her

blood pressure and she feel dizzy only

last week I had to recommence her tell

me Satan again just because her blood

pressures were uptrending but she's on

one drug after that massive weight loss

in a dialysis

patient I did a recent body composition

scan after she lost all this weight her

body fat percentage is now 50% so God

knows what would have been her

percentage at this

start but I guess she lost a bit of

fluid weight as well um as she lost her

weight so what do I do in my practice so

since last 3 years um looking from my

own example and this lady I I try to do

a low car practice in my clinic across

the board different stages of kidney

diseases but I adopt a more liberal Loca

50 to 100 G of nonfiber carbohydrate

intake um again I go to a whole food um

uh approach rather than a an avoiding

processed food avoiding sugars

starchy vegetables sugary fruits and

don't necessarily restrict their protein

but I ask them don't go overboard don't

become a

carnivore um but but have a good mix of

healthy U fats and proteins to for

satiation and reduce your

Cravings um I borrowed this list from

the low cab down under website and made

my own list uh with some little bit of

modification I give them this list

choose this is your uh 10 commandants

and pick up your choices from this

particular

list um and I very closely monitor the

electrolytes and GFR particularly

moderate to severe chronic kidney

disease uh I am preemptively a reduce

their diuretics in particular because as

soon as they drop their carb intake they

lose fluid and weight as Penny showed in

her study presented last year and I

aggressively reduced their diuretics in

particular if they're diabetic they're

on insulin I try to make sure their

insulin doses go down they have a plan

to reduce insulin once they reduce their

carbohydrate intake avoiding

hypoglycemia and I'm aggressive in Bop

supplementation again pennies study

showed that their serum byar drops

because if you're eating more animal

proteins your net acid load go up and

I've seen the bicar drop so I'm

aggressive in bicarbonate

supplementation and I'm a fan of CGM

monitoring and I think it clearly

empowers these patients looking at the

effect of food on their blood sugars

patients come to me and say I had two

pieces of bread in my breakfast and my

blood sugar went up so that empowers

them that patient realizes that this

food is not good for me because it's

worsening my blood sugar and my diabetes

doctor or GP or specialist ask me to

take more insulin to counter that

insulin that glucose response rather

than cutting back on my

breads so these are some of the

references which I went through while um

uh preparing this talk and this is a

picture of a fat massive fat around a

kidney compressing the kidney so uh low

carb diet in my opinion um by improving

their metabolic health is helpful even

in the CKD space but you have to be a

bit careful monitor them very closely um

and have an open discussion with them

how to manage their um Kidney Health

particularly when they are approaching

uh higher stages of chronic kidney

disease stage four five and pre-dialysis

but it's very safe to practice if they

have normal kidney function early stage

mild to moderate U mild to moderate

chronic kidney disease is very safe to

practice a lcop approach thank

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