The past week I have been attempting to accomplish some heavy-duty yard work. Here in North Texas where we live, Spring can be short and before you turn around we’re in for suffering heat, as high as 112 F or so. So we have a rather narrow window to get our yards in order before Satan’s Inferno hits.

Tuesday I worked on a bed, we have on the order of 15 flower beds on our 0.52-acre homestead, which is in full sun and borders the side of our main garage. It is mostly clay but grows weeds well. I installed a border around it, made a brick runoff for the drain spout, and augered holes for 12 tomato plants. At this point, I ran out of git up and go. See the lead picture.

In normal times, I would have done this without breaking a sweat. But with my PD-associated low blood pressure, I’m a different person. I have to frequently stop for a breath, and break up any work into chunks. Upon arising Tuesday my blood pressure was 111/74. When I took it before lunch it was 90/57. I have ascertained that once my diastolic drops below 60, I start to feel bummer. Get light-headed and cannot work. Have to sit down. After I rest for five minutes or so I generally can have another go at it.

So here’s the deal. Is this due to dialysis, or is it because I am, after all, 85? I like to think it is dialysis-related. And no, I’m using only 1.5% dialysis solution. And yes, I have worked more salt into my diet. And still, I am experiencing blood pressure readings toward the lower safe boundary.

The most searched subject on this blog is “Alarms.” Seems almost all users of the subject machine experience them, some more than others. In this blog I am going to relate my experience with alarms, and what I have found to somewhat mitigate their occurrence.

First of all, I would like to state up front that Fresenius knows full well that its Liberty Cycler has “alarm challenges.” When they were in the PR mode in pre-rollout of a new Cycler, now since abandoned for business reasons, they touted its reduced alarm rate. Alas, it does not appear that this improved cycler will be available, period. My Dialysis Team, in particular, my nurse, has been most helpful in attempting to troubleshoot alarms. Let’s jump into alarms.

What are alarms? The Cycler throws obnoxious beeping alarms when it determines that something in the Drain-Fill cycle is not going according to its parameters. In general, it appears that the pneumatic pumps in the Cycler have more oomph in the Fill cycle than in the Drain cycle. I have always experienced more alarms during Drain than Fill, by a long shot. This is particularly true if you are slightly lying on or have a bend or kink in your catheter line. But I digress – some history.

I started on PD using the Liberty Cyler on 9/30/2022. At first, I experienced a few alarms, but not so many that I couldn’t handle them sleep-wise. Over time, they increased to the level that I was having multiple alarms, mainly drain, each night, and had to get up out of bed in a verticle position for drains to complete, as much as on every drain. I started calling tech support documenting what was going on and was finally issued a new Cycler. This seemed to alleviate the alarm problem but again, over time I was back to the old alarm situation. Yet another replacement Cycler and the same story. So we had pretty much eliminated the Cycler as being the problem. That left me. Of course, this is what Fresenius tech support said all along.

In concert with my dialysis team, it was decided that I needed to have my catheter placement looked at which required me to go back to the hospital and have a surgeon again look at it which I did. So now I’m on my third Cycler and second catheter placement which seems to be working. In three weeks, I generally have four alarms, This is out of a possible 184 drain/fills which is more than acceptable. What is the secret? I have found through trial and error that I cannot sleep on my left side during any drain cycle, and have to be careful during fills. I can sleep on my back in general but have to make certain my catheter line is flaked out straight from my left side toward the cycler. I should note here that my catheter is positioned on the right side of my body and runs from right to left across my stomach. A natural position for it it exit without obstruction is from left to right thus having to make certain it runs straight to my left side which is also the side where the Cycler is located. My best sleep position is on my right side. While on my right side, I make certain my catheter line is running free and not kinked over my side and toward the Cycler. Turns out my wife of 62 years is prone to sleeping on her right side so as often as not I snuggle up to her back and that’s where I wake up in the morning, alarm-free.

While my configuration may not work for you, the point is there is some optimum sleep-catheter configuration that should minimize alarms. I doubt those of us on PD using the Fresenius Liberty Cycler will ever be without alarms.

Chronic Kidney Disease is projected to be the 5th leading cause of death globally by 2040. Folks, it’s not getting any better. Currently, about 10% of the world’s population is affected by CKD. In 1990 it was the 27th leading cause of death, and by 2010 has risen to 18th. by 2040 it’s expected to skyrocket to 5th.

Here’s the basic research behind these projections from Perplexity:

AstraZeneca has conducted a comprehensive study called “IMPACT CKD” that provides a 10-year forecast on the impact of chronic kidney disease (CKD) across clinical, economic, societal, and environmental dimensions.234 The key findings from the IMPACT CKD study include:

• The study projects that by 2032, up to 16.5% of the population in 8 countries (US, Brazil, UK, Spain, Germany, Netherlands, China, Australia) could suffer from CKD, with a staggering 59.3% rise in advanced-stage cases.23
• The number of people with advanced CKD in these countries is expected to reach nearly 125 million by 2032, a 25% increase from 2022.23
• The economic burden of renal replacement therapy, including dialysis and transplants, is forecast to exceed $186 billion.23
• Dialysis requirements are projected to surge by over 75%, significantly contributing to the healthcare sector’s carbon footprint – equivalent to adding 17.3 million cars’ worth of CO2 emissions.2

The IMPACT CKD study is part of AstraZeneca’s “Accelerating Change Together (ACT) for CKD” initiative, which aims to improve understanding and outcomes of CKD globally. The findings underscore the urgent need for proactive measures to address the growing CKD burden through earlier diagnosis, optimized treatment, and effective policy reforms.24

What can readers of this blog do about this in their own back yard? If you or yours has diabetes hypertension or both have your kidneys checked out annually as part of your annual physical. A simple blood test produces eGFR which is the gold standard (It’s what the US VA looks at and only this) for the status of one’s kidneys. Do it.

Late Tuesday afternoon I was working with a high school senior that we have hired to help us with out 15+ flower beds. He was unloading mulch from our BMW X5 and I was walking from the garage toward him where he was parked in the driveway unloading. My feet lost purchase in mulch that had eased onto the driveway and I fell full frontal forward, scraping a raised sprinkler head on the way down. I ended up with a large scrape across my chest, where my catheter hangs and my stomach access lies, and a huge bruise on my forearm where I landed with all my weight on it. See the lead photo of my arm.

I have been feeling better and better since my last prescription change, and am not prone to falling per se. While this MAY BE an outlier, it is still worth considering what research into the following question offers: “Are patients on PD more prone to falling?” This is what Poe had to say about this topic:

The impact of PD on the risk of falling depends on several factors, including the patient’s overall health, age, comorbidities, and any existing mobility issues.

While there is no direct causal relationship between PD and an increased risk of falling, certain factors associated with PD may contribute to a higher risk. For example:

Fluid and electrolyte imbalances: PD can affect fluid and electrolyte levels in the body, potentially leading to dizziness, weakness, or changes in blood pressure that may increase the risk of falling.

Muscle weakness: If a person on PD experiences muscle wasting or weakness, their balance and coordination could be compromised, potentially increasing the risk of falling.

Underlying health conditions: Many individuals who require PD have underlying health conditions that can impact their mobility and balance, such as diabetes, peripheral neuropathy, or musculoskeletal disorders. These conditions can increase the risk of falling.

Of the possibilities above, I am to a degree suffering from muscle weakness due to dialysis, and also have been diagnosed as having peripheral neuropathy as a result of being a diabetic. I am receiving VA Disability for the latter in both legs. So I suggest readers on PD take this as a warning and lesson learned; out of the blue, so to speak, you may fall through no fault of your own. How to preclude the occurrence is beyond my skill set.

In yesterday’s blog, I wrote about the central position urine has in the calculation of Kt/V, the output of the PD Adequacy Test that informs us as to how well our dialysis is working. Let’s face it, kidneys are about manufacturing urine in our bodies and the eventual discharge of same, whether male or female. Being on dialysis is a result of our kidney’s failure to produce a “normal” amount of urine, that is, to remove waste products from our bodies.

https://www.unilad.com/news/health/peeing-sitting-down-as-a-man-better-806567-20240415Getting the urine out of our bodies is pretty elementary; in general, men in the US are taught and expected to stand up while urinating and by and large, but not in all cultures, women sit while urinating. In an article in UNILAD titled “Doctor claims men in the US are peeing incorrectly and reveals why,” Poppy Bilderberg on April 15, 2024, wrote “…the sitting position is ‘probably the most efficient way’ to properly empty your bladder.” (Link)

So for the men reading this blog, you now must revise centuries of ingrained peeing posture and just sit down when you pee. Good luck with that!

As consistent readers of this blog may recall, I am a Type II diabetic and have been so diagnosed for going on fifty years. I was diagnosed while on active duty USN, controlled diabetes first with diet and exercise, then diet, exercise and medication, and finally, these three along with insulin. Thus I am interested in almost anything related to the treatment of diabetes.

https://diabetesjournals.org/care/article/44/1/89/33032/Worldwide-Epidemiology-of-Diabetes-Related-EndFurthermore, there is a direct correlation between diabetes and End Stage Renal Failure (ESRF) approaching the mid-30 % level. In other words, if you have diabetes, then there is a good chance you will experience ESRF and have to go on dialysis or a kidney transplant route. “The global percentage of the prevalent ESRD patients with diabetes increased from 19.0% in 2000 to 29.7% in 2015 worldwide, while the percentage of incident ESRD patients due to diabetes increased from 22.1% to 31.3%. The global annual incidence of ESRD among patients with diabetes increased from 375.8 to 1,016.0/million with diabetes during 2000–2015. The highest average rates were observed in the Western Pacific Region. Comparatively, the rates of incident ESRD among European patients with diabetes ranged from one-half (309.2 vs. 544.6) to one-third (419.4 vs. 1,245.2) of the rates of the Western Pacific population during 2000–2015.” (Link)

https://www.thebrighterside.news/post/diabetes-breakthrough-out-patient-procedure-eliminates-the-need-for-insulinBrighter Side of the News in an April 4, 2024 article by Joseph Sherit titled “Diabetes breakthrough: Out-Patient procedure eliminates the need for insulin” writes: “Electrical stimulations administered to the duodenum, the initial segment of the small intestine, might offer a one-time outpatient endoscopic procedure for Type 2 diabetes patients, potentially enabling them to sustain glycemic balance and discontinue insulin use, a preliminary study suggests.” (Link)

Needless to say, this research is in the infant stage, but if it bears fruit, will be a Godsend for those of us who are insulin-taking diabetics and may just preclude the future need for dialysis. We can only hope!

I have previously blogged about having to do an Adequacy Test, the output of which is a lab-derived number Kt/V. The higher this number, the better the dialysis is working. As part of the workup for this Test, we are required to gather our urine for 24 hours before the test and submit it, along with our drain bags from the previous peritoneal session. This all got me thinking about something named “Residual Kidney Function.”

When I started on PD, I was still urinating fairly copiously. Over time, my urine production has dwindled to a trickle, This is what Perplexity has to say about RKF:

Residual kidney function (RKF) refers to the remaining ability of the kidneys to filter and excrete waste products and excess fluid from the body in individuals undergoing peritoneal dialysis (PD). In patients with end-stage renal disease (ESRD), the kidneys are severely damaged and their function is significantly impaired. However, even in these cases, some residual kidney function may persist.

RKF plays a crucial role in the overall management of patients undergoing peritoneal dialysis. It provides additional clearance of waste products and fluids, which can help improve patient outcomes and reduce the reliance on dialysis treatments. Here are some key points to understand about residual kidney function in the context of peritoneal dialysis:

Clearance of Waste Products: Residual kidney function contributes to the removal of waste products, such as urea, creatinine, and other toxins, from the bloodstream. This can help reduce the burden on peritoneal dialysis and enhance the overall efficiency of waste removal.

Fluid Balance: Residual kidney function also aids in maintaining fluid balance. The kidneys are responsible for regulating the body’s fluid volume by adjusting urine output. In peritoneal dialysis, RKF helps in the removal of excess fluid, reducing the need for ultrafiltration during dialysis exchanges.

Nutrient and Electrolyte Management: The kidneys play a vital role in maintaining the balance of electrolytes, such as sodium, potassium, and calcium, in the body. Residual kidney function contributes to the regulation of these electrolytes, which is important for maintaining overall health. Additionally, RKF can also impact nutrient management, including the clearance of waste products derived from protein metabolism.

Preservation of Peritoneal Membrane: Residual kidney function has been associated with a decreased rate of decline in peritoneal membrane function. The peritoneal membrane is responsible for the exchange of solutes and fluid during peritoneal dialysis. Preserving the peritoneal membrane function is important for the long-term success of peritoneal dialysis.

Monitoring and Management of Residual Kidney Function:

To assess residual kidney function, regular monitoring of various parameters is conducted. These may include measuring urine output, creatinine clearance, or estimating glomerular filtration rate (eGFR) through blood tests. Monitoring helps healthcare providers understand the extent of residual kidney function and make appropriate adjustments to the dialysis prescription.

In peritoneal dialysis, preservation of residual kidney function is desirable. Strategies to support and protect RKF may include maintaining optimal blood pressure control, managing fluid balance, and avoiding nephrotoxic medications whenever possible. Adequate nutrition and hydration also play a role in supporting residual kidney function.

However, it is important to note that over time, residual kidney function may decline in patients with ESRD. The rate of decline varies among individuals and is influenced by factors such as the underlying kidney disease, comorbidities, and the duration of dialysis therapy.

In conclusion, residual kidney function refers to the remaining kidney function in individuals undergoing peritoneal dialysis. It provides additional clearance of waste products and fluids, contributing to improved outcomes and reduced reliance on dialysis treatments. Monitoring and managing residual kidney function are important aspects of peritoneal dialysis care, aiming to optimize overall patient well-being.

As a result of RKF, I conjecture, we have had to modify my PD prescription over time. I also conjecture that the reduced volume of urine contributes to the calculation of Kt/V and thus impacts the efficacy of my PD. Less urine, smaller Kt/V?

Had my monthly meeting with my Dialysis Team as scheduled yesterday. As expected, they were very pleased with my lab results. We will stay the course on my dialysis prescription, not take any blood pressure meds, and continue to monitor, but work on more protein in my diet. My dialysis nurse Cindy also provided four boxes of 6 liters of 1.5% dialysis solution so I have a buffer against the Sanfu reported yesterday. Again, hopefully, the supply that went missing will be delivered on schedule on 4/17/2024.

My lab results indicate that I am on the cusp of at least from a number of perspectives getting enough dialysis. This is also reflected in how I feel. Upon returning from walking our Golden Retriever, I no longer have to sit down and rest. I am not getting slightly out of breath. I can go longer and stronger and accomplish some yard work without having to take a break every five minutes. While I am some distance from the former lean and mean machine known in Porsche racing circles as “Hammerin’ Hank,” at this stage in my life things look pretty good from where I’m standing. Hope they do for you also!

I have been sailing along ordering dialysis supplies from Fresenius for my dialysis requirements without a hitch since October 2022. The hitch became unhitched with a blaring crash Tuesday. Here’s the deal:

I put in an order of 36 – 6 L 1.5% boxes, 7 – 2 L 1.5% manual boxes, 4 cassette boxes, and 2 StayCap boxes. Only the latter two were delivered. No fluids whatsoever were delivered. I called the Fresenius order desk and was informed they screwed up, something about when they talked to my dialysis nurse to get approval for the larger than typically allowed 6 L request things got discombobulated. I was informed that the “real” order will arrive on 4/17/2024.

I politely inquired as to how this could even happen. Alarms should have gone off when my orders, which from the beginning have included copious amounts of the required fluids, suddenly went to zero! This makes absolutely no sense to me at all. It is an obvious fault line in one of Fresenius’ most important functions. To add to this, the voice on the other end of the phone call indicated that she had no way of reporting this abdication of duty to patients up the chain to preclude it from happening in the future, stating “These things do happen.”

So the message for those on peritoneal dialysis herein: Despite your best effort, the “system” can and will leave you hanging out in left field. Keep your powder dry and have extra supplies on hand. It is a pain and takes up extra space but…

BTW, it turns out I have a meeting with my dialysis team today and have corresponded this situation to my dialysis nurse and have arranged to pick up four 6 Liter 1.5% boxes at our meeting. There is a God!