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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 1  |  Page : 102-104
Combination of oral activated charcoal plus low protein diet as a new alternative for handling in the old end-stage renal disease patients


1 Nephrology Division, Hospital Italiano De Buenos Aires, Argentina
2 Internal Medicine Divisions, Hospital Italiano de Buenos Aires, Argentina

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Date of Web Publication8-Jan-2010
 

   Abstract 

Chronic dialysis is a valid therapeutic option in very elderly ESRD patients, even though the decision to dialyze or not has little impact on survival. Additionally, very old patients usually do not agree with starting chronic dialysis. Even though, activated charcoal is a cheap treatment for working as adsorbent for nitrogenous products its utility is very limited. We studied the combination of a low protein diet and oral activated charcoal to reduce serum urea and crea­tinine levels in very old ESRD patients who had refused to start chronic dialysis. Nine lucid, very old > 80 years, ESRD patients who had refused to start dialysis were prescribed a treatment based on a combination of a very low protein diet and oral activated charcoal (30 gram/day). None of the patients had anuria, oliguria, edema, significant metabolic acidosis or hyperkalemia. None of them had significant gastrointestinal symptoms. After one week and ten months of charcoal use signi­ficant decrease in blood urea and creatinine levels was observed and none of them required emer­gency dialysis during this time. In conclusion, in patients more than 80 years of age low protein diet and oral activated charcoal may control the uremic symptoms effectively.

How to cite this article:
Musso C G, Michelangelo H, Reynaldi J, Martinez B, Vidal F, Quevedo M, Parot M, Waisman G, Algranati L. Combination of oral activated charcoal plus low protein diet as a new alternative for handling in the old end-stage renal disease patients. Saudi J Kidney Dis Transpl 2010;21:102-4

How to cite this URL:
Musso C G, Michelangelo H, Reynaldi J, Martinez B, Vidal F, Quevedo M, Parot M, Waisman G, Algranati L. Combination of oral activated charcoal plus low protein diet as a new alternative for handling in the old end-stage renal disease patients. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Jul 18];21:102-4. Available from: http://www.sjkdt.org/text.asp?2010/21/1/102/58781

   Introduction Top


Patients older than 75 have a 67 % rise in the incident rate of end-stage renal disease (ESRD) as compared to 24 % for those between 5 and 74 years. Chronic dialysis is a valid therapeutic option for senior ESRD patients, even though the survival for octogenarians on dialysis is far lower than age-matched general population. Additionally, very old patients usually disagree with starting chronic dialysis when offered. [1],[2],[3]

Conservative treatments for ESRD have already been described. Caloric diet enriched with essen­tial ketoacids and reduced protein intake is one of the options though expensive. The other the­rapeutic alternative is represented by oral pre­parations acting as nitrogenous waste product (urea, etc) sorbents such as activated charcoal. Even though, activated charcoal is cheap, its ability to reduce nitrogenous products is very limited [4],[5],[6]

Metabolism is also markedly diminished in very old people, and consequently their nutri­tional requirements as well as their nitroge­nous waste products production are conside­rably reduced. We therefore decided to eva­luate if a combination of a low protein diet (0.8 g/kg/day) and oral activated charcoal could sig­nificantly reduce serum urea and creatinine le­vels in very old ESRD patients who had re­fused to start chronic dialysis


   Material and Method Top


Nine lucid, very old patients; mean age 84 year (80-90yrs), ESRD (stage V: GFR 11 mL/min) and had refused to start dialysis, were pro­posed to initiate a treatment based on a com­bination of a low protein diet and oral acti­vated charcoal: 30 gram/day (15 grams bid). None of the studied patients had oliguria, signi­ficant metabolic acidosis, edema, hyponatre­mia, or hyperkalemia. No significant gastro­intestinal contraindication existed for activated charcoal intake. Charcoal was given far from patients' medication intake time although they were not on any medications that could have caused interference with its absorption.

All patients were trained for peritoneal dia­lysis just in case they changed their mind re­garding starting dialysis, as well as they signed an informed consent for charcoal treatment. Monthly laboratory investigations included: se­rum urea, creatinine, electrolytes, albumin, cho­lesterol, and acid-base status. Statistical ana­lysis was performed applying Wilcoxon test (SPSS, Chicago, Illinois, USA).


   Results Top


In the present study a significant reduction in serum creatinine and urea levels were docu­mented after one week of oral activated char­coal treatment, similarly after a mean period of 10 months significant reduction was noted in serum urea levels and a trend in serum crea­tinine levels [Table 1].

Three patients developed uremic symptoms after 7 months of activated charcoal treatment, and while two of them finally accepted to start dialysis, the other patient refused it.

No significant changes in neither their nutri­tional parameters (weight, albumin and choles­terol) nor in their daily activity geriatric scores were noted during the whole study (data not shown here). All patients remained non oli­guric and no significant changes in biochemical profile were noted. The only adverse effect do­cumented was mild constipation in one patient which responded to oral laxative.


   Discussion Top


Charcoal is activated by exposing it to oxi­dizing gas compound at high temperatures re­sulting in the production of increased surface area from the creation of pores. A 50 grams dose of activated charcoal has a surface appro­ximately equal to 10 football fields. Urea and other waste products which diffuse into the gastrointestinal tract from the blood are bound to charcoal and excreted in the feces, creating a concentration gradient for continued diffu­sion, giving place to a process called "intestinal dialysis". [7] Although it has minimal adverse effects besides reported vomiting, acute appen­dicitis, allergic reaction, and luminal drug ad­sorption: carbamazepine, digoxine, furosemide, mycophenolate, theophylline, and olanzapine. [8]

In this study, we documented a significant reductions in serum urea level in end-stage re­nal disease very old patients who refused dia­lysis. We were also able to maintain fair meta­bolic and clinical profile during this long term follow up. This might help the nephrologists to buy time for ultimately convincing the octoge­narians who have ESRD to dialyze but are otherwise in good shape.

In conclusion, it seems that activated char­coal plus a low protein diet could be a useful therapeutic alternative in order to handle end­stage renal disease in very old patients who had refused dialysis, not only because of its impact in serum urea reduction but also for providing the opportunity to the patient for re­thinking about their dialysis refusal.

 
   References Top

1.Misra M. Dialysis in the elderly. Blood Purif 2008;26:41-4.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Cook W, Jassal V. Prevalence of fall among seniors maintained on hemodialysis. Int Urol Nephrol 2005;37:649-52.  Back to cited text no. 2      
3.Kurella M, Covinsky K, Collins A, Chertow G. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med 2007;146:177-83.  Back to cited text no. 3      
4.Brunori G, Viola B, Maiorca P, Cancarini G. How to manage elderly patients with chronic renal failure: conservative management versus dialysis. Blood Purif 2008;26:36-40.  Back to cited text no. 4      
5.Pendse S, Singh A. Approach to patients with chronic kidney disease, stages 1- 4: 3-13  Back to cited text no. 5      
6.Friedman E. Bowel as a kidney substitute in renal failure. Am J Kidney Dis 1996;28(6):943-50.  Back to cited text no. 6      
7.Charcoal. In Lacy C, Armstrong L, Goldman M, Lance L (Eds). Drug information handbook. Lexi-Comp. 2004:310-311  Back to cited text no. 7      
8.Micromedex Healthcare Series - Drugdex - 2008.  Back to cited text no. 8      

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Correspondence Address:
C G Musso
Nephrology Division, Hospital Italiano De Buenos, Aires
Argentina
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PMID: 20061701

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    Abstract
    Introduction
    Material and Method
    Results
    Discussion
    References
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