Never ring the bell!
It is a short and sweet blog. Our son was released from the ICU at Fort Worth Medical City mid-afternoon yesterday. My wife and I picked him up and took him home to Palo Pinto County via Mineral Wells to pick up prescribed drugs and a blood pressure cuff—more tomorrow.
Our son is still in ICU recovering from his recent quadruple heart bypass. Most of the associated tubes have been removed and he is urinating on his own now; catheters have been removed. He still has to do the big BM soon but hopefully, nature will take its course. If things go as suggested by hospital staff, he should be moved to a regular care hospital room tomorrow from ICU, and possibly be released Tuesday or Wednesday.
Our son has exhibited a side I did not know he had/has. He seems anxious over the least little perturbation like his BP going up a couple of points or one of the many machines he is hooked up to beeping. Recall that he has an ICU nurse devoted full time to his care and feeding so it’s not like he is winging it all alone. I guess stress can do things to our minds and bodies that bring out another side of our personality.
Since dialysis has been known to be somewhat stressful, it would be interesting to know how dialysis patients manifest their response to stress?
Yesterday morning on schedule our son had a quadruple heart bypass at Fort Worth Medical City. He went in on schedule and came out a couple of hours sooner than expected. We visited him Thursday afternoon. He was awake, sitting up, talking, and lucid. Pain yes. But, hanging in there. He is in a single-room ICU with a devoted ICU nurse tending to his every need. Today he is to start walking and doing breathing exercises. He is progressing well and I am convinced he will be up and at them before we know it.
As a result of our son’s plight, dialysis, while still going on as prescribed, has taken a back seat as it should. Hopefully, by some time next week, we’ll be of a mindset to more deeply relate the ins and outs of my dialysis. At the present time, I’m in automatic.
Yesterday I wrote about how the PET and other tests tie together to present an overall picture of the efficacy of a given Dialysis Prescription. Recall also that this past Monday I underwent yet another PET. The results are in, and would you believe, my Transport flipped 180 degrees again, to Low from High. This will require/support yet another prescription from my Nephrologist. Please stand by for more on this as it develops. How this can happen is beyond my understanding at this point.
As a result of an investigation by the Wetherford CathLab, it was ascertained that our son needs a quadruple bypass ASAP. He was transferred to the Fort Worth Medical Center yesterday evening, where he is in the surgery queue for an 0730 procedure today. He is still fighting Hypertension.
And if this isn’t enough, my brother-in-law with AML Leukemia is soon to be released from the hospital into hospice care at his home in Mulberry, Indiana.
For all you dialysis patients who think you are carrying the weight of the world on your shoulders, get a grip. You are undergoing a life-giving procedure. Things could certainly be much worse as suggested above.
BTW, here in North Texas, we have been experiencing 80+ degree days. All over Pecan Plantation where we live the Daffodils are starting to bloom. See the lead picture from our front yard.
In a discussion with my dialysis nurse during my PET Monday, she reflected that patients have a difficult time putting together all the tests that are required while on PD into an integrated whole understanding of the Big Picture. This blog is meant for those seeking such an understanding. I turned to Poe with the following Prompt and results.
Prompt: Write a 500-word blog entry putting together for the laymen the peritoneal dialysis PET test, adequacy test, and the resulting Kt/V and what the doctor does with each one.
Assistant Poe
Title: Understanding Peritoneal Dialysis PET Test, Adequacy Test, and Kt/V: A Layman’s Guide
Introduction:
When it comes to managing kidney disease, dialysis plays a crucial role in assisting the body’s natural filtration processes. Peritoneal dialysis (PD) is a common form of dialysis that utilizes the peritoneal membrane within the abdomen to remove waste and excess fluids from the body. To ensure the effectiveness of PD treatment, doctors employ various tests, including the Peritoneal Equilibration Test (PET) and the Adequacy Test, which provide valuable insights into the patient’s dialysis prescription. One of the key parameters derived from these tests is Kt/V, a measure used to gauge the efficiency of dialysis. In this blog post, we will explore the significance of each test and how doctors utilize the resulting Kt/V value.
Peritoneal Equilibration Test (PET):
The Peritoneal Equilibration Test (PET) is a diagnostic tool used by doctors to evaluate the efficiency of solute transport across the peritoneal membrane during peritoneal dialysis. The test involves the introduction of a special dialysis solution into the abdominal cavity through the PD catheter. Over a specified period, samples of the dialysate are collected and analyzed to measure the clearance rates of different solutes, such as creatinine and glucose. These clearance rates provide information about the transport characteristics of the peritoneal membrane.
Adequacy Test:
The Adequacy Test is conducted to assess the effectiveness of the peritoneal dialysis treatment in removing waste products and excess fluids from the body. It helps doctors determine if the prescribed dialysis regimen is adequate for a particular patient. The test involves collecting a sample of the patient’s blood and measuring various parameters, such as urea and creatinine levels. By comparing these levels with the target values, doctors can assess the adequacy of dialysis in removing waste products.
Kt/V:
Kt/V is a numeric value derived from the results of the Adequacy Test that quantifies the efficiency of dialysis. It takes into account three important factors: K (clearance of urea), t (time of dialysis), and V (volume of distribution of urea). K represents the ability of the dialysis treatment to remove urea from the blood, while t represents the duration of the dialysis session. V represents the volume of distribution of urea, which is an estimate of the amount of urea in the body.
The doctor’s role:
Based on the PET test results, doctors can classify patients into different transport categories: high transporters, low transporters, and average transporters. This information helps doctors individualize the dialysis prescription to optimize the treatment for each patient. For example, high transporters may require more frequent exchanges or adjustments in dialysate concentration to achieve adequate clearance.
The Kt/V value derived from the Adequacy Test is used by doctors to assess the effectiveness of the peritoneal dialysis treatment. A higher Kt/V value indicates better removal of waste products and excess fluids, suggesting a more efficient dialysis treatment. If the Kt/V value falls below the target range, doctors may adjust the dialysis prescription by increasing the duration of dialysis or making changes to the dialysate concentration.
Conclusion:
In the realm of peritoneal dialysis, the Peritoneal Equilibration Test (PET), Adequacy Test, and Kt/V play crucial roles in evaluating the efficiency of treatment and optimizing the dialysis prescription for individual patients. These tests provide valuable insights into the transport characteristics of the peritoneal membrane, the adequacy of waste product removal, and the overall efficiency of dialysis. By utilizing these tests and the resulting Kt/V values, doctors can tailor the treatment plan to meet the specific needs of each patient, ultimately improving the outcomes and quality of life for individuals undergoing peritoneal dialysis.
Yesterday my dialysis nurse Cindy conducted a PET again. In a couple of days, we should have a readout on my Transport “Function” and go from there on whether or not my prescription should be altered. To uninitiated reading about a PET concerning dialysis involves manually loading 2000 mL of 2.5% fluid the night before the test, at home, and several loads and drains at the dialysis center the following day along with lab draws. The whole PET takes several hours. I started at 0900 and got back home about 1500.
We dialysis patients often get caught up in our little worlds. Friday night our son, a robust 61-year-old hard-working man, was admitted to the hospital with chest pains. He has been experiencing high blood pressure for some time and also experiences white coat anxiety. He was scheduled to go to the CathLab early Monday but was postponed to Tuesday because of continued hypertension. Stay tuned.
Over the past few years, my fingernails have become thinner and more prone to cracking. Small scraping tasks I could perform previously were no longer possible without bending or cracking my fingernail(s). Since we know diabetes and CKF impact our bodies in ways that are not always apparent, I explored the ties between fingernail health diabetes and CKF. Recall that quite often diabetes is a precursor of CKF; they often go hand-in-hand. Likewise, CKF more often than not leads to dialysis.
For this research I used Perplexity.ai. Recall that perplexity.ai is an intelligent “Google” that provides textual responses not just links as Google does. I first inquired about the link between nail failure and diabetes, then CKF. Perplexity’s responses followed by my closing remarks are below:
1. Research also suggests that long-term type 2 diabetes affects the intrinsic material properties and structural integrity of tissues, including the fingernails, due to prolonged hyperglycemia causing chronic damage to tissue quality2. Furthermore, people with diabetes have a higher risk of fungal nail infections, as diabetes can make nails brittle and prone to splitting due to changes in the protein composition of the nail plate3. Therefore, individuals with type 2 diabetes should be mindful of changes in their fingernails and seek medical advice if they notice any abnormalities, as these could be indicative of underlying diabetic-induced tissue damage.
The search results indicate that there is a tie between chronic kidney disease (CKD) and fingernail changes, such as becoming thinner and cracking. CKD can cause various nail disorders and abnormalities, including half-and-half nails (Lindsay’s nails), absent lunula, splinter hemorrhages, and changes in color and texture. These nail changes can be non-specific signs of renal impairment and may precede other symptoms of CKD. The presence of half-and-half nails, where the top part of the nails is white and the bottom part is a reddish-brown color, can be a valuable clue to underlying kidney disease, especially when serum creatinine levels are not readily available
1234. Therefore, individuals experiencing changes in their fingernails, such as becoming thinner and cracking, should consider consulting a healthcare professional to evaluate the possibility of underlying kidney disease.
We deduce from the above that both diabetes and CKF may lead to fingernail abnormalities. Along with diabetes, I also have been diagnosed with peripheral artery disease and peripheral neuropathy both of which may impact nails. The bottom line is it’s just something I’m going to have to learn to live with. If you’re also in my boat, you probably will have to also.
Introduction:
Palliative care and hospice are essential components of comprehensive healthcare that aim to improve the quality of life for patients with serious illnesses. While peritoneal dialysis is an effective treatment option for end-stage renal disease (ESRD), some patients may eventually require palliative care or transition to hospice as their condition progresses. In this blog entry, we will explore what palliative care and hospice entail and provide definitive examples of how they can benefit a patient on peritoneal dialysis.
Understanding Palliative Care:
Palliative care is a specialized medical approach that focuses on relieving symptoms and improving the overall well-being of patients facing serious illnesses. It is not limited to end-of-life care but can be initiated at any stage of a chronic illness. The primary goal of palliative care is to enhance the patient’s quality of life by managing pain, addressing emotional and psychological needs, and providing support for the patient’s family.
For a patient on peritoneal dialysis, palliative care can play a crucial role in managing symptoms and complications associated with the treatment. For instance, a patient may experience chronic pain, fatigue, or anxiety due to the dialysis process. Palliative care specialists can work collaboratively with the patient’s healthcare team to develop a comprehensive care plan that addresses these issues. They may prescribe medications to alleviate pain, provide counseling to manage emotional distress, and offer guidance on lifestyle modifications to enhance the patient’s overall well-being.
Exploring Hospice Care:
Hospice care is a form of specialized care provided to individuals who have a limited life expectancy, usually estimated to be six months or less. It is primarily focused on providing comfort and support to patients and their families during the end stages of a terminal illness. Hospice care can be delivered in various settings, including the patient’s home, a specialized hospice facility, or a hospital.
In the context of peritoneal dialysis, a patient may reach a stage where the treatment is no longer effective or desired. In such cases, the patient may choose to transition to hospice care to receive comprehensive support during their end-of-life journey. Hospice professionals can assist in managing symptoms such as pain, nausea, and breathing difficulties, while also providing emotional and spiritual support to both the patient and their loved ones. Additionally, they can help with organizing and coordinating necessary caregiving services, ensuring the patient’s comfort and dignity.
Definitive Examples of Palliative Care and Hospice for a Peritoneal Dialysis Patient:
Let’s consider the case of a patient on peritoneal dialysis who has advanced kidney disease and experiences significant fatigue, anxiety, and depression. Palliative care specialists can intervene by prescribing medications to alleviate the patient’s fatigue, offering counseling sessions to address anxiety and depression, and collaborating with the patient’s healthcare team to optimize the dialysis regimen. This holistic approach can enhance the patient’s quality of life, allowing them to engage in activities they enjoy and maintain emotional well-being.
In another scenario, imagine a patient on peritoneal dialysis who has progressed to the end stages of kidney disease and decides to discontinue treatment due to personal preferences or worsening health conditions. Hospice care professionals can step in to provide support during the patient’s remaining time. They can focus on pain management, ensure symptom control, and offer emotional support to the patient and their family members. This compassionate care allows the patient to spend their final days in comfort and dignity, surrounded by loved ones.
Conclusion:
Palliative care and hospice play vital roles in enhancing the quality of life for patients on peritoneal dialysis, both during active treatment and at the end stages of their illness. From managing symptoms to providing emotional support, these specialized care approaches ensure that patients receive holistic, patient-centered support. By integrating palliative care and hospice into the treatment plan, patients and their families can navigate the challenges of renal disease with dignity, compassion, and improved well-being.
I had the gut feeling that there’s more to the potential deleterious effect of Hypotension, that is low blood pressure, on Peritoneal Dialysis. So with the help of Poe, I dug deeper and questioned it along the lines of the impact on an 85-year-old male with hypotension and diabetes. The results bear out my suspicions. Read on. (To me, the most important finding is that of Impaired clearance of waste products which it is conjectored directly impacts Kt/V, the effectiveness of the peritoneal dialysis process itself. I hypothesize there is a direct correlation link between hypotension and Kt/V: decreased blood pressure results in decreased Kt/V.)
Low blood pressure, also known as hypotension, can potentially present challenges for an 85-year-old diabetic individual on peritoneal dialysis. Here are some issues that low blood pressure may pose in such a circumstance:
Certainly! In the context of peritoneal dialysis, low blood pressure can have several implications:
Tissue perfusion refers to the blood flow and distribution of oxygen, nutrients, and other vital substances throughout the body’s tissues and organs. It is essential for maintaining the normal functioning of organs and sustaining cellular activities.
Adequate tissue perfusion ensures that every cell in the body receives sufficient oxygen and nutrients while facilitating the removal of waste products. The circulatory system with its network of blood vessels, such as arteries, arterioles, capillaries, venules, and veins, plays a vital role in maintaining tissue perfusion.
When blood pressure and blood flow are within a normal range, tissue perfusion remains optimal. However, factors such as decreased blood pressure, impaired circulation, or narrowed blood vessels can negatively affect tissue perfusion. Reduced tissue perfusion may result in inadequate oxygenation, diminished nutrient supply, impaired waste removal, and cellular dysfunction.
Most vulnerable to the effects of inadequate tissue perfusion are vital organs like the heart, brain, kidneys, liver, and lungs. Insufficient perfusion in these organs can lead to severe consequences such as organ dysfunction, tissue damage, or organ failure.
Healthcare providers closely monitor tissue perfusion in various medical and clinical settings to ensure efficient body functioning. Adequate perfusion is a key consideration in managing and treating conditions such as cardiovascular disease, sepsis, shock, and other critical illnesses.
In medical settings, tissue perfusion can be assessed through various methods. Some common approaches include:
So what’s the bottom line here? It should be clear that the ramifications of hypotension on peritoneal dialysis patients can be indeed very serious to the point of death and should not be shrugged off.
My wife Linda and I are on separate ends of the blood pressure spectrum. She is struggling with high blood pressure while I am at the other end with chronically low. While she has received specific guidelines from her GP on what her upper normal target should be, 135 over 85, nothing is ever mentioned about hypotension, that is, low blood pressure. We don’t even see the term, hypotension, to any extent when blood pressure is discussed. As a society, we seem to be fixated on hypertension. My first approved disability with the US Veteran’s Association was for “Diabetes with Hypertension.”
There seem to be philosophical differences between medical professionals as to what constitutes hypertension. For instance, my current dentist takes my blood pressure before opening my mouth for any dental procedure. By current guidelines, in the past, I have been hypertensive but nothing was ever said or done about it. Compounding this are definitional concepts like who are the “elderly” that have different parameters than the “normal” population. To illustrate this point, I queried Poe as to what the definition of “elderly” is in the USA with the following results:
“In the USA, the term “elderly” generally refers to individuals who are considered to be advanced in age or the later stages of life. However, it’s important to note that there isn’t a universally agreed-upon definition of when someone is considered elderly. The perception of old age can vary depending on cultural, social, and individual factors. In many contexts, the term “elderly” is often used to describe individuals who are around 65 years of age or older, which is the age at which many people become eligible for certain government benefits and programs such as Medicare. However, it’s worth mentioning that this age threshold is not fixed or definitive, and some organizations or researchers may utilize different age ranges or criteria when discussing the elderly population. Additionally, it’s important to recognize that the term “elderly” can be subjective and may carry different connotations for different people. Some individuals may consider themselves elderly at a younger age, while others may not identify as elderly even at an older age. It’s always best to consider individual preferences and perspectives when discussing age-related topics.” (Emphasis provided.)
Since I am interested in specific guidelines for my particular case, an 85-year-old male on peritoneal dialysis, I went back to Perplexity to ascertain what current research indicates for my particular case with the following Prompt and results:
What are the most recent guidelines for both high and low limits on blood pressure for an 85-year-old male on peritoneal dialysis?
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The most recent guidelines for blood pressure management in elderly patients with chronic kidney disease (CKD) on peritoneal dialysis are not explicitly detailed in the search results provided. However, the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest a target blood pressure of less than or equal to 140/90 mmHg if albuminuria is present
2. Additionally, the 2015 International Society of Peritoneal Dialysis (ISPD) guidelines recommend that persistently high blood pressure in peritoneal dialysis patients should be corrected to levels below 140/90 mmHg5.For patients with CKD not receiving dialysis, the KDIGO 2021 Clinical Practice Guideline suggests a target systolic blood pressure (SBP) of less than 120 mm Hg3. However, this target may not be directly applicable to patients on peritoneal dialysis, such as the 85-year-old male in question. It is important to note that individual patient factors, such as the presence of other comorbidities, should be considered when determining the appropriate blood pressure targets. Therefore, the patient should consult with their healthcare provider to determine the most appropriate blood pressure goals based on their specific health status and the latest clinical guidelines.
So although I specifically requested a lower limit, Perplexity aka a smart Google did not provide any, just the 140 number for an upper limit. I went one step further and quizzed Perplexity about my potential problems related to blood pressure while on PD with the following Prompt and results:
Prompt:
What are the most recent guidelines for both high and low limits on blood pressure for a 85 year old male on peritoneal dialysis?
The most recent guidelines for blood pressure management in elderly patients with chronic kidney disease (CKD) on peritoneal dialysis are not explicitly detailed in the search results provided. However, the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest a target blood pressure of less than or equal to 140/90 mmHg if albuminuria is present
2. Additionally, the 2015 International Society of Peritoneal Dialysis (ISPD) guidelines recommend that persistently high blood pressure in peritoneal dialysis patients should be corrected to levels below 140/90 mmHg5.For patients with CKD not receiving dialysis, the KDIGO 2021 Clinical Practice Guideline suggests a target systolic blood pressure (SBP) of less than 120 mm Hg3. However, this target may not be directly applicable to patients on peritoneal dialysis, such as the 85-year-old male in question.It is important to note that individual patient factors, such as the presence of other comorbidities, should be considered when determining the appropriate blood pressure targets. Therefore, it is advisable for the patient to consult with their healthcare provider to determine the most appropriate blood pressure goals based on their specific health status and the latest clinical guidelines.
what are the risks of low blood pressure for elderly patients on peritoneal dialysis?
1. Additionally, low blood pressure during dialysis can lead to various short-term symptoms such as nausea, dizziness, and gastrointestinal, muscular, and neurologic symptoms13. Furthermore, the 2015 International Society of Peritoneal Dialysis (ISPD) guidelines recommend that persistently high blood pressure in peritoneal dialysis patients should be corrected to levels below 140/90 mmHg, highlighting the significance of blood pressure control in this population4. Therefore, it is essential to monitor and manage blood pressure carefully in elderly patients on peritoneal dialysis to mitigate these potential risks.
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