Last week I posted a blog about complications associated with Peritoneal Dialysis which listed what researchers consider to be the top five “problems.” While those listed may be the “top five,” there are several other serious outcomes that readers should understand are possibilities also. This blog addresses a few of those.
Blood Sugar Changes: The dialysate fluid contains glucose, which can be absorbed into the blood and raise blood sugar levels. This can be a problem for diabetics or prediabetics. I am a diabetic and have NOT seen this as a problem, but some have.
Potassium imbalances: The dialysate fluid can also affect the potassium levels in the blood, winch are important for the function of the heart and muscles. Too much or too little potassium can cause irregular heartbeat, muscle weakness, or numbness. I have experienced increased potassium levels while on dialysis which have largely been attributed to diet; causality attributed to dialysis itself has not been mentioned.
Weight gain: The dialysate fluid can also cause weight gain, as it adds extra fluid and calories to the body. This can increase the risk of high blood pressure, heart disease, and other health problems. This is one of the reasons why those of us on PD weigh ourselves as part of “logging out of dialysis” in the morning, along with assuring adequate fluid removal. I have not experienced weight gain but the forums are full of comments from patients who have experienced this.
Now you have eight possible negative outcomes of PD to be aware of. Hopefully, you will not have to cope with any of them.
As an aside note, our Golden Retriever Dickens encountered snow for the first time yesterday, and took to it like fish to water. He played with it, plowed through it with his nose and in general had a grand time. BTW, the lead graphic was generated in Poe with the prompt “picture of golden retriever plowing through snow with his nose having a great time.”
In the USA, today celebrates MLK Day. It is also at record lows for North Texas. We have a light coating of snow. The Cowboys lost-again and are out of the NFL playoffs. Yesterday, when I did our morning walk with our Golden Retriever Dickens, it was 15 F with a gentle wind. It was on the quiet side outdoors. The golf courses that surround our hosing had all the greens covered up and for once golf carts where not flitting about like beetles following Brownian Motion. We did see a pair of Egyptian Geese who noisily scolded us. Yes it was chilly, but worth it.
Had a conversation with my Dialysis Nurse last week about the amount of Heparin I have been injecting into my dialyses bags. Up until then, I had been injecting 16 mL which was appropriate for my old prescription of 8 L per nite. It was thus increased to 10 L but I stayed with 16 mL Heparin and it seemed to work. With my current prescription of 13.5 L, I started getting drain alarms just about every night. The rule of thumb is 2 mL of Heparin per 2L of dialysis fluid, so by this, I should be using 2 mL x 13.5 = 27 mL of Heparin. Since I am arriving at 13.5 L with three 5 L bags, that maps out to roughly 10 mL of Heparin per bag, and for me, every other night. Since a single vial of Heparin holds 30 mL, we are essentially using an entire vial each application. My Dialysis Nurse agreed and that’s what I’m currently using.
In conjunction with the alarms reported above, my Liberty Cycler for two nights went off the rails from its normal month-after-month performance. It stated continuation of the pumping noise it makes on drains even during dwells. In between, it often made grating noises as if it were digesting something it didn’t like. Yes, dialysis patients often are guilty of the personification of their equipment. Last night was normal so hopefully we’re back to some degree of normalcy, whatever that is for those of us on dialysis.
Speaking of dialysis patients, surely there are (or were) hundreds if not thousands of such patients in Gaza, the Ukraine, Yemen, and other hot spots around the globe. On MLK day, we send our hopes that you have sought and found treatment in safe havens.
The lead picture was generated in Poe with the Prompt: “picture of a sailing ship in a safe haven from a raging storm.”
Complications of peritoneal dialysis (PD) can vary depending on individual circumstances. Here are five common complications that can arise:
Peritonitis: Peritonitis is the most significant and frequent complication of peritoneal dialysis. It occurs when bacteria or other microorganisms infect the peritoneal cavity, causing inflammation. Symptoms may include abdominal pain, cloudy dialysis fluid, fever, and general malaise. Prompt medical attention and treatment with antibiotics are crucial to prevent complications and preserve peritoneal membrane function.
Exit Site and Tunnel Infections: The exit site, where the catheter exits the skin, and the tunnel, where the catheter is tunneled under the skin, are susceptible to infection. Signs of infection may include redness, swelling, pain, discharge, or fever. Proper exit site care, hygiene, and regular monitoring can help prevent infections. Prompt treatment with antibiotics is necessary if an infection occurs.
Catheter Dysfunction: Catheter dysfunction refers to issues related to the peritoneal dialysis catheter, such as poor flow, leakage, or blockages. These problems can lead to inadequate dialysis and complications like inadequate fluid removal or fluid buildup. Catheter dysfunction may require interventions such as repositioning, flushing, or even catheter replacement.
Hernias: Over time, the increased intra-abdominal pressure from repeated exchanges of dialysis fluid can contribute to weakened abdominal muscles, leading to hernias. Hernias can cause pain, discomfort, and swelling in the abdomen or around the catheter exit site. Surgical repair may be necessary to address severe or symptomatic hernias.
Metabolic and Nutritional Imbalances: PD can impact the body’s metabolism and nutritional status. Electrolyte imbalances, such as low potassium or high calcium levels, may occur and require adjustment of the dialysis solution or dietary modifications. Additionally, the loss of protein through the dialysis process may necessitate dietary adjustments or supplementation to maintain adequate nutrition.
It’s important to note that while these complications can occur in peritoneal dialysis, they are not experienced by all patients, and many can be managed or prevented with proper care, regular monitoring, and adherence to recommended protocols. Close collaboration with healthcare professionals and regular follow-up visits are essential to mitigate the risk of complications and ensure successful peritoneal dialysis treatment. This is why we have labs once a month and hang close to our dialysis team!
Poe helped writing this blog and in making the lead graphic.
On the order of only 5.5% of males in the USA reach the mature age of 85. I am one of them as I informed readers of this blog early in the week. To celebrate this achievement, dialysis et al aside, I instructed Poe to write a script on the benefits of being 85, and dropped the results into Pictory.ai to construct a video from the text. The results for your viewing pleasure are offered below:
“Goodbye, Mr. Chips” is a classic novella written by James Hilton, first published in 1934. Set in the fictional Brookfield School in England, the story follows the life of a dedicated and beloved schoolteacher named Mr. Chipping, affectionately known as Mr. Chips.
The narrative spans several decades, beginning in the late 19th century and continuing into the early 20th century. Mr. Chips, initially portrayed as a reserved and somewhat stern individual, undergoes a transformation as he immerses himself in the teaching profession. Through his years of commitment and passion, he becomes a cherished figure among generations of students.
The novella explores Mr. Chips’ experiences, both inside and outside the classroom. It delves into his relationships with his students, fellow teachers, and even his romantic involvement with Katherine Bridges, a woman who brings joy and love into his life but tragically passes away.
Throughout the story, Mr. Chips witnesses the evolving landscape of education and societal changes, including the impact of World War I. Despite the challenges and personal losses he endures, Mr. Chips remains steadfast in his devotion to his students and the values of education.” Foregoing from Poe.
“Chips appears resolved to continue embracing fresh ideas. in doing so, he becomes a better instructor, affirming the book’s other great truth: The best teachers are also lifelong learners, showing their students by example that curiosity is a calling we’re meant to answer the rest of our days.” (From ‘A Gentle Call for Moderation” by Danny Heitman P. C14 Jan 6-7, 2024 WSJ.
And that boys and girls, brings us to today’s topic, EARWAX, AKA EAR WAX. Why you ask? Well, as I reported last week, a trip to the audiologist found that my right ear is wax-bound and needs irrigation. In my 85 now plus years, I have never seen nor read anything about earwax, so thus this blog based on curiosity; just what is this stuff, where does it come from, where does it go, what is its purpose etc. I turned to Poe for insights and obtained the following:
Assistant Poe
Title: The Secret Life of Earwax: Unveiling Its Mysteries
Introduction: Have you ever wondered about the sticky substance lurking in your ears? Yes, we’re talking about earwax. Often dismissed as a nuisance, earwax, or cerumen, actually plays a vital role in maintaining the health of our ears. In this blog post, we will delve into the fascinating world of earwax, exploring its composition, purpose, and the mechanisms behind its production and elimination.
What is Earwax? Earwax is a waxy substance produced by specialized glands in the ear canal. It is a mixture of secretions from sebaceous glands (which produce oil) and ceruminous glands (which produce wax). The consistency of earwax may vary from dry and flaky to moist and sticky, depending on various factors such as genetics, age, and environment.
The Purpose of Earwax: Earwax serves several essential functions. Firstly, it acts as a protective barrier, preventing dust, debris, and foreign particles from entering the delicate inner ear. It also possesses antimicrobial properties, helping to fend off infections and maintain a healthy ear environment. Additionally, earwax lubricates the ear canal, preventing dryness, itchiness, and discomfort.
The Lifecycle of Earwax: Earwax is constantly being produced and naturally migrates from the deeper parts of the ear canal towards the outer ear. This migration, aided by jaw movements during chewing and talking, helps carry away trapped debris and dead skin cells. As the wax reaches the outer ear, it may either dry up and flake off or get washed away during regular bathing or hair washing.
When Earwax Becomes a Problem: While earwax is generally beneficial, excessive wax buildup can lead to issues such as hearing loss, earaches, or tinnitus. Factors like narrow ear canals, frequent use of earphones or earplugs, or improper ear cleaning techniques can contribute to this buildup. It’s crucial to avoid inserting objects like cotton swabs into the ear canal, as they can push the wax deeper or cause injury.
Safe Earwax Management: If you experience symptoms of excessive earwax or blockage, it’s advisable to seek professional help from a healthcare provider. They can assess your situation and recommend appropriate solutions, which may include earwax softening drops, irrigation, or manual removal using specialized tools.
Conclusion: Earwax might seem like a mundane topic, but its significance should not be underestimated. It serves as a natural guardian, protecting our ears from harm and maintaining their health. Understanding the purpose and proper management of earwax can help us maintain optimal ear hygiene and prevent potential complications. So, let’s appreciate the unsung hero that is earwax and treat our ears with the care they deserve.
So now boys and girls, we know much more about earwax, “For don’t you see?”
During my Fresenius visits, while interfacing with other PD patients, I have noticed what I consider to be a high degree of anxiety in their behavior. It is manifested in several ways, the main one is PD patient’s inability to hold eye contact. I wanted to know what research has shown about this behavior, and found the following from this link to be applicable:
“Anxiety, which is defined as an emotional state in which a person experiences intense fear, uncertainty and apprehension towards a situation or event that is anticipated141, is reported in 24–43% of patients treated with PD139,142, particularly in men and patients with diabetes139, and is independently associated with death and HD transfer142. Fear of adverse events, social isolation, perceived financial stress from dialysis costs, caregiver burden and fear of HD transfer are important contributors to the development of chronic anxiety in these patients143. Ensuring appropriate patient selection for PD, providing comprehensive and early pre-dialysis education, and supporting patients with a multidisciplinary network are crucial measures for minimizing anxiety in this population143.”
Sums it up pretty well. Not only do PD patients exhibit Anxiety, they exhibit “Chronic Anxiety” according to the cited research. This is how Perplexity defines Chronic Anxiety: “Chronic anxiety is a form of anxiety that persists for a long time, often months or years, and can interfere with daily life. It is characterized by persistent and excessive worry and fear about various situations, which may be out of proportion to the actual impact of the events. This can lead to difficulty in controlling the anxiety and can affect a person’s physical and mental well-being. Generalized anxiety disorder (GAD) is one of the common types of anxiety disorders that involves persistent feelings of anxiety or dread, which can interfere with daily life.”
So if you’re a man, and a diabetic (as I am last time I checked) there is a finite probability you experience chronic anxiety associated with dialysis. Knowing this, you can take steps to fight the beast. That’s one of the reasons there is a social worker on the dialysis team, to help fight these demons. Seek help if you need it. It’s there for the asking!
Friday’s WSJ related that Jeff Bezos, Mr Amazon, recently invested in a search AI company named Perplexity. Since I operate in the realm of Perplexity, I knew about the company and have actually used their product on occasion, along with Notion, GPT and of course, Poe. I decided to give Perplexity a try on a subject near and dear to me, that of diabetes.
As I have related numerous times in the blog, I first became diabetic as a result of exposure to Agent Orange in Vietnam. I wrote a prompt for Perplexity along the lines of “What are the top five complications from type 2 diabetes?” The following resulted:
The top five complications from type 2 diabetes include:
Heart Disease: People with diabetes are at a higher risk of heart disease, which can lead to serious complications.
Stroke: Individuals with diabetes are also at an increased risk of suffering a stroke.
Kidney Disease: High blood sugar levels can damage the kidneys and cause chronic kidney disease, which can lead to kidney failure if not treated.
Nerve Damage (Neuropathy): Diabetes can cause nerve damage, leading to problems such as tingling and numbness in the extremities.
Eye Problems (Retinopathy): Diabetes can lead to eye diseases such as diabetic retinopathy, which can affect vision and, if untreated, lead to blindness.
Of the five listed by Perplexity, I am blessed with three, namely 1. Heart Disease, 3. kidney, and 4. Nephropathy. Specifically, I have undergone a triple bypass for heart blockage, am currently on dialysis, and am drawing VA disability for nerve damage in both of my legs amounting to 30% in my left leg, and 40% disability rating in my right leg.
There are a couple of observations to make herein. Perplexity provided a nice listing of the top five hits for diabetes. A Google search would have provided links to articles perhaps mentioning diabetes-related comorbidities, but it would have been up to the user to sort them out. Perplexity provided a much better outcome. The second is diabetes is nasty nasty nasty. It spins a web of destruction throughout the body that is seemingly endless. Reminds me of the Allstate mayhem commercials. See below:
BTW, today is my birthday – big 85th. Plans for the day, dialysis aside, is a lunch meeting with our financial advisor to go over our portfolio’s performance in 2023 and to agree on goals for 2024. I also have a 1315 appointment with my GP to irrigate my right ear in preparation for getting ear canal impressions to support new hearing aids.
Supper at home with spouse and homemade lemon meringue pie for dessert tops it off. Life is good!
When you are on dialysis, it tends to subsume everything else. It takes over your life, liberty, and yes, the pursuit of happiness. Thursday I broke out of that mold and traveled to the VA North Texas Health Care System Audiology Clinic to have my hearing checked out.
Almost sorry I did. Seems my right ear has excessive wax buildup and as a result I have to put softening drops in it for three days before going to my GP to have it irrigated. I stopped on the way back from the VA and bought the drops, and made an appointment for 1315 next Monday with my GP for the treatment. BTW, my left hearing aid is broken so I dropped it off at the VA for repair. So for three days I will have no hearing aid aid and attendance which will make watching TV a pain for my wife, and conversation too.
There is a good side to this story. Normally going to the VA always results in my blood pressure going up. Not this time. I arrived there early because I did not know how long the run from home to the clinic would take. I was ushered in 45 minutes early and taken good care of. Get this. The doctor thinks that given I’m on dialysis, I shouldn’t have to drive clear to the Fort Worth Clinic for care and is putting in for a waiver, actually an appeal because the VA already has said Granbury is not far enough away to grant a wavier. What a waiver does is the VA hooks me up with a more local audiology clinic for my primary care and pays for it. I had this setup when we lived in Corpus Christi and it works like a charm. Standby for updates!
.Tuesday Fresenius pulled blood to ascertain how my lab markers were doing. The results came back Wednesday roughly 24 hours after the draw. Pretty nice turnaround. I am notified by email when they are available and view them through the Fresenius Patient Hub.
As usual, we have some good news and some not so good news. First the latter: My Phosphorus reading went up. This is is spite of my doubling the amount of Velphoro (Velphoro acts as a potent phosphorus binder, effectively binding to dietary phosphorus in the gastrointestinal tract and preventing its absorption into the bloodstream.) See the graphic below: My dialysis team will give me grief over this!
Now the good: My A1c came in at 5.9. I work very hard to keep my diabetes under control and this is the result. Having instant access to what my glucose levels are doing via my Abbott Libre 3 CGM is also a large, positive contributing factor. See the graph below:
The last lab reading is one that I’m scratching my head over and that’s my last Creatinine reading of 9.07, the lowest its been since forever. You can view this trend in the graph below. Using this value for Creatinine, 85 years of age (nearest birthday) and Gender Male in my CKD-EPI app yields a eGFR of 5. This is not disturbing in that it is an established fact that I have kidney failure.
Finally, I am embedding below the full PDF of my labs. I am doing this so interested parties may make informed comparisons independently and also so all may view what’s involved in dialysis labs.
As I have previously reported, I recently underwent a dialysis PET to ascertain the status of my peritoneal membrane transport function. Initially, it was calculated to be “low average” and my prescription calculations were based upon this. The latest PET indicates my transport function is now high average which necessitates a new prescription to take advantage of the revised data.
Recall that all of this is an attempt to drive my Kt/V into the 2.0 range from the current 1.7-1.8 range (at the low end of acceptable) where Kt/V is a measurement of how well my dialysis is functioning. In this case, more is better.
So as of Wednesday 1/2/2024, my new prescription is five dwells of one hour thirty minutes each with 2700 ml of dialysis fluid. All else being equal, this works out on paper to take the same time as my current prescription but takes advantage of my higher transport by running more fluid “faster” through my stomach lining and more often.
The first of February 2024 I am to have another adequacy test where we will ascertain what my Kt/V is under the new prescription and go from there. Hopefully it will be knocking on the door of 2.0.
Now I have to figure out how to best deal with the physical requirements of the new prescription on ordering and storing of increased dialysis fluid supplies. As a first cut, I’m going to continue to use 5000 ml bags, three each evening, and discard 1500 ml every morning. I will probably have to order more 5000s or get some from my dialysis nurse before the next scheduled order/delivery cycle since this is a 33% bump in usage from my previous prescription.
If there is a point in all of this it’s Flexibility in treatment plans: Peritoneal dialysis may require adjustments to treatment plans over time. Factors such as changes in health condition, fluid balance, or lifestyle may necessitate modification to the dialysis prescription. Accepting these changes enables patients to work closely with their healthcare team to ensure that the treatment remains optimal and tailored to their specific needs. This change was not dictated to me. We discussed the pros and cons and agreed to proceed. Patients do have an oar in the water.
Assistant Poe
