Avoiding kidney disease; a kidney-friendly diet; how bones heal: Upstate Medical University's HealthLink on Air for Sunday, July 7, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an overview of kidney disease, including how it's diagnosed and treated, and what you can do to reduce your risk.

Michael Lioudis, MD: ... Kidney disease is a type of disease that you don't have symptoms until you are very well progressed. Up to about 90% of individuals don't even know that they have chronic kidney disease. ...

Host Amber Smith: And the benefits of a plant-based diet, even for people who have kidney disease.

John Babich: ... When you have kidney disease, your kidneys are not functioning as effectively as they were prior, and so they're not filtering as effectively. And so this leads to buildup of those electrolytes. And potassium is one of the more concerning ones. ...

Host Amber Smith: All that, a description of how bones heal in children, and a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll explore a diet designed to keep your kidneys healthy. Then an orthopedic surgeon tells how bones heal in children. But first, Upstate's chief of nephrology goes over how you can reduce your risk of developing kidney disease.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Today we're talking about the early stage of kidney disease with Dr. Michael Lioudis. He's an assistant professor of medicine at Upstate and the division chief of nephrology. Welcome back to "HealthLink on Air," Dr. Lioudis.

Michael Lioudis, MD: I'm delighted to be here. Amber. Thank you for inviting me.

Host Amber Smith: Well, I guess the first thing is for people to know if they're at risk for chronic kidneys disease, so can we go over what the risk factors are?

Michael Lioudis, MD: One of the things that tends to be a big risk factor for patients that I take care of with chronic kidney disease is diabetes. High blood pressure and really even a family history of kidney disease can really influence whether or not somebody may be at risk. As we think about just diabetes and those three things, the family history, diabetes, high blood pressure, they can really increase your risk.

Host Amber Smith: Are men and women equally at risk?

Michael Lioudis, MD: Well, they're almost the same, and we don't know exactly why that women are a little bit more prone to kidney disease than men are.

It's basically like 13% or 14% women and 12% men. But it's different, and what I'd like to actually kind of tease out a little bit more is, there's kidney disease, and then, well, I'm sure we'll get into this, about dialysis. So not everybody that has kidney disease will ever progress to dialysis, so I want to make sure that we can separate those as we go along.

So what's the difference between men and women? Well, the thought is, and we don't have solid evidence on this one, but the theory is, well, women are more prone to recurring urinary tract infections, complications that can happen with pregnancy, and sometimes with pregnancy, they get eclampsia (a serious complication involving high blood pressure), large weight gains, other things that can specifically affect the kidneys during that time.

But men, even though they're a little bit less likely to have chronic kidney disease, they're the ones that can progress to dialysis, which is what we're all trying to avoid.

And that also is a little bit more complicated, too, because the theory is, well, maybe it's testosterone levels with men that are a little bit higher and that that may have an influence for progressing more rapidly with kidney disease.

Maybe it's the protective aspect of estrogen that prevents women from ultimately progressing as quickly to end-stage kidney disease. And then there's the other things that are those factors that are a little bit fuzzier. For instance, perhaps men engage in riskier lifestyle habits, perhaps men are more likely to smoke, for instance, more likely to consume alcohol, more likely to get into severe auto accidents. And so it's like a big pool of things that influence both. But at the end of the day, it's very similar factors that come into play for both men and women.

Host Amber Smith: What impact does obesity or being overweight have on the kidneys and how well they can function?

Michael Lioudis, MD: So, obesity is becoming a big epidemic in many countries that are more developed. And so part of where I think about obesity playing in this is, it's sort of like a "Bonnie and Clyde" (partners in crime). There's something else over there with obesity that then starts to rob somebody of their health.

For instance, people that are obese may have more of a tendency of having Type 2 diabetes. People that are obese may have higher blood pressures. And then other things, too, that are the subtle things. Think about heart disease. There's more of a risk of sleep apnea. Is there maybe more of a risk of a stroke for people that are obese?

And then it becomes even more complex than that because we think obesity is linked to so many bad things that people go through. Could it be that this is one thing that's coming on up in a lot of countries right now, which is fatty liver disease? Being obese can add to liver disease that then can subsequently cause kidney disease.

Metabolic syndrome that maybe some of our listeners may be familiar with, where you have high blood pressure, high blood sugars, high cholesterol. There's these thoughts about whether or not this causes more issues even with cancers. There's been some links between some types of cancers, colon, breast cancer, liver cancer and kidney cancer, with people that are obese.

Host Amber Smith: And I also was going to ask about whether our risk for developing kidney disease gets greater as we get older because I don't hear about kidney disease that often in younger people. Is this a disease for people who are older?

Michael Lioudis, MD: Kidney disease is not very prevalent in our younger patients, but there are types of kidney disease that do affect younger individuals that tend to be more inherited or that can be issues with regards to different type of medical problems that have taken place very early on. But the answer in short is yes, as we get older, we are at more risk for kidney disease.

However, I like to think about it as almost like that time where you get a relatively new car, and everything is working so nicely, everything is nice and smooth, but as it goes on, there's things that come on up and things have to be repaired, things have to be replaced, things that happen to that automobile as it gets older. People are in the same way, too. You can think about the accumulated mileage of not treating your high blood pressure very well, the accumulated mileage of not taking care of your diabetes very well. The accumulated mileage of living an unhealthy lifestyle, for instance, smoking, that may, over time, increase your risk of chronic kidney disease, and the more years that you engage in those unfortunately add up, and they can result in you having chronic kidney disease later in life.

Host Amber Smith: You're listening to Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Upstate's chief of nephrology, Dr. Michael Lioudis, about treatment for early-stage kidney disease.

From what I understand, it's hard to notice symptoms early in kidney disease, so what do you tell patients to look out for?

Michael Lioudis, MD: Well, that's the challenge, Amber, because kidney disease is a type of disease that you don't have symptoms until you are very well progressed. Up to about 90% of individuals don't even know that they have chronic kidney disease, and even basically 40% of those with severe kidney disease don't even know that they have it. And so, that is really not to scare our audience, but it is to empower our audience to go ahead and seek yearly physicals, so that they can go ahead, do the appropriate screening, get looked at and make sure that they're doing well. Because as with any problem, the sooner that you could go ahead and intervene or recognize it, the more options that are available for you to try, and with your health care team to try, and intervene and get it better and stabilize it.

Host Amber Smith: So there are tests that can tell us if our kidneys are healthy?

Michael Lioudis, MD: Indeed. So, Amber, there's two very simple tests that can be done, and usually these are done at everyone's annual physical exam. One is a urinalysis, which is a very simple way of looking at how the kidneys are, in some ways, removing some waste. You can tell a lot by making sure that there's no infection there, making sure that there's no protein in there, making sure that there's no blood in there, because urine should be sterile. And it's a very, very simple test to do.

Additionally, there's blood work, too, that can be done. And as most of us know, when we go on in and get our physical exams done, we get a cholesterol screening. We get a basic metabolic panel (series of tests), but it is actually a very nice and easy screen that gives us something called the creatinine. Creatinine helps us to identify, well, how are we doing from a kidney perspective with filtering?

And it really helps our primary team to think about the individual and think, are they doing well or not doing well? It's a very useful test to do.

Host Amber Smith: Is there a recommendation for at what age people should start being screened for kidney disease?

Michael Lioudis, MD: They're not solid recommendations. However, many medical societies will say those that have high blood pressure, those that have diabetes should be screened for kidney disease. People above the age of 60 should be screened for kidney disease.

However, what we've realized is because of the simplicity of the urinalysis and the blood work that we ordinarily do, odds are that those are done anyways as a routine in most physicians' or advanced practice providers' offices.

Host Amber Smith: If you were developing kidney disease, would you feel pain in your kidneys, in your back, near where the kidneys are located? Is that how you would tell?

Michael Lioudis, MD: No, you actually wouldn't. People that talk about having kidney pain, in general, they may be thinking more along the lines of kidney stones.

So, kidney stones can cause kidney disease, and if we're really thinking about a proper definition, yeah, you're not supposed to have kidney stones. It does, and can cause, problems down the road, but mostly it's asymptomatic. There is no pain. You may find that perhaps with very advanced degrees of kidney disease that you can have trouble thinking clearly, itchiness, swollen feet and ankles, but not the kind of swollen feet and ankles that we get if we stand, on our feet all day long at work. This is something where if you were actually to press on that swelling, you can actually leave a dent. It's called edema. It's a different, pitting edema, to think about. Sometimes people can have even puffiness around the eyes, but again, those are very, very advanced levels of kidney disease.

Most people, again, it's very subtle. You won't have pain, you won't necessarily see a red-appearing urine. You are otherwise asymptomatic.

Host Amber Smith: You mentioned kidney stones. If someone has a history of having had kidney stones, does that increase their risk of developing kidney disease?

Michael Lioudis, MD: It does to the extent that it depends on the frequency of the stones and what else those stones cause, within a patient, because people will equate passing a kidney stone to some of the most excruciating pain that they've ever experienced. And as this stone passes, sometimes it can even obstruct, or basically block, the passage of urine from the kidney down to the bladder. And so when you have those instances, that can cause infection, that can cause kidney failure on that side.

Kidney stones themselves, they're a big burden to society and cost billions of dollars, lost wages for people, hospitalizations, pain and also sometimes even what people do to try and help to alleviate that pain, such as ibuprofen, Motrin, Aleve, naproxen, that can actually cause problems, too, down the road for individuals.

Host Amber Smith: Can you go over what the glomerular filtration rate means, the GFR? What does that measure?

Michael Lioudis, MD: Sure. So the glomerular filtration rate really helps to pinpoint a little bit better on the actual health of your kidneys in terms of how well they are functioning. And so what that is designed to do, it's an equation that takes into account age and sex and helps to put together basically a number that helps the provider to think about how the kidney is functioning at a snapshot in time.

And if you have a series of those numbers over time, and this is calculated off of blood work using that creatinine that we talked about a little bit earlier, and if you have that as a series of measurements over time, which can be months or years, then you can see also, and plot out, a rate of progression, where, is the kidney disease staying stable? Is it getting worse? How much worse? And it can help us to think about other different interventions or other different things along the way to try and prevent worsening of the kidney function.

Host Amber Smith: Is the GFR number, is it normal for that to fluctuate or be high one day and low the next?

Michael Lioudis, MD: No, it's a fairly stable number over time, and it can fluctuate just a little bit by small amounts, based on if you are, let's just say volume depleted, if you don't drink enough water, if you're not well hydrated. It can fluctuate just a little bit, but in most individuals it's a very consistent and reproducible number.

Host Amber Smith: Is it useful and accurate for all ages and genders and races?

Michael Lioudis, MD: Well, there's a few things to think about on that one, so let's kind of split it up into three separate questions with what you asked, and I'll take the last one first.

When the GFR and the equation was first put together, it took race into account. And there's these theories that perhaps people of African heritage may produce more creatinine, may have variations in muscle mass. And what it did over time is really not take into account the heterogeneity of our population here, where we can go ahead and say, well, maybe race isn't something that we should be including in medicine and in these kinds of calculations, because it may very well have underserved people of African heritage, so we're trying to remove that completely. And so thankfully we have far newer ways of looking at this, so race isn't included.

Now when we think about ages and genders, really we're looking at adults, and we're looking at it that it can be very good, especially when we're looking for people that are outside of basically Stage 1 or Stage 2 chronic kidney disease. So it is useful. It's another tool to help us to put together a picture and to really put forth a collaborative effort between the patient and the health care provider to really talk about and have a frank discussion about kidney function, what does it mean, where are they at, and what are things that are maybe affecting that kidney function?

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more talk about early-stage kidney disease.

This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Upstate's chief of nephrology, Dr. Michael Lioudis, about early-stage kidney disease.

Now, you mentioned Stage 1 and Stage 2. How many stages are there of kidney disease?

Michael Lioudis, MD: There are actually five stages of chronic kidney disease, Amber, and then I think about one additional one after that.

There's five stages, Stage 1, 2, 3, 4, 5. One is very mild; 5 is very severe. And then after that, it's people that will require dialysis, and so that's kind of the way that I think about it, and people sometimes do progress from Stage 1 to 2 to 3 to 4 to 5, and then to dialysis, or sometimes it can be very abrupt, depending upon circumstances or very traumatic medical events that go on.

Host Amber Smith: Is Stage 6, when you're on dialysis, is that considered kidney failure?

Michael Lioudis, MD: Kidney failure is basically, in a way, we kind of use it very differently. So let's not talk about dialysis as Stage 6, but its own separate category. But kidney failure is anything that is less than optimal kidney function. But just because you may have some decrease in your kidney function does not mean, and I want to really emphasize that for our audience, does not mean that you will progress to dialysis. I mean, we have 37 million people in this country that have chronic kidney disease, and we have about 650,000 people on dialysis.

So think about it as an upside-down pyramid, where you have a huge majority of people that have kidney disease, but relatively few that progress to dialysis.

Host Amber Smith: People with kidney disease, how were they affected by COVID during the pandemic?

Michael Lioudis, MD: Kidney disease, really, should have been, and has been, thought of as a pree-xisting condition.

So as we were talking about people that were affected by COVID, those with pre-existing conditions -- high blood pressure, diabetes, other infections, and chronic kidney disease -- they were at increased risk for further progression and with the complications that COVID could, actually, and did, unfortunately, cause many, many Americans and people all around the world.

Host Amber Smith: Let me ask you, if someone is told they have protein in their urine, does that indicate kidney disease?

Michael Lioudis, MD: Not necessarily. It depends on the age of the individual. Sometimes with some individuals, especially younger individuals, they may have asymptomatic protein and that can be teased on out with a very simple kind of urine collection testing that's done either at nighttime and also during the day.

But if you have protein in your urine, and if it's measurable to that extent, then it does mean that something may be amiss. It may be issues with medications, it could be issues with the other diseases we were talking about, especially with diabetes. And individuals with diabetes may have proteinuria, and that is a sign that perhaps their diabetes has not been very well controlled or that they have other additional factors in addition to the diabetes, such as morbid obesity, too, that that need to be addressed the best that we can.

Host Amber Smith: So what should primary care doctors do with patients who they suspect may be developing early-stage kidney disease? Maybe they have some protein in their urine, maybe their GFR number is not exactly what it should be.

Where do they go from there?

Michael Lioudis, MD: That's where you have that conversation with your patients. Not every patient that has less than optimal kidney function needs to see a kidney specialist. It may very well be an opportunity to say, well, you know, if you are taking ibuprofen every single day for osteoarthritis, for instance, that is an opportunity to actually think about, well, how do we get off of that medication?

It may be opportunities to have a more frank discussion regarding weight and the negative effects that it's having on the body. It may be, again, a discussion to be able to say to someone, your blood pressure is not responding to lifestyle modifications. This is where we need to go ahead and now really look at and start antihypertensive medications.

It's all these different things where you could say the earlier that you touch this and make sure that you're putting together these interventions, the better off you will be and the fewer specialists, hopefully, that you'll need to see down the road.

Host Amber Smith: So at this stage, especially if it's early, can dietary changes make a difference, or do you already have damage to the kidneys that won't be reversed?

Michael Lioudis, MD: It depends on how long it has been going on for, Amber. If we think about somebody that is taking ibuprofen, and we've noticed that maybe there's a change, and we say, let's stop it. Let's repeat these labs, and let's see how this changes in a week. It may very well go back to normal, and we're like, whew, we caught this early. But if somebody has been taking it for years, and what could have been stopped early on, this damage has been going on for a period of time. And so maybe you can't stop it. Maybe what you can do is, you can prevent it from further deterioration, but once you've lost any function, It's very few instances that you can go and regain that back.

The kidney is a very interesting organ. It's about the size of your fist, Amber, and we have two kidneys, and if you bend your elbows all the way back and kind of put it towards either side of your spine, that's roughly where your kidneys are located, but they're full of capillaries, blood vessels and millions of microscopic filters that are filtering your blood all the time, 24/7. And so the filters themselves are, dare I say, a little fragile. If they get damaged, they don't regenerate. And so if they get damaged to an extent where it causes that permanent dysfunction, well, I can't fix those, but my goal is to make sure I can preserve all the other ones that are there.

Host Amber Smith: So if a patient has kidney disease, does it necessarily affect both kidneys?

Michael Lioudis, MD: Yeah, it's rare that it just affects only the one side. The one side would be that example back where we were talking a little bit earlier about kidney stones, and if you have a kidney stone that causes an acute blockage on one kidney, well, I can see that as causing just an individual kidney issue.

But ordinarily, what affects the right kidney affects the left and vice versa.

Host Amber Smith: Well, I'd like to have you focus a little on how we can keep our kidneys healthy. And you've touched on a few things I wanted to ask you more about. Why is ibuprofen bad for the kidneys?

Michael Lioudis, MD: Ibuprofen in short doses is fine. It's very tolerable. But over time, the benefits that we have from just decreased pain, especially with osteoarthritis and especially as we've had so many problems with narcotics and fentanyl and so forth, that used to be used far more frequently for pain control, people have resorted to using more ibuprofen.

I see this used quite often, especially in student athletes, because it really helps with relieving pain, especially after a tough game, a tough workout, et cetera. But what it does is actually, it affects prostaglandins in the body. So in short, what it does is, it can affect blood flow to the kidneys, and it can decrease blood flow to the kidneys.

So, over time, if you are decreasing blood flow enough to the kidneys, the kidneys will respond by, unfortunately, getting smaller and, unfortunately, causing this kidney disease to get more pronounced.

Host Amber Smith: I see. We also hear about salt in the diet, but I don't really understand why that's bad.

Michael Lioudis, MD: We need salt in our diets, Amber. You cannot get rid of salt entirely from our diets because it is a part of us, it is a part of what makes our cellular growth and processes and function take place. So sodium is really an essential component, but what we're really talking about here, Amber, is excessive sodium intake, and people especially that have heart disease and kidney disease, we really counsel them in trying to limit sodium to really no more than 2,000 or 2,500 milligrams per day. And the thought is that sodium in excessive amounts for some people that are what we call salt sensitive, what it can do is it can cause increased fluid retention, increased hypertension, and that in itself then causes cascade of effects downstream, especially with the hypertension aspect of things.

Hypertension is that one thing that affects every single part of the body. We're focusing on the kidneys, but the kidneys don't act in isolation. We're all one big domino set, the way that I think about us, and what's good for our kidneys will be good for our heart, which will be good for our liver, which will be good for our lungs, which will be good for our brain and decrease age-associated vascular dementia and other things that happen over time. Decreasing stroke risk. So the way that I look at it is, salt is absolutely necessary in our diets to some extent. It's just the excessive amounts that we look at, and, unfortunately, it is ubiquitous out in our diets and out in the community, especially if you go and indulge a little bit more in fast food. You'll find that they have very high rates of sodium.

Host Amber Smith: How do smoking or vaping affect the kidneys?

Michael Lioudis, MD: I think about smoking and vaping somewhat similarly. There's this kind of misconception that vaping is a healthier form of smoking.

That makes no sense. There is no healthier form of smoking. And the way that I look at it is, though you may not have more of the cigarette-related smoke inhalation that affects not only the increased risk of lung cancers and throat and oral cancers, but vaping itself has the nicotine components. And as we've seen troubling reports with regards to just some of the chemicals that are in the vaping liquids that can cause some severe lung problems.

But both of those things, over time, what smoking does is, it increases your risks of blood pressure and heart disease, and therefore subsequently causes that domino effect that we were talking about that can affect your kidneys. And we think, too, that it can cause some narrowing of the blood vessels and the capillaries within the kidneys.

And so again, the biggest thing about smoking is, it affects so many different organ systems, and the effects of nicotine, the addictive aspects of nicotine, and the chemicals that are in the vaping solutions ... there is no healthy form of smoking or vaping, unfortunately.

Host Amber Smith: Before we wrap up, how much water do we need to drink each day for our kidneys?

Michael Lioudis, MD: That was a big question that we had about 25 years ago, and well, how much is too much? Or what is the bare minimum of fluid intake that we need? It's very interesting, Amber. It was teased out initially over at the University of Pennsylvania, and basically what it found was, these studies, that you drink when you're thirsty. Instances where you need to consume more fluid than normal are really those instances, and there are specific instances, such as with recurring kidney stones, where the thought is that you need to have a very robust fluid intake of about 2 liters to 2 1/2 liters of fluid a day, ideally water, that will help to flush out these microscopic crystals out of the body before they become big stones.

The thought is if you throw a stone into a pot, it just goes plop; it goes right to that bottom. But if you put it into like a raging river, it should hopefully go downstream. And that's the thought about people that have any stones.

Well, how much water?

There are a lot of social media influencers that will say, well, you need to drink six to eight glasses of water a day in order to maintain healthy skin, healthy kidneys, healthy everything about your body.

But the truth is, it really is, drink when you're thirsty. And making sure that you are hydrated appropriately, and what that hydration will mean will vary based on just what you do. If today's a beautiful, sunny day in Syracuse, it's 89 degrees, we're going to be drinking a whole lot more than if it's one of those cold days that we sometimes may have.

Unfortunately, it's a wishy-washy answer, but it is about making sure that you are just cognizant that when you're thirsty, grab something and drink.

Host Amber Smith: I like that advice. Drink when you're thirsty. It's easy to understand and easy to do.

Thank you, Dr. Lioudis, for making time for this interview.

Michael Lioudis, MD: Amber, I was delighted to be here today. Thank you for inviting me.

Host Amber Smith: My guest has been Dr. Michael Lioudis, the chief of nephrology at Upstate and an assistant professor of medicine.

I'm Amber Smith for Upstate's "HealthLink on Air."

Are plant foods included on a healthy renal diet? Next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

People with kidney disease traditionally have been told to restrict their intake of plant foods. Some researchers are questioning that advice. Here to explain is John Babich, a third-year student in Upstate's Norton College of Medicine. Welcome to "HealthLink on Air," Mr. Babich.

John Babich: Hi, Amber. Thanks for having me.

Host Amber Smith: Why have people with kidney disease been told to avoid plant foods? And I'm assuming we're talking about vegetables.

John Babich: Yeah. So, this is an interesting area of focus, but traditionally folks with kidney disease have been told to follow a kidney or renal diet. And this restricts plant foods, mainly because there's a concern about potassium content. And plant foods tend to be higher in potassium, and so I've been working with some colleagues looking at the evidence and trying to understand if there is a strong connection between the potassium that's found in the food and whether or not you actually absorb all of that potassium.

Host Amber Smith: So what makes the body potentially retain potassium?

John Babich: Kidneys basically act as a filter for your blood, and their job is to get rid of excess electrolytes. And electrolytes mostly include sodium, potassium, bicarbonate, other components of the blood that are important for your body's functions.

But when you have kidney disease, your kidneys are not functioning as effectively as they were prior, and so they're not filtering as effectively. And so this leads to buildup of those electrolytes. And potassium is one of the more concerning ones.

Host Amber Smith: So when the kidneys aren't functioning, and they're not filtering, that impacts digestion, it sounds like. Is it just potassium, or does it have an impact on other parts of digestion?

John Babich: So there is a relationship with digestion as well with your gastrointestinal system. And there is some research that shows that when your kidneys are not filtering as effectively, your digestive system will sort of upregulate or increase the amount of excretion of potassium that your body will do to sort of compensate and balance things out.

Host Amber Smith: Now we need potassium though, right? That's an essential... We need that, but we don't need too much of it?

John Babich: Right. So just like any component of your blood or any other electrolyte. It's important to have not too much, not too little. But the thing with potassium is that it's mainly found inside of our cells, whereas sodium is mainly found outside of our cells. The relationship between those two is really important for cells to do their normal function.

And so the main issue with having too much potassium, in your blood, which is referred to as hyperkalemia -- hyper meaning too much, and emia meaning of the blood, and the kal being for potassium -- the main concern is that this can lead to abnormal heart rhythms, or cardiac arrhythmia. And that can be very dangerous for patients.

Host Amber Smith: So that is the fear that ... that's why people were told to reduce plant food intake if they had kidney disease, right?

John Babich: Exactly. So the idea was that you eat these foods and they are high in potassium, and that you absorb probably most, if not all, of that. And since your kidneys are not functioning as well, you may not get rid of it, and it starts to build up. And some dangerous effects and complications can occur.

Host Amber Smith: So what kinds of foods are we talking about that are high in potassium and potentially dangerous to people with kidney disease?

John Babich: So the traditional wisdom was really about avoiding many foods like tomatoes, potatoes, greens, et cetera. And there's still a question of how much and how we should be encouraging patients to use those foods.

But the data that we examined showed that many of the instances in some of these research studies of hyperkalemia, or having too much potassium, were from plant foods like fruit juices, purees, sauces, dried fruit, things that are plant foods that have been processed. And so the potassium that is there is a lot easier for your body to absorb.

There are also potassium salt alternatives that are used for people who have high blood pressure. And so instead of it being NaCl, which is sodium chloride for common table salt, you have KCl, so potassium chloride. And this potassium is also very accessible for your body. But there are reasons that people would use those salt alternatives, and it's important to understand some of the balances that are necessary to make those decisions.

Host Amber Smith: Now, don't people with kidney disease also have to watch their protein intake?

John Babich: Yes. So, that's also something that's typically modified for people with kidney disease. And it's often restricted, moreso in later stages of kidney disease. So as the filtration of the kidneys is diminishing the amount of protein that is recommended in the diet is usually restricted further.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with John Babich. He's a third-year medical student at Upstate's Norton College of Medicine.

Your paper, which was published in Advances in Kidney Disease and Health, says that plant foods may have qualities that would blunt potassium retention. Can you explain that a little bit?

John Babich: Yeah, so there are three factors that we discuss, and those are the alkalinizing effects of plant foods. So they can help to reduce a complication called metabolic acidosis, basically having too much acid in your blood. And this is also linked to having too much potassium, so hyperkalemia.

There's also the fact that, generally speaking, unprocessed plant foods have low potassium bioavailability. And then lastly, plant foods, as we know, are high in fiber, and fiber has an impact as well.

Host Amber Smith: I'm just thinking about a vegetarian or a vegan who has kidney disease would really be challenged to eat properly, right?

John Babich: I think the prevailing wisdom that we are sort of promoting here is that you might actually be able to do this more effectively by eating more plant foods.

Host Amber Smith: So what are the benefits of plant foods that patients with kidney disease may be missing out on if they've cut back on plant foods?

John Babich: Just aside from kidney disease, there are a lot of cardiovascular metabolic benefits to eating more plant foods. I think many folks know that eating more fruits and vegetables is generally a good part of a balanced diet. And so, having a restricted diet that is avoiding these things, you're missing out on things like fiber, many of the vitamins and minerals.

Host Amber Smith: It seems like it can be pretty complicated, following a diet. People with kidney disease may have other health conditions that come with dietary advice as well. So how do they follow more than one eating plan at a time, especially if they conflict?

John Babich: Yeah, it definitely is a challenge balancing any conditions, as well as maintaining sort of a patient-centered perspective. Because I think any of us who are trying to eat differently or avoiding certain foods in our environments, know that dietary adherence is a challenge. And a prescribed diet can be pretty hard to follow. So you need to strike the right balance between patient well-being and, of course, safety.

But as you mentioned, like folks with kidney disease often have other comorbidities like diabetes, hypertension. And so it's really important to understand what's needed in those different dietary patterns, to improve the condition. And my colleagues recommend working with a registered dietitian. And there are, also, renal dietitians specifically who work with patients with kidney disease and have an expertise in this area. And there are also online resources like nephrology groups and other patient organizations that can provide good information on this.

The nephrology groups online are starting to incorporate some of these guidelines and move away from the sort of traditional perspective of the renal diet, as we call it. And so I think there are a lot of great resources online now, or are starting to be, that encourage patients to sort of liberate their diet a little bit. Again, with caution, because this is still a moving process, and working with the health care team is essential.

Host Amber Smith: Now you're relatively early in your training, in your third year of medical school. But are you thinking that your practice is going to include some nutrition?

John Babich: Yeah. I'm really interested in nutrition, and it's been something that I've been focused on prior to enrolling at Upstate and even choosing to pursue medicine.

I learned about this emerging field in medicine called lifestyle medicine. And I actually established a student interest group here at Upstate as well. Basically, lifestyle medicine seeks to treat chronic disease with behavior change through things like nutrition, but also exercise, sleep health, stress management. And we know that so many chronic diseases today are related to these factors. And we need to move toward giving patients information and guidance on how to learn these skills and hopefully to take more control of their health outcomes.

So I really hope to incorporate that into my practice and be an advocate for broadening that perspective in medicine.

Host Amber Smith: So lifestyle medicine. I had not heard that before, but that seems very, kind of, proactive and like it maybe involves the patient, like they've got to kind of be involved in their health more.

John Babich: Absolutely. It's a team approach. I've been associated with a lifestyle medicine team in New York City at Health + Hospitals. And seeing this in action -- and it's very much a multidisciplinary approach where you have a dietitian, you have a health coach, you have the physician, and many other folks depending on what the patient sort of needs at the moment -- and the idea is working with the patient to learn about positive health changes, and then guiding them to make those changes with support, including from other patients who are going through the same process. And so it really helps to kind of kick-start those behavior changes and to kind of move in the positive direction for their own health.

Host Amber Smith: Well, that sounds very interesting. Good luck to you. And thank you so much for making time for this interview.

John Babich: Thank you so much, Amber.

Host Amber Smith: My guest has been medical student John Babich, who's in his third year at Upstate's Norton College of Medicine. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Rajin Shahriar from Upstate Medical University. How long do bone fractures take to heal in children?

Rajin Shahriar, MD: Generally fractures have a three-part process by which they heal. And the first part of the healing process is actually the fracture itself creates bleeding and injury that the body knows to respond to. So what happens is that when the bone breaks, it bleeds, and the signals from that bleeding create an inflammatory response. And the body sends themselves and other tissue-healing properties to regenerate that area of damaged bone. And that process starts immediately after the fracture happens and continues for several weeks.

Then, there's a process by which the body will try to unite or bring those two pieces of bone back together. Oftentimes, the way that the body will do that is by actually forming cartilage first. And that cartilage basically increases the stiffness at the fracture site, and that callus eventually turns into bone through the body's healing process. But interestingly, you can't see a lot of that callus on the X-ray. So many times when we see families in clinic, we have to tell them about the way the fractures healed because oftentimes they're looking for the signs of healing very early on when it is probably healing, but we can't see it on X-ray.

So once the bone has joined back up together, we call that "union," basically the fracture having joined back together. But there's a third phase called remodeling, and that takes many months to years. The way that I like to talk about remodeling is comparing it to when you get a big cut on your skin. So the first thing that happens is that, just like with bone, it bleeds, but then it heals together, and it makes a scab. So that scab is what we call callus, or union for bone. And then remodeling is when that scab falls off, and then the skin is usually a little bit hyperpigmented or dark. And then it takes months for that color to fade away and go back to normal.

So that's what remodeling is in bone as well, where the bone will change shape, straighten out, do other things in order to go back to its final form. And that takes many months to years.

Host Amber Smith: You've been listening to pediatric orthopedic surgeon Rajin Shahriar from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Ken Haas lives in San Francisco. He works in health care and sponsors a poetry writing workshop at UCSF's Children's Hospital. His powerful poem "The Herebefore" navigates the telling of bad news to someone he loves who is very sick.

"The Herebefore"

Someone needed to break the news.

Her father had passed overnight.

I drove early

as I had every day for months,

as I would for two weeks more,

to wait on a snaking line,

masked in the fog,

for visiting hours.

She was sitting in the easy chair

next to her bed,

morphine drip hissing.

I rolled the food cart away,

pulled a folding chair up close,

smoothed her hand,

called her younger sister

two time zones east, as arranged,

passed her my phone,

which she pressed to an ear,

listening to a soft voice.

Cancer had entered her brain.

She could understand, but not speak.

Her eyes filled and drained

like they had no other purpose.

These things

that pretend they just happen

but we know otherwise.

There is no good in them. None.

No learning. No lining. No blessing.

I squeezed next to my love

in the padded chair.

Her arms poured around me.

I have never been held like that.

Not even the day I was born.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," the meat allergy you can get after a tick bite.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.