Herbs and supplements in dialysis patients: panacea or poison?

Frequency, types, and factors associated with complementary and alternative medicine use among patients on maintenance haemodialysis

BACKGROUND

Despite progress in haemodialysis and conventional medicine approaches, many patients still struggle to maintain an acceptable quality of life and turn to complementary and alternative medicine (CAM) to address their unmet needs.

OBJECTIVE

This study aims to determine the prevalence, types, indications, and factors associated with CAM use by patients on maintenance haemodialysis (MHD) in Cameroon.

MATERIALS AND METHODS

This was a multicentric cross-sectional study involving MHD patients in Cameroon from February 2019 to May 2019. We included all consenting participants on MHD for at least 3 months and excluded participants with cognitive and behavioral problems. Face-to-face interviews were conducted.

RESULTS

A total of 224 participants (145 males) with a mean age of 56.5 ± 14.2 years and a median haemodialysis vintage of 34.5 [IQR: 17.3-64.4] months were recruited. In all, 89.7% (n = 201) reported having used CAM before, while 71.6% (n = 144) were still using it. Biologically based therapies were the most popular (94%, n = 189), with herbal medicine (81.5%, n = 154) and Calabar chalk (52.4%, n = 99) being the most common. Physical well-being (57.2%), nausea (52%), and insomnia (42.7%) were the main indications for CAM use. Most respondents did not disclose their CAM use to their physicians (61.2%). Long haemodialysis vintage was associated with CAM use (AOR: 7.9; CI = 2.8-22.3; p < 0.001).

CONCLUSIONS

The use of CAM is common among Cameroon's haemodialysis population, with herbal medicines and Calabar chalk being the most frequent. The high symptom burden makes CAM attractive to them. Healthcare teams should be aware of these practices, initiate an open discussion, and appropriately advise patients about dangers, risks, and safety associated with their use.

TRIAL REGISTRATION

The institutional review board of the University of Bamenda. Reference: 2019/0038H/UBa/IRB UPM/TNCPI/RMC/1.4.18.2.

Assessing the efficacy and safety of Juan Bi Tang for dialysis-related myofascial pain in the fistula arm: Study protocol for a randomized cross-over trial

Background

Dialysis-related myofascial pain in hemodialysis (HD) patients is an important issue that is associated with many other psychosomatic problems. Effective interventions are required to alleviate pain in this group. Chinese herbal medicine (CHM) may be a potential therapeutic treatment for reducing pain. The aim of this study is to evaluate the effects of a classic CHM formula intervention on pain intensity, daily function, quality of life (QOL), and safety in patients receiving HD in a dialysis center within the context of southern Taiwan.

Methods

This will be a randomized, open label, cross-over trial with two parallel groups in a pre- and post-test study. Forty patients reporting myofascial pain related to the arteriovenous (AV) fistula in the arm during regular HD sessions will be recruited. Participants will receive 4 weeks of treatment with Juan Bi Tang (JBT) and 4 weeks of no treatment in a random order, separated by a washout period of 2 weeks. Treatment doses (3 g JBT) will be consumed thrice daily. The primary outcome measure will be the Kidney Disease Quality of Life 36-Item Short-Form Survey. Secondary outcomes will include the Fugl-Meyer Assessment-arm, Visual Analogue Scale (VAS) of pain, and grip strength. Outcomes will be collected before and after each intervention, for a total of four times per participant. The safety evaluation will focus on adverse events (AEs).

Discussion

This study will be the first to use CHM to treat patients receiving HD with dialysis-related myofascial pain in their fistula arm and to perform a complete assessment of the treatment, including records of QOL, arm function and muscle power, severity of pain, and safety. The results of the study will provide convincing evidence on the use of JBT as an adjuvant treatment for dialysis-related myofascial pain.

Trial registration

Clinicaltrials.gov registry (NCT04417101) registered 30 May 2020.

Polypharmacy and mortality association by chronic kidney disease status: The REasons for Geographic And Racial Differences in Stroke Study

Many Americans take multiple medications simultaneously (polypharmacy). Polypharmacy's effects on mortality are uncertain. We endeavored to assess the association between polypharmacy and mortality in a large U.S. cohort and examine potential effect modification by chronic kidney disease (CKD) status. The REasons for Geographic And Racial Differences in Stroke cohort data (n = 29 627, comprised of U.S. black and white adults) were used. During a baseline home visit, pill bottle inspections ascertained medications used in the previous 2 weeks. Polypharmacy status (major [≥8 ingredients], minor [6-7 ingredients], and none [0-5 ingredients]) was determined by counting the total number of generic ingredients. Cox models (time-on-study and age-time-scale methods) assessed the association between polypharmacy and mortality. Alternative models examined confounding by indication and possible effect modification by CKD. Over 4.9 years median follow-up, 2538 deaths were observed. Major polypharmacy was associated with increased mortality in all models, with hazard ratios and 95% confidence intervals ranging from 1.22 (1.07-1.40) to 2.35 (2.15-2.56), with weaker associations in more adjusted models. Minor polypharmacy was associated with mortality in some, but not all, models. The polypharmacy-mortality association did not differ by CKD status. While residual confounding by indication cannot be excluded, in this large American cohort, major polypharmacy was consistently associated with mortality.

Traditional and complementary medicine use among chronic haemodialysis patients: a nationwide cross-sectional study

Background

In the era of digital and improved conventional medicine, many continue to use traditional and complementary medicine (TCM). The prevalence of its usage is not well reported, especially in patients with end-stage kidney disease (ESKD) receiving haemodialysis, thus its benefits and adverse effects are not widely known. This study determines the prevalence, types, perceptions and factors associated with TCM use by chronic haemodialysis patients in Malaysia.

Methods

This is a multi-centre cross-sectional study involving patients undergoing haemodialysis treatment in Malaysia. A validated face-to-face questionnaire-based interview was conducted. Sociodemographic and clinical profiles of the patients, factors associated with TCM use, perceptions, sources of information, and disclosures to treating doctors were obtained. Data were analysed using SPSS software.

Results

A total of n = 329 participants were recruited. The mean age of the participants was 54.9 ± 12.5 years. The majority were Malays (72%) and females (54.7%). A total of 64.7% (n = 213) reported TCM use; n = 132 used TCM before the initiation of dialysis, while n = 81 used TCM after initiation. In the post-hoc analysis, patients who had never used TCM had a higher mean age (56.7 ± 12.3 years) than the patients who used TCM (51.1 ± 13.1) (p = 0.015) and were likely to have received primary education (p = 0.011). Unemployment was more likely to be associated with non-TCM use; with odds ratio 1.85 (95% CI: 1.15, 2.98). Biologically based therapy was found to be the most popular (97.2%) type of TCM, including herbal medicine (67.6%) and supplements (58.0%). Most respondents did not disclose their TCM use to their doctors (72.3%), and 41.8% had the perception that they felt better.

Conclusions

TCM is widely used among chronic haemodialysis patients in Malaysia, mainly herbal medicine and supplements. Non-disclosure to healthcare professionals and a poor monitoring and regulation of its use in ESKD patients could be detrimental. Awareness needs to be raised among healthcare professionals and the general population.

Trial registration

The Ethics Committee for Research, University Putra Malaysia (13th March 2019). Reference: UPM/TNCPI/RMC/1.4.18.2 (JKEUPM).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03268-4.

Factors associated with the frequency of antihypertensive drug adjustments in chronic kidney disease patients: a multicentre, 2-year retrospective study

Background Optimum antihypertensive drug effect in chronic kidney disease is important to mitigate disease progression. As frequent adjustments to antihypertensive drugs might lead to problems that may affect their effectiveness, the modifiable factors leading to frequent adjustments of antihypertensive drugs should be identified and addressed. Objective This study aims to identify the factors associated with frequent adjustments to antihypertensive drugs among chronic kidney disease patients receiving routine nephrology care. Setting Nephrology clinics at two Malaysian tertiary hospitals. Method This multi-centre, retrospective cohort study included adult patients under chronic kidney disease clinic follow-up. Demographic data, clinical information, laboratory data and medication characteristics from 2018 to 2020 were collected. Multiple logistic regression was used to identify the factors associated with frequent adjustments to antihypertensive drugs (≥ 1 per year). Main outcome measure Frequent adjustments to antihypertensive drugs. Results From 671 patients included in the study, 219 (32.6%) had frequent adjustments to antihypertensive drugs. Frequent adjustment to antihypertensive drugs was more likely to occur with follow-ups in multiple institutions (adjusted Odds Ratio [aOR] 1.244, 95% confidence interval [CI] 1.012, 1.530), use of traditional/complementary medicine (aOR 2.058, 95% CI 1.058, 4.001), poor medication adherence (aOR 1.563, 95% CI 1.037, 2.357), change in estimated glomerular filtration rate (aOR 0.970, 95% CI 0.951, 0.990), and albuminuria categories A2 (aOR 2.173, 95% CI 1.311, 3.603) and A3 (aOR 2.117, 95% CI 1.349, 3.322), after controlling for confounding factors. Conclusion This work highlights the importance of close monitoring of patients requiring initial adjustments to antihypertensive drugs. Antihypertensive drug adjustments may indicate events that could contribute to poorer outcomes in the future.

Use of Dietary Supplements in Living Kidney Donors: A Critical Review

Dietary supplement use is high among US adults, with the intention by users to promote overall health and wellness. Kidney donors, who are selected based on their overall good health and wellness, can have high utilization rates of dietary supplements. We provide a framework for the evaluation of living kidney donors and use of dietary supplements. In this review, dietary supplements will include any orally administered dietary or complementary nutritional products, but excluding micronutrients (vitamins and minerals), food, and cannabis. Use of dietary supplements can influence metabolic parameters that mask future risk for chronic illness such as diabetes and hypertension. Dietary supplements can also alter bleeding risk, anesthesia and analgesic efficacy, and safety in a perioperative period. Finally, postdonation monitoring of kidney function and risk for supplement-related nephrotoxicity should be part of a kidney donor educational process. For practitioners evaluating a potential kidney donor, we provide a list of the most commonly used herbal supplements and the effects on evaluation in a predonation, perioperative donation, and postoperative donation phase. Finally, we provide recommendations for best practices for integration into a comprehensive care plan for kidney donors during all stages of evaluation. We recommend avoidance of dietary supplements in a kidney donor population, although there is a paucity of data that identifies true harm. Rather, associations, known mechanisms of action, and common sense suggest that we avoid use in this population.

Herbal Supplement Use and Herb-drug Interactions among Patients with Kidney Disease

Objective:

The prevalence of herb–drug interactions and herb's adverse effects may be serious in susceptible population such as patients with chronic kidney disease (CKD). In this study, we planned to determine the usage prevalence of herbal products and herb–drug interactions in CKD patients.

Methods:

A cross-sectional prospective study was conducted on CKD and posttransplant patients with a history of using herbal supplements in Isfahan, Iran. The patients were subjected to a validated checklist, containing demographic and clinical information. The knowledge of herbal use, side effects, and herb–drug interactions was assessed based on patients' responses. Data were reported as prevalence (percent) of the occurrence.

Findings:

The prevalence of herbal supplement usage among CKD patients was 18.6% in this study. The study included 400 patients (261 males and 139 females). The majority of the study population were in the age range of 50–70 years (61.5%). Hypertension (34.36%) was the most common cause of kidney failure, while diabetes mellitus (21.80%) took the second place. The most frequently used unformulated medicinal herb was Echium (Echium amoenum) (15.27%), and the most commonly used formulated herbal products were anticough and mucolytic based on Thymus vulgaris (24.27%). Eighteen patients (4.5%) used herbal mix with unknown entity and sources. In this study, ginseng has the most possible interactions with prescription drugs (18 interactions), while this interaction (with clopidogrel, warfarin, and heparin) was severe in six cases.

Conclusion:

The present study provided the information on possible herb–drug interactions in CKD patients on herbal usage. Since the issue of using herbal products may be arbitrarily in the majority of the patients, and considering the importance of adverse reactions or major interactions, health-care providers should play an active role to identify these cases and inform the patients regarding herbal product safety, adverse effects, and possible interactions.

Complementary and Alternative Medicine Practice Among Saudi Patients with Chronic Kidney Disease: A Cross-Sectional Study

Objective

Complementary and alternative medicine (CAM) practice in patients with chronic kidney disease (CKD) has significantly increased. However, statistics regarding CAM practices among patients with CKD in Saudi and worldwide are limited. Hence, this study aimed to explore the prevalence and types of CAM in Saudi patients with CKD.

Methods

A cross-sectional study was conducted in 315 patients, who were divided into CKD stages 3-4, CKD stage 5-hemodialysis, and kidney transplant with functioning allografts, by using a convenience sampling technique between September and December 2018. Next, they answered a self-administered questionnaire. The study outcomes were the prevalence of CAM, CAM types, reasons for using herbs, and the source of information about CAM.

Results

Overall, 54.9% of the study participants were current CAM users, of which 88.4% were herbal consumers. Patients with CKD stages 3-4 accounted for 87.3% of the CAM users, followed by those with CKD 5-hemodialysis (7.5%) and CKD-transplant recipients (5.2%). CAM practice was associated with monthly income (P = 0.021). Meanwhile, 79% of CAM users did not report their CAM practices to their primary physicians. Nigella sativa and parsley were the most commonly consumed herbs by CAM users [94 (61.4%) and 78 (51%), respectively].

Conclusion

CAM practice and herb consumption were highly prevalent among patients with CKD. Patients inadequately inform the primary physicians about their CAM practices. Therefore, healthcare providers are encouraged to inquire about these practices.

Creation of a Natural Health Products Database for Assessing Safety for Patients with Chronic Kidney Disease or Renal Transplant

Introduction

There is a lack of published safety information on the use of natural health products (NHPs) for patients with chronic kidney disease (CKD) or renal transplant.

Objective

To create an online database to provide evidence-based safety recommendations for commonly used NHPs, specific to patients with CKD or renal transplant.

Methods

NHPs used by CKD and transplant patients in British Columbia were identified from the records of the BC Provincial Renal Agency. For each NHP, several databases (MEDLINE, Embase, Lexi-Natural Products, PubMed Dietary Supplement Subset, and Natural Medicines) were searched for any information pertaining to dosage, adverse drug reactions, drug interactions, immunomodulatory effects, and pharmacokinetics in patients with renal disease. Each NHP was given 1 of 4 safety ratings: likely safe, possibly safe, possibly unsafe, and likely unsafe. An NHP was classified as "possibly unsafe" for patients with renal transplant if it had demonstrated in vitro immunomodulatory effects and/or significant interactions with transplant medications due to effects on the cytochrome P450 3A4 isozyme.

Results

Of the 19 627 BC-registered patients with renal disease (as of August 2014), 4122 (21%) were using one or more NHPs. The Herbal-CKD website (www.herbalckd.com) was created in 2015 to provide information about 47 commonly used NHPs and 2 known nephrotoxins (aristolochic acid and silver). This website provides a systematic evaluation of safety information for selected NHPs for patients with CKD (both nondialysis and dialysis-dependent) and kidney transplant. The most common NHP safety classification was "possibly safe", reflecting the paucity of studies in renal populations and the availability of safety data for the general population. Limitations of the website include difficulty in interpreting and generalizing the safety literature because most NHP formulations are not standardized, and others are combination products.

Conclusion

The website www.herbalckd.com provides an easy-to-use, evidence-based tool for health care professionals to assess the safety of NHPs for CKD and transplant patients.

Use of complementary and alternative medicines in haemodialysis patients: a cross-sectional study from Palestine

BACKGROUND

Complementary and alternative medicine (CAM), and herbal therapies, are accepted worldwide, and have been important from medical, sociological and economic perspectives, among haemodialysis (HD) patients. The primary aim of this study was to evaluate the use of CAM among patients with end-stage renal disease (ESRD) who are undergoing HD.

METHODS

Face-to-face interviews of patients with ESRD undergoing HD from ten outpatient renal departments at a national level in Palestine were conducted from June 2014 to January 2015. A survey questionnaire, which included questions on socio-demographic and clinical characteristics, and on the CAM therapies that were used, was administered.

RESULTS

Out of 267 patients interviewed, 172 patients used at least one type of CAM in the last month prior to the interview, and thus the utilisation rate was 64.4 %. Forty one (15.4 %) patients reported using one type of CAMs, while 18.7 % used two different CAMs and 30.3 % used more than two types of CAMs for their health status. Of the patients who used CAM, herbal therapies were used most often (43.5 %), followed by honey (35.6 %), diet (22.8 %), and exorcism in Islam (16.9 %). The herbal therapies mentioned most often were Nigella sativa L. (18.7 %), followed by Salvia officinalis L. (16.9 %), and Pimpinella anisum L. (10.5 %).

CONCLUSIONS

In conclusion, the prevalence of CAM is relatively high in the selected population. Most patients used biological therapies such as herbal remedies, thus highlighting a greater need for patient education regarding CAM therapies and possible herb-drug interactions. Health care providers must be aware of the potential benefits and risks related to CAM use. There is a need for more clinical research pertaining to CAM to reach stronger evidence regarding potential benefits and risks related to CAM use.

Usage of complementary and alternative medicine among patients with chronic kidney disease on maintenance hemodialysis

Aim:

To determine the prevalence and the type of complementary and alternative medicine (CAM) use among chronic kidney disease (CKD) patients on maintenance hemodialysis (MHD).

Materials and Methods:

The study was conducted in 200 CKD patients who were on MHD. The patients were subjected to a validated interviewer-administered questionnaire adopted from the National Health Interview Survey Adult CAM. The knowledge on CAM and its usage by the patients were assessed based on the responses given by the patients.

Results:

Of the 200 patients, 52 (26%) patients were identified to be using CAM therapy. The most commonly used CAM modality by these patients was Ayurveda both alone (30.4%) and in combination with other CAM modalities (23.2%), followed by acupuncture in 17.3% patients. CAM usage was high in the age range of 50–64 years (67%). Of the CAM users, 21% of patients were from a rural area; 16.5% of patients were from upper middle class, and 24% were on dialysis for 1–4 years. There was a statistically significant association between CAM usage and age, gender, place of living, socioeconomic status, and duration of dialysis (P < 0.01).

Conclusion:

The present survey provides the data on the usage of CAM among dialysis patients and adds to the increasing evidence about CAM use. Because many products are at risk to either accumulate or cause interactions with medication, a better education on the risks and benefits of the CAM therapy by the health care providers to the end stage renal disease patients is needed.

Relation of Complementary-Alternative Medicine use with glomerular filtration rate and depression in patients with chronic kidney disease at predialysis stage

AIM

Complementary and alternative medicine is a broad field of health including all health care practices and methods, and their accompanying theories and beliefs. In the present study, we aimed to examine the frequency of complementary-alternative medicine use, and its relation with glomerular filtration rate and depression in patients with chronic kidney disease at predialysis stage.

METHODS

A total of 1053 predialysis patients; 518 female and 535 male, that were followed up with chronic kidney disease for at least 3 months were enrolled into the study. Demographic features, biochemical parameters and findings of physical examination were recorded. Their compliance to diet, and knowledge about disease were questioned. Beck depression inventory and questionnaire regarding complementary-alternative medicine use were performed.

RESULTS

The overall frequency of complementary-alternative medicine use was 40.3% . Total ratio of herbal products was 46%. Complementary-alternative medicine use was significantly more frequent in female or single patients, and patients that informed about chronic kidney disease or under strict diet (P = 0.007, P = 0.016, P = 0.02, P = 0.016, respectively). When glomerular filtration rate of participants were considered, complementary-alternative medicine use was similar in different stages of kidney disease. Depression was observed in 41.9% of patients and significantly frequent in patients with alternative method use (P = 0.002). Depression score was higher as creatinine increases and glomerular filtration rate decreases (P = 0.002; r = 0.093).

CONCLUSION

We determined that complementary-alternative medicine use gradually increases at predialysis stage as glomerular filtration rate decreases and there is a strict relation between complementary-alternative medicine use and depression or female gender. Disorder related stressors may lead to seeking of alternative methods.

The use of complementary and alternative medicine among chronic renal failure patients

AIMS AND OBJECTIVES

The aim of this study is to evaluate the factors affecting the use and frequency of use of complementary and alternative medicine among chronic renal failure patients.

BACKGROUND

The use of complementary and alternative medicine in the general population and patients with chronic renal failure has increased significantly. Despite this, there is limited information concerning the use of complementary and alternative medicine among chronic renal failure patients.

DESIGN

Cross-sectional survey.

METHOD

The research was carried out at the nephrology and internal medicine outpatient clinics. Two hundred and six chronic renal failure patients admitted to the outpatient clinics were included in the study. Mean outcomes measures were the frequency and type of complementary and alternative medicine use, demographic and disease-related characteristics affecting complementary and alternative medicine use and the reasons for using complementary and alternative medicine. The data were evaluated by Pearson's chi-square test and Fisher's exact test.

RESULTS

While 2·9% of the patients had been using complementary and alternative medicine before the renal disease occurred, 25·2% of the patients reported that they had at least once used complementary and alternative medicine methods after the renal disease occurred. A significant difference was found between complementary and alternative medicine usage and age, gender, place of living, occupational status and educational background (p < 0·05). While most of the patients using complementary and alternative medicine (78·3%) stated that they used such methods as a cure for their disease, 46·1% used body-mind techniques.

CONCLUSIONS

The results of our study showed that one-fourth of the chronic renal failure patients were using complementary and alternative medicine, mainly body-mind techniques. In addition, the study proved that most of the patients do not discuss their complementary and alternative medicine usage with their doctors and nurses.

RELEVANCE TO CLINICAL PRACTICE

It is essential that nephrology doctors and nurses should ask specific questions about complementary and alternative medicine usage while taking anamnesis on the patients' disease and nutritional status and that the nephrology team should expand their knowledge on complementary and alternative medicine methods to ensure patient and treatment safety.

Use of Over-the-Counter Medications and Natural Products in Patients With Moderate and Severe Chronic Renal Insufficiency

BACKGROUND

Use of over-the-counter medications and natural products may be associated with drug-related problems among patients with chronic renal insufficiency. The aim of this study is to describe the use of nonprescription medications in patients attending a predialysis clinic and identify drug-related problems associated with the use of these products.

METHODS

In a 6-month cluster randomized controlled trial, patients with moderate (n = 46) and severe (n = 41) chronic renal insufficiency were interviewed over the telephone at baseline by a community pharmacist to document their use of over-the-counter medications and natural products. The safety of each product was assessed, and drug-related problems were identified independently by 2 pharmacists.

RESULTS

Overall, 83% (95% confidence interval [CI], 72 to 94) of patients with moderate chronic renal insufficiency and 68% (95% CI, 54 to 83) with severe chronic renal insufficiency reported using at least 1 over-the-counter medication. Contraindicated over-the-counter medications were reported by 9% of patients. Natural products were used by 22% (95% CI, 10 to 34) and 29% (95% CI, 15 to 43) of patients with moderate and severe chronic renal insufficiency, respectively. Similarly, 3% of patients reported using at least 1 contraindicated natural product. Patients had consulted a health professional for 49% of over-the-counter medications and 19% of natural products. Overall, 65 drug-related problems were identified.

CONCLUSION

The use of over-the-counter medications and natural products is highly prevalent in patients with chronic renal insufficiency and often is associated with a drug-related problem. These results emphasize the importance for community pharmacists to closely monitor the use of these products in patients with chronic renal insufficiency.

Kidney injury from alternative medicines

In the developing world, up to 80% of the population uses traditional medicine for primary health care. In industrialized countries, adaptations of traditional medicine, termed "complementary" or "alternative" medicine (CAM), are used by a growing number of patients for preventive or palliative care. However, alternative medicine (AM) may be an important risk for the development of acute and chronic kidney injury because of several factors: nonconventional preparations rarely meet the required essential standards of consistency in composition and biological activity; many of these products contain undisclosed over-the-counter or prescription drugs or can be adulterated with hormones and glandular extracts; herbal preparations can be contaminated by pesticides and heavy metals; and because of errors in plant identification and confusing terminology, opportunities for mistakes and deliberate substitution can occur. Furthermore, there is a lack of reports of adverse events and drug interactions because of a lack of professional surveillance, and specific data on systemic and kidney toxicity are not easily available. Kidney injury/kidney syndromes caused by AM consist of acute tubular necrosis/toxicity (eg, Fanconi's syndrome), acute interstitial nephritis, papillary necrosis, hypertension, kidney stones, urinary retention, chronic tubulointerstitial nephritis with fibrosis, urinary tract carcinoma, and acute rejection of the kidney transplant. To improve the care for patients using AM, extension of physicians' knowledge about its possible hazards and toxicity is essential. This review deals with acute and chronic kidney toxicity caused by animal-, plant-, and mineral-based, nonconventional medicine and kidney failure caused by drug interactions with AM.

Potential benefits of complementary medicine modalities in patients with chronic kidney disease

Use of complementary and alternative medicine (CAM) by the general population is common, and, although potential for harm exists, evidence is accumulating that several modalities, including acupuncture, massage, relaxation response/guided or integrative imagery, meditation, and herbal supplements, have actions that are beneficial for patients with chronic illness. Potential areas in which CAM might benefit patients with kidney disease include prolonging time of progression to kidney failure as well as treatment of concomitant problems, including arthritides, pruritus, cardiovascular risk factors, anxiety, depression, and fatigue, as well as hepatoprotection and treatment of uremic bruising. Although no systematic survey of prevalence of use has been performed in patients with chronic kidney disease and much research remains to be done so that safety and efficacy issues can be resolved, it is likely that many patients are using the services of CAM providers without the knowledge of their nephrologists. Thus, it behooves us to become conversant in these therapies so that we may hold open dialogues with our patients, discouraging potentially harmful treatments, suggesting potentially helpful ones, and monitoring them for effects, both beneficial and harmful.

Use of alternative medicine by patients with stage 5 chronic kidney disease

The use of complementary and alternative medicine (CAM) in the United States is growing at a remarkable speed. Herbal products and dietary supplements are CAM therapies that have grown faster than any other CAM treatments. Little information is available about herbs and dietary supplement use in the stage 5 chronic kidney disease population. These products contain a myriad of pharmacologically active compounds that, when used by people with kidney disease, may be hazardous. Members of the renal dietitian listserv were queried about herbs and dietary supplements reportedly used by dialysis patients. Up-to-date information on the use, safety, efficacy, adverse effects, and recommended dosages in the nondialysis population are presented for 24 products. In the dialysis population, Noni juice should be avoided because of its high potassium content. In addition, bulk-forming laxatives such as flaxseed should be used with caution because of the need for increased fluid intake. Dialysis practitioners should include specific questions about herbs and dietary supplement use in medical and nutrition histories, and they should increase their knowledge about these products to advise patients appropriately. A list of reliable sources of information for the health care provider on herbs and dietary supplements is also presented.

Medicinal herbal extracts -- renal friend or foe? Part one: the toxicities of medicinal herbs

In recent years, an increasing percentage of people from industrialized countries have been using complementary and alternative medicines (CAM). This, combined with numerous warnings regarding the potential toxicity of these therapies, suggests the need for practitioners to keep abreast of the reported incidence of renal toxicity caused by the ingestion of medicinal herbs. The goal of the present two-part series, on the toxic or beneficial effects of medicinal herbs on renal health, is to provide practitioners with a summary of the most recent information as well as the means by which evidence for benefit or toxicity has been found. In this first article, we explore in vivo evidence of toxicity. Included are nephrotoxicity from aristolochic acid and other components within herbs, herb--drug interactions resulting in adverse renal effects, and renal toxicity from contaminants within the extracts. The review aims to provide a guide to encourage future toxicity studies and rigorous clinical trials.

Safety evaluation of functional ingredients

Functional ingredients are a diverse group of compounds that are intended to produce a positive effect on the health of the consumer. The term "functional" is not meant to differentiate these ingredients from other ingredients historically consumed as part of the food supply that are indeed biologically active constituents, for example, nutrients. Indeed, all foods should be considered "functional". The term functional ingredient is meant to convey the function of these new ingredients, which is to produce a positive health outcome via physiological activity in the body. Functional ingredients encompass elements of drugs, nutrients and food additives. A framework for evaluation of the safety of functional ingredients utilizes an understanding of both the current regulatory frameworks in place as well as the characteristics that define these particular ingredients. The types of studies conducted and the data generated to support safety of functional ingredients is product-specific and can include compositional analysis, structure/toxicity analysis, evaluation of historical and intended exposure, animal studies, clinical/epidemiologic studies, and evaluation of special considerations such as potential for adverse food or drug interactions.

A survey of herbal product use in a dialysis population in Northwest Ohio

OBJECTIVE

To identify herbal product use in a dialysis population.

DESIGN AND SETTING

Cross-sectional survey conducted at 2 freestanding dialysis centers in Northwest Ohio.

PATIENTS

Two hundred and sixteen hemodialysis and peritoneal dialysis patients who provided informed consent.

INTERVENTION

All patients were surveyed by personal interview regarding use of herbal products. Patients identified as current users were asked questions about specific agents. Respondents reporting past but not current use were questioned about specific agents and reasons for discontinuation.

RESULTS

Thirty-one patients reported taking herbal therapies. Twenty-six patients discontinued use before the survey. Sixteen different herbal products were reported being used in our study population. Those who reported ever using an herbal product were more likely to be employed or disabled and have higher education when compared with nonusers.

CONCLUSION

Our data suggest a lower frequency of herbal product use in the dialysis population as compared with the general population and other chronically ill populations. Education and employment are factors associated with use. Many of the herbal therapies used potentially could have significant adverse effects in dialysis patients. These include effects on blood pressure, blood glucose, coagulation parameters, and electrolyte disturbances. Dialysis patients currently taking herbal products may not be reevaluating their need for continuation and may not be informing members of the nephrology care team about their use.

Herbs, menopause, and dialysis

Women with chronic kidney disease (CKD) are at increased risk for menstrual disorders, early menopause, and osteoporosis, and rarely discuss gynecologic and reproductive issues with their nephrologist. Various complementary and alternative medicine (CAM) products are of interest to women with end-stage renal disease (ESRD) who have these disorders. However, very little is known about the specifics of using herbal medicines in patients on chronic dialysis, resulting in numerous problems when patients and providers try to ascertain the safety and efficacy of these products. This article reviews evidence regarding the safety and efficacy of black cohosh, ginseng, chastetree, dong quai, evening primrose oil, soy products, and the so-called natural hormones. Pharmacologic parameters important to evaluating the quality of botanical products are discussed, along with recommendations and information resources.