Fluid Retention

Catherine Wells and Anthony DeAntry discuss the importance of fluid intake for individuals with kidney disease or on dialysis. They explain that kidneys are responsible for filtering and removing excess water from the body, but when they fail, fluid can accumulate and lead to problems such as swelling, shortness of breath, and organ damage. The stage of kidney disease determines when fluid intake should be closely monitored, with stage 4 and 5 being critical. Dialysis and transplant are effective treatments for removing fluid, and individuals on dialysis should adjust their fluid intake based on urine output. Hidden sources of fluid, such as certain foods, should also be considered. Excessive salt intake can exacerbate fluid retention and make individuals feel unwell. Rapid fluid removal during dialysis can have negative effects, so it is important to manage fluid levels carefully. Finally, they discuss the challenges of transitioning from a high fluid intake to a limited one when star Welcome, everybody. It is great to be here on the NKA podcast. I am one of the hosts, Anthony DeAntry. I am a current transfer recipient and a biomedical equipment technician in dialysis. I'm Catherine Wells. I'm a nurse practitioner in nephrology for the past 19 years in Jackson, Mississippi. I share some of the things patients have told me with you. That sounds wonderful. You know, and the thing is, what we're going to be talking today, I think it's going to be very important and vital to those out there that have kidney disease or have to be on dialysis or something of that nature. If somebody has kidney disease, why would they need to, first of all, limit their fluid intake? And when, you know, depending on the stage of kidney disease, and we get into that later on, when would they need to start really watching it very closely? Great. I think this is the fundamental piece to talking about fluid. So when your kidneys, so kidneys actually do a lot of different things. We're going to talk only about the fluid aspect today, but we know they fail to filter, but they also fail to get rid of the water that you have in your body. So your body is made for you to put water in, but also to put that water out in your urine. I want to also mention that when we talk about fluid, we also always talk about salt, because wherever salt goes, water goes. So you'll hear me mention salt a couple of times throughout this podcast. So when your kidneys fail and these functions start to fail, it's a little different for everyone. Some people, that filter portion of their kidney function fails, but they still make a lot of urine. For some people, they lose both. They lose the filtering function and the ability to put water out through their kidneys. So it's a little bit different for everyone, and so everyone's prescription for how much fluid they should take in should be different because it should be based on how much kidney function you have and how that kidney function is working for you to get rid of fluid. So also let's talk a little bit about why. So if you don't get rid of salt and fluid, what happens? So we all know that you swell and that you can get short of breath. You can have a lot of problems, but that's actually sort of a first symptom of a much bigger problem, which is the fluid in your body can start affecting your other organs. We talk most about your heart. It can lead to heart failure, but it also affects your lungs. That's why you get shortness of breath. Some people that are very volume overloaded even need help breathing. You have to think about all of your other organs except for your kidneys. They don't need all of that extra fluid. And also, like I mentioned, you have salt in your body too if you have all that fluid in your body, which is also going to hurt your heart function. When we talk about that, you know, there's different stages of kidney disease. There's 1, 2, 3, 4, and 5. At what stage should people really start to limit that fluid intake? Looking more towards 4 and 5, most people that have chronic kidney disease, stages 1 through 3, I always say their kidneys are still doing what they need them to do, including putting out water. It can be a little different for some people and it can start a little earlier, but for most people it's actually in those late stages, stage 4 and stage 5, when you're getting ready to need a renal replacement therapy most often. As far as renal replacement therapy, we're looking at some of the options out there is dialysis, possibly a transplant, correct? Right, and both dialysis and transplant are very effective at getting rid of fluid. So dialysis, we can clearly remove fluid directly, but with a transplant, you start putting out that urine again because you have a healthy kidney. So I would say both options are the treatment for this type of kidney function. If somebody's in stage 4 and 5, around how much fluid should they be looking at daily? How much intake should they be putting in daily? My rule is if it's coming out, you can keep putting it in. So you have to watch your urine output and you can definitely supplement that with diuretics. There are a lot of different ways to help the kidneys put out more urine. All of these drugs, rather, work by getting rid of salt and water follows salt. So you can supplement that urine output using diuretics. You can continue those diuretics, by the way, once you start dialysis or usually don't need them, like I said, if you have a transplant. The amount that you can get rid of is going to determine the amount that you can put back in. So what we're trying to avoid are the things we talked about at the beginning, all of the swelling and the problems breathing and the heart failure. So we want to make sure to keep the fluid off of you either by convincing your kidneys to do it. So that is my favorite way, right? So convince the kidneys to get rid of the water so that you can keep drinking water. If that isn't working, then that's when you need to start backing off. It's usually going to be an advanced kidney disease that we start doing this. It's pretty rare for me to have to do that in clinic until we are at the point of starting dialysis. At age 22, when I was diagnosed with end-stage renal disease, ladies and gentlemen, one day out of the blue, you're not expecting, you're told, hey you've got end-stage renal disease or kidney disease stage 5 and you've got to go dialysis. That is a very hard transfer, right? From having to drink all this all this fluid and intake and all this fluid and now you're limited to how much a day? Right. So yes, it's very common in early stages of CKD that we tell you drink, drink, drink, drink lots of water. Then we suddenly take it away from you. So when we get to the point when you're on dialysis, if you're not putting out a lot of fluid, then you're going to need to drink. Almost everyone needs less than two liters a day and that's total. Some people need less than that. Some people need to try less than one and a half liters a day. So when I say total, let's mention really quick all those hidden sources of fluid. Anthony and I both live in the South and so one of the biggest things I talk to people about is pot liquor. Do you eat things like greens or a lot of vegetables? There are a lot of people that just say love that fluid and but remember that count towards your two liters a day. Everything you drink, also foods like that, watermelons another one. We have some of the best watermelons in Mississippi so it's really tough. That's all water. So when someone is overloaded, especially if they're a patient, there's someone that needs dialysis, then that fluid is immediately going to start going into your tissues but also affecting all of your other organs. And if you can't get the fluid out, then everything you drink after that is going to add to it. So if you start getting short of breath, for instance, because you've been drinking too much fluid, that is not going to get better until we get rid of the fluid. Where salt is, water is. So if you eat a lot of salt, it's going to do a couple of things. First, it's going to make you thirsty because your body wants a little bit more balance. They don't want you to be super salty without having that water to balance it out. So you do get thirsty that also happens with sugar, mentioning sweet tea. Sugar can also make you really thirsty. Then the goal is we have to not only get rid of water but get rid of salt so that you feel good. So if you always have a lot of salt or if you're putting on a lot of fluid and salt and then we're taking a lot off during dialysis, that makes people feel really bad because they're thirsty all the time because of all of the salt. They don't feel good because of the things that we've mentioned that are from fluid overload. Very much a zigzag up and down with your body where things are not stable. Almost exclusively everyone says it makes them feel bad and I will let Anthony talk about that more because he probably knows more than I do about that. From my experience to our audience, just share just a little bit. You know, when I went into dialysis, I was given a certain target weight, okay, and if I had ate too much salt or drank too much fluid, my weight would increase and getting that target weight would be much more difficult, which means that they'd have to try to pull more, which in turn, one time I ate a certain type of sub and it started in my toes and shot straight through my nose. It hit my whole body and I cramped up like this. The individual that was taking care of me said, what'd you get into? I didn't eat nothing. I didn't drink nothing. I was good. Oh, I had to tune this up from such-and-such place. I ate the wrong stuff and the next thing I know, I didn't just reap that one bad seed. I reaped the whole harvest in one treatment within the last five minutes. Absolutely. So we do know a little bit more now about pulling fluid on dialysis. What we know is that those fluid removal rates low. Makes you feel better, but it's also healthier, faster, and the more fluid we pull over a short period of time, the higher risk that you have of having complications from the fluid and from removing it because it can make your blood pressure drop low. It can cause a lot of problems. It's caused some people that need to go to the hospital. It's caused a lot of bad outcomes. Most often, what you described is exactly what I hear about. Yeah, if you don't learn it the first time, trust me, the second time it's gonna just be just as bad if not worse. Right. But now let's switch gears just a little bit here. Somebody's been on dialysis for a few years and all of a sudden they get that call. Right. They get that call they've been waiting on for so long and there's so many people out there that's waiting on that call and next thing you know, they answer the phone and they pick it up and it's their transplant center or somebody had offered to donate to them, whatever it may be, and that time comes. Okay, so now they're in this transition. They get the transplant. They start getting back to normal with the transplant, but now you have this another switch that you have to make because in dialysis you're told only drink this and now in the transplant, when you transplant it, it's like you're having to change your habits now. What would be your piece of advice for somebody that is going from this restrictive and now they're transplanting, now they have to push to make that switch if they're transplanted and they're doing well? Right, so yes, most transplanted kidneys immediately start putting out urine even in the operating room. Some people there's a delay going from having dialysis where we were very restricted back to being a chronic kidney disease patient. Usually after a transplant you are a very early, the CKD 1 through 3 that we were talking about, which means you're putting out your kidney doing what it should. You're putting out a lot of urine. Like I mentioned, if it comes out, you have to put it back in, right? Instead of us moving towards the restriction, now we're moving in the opposite direction which is not getting dehydrated. Sweating, that's a big thing in the cell. So when we talk about not getting dehydrated and how much you should drink, you have to increase as long as your urine output is increasing. For a while, that new kidney will put out a lot of urine. You have to put that back in. But also if you sweat, you know, anything that you do that you lose fluid. If you have a sickness, if you have diarrhea, if you are throwing up, you need to replace all of those fluids also. Because remember, now the fluid is going out. You're not used to it. You have to put it back in. Yes, and I can tell you that you never take for granted the output. Because there is a lot of people that are still on dialysis and they may not have the opportunity or the option of a transplant. So it's kind of now a way of living or a lifestyle that they have to adapt to. As far as successfully tracking this, what are some of the things that have worked, that you have seen work? Most people find it is much easier to get into the habit of weighing themselves every day so you know what weight you should be at. And if you're weighing yourself every day, you can catch yourself if you've gotten into some fluid. Because like I said, sometimes it's things that you don't think about like salty vegetables and you've got more fluid. Habits are extremely hard to break. Think about things like, so in the South we have Sonic and we go to Sonic and we get these huge drinks. I think they call them Route 44. It's just huge. You have to break the habit of getting that size drink. Restart a habit of getting the small. You're going to feel thirsty at first because your body's sensing the change because you're used to putting all that fluid in. But you also have to think about it in those terms. Whatever fluid intake for the day is a budget. If I decide I want a really large drink, this may be a liter of my fluid, I've still got pills to take throughout the day. So I know at the very least I've got to drink fluid to swallow the pills. So don't use up your budget first thing in the morning with a large drink. Get a small drink instead. Another thing that I see people get in trouble with, they don't want to drink water so they get a cup of ice and try to use that instead. The problem is that a very large cup of ice is still a pretty big cup of water. What's harder, to break the habit or create a new habit? I will say I've met several people who take their diet so very seriously that will just come in crying and they'll be like, there was nothing I could eat, it all had salt in it or all I really wanted was a big drink and I know I can't have that and it was noon and I'd already had everything that I could have. There is a huge emotional aspect to our eating habits for one thing but also we need to be sure we're giving alternatives. Don't ever get to noon and and stop eating for the day and cry because you don't have anything else to eat. Learn up front to budget and learn that if you mess up once, that's a lesson not a failure. Tracking your fluids can be kind of difficult because you say daily habit that we do and I'm sure especially somebody that's in a place that the weather is constantly a lot warmer than in other locations or to say we have a really hot summer. What would be recommendations you'd leave for them? So I usually recommend that when they drink something, for some reason if you drink it cold, it seems to be more refreshing for most people. Try cold drinks like cold towels on your neck. Make sure you're not drinking to try to adjust your temperature and the way you're feeling. Know that there are other options other than drinking a big glass of ice water if you're hot. There are a lot of different sports products out there now, rags that stay cold and things like that that can help if that is what you're drinking. Now also focus a lot on salt when it's hot because of the diet in the south. You don't want an extra source of thirst. When it's hot and humid outside and you're sweating, you're going to be thirsty. Now that said, you can sweat enough if you're not drinking enough to actually get dehydrated if you're on dialysis. People that work outside have to be really careful and account when they're replacing their fluids for also the sweating losses. Right. Listen to what Catherine said. Be careful with that. You know you want to be careful especially in the hot weather I'd say. So for most people I recommend that. I recommend a lot of shade. Remember that you still need sunscreen. I know that's off-topic but it's just very much a habit. If you need the fluid, so we talked a little bit about if you don't need the fluid, but if you are someone who needs extra fluid when it's hot outside you're automatically sweating when you walk outside. So when it is hot you know you need to increase your water. You know you need more fluid intake. Things like staying in the shade, staying cool, trying not to spend a lot of time getting excessively sweaty definitely fits this population because you can get dehydrated that way. We have a lot of issues with even heat stroke from severe dehydration and heat. So that's something that you need to pay closer attention to. Yes, yes. I would agree with that. Agree from the patient aspect. Ladies and gentlemen, I used to be a patient. I am in no way a medical professional. That's what Catherine's here for. She has the medical advice. So I do have this question. This popped in my mind because at one of the clinics I'd heard that they had done the dialysis fluid challenge. Have you ever done a dialysis fluid challenge? So we've not done that here but I have seen where a lot of other people have done it. The goal for most of those challenges is to reduce the amount of weight gain between treatments. CMS is now actually tracking how fast we're removing fluid on dialysis patients because like we mentioned earlier, removing too fast is not only terrible from the perspective of the patient but there are risks involved. There are medical risks. So the goal being to do education to everybody all at once so we're definitely not singling people out, making sure that we're all of these concepts that we've been talking about are talked about but that with the addition of how much weight are you gaining between dialysis treatments and let's keep that down. Know exactly for you, you can talk to the dialysis nurses, they can tell you, look this is how much we can pull off per treatment. You need to be gaining less than that. So if they tell you they can pull two liters off per treatment and I'm just throwing out numbers, then you don't need to drink two liters. You need to drink less than two liters. Got you. Your life if you're a dialysis patient and if you are someone that doesn't know anything about kidney disease, this is what those on dialysis have to face. Maybe you have a loved one. I know there's many people I've talked to, they don't have kidney disease but they know somebody, a close family, a relative. We could talk all day about diet, we can talk about so much more, you know, of course this is fluid so that's what we're focusing but there's more that goes into all of this and fluid can be a really big thing. It can be a if somebody drinks too much in their own dialysis, it's got a negative aspect and if they drink enough and they have a good treatment, a good outcome, it's better for them. Encourage your family members to stick within the guidelines that are given to them by the medical provider. See how you can help as maybe their caretaker or their family member, how you can encourage them in this journey because it really is a journey. So I definitely recommend that. I'd heard some nurses talking about that they had challenged themselves to try one day to try to drink like a dialysis patient. That's interesting to me. Okay, so I'm guessing from your take you've never done that before, correct? No. So I actually do the opposite. I try to drink more than two liters a day because I have good kidney function and that's also difficult. I rarely make it. Right, yeah. So is there anything out there other than maybe a sheet that somebody can make? I know anybody can use the spreadsheets or different forms online to make their own but is there any kind of app or anything that you know of or anything out there that would help track that fluid? There are a lot of fluid tracking apps now. Most of them are intended to encourage people to drink more water but any of these apps you can set your goal and put in what you're drinking so it can track it. So some people do like to do that. They like to keep it electronic on their phone. Some people keep their own paper records for themselves at home. Make sure that you're weighing yourself every day. When I say weigh yourself, it should be first thing in the morning, same time every day with the same clothes on. You know, you don't want to see a change in your weight because you have on heavy boots or things like that. But so track your weight every day because that's going to help you see those fluid gains. However, if the weight's gone up, it's already too late. So the things like the apps or the paper logs help you up front know where am I today in my budget of fluid. So if I can have only two liters total and you're just basically subtracting from that every time. People that drink very consistent about only drinking water can use things like pitchers that are measured. You know, this is my allocation of water for today and I know when it's gone, it's gone. Keep that in the refrigerator. I always remind people that two liters a day is a two, think of a two liter drink. It's not that I want you to drink it, drink a two liter Coke a day, but that's a visual that we all know to be able to see how much fluid that is. If you can watch it going down throughout the day, it's a little easier to track and everybody's a little different about how they like to track it. So I think it's important to sit and talk and say if you're tracking things in your life, how do you like to track it electronically or on paper or should we come up with some other tool like a pitcher? Right, but the tools are only good if someone uses them. Right. And for me, I didn't use anything. I just used memory, which kind of got me in trouble once or twice. Right. You know, I had this much. Well, how much did I have? Well, maybe I better not. Maybe I better drink, you know. Oh, it'll be okay. It'll be okay until the next drink. The next thing you know, it's like probably shouldn't have that much. So and the worst thing you can do at that moment, like I see people doing sometimes, is they'll say, well, I think my fluid's okay, so I'm going to skip this treatment. Don't forget that your kidneys normally work 24 hours a day, seven days a week. And when you're on dialysis, most often it's three days a week. That's your opportunity now. A lot of people are now doing more or doing daily. Daily dialysis can actually help a lot with that. It's just one day and I pull more fluid. Right, right. Definitely, no matter which, which modality you're in, get your treatment. I guess one thing is, we're talking about fluid, right? So you have this goal, you know, this fluid goal. This is how much I can drink. So if I hit this goal every day, meaning I don't drink above this, okay, I don't drink more than this, then I've hit that goal. So that's a good starting goal setting. Another great goal to go along with that coordination is making every treatment say, I've got to be treatment this time, here, there. Again, you know, somebody wants to do something wonderful in their life and they want to run a business or something. They set goals for themselves, right? Those in dialysis, they want to live a healthy life. So set those goals. That's a wonderful start to enjoying the life that you dreamed of. Absolutely, because dialysis should support that. But then when you get into some of the, you know, if you're not being really consistent with some of these things, then your kidney disease is going to get in the way of your life if you're fluid overloaded. I can guarantee you, if you stay fluid overloaded, your kidney disease is going to get in the way of the life you want. That's right. You won't be able to go out and enjoy the children, your family, I guess would be a better term, your family. You're not gonna be able to go out and work. I mean, I worked 40 to 60 hours a week. So let's put it this way, by me taking the negative steps, okay, and drinking a little too much, it had a negative effect on me the rest of that week because I was very sore and I was trying to do my job, which I was able to do, but it wasn't easy. And that all could have been avoided that weekend. But the reason is, had I said no to that tuna salad and said, let me go with something a little bit more healthy conscious, let me not drink as much water because that tuna made me really, really, really thirsty, my whole weekend could have been different. Absolutely, absolutely. I think that fatigue is something else, that just exhaustion is something else that a lot of people talk about that is definitely associated with either carrying too much fluid or trying to pull too much off during dialysis. Keeping everything stable and steady is a great way to keep your energy level up. Whether you're on dialysis or in transplant, remember you have a dietician or nutritionist, you have a social worker, you have nurses, and then you also have nurse practitioners and physicians. So keep asking until you find a way, so you're comfortable with those goals, just keep asking different people to help support you in creating those. And because you may need a little bit of input from everyone. That's true. That's true. So I think what we're going to do is we're going to wrap up here. And Catherine, is there any last words that you have that you would like to share with the audience? I think that so we spent a lot of time talking about how horrible it's going to be if you if you gain all of this fluid, I think we should spend more time on the things that you were talking about setting goals and making sure up front that you know how to do things well so that you can feel good. Because everyone will learn a lot from any dialysis unit and any transplant center about the consequences of their actions, because we tend to talk about that a lot. But I think that a lot of people spend so much time on consequences that they they do get they get depressed, they can't handle it because they're not focused. Right. So I really like the way that you focus setting goals and making sure that you are not only honest with yourself, but you're encouraging yourself. Well, I appreciate your time. And who knows, maybe a goal setting could be in the future. We never know. I think it's highly important. Ladies and gentlemen, I want to thank each and every one of y'all for being here and taking the time out of your day to listen. And hopefully you've learned hopefully you can apply some of these things that we've talked about to your life. Maybe share it with the individuals that you know that may need this. Y'all have a great, great life.