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Nephrology

Patient Care

The Division of Nephrology provides primary care and consultative care for patients with various renal diseases. These services are offered in inpatient and outpatient settings at both the Froedtert Hospital (FH) and Clement J. Zablocki VA Medical Center, as well as through Fresenius and DaVita outpatient dialysis units. All of our physicians and midlevel providers are committed to delivering quality care for all renal patients. Many of them are recognized and renowned clinicians, clinical science researchers, and basic science researchers. They provide care for a wide range of renal failure patients, including acute renal failure, chronic renal failure, chronic kidney disease, diabetic kidney disease, hypertension and hypertensive kidney disease, electrolyte imbalance, glomerulonephritis, cystic kidney disease and medical management of renal and pancreas transplantation.

Inpatient care for renal patients at the FH is provided through dedicated inpatient service. Comprehensive medical care is provided for renal patients, including treatment for chronic kidney disease, end stage renal failure and transplant recipients. Consultative service at the FH and VA medical center is available throughout the year for all renal and electrolyte issues for all patients admitted to our institution. Through inpatient services, specialized nephrology procedures such as hemodialysis, peritoneal dialysis, continuous veno-venous dialysis and renal biopsies are offered.

Outpatient clinical activities are performed at FH, several Froedtert satellite clinics, the dialysis centers and VA Medical Center. Through these clinics, primary and consultation services are available for patients with various renal diseases. Comprehensive medical management of chronic kidney disease with special focus on anemia, hypertension and bone disease treatment is provided through the CKD clinic at FH. Through this clinic, education and preparation for end stage renal failure, including information on dialysis access and selecting mode of therapy for ESRD, is provided to patients with renal failure.

Areas of Expertise

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Anemia
Learn about anemia, a condition that happens when blood lacks healthy red blood cells.

View Froedtert Hospital's Anemia & Kidney Disease Clinic site for more information
Diabetes Mellitus (Diabetes)
Diet for Renal Patient

Fluid & Fluid Control

Kidneys help control the amount of fluid that leaves your body. If your kidney disease progresses, your kidneys may be unable to regulate the removal of fluid from your body and as a result your doctor may ask you to limit your fluid intake. Too much fluid may cause swelling, shortness of breath, or high blood pressure.

What exactly is a fluid? Fluids are any food that is liquid or anything that melts into a liquid. Examples of fluids include coffee, tea, sodas, soups, popsicles, ice cream, sherbet, ice cubes, gelatin, milk, liquid creamer, water, wine and beer.

If your doctor advises you to decrease the amount of fluids you eat and drink each day these tips may help you.

  • Drink only when thirsty. Do not drink out of habit or to be social.
  • Eat less salt so you will feel less thirsty.
  • Suck on ice chips. (Measure small units into a cup)
  • Brush your teeth three to four times a day; this is to prevent your mouth from drying out.
  • Suck on a lemon wedge.
  • If you have diabetes, control your blood sugar.
  • Chew sugarless gum or suck on sugarless hard candy.
  • Take your medications with sips of fluid.
  • When dining out, ask your beverage to be served in a child-size glass.
  • Measure how much fluid your favorite cup or glass holds so you will be better able to monitor the amount of fluid you drink.
  • After measuring out the total amount of fluid you can drink for the day, place the water in a container. During the day drink only from this container so you can keep an eye on the amount of fluid you have consumed.

Potassium

Before making any changes to your diet, make sure you discuss them with your doctor or dietitian.

Potassium helps to keep your nerves and muscles, especially your heart, working properly. Potassium is a mineral and can be found in many foods. The kidneys are responsible for helping to keep the correct amount of potassium in your body. It can be very dangerous if your potassium level is too high. Too much potassium can make your hear beat irregularly or even stop without warning.

Foods that are high in potassium include the following:

  • Fruits Vegetables Other Food
  • Bananas Broccoli Chocolate
  • Oranges Potatoes Coffee (limit to 2 cups per day)
  • Cantaloupe Tomatoes Salt Substitute
  • Prunes Mushrooms Bran & bran products
  • Raisins Greens (Swiss chard, Nuts & dried fruit
  • Collard, dandelion,
  • Mustard, and beet)
  • Apricots

Low-potassium foods include the following:

  • Fruits Vegetables Other Food
  • Apples Beans (green or wax) Rice
  • Grapes Cucumber Noodles
  • Pears Onions Cake
  • Watermelon Lettuce Cereal
  • Cranberries Carrots Bread & bread products
  • Cherries

It is important to remember that almost all foods contain potassium. Serving size will determine whether foods are a low, moderate, or high potassium level.

A large serving size of a low potassium food can become a high potassium food.

Protein

Before making any changes to your diet, make sure you discuss them with your doctor or dietitian.

Diet plays an important role in the management of kidney disease. The diet your physician will ask you to follow will be based upon your level of kidney function, your body size, and any other medical conditions you may have. Your diet may be helpful in delaying the need for dialysis.

Protein is needed to maintain muscles, aid in building resistance to infections, and repair and replace body tissue. As your body breaks down protein foods, waste products called urea are formed. As kidney function declines, urea builds up in the bloodstream. Eating to much protein may cause urea to build up more quickly. This will make you feel sick. Eating less protein may be helpful in reducing your blood urea levels. Reducing protein intake must be monitored by your doctor and dietician.

Examples of foods high in protein are:

  • Meat
  • Poultry
  • Milk Products
  • Eggs

Foods low in protein includes the following:

  • Fresh beans (pinto, kidney, navy)
  • Grains
  • Vegetables

You need both high quality and low quality protein in your diet. Your physician will determine how much protein should be in your diet.

Sodium

Before making any changes to your diet, make sure you discuss them with your doctor or dietitian.

Sodium is needed by the body for many functions such as controlling muscle contractions, balancing fluids, and controlling blood pressure. Healthy kidneys remove excess sodium in the urine. As kidney function declines, sodium and fluids may accumulate in your body. Fluid retention may cause swelling in your eyes, hands, and/or ankles. To keep your sodium level in balance, your doctor may ask you to limit the sodium in your diet.

Foods high in sodium include the following:

  • Table salt
  • Bouillon cubes
  • Potato chips
  • Nuts
  • Bacon
  • Cold Cuts
  • Cheese
  • Canned, dehydrated, or instant soup
  • Canned vegetables
  • Processed dinner mixes (such as Hamburger Helper, Rice-a-Roni)

Low sodium alternatives:

  • Season with a variety of spices like garlic and oregano
  • Use lemon
Electrolyte Disorders

Topic written or edited by:

Aaron Dall, MD
Samuel S. Blumenthal, MD
Kevin R. Regner, MD, MS, FASN
Barbara A. Bresnahan, MD
Jack G. Kleinman, MD

Hyperkalemia (High Potassium)

The most common cause of high potassium (hyperkalemia) is impaired kidney function. Other causes of hyperkalemia include:

  • Certain medications, such as angiotensin-converting enzyme (ACE) inhibitors, Angiotensin Receptor Blocker (ARB), Heparin, Bactrim.
  • Hormone deficiencies – including adrenal failure (Addison's disease)
  • Destruction of red blood cells due to severe injury or burns
  • Excessive use of potassium supplements

Most of the potassium in your body is within your cells. As a result, the amount of potassium in your red blood cells is much greater than in the liquid part of your blood (plasma or serum). Your kidneys control the excretion of potassium in your urine.
True hyperkalemia is a serious and potentially life-threatening disorder. It can cause:

  • Muscle fatigue
  • Weakness
  • Paralysis
  • Abnormal heart rhythms (arrhythmias)

Sometimes a report of high blood potassium isn't true hyperkalemia. Instead it may be caused by the rupture of red blood cells in the blood sample during or shortly after drawing the sample. The ruptured cells leak their potassium into the serum. This falsely elevates the amount of potassium in the blood sample, even though the potassium level in your body is actually normal.

Hypokalemia (Low Potassium)

Low potassium in the blood (hypokalemia) may result from many different conditions. The most common cause is excessive potassium loss in the urine or from the gastrointestinal tract. Examples include:

  • Use of diuretics (water pills)
  • Excessive production of the hormone aldosterone (hyperaldosteronism) by the adrenal gland
  • Excessive use of laxatives
  • Eating disorders
  • Severe vomiting or diarrhea
  • Certain kidney diseases such as renal tubular acidosis

Rarely, hypokalemia is due to not getting enough potassium in your diet.

Potassium is an electrolyte that is critical to the function of nerve and muscles cells, including those in your heart. Most of the potassium in your body is inside your cells. So the levels of potassium in your blood may not reflect your total body potassium.
Signs and symptoms of low potassium may include:

  • Weakness
  • Fatigue
  • Muscle cramps
  • Constipation
  • Abnormal heart rhythms (arrhythmias)

Treatment is directed at the underlying cause of the low potassium and may include potassium supplements. A very low potassium level is life-threatening.

Hypercalcemia (High Calcium)

High calcium (hypercalcemia) is most commonly caused by an overactive parathyroid gland (hyperparathyroidism). The parathyroid glands, which are located below the thyroid gland, regulate calcium in your body.

Other causes of hypercalcemia include:

  • Certain medications, such as lithium or thiazide diuretics
  • Certain cancers, including breast, lung and certain blood cancers
  • Sarcoidosis, an inflammatory disorder
  • Excessive intake of calcium or vitamin D supplements
  • Familial hypocalciuric hypercalcemia, a genetic disorder
  • Dialysis for chronic kidney failure
  • Adrenal gland failure
  • Overactive thyroid (hyperthyroidism)

Severe hypercalcemia may cause:

  • Nausea, vomiting
  • Excessive thirst
  • Constipation
  • Abdominal pain
  • Muscle weakness
  • Confusion
  • Lethargy and fatigue

A doctor may make a diagnosis of hypercalcemia by a blood test. Treatment is directed at the underlying cause. Severe hypercalcemia may require hospitalization to reduce calcium to safe levels. In such cases, treatment may include:

  • Intravenous fluids
  • Diuretics (water pills)
  • Bisphosphonates
  • Glucocorticoids (corticosteroids)

If untreated, hypercalcemia can lead to:

  • Kidney stones
  • Osteoporosis
  • Abnormal heart rhythm (arrhythmia)
  • Kidney failure
Hemodialysis

Topic written or edited by:

Samuel S. Blumenthal, MD
Walter F. Piering, MD, FACP
Aaron Dall, MD
Kevin R. Regner, MD, MS, FASN
Ashraf El-Meanawy, MD, PhD
Jeffrey A. Wesson, MD, PhD

Hemodialysis removes wastes and excess fluid outside your body. During a hemodialysis treatment, blood is removed from your body and pumped by a machine through a dialyzer. The dialyzer is the semipermeable membrane that cleans your blood.

While having your treatment, you sit or lie next to a hemodialysis machine. A nurse or technician puts two needles into a vein in your forearm called an access. One needle is connected to tubing, which takes your blood out of your body to be cleaned. The blood goes back into your body through tubing attached to the other needle. There is about on cup of blood outside your body at any time. All your blood is filtered through the dialyzer several times. At the end of treatment, all the blood is back in your body.

Putting the needles into your arm can cause a little discomfort. Dialysis does not hurt, although some people do feel nauseated or dizzy during parts of the treatment. Mostly, hemodialysis is a quiet time. During treatments, most people keep busy doing things like watching TV, reading or talking.

Most people need hemodialysis three times a week. Each treatment lasts about four hours. You will be weighed before and after each treatment to make sure extra fluid is removed.

Most of the time, hemodialysis treatments are done in-center, which means they take place in a special clinic called a dialysis unit. Appointments must be scheduled in advance.

Home Hemodialysis

Home Hemodialysis is another way to do hemodialysis. It frees you from the dialysis center schedule, but it requires a strong commitment from a partner who must be present during all dialysis treatments. You will need to have a machine and supplies in your home.

To place an access, to get your blood, a surgeon will perform an operation to strengthen one of your veins or to put a soft tube inside your arm or thigh.

Fistula

Fistula - The surgical linking of an artery to a vein, providing access to blood vessels.

Graft

Graft - A tube surgically placed under the skin linking an artery to a vein.

If possible, the surgeon will attach a vein and an artery together to form a fistula. This is the best possible type of access. If your veins are small or weak, the surgeon inserts a graft instead. This is a soft tube connected to an artery on one end and a vein on the other. Blood runs through the graft. Both a fistula and a graft are underneath the skin. The surgery needed to place an access is done in the hospital and may require an overnight stay. A permanent access can take up to a few months to heal properly.

If you need dialysis before a permanent access is in place, the doctor will create a temporary access. This is done by placing a special tube, called a catheter, in a large blood vessel under the collarbone or in the leg.

Caring for a hemodialysis access

  • Check your access every day to be sure that blood is flowing through it. You can do this by placing your fingers lightly over the access to feel the pulse.
  • Don’t put pressure on the access; it can cause clotting.
  • Don’t sleep on the access arm.
  • Don’t hold a child or anything heavy with the arm that has the access.
  • Don’t wear jewelry or tight clothing over the access.
  • Don’t let anyone draw blood or take your blood pressure in the arm with your access.

How will hemodialysis affect your lifestyle?

You might enjoy having four days a week when you do not have to worry about dialyzing. You will probably be able to travel if you make arrangements in advance to dialyze at another clinic (center). You can exercise and do most sports after checking with your doctor.

You will probably have to limit your intake of salt, foods rich in potassium, dairy products and fluids.

It is also very important to follow the meal plan recommended by your dietitian in order to avoid malnutrition. Poor diet can cause depression, tiredness, and a lower quality of life.

Since your body will hold on to fluids until you have your next dialysis treatment, you will gain fluid weight between sessions.

Possible complications of HD

  • Blood clots
    The major complication of hemodialysis is blood clots, clumps, of blood that block the fistula or graft. A clot must be removed or it can permanently block the access. If an access is blocked, you may need to use a temporary catheter.
  • Hypotension
    During a hemodialysis session, it is normal for your body to lose fluid and salt, which can cause hypotension, low blood pressure. You may feel light-headed, sweaty or nauseated. You may also develop leg cramps or headaches during dialysis or at other times. Your doctor should be able to solve some of these problems by adjusting your dialysis. Following your diet and restricting fluids may also help.
  • Infection
    The access may become infected. To avoid infection, the skin over the access must be cleaned before the needles are put in, and needle wounds that have not healed must be protected. The signs of infection are redness at the access site, fever, and/or chills. If you have any of these signs, you should report them immediately.

In-Center Hemodialysis Advantages

  • Nurses and technicians perform treatment for you
  • Regular contact with other hemodialysis patients and staff
  • Usually three treatments per week; four days off
  • No equipment/supplies kept at home
  • Medical help is available quickly in an emergency

In-Center Hemodialysis Disadvantages

  • Travel to center three times a week on a fixed schedule
  • Permanent access required, usually in your arm
  • Insertion of two needles for each treatment
  • Restricted diet/limited fluid intake
  • Runs some risk of infection
  • Possible discomfort like headache, nausea, leg cramps, tiredness
Nocturnal Dialysis

Nocturnal dialysis is offered at the Pleasant Street Fresenius Unit in Milwaukee. It is offered on Sunday, Tuesday and Thursday nights. The dialysis sessions are eight hours.

Why do nocturnal dialysis?

Nocturnal dialysis has been studied extensively in Tassin, France. More than 35 years of data from this French group shows patients on nocturnal dialysis with excellent survival compared to conventional dialysis. Patients on nocturnal dialysis have very good blood pressure, phosphate and volume control. Fluid is removed gently as compared to a patient on conventional dialysis. This, in turn, is thought to help lessen post dialysis fatigue in patients.

Who would be ideal candidates for nocturnal dialysis?

  1. Any patient who wants dialysis that can maintain the quality of life.
  2. Patients who work during the day.
  3. Patients having difficulty with fluid removal on conventional dialysis.
  4. Patients having difficulty with blood pressure and phosphorous control on dialysis.

How does a night for a nocturnal dialysis patient look like?

You will have a large reclining chair to spend the night. Most patients come in between 7:00-8:00 pm and stay eight hours. The nurses will do the same procedures to dialyze you as a conventional unit. Your physician will see you while you are on dialysis. You will have a TV monitor that you can use to spend time or sleep. Patients do sleep on dialysis; lights in the unit are turned off at 10:00 pm. All patients leave the unit by 3:00 am or earlier.


Peritoneal Dialysis

Topic written or edited by:

Ehab R. Saad, MD, FACP, FASN, MA

Peritoneal dialysis (or PD) cleans your blood and removes extra fluids using one of your body’s own membranes, the peritoneal membrane, as the filter. The peritoneal membrane is the lining that surrounds the peritoneum or abdominal cavity, which contains your stomach, spleen, liver and intestines.

PD solution is a place in the peritoneum. The peritoneal membrane filters waste and fluids from your blood into the solution. The solution containing the wastes is drained from your peritoneum after several hours and replaced with fresh solution. This is called an exchange. A nurse experienced in PD will train you to perform peritoneal dialysis in the dialysis unit as an outpatient. Most people can learn to do PD within a few days. If you have concerns or problems, the nurse and doctor are never more than a phone call away. You will probably need to visit your clinic each month.

PD Supplies

Your doctor will write a prescription for the dialysis supplies you need. Your nurse will help you learn to order them. The supplies are delivered to your house. The driver of the van carries the supplies into your house and helps you organize them. You will need a place in your home to store 25-30 boxes.

Removing PD solution containing wastes and excess fluids from the peritoneum (drain) and replacing it with fresh PD solution (fill) is called an exchange. An exchange takes 20-30 minutes. After you fill the peritoneum with fresh PD solution, you leave this solution in the peritoneal cavity for four hours or more (dwell).

Peritoneal Dialysis Catheter

PD Supplies

A small, soft tube called a catheter is put through the wall of your abdomen into the peritoneal cavity. The catheter is called an access because it provides a way to get PD solution into your peritoneum. Solution flows in and out of the peritoneal cavity through the catheter. Placing the catheter requires minor outpatient surgery.

The opening for the catheter should heal for a few weeks before starting dialysis. The catheter is usually not painful and stays in place throughout your time on PD.

Catheter

Catheter

The catheter is usually placed about 1 inch below and to the side of the navel. It is about ¼ -inch in diameter. Only 4-6 inches of it are outside of your body. You and your doctor can plan where to place the catheter so that it is comfortable and hidden by clothing.

Two types of Peritoneal Dialysis

  1. Continuous Ambulatory Peritoneal Dialysis (CAPD)
  2. Automated Peritoneal Dialysis (APD)

How will PD affect your lifestyle?

Most people enjoy the flexibility and independence that they have with PD. Your dietician can help you manage your diet. It is very important to follow the meal plan recommended by your dietician in order to avoid malnutrition. Also, poor diet can cause depression, tiredness, and a lower quality of life.

You can do most sports and exercise after checking with your doctor. To travel, you pack your CAPD supplies in a suitcase. If you use APD, you can pack along your cycler, or you can switch to CAPD while you are traveling. If you go on a long trip or travel to a foreign country, the dialysis company can ship supplies to your destination ahead of time.

People on PD can lead normal lives. It is easy to adjust the treatment schedule according to your work, school, or travel plans because you are in charge of your own treatment.

Possible complications of PD

Peritonitis
The major complication of PD is an infection of the peritoneal membrane called peritonitis. The best way to keep from getting an infection is to wash your hands and to perform your exchanges exactly as instructed. You will be taught to recognize the early signs of infection. Peritonitis is treated with antibiotics, which usually can be taken at home.

Exit-Site Infection
The area around your catheter can also become infected. This area, called the exit-site, should be cleaned daily. You will learn how to care for your exit site during PD training. Exit-site infections are treated with antibiotics.

Peritoneal Dialysis Advantages

  • A flexible lifestyle and independence
  • Clinic visits about once a month
  • Doesn’t use needles
  • Provides continuous therapy, which is more like your natural kidneys
  • Don’t have to travel to dialysis unit for treatment
  • Easy to do your therapy while you travel
  • Can do therapy while sleeping (APD)

Peritoneal Dialysis Disadvantages

  • Need to schedule exchanges into your daily routine, seven days a week
  • Requires a permanent catheter, outside the body
  • Runs some risk of infection
  • May gain weight/have a larger waistline
  • Very large people may need extra therapy
  • Need storage space in your home for supplies
  • Need space in your bedroom for equipment (APD)
Polycystic Kidney Disease (PKD)
Polycystic kidney disease is a genetic condition where fluid-filled cysts develop in both kidneys. As the cysts grow and multiply, the kidneys are damaged and lose function over time.

View Froedtert Hospital's Polycystic Kidney Disease (PKD) site for more information

Schedule an Appointment

New Nephrology and New Transplant Patients: (414) 805-3666
Established Nephrology and Transplant Patients: (414) 805-3100
Transplant Patients Fax Number: (414) 259-1145
Nephrology Patients Fax Number: (414) 805-9059

Froedtert Nephrology Clinic
8900 W. Doyne Ave.
CFAC 2nd Floor
Milwaukee, WI 53226
(414) 805-3100
(262) 532-9584 (fax)

Nephrology Administrative Office
8701 Watertown Plank Rd.
Hub for Collaborative Medicine
Milwaukee, WI 53226
(414) 955-0300
(414) 955-0098 (fax)

Community Memorial Medical Commons (CMMC) - Nephrology Clinic
W129 N7055 Northfield Dr.
Menomonee Falls, WI 53051
(262) 253-5400

Zablocki VA Medical Center
Nephrology Section
5000 W. National Ave.
Milwaukee, WI 53295
(414) 384-2000
(414) 383-9333 (fax)


Dialysis Units

Fresenius Medical Care
1409 E. Capitol Dr.
Shorewood, WI 53211
(414) 962-1625
(414) 962-1864 (fax)

Fresenius Medical Care Center Point
11340 W. Theodore Trecker Way
West Allis, WI 53214
(414) 774-1244
(414) 774-8130 (fax)

Fresenius Kidney Care - Grand Avenue - Milwaukee
161 W Wisconsin Ave.
Milwaukee, WI 53203
(414) 224-7666
(414) 224-7723 (fax)

Fresenius Kidney Care – Silver Spring
2615 W. Silver Spring Dr.
Milwaukee, WI 53209
(414) 461-2421

DaVita Dialysis
19395 W. Capitol Dr., Suite 100
Brookfield, WI 53045
(262) 781-0273
(262) 781-0305 (fax)