Introduction: Startling Facts
Some Common Kidney Diseases
How does one get it?
How is it treated?
How should you take your medicines
How can one avoid it?
More Info...
Diet Sheet*
High Protein Diets*
Staying Fit
 
 
INTRODUCTION : STARTLING FACTS
 
Startling Facts


Facts:
10% of all people in the world have some form of kidney disease.
Anybody with increased micro albumin or protein in the urine has a 5-8 times higher risk of dying from Cardio-Vascular disease than those without. This mobility is at a younger age.
Kidney failure in South African adults is mainly due to inherited Hypertension (60-65%) or Type 2 Diabetes (another 20-25%)
Kidney failure in the black population is 4 times higher than other groups – due to the high incidence of Hypertension.
Hypertension and Diabetes can be:
  • Prevented
  • Diagnosed early
  • Properly treated

  • And in doing so, potentially 70-80% of all chronic kidney failure and /or cardio-vascular deaths are PREVENTABLE. (See How? after the next point.)


    How does one suspect kidney disease?


    The best advice to the PUBLIC and to DOCTORS is to realize that many of the dangerous kidney disorders (including Hypertension and Diabetes) can be SILENT. Remember:

    SALT AND HIGH BLOOD PRESSURE:
    TWO SILENT KILLERS.
    In other words, by the time many (not all) people present with symptoms and signs of kidney disease (especially Hypertension and Diabetes), it may be too late to have prevented serious kidney and/or cardio-vascular dysfunction.


    SOME COMMON KIDNEY DISEASE

     

    Diabetic Kidney Disease


    What is it?
    A kidney disease caused by the deposition of a substance in the kidney filters that gums them up and blocks their capacity to filter, unique in diabetes.

    Is it common?
    Diabetic kidney disease is the second most common disease, and in many cases is the most common cause of kidney failure.

    How is it treated?
    Much can be done to prevent or slow progression into kidney failure by rigorous control of blood sugar and blood pressure and the use of special medication proven to protect the kidneys from further damage.



    Polycystic Kidney Disease


    What is it?
    This is an inherited condition associated with the development of thousands of cysts in each kidney. It usually causes kidney failure after the age of 40 and may be complicated by severe hypertension.

    Is it common?
    Polycystic kidney disease occurs in 1 in 800 live births, and many of those affected would not even be aware that they have the condition.

    How is it treated?
    There is no specific treatment although rigorous blood pressure control helps to prevent complications.



    Glomerulonephritis


    What is it?
    A type of kidney disease that damages the kidney filters.

    Is it common?
    A very common cause of kidney failure worldwide.

    How is it treated?
    Specific treatments to cure on control this condition are available in very few cases. In the rest, simple measures are used to slow down progression to kidney failure.



    IgA Nephropathy


    What is it?
    This is the most common type of glomerunephritis and presents with blood in the urine (often not visible to the naked eye). It is often associated with recurrent sore throats and pain in the loins.

    Is it common?
    IgA nephropathy accounts for probably about 8 percent of all cases of kidney failure and sometimes runs in families.

    How is it treated?
    There is currently no cure for IgA nephropathy, although much can be done to stabilise the condition and slow down its progression. Many people diagnosed with this do not ever progress into kidney failure.



    Kidney Stones


    What are they?
    They are hard, rock-like crystals that form when certain chemicals in the urine stick together. They can range in size from as small as a grain of sand to as big as a golf ball.

    Are they common?
    They are one of the most common disorders of the urinary tract. The likelihood of developing a kidney stone increases with age and family history.

    How are they treated?
    Most stones (90 percent) will pass by themselves. If a stone is too large to pass, is blocking urine flow or is causing bleeding or infection, surgery may be required.



    Kidney Cancer


    What is it?
    There are several types of kidney cancer, and the most common is renal cell carcinoma. As with all cancers, tumors begin small and grow larger over time. Some kidney cancers can spread through the blood stream or lymph vessels to other areas of the body.

    Is it common?
    Kidney cancers account for about 2.5 percent of all cancers. They occur twice as often in men as women.

    How is it treated?
    There are four types of treatment. These are surgery, chemotherapy, radiation therapy and immunotherapy, with treatments done singularly or in combination.



    HOW SHOULD YOU TAKE YOUR MEDICINES?
    Between 2006 and 2007 a UK study showed that they spent about £10.6 billion on
    30 – 50% of these patients did not take their prescription medicines!

    This cost the UK £100 million per year.

    Although the medicine expenditure in RSA would be a little lower, it could still mean that we could be “wasting” up to one thousand five hundred million rand per year, i.e. R1.5 billion!

    Additional costs came, not surprisingly, from patients being admitted to hospital and/or dying directly because of this non-adherence.

    A Cochrane study (the Cochrane group only accepts medications for all diseases which have been unequivocally scientifically proven) showed that, by improving medication adherence, a far greater impact on Clinical Outcomes (cure or control) was seen than the degree of improvement from the treatment itself!

    This applies the most to:
  • Hypertension control
  • Diabetes control


  • So TAKE YOUR MEDICINES! All medicines prescribed should have clear instructions on how and when to take it. For any problems with your medication, phone your doctor and discuss it!


    HOW DOES ONE GET?
     

    ABOUT OUR KIDNEYS

    Kidney disease can kill – take care of your kidneys and enjoy a long and healthy life.

    Ten thousand South African, men and women, young and old, will die of kidney disease or kidney failure every year. Others are luckier and can be treated by dialysis or a kidney transplant. There are also other kidney conditions which don’t require dialysis, but which adversely affect the lives of thousands of South Africans. All of these conditions require early detection, and many can be prevented.

    Detected kidney disease needs to be appropriately and skillfully treated. This demands good medical training, active and relevant medical research, and committed support for kidney sufferers. Potentially fatal kidney disorders occur three to four times more commonly in our underprivileged African population.

    HOW DO OUR KIDNEYS WORK?

    Our hearts function as a pump for pumping blood through our lungs to capture oxygen for the body, and to eliminate carbon dioxide. Our muscles, joints and bones enable us to stand and move, and our bowels and liver digest and absorb nutrients.

    By contrast, our kidneys are filters which perform the varied functions of all our organs other than the brain. Kidneys manufacture essential chemicals, they break down (metabolize) unnecessary or dangerous chemicals, and they retain necessary substances and eliminate toxic waste.

    In everyday life, our kidneys:

    • Make 150 litres of urine a day, but keep back (reabsorb) 149 litres of useful substances, like protein, and excrete 2 litres of waste. They can be likened to a huge swimming pool filter which never needs backwashing, and will rarely need an overhaul if you look after your health!

    The Kidneys:

    • Excrete drugs, medicines and poisons.
    • Provide the nutrients to take care of our bones and joints, allowing for a solid and healthy skeleton.
    • Control the amount of acidity and alkalinity (pH) in the body.
    • Produce chemicals which control our blood pressure, and produce other chemicals which produce our red blood cells – which carry oxygen to our whole body.
    • Destroy chemicals and hormones which the body doesn’t need any more – like insulin.

    Thus the following may occur:

    • Kidney failure will eventually poison the body and mind.
    • Swelling of the body can occur
    • Shortness of breath
    • Weakness
    • Poor appetite
    • Insomnia (sleeplessness)
    • Body aches and pains
    • Impairment of thought processes
    • Headaches and high blood pressure
     
    How do you avoid this?

    • Healthy living – see the heading on how to avoid kidney disease
    • All people with a family history (even in old people) of Hypertension or Diabetes (Type 2) should have an ANNUAL Blood Pressure check-up from the age of 20 years and Blood Sugar check-up from the age of 30 years.
    • Also very important, all sick people seeking a doctor’s advice – usually their GP or a nurse in a clinic – should have their URINE examined with a dipstick test. If there is Protein, Blood, White Cells or Glucose shown as present on the dipstick test, they must immediately be referred to their doctors (in the case of nurses doing the test). In many instances with the above problems the patient may have to also be referred to a Kidney Specialist i.e. a Nephrologist.
    • So what must you – the patient, do? Ask your doctors to test your urine (especially young ? with ? livers) if you go to see them with an illness.
    • Produce chemicals which control our blood pressure, and produce other chemicals which produce our red blood cells – which carry oxygen to our whole body.
    • Destroy chemicals and hormones which the body doesn’t need any more – like insulin.

    Thus the following may occur:

    • Kidney failure will eventually poison the body and mind.
    • Swelling of the body can occur
    • Shortness of breath
    • Weakness
    • Poor appetite
    • Insomnia (sleeplessness)
    • Body aches and pains
    • Impairment of thought processes
    • Headaches and high blood pressure
     


    HOW IS IT TREATED?
     

    HOW IS KIDNEY DISEASE TREATED?

    The major complication of kidney disease is progression into kidney failure. Recent studies have proved that for most kidney conditions APPROPRIATE TREATMENT can stabilise or significantly slow down the rate of progression by up to half. But, if the kidneys are only working at 5 to 10 percent of their normal rate, DIALYSIS or a KIDNEY TRANSPLANT is the only option.

    DIALYSIS
    Essentially, dialysis means the replacement of the kidneys’ excretionary role by artificial means. There are two types of dialysis – haemodialysis and peritoneal dialysis. The type of dialysis used depends on many factors – age, access to resources, overall health and lifestyle.
    Haemodialysis requires a minor operation to allow access to blood circulation, usually through the wrist or chest. Blood is then removed from the body, cleaned by an artificial kidney attached to a machine and then returned. Each treatment lasts for four to six hours, and is required three times a week for life or until a transplant donor is found.
    Peritoneal dialysis also requires a minor operation, but this time a catheter is inserted into the abdomen. Unlike haemodialysis, where waste removal and blood cleansing takes place outside the body, during peritoneal dialysis this is done inside the body, using the body’s own peritoneal membrane – the lining of the abdominal cavity – as a filter. The catheter acts as an entrance for a dialysis solution to enter and leave the cavity. Dialysis takes place four times a day, seven days a week, but can be performed almost anywhere. Again, this treatment is for life, or until a transplant donor is found.

    KIDNEY TRANSPLANT
    While kidney transplantation delivers a healthy, functioning kidney to someone suffering from kidney failure, it is important to remember that it is a treatment, not a cure. Transplantation gives people with kidney failure a chance to get their old lives back, free from dialysis.
    Donated kidneys come from either deceased donors or from live donors. Live donors are usually close relatives, but spouses, distant relatives and even close friends can donate a kidney.
    Kidney transplantation is successful, with more than 90 percent of transplants still working one year on. However, it is not a “quick fix”. A new kidney requires a lifetime of care, including taking daily anti-rejection medication.

    The average waiting time for a new kidney is four years.


    HOW CAN ONE AVOID IT?

     

    How do you avoid this?


    •  Healthy living – see the heading on how to avoid kidney disease
    •  All people with a family history (even in old people) of Hypertension or Diabetes (Type 2) should have an ANNUAL Blood Pressure check-up from the age of 20 years and Blood Sugar check-up from the age of 30 years.
    • vAlso very important, all sick people seeking a doctor’s advice – usually their GP or a nurse in a clinic – should have their URINE examined with a dipstick test. If there is Protein, Blood, White Cells or Glucose shown as present on the dipstick test, they must immediately be referred to their doctors (in the case of nurses doing the test). In many instances with the above problems the patient may have to also be referred to a Kidney Specialist i.e. a Nephrologist.
    •  So what must you – the patient, do? Ask your doctors to test your urine (especially young ? with ? livers) if you go to see them with an illness.


    How can I keep my kidneys healthy?

    SMOKING
    If you don’t smoke, don’t start. If you do, quit! This is the simplest, most important lifestyle habit to change to reduce the risk of kidney disease. People who smoke are three times more likely to have reduced kidney function, and have a four to five times greater risk of heart attack and stroke.
    Tips to help you quit
    • Get the appropriate help, with referral to a smokenders or quitting programme.
    • Surround yourself with people who are non-smokers.
    • Talk to your doctor – research shows that spending as little time as three to five minutes talking with your doctor. This will increase your quit rate.
    • Find healthy alternatives to smoking, such as exercise, meditation and yoga.

    LIMIT ALCOHOL
    Excessive alcohol intake can lead to heart disease and high blood pressure, increasing the risk of kidney disease.
    Tips to cut down on your alcohol intake
    • Limit alcohol to two standard drinks per day for men, and one per day for women.
    • Ask for ice with your drinks – when the ice melts it will dilute alcohol.
    • Alternate your drinks by having a glass of water in between each alcoholic drink.
    • If you want to participate in a drinking session, fake it – drink your water from a wine glass.

    ENJOY LIFE
    Good health and well being means that we are healthy from all dimensions of our lives – physically, mentally, socially and spiritually.
    Tips for an enjoyable life
    • Have less stress in your life
    • Do the things you love
    • Spend more time with people you enjoy being with – those who challenge you to be more … not less.
    • Balance the load.

    NUTRITION
    The food you eat plays a huge role in the health and well being of your body. It can help to prevent some diseases, and help to manage others. As well as providing the body with a variety of nutrients, diet can also help in weight reduction and weight control.
    People who are overweight are at an increased risk of developing diabetes and high blood pressure, major risk factors in kidney disease. In fact, losing as little as five kg. reduces blood pressure in most people who are 10 percent over their ideal weight.
    People with kidney disease may need to make some dietary changes to help manage their condition. Not all people with kidney disease will need to follow the same diet. Dietary guidelines will need to be made on a personal basis, taking into account age, lifestyle, health status and body chemistry.
    Tips for a healthy diet
    • Eat lots of fruit, vegetables, legumes and wholegrain bread and rice.
    • Eat some lean meat such as chicken and fish at least once a week.
    • Eat reduced-fat and low-fat dairy products.
    • Limit the amount of fatty foods you eat, such as fried fish and chips, fried or roast chicken, and potato crisps
    • Lower your salt intake. Buy low- or no-salt products and don’t add salt to food at the dinner table.
    • Eat more at home, not take-aways – less temptation.
    If you need extra guidance on a healthy diet, visit your doctor for advice on nutrition and your ideal weight.

    QUENCH YOUR THIRST
    While it has long been thought that 6 to 8 glasses of water a day is beneficial to health, there is no evidence to suggest that drinking in excess of thirst has any extra benefits. Use your thirst as a guide.
    Tips for drinking
    • Make water your tipple of choice. Water assists in transporting nutrients around the body, as well as helping to eliminate waste. It contains no kilojoules, and in most areas of South Africa tap water is excellent with good mineral content.
    • Limit your intake of caffeine and cola. These can irritate the bladder and can act as a diuretic. Instant coffee has less caffeine than espresso or percolated coffee, while tea has less caffeine than coffee. Rooibos tea has no caffeine, and plenty of healthy anti-oxidants and minerals.

    EXERCISE
    The benefits of regular exercise are wide-reaching. Not only can it help to maintain and reduce weight, it can also reduce the risk of developing heart disease and diabetes, risk factors for kidney disease. You only need to exercise for 30 minutes on at least five days a week to reap the benefits. And you don’t have to sweat it out at the gym or pound the pavement – a brisk walk is sufficient.
    Tips to get more exercise
    • Break your 30 minutes up into 10-minute intervals if time is limited.
    • Walk as much as you can – walk to the shop instead of taking the car, and take the stairs instead of the lift or escalator.
    • Choose exercise that you enjoy, like swimming, walking, aerobics or cycling.
    • Get a friend to exercise with you … not only will you lose track of time as you work out, you’ll also help to motivate each other.
    • Simple daily activities such as mowing the lawn, or even shopping can be counted in your daily exercise quota. If shopping takes your fancy, do a quick lap of the shopping centre before actually hitting the shops.
    • If you have small children, join the local pram-pushers’ walking club. Contact your early-childhood centre or clinic, to find if a club exists near you. If not, start you own!



     

    Malnutrition whether manifested as over- or under-nutrition may have many adverse effects on your health. Weight loss is associated with a weaker prognosis in terms of survival and response to treatment as well as poor tolerance for surgery. In addition, it leads to a loss of lean muscle which results in disability to perform normal daily activities as well as anxiety, depression, and fatigue. In contrast over-nutrition (obesity / overweight) is a well established cause of diabetes mellitus, hypertension and lipid abnormalities. In summary, malnutrition is a cause of severe cardiovascular complications and more rapid renal decline.

    Nutrition guidelines for patients with a high blood pressure:

    High blood pressure is a major risk factor for cardiovascular disease. With renal involvement, this risk is increased 3 to 5 fold.
    Hypertension, and therefore cardiovascular disease risk, can be largely prevented by following a diet low in:
    - saturated fats and cholesterol (chicken skin, visible fat on meat, full fat dairy products, palm kernel oil, coconut, butter and hard margarine. Eggs should be limited to 2 – 3 per week, and not all at the same time)
    - salt (tinned, canned and processed foods, spices containing sodium, biltong, salty biscuits, stock cubes, packet soups, health, onion or garlic salt, pre-prepared meals, take-aways, meat and vegetable extracts, food flavourants containing MSG).

    A diet high in fibre (oats, fruits and vegetables, as well as whole grain products) is also important in lowering cholesterol levels.
    Cessation of smoking, weight loss and physical activity also play an important role in managing cardiovascular disease and associated renal complications.

    Nutrition guidelines for patients with renal stones

    Calcium oxalate stones are found in 80 per cent of patients, and are largely preventable by diet. The cornerstone of this diet is avoidance of oxalate containing foods, namely rhubarb, strawberries, nuts, regular tea, wheat bran (digestive bran etc.), spinach, chocolate, beetroot and Swiss chard. The following must also be consumed in limited quantities (i.e. ~ once a month):

    celery   green beans   beans in tomato sauce
    collards   okra   tomato juice/puree/ paste
    lemon peel   cocoa powder   tomato/ vegetable soup
    chocolate-type drinks   brinjal
      leeks
    red currants   cranberry juice   berries: black, blue, goose, raspberries etc.

    Adequate calcium intake is also important, thus milk, cheese and yogurt should be eaten daily.
    Fluid intake of 2 l of water daily is vital to ensure an adequate urine volume and thus a decreased risk of stone formation.

    Nutrition for patients with proteinuria

    This implies that protein is being lost in the urine. Adequate but not excessive protein intake at between 0, 8 – 1 g / kg is recommended as a protein intake. Exceeding this leads to further protein losses in the urine and further damage to the kidneys. This translates to a 90 g meat portion (size of palm of hand) at both lunch and dinner.

    Nutrition for patients with diabetes mellitus and kidney involvement
    Patients with diabetes should be following a diet that excludes sugar and all sugar containing products. When the kidneys are involved, this becomes even more important as high levels of sugar in the blood (blood glucose) can result in further damage to the kidneys and other organs (heart, lungs etc.). Contrary to normal diabetic guidelines where whole wheat and whole grain foods are recommended, these patients should be eating rye, brown or white bread. Cereals allowed would include oats, sorghum and mealie meal. The reasoning behind this is that whole grain products contain phosphate which is one of the first “waste products” to be retained by the body when the kidneys are impaired. When phosphate levels become too high, calcium is taken out of the bones and teeth leading to weak and brittle bones and thus an increased risk for osteomalacia and osteoporosis. Furthermore, calcium and phosphate form small crystals which can then be deposited on the kidneys, heart, lungs, liver and skin leading to organ damage. Foods that are high in phosphates and should therefore be taken in limited amounts, if at all, include:
    chocolate containing drinks, nuts and seeds, dairy (not fat free), sardines and pilchards with bones, cola drinks, cocoa (therefore all chocolates), whole grain products and legumes.
    Eating regular meals of the same size and at the same time daily are still very important in managing blood glucose levels. Fruits should always be eaten with a meal (never on their own) as although they contain natural sugar (fructose) they will still result in a rapid increase in blood glucose levels. This can be counteracted by eating fruits with a meal or snack (e.g. small apple eaten with one slice rye bread with one teaspoon tub margarine and sugar free jam).

    Nutrition for patients with moderate to severe renal impairment

    The degree of renal impairment will be determined by your doctor (by means of blood and urine tests) and conveyed to you. When renal function is 25 – 30 per cent (moderate impairment) of normal, a moderate reduction of excessive protein intake must be adhered to. This translates to 1 g of protein per kg body weight or 90 g meat/chicken or fish portion at both lunch and dinner. 90g is approximately equal to the size of your palm. High phosphate foods (chocolate containing drinks, nuts and seeds, dairy (not fat free), sardines and pilchards with bones, cola drinks, cocoa (therefore all chocolates), whole-grain products and legumes) must also be taken in limited amounts. Certain fruits and vegetables must also be avoided or consumed in limited quantities. The most important of these to avoid are pumpkin, spinach, olives, coleslaw, pickled onion and vegetables, tinned vegetables, bananas, oranges, grapes, mulberries, paw paws and cherries. The reasoning behind this is that these foods are high in potassium, a type of salt that is involved in muscle contraction and heart function. An excess of potassium and phosphates can cause nausea, vomiting, confusion, fatigue, itching and loss of appetite as well as further kidney damage. It is thus vital to limit intake of these foods.
    With severe renal impairment (function 50 per cent of normal) dietary limitation of the above foods becomes even more important to maintain a degree of renal function and quality of life. Protein intake should be reduced to 0, 8 g / kg (60 g meat portion at lunch and dinner – 60 g is approximately equivalent to the size of 2 match boxes). Vegetables should be peeled and chopped into small pieces and then soaked in a large bowl of water for two hours before being boiled. This further reduces the potassium content of your vegetables. Foods high in salt (processed, tinned, canned foods etc) must also be avoided as these can cause water retention which can in itself be dangerous. Carbohydrate (bread and cereals) intake is very important in these patients to ensure that muscle protein is not broken down. Breakdown of muscle protein is associated with disability to perform normal daily activities, lethargy and fatigue.

    Diet is very important in maintaining residual renal function and quality of life. It is recommended that all patients suffering from renal disease consult a nephrologist and dietician that has a good understanding of nephrology as this is a highly specified diet that plays a pivotal role in prevention of further renal decline and quality of life.


    Keren Gordon
    Registered Dietician



      …First find out whether your kidneys can handle it

    As weight loss diets go, high protein plans seem to have more staying power - but so do questions about their safety. One concern is for your kidneys, since it is their primary function to filter out protein by-products.

    Some kidney wear-and-tear is normal over time. But scientists were surprised to find that, among a middle-aged group, one in four people had signs of mild kidney decline. Because this compromises their protein-processing ability, high protein intake could damage their kidneys.

    Scientists are now warning that high protein diets are a bad choice for many who have unsuspected kidney problems – and you could be one of them. If you want to try a high protein diet, such as Atkins, and have any kidney disease risk factors – middle age, high blood pressure, or diabetes – first get a blood test for creatinine levels, a measure of your kidney function. If you have even mild kidney dysfunction, this study suggests a safe limit of 90g of animal protein a day – the size of a deck of cards. The amount of protein in high protein diets can go up to more than 250g a day.

    Juliet Fearnhead – Dietician, Pick ‘n Pay Healthcare Hotline

    STAYING FIT WITH KIDNEY DISEASE

     
      Physical fitness is very important in today's world. Everyone is enjoying the benefits of greater strength and feeling better. Exercise keeps your body strong and healthy.

    Can I take part in vigorous physical activity?

    Yes. In the past, it was thought that people with kidney disease would not be able to join in vigorous activity. We know now that patients who decide to follow an exercise program are stronger and have more energy.

    How does exercise benefit me?

    With exercise, it becomes easier to get around, do your necessary tasks and still have some energy left over for other activities you enjoy.

    In addition to increased energy, other benefits from exercise may include:
    • improved muscle physical functioning
    • better blood pressure control
    • improved muscle strength
    • lowered level of blood fats (cholesterol and triglycerides)
    • better sleep
    • better control of body weight.

    Do I need to see my doctor before starting exercise?

    Yes. Before beginning any exercise program, be sure to check with your doctor.
    When planning a directed exercise program, you need to look at four things:

    • type of exercise
    • length of time you spend exercising
    • how often you exercise
    • how hard you work while exercising.

    Here are some tips on each:

    Type of Exercise

    Choose continuous activity such as walking, swimming, bicycling (indoors or out), skiing, aerobic dancing or any other activities in which you need to move large muscle groups continuously.
    Low-level strengthening exercises may also be beneficial as part of your program. Design your program to use low weights and high repetitions, and avoid heavy lifting.

    How Long to Exercise

    Work toward 30 minutes a session. You should build up gradually to this level.
    There is nothing magical about 30 minutes. If you feel like walking 45 to 60 minutes, go ahead. Just be sure to follow the advice listed under "When should I stop exercising?" in this brochure.

    How Often to Exercise

    Exercise at least three days a week. These should be non-consecutive days, for example, Monday, Wednesday and Friday. Three days a week is the minimum requirement to achieve the benefits of your exercise.

    How Hard to Work While Exercising

    This is the most difficult to talk about without knowing your own exercise capacity. Usually, the following ideas are helpful:

    • Your breathing should not be so hard that you cannot talk with someone exercising with you. (Try to get an exercise partner such as a family member or a friend.) You should feel completely normal within one hour after exercising. (If not, slow down next time.)
    • You should not feel so much muscle soreness that it keeps you from exercising the next session.
    • The intensity should be a "comfortable push" level.
    • Start out slowly each session to warm up, then pick up your pace, then slow down again when you are about to finish.

    The most important thing is to start slowly and progress gradually, allowing your body to adapt to the increased levels of activity.

    When should I exercise?

    Try to schedule your exercise into your normal day. Here are some ideas about when to exercise:

    • Wait one hour after a large meal.
    • Avoid the very hot times of the day.
    • Morning or evening seems to be the best time for exercising.
    • Do not exercise less than an hour before bedtime.

    When should I stop exercising?

    • If you feel very tired
    • If you are short of breath
    • If you feel chest pain
    • If you feel irregular or rapid heart beats
    • If you feel sick to your stomach
    • If you get leg cramps
    • If you feel dizzy or light-headed.

    Are there any times when I should not exercise?

    Yes. You should not exercise without talking with your doctor if any of the following occurs:

    • you have a fever.
    • you have changed your dialysis schedule.
    • you have changed your medicine schedule.
    • your physical condition has changed.
    • you have eaten too much.
    • the weather is very hot and humid, unless you exercise in an air-conditioned place.
    • you have joint or bone problems that become worse with exercise.

    If you stop exercising for any of these reasons, speak to your doctor before beginning again.