Treatment for Crohns disease depends on

- where the disease is located in the GI tract  - what problems you already have from the disease  - what past treatments you have had for the disease

The goals of treatment are to

- decrease the inflammation  - relieve symptoms such as abdominal pain, diarrhea, and rectal bleeding  - correct nutritional problems

Treatment may include

- medicines  - surgery  - eating, diet, and nutrition

Medicines

One or more of the following medicines may be used to treat Crohns disease:

- Anti-inflammation medicines may be used first to treat your Crohn's disease. These medicines help lower inflammation in the intestine and relieve the pain and diarrhea. Sometimes anti-inflammation medicines cause side effects, so you should talk with your health care provider about what to expect.  - Steroids also help lower inflammation. Steroids are similar to natural chemicals in the body. However, steroids are used only for a short time because long-term use can lead to serious side effects.  - Immune system suppressors. Azathioprine and 6-mercaptopurine work by keeping your immune system from attacking harmless foreign substances. Immune system suppressors also cause side effects, so you should talk with your health care provider about what to expect.  - Biological therapies. Biological therapies are medicines that are given by an injection in the vein, infliximab (Remicade), or an injection in the skin, adalimumab (HUMIRA). Your health care provider may treat you with these medicines if others are not helping to decrease inflammation, or if you have fistulas with abscesses. The goals for using these medicines are to get you better, keep you better, and avoid long-term steroid use.  - Antibiotics. Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or metronidazole.

- Anti-diarrheal medicines and fluid replacements. Diarrhea and abdominal cramps are often relieved when the inflammation improves, but more medicine may be needed. Anti-diarrheal medicines include diphenoxylate, loperamide, and codeine. People with diarrhea should drink plenty of fluids to prevent dehydrationloss of fluids from the body. If diarrhea does not improve, the person should see the doctor promptly for possible treatment with fluids given through a small tube inserted into an arm vein.

Surgery

Some people with Crohns disease need surgery if medicines are no longer working to control blockage, fistulas, abscesses, and bleeding. A surgeon performs the procedure in a hospital, where you will receive medicine to make you sleep during the surgery.

One or more of the following surgeries may be needed:

- Intestinal resection. The surgeon removes the diseased section of intestine and puts the ends of the intestine back together.  - Proctocolectomy. Proctocolectomy is surgery to remove the rectum and part or all of the colon. An ileostomy is performed with a proctocolectomy.  - Ileostomy. Ileostomy is an operation to create an openingcalled a stomafor the stool to exit the body when the ends of the intestine cannot be put back together. To create a stoma, an end of the intestine is brought out through a small opening made on the lower right part of the abdomen near the beltline. The stoma is about the size of a quarter. An ostomy pouch is worn outside the body over the stoma to collect waste, and it is emptied several times a day. Your health care provider may refer you to an ostomy nursea specialist who cares for people with an ostomy pouch.

Surgery usually does not cure Crohn's disease forever. Sometimes you need to have more than one surgery because the disease returns next to where the intestine was removed. Because Crohns disease can return after surgery, you can talk with your health care provider and other patients to get as much information as possible before having surgery.


Your health care provider may start you on a special diet, so you get extra nutrition and calories. High-calorie liquid supplements are often used to give you the extra calories and right amount of vitamins and minerals to keep you healthy. During acute phases of the disease, you may need to receive intravenous nutrition to give the intestine a rest.

No foods are known to cause injury or inflammation to the intestine. But foods such as hot spices, alcohol, greasy foods, and milk products may make diarrhea and cramping worse. You should eat a healthy diet and avoid foods that make symptoms worse. Your health care provider may refer you to a dietitian to help you with meal planning.


- Crohn's disease is a disease that causes inflammation, or swelling, and irritation of any part of the digestive tractalso called the gastrointestinal (GI) tract.  - People with Crohns disease may have a blood relative with the disease or another type of inflammatory bowel disease (IBD).  - Symptoms of Crohns disease include abdominal pain, diarrhea, bleeding, weight loss, and fever.  - A physical exam, blood tests, stool tests, and other tests are needed to diagnose Crohns disease.  - Problems of Crohns disease include intestinal blockage, fistulas, abscesses, anemia, and slower growth in children.  - Doctors treat Crohns disease with medicines, surgery, diet, and nutrition.  - People with Crohns disease should eat a healthy diet and avoid foods that make symptoms worse.  - Quitting smoking can help make Crohns disease less severe. Ask your health care provider if you need help quitting smoking.  - Support groups may help lower stress for people with Crohns disease.  - Most people with Crohns disease are able to work, raise families, and live full lives.  - Many women with Crohns disease can become pregnant and have a baby. You should talk with your health care provider before getting pregnant.


The digestive system is made up of the gastrointestinal (GI) tractalso called the digestive tractand the liver, pancreas, and gallbladder. The GI tract is a series of hollow organs joined in a long, twisting tube from the mouth to the anus. The hollow organs that make up the GI tract are the mouth, esophagus, stomach, small intestine, large intestinewhich includes the colon and rectumand anus. Food enters the mouth and passes to the anus through the hollow organs of the GI tract. The liver, pancreas, and gallbladder are the solid organs of the digestive system. The digestive system helps the body digest food, which includes breaking food down into nutrients the body needs. Nutrients are substances the body uses for energy, growth, and cell repair.


Smoking has been found to increase the risk of cancers of the3

- mouth  - esophagus  - stomach  - pancreas

3

,

4

,

5

- liver  - colon  - rectum

More information about the link between smoking and cancers of the digestive system can be found on the National Cancer Institute website at www.cancer.gov/cancertopics/tobacco/smoking.


Smoking contributes to many common disorders of the digestive system, such as heartburn and gastroesophageal reflux disease (GERD), peptic ulcers, and some liver diseases. Smoking increases the risk of Crohns disease, colon polyps, and pancreatitis, and it may increase the risk of gallstones.


Eating, diet, and nutrition can play a role in causing, preventing, and treating some of the diseases and disorders of the digestive system that are affected by smoking, including heartburn and GERD, liver diseases, Crohns disease, colon polyps, pancreatitis, and gallstones. More information about eating, diet, and nutrition and these conditions can be found on the Digestive Diseases A-Z list.


- Smoking has been found to increase the risk of cancers of the mouth, esophagus, stomach, and pancreas. Research suggests that smoking may also increase the risk of cancers of the liver, colon, and rectum.  - Smoking increases the risk of heartburn and gastroesophageal reflux disease (GERD).  - Smoking increases the risk of peptic ulcers.  - Smoking may worsen some liver diseases, including primary biliary cirrhosis and nonalcoholic fatty liver disease (NAFLD).  - Current and former smokers have a higher risk of developing Crohns disease than people who have never smoked.  - People who smoke are more likely to develop colon polyps.  - Smoking increases the risk of developing pancreatitis.  - Some studies have shown that smoking may increase the risk of developing gallstones. However, research results are not consistent and more study is needed.  - Quitting smoking can reverse some of the effects of smoking on the digestive system.


Blood pressure is the force of blood pushing against blood vessel walls as the heart pumps out blood, and high blood pressure, also called hypertension, is an increase in the amount of force that blood places on blood vessels as it moves through the body. Factors that can increase this force include higher blood volume due to extra fluid in the blood and blood vessels that are narrow, stiff, or clogged.

Blood pressure test results are written with two numbers separated by a slash. For example, a health care provider will write a blood pressure result as 120/80. A health care provider will say this blood pressure result as 120 over 80. The top number is called the systolic pressure and represents the pressure as the heart beats and pushes blood through the blood vessels. The bottom number is called the diastolic pressure and represents the pressure as blood vessels relax between heartbeats.

Most people without chronic health conditions have a normal blood pressure if it stays below 120/80. Prehypertension is a systolic pressure of 120 to 139 or a diastolic pressure of 80 to 89. High blood pressure is a systolic pressure of 140 or above or a diastolic pressure of 90 or above.1

People should talk with their health care provider about their individual blood pressure goals and how often they should have their blood pressure checked.


The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the two kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra fluid. The urine flows from the kidneys to the bladder through tubes called ureters. The bladder stores urine. When the bladder empties, urine flows out of the body through a tube called the urethra, located at the bottom of the bladder. In men the urethra is long, while in women it is short.

Kidneys work at the microscopic level. The kidney is not one large filter. Each kidney is made up of about a million filtering units called nephrons. Each nephron filters a small amount of blood. The nephron includes a filter, called the glomerulus, and a tubule. The nephrons work through a two-step process. The glomerulus lets fluid and waste products pass through it; however, it prevents blood cells and large molecules, mostly proteins, from passing. The filtered fluid then passes through the tubule, which sends needed minerals back to the bloodstream and removes wastes. The final product becomes urine.


Most people with high blood pressure do not have symptoms. In rare cases, high blood pressure can cause headaches.

Kidney disease also does not have symptoms in the early stages. A person may have swelling called edema, which happens when the kidneys cannot get rid of extra fluid and salt. Edema can occur in the legs, feet, or ankles and less often in the hands or face. Once kidney function decreases further, symptoms can include

- appetite loss  - nausea  - vomiting  - drowsiness or feeling tired  - trouble concentrating  - sleep problems  - increased or decreased urination  - generalized itching or numbness  - dry skin  - headaches  - weight loss  - darkened skin  - muscle cramps  - shortness of breath  - chest pain


A health care provider diagnoses high blood pressure when multiple blood pressure testsoften repeated over several visits to a health care providers officeshow that a systolic blood pressure is consistently above 140 or a diastolic blood pressure is consistently above 90. Health care providers measure blood pressure with a blood pressure cuff. People can also buy blood pressure cuffs at discount chain stores and drugstores to monitor their blood pressure at home.

Kidney disease is diagnosed with urine and blood tests.

Urine Tests

Dipstick test for albumin. A dipstick test performed on a urine sample can detect the presence of albumin in the urine. Albumin is a protein in the blood that can pass into the urine when the kidneys are damaged. A patient collects the urine sample in a special container in a health care providers office or a commercial facility. The office or facility tests the sample onsite or sends it to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color when blood or protein is present in urine.

Urine albumin-to-creatinine ratio. A health care provider uses the albumin and creatinine measurement to determine the ratio between the albumin and creatinine in the urine. Creatinine is a waste product in the blood that is filtered in the kidneys and excreted in the urine. A urine albumin-to-creatinine ratio above 30 mg/g may be a sign of kidney disease.

Blood Test

A blood test involves having blood drawn at a health care providers office or a commercial facility and sending the sample to a lab for analysis. A health care provider may order a blood test to estimate how much blood the kidneys filter each minute, called the estimated glomerular filtration rate (eGFR). The results of the test indicate the following:

- eGFR of 60 or above is in the normal range  - eGFR below 60 may indicate kidney damage  - eGFR of 15 or below may indicate kidney failure

Get Screened for Kidney Disease   Kidney disease, when found early, can be treated to prevent more serious disease and other complications. The National Kidney Foundation recommends people with high blood pressure receive the following regular screenings:   - blood pressure tests   - urine albumin   - eGFR    Health care providers will help determine how often people with high blood pressure should be screened.


The best way to slow or prevent kidney disease from high blood pressure is to take steps to lower blood pressure. These steps include a combination of medication and lifestyle changes, such as

- healthy eating  - physical activity  - maintaining a healthy weight  - quitting smoking  - managing stress

No matter what the cause of the kidney disease, high blood pressure can increase damage to the kidneys. People with kidney disease should keep their blood pressure below 140/90.4

Medication

Medications that lower blood pressure can also significantly slow the progression of kidney disease. Two types of blood pressure-lowering medications, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have been shown effective in slowing the progression of kidney disease. Many people require two or more medications to control their blood pressure. In addition to an ACE inhibitor or an ARB, a health care provider may prescribe a diuretica medication that helps the kidneys remove fluid from the blood. A person may also need beta blockers, calcium channel blockers, and other blood pressure medications.


Following a healthy eating plan can help lower blood pressure. A health care provider may recommend the Dietary Approaches to Stop Hypertension (DASH) eating plan. DASH focuses on fruits, vegetables, whole grains, and other foods that are heart healthy and lower in sodium, which often comes from salt. The DASH eating plan

- is low in fat and cholesterol  - features fat-free or low-fat milk and dairy products, fish, poultry, and nuts  - suggests less red meat, sweets, added sugars, and sugar-containing beverages  - is rich in nutrients, protein, and fiber

Read more about DASH at www.nhlbi.nih.gov/health/resources/heart/hbp-dash-index.htm.

A dietitian may also recommend this type of diet for people who have already developed kidney disease. A diet low in sodium and liquid intake can help reduce edema and lower blood pressure. Reducing saturated fat and cholesterol can help control high levels of lipids, or fats, in the blood.

Health care providers may recommend that people with kidney disease eat moderate or reduced amounts of protein, though the benefits of reducing protein in a persons diet is still being researched. Proteins break down into waste products that the kidneys filter from the blood. Eating more protein than the body needs may burden the kidneys and cause kidney function to decline faster. However, protein intake that is too low may lead to malnutrition, a condition that occurs when the body does not get enough nutrients. People with kidney disease who are on a restricted protein diet should be monitored with blood tests that can show low nutrient levels.

In addition, consuming too much alcohol raises blood pressure, so people should limit alcoholic drinkstwo per day for men and one per day for women.

A health care provider can help people change their diet to meet their individual needs.

Physical Activity

Regular physical activity can lower blood pressure and reduce the chances of other health problems. A health care provider can provide information about how much and what kinds of activity are safe. Most people should try to get at least 30 to 60 minutes of activity most or all days of the week. A person can do all physical activity at once or break up activities into shorter periods of at least 10 minutes each. Moderate activities include brisk walking, dancing, bowling, riding a bike, working in a garden, and cleaning the house.

Body Weight

People who are overweight or obese should aim to reduce their weight by 7 to 10 percent during the first year of treatment for high blood pressure. This amount of weight loss can lower the chance of health problems related to high blood pressure. Overweight is defined as a body mass index (BMI)a measurement of weight in relation to heightof 25 to 29. A BMI of 30 or higher is considered obese. A BMI lower than 25 is the goal for keeping blood pressure under control.5

Smoking

People who smoke should quit. Smoking can damage blood vessels, raise the chance of high blood pressure, and worsen health problems related to high blood pressure. People with high blood pressure should talk with their health care provider about programs and products they can use to quit smoking.

Stress

Learning how to manage stress, relax, and cope with problems can improve emotional and physical health. Some activities that may help reduce stress include

- exercising  - practicing yoga or tai chi  - listening to music  - focusing on something calm or peaceful  - meditating


- Blood pressure is the force of blood pushing against blood vessel walls as the heart pumps out blood, and high blood pressure, also called hypertension, is an increase in the amount of force that blood places on blood vessels as it moves through the body.  - High blood pressure can damage blood vessels in the kidneys, reducing their ability to work properly. When the force of blood flow is high, blood vessels stretch so blood flows more easily. Eventually, this stretching scars and weakens blood vessels throughout the body, including those in the kidneys.  - High blood pressure is the second leading cause of kidney failure in the United States after diabetes.  - A health care provider diagnoses high blood pressure when multiple blood pressure testsoften repeated over several visits to a health care providers officeshow that a systolic blood pressure is consistently above 140 or a diastolic blood pressure is consistently above 90.  - Kidney disease is diagnosed with urine and blood tests.  - The best way to slow or prevent kidney damage from high blood pressure is to take steps to lower blood pressure. These steps include a combination of medication and lifestyle changes, such as      - healthy eating    - physical activity    - maintaining a healthy weight    - quitting smoking    - managing stress    - No matter what the cause of the kidney disease, high blood pressure can increase damage to the kidneys. People with kidney disease should keep their blood pressure below 140/90.


Hypoglycemia, also called low blood glucose or low blood sugar, occurs when blood glucose drops below normal levels. Glucose, an important source of energy for the body, comes from food. Carbohydrates are the main dietary source of glucose. Rice, potatoes, bread, tortillas, cereal, milk, fruit, and sweets are all carbohydrate-rich foods.

After a meal, glucose is absorbed into the bloodstream and carried to the body's cells. Insulin, a hormone made by the pancreas, helps the cells use glucose for energy. If a person takes in more glucose than the body needs at the time, the body stores the extra glucose in the liver and muscles in a form called glycogen. The body can use glycogen for energy between meals. Extra glucose can also be changed to fat and stored in fat cells. Fat can also be used for energy.

When blood glucose begins to fall, glucagonanother hormone made by the pancreassignals the liver to break down glycogen and release glucose into the bloodstream. Blood glucose will then rise toward a normal level. In some people with diabetes, this glucagon response to hypoglycemia is impaired and other hormones such as epinephrine, also called adrenaline, may raise the blood glucose level. But with diabetes treated with insulin or pills that increase insulin production, glucose levels can't easily return to the normal range.

Hypoglycemia can happen suddenly. It is usually mild and can be treated quickly and easily by eating or drinking a small amount of glucose-rich food. If left untreated, hypoglycemia can get worse and cause confusion, clumsiness, or fainting. Severe hypoglycemia can lead to seizures, coma, and even death.

In adults and children older than 10 years, hypoglycemia is uncommon except as a side effect of diabetes treatment. Hypoglycemia can also result, however, from other medications or diseases, hormone or enzyme deficiencies, or tumors.


Hypoglycemia causes symptoms such as

- hunger  - shakiness  - nervousness  - sweating  - dizziness or light-headedness  - sleepiness  - confusion  - difficulty speaking  - anxiety  - weakness

Hypoglycemia can also happen during sleep. Some signs of hypoglycemia during sleep include

- crying out or having nightmares  - finding pajamas or sheets damp from perspiration  - feeling tired, irritable, or confused after waking up


Diabetes Medications

Hypoglycemia can occur as a side effect of some diabetes medications, including insulin and oral diabetes medicationspillsthat increase insulin production, such as

- chlorpropamide (Diabinese)  - glimepiride (Amaryl)  - glipizide (Glucotrol, Glucotrol XL)  - glyburide (DiaBeta, Glynase, Micronase)  - nateglinide (Starlix)  - repaglinide (Prandin)  - sitagliptin (Januvia)  - tolazamide  - tolbutamide

Certain combination pills can also cause hypoglycemia, including

- glipizide + metformin (Metaglip)  - glyburide + metformin (Glucovance)  - pioglitazone + glimepiride (Duetact)  - rosiglitazone + glimepiride (Avandaryl)  - sitagliptin + metformin (Janumet)

Other types of diabetes pills, when taken alone, do not cause hypoglycemia. Examples of these medications are

- acarbose (Precose)  - metformin (Glucophage)  - miglitol (Glyset)  - pioglitazone (Actos)  - rosiglitazone (Avandia)

However, taking these pills along with other diabetes medicationsinsulin, pills that increase insulin production, or bothincreases the risk of hypoglycemia.

In addition, use of the following injectable medications can cause hypoglycemia:

- Pramlintide (Symlin), which is used along with insulin  - Exenatide (Byetta), which can cause hypoglycemia when used in combination with chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, and tolbutamide

More information about diabetes medications is provided in the NIDDK health topic, What I need to know about Diabetes Medicines, or by calling 18008608747.

Other Causes of Hypoglycemia

In people on insulin or pills that increase insulin production, low blood glucose can be due to

- meals or snacks that are too small, delayed, or skipped  - increased physical activity  - alcoholic beverages


Diabetes treatment plans are designed to match the dose and timing of medication to a person's usual schedule of meals and activities. Mismatches could result in hypoglycemia. For example, taking a dose of insulinor other medication that increases insulin levelsbut then skipping a meal could result in hypoglycemia.

To help prevent hypoglycemia, people with diabetes should always consider the following:

- Their diabetes medications. A health care provider can explain which diabetes medications can cause hypoglycemia and explain how and when to take medications. For good diabetes management, people with diabetes should take diabetes medications in the recommended doses at the recommended times. In some cases, health care providers may suggest that patients learn how to adjust medications to match changes in their schedule or routine.  - Their meal plan. A registered dietitian can help design a meal plan that fits one's personal preferences and lifestyle. Following one's meal plan is important for managing diabetes. People with diabetes should eat regular meals, have enough food at each meal, and try not to skip meals or snacks. Snacks are particularly important for some people before going to sleep or exercising. Some snacks may be more effective than others in preventing hypoglycemia overnight. The dietitian can make recommendations for snacks.  - Their daily activity. To help prevent hypoglycemia caused by physical activity, health care providers may advise      - checking blood glucose before sports, exercise, or other physical activity and having a snack if the level is below 100 milligrams per deciliter (mg/dL)    - adjusting medication before physical activity    - checking blood glucose at regular intervals during extended periods of physical activity and having snacks as needed    - checking blood glucose periodically after physical activity    - Their use of alcoholic beverages. Drinking alcoholic beverages, especially on an empty stomach, can cause hypoglycemia, even a day or two later. Heavy drinking can be particularly dangerous for people taking insulin or medications that increase insulin production. Alcoholic beverages should always be consumed with a snack or meal at the same time. A health care provider can suggest how to safely include alcohol in a meal plan.  - Their diabetes management plan. Intensive diabetes managementkeeping blood glucose as close to the normal range as possible to prevent long-term complicationscan increase the risk of hypoglycemia. Those whose goal is tight control should talk with a health care provider about ways to prevent hypoglycemia and how best to treat it if it occurs.

What to Ask the Doctor about Diabetes Medications

People who take diabetes medications should ask their doctor or health care provider

- whether their diabetes medications could cause hypoglycemia  - when they should take their diabetes medications  - how much medication they should take  - whether they should keep taking their diabetes medications when they are sick  - whether they should adjust their medications before physical activity  - whether they should adjust their medications if they skip a meal


Signs and symptoms of hypoglycemia vary from person to person. People with diabetes should get to know their signs and symptoms and describe them to their friends and family so they can help if needed. School staff should be told how to recognize a child's signs and symptoms of hypoglycemia and how to treat it.

People who experience hypoglycemia several times in a week should call their health care provider. They may need a change in their treatment plan: less medication or a different medication, a new schedule for insulin or medication, a different meal plan, or a new physical activity plan.

Prompt Treatment for Hypoglycemia

When people think their blood glucose is too low, they should check the blood glucose level of a blood sample using a meter. If the level is below 70 mg/dL, one of these quick-fix foods should be consumed right away to raise blood glucose:

- 3 or 4 glucose tablets  - 1 serving of glucose gelthe amount equal to 15 grams of carbohydrate  - 1/2 cup, or 4 ounces, of any fruit juice  - 1/2 cup, or 4 ounces, of a regularnot dietsoft drink  - 1 cup, or 8 ounces, of milk  - 5 or 6 pieces of hard candy  - 1 tablespoon of sugar or honey

Recommended amounts may be less for small children. The child's doctor can advise about the right amount to give a child.

The next step is to recheck blood glucose in 15 minutes to make sure it is 70 mg/dL or above. If it's still too low, another serving of a quick-fix food should be eaten. These steps should be repeated until the blood glucose level is 70 mg/dL or above. If the next meal is an hour or more away, a snack should be eaten once the quick-fix foods have raised the blood glucose level to 70 mg/dL or above.

For People Who Take Acarbose (Precose) or Miglitol (Glyset)

People who take either of these diabetes medications should know that only pure glucose, also called dextroseavailable in tablet or gel formwill raise their blood glucose level during a low blood glucose episode. Other quick-fix foods and drinks won't raise the level quickly enough because acarbose and miglitol slow the digestion of other forms of carbohydrate.

Help from Others for Severe Hypoglycemia

Severe hypoglycemiavery low blood glucosecan cause a person to pass out and can even be life threatening. Severe hypoglycemia is more likely to occur in people with type 1 diabetes. People should ask a health care provider what to do about severe hypoglycemia. Another person can help someone who has passed out by giving an injection of glucagon. Glucagon will rapidly bring the blood glucose level back to normal and help the person regain consciousness. A health care provider can prescribe a glucagon emergency kit. Family, friends, or coworkersthe people who will be around the person at risk of hypoglycemiacan learn how to give a glucagon injection and when to call 911 or get medical help.

Physical Activity and Blood Glucose Levels

Physical activity has many benefits for people with diabetes, including lowering blood glucose levels. However, physical activity can make levels too low and can cause hypoglycemia up to 24 hours afterward. A health care provider can advise about checking the blood glucose level before exercise. For those who take insulin or one of the oral medications that increase insulin production, the health care provider may suggest having a snack if the glucose level is below 100 mg/dL or adjusting medication doses before physical activity to help avoid hypoglycemia. A snack can prevent hypoglycemia. The health care provider may suggest extra blood glucose checks, especially after strenuous exercise.

Hypoglycemia When Driving

Hypoglycemia is particularly dangerous if it happens to someone who is driving. People with hypoglycemia may have trouble concentrating or seeing clearly behind the wheel and may not be able to react quickly to road hazards or to the actions of other drivers. To prevent problems, people at risk for hypoglycemia should check their blood glucose level before driving. During longer trips, they should check their blood glucose level frequently and eat snacks as needed to keep the level at 70 mg/dL or above. If necessary, they should stop for treatment and then make sure their blood glucose level is 70 mg/dL or above before starting to drive again.

Hypoglycemia Unawareness

Some people with diabetes do not have early warning signs of low blood glucose, a condition called hypoglycemia unawareness. This condition occurs most often in people with type 1 diabetes, but it can also occur in people with type 2 diabetes. People with hypoglycemia unawareness may need to check their blood glucose level more often so they know when hypoglycemia is about to occur. They also may need a change in their medications, meal plan, or physical activity routine.

Hypoglycemia unawareness develops when frequent episodes of hypoglycemia lead to changes in how the body reacts to low blood glucose levels. The body stops releasing the hormone epinephrine and other stress hormones when blood glucose drops too low. The loss of the body's ability to release stress hormones after repeated episodes of hypoglycemia is called hypoglycemia-associated autonomic failure, or HAAF.

Epinephrine causes early warning symptoms of hypoglycemia such as shakiness, sweating, anxiety, and hunger. Without the release of epinephrine and the symptoms it causes, a person may not realize that hypoglycemia is occurring and may not take action to treat it. A vicious cycle can occur in which frequent hypoglycemia leads to hypoglycemia unawareness and HAAF, which in turn leads to even more severe and dangerous hypoglycemia. Studies have shown that preventing hypoglycemia for a period as short as several weeks can sometimes break this cycle and restore awareness of symptoms. Health care providers may therefore advise people who have had severe hypoglycemia to aim for higher-than-usual blood glucose targets for short-term periods.

Being Prepared for Hypoglycemia

People who use insulin or take an oral diabetes medication that can cause low blood glucose should always be prepared to prevent and treat low blood glucose by

- learning what can trigger low blood glucose levels  - having their blood glucose meter available to test glucose levels; frequent testing may be critical for those with hypoglycemia unawareness, particularly before driving a car or engaging in any hazardous activity  - always having several servings of quick-fix foods or drinks handy  - wearing a medical identification bracelet or necklace  - planning what to do if they develop severe hypoglycemia  - telling their family, friends, and coworkers about the symptoms of hypoglycemia and how they can help if needed

Normal and Target Blood Glucose Ranges          Normal Blood Glucose Levels in People Who Do Not Have Diabetes          Upon wakingfasting    70 to 99 mg/dL        After meals    70 to 140 mg/dL          Target Blood Glucose Levels in People Who Have Diabetes          Before meals    70 to 130 mg/dL        1 to 2 hours after the start of a meal    below 180 mg/dL

For people with diabetes, a blood glucose level below 70 mg/dL is considered hypoglycemia.


Two types of hypoglycemia can occur in people who do not have diabetes:

- Reactive hypoglycemia, also called postprandial hypoglycemia, occurs within 4 hours after meals.  - Fasting hypoglycemia, also called postabsorptive hypoglycemia, is often related to an underlying disease.

Symptoms of both reactive and fasting hypoglycemia are similar to diabetes-related hypoglycemia. Symptoms may include hunger, sweating, shakiness, dizziness, light-headedness, sleepiness, confusion, difficulty speaking, anxiety, and weakness.

To find the cause of a patient's hypoglycemia, the doctor will use laboratory tests to measure blood glucose, insulin, and other chemicals that play a part in the body's use of energy.

Reactive Hypoglycemia

Diagnosis

To diagnose reactive hypoglycemia, the doctor may

- ask about signs and symptoms  - test blood glucose while the patient is having symptoms by taking a blood sample from the arm and sending it to a laboratory for analysis*  - check to see whether the symptoms ease after the patient's blood glucose returns to 70 mg/dL or above after eating or drinking

A blood glucose level below 70 mg/dL at the time of symptoms and relief after eating will confirm the diagnosis. The oral glucose tolerance test is no longer used to diagnose reactive hypoglycemia because experts now know the test can actually trigger hypoglycemic symptoms.

Causes and Treatment

The causes of most cases of reactive hypoglycemia are still open to debate. Some researchers suggest that certain people may be more sensitive to the body's normal release of the hormone epinephrine, which causes many of the symptoms of hypoglycemia. Others believe deficiencies in glucagon secretion might lead to reactive hypoglycemia.

A few causes of reactive hypoglycemia are certain, but they are uncommon. Gastricor stomachsurgery can cause reactive hypoglycemia because of the rapid passage of food into the small intestine. Rare enzyme deficiencies diagnosed early in life, such as hereditary fructose intolerance, also may cause reactive hypoglycemia.

To relieve reactive hypoglycemia, some health professionals recommend

- eating small meals and snacks about every 3 hours  - being physically active  - eating a variety of foods, including meat, poultry, fish, or nonmeat sources of protein; starchy foods such as whole-grain bread, rice, and potatoes; fruits; vegetables; and dairy products  - eating foods high in fiber  - avoiding or limiting foods high in sugar, especially on an empty stomach

The doctor can refer patients to a registered dietitian for personalized meal planning advice. Although some health professionals recommend a diet high in protein and low in carbohydrates, studies have not proven the effectiveness of this kind of diet to treat reactive hypoglycemia.

Fasting Hypoglycemia

Diagnosis

Fasting hypoglycemia is diagnosed from a blood sample that shows a blood glucose level below 50 mg/dL after an overnight fast, between meals, or after physical activity.

Causes and Treatment

Causes of fasting hypoglycemia include certain medications, alcoholic beverages, critical illnesses, hormonal deficiencies, some kinds of tumors, and certain conditions occurring in infancy and childhood.

Medications. Medications, including some used to treat diabetes, are the most common cause of hypoglycemia. Other medications that can cause hypoglycemia include

- salicylates, including aspirin, when taken in large doses  - sulfa medications, which are used to treat bacterial infections  - pentamidine, which treats a serious kind of pneumonia  - quinine, which is used to treat malaria

If using any of these medications causes a person's blood glucose level to fall, the doctor may advise stopping the medication or changing the dose.

Alcoholic beverages. Drinking alcoholic beverages, especially binge drinking, can cause hypoglycemia. The body's breakdown of alcohol interferes with the liver's efforts to raise blood glucose. Hypoglycemia caused by excessive drinking can be serious and even fatal.

Critical illnesses. Some illnesses that affect the liver, heart, or kidneys can cause hypoglycemia. Sepsis, which is an overwhelming infection, and starvation are other causes of hypoglycemia. In these cases, treating the illness or other underlying cause will correct the hypoglycemia.

Hormonal deficiencies. Hormonal deficiencies may cause hypoglycemia in very young children, but rarely in adults. Shortages of cortisol, growth hormone, glucagon, or epinephrine can lead to fasting hypoglycemia. Laboratory tests for hormone levels will determine a diagnosis and treatment. Hormone replacement therapy may be advised.

Tumors. Insulinomas are insulin-producing tumors in the pancreas. Insulinomas can cause hypoglycemia by raising insulin levels too high in relation to the blood glucose level. These tumors are rare and do not normally spread to other parts of the body. Laboratory tests can pinpoint the exact cause. Treatment involves both short-term steps to correct the hypoglycemia and medical or surgical measures to remove the tumor.

Conditions occurring in infancy and childhood. Children rarely develop hypoglycemia. If they do, causes may include the following:

- Brief intolerance to fasting, often during an illness that disturbs regular eating patterns. Children usually outgrow this tendency by age 10.  - Hyperinsulinism, which is the overproduction of insulin. This condition can result in temporary hypoglycemia in newborns, which is common in infants of mothers with diabetes. Persistent hyperinsulinism in infants or children is a complex disorder that requires prompt evaluation and treatment by a specialist.  - Enzyme deficiencies that affect carbohydrate metabolism. These deficiencies can interfere with the body's ability to process natural sugars, such as fructose and galactose, glycogen, or other metabolites.  - Hormonal deficiencies such as lack of pituitary or adrenal hormones.

*A personal blood glucose monitor cannot be used to diagnose reactive hypoglycemia.


Diabetes-related Hypoglycemia

- When people with diabetes think their blood glucose level is low, they should check it and treat the problem right away.  - To treat hypoglycemia, people should have a serving of a quick-fix food, wait 15 minutes, and check their blood glucose again. They should repeat the treatment until their blood glucose is 70 mg/dL or above.  - People at risk for hypoglycemia should keep quick-fix foods in the car, at workanywhere they spend time.  - People at risk for hypoglycemia should be careful when driving. They should check their blood glucose frequently and snack as needed to keep their level 70 mg/dL or above.

Hypoglycemia Unrelated to Diabetes

- In reactive hypoglycemia, symptoms occur within 4 hours of eating. People with reactive hypoglycemia are usually advised to follow a healthy eating plan recommended by a registered dietitian.  - Fasting hypoglycemia can be caused by certain medications, critical illnesses, hereditary enzyme or hormonal deficiencies, and some kinds of tumors. Treatment targets the underlying problem.


A kidney stone is a solid piece of material that forms in a kidney when substances that are normally found in the urine become highly concentrated. A stone may stay in the kidney or travel down the urinary tract. Kidney stones vary in size. A small stone may pass on its own, causing little or no pain. A larger stone may get stuck along the urinary tract and can block the flow of urine, causing severe pain or bleeding.

Kidney stones are one of the most common disorders of the urinary tract. Each year in the United States, people make more than a million visits to health care providers and more than 300,000 people go to emergency rooms for kidney stone problems.1

Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Other frequently used terms are urinary tract stone disease and nephrolithiasis. Terms that describe the location of the stone in the urinary tract are sometimes used. For example, a ureteral stoneor ureterolithiasisis a kidney stone found in the ureter.


The urinary tract is the bodys drainage system for removing wastes and extra water. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. The kidneys are two bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, one on each side of the spine. Every day, the two kidneys process about 200 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra water. The urine flows from the kidneys to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination. When the bladder empties, urine flows out of the body through a tube called the urethra at the bottom of the bladder.


Anyone can get a kidney stone, but some people are more likely to get one. Men are affected more often than women, and kidney stones are more common in non-Hispanic white people than in non-Hispanic black people and Mexican Americans. Overweight and obese people are more likely to get a kidney stone than people of normal weight. In the United States, 8.8 percent of the population, or one in 11 people, have had a kidney stone.2


Kidney stones can form when substances in the urinesuch as calcium, oxalate, and phosphorusbecome highly concentrated. Certain foods may promote stone formation in people who are susceptible, but scientists do not believe that eating any specific food causes stones to form in people who are not susceptible. People who do not drink enough fluids may also be at higher risk, as their urine is more concentrated.

People who are at increased risk of kidney stones are those with

- hypercalciuria, a condition that runs in families in which urine contains unusually large amounts of calcium; this is the most common condition found in those who form calcium stones  - a family history of kidney stones  - cystic kidney diseases, which are disorders that cause fluid-filled sacs to form on the kidneys  - hyperparathyroidism, a condition in which the parathyroid glands, which are four pea-sized glands located in the neck, release too much hormone, causing extra calcium in the blood  - renal tubular acidosis, a disease that occurs when the kidneys fail to excrete acids into the urine, which causes a persons blood to remain too acidic  - cystinuria, a condition in which urine contains high levels of the amino acid cystine  - hyperoxaluria, a condition in which urine contains unusually large amounts of oxalate  - hyperuricosuria, a disorder of uric acid metabolism  - gout, a disorder that causes painful swelling of the joints  - blockage of the urinary tract  - chronic inflammation of the bowel  - a history of gastrointestinal (GI) tract surgery

Others at increased risk of kidney stones are people taking certain medications including

- diureticsmedications that help the kidneys remove fluid from the body  - calcium-based antacids  - the protease inhibitor indinavir (Crixivan), a medication used to treat HIV infection  - the anti-seizure medication topiramate (Topamax)


Four major types of kidney stones can form:

- Calcium stones are the most common type of kidney stone and occur in two major forms: calcium oxalate and calcium phosphate. Calcium oxalate stones are more common. Calcium oxalate stone formation may be caused by high calcium and high oxalate excretion. Calcium phosphate stones are caused by the combination of high urine calcium and alkaline urine, meaning the urine has a high pH.  - Uric acid stones form when the urine is persistently acidic. A diet rich in purinessubstances found in animal protein such as meats, fish, and shellfishmay increase uric acid in urine. If uric acid becomes concentrated in the urine, it can settle and form a stone by itself or along with calcium.  - Struvite stones result from kidney infections. Eliminating infected stones from the urinary tract and staying infection-free can prevent more struvite stones.  - Cystine stones result from a genetic disorder that causes cystine to leak through the kidneys and into the urine, forming crystals that tend to accumulate into stones.


People with kidney stones may have pain while urinating, see blood in the urine, or feel a sharp pain in the back or lower abdomen. The pain may last for a short or long time. People may experience nausea and vomiting with the pain. However, people who have small stones that pass easily through the urinary tract may not have symptoms at all.


To diagnose kidney stones, the health care provider will perform a physical exam and take a medical history. The medical history may include questions about family history of kidney stones, diet, GI problems, and other diseases and disorders. The health care provider may perform urine, blood, and imaging tests, such as an x ray or computerized tomography (CT) scan to complete the diagnosis.

- Urinalysis. Urinalysis is testing of a urine sample. The urine sample is collected in a special container in a health care providers office or commercial facility and can be tested in the same location or sent to a lab for analysis. Urinalysis can show whether the person has an infection or the urine contains substances that form stones.  - Blood test. A blood test involves drawing blood at a health care providers office or commercial facility and sending the sample to a lab for analysis. The blood test can show biochemical problems that can lead to kidney stones.  - Abdominal x ray. An abdominal x ray is a picture created using radiation and recorded on film or on a computer. The amount of radiation used is small. An x ray is performed at a hospital or outpatient center by an x-ray technician, and the images are interpreted by a radiologista doctor who specializes in medical imaging. Anesthesia is not needed. The person will lie on a table or stand during the x ray. The x-ray machine is positioned over the abdominal area. The person will hold his or her breath as the picture is taken so that the picture will not be blurry. The person may be asked to change position for additional pictures. The x rays can show the location of stones in the kidney or urinary tract.  - CT scans. CT scans use a combination of x rays and computer technology to create three-dimensional (3-D) images. A CT scan may include the injection of a special dye, called contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. The procedure is performed in an outpatient center or hospital by an x-ray technician, and the images are interpreted by a radiologist. Anesthesia is not needed. CT scans can show stone locations and conditions that may have caused the stone to form.


Treatment for kidney stones usually depends on their size and what they are made of, as well as whether they are causing pain or obstructing the urinary tract. Kidney stones may be treated by a general practitioner or by a urologista doctor who specializes in the urinary tract. Small stones usually pass through the urinary tract without treatment. Still, the person may need pain medication and should drink lots of fluids to help move the stone along. Pain control may consist of oral or intravenous (IV) medication, depending on the duration and severity of the pain. IV fluids may be needed if the person becomes dehydrated from vomiting or an inability to drink. A person with a larger stone, or one that blocks urine flow and causes great pain, may need more urgent treatment, such as

- Shock wave lithotripsy. A machine called a lithotripter is used to crush the kidney stone. The procedure is performed by a urologist on an outpatient basis and anesthesia is used. In shock wave lithotripsy, the person lies on a table or, less commonly, in a tub of water above the lithotripter. The lithotripter generates shock waves that pass through the persons body to break the kidney stone into smaller pieces to pass more readily through the urinary tract.  - Ureteroscopy. A ureteroscopea long, tubelike instrument with an eyepieceis used to find and retrieve the stone with a small basket or to break the stone up with laser energy. The procedure is performed by a urologist in a hospital with anesthesia. The urologist inserts the ureteroscope into the persons urethra and slides the scope through the bladder and into the ureter. The urologist removes the stone or, if the stone is large, uses a flexible fiber attached to a laser generator to break the stone into smaller pieces that can pass out of the body in the urine. The person usually goes home the same day.

- Percutaneous nephrolithotomy. In this procedure, a wire-thin viewing instrument called a nephroscope is used to locate and remove the stone. The procedure is performed by a urologist in a hospital with anesthesia. During the procedure, a tube is inserted directly into the kidney through a small incision in the persons back. For large stones, an ultrasonic probe that acts as a lithotripter may be needed to deliver shock waves that break the stone into small pieces that can be removed more easily. The person may have to stay in the hospital for several days after the procedure and may have a small tube called a nephrostomy tube inserted through the skin into the kidney. The nephrostomy tube drains urine and any residual stone fragments from the kidney into a urine collection bag. The tube is usually left in the kidney for 2 or 3 days while the person remains in the hospital.


The first step in preventing kidney stones is to understand what is causing the stones to form. The health care provider may ask the person to try to catch the kidney stone as it passes, so it can be sent to a lab for analysis. Stones that are retrieved surgically can also be sent to a lab for analysis.

The health care provider may ask the person to collect urine for 24 hours after a stone has passed or been removed to measure daily urine volume and mineral levels. Producing too little urine or having a mineral abnormality can make a person more likely to form stones. Kidney stones may be prevented through changes in eating, diet, and nutrition and medications.

Eating, Diet, and Nutrition

People can help prevent kidney stones by making changes in their fluid intake. Depending on the type of kidney stone a person has, changes in the amounts of sodium, animal protein, calcium, and oxalate consumed can also help.

Drinking enough fluids each day is the best way to help prevent most types of kidney stones. Health care providers recommend that a person drink 2 to 3 liters of fluid a day. People with cystine stones may need to drink even more. Though water is best, other fluids may also help prevent kidney stones, such as orange juice or lemonade. Talk with your health care provider if you cant drink the recommended amount due to other health problems, such as urinary incontinence, urinary frequency, or kidney failure.

Recommendations based on the specific type of kidney stone include the following:

Calcium Oxalate Stones

- reducing sodium  - reducing animal protein, such as meat, eggs, and fish  - getting enough calcium from food or taking calcium supplements with food  - avoiding foods high in oxalate, such as spinach, rhubarb, nuts, and wheat bran

Calcium Phosphate Stones

- reducing sodium  - reducing animal protein  - getting enough calcium from food or taking calcium supplements with food

Uric Acid Stones

- limiting animal protein

More information about how changes in diet affect kidney stone formation is provided in the NIDDK health topic, Diet for Kidney Stone Prevention.

Medications

The health care provider may prescribe certain medications to help prevent kidney stones based on the type of stone formed or conditions that make a person more prone to form stones:

- hyperuricosuriaallopurinol (Zyloprim), which decreases uric acid in the blood and urine  - hypercalciuriadiuretics, such as hydrochlorothiazide  - hyperoxaluriapotassium citrate to raise the citrate and pH of urine  - uric acid stonesallopurinol and potassium citrate  - cystine stonesmercaptopropionyl glycine, which decreases cystine in the urine, and potassium citrate  - struvite stonesantibiotics, which are bacteria-fighting medications, when needed to treat infections, or acetohydroxamic acid with long-term antibiotic medications to prevent infection

People with hyperparathyroidism sometimes develop calcium stones. Treatment in these cases is usually surgery to remove the parathyroid glands. In most cases, only one of the glands is enlarged. Removing the glands cures hyperparathyroidism and prevents kidney stones.


- A kidney stone is a solid piece of material that forms in a kidney when substances that are normally found in the urine become highly concentrated.  - Kidney stones are one of the most common disorders of the urinary tract.  - Certain foods may promote stone formation in people who are susceptible, but scientists do not believe that eating any specific food causes stones to form in people who are not susceptible.  - People with kidney stones may have pain while urinating, see blood in the urine, or feel a sharp pain in the back or lower abdomen. However, people who have small stones that pass easily through the urinary tract may not have symptoms at all.  - To diagnose kidney stones, the health care provider will perform a physical exam and take a medical history. The health care provider may perform urine, blood, and imaging tests to complete the diagnosis.  - Treatment for kidney stones usually depends on their size and what they are made of, as well as whether they are causing pain or obstructing the urinary tract. Treatments may include shock wave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy.  - Kidney stones may be prevented through changes in eating, diet, and nutrition and medications.


Anemia is a condition in which the body has fewer red blood cells than normal. Red blood cells carry oxygen to tissues and organs throughout the body and enable them to use energy from food. With anemia, red blood cells carry less oxygen to tissues and organsparticularly the heart and brainand those tissues and organs may not function as well as they should.


The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine.

Healthy kidneys produce a hormone called erythropoietin (EPO). A hormone is a chemical produced by the body and released into the blood to help trigger or regulate particular body functions. EPO prompts the bone marrow to make red blood cells, which then carry oxygen throughout the body.


When kidneys are diseased or damaged, they do not make enough EPO. As a result, the bone marrow makes fewer red blood cells, causing anemia. When blood has fewer red blood cells, it deprives the body of the oxygen it needs.

Other common causes of anemia in people with kidney disease include blood loss from hemodialysis and low levels of the following nutrients found in food:

- iron  - vitamin B12  - folic acid

These nutrients are necessary for red blood cells to make hemoglobin, the main oxygen-carrying protein in the red blood cells.

If treatments for kidney-related anemia do not help, the health care provider will look for other causes of anemia, including

- other problems with bone marrow  - inflammatory problemssuch as arthritis, lupus, or inflammatory bowel diseasein which the bodys immune system attacks the bodys own cells and organs  - chronic infections such as diabetic ulcers  - malnutrition


The signs and symptoms of anemia in someone with CKD may include

- weakness  - fatigue, or feeling tired  - headaches  - problems with concentration  - paleness  - dizziness  - difficulty breathing or shortness of breath  - chest pain

Anyone having difficulty breathing or with shortness of breath should seek immediate medical care. Anyone who has chest pain should call 911.


Heart problems are a complication of anemia and may include

- an irregular heartbeat or an unusually fast heartbeat, especially when exercising.  - the harmful enlargement of muscles in the heart.  - heart failure, which does not mean the heart suddenly stops working. Instead, heart failure is a long-lasting condition in which the heart cant pump enough blood to meet the bodys needs.


A health care provider diagnoses anemia based on

- a medical history  - a physical exam  - blood tests

Medical History

Taking a medical history is one of the first things a health care provider may do to diagnose anemia. He or she will usually ask about the patients symptoms.

Physical Exam

A physical exam may help diagnose anemia. During a physical exam, a health care provider usually examines a patients body, including checking for changes in skin color.

Blood Tests

To diagnose anemia, a health care provider may order a complete blood count, which measures the type and number of blood cells in the body. A blood test involves drawing a patients blood at a health care providers office or a commercial facility. A health care provider will carefully monitor the amount of hemoglobin in the patients blood, one of the measurements in a complete blood count.

The Kidney Disease: Improving Global Outcomes Anemia Work Group recommends that health care providers diagnose anemia in males older than age 15 when their hemoglobin falls below 13 grams per deciliter (g/dL) and in females older than 15 when it falls below 12 g/dL.2 If someone has lost at least half of normal kidney function and has low hemoglobin, the cause of anemia may be decreased EPO production.

Two other blood tests help measure iron levels:

- The ferritin level helps assess the amount of iron stored in the body. A ferritin score below 200 nanograms (ng) per liter may mean a person has iron deficiency that requires treatment.2  - The transferrin saturation score indicates how much iron is available to make red blood cells. A transferrin saturation score below 30 percent can also mean low iron levels that require treatment.2

In addition to blood tests, the health care provider may order other tests, such as tests for blood loss in stool, to look for other causes of anemia.


Depending on the cause, a health care provider treats anemia with one or more of the following treatments:

Iron

The first step in treating anemia is raising low iron levels. Iron pills may help improve iron and hemoglobin levels. However, for patients on hemodialysis, many studies show pills do not work as well as iron given intravenously.2

Erythropoietin

If blood tests indicate kidney disease as the most likely cause of anemia, treatment can include injections of a genetically engineered form of EPO. A health care provider, often a nurse, injects the patient with EPO subcutaneously, or under the skin, as needed. Some patients learn how to inject the EPO themselves. Patients on hemodialysis may receive EPO intravenously during hemodialysis.

Studies have shown the use of EPO increases the chance of cardiovascular events, such as heart attack and stroke, in people with CKD. The health care provider will carefully review the medical history of the patient and determine if EPO is the best treatment for the patients anemia. Experts recommend using the lowest dose of EPO that will reduce the need for red blood cell transfusions. Additionally, health care providers should consider the use of EPO only when a patients hemoglobin level is below 10 g/dL. Health care providers should not use EPO to maintain a patients hemoglobin level above 11.5 g/dL.2 Patients who receive EPO should have regular blood tests to monitor their hemoglobin so the health care provider can adjust the EPO dose when the level is too high or too low.2 Health care providers should discuss the benefits and risks of EPO with their patients.

Many people with kidney disease need iron supplements and EPO to raise their red blood cell count to a level that will reduce the need for red blood cell transfusions. In some people, iron supplements and EPO will improve the symptoms of anemia.

Red Blood Cell Transfusions

If a patients hemoglobin falls too low, a health care provider may prescribe a red blood cell transfusion. Transfusing red blood cells into the patients vein raises the percentage of the patients blood that consists of red blood cells, increasing the amount of oxygen available to the body.

Vitamin B12 and Folic Acid Supplements

A health care provider may suggest vitamin B12 and folic acid supplements for some people with CKD and anemia. Using vitamin supplements can treat low levels of vitamin B12 or folic acid and help treat anemia. To help ensure coordinated and safe care, people should discuss their use of complementary and alternative medical practices, including their use of dietary supplements, with their health care provider.

Read more about vitamin B12 and folic acid on the MedlinePlus website at www.nlm.nih.gov/medlineplus. Read more about complementary and alternative medicine at www.nccam.nih.gov.


A health care provider may advise people with kidney disease who have anemia caused by iron, vitamin B12, or folic acid deficiencies to include sources of these nutrients in their diets. Some of these foods are high in sodium or phosphorus, which people with CKD should limit in their diet. Before making any dietary changes, people with CKD should talk with their health care provider or with a dietitian who specializes in helping people with kidney disease. A dietitian can help a person plan healthy meals.

Read more about nutrition for people with CKD on the National Kidney Disease Education Program website.

The following chart illustrates some good dietary sources of iron, vitamin B12, and folic acid.

Food    Serving Size    Iron    Vitamin B12    Folic Acid          Recommended Daily Value        18 mg    6 mcg    400 mcg        100 percent fortified breakfast cereal     cup (1 oz)    18 mg    6 mcg    394 mcg        beans, baked    1 cup (8 oz)    8 mg    0 mcg    37 mcg        beef, ground    3 oz    2 mg    2 mcg    8 mcg        beef liver    3 oz    5 mg    67 mcg    211 mcg        clams, fried    4 oz    3 mg    1 mcg    66 mcg        spinach, boiled    1 cup (3 oz)    2 mg    0 mcg    115 mcg        spinach, fresh    1 cup (1 oz)    1 mg    0 mcg    58 mcg        trout    3 oz    0 mg    5 mcg    16 mcg        tuna, canned    3 oz    1 mg    1 mcg    2 mcg


- Anemia is a condition in which the body has fewer red blood cells than normal. Red blood cells carry oxygen to tissues and organs throughout the body and enable them to use energy from food.  - Anemia commonly occurs in people with chronic kidney disease (CKD)the permanent, partial loss of kidney function. Most people who have total loss of kidney function, or kidney failure, have anemia.  - When kidneys are diseased or damaged, they do not make enough erythropoietin (EPO). As a result, the bone marrow makes fewer red blood cells, causing anemia.  - Other common causes of anemia in people with kidney disease include blood loss from hemodialysis and low levels of the following nutrients found in food:      - iron    - vitamin B12    - folic acid    - The first step in treating anemia is raising low iron levels.  - If blood tests indicate kidney disease as the most likely cause of anemia, treatment can include injections of a genetically engineered form of EPO.  - Many people with kidney disease need iron supplements and EPO to raise their red blood cell count to a level that will reduce the need for red blood cell transfusions.  - A health care provider may suggest vitamin B12 and folic acid supplements for some people with CKD and anemia.  - A health care provider may advise people with kidney disease who have anemia caused by iron, vitamin B12, or folic acid deficiencies to include sources of these nutrients in their diets.


You and your doctor will work together to choose a treatment that's best for you. The publications of the NIDDK Kidney Failure Series can help you learn about the specific issues you will face.

Booklets

- Treatment Methods for Kidney Failure: Hemodialysis  - Treatment Methods for Kidney Failure: Peritoneal Dialysis  - Treatment Methods for Kidney Failure: Kidney Transplantation  - Kidney Failure: Eat Right to Feel Right on Hemodialysis

Fact Sheets

- Kidney Failure: What to Expect  - Vascular Access for Hemodialysis  - Treatment Methods for Kidney Failure: Hemodialysis  - Hemodialysis Dose and Adequacy  - Peritoneal Dialysis Dose and Adequacy  - Amyloidosis and Kidney Disease  - Anemia in Chronic Kidney Disease  - Chronic Kidney Disease-Mineral and Bone Disorder  - Financial Help for Treatment of Kidney Failure

Learning as much as you can about your treatment will help make you an important member of your health care team.

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.

The NIDDK would like to thank: John C. Stivelman, M.D., Emory University School of Medicine; Kerri Cavanaugh, M.D., M.H.S., Vanderbilt University

This information is not copyrighted. The NIDDK encourages people to share this content freely.

July 2014


Lupus nephritis is kidney inflammation caused by systemic lupus erythematosus (SLE or lupus). SLE is an autoimmune diseasea disorder in which the bodys immune system attacks the bodys own cells and organs. Up to 60 percent of people with SLE are diagnosed with lupus nephritis, which can lead to significant illness and even death.1


The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the two kidneys filter about 120 to 150 of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra fluid. The urine flows from the kidneys to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination.


The symptoms of lupus nephritis may include high blood pressure, foamy urine, and edemaswelling, usually in the legs, feet, or ankles and less often in the hands or face.

Kidney problems often develop at the same time or shortly after lupus symptoms appear and can include

- joint pain or swelling  - muscle pain  - fever with no known cause  - red rashes, often on the face, which are also called butterfly rashes because of their shape


Lupus nephritis is diagnosed through urine and blood tests and a kidney biopsy:

- Urinalysis. Urinalysis is testing of a urine sample. The urine sample is collected in a special container in a health care providers office or commercial facility and can be tested in the same location or sent to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color when blood or protein is present. A high number of red blood cells or high levels of protein in the urine indicate kidney damage.  - Blood test. A blood test involves drawing blood at a health care providers office or commercial facility and sending the sample to a lab for analysis. The blood test can show high levels of creatinine, a waste product of normal muscle breakdown excreted by the kidneys, which increases when the kidneys are not functioning well.   - Biopsy. A biopsy is a procedure that involves taking a small piece of kidney tissue for examination with a microscope. The biopsy is performed by a health care provider in a hospital with light sedation and local anesthetic. The health care provider uses imaging techniques such as ultrasound or a computerized tomography scan to guide the biopsy needle into the kidney. The kidney tissue is examined in a lab by a pathologista doctor who specializes in diagnosing diseases. The test can confirm a diagnosis of lupus nephritis, determine how far the disease has progressed, and guide treatment. The American College of Rheumatology recommends biopsies for all people with evidence of active lupus nephritis that has not been previously treated.


Lupus nephritis is treated with medications that suppress the immune system, so it stops attacking and damaging the kidneys. Standard treatment includes a corticosteroid, usually prednisone, to reduce inflammation in the kidneys. An immunosuppressive medication, such as cyclophosphamide or mycophenolate mofetil, is typically used with prednisone. These medicationswhen taken as prescribed by a health care providerfurther decrease the activity of the immune system and block the bodys immune cells from attacking the kidneys directly or making antibodies that attack the kidneys. Antibodies are proteins made by the immune system to protect the body from foreign substances such as bacteria or viruses. Hydroxychloroquine, a medication for treating SLE, should also be prescribed or continued for people with lupus nephritis.

People with lupus nephritis that is causing high blood pressure may need to take medications that lower their blood pressure and can also significantly slow the progression of kidney disease. Two types of blood pressure lowering medications, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease. Many people require two or more medications to control their blood pressure. In addition to an ACE inhibitor or an ARB, a diuretica medication that helps the kidneys remove fluid from the bodymay be prescribed. Beta blockers, calcium channel blockers, and other blood pressure medications may also be needed.

Blood pressure is written with two numbers separated by a slash, 120/80, and is said as 120 over 80. The top number is called the systolic pressure and represents the pressure as the heart beats and pushes blood through the blood vessels. The bottom number is called the diastolic pressure and represents the pressure as blood vessels relax between heartbeats. High blood pressure is a systolic pressure of 140 or above or a diastolic pressure of 90 or above.2


In many cases, treatment is effective in completely or partially controlling lupus nephritis, resulting in few, if any, further complications. However, even with treatment, 10 to 30 percent of people with lupus nephritis develop kidney failure, described as end-stage renal disease when treated with blood-filtering treatments called dialysis or a kidney transplant.3 Scientists cannot predict who will or will not respond to treatment. The most severe form of lupus nephritis is called diffuse proliferative nephritis. With this type of illness, the kidneys are inflamed, many white blood cells invade the kidneys, and kidney cells increase in number, which can cause such severe damage that scars form in the kidneys. Scars are difficult to treat, and kidney function often declines as more scars form. People with suspected lupus nephritis should get diagnosed and treated as early as possible to prevent such chronic, or long lasting, damage.

People with lupus nephritis are at a high risk for cancer, primarily B-cell lymphomaa type of cancer that begins in the cells of the immune system. They are also at a high risk for heart and blood vessel problems.


Eating, diet, and nutrition have not been shown to play a role in causing or preventing lupus nephritis. People with kidney disease that progresses may need to talk with a health care provider about changes they may need to make to their diet. People with lupus nephritis and high blood pressure may benefit from reducing sodium intake, often from salt. More information about nutrition in people with kidney disease is provided in the NIDDK health topics, Nutrition for Early Chronic Kidney Disease in Adults and Nutrition for Advanced Chronic Kidney Disease in Adults.


- Lupus nephritis is kidney inflammation caused by systemic lupus erythematosus (SLE or lupus).  - The symptoms of lupus nephritis may include high blood pressure, foamy urine, and edema.  - Lupus nephritis is diagnosed through urine and blood tests and a kidney biopsy.  - Lupus nephritis is treated with medications that suppress the immune system, so it stops attacking and damaging the kidneys. Standard treatment includes a corticosteroid, usually prednisone, to reduce inflammation in the kidneys. An immunosuppressive medication, such as cyclophosphamide or mycophenolate mofetil, is typically used with prednisone.  - People with lupus nephritis that is causing high blood pressure may need to take medications that lower their blood pressure, which can also significantly slow the progression of kidney disease.  - In many cases, treatment is effective in completely or partially controlling lupus nephritis, resulting in few, if any, further complications. However, even with treatment, 10 to 30 percent of people with lupus nephritis develop kidney failure.


Dermatitis herpetiformis is characterized by small, clustered papules and vesicles that erupt symmetrically on the elbows, knees, buttocks, back, or scalp. The face and groin can also be involved. A burning sensation may precede lesion formation. Lesions are usually scratched off by the time a patient comes in for a physical exam, and the rash may appear as erosions and excoriations.

Patients with DH may also experience dental enamel defects to permanent teeth, which is another manifestation of celiac disease. Less than 20 percent of people with DH have symptoms of celiac disease.3


Dermatitis herpetiformis is caused by the deposit of immunoglobulin A (IgA) in the skin, which triggers further immunologic reactions resulting in lesion formation. DH is an external manifestation of an abnormal immune response to gluten, in which IgA antibodies form against the skin antigen epidermal transglutaminase.

Family studies show that 5 percent of first-degree relatives of a person with DH will also have DH. An additional 5 percent of first-degree relatives of a person with DH will have celiac disease.4 Various other autoimmune diseases are associated with DH, the most common being hypothyroidism.


A skin biopsy is the first step in diagnosing DH. Direct immunofluorescence of clinically normal skin adjacent to a lesion shows granular IgA deposits in the upper dermis. Histology of lesional skin may show microabscesses containing neutrophils and eosinophils. However, histology may reveal only excoriation due to the intense itching that patients experience.

Blood tests for antiendomysial or anti-tissue transglutaminase antibodies may also suggest celiac disease. Blood tests for epidermal transglutaminase antibodies are positive in more than 90 percent of cases.5 All of these tests will become negative with prolonged adherence to a gluten-free diet.

A positive biopsy and serology confirm DH and should be taken as indirect evidence of small bowel damage. A biopsy of the small bowel is usually not needed for DH diagnosis. However, if clinical signs of gastrointestinal disease are evident on examination, further workup may be required.2 Whether or not intestinal damage is evident, a gluten-free diet should be implemented because the rash of DH is gluten sensitive.4


The sulfone dapsone can provide immediate relief of symptoms. For patients who cannot tolerate dapsone, sulfapyridine or sulfamethoxypyridazine may be used, although these medications are less effective than dapsone. A strict gluten-free diet is the only treatment for the underlying disease. Even with a gluten-free diet, medication therapy may need to be continued from a few months to 2 years.

DH can go into remission, which is defined as absence of skin lesions and symptoms of DH for more than 2 years while not taking sulfones or other treatments and not adhering to a gluten-free diet. Cohort studies showing DH remission provide support for reducing sulfone therapy and weaning from a gluten-free diet in patients with well-controlled DH.6


Goodpasture syndrome is a pulmonary-renal syndrome, which is a group of acute illnesses involving the kidneys and lungs. Goodpasture syndrome includes all of the following conditions:

- glomerulonephritisinflammation of the glomeruli, which are tiny clusters of looping blood vessels in the kidneys that help filter wastes and extra water from the blood  - the presence of anti-glomerular basement membrane (GBM) antibodies; the GBM is part of the glomeruli and is composed of collagen and other proteins  - bleeding in the lungs

In Goodpasture syndrome, immune cells produce antibodies against a specific region of collagen. The antibodies attack the collagen in the lungs and kidneys.

Ernest Goodpasture first described the syndrome during the influenza pandemic of 1919 when he reported on a patient who died from bleeding in the lungs and kidney failure. Diagnostic tools to confirm Goodpasture syndrome were not available at that time, so it is not known whether the patient had true Goodpasture syndrome or vasculitis. Vasculitis is an autoimmune conditiona disorder in which the bodys immune system attacks the bodys own cells and organsthat involves inflammation in the blood vessels and can cause similar lung and kidney problems.

Goodpasture syndrome is sometimes called anti-GBM disease. However, anti-GBM disease is only one cause of pulmonary-renal syndromes, including Goodpasture syndrome.

Goodpasture syndrome is fatal unless quickly diagnosed and treated.


The causes of Goodpasture syndrome are not fully understood. People who smoke or use hair dyes appear to be at increased risk for this condition. Exposure to hydrocarbon fumes, metallic dust, and certain drugs, such as cocaine, may also raise a persons risk. Genetics may also play a part, as a small number of cases have been reported in more than one family member.


The symptoms of Goodpasture syndrome may initially include fatigue, nausea, vomiting, and weakness. The lungs are usually affected before or at the same time as the kidneys, and symptoms can include shortness of breath and coughing, sometimes with blood. The progression from initial symptoms to the lungs being affected may be very rapid. Symptoms that occur when the kidneys are affected include blood in the urine or foamy urine, swelling in the legs, and high blood pressure.


A health care provider may order the following tests to diagnose Goodpasture syndrome:

- Urinalysis. Urinalysis is testing of a urine sample. The urine sample is collected in a special container in a health care providers office or commercial facility and can be tested in the same location or sent to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color when protein or blood are present in urine. A high number of red blood cells and high levels of protein in the urine indicate kidney damage.  - Blood test. A blood test involves drawing blood at a health care providers office or commercial facility and sending the sample to a lab for analysis. The blood test can show the presence of anti-GBM antibodies.  - Chest x ray. An x ray of the chest is performed in a health care providers office, outpatient center, or hospital by an x-ray technician, and the images are interpreted by a radiologista doctor who specializes in medical imaging. Abnormalities in the lungs, if present, can be seen on the x ray.  - Biopsy. A biopsy is a procedure that involves taking a piece of kidney tissue for examination with a microscope. The biopsy is performed by a health care provider in a hospital with light sedation and local anesthetic. The health care provider uses imaging techniques such as ultrasound or a computerized tomography scan to guide the biopsy needle into the kidney. The tissue is examined in a lab by a pathologista doctor who specializes in diagnosing diseases. The test can show crescent-shaped changes in the glomeruli and lines of antibodies attached to the GBM.


Goodpasture syndrome is usually treated with

- immunosuppressive medications, such as cyclophosphamide, to keep the immune system from making antibodies  - corticosteroid medications to suppress the bodys autoimmune response  - plasmapheresisa procedure that uses a machine to remove blood from the body, separate certain cells from the plasma, and return just the cells to the persons body; the anti-GBM antibodies remain in the plasma and are not returned to the persons body

Plasmapheresis is usually continued for several weeks, and immunosuppressive medications may be given for 6 to 12 months, depending on the response to therapy. In most cases, bleeding in the lungs stops and no permanent lung damage occurs. Damage to the kidneys, however, may be long lasting. If the kidneys fail, blood-filtering treatments called dialysis or kidney transplantation may become necessary.


Eating, diet, and nutrition have not been shown to play a role in causing or preventing Goodpasture syndrome.


- Goodpasture syndrome is a pulmonary-renal syndrome, which is a group of acute illnesses involving the kidneys and lungs. Goodpasture syndrome includes all of the following conditions:      - glomerulonephritis    - the presence of anti-glomerular basement membrane (GBM) antibodies    - bleeding in the lungs    - Goodpasture syndrome is fatal unless quickly diagnosed and treated.  - People who smoke or use hair dyes appear to be at increased risk for this condition. Exposure to hydrocarbon fumes, metallic dust, and certain drugs may also raise a persons risk.  - The symptoms of Goodpasture syndrome may initially include fatigue, nausea, vomiting, and weakness. The lungs are usually affected before or at the same time as the kidneys, and symptoms can include shortness of breath and coughing, sometimes with blood. Symptoms that occur when the kidneys are affected include blood in the urine or foamy urine, swelling in the legs, and high blood pressure.  - A urinalysis, blood test, chest x ray, and kidney biopsy are used to diagnose Goodpasture syndrome.  - Goodpasture syndrome is usually treated with immunosuppressive medications, corticosteroid medications, and plasmapheresis.


Interstitial cystitis*painful bladder syndrome (IC/PBS) is one of several conditions that causes bladder pain and a need to urinate frequently and urgently. Some doctors have started using the term bladder pain syndrome (BPS) to describe this condition.

Your bladder is a balloon-shaped organ where your body holds urine. When you have a bladder problem, you may notice certain signs or symptoms.

*See Pronounciation Guide for tips on how to say the words in bold type.


Signs of bladder problems include

-  Urgency. The feeling that you need to go right now! Urgency is normal if you haven't been near a bathroom for a few hours or if you have been drinking a lot of fluids. But you may have a problem if you have strong urges before your bladder has had time to fill. All of a sudden, you feel a strong urge to go. At times, you may even have an accident because the urge strikes so quickly you don't have time to find a bathroom.    - Frequency. The feeling that you need to go much more often than anyone else. Doctors and nurses use the term void, which means to empty the bladder. Most people void between four and seven times a day. Drinking large amounts of fluid can cause more frequent voiding. Taking blood pressure medicines called diuretics, or water pills, can also cause more frequent voiding. If you void more than eight times a day, and you dont take diuretics or drink large amounts of fluid, it may be the sign of a problem.  - Pain. The feeling of more than discomfort when you need to go. Having a full bladder may be uncomfortable, but it should not be painful. You may have a problem if you feel burning or sharp pain in your bladder or urethrathe opening where urine leaves the body.

Some people may have pain without urgency or frequency. Others have urgency and frequency without pain.


Many different problems can cause urgency, frequency, and bladder pain. Just a few of them are

- infections  - bowel disorders  - endometriosistissue that normally lines the womb that appears in other places outside of the womb  - bladder cancer

Your doctor will ask you questions and run tests to find the cause of your bladder problems. Usually, the doctor will find that you have either an infection or an overactive bladder. But urgency, frequency, and pain are not always caused by infection.

Sometimes the cause is hard to find. If all the test results are normal and all other diseases are ruled out, your doctor may find that you have IC/PBS.


Both men and women can get IC/PBS, though twice as many women are affected as men. It can occur at any age, but it is most common in middle age.

People with IC/PBS rarely have bladder pain all the time. The pain usually comes and goes as the bladder fills and then empties. The pain may go away for weeks or months and then return. People with IC/PBS sometimes refer to an attack of bladder pain as a flare or flare-up. Stress may bring on a flare-up of symptoms in someone who has IC/PBS. But stress does not cause a person to get IC/PBS.


Finding the cause of bladder pain may require several tests.

While tests may aid your doctor in making a diagnosis of IC/PBS, a careful review of your symptoms and a physical exam in the office are generally the most important parts of the evaluation.


No one treatment for IC/PBS has been found that works for everyone. Your doctor or nurse will work with you to find a treatment plan that meets your special needs. The plan may include diet and lifestyle changes, bladder retraining, activity and exercise, physical therapy, and various types of medicines. You should expect some treatment failures along the way, but, with time, you and your doctor or nurse should find a treatment that gives you some relief and helps you cope with your disease.

Diet and Lifestyle Changes

Some people with IC/PBS find that certain foods or drinks bring on their symptoms. Others find no link between symptoms and what they eat.

Learning what foods cause symptoms for you may require some trial and error. Keep a food diary and note the times you have bladder pain. The diary might reveal that your flare-ups always happen, for example, after you eat tomatoes or oranges.

Some doctors recommend taking an antacid medicine with meals. The medicine reduces the amount of acid that gets into the urine.

If you make changes to your diet, remember to eat a variety of healthy foods.

Bladder Retraining

Bladder retraining is a way to help your bladder hold more urine. People with bladder pain often get in the habit of using the bathroom as soon as they feel pain or urgency. They then feel the need to go before the bladder is really full. The body may get used to frequent voiding. Bladder retraining helps your bladder hold more urine before signaling the urge to urinate.

Keep a bladder diary to track how you are doing. Start by noting the times when you void. Note how much time goes by between voids. For example, you may find that you return to the bathroom every 40 minutes.

Try to stretch out the time between voids. If you usually void every 40 minutes, try to wait at least 50 minutes before you go to the bathroom.

If your bladder becomes painful, you may use the bathroom. But you may find that your first urge to use the bathroom goes away if you ignore it. Find ways to relax or distract yourself when the first urge strikes.

After a few days, you may be able to stretch the time out to 60 or 70 minutes, and you may find that the urge to urinate does not return as soon.

Activity

If you have IC/PBS, you may feel the last thing you want to do is exercise. But many people feel that easy activities like walking or gentle stretching exercises help relieve symptoms.

Physical Therapy

Your doctor or nurse may suggest pelvic exercises. The pelvic muscles hold the bladder in place and help control urination. The first step is to find the right muscle to squeeze. A doctor, nurse, or physical therapist can help you. One way to find the muscles is to imagine that you are trying to stop passing gas. Squeeze the muscles you would use. If you sense a "pulling" feeling, you have found the right muscles for pelvic exercises.

You may need exercises to strengthen those muscles so that it's easier to hold in urine. Or you may need to learn to relax your pelvic muscles if tense muscles are part of your bladder pain.

Some physical therapists specialize in helping people with pelvic pain. Ask your doctor or nurse to help you find a professional trained in pelvic floor physical therapy.

Reducing Stress

Stress doesn't cause IC/PBS. But stress can trigger painful flare-ups in someone who has IC/PBS. Learning to reduce stress in your life by making time for relaxation every day may help control some symptoms of IC/PBS.

Oral Medicines

Pain pills like aspirin, ibuprofen, or acetominophen can help control mild bladder pain. Advil and Motrin are examples of ibuprofen. Tylenol is an example of acetominophen. Talk with your doctor if you feel you need a stronger pain medicine.

Your doctor may recommend a medication, pentosan polysulfate sodium, sold as Elmiron, which is approved for treating the pain of IC/PBS. You may need to take this medicine for up to 6 months before you notice improvement. Elmiron does not work for everyone, but some people with IC/PBS have found relief taking it. You need a doctor's order for Elmiron. If you don't notice improvement of your symptoms in 6 months, this medicine is not likely to work.

Researchers are also looking at other kinds of medicines. Medicines that treat heartburn might help bladder symptoms by reducing the amount of acid made in the body. Muscle relaxants can keep the bladder from squeezing at the wrong time. Keeping the bladder muscle relaxed helps ease the symptoms of IC/PBS.

Bladder Stretching

The doctor may stretch the bladder by filling it with liquid. You will be given an anesthetic to prevent pain and help relax your bladder muscles. Some patients have said their symptoms were helped after this treatment.

Bladder Medicines

Many patients who have IC/PBS find relief after a treatment in which their bladders are filled with a liquid medicine. The doctor guides a tube into your bladder and slowly fills the bladder with a liquid that eases irritation of the bladder wall. The liquid may be a compound called DMSO or a solution that contains heparin and a pain medicine called lidocaine.

You will keep the liquid in your bladder for about 15 minutes and then release it. You can have this treatment once every week or every other week for 1 or 2 months. You may not feel any better until the third or fourth treatment.

Nerve Stimulation

If you have tried diet changes, exercise, and medicines and nothing seems to help, you may wish to think about nerve stimulation. This treatment sends mild electrical pulses to the nerves that control the bladder.

At first, you may try a system that sends the pulses through electrodes placed on your skin. If this therapy works for you, you may consider having a device put in your body. The device delivers small pulses of electricity to the nerves around the bladder.

For some patients, nerve stimulation relieves bladder pain as well as urinary frequency and urgency. For others, the treatment relieves frequency and urgency but not pain. For still other patients, it does not work.

Scientists are not sure why nerve stimulation works. Some believe that the electrical pulses block the pain signals carried in the nerves. If your brain doesn't receive the nerve signal, you don't feel the pain. Others believe that the electricity releases endorphins, which are hormones that block pain naturally.

Surgery

As a last resort, your doctor might suggest surgery to remove part or all of the bladder. Surgery does not cure the pain of IC/PBS in all cases, but if you have tried every other option and your pain is still unbearable, surgery might be considered.

Talk with your doctor and family about the possible benefits and side effects.


- Bladder problems have many possible causes.  - Your doctor will need to do tests to find the cause of your bladder problems. If all the test results are normal, you may have IC/PBS.  - No one treatment option for IC/PBS works for everybody.  - Treatments for IC/PBS may include changing your diet and exercising.  - Medicines for IC/PBS may be taken by mouth or put directly into the bladder through a tube by a doctor.  - Nerve stimulation helps some people with IC/PBS.  - Surgery is a last resort for treating IC/PBS.


Hematuria is blood in the urine. Two types of blood in the urine exist. Blood that can be seen in the urine is called gross hematuria. Blood that cannot be seen in the urine, except when examined with a microscope, is called microscopic hematuria.


Most people with microscopic hematuria do not have symptoms. People with gross hematuria have urine that is pink, red, or cola-colored due to the presence of red blood cells (RBCs). Even a small amount of blood in the urine can cause urine to change color. In most cases, people with gross hematuria do not have other symptoms. However, people with gross hematuria that includes blood clots in the urine may have pain.


The urinary tract is the bodys drainage system for removing wastes and extra water. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. The kidneys are two bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, one on each side of the spine. Every day, the two kidneys process about 200 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra water. The urine flows from the kidneys to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination. When the bladder empties, urine flows out of the body through a tube called the urethra at the bottom of the bladder.


Hematuria can be caused by menstruation, vigorous exercise, sexual activity, viral illness, trauma, or infection, such as a urinary tract infection (UTI). More serious causes of hematuria include

- cancer of the kidney or bladder  - inflammation of the kidney, urethra, bladder, or prostatea walnut-shaped gland in men that surrounds the urethra at the neck of the bladder and supplies fluid that goes into semen  - polycystic kidney diseasean inherited disorder characterized by many grape-like clusters of fluid-filled cysts that make both kidneys larger over time, taking over and destroying working kidney tissue  - blood clots  - blood clotting disorders, such as hemophilia  - sickle cell diseasean inherited disorder in which RBCs form an abnormal crescent shape, resulting in less oxygen delivered to the bodys tissues, clogging of small blood vessels, and disruption of healthy blood flow


Almost anyone, including children and teens, can have hematuria. Factors that increase the chance a person will have hematuria include

- a family history of kidney disease  - an enlarged prostate, which typically occurs in men age 50 or older  - urinary stone disease  - certain medications including aspirin and other pain relievers, blood thinners, and antibiotics  - strenuous exercise such as long-distance running  - a recent bacterial or viral infection