[Music] all right welcome everyone to plant-based kidney health as always i'm dr sean hashmi my partner is here michelle krosmer you guys know us we're the mdrd twinsies i i've been joking around i have to tell you michelle you know i've been joking around with my daughter lately i call her my twinsie because my wife says that she behaves just like me and that's so scary it's so scary but she has all my bad habits yeah hopefully you're good habits too she has the good habits too but you know it's the bad ones that are like it just scares you right oh my god so they're the ones that stand out right now yeah so so before we get started michelle i wanted to make a complaint and this is a really important complaint so i went to costco and you know sometimes when i'm really tired and lazy and you know i'm just like really stressed out i get like these pre-packaged stuff so they have these lentils that are pre-packaged it's great in terms of health but the other part of health is not so great is it has so much salt i i don't know why the heck it does right so if you took a full like bag of it you would get like a thousand milligrams of sodium in just that one thing so i'm trying to get one serving out of it and they say one serving is two-thirds cup now i'm like i have no idea because you put it you put the whole thing in the microwave you warm it up for a minute and then you pour it out but you know i got my little like bowl there and i have my little bit of brown rice and i'm like what's two thirds of a cup because i don't want that much salt so that's my complaint about costco if they're listening please make it easier for people like me put a mark on the bag or something that's a good idea putting a mark on the bag or get a two-thirds cup measuring cup and then you can measure it out but which of course all dietitians have that but not everyone else but um trader joe's has for anyone who does have trader joe's they have um steamed lentils like and it's like a vacuum packed package and i think what it is for the serving size is a half a cup but it's around 230 milligrams of sodium for that amount so not even close to as high as the costco one um and i think you get a couple servings in the package and what i normally do if i get that is it's all vacuum packed and i'll basically break it up into a bowl and then i get my half cup measuring cup out just you know okay i'm gonna measure this portion and it's i mean it's already cooked you could eat it cold you could heat it up you could throw it into a stir fry or something but it is lower in sodium at least than that one got it got it i'll i'll put it on my christmas list by the end of this year i will have a measuring cup i'll get you one to do yes there you go oh well today we are another really big topic where again there's lots of um myths and confusion and miscommunications around it but we're talking about potassium today and again this will also be broken into multiple episodes because we have a lot to talk about there's a lot to explain and then we have tons of questions that we get so don't worry if you've submitted something and we haven't gotten to it yet you can still submit your questions to plant-based kidneyheld gmail.com because we will add them we'll answer them and especially around something as confusing as potassium is excellent excellent so where do you want to start on this really huge yeah let's start with just simply um you know what is potassium and what is its you know importance and relationship to kidney disease and kidney health yeah so potassium is a huge topic and it's so so so so so important you know when we were talking about high phos we said you know high phos so forth and so on these are the treatments higher phosphorus is forgiving in the sense that over time it does a lot of damage but in the immediate term it's okay but potassium is absolutely critical so first potassium is an electrolyte right it has a lot of functions the main function which by the way a lot of people don't really realize is its job is to maintain fluid levels inside your cells so remember salt or sodium its job is to maintain fluid levels outside of cells so that's where people like yeah really potassium does that yes now the other stuff potassium does that's really helpful is it's important muscle contractions right so if i had a gun show here and i'm trying to contract my muscles well that's exactly by the way my daughter and i we have this thing about gun shows so she's like four right and so she works out with me in the morning she's like daddy daddy look at my muscles so every morning i get a free gun show and it's really really awesome and cute um so muscle contraction is one of it and then the other thing is it's really important in supporting blood pressure meaning keeping your blood pressure in a healthy level now here's where it gets really fascinating and people like myself who we like to call ourselves nephrons because it sounds really cool it's not that cool right but when you look at potassium potassium inside your blood has a concentration about three and a half all the way up to five mil equivalents per liter so three and a half to five remember that number but now let's look at the concentration of potassium inside cells it's about a hundred and forty and why should you care because if potassium which in your blood is about three and a half to five if it goes up to about 5.5 or above you start to have all of these things happen in your heart so imagine if some of those cells that have 140 milligrams per liter start to break apart that can have devastating effects on your body so as you think about that realize how amazing your body is that your kidneys work so well that you're constantly flowing potassium back and forth between your blood and your cells going on now one thing that's important to understand is is that what the data shows is if you eat a diet that's rich in potassium going on you can actually lower your blood pressure naturally by about anywhere between three and a half to a little bit over seven points and you can reduce your risk of strokes by as much as 24 this is simply by adding more potassium to your diet how with everything michelle that you talk about which is eating lots of fruits lots of vegetables which come naturally in potassium so you don't have to do anything fancy going on and overall people who have diets that are rich in potassium they actually have a substantially lower risk of developing cardiovascular disease in one study in a meta-analysis that was done in 2021 what they showed was that people who are having over 1 000 milligrams of potassium excretion in the urine which means that you're taking more potassium than you need so you're excreting more potassium to keep that balance but what they were finding was that those folks had an 18 lower risk of developing cardiovascular disease so potassium is amazing in terms of what it does but high potassium is stuff that you do need to worry about because the symptoms are life threatening so let me repeat high potassium is life threatening so when your kidney doctor when your nurse when anybody in your health care team calls you and says mrs jones your potassium is very high and we need to act on it you must act on it because it can cause muscle weakness substantial muscle weakness it can cause paralysis it can cause fatal arrhythmias meaning your heart goes on to rhythms like ventricular tachycardia which in order to break it we have to shock you they can go into ventricular fibrillation where instead of squeezing the bottom of the heart is doing this number where it's just fibrillating meaning blood isn't getting to the organ so all your body is starving or your heart can stop altogether the net consequence of all of these things from hyperkalemia is death so when i teach medical students or residents or fellows what i tell them is is the first symptom of hyperkalemia the first symptom of hyperkalemia is death if you wait for symptoms you are going to be absolutely too late now why does this matter to chronic kidney disease patients because more than half of patients who have chronic kidney disease they will go on to develop hyperkalemia at one point in time or another and the biggest causes of it is as your gfr goes down your ability of your kidneys to get rid of that potassium goes down as a result excess potassium starts to build in the diet so the main thing that really contributes to high potassium is really a high potassium diet there are other things right so things for example is tissue breakdown or muscle breakdown let's say you go run a marathon you're going to break down a bunch of muscle and as a result you're going to release potassium but if you have normal kidney function those kind of things are much rare or if you're in god forbid in a car accident there's a crush injury all those cells break remember the concentration was 100 540 inside those cells so all that potassium gets released and it comes into the blood but once again rare but when it comes to diet that's the biggest thing now we're going to talk all about medications and stuff in a different episodes but medications like ace inhibitors arbs aldosterone antagonists so things like cinnamon bonazopril losartan spironolactone these are all things that can increase your potassium and of course other stuff is is if you develop acidosis what's acidosis it's where the acid in your blood starts to increase now when that happens potassium from inside your cells will move to outside of your cells and end up in the blood and for all of the science people who are there is yeah yeah but there are exceptions to metabolic acidosis yes they are lactic acidosis ketoacidosis you don't develop hyperkalemia but that's beyond the scope of this if you have acid in the blood and with kidney disease your doctor may say you know mrs jones your bicarb or your bicarbonate level or your base level is too low i'm going to give you some baking soda pills right the reason they do that is because that acid starts to leach away the calcium out of the bones the phosphorus out of the bones starting to break down the bones it's putting stress on all of your organs going on and by the way if you're thinking that you have more acid one of the easiest things is add lemons and limes to your diet everything you eat add lemons and limes to it and you can do the same thing as the sodium bicarbonate pill will do without the sodium component of it now other things to remember about this whole issue that happens with hyperkalemia is is if you're somebody who is a diabetic and you have essentially a situation where your sugars are becoming very very high and you don't have enough insulin especially if you're a type 1 diabetic insulin deficiency can also shift potassium from the cells into the blood the bottom line with hyperkalemia the thing that i want you guys to take home is it is very very very serious and please do not ignore it if you have it and you think well you know i've always run a k of six and nothing has happened therefore i'm okay your body does not get used to high potassium levels it's not like all of a sudden your heart is gonna get used to it and you're not gonna have an arrhythmia anymore because you've had it for a year now that's not how the body works so this is something that we have to emphasize if you have it you must talk to your health care team now the flip side sorry i just have a question on that with the high potassium or hyperkalemia but is there a certain gfr that you see where it becomes more of a concern with high with high blood potassium levels yeah so generally speaking as you start to go into stage four and stage five so remember when we start to define stage four stage four is when your gfr starts to drop below thirty that's where you know that hyperkalemia is a lot more sensitive so we as nephrologists when we prescribe medications the reason we ask you is is you know go ahead and do a blood test for us in seven to ten days after we start or change the dose of a medication is because we're more concerned but it's a misnomer to think that just because you're stage 3 you won't develop it hyperkalemia is just overloading your body's ability to maintain that balance that's all it is and that can happen very very easily so even if you're stage three and you're on certain medications we still want to make sure that your potassium stays in the normal range okay thank you and and once again you do not get used to hyperkalemia your body will not get used to having high potassium levels so you've got to know this because a lot of patients come back to me and say oh yeah it's no big deal i always get called every week from my doctor because my potassium is 6.5 and you know i don't do anything about it i can tell you having done this for so long now i have seen so many bad things happen because the patient purposely chose not to take action on it now let's flip the equation a little bit let's go to hypokalini which means low potassium so low potassium can happen for a number of causes but the biggest one is if you lose potassium through your gut meaning the gi tract and the most common reason is you got diarrhea so people who have significant diarrhea they can have it the other way that happens is something called renal tubular acidosis or an rta but essentially the kidney is losing potassium instead of trying to hold on to it it's losing how do we check same thing by measuring the urine that's coming out we can look at the potassium and calculate the excretion and know that if it's excreting too much potassium and you have low potassium in the blood the kidney is not doing its job it must be the kidneys right and if that's not the case it means it's coming from the gi tract so what are the symptoms of hypokalemia well the first thing you got to know is just like hyperkalemia hypokalemia can be very very dangerous as well so it also causes weakness it can also cause muscle breakdown what we call rhabdomyolysis which is your tissues and muscles starting to break down and releasing all of the stuff inside them it can slow down your heart cause bradycardia it can cause the opposite or speed up your heart with an rhythm that we have to shock you for called ventricular tachycardia or the worst one yet which is fibrillation where the heart fibrillates instead of squeezes and knowing all of those those are things that can occur right away but what's interesting and scary about hypokalemia is if you leave hypokalemia alone meaning you don't do anything about it for a long time it can actually cause some very serious stuff to occur so for example people can find that their ability to for neurologically their ability to concentrate actually starts to go down and one of the things is their potassium is low and if you correct that they find pie you know things are getting better again they also find that they may have issues where the kidney itself starts to have an issue with concentrating and so when that happens is its ability to be able to hold on to urine goes away and it starts to have so much urine coming out that people can get dehydrated going on and that's a big deal some people interestingly enough when they have low potassium they start to see high blood pressure remember the data shows if you raise your potassium in your body the blood pressure comes down the opposite has the same effect and then the last thing that you want to remember is is that there are certain things where you start to spill more protein in the urine simply because your potassium is low now those are the things that we talk about high and low potassium but that's not where the story ends there are two more things that you got to know first one is there's also a fake high potassium and there's a fake low potassium and you got to know this because oftentimes when we get a blood sample and it's high potassium we want to know is it pseudo hyperkalemia or fake high potassium and how does that happen the most common is doing the blood draw if there's a lot of trauma if they left the tourniquet on when they were actually trying to go into the vein that would cause it so as soon as you get the needle in the vein you want to take the tourniquet off if you leave it on and the needle is in and you're drawing the blood you can actually cause the blood the cells to break apart and remember inside the cells is a massive increase in concentration going on other thing that can do it is exercise if you exercise right before you have your blood drawn it will cause more potassium to come out of cells but you know what's even simpler than that is a lot of patients i see they clench their fist before getting their blood drawn because they might have small veins repeatedly clenching your fist will do what it can actually cause exactly the same thing which is increase the potassium concentration release more potassium out of the cell so that tube can look like it has an increase by as much as one to two mil equivalents so if you were four you might be six so can you tell that on like does the person who's drawing the blood can they tell that or you see that on the report when it comes back or you just don't know you don't know and this is why these things are so important right so knowing that you can't leave the tourniquet on too long knowing that repeated clenching is an issue knowing that you don't want to exercise before and then of course when they draw the tube nowadays this is not an issue but back in the day if you were to leave the tube alone and let the blood kind of sit there and it clots up and everything the cells in there would break and as they would break they would start to release potassium going on so what happens is as you draw the blood the platelets that are in there in that blood they will actually break apart and release the potassium inside them so people who might have a condition called thrombocytosis where they have a lot of extra platelets you can actually see this going on same thing is if you have a lot of white blood cells let's say that you have a type of leukemia called chronic lymphocytic leukemia when you get that blood drawn those white blood cells are so much and they're so fragile that taking it out through the needle they start to break so if you're somebody who always has normal potassium and all of a sudden you have high potassium and you're like there's no way i didn't do anything different i listened to everything michelle said and why the heck do i have high potassium it must be michelle's fault no it's not michelle's fault and when in doubt what we recommend is let's just do another potassium and as a informed patient when you go in remember don't go crazy with the clenching don't leave the tourniquet on too long once the needle is in take the tourniquet off okay so that's the fake hype potassium let's do the fake low potassium so what can do that so in terms of fake low potassium going on is other conditions so for example people who have aml or acute myeloid leukemia going on what happens there is is those cells they're so rapidly moving and trying to suck everything in that after you draw the blood they can suck in all of the potassium and make it seem like you have low potassium when you actually don't so it's the opposite effect same thing if i gave you too much insulin all of a sudden it would drive the potassium into cells make it look like you have low potassium but really i just drove it into cells if i gave you too much bicarbonate it would do exactly the same thing going on and of course if i gave you a type of medication that's called a beta agonist that would make your heart speed up like crazy and it would also drive the potassium into cells so now you have four types of potassium issues hyper hypo pseudo hyper and pseudo hypo that's a lot to learn today so with those four types regardless of whether someone is if they're normal usually have normal potassium and all of a sudden it's really low or it's high or someone at any point has a high or low value when should they have a lab draw repeat done is it seven days is it ten is it a couple months when should that be checked again yeah so this is this is really key is is you know if they have high potassium i want to make sure that their potassium is in a better safer place so we're going to talk about the treatments of high potassium in a different episode but once we do the treatments for high potassium we go ahead and repeat that in a couple of days if it's super high i'll repeat it the next day just because from first do no harm i need to make sure that they're a safe place that when they go to bed at night i feel safe that i have done everything i can to protect them so it's not one size fits all but it's really about making sure that they're stable and it depends on what treatment you're using so if it's something like one of the gi treatments where it's going to cause you to excrete it out right that's going to take about six plus hours to work and so at a minimum i need to wait that much to see the effect going on if it's other things like the iv treatments such as the insulin going on right such as the beta agonist going on those kind of things those are immediate and they last only 15 to 30 minutes okay and then they're gone interesting and for people who are always in the normal range you know they're between 3.5 and 5 if they see is it fine as long as they're within that range or what if they go from 3.6 up to 4.9 is that big jump concerning or is it ok like can people move around a lot within that normal range yeah so people move around all the time in fact if i was to take let's say i took your blood three times today i guarantee you i would get three different values and if it was in the morning after you'd worked out or done everything versus you just woke up from sleeping you could change the values so significantly so in terms of that no issue going on but the thing is is when it goes higher than 5.5 that's where all of these issues of arrhythmias come in because the thing that we worry about with high and low potassium is death death and death got it okay and so and knowing then the importance of all this and i this is something that i think comes up a lot is um let's say someone does have high high blood potassium levels are they trend on the higher end and they are following a lower potassium diet is it that and i get asked this a lot is it that the high potassium foods or if they're eating a high potassium diet is causing their kidney disease to accelerate more quickly and damaging the kidney or is it that it's simply causing the side effect of hyperkalemia which needs obviously to be addressed or both yeah so in this you know normally we say it's like a chicken and egg thing this is not a chicken and egg thing high potassium is not damaging the kidneys it's the fact that the kidneys can't regulate the potassium enough and that's why the potassium is building up so as the kidneys lose their kidney cells they just can't get rid of it but high potassium is not directly damaging the kidneys now if high potassium causes an arrhythmia in the heart and you don't send enough blood flow to the kidney that's a whole other story but no it's not high potassium leading to kidney disease it's kidney disease leading to high potassium got it got it so then someone who has normal blood potassium levels they're consistently normal it's not that eating you know a normal potassium diet or even a higher potassium diet is causing kidney disease to get worse it's your blood your kidneys are working enough and efficiently and well enough to be able to prevent too low or too high potassium levels right because remember so if you guys remember the phosphorus episode we did in that one we said even if your phosphorus levels are normal but your ckd is three or worse meaning your gfr is dropping below 60 you still want to make sure that you cut down on high phosphorus foods because of all of the secondary things it's doing and because other organs are compensating but with potassium remember as long as you're in the safe range you want to eat a high potassium diet because of all of the benefits on things like stroke on things like heart disease on things like blood pressure going on so it's totally different so don't let the phosphorus and potassium story confuse you as long as your potassium levels are okay there is no reason to restrict fruits and veggies out of your diet perfect thank you for saying that and i think that's that is the biggest one of the biggest myths and misconceptions it's not downplaying the the uh you know how important it is to address high potassium blood levels but in people and like you said i mean at least half the people with kidney disease have normal blood potassium levels and that's where it really needs to be individualized based on your labs and you knowing your labs because you don't want to be restricting potassium or overly restricting it if you don't need to because there's a lot of benefits of these potassium-rich foods in your diet yep absolutely so so let's go a little bit further michelle what would you say you know when we talk about a low potassium or high potassium diet in terms of specifics so you know milligrams per day or milligrams per week and really same question that we had talked about with phosphorus is how do i sort of know how much i'm getting for potassium yep great question so um there's definitely ranges for everything but in general a so let's start with what is recommended for the general population so the um the rda for potassium for the general populations around 4 700 milligrams of potassium a day now most people don't eat that much potassium i think it's something like 2500 to 3000 milligrams of potassium a day is what the general population consumes so it's much less than what that recommended amount is now when we get into kidney disease someone who needs a low potassium diet or needs to restrict the potassium in their diet typically that's around 2000 milligrams of potassium a day so it's significantly lower than what the rda is um and it might be you know maybe it's 2000 maybe it's 2300 maybe it's you know 1800 milligrams we don't eat the same exact foods every day so we're not necessarily having the same amount of milligrams but a low potassium diet is usually around two thousand milligrams a day now it's important to remember that that's low potassium it's not no potassium and even if someone is on a low potassium diet i mean depending if they're having two to three meals a day one to two snacks i mean their meals could be 500 to maybe 800 milligrams of potassium snacks could be 100 maybe 300 milligrams of potassium and that's just for a low potassium diet when we look at a moderate potassium so maybe they don't have a a tight restriction but they need to be a little careful that might be anywhere from 2500 to 3500 milligrams of potassium a day somewhere in that range and then usually what we consider to be high potassium or like no restriction limitation at all it's usually over 4 000 milligrams a day that can vary from person to person again depending on medications they're on um depending on you know other factors but that's just in general what you can use as a guideline and if you're curious how much you're consuming then you can always track in an application so something like um chronometer or chronometer is pretty good at you know you can log your food intake for the day and you could see how much potassium you're consuming and that's really helpful because a lot of the times what i see at least from if if diet is causing someone to have high blood potassium levels oftentimes they've been consuming these like crazy amounts of very high potassium foods and it's adding up to be a lot so they might be having like multiple sweet potatoes and avocados and tomatoes and brussels sprouts and mangoes and guava and all these very very high potassium foods versus just having you know okay i normally eat low to moderate potassium foods and have a moderate potassium diet and then if you have half of a banana right then it's not this drastic increase in potassium intake so those are general guidelines and ranges and again it's really important to be looking at your blood test results because if you have especially if you're an early stage of kidney disease and especially if you have normal blood potassium levels if you're trying to and i unfortunately hear this a lot of like okay diagnosed with kidney disease i went online and started you know googling what to eat and now you get all these lists of don't eat all of these you know don't eat all these fruits and veggies or don't eat beans or lentils and so people are i'm avoiding high potassium foods but they have their blood levels are normal they're consistently normal um all they're really doing is restricting their intake and how much flexibility and variety they have and also potentially impacting their blood pressure um potentially reducing the amount of fiber they get in their diet at that point so that's where it's super important um so i would say track you know use those guidelines that i said as guidelines again you want your doctor or your renal dietitian they can give you specifics but um and then again remember that we eat in like ranges and so don't be so like okay my dietitian told me to have 2500 milligrams of potassium a day and i had 2600 now i'm all of a sudden my blood levels are getting elevated it doesn't work exactly like that it's if you need 20 around 2500 milligrams of potassium in your diet a day you don't want to be consuming 5 000 milligrams or 6 000 milligrams and again generally the general population is not consuming that much potassium because they're not eating enough whole plant foods in their diet to begin with that's excellent that's excellent so folks i i hope you guys learned a lot from today's talk on potassium this is part one we're gonna have a part two and talk more about some of the specifics on medications and so forth as always we really really appreciate your questions that are coming in because they're helping us to really guide where the show goes the goal of this show was michelle and i talked about it and what we wanted to do was make this a labor of love we both have our day jobs this is really about us giving back and that's what we do here so please send us the questions plant based kidney health gmail.com michelle any closing remarks um i think i would just say stay tuned for our next episodes on potassium i you know we try to keep these episodes not too long so that's why trust me we have a long list of more potassium questions that we will be addressing but i think a good takeaway is one knowing knowing what your labs are knowing what you are eating and then um you know making sure that you are you know working to prevent high blood potassium levels are treated urgently if they're high but ultimately it is individualized based on you and your labs and you don't want to be restricting when you don't need to and um you know hopefully working with your nephrologist and a renal dietitian can help you figure out okay how exactly how much potassium you need what sources to get that way you don't feel overly restricted and deprived in your diet and like you can't eat any of the delicious plant foods that are good for you well awesome with that thank you everybody so much and we will see you next week take care bye everyone see you next week [Music] [Applause]
