Henry Feeser's Peritoneal Dialysis (PD) journey

While it’s a mouthful, the subject is what was conducted on my tired old bones yesterday. My GP ordered it in an attempt to get a handle on what is going on with the numbness in my legs, and in particular, my right leg. The test was called an MRA by my GP. This Friday, I am to have an MRI ordered by Trinity Paine Management to aid in the diagnosis of the same problem. Naturally, we need to know more about this procedure, so I turned to Perplexity with the following result:

A Doppler ultrasound scan of the legs from groin to ankles—often called a lower extremity arterial and venous Doppler—is a noninvasive test used to assess blood flow in the arteries and veins of your legs124. Here’s what the results can tell you:

What the Test Evaluates

• Blood Flow: Measures the speed and direction of blood flow through the major arteries and veins in your legs, detecting any abnormalities124.
• Blockages or Narrowing: Identifies areas where arteries or veins are narrowed or blocked, which could be due to atherosclerosis (plaque buildup), blood clots (such as DVT), or other vascular diseases1247.
• Venous Insufficiency: Detects if blood is flowing backward in veins (venous reflux), which can lead to varicose veins or swelling2.
• Arterial Insufficiency: Assesses for reduced blood flow due to narrowed or hardened arteries, which can cause leg pain, cramping, or skin discoloration12.
• Other Abnormalities: Can identify vascular tumors, inflammation, or structural changes in blood vessels1.

Normal Results

• No Narrowing or Blockages: Arteries and veins are open, with normal blood flow.
• No Blood Clots: No evidence of deep vein thrombosis (DVT) or other clots.
• Normal Blood Pressure Differences: Blood pressure measurements at the thigh, calf, and ankle are within expected ranges, indicating healthy circulation5.

Abnormal Results

• Arterial Blockage: May indicate peripheral artery disease (PAD), often due to atherosclerosis. This can cause pain, cramping, or even non-healing wounds in severe cases25.
• Venous Blockage or Clot: Suggests deep vein thrombosis (DVT), which is a risk for pulmonary embolism if the clot travels to the lungs24.
• Venous Insufficiency: Backflow of blood in veins, leading to swelling, varicose veins, or skin changes2.
• Other Findings: May reveal vessel narrowing (stenosis), widening (aneurysm), or inflammation.

How the Test Is Performed

• Gel and Transducer: A gel is applied to your skin, and a handheld device (transducer) is moved along your leg from the groin to the ankle to capture images and measure blood flow124.
• Blood Pressure Cuffs: Cuffs may be placed at various points (thigh, calf, ankle) to compare blood pressures and help pinpoint blockages5.

Why It’s Ordered

• Symptoms: Leg pain, swelling, discoloration, ulcers, or suspected blood clots.
• Risk Factors: History of vascular disease, diabetes, smoking, or prior clots.

Preparation and Risks

• Preparation: Usually minimal; you may be asked not to smoke before the test, as nicotine can constrict blood vessels and affect results12.
• Risks: The test is painless, noninvasive, and has no associated risks124.

In summary: A Doppler ultrasound of the legs from groin to ankles provides detailed information about blood flow, helping diagnose blockages, clots, and circulation problems in the lower extremities. Normal results show open vessels and healthy flow; abnormal results may indicate serious vascular conditions requiring further treatment or monitoring1245.

1. https://www.beatscardiology.com/arterial-and-venous-lower-extremity-doppler.html
2. https://www.mountsinai.org/health-library/tests/doppler-ultrasound-exam-of-an-arm-or-leg
3. https://www.mayoclinic.org/tests-procedures/ultrasound/expert-answers/doppler-ultrasound/faq-20058452
4. https://my.clevelandclinic.org/health/diagnostics/22715-doppler-ultrasound
5. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/vascular-studies
6. https://www.mayoclinic.org/tests-procedures/echocardiogram/about/pac-20393856
7. https://www.heartandstroke.ca/heart-disease/tests/doppler-ultrasound
8. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/echocardiogram
9. https://www.ncbi.nlm.nih.gov/books/NBK576430/
10. https://www.sciencedirect.com/science/article/pii/S0914508709002731

So far, I have been on IPN for four bags full, that is to say, four nights. The procedure is very straightforward. I set up the Cycler in the morning as part of my morning routine, which includes making the bed and preparing the night’s Cycler supplies. In this case, I remove a modified IPN bag from the provided refrigerator, place it on the hanging protrusion on the left side of the Cycler cart, and in the evening, connect it to the first white bag connector. My regular 6-liter bag goes on the heater tray, and we’re good to go.

My weight thus far has not varied more than a pound, down for me. My appetite is about the same as far as I can tell. Nothing weird has happened to my bowels. I sense that I am feeling a little more energetic and look forward to taking Dickens on his twice-daily golf cart rides. At least on the onset, it looks like we may be headed in the right direction. So Be Happy!

1

The purpose of this blog is to provide pertinent information we received on Tuesday from our contact at Pentac concerning the deployment of their IPN product.

1. Tuesday, Lowe’s delivered the refrigerator to be used for keeping the IPN-infused bags cool. We received a Hisense 4.4 Cu Ft Model # HRC044AVE ($139.00) with an additional standalone thermostat. We are to keep the IPN bags between 36 and 46 F in the frig until up to 24 hours before use. After that, it must be disposed of and replacement(s) ordered.
2. Pentac’s Clinical Nutrition Pharmacy (800-223-4376, then 4, then option 2) will ship the product to us overnight via UPS or FedEx. We don’t have to be home to receive the product; it will be left on the porch. We opted to receive one shipment of seven bags on Tuesdays every week. Our first shipment of six will arrive on Thursday, my first treatment day.
3. If hospitalized, call the pharmacy to “hold” the shipment. For travel, notify Pharm so supplies can be shipped anywhere in the USA.
4. Inspect bags upon arrival. It should be cold, not frozen, and clear. Check white tags on bags. In a given shipment, all should have the same expiring date.
5. We are to receive 5 L bags, which for the IPN procedure should be placed on a peg as the second bag, with the normal, yellow bag for me, on the heater. Note this is contrary to direction elsewhere.
6. If you feel bad, notify the dialysis nurse. Adjustments will be made for too much or too little IPN. May experience an upset stomach and affect hydration, but this is unusual.
7. Call the Pharmacy if problems – physical problems with bags or shipment. Call Cynthia with Clinical questions (385-230-5388).

My wife, Linda, received a phone call from our IPN provider, Pentec Health. She was informed that we would receive a shipment of three of their protein-enhanced five-liter dialysis bags today/Tuesday, and four on Friday. Assuming Lowe’s delivers the refrigerator on Tuesday, we should be good. Also, we are to receive a phone call this afternoon at 1330 to bring us up to speed on the IPN gambit.

In doing research on IPN, a basic question arises. To wit, why do I need this? Why am I not getting enough protein via my diet, which lately has seen a large increase in protein-rich foods? What’s going on here?

I turned to Perplexity with the following Prompt and response:

Prompt: Is it possible that peritoneal dialysis reduces body protein to the extent that the patient is weak, gets winded after the slightest exertion, etc.

Peritoneal dialysis (PD) can contribute to significant protein loss, which may lead to muscle wasting, weakness, and fatigue. Here’s a detailed analysis:

Protein Loss in Peritoneal Dialysis

• PD patients lose 5–7 grams of protein daily through dialysate, primarily albumin217.
• This loss occurs because the peritoneum allows serum proteins to leak into the dialysis fluid during exchanges27.

Mechanisms Linking Protein Loss to Weakness

1. Muscle Wasting (Sarcopenia)
   • Chronic protein loss exacerbates protein-energy wasting, reducing muscle mass and strength37.
   • Uremia, inflammation, and hormonal imbalances further accelerate muscle breakdown34.
2. Fatigue and Exertional Limitations
   • Protein depletion impairs muscle repair and energy metabolism, causing fatigue and breathlessness during minimal exertion456.
   • Anemia (common in dialysis) reduces oxygen delivery, worsening fatigue6.
3. Inflammation and Metabolic Dysfunction
   • Chronic inflammation from PD increases catabolism (muscle breakdown)37.
   • Acidosis and insulin resistance further disrupt protein synthesis34.

Contributing Factors

• Fluid Overload: Exacerbates protein loss and inflammation7.
• Inadequate Nutrition: PD patients require 1.3g/kg/day of protein to offset losses1. Failure to meet this accelerates muscle loss.
• Physical Inactivity: A vicious cycle where fatigue reduces activity, further diminishing muscle mass45.

Management Strategies

• Nutritional Intervention: High-protein diets (e.g., eggs, lean meats) to counter losses13.
• Exercise: Resistance training preserves muscle mass and reduces fatigue56.
• Volume Control: Optimizing fluid removal minimizes overhydration-related protein leakage7.

Conclusion

Yes, peritoneal dialysis can deplete body proteins sufficiently to cause weakness and exertional intolerance. This stems from direct protein loss, compounded by inflammation, metabolic dysregulation, and inadequate nutritional compensation. Addressing protein intake, volume status, and physical activity is crucial to mitigate these effects2137.

1. https://www.dpcedcenter.org/wp-content/uploads/2021/02/Protein-and-Dialysis.pdf
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC3082414/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC12005912/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC2582327/
5. https://www.nhs.uk/tests-and-treatments/dialysis/side-effects/
6. https://www.dpcedcenter.org/news-events/news/conquering-dialysis-fatigue/
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC9178188/
8. https://www.sciencedirect.com/science/article/pii/S0085253815324741
9. https://onlinelibrary.wiley.com/doi/10.1111/sdi.13194
10. https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2021.653807/full
11. https://www.mdpi.com/2077-0383/12/7/2670
12. http://www.davita.com/treatment-services/peritoneal-dialysis/protein-and-your-peritoneal-dialysis-diet
13. https://advancingdialysis.org/peritoneal-dialysis/nutritional-status-concerns-for-peritoneal-dialysis-patients/
14. https://www.kidney.org/kidney-topics/getting-more-protein-while-dialysis
15. https://homedialysis.org/news-and-research/blog/547-muscle-stiffness-in-dialysis-patients-tips-to-prevent-and-overcome
16. https://onlinelibrary.wiley.com/doi/10.1155/2014/614846

As I have been blogging about, I am in the throes of entry into the world of IPN. The refrigerator to cool the mixture is due to arrive tomorrow from Lowe’s. We expect to hear soon from Pentec to receive the training they provide for IPN usage. Soon to follow this should be the actual receipt of our weekly allotment of IPN-fused dialysis bags.

In preparation for our IPN gig, I quizzed Perplexity about the nuts and bolts of IPN actual use with the following Prompt and results. Doesn’t seem to be all that complicated after all.

Prompt: What are the nuts and bolts of actually using IPN from Pentec?

The nuts and bolts of actually using IPN (Intraperitoneal Nutrition) from Pentec Health involve several key steps and considerations to ensure safe and effective therapy for peritoneal dialysis patients who need additional protein supplementation:

What is IPN from Pentec?

• IPN is a nutritional therapy that adds protein directly into the peritoneal dialysis fluid (dialysate) by replacing some of the usual dextrose with protein. This helps replenish protein losses that dialysis patients experience and supports nutritional status without requiring oral intake123.

How IPN is Prepared and Delivered

• Pentec Health prepares customized IPN bags based on the patient’s specific dialysis regimen and nutritional needs. A Pentec nurse or pharmacist compounds the sterile bags by adding protein to the patient’s cycler or CAPD bag, removing some dextrose to maintain fluid balance14.
• The IPN bags are shipped weekly to the patient’s home and must be refrigerated between 36-46°F. Pentec provides a refrigerator for storage. Patients are instructed to inspect bags for damage or discoloration immediately upon delivery and before use25.

Administration of IPN

• IPN is typically administered daily at home as a replacement for one of the patient’s regular exchange bags, either manually or via cycler. Patients are trained on how to handle and infuse the bags safely25.
• The IPN bag is usually the first bag on the cycler machine or hung to replace one exchange5.

Monitoring and Clinical Support

• Pentec provides a clinical case manager and registered dietitians who work closely with the patient’s nephrologist and dialysis clinic. They:
  • Confirm patient eligibility and customize the IPN prescription.
  • Monitor nutritional status through labs (e.g., albumin levels) and clinical assessments.
  • Adjust therapy as needed based on patient response.
  • Help manage any side effects, such as dehydration, which can occur if IPN causes additional ultrafiltration14.
• Fluid removal goals during dialysis are adjusted carefully. For example, for IDPN (similar therapy for hemodialysis), 75-80% of the total volume is suggested to be removed; similar judgment applies to IPN fluid management14.

Duration and Goals of Therapy

• The length of IPN therapy varies per individual and depends on nutritional needs and response. Typically, improvements in appetite, strength, and energy are expected within a few months2.
• Once protein levels normalize, clinicians may consider discontinuing or pausing therapy to see if nutrition can be maintained independently1.

Insurance and Financial Considerations

• IPN therapy is covered by many commercial and Medicaid insurance plans. Pentec Health handles billing directly and offers flexible payment options and assistance programs if needed2.

Summary Table of Key Steps in Using Pentec IPN

Step	Description
Prescription	Nephrologist and dietitian determine need; PD nurse completes IPN prescription form with Pentec CCM
Preparation	Pentec compounds sterile, patient-specific IPN bags by adding protein and removing dextrose
Delivery & Storage	Weekly home shipment; refrigerate at 36-46°F; inspect bags for damage or discoloration
Administration	Replace one PD exchange bag daily with IPN bag; use cycler or manual exchange
Monitoring & Support	Regular lab tests (albumin), clinical assessments, therapy adjustments by Pentec clinical team
Side Effect Management	Watch for dehydration or other issues; clinical team intervenes as needed
Duration	Individualized; often several months until nutritional goals met
Insurance & Billing	Pentec handles insurance; offers payment plans and assistance

In essence, using Pentec’s IPN involves a coordinated clinical approach with personalized sterile nutrition bags integrated into the patient’s peritoneal dialysis routine, supported by ongoing clinical monitoring and patient education to optimize nutritional outcomes safely and effectively1245.

1. https://pentechealth.com/idpnipn/
2. https://pentechealth.com/media/hi4hdpco/23pen01008-0124-ipn-patient-brochure.pdf
3. https://pentechealth.com/newsroom/idpn-ipn-nutrition-therapy-for-dialysis-patients-what-s-the-difference/
4. https://pentechealth.com/renal-nutrition-faqs/
5. https://pentechealth.com/media/lxgjflej/23pen01071_ipn-home-therapies.pdf
6. https://pentechealth.com
7. https://pentechealth.com/media/bfolvrox/pentechealth_guide-to-idpn.pdf
8. https://www.pharmko.com/blog/understanding-intraperitoneal-nutrition-ipn-and-its-uses
9. https://pentechealth.com/dialysis-clinics/
10. https://pentechealth.com/media/g0kbui5t/patient-and-hcp-proplete-info-sheets.pdf
11. https://www.pharmko.com/blog/how-ipn-supports-patients-with-severe-malnutrition
12. https://pentechealth.com/clinical-assistance-program/
13. https://www.pharmko.com/blog/how-to-monitor-and-adjust-ipn-for-optimal-patient-outcomes
14. https://pentechealth.com/patient-information/
15. https://pentechealth.com/patient-education/
16. https://www.kidneywi.org/wp-content/uploads/2020/11/How-IDPN-and-IPN-Can-Benefit-Your-Patinets.pdf
17. https://www.reddit.com/r/dietetics/comments/17f4zgj/renal_question_idpn/

This blog follows along with my recent prescription to incorporate more protein in my diet to raise my albumin to acceptable levels. It is currently in the mid-threes, where it should be a minimum of five. I also have the lingering question of cause and effect of protein loss and my current tiredness and general lack of git up and go.

To look into this aspect of our dialysis burden, I turned to Perplexity with the following Prompt and result – spoiler – they go hand in glove:

Prompt: Is it possible that peritoneal dialysis reduces body protein to the extent that the patient is weak, gets winded after the slightest exertion, etc?

Peritoneal dialysis (PD) can contribute to significant protein loss, which may lead to muscle wasting, weakness, and fatigue. Here’s a detailed analysis:

Protein Loss in Peritoneal Dialysis

• PD patients lose 5–7 grams of protein daily through dialysate, primarily albumin217.
• This loss occurs because the peritoneum allows serum proteins to leak into the dialysis fluid during exchanges27.

Mechanisms Linking Protein Loss to Weakness

1. Muscle Wasting (Sarcopenia)
   • Chronic protein loss exacerbates protein-energy wasting, reducing muscle mass and strength37.
   • Uremia, inflammation, and hormonal imbalances further accelerate muscle breakdown34.
2. Fatigue and Exertional Limitations
   • Protein depletion impairs muscle repair and energy metabolism, causing fatigue and breathlessness during minimal exertion456.
   • Anemia (common in dialysis) reduces oxygen delivery, worsening fatigue6.
3. Inflammation and Metabolic Dysfunction
   • Chronic inflammation from PD increases catabolism (muscle breakdown)37.
   • Acidosis and insulin resistance further disrupt protein synthesis34.

Contributing Factors

• Fluid Overload: Exacerbates protein loss and inflammation7.
• Inadequate Nutrition: PD patients require 1.3g/kg/day of protein to offset losses1. Failure to meet this accelerates muscle loss.
• Physical Inactivity: A vicious cycle where fatigue reduces activity, further diminishing muscle mass45.

Management Strategies

• Nutritional Intervention: High-protein diets (e.g., eggs, lean meats) to counter losses13.
• Exercise: Resistance training preserves muscle mass and reduces fatigue56.
• Volume Control: Optimizing fluid removal minimizes overhydration-related protein leakage7.

Conclusion

Yes, peritoneal dialysis can deplete body proteins sufficiently to cause weakness and exertional intolerance. This stems from direct protein loss, compounded by inflammation, metabolic dysregulation, and inadequate nutritional compensation. Addressing protein intake, volume status, and physical activity is crucial to mitigate these effects2137.

1. https://www.dpcedcenter.org/wp-content/uploads/2021/02/Protein-and-Dialysis.pdf
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC3082414/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC12005912/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC2582327/
5. https://www.nhs.uk/tests-and-treatments/dialysis/side-effects/
6. https://www.dpcedcenter.org/news-events/news/conquering-dialysis-fatigue/
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC9178188/
8. https://www.sciencedirect.com/science/article/pii/S0085253815324741
9. https://onlinelibrary.wiley.com/doi/10.1111/sdi.13194
10. https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2021.653807/full
11. https://www.mdpi.com/2077-0383/12/7/2670
12. http://www.davita.com/treatment-services/peritoneal-dialysis/protein-and-your-peritoneal-dialysis-diet
13. https://advancingdialysis.org/peritoneal-dialysis/nutritional-status-concerns-for-peritoneal-dialysis-patients/
14. https://www.kidney.org/kidney-topics/getting-more-protein-while-dialysis
15. https://homedialysis.org/news-and-research/blog/547-muscle-stiffness-in-dialysis-patients-tips-to-prevent-and-overcome
16. https://onlinelibrary.wiley.com/doi/10.1155/2014/614846

My wife and I are in discussions about the new routine we’re about to embark upon, that of IPN. We debated how long it takes for it to take effect, so to speak. Is a day, a week, a month, or longer.

To obtain a definitive answer to this question, I turned to Perplexity with the following Prompt and response. Spoiler – it will take some time.

Prompt: How rapidly does IPN take effect? days, weeks, months?

Intraperitoneal Nutrition (IPN) typically takes several weeks to months to show measurable effects in patients on peritoneal dialysis. Here’s what the evidence and clinical experience indicate:

• Improvements in nutritional markers such as serum albumin and prealbumin—key indicators of protein status and overall nutrition—are generally observed after several months of IPN therapy.
• Positive changes in strength, physical health, and appetite are commonly reported by patients, but these also tend to develop over the course of months rather than days or a few weeks.
• Clinical monitoring is usually performed at least quarterly (every three months), and the goal is often to see an albumin increase to around 4.0 g/dL. The time to reach this target varies, but most patients require ongoing therapy for a minimum of 3 months, with many continuing for longer depending on their response and nutritional needs.
• Incremental improvements—such as a 0.2 g/dL increase in albumin—are considered clinically meaningful and can be seen during this period, with about 70% of patients in one cohort showing such improvements within several months.
• If there is no significant improvement after 3 to 6 months, clinicians may consider discontinuing IPN and exploring alternative interventions.

In summary:
Most patients will not see immediate effects within days; meaningful improvements typically require several weeks to months of consistent IPN therapy. The exact timeline can vary based on the individual’s baseline nutritional status, the degree of malnutrition, and how well they tolerate and absorb the therapy.