Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the panelists are presented.

My physician told me that diet in a diabetic kidney patient was not important
Are there any side effect of EPO to watch out for?
What are the long-term effects of a low hemoglobin level?
Are there non-pharmacologic methods of keeping up your hemoglobin?

Dr. Levin's answers
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My physician told me that diet in a diabetic kidney patient was not important
Dr. Levin:
In fairness, there was a study that came out in 1994 that sort of said you should throw diet out the window (MDRD Study). And the problem is that by the time we catch up with what the new thing is, people are walking around giving information. The thing is, it is not all or none. It is not that there is a perfect diet that will keep you well forever, and there is not that there is no diet, as Dr. Fine was trying to say. Each one of us needs to tailor it to the patient. When you have diabetic kidney disease, there is less good evidence that huge changes in diet would help delay the progression of kidney disease. And lots of kidney doctors were thinking about only the kidney disease. It is only more recently that we've remembered all about the bone disease and the hemoglobin and all the other things that can also be impacted. We are only human, and we only know as much as we know. I think the whole value of this sort of a forum that John so nicely put together is that through this sort of interactive stuff, the more people know, the more questions they ask, the more responsibility they take. I think things will be better over the next years.

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My father is on EPO. He was twice a week, and now he takes the needle once a week. He is closely being monitored. He is also on iron pills. I take him for blood work every two weeks. Are there any side effects I should watch out for while he is on this EPO?
Dr. Levin:
As long as he is getting his blood pressure carefully monitored, things should go well. One of the things that happens with people with EPO, and it is not everybody, but about 30 percent of people might have a rise in their blood pressure that would cause you to change the blood pressure pills around a little bit. But of all the medicines we have... it is a little bit like insulin--it is just a hormone that your body would have made if it could. So there are very few side effects that anyone has reported, especially in people before dialysis and the way we know how to use it now.

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What are the long-term effects of a low hemoglobin level?
Dr. Levin:
Before we had erythropoietin, people with kidney disease routinely had hemoglobins of 60 g/L (or 6.0 mg/dL). Sandy will remember when I first started doing nephrology that we were all excited that we got people's hemoglobins to go from 60 to 85 g/L. We thought we had done something amazing. Now we don't let it get below 100-110. The long-term effects are all the things I mentioned: the growth of the heart muscle, problems with the vasculature, problems with thinking, muscle wasting, etc.

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Are there non-pharmacologic methods of keeping up your hemoglobin?
Dr. Levin:
Apart from blood transfusion, no. There are things you can do to minimize the bad effects of having low hemoglobin, like exercising but this won't make your hemoglobin go up, although it they will help your body deal with a hemoglobin that is low. So it keeps you fit and well. Even when you are tired and your muscles ache, if you still keep walking, that is better than not. Think about low hemoglobin as people think about diabetes. It is a loss of a hormone that we know how to replace.