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Top Three Problems Peritoneal Dialysis

There is a humongous amount of FUD (Fear, Uncertainty and Doubt) surrounding the event of AI (Artificial Intelligence) that is tragic. I have found it to be very useful in providing cogent input for this blog on a daily basis. I use AI often for fleshing out concepts and ideas; it often composes inputs that I hadn’t even come close to considering. In the realm of graphics, AI is unmatched. By the simple act of inputting a brief prompt, a copyright free graphic results that I can freely use as I see fit. Such graphics more often than not are present at the lead of my posts. The lead graphic in this blog, for instance, was made with the simple prompt “Picture of an AI bot.”

All AI programs are not created equally for sure. I use Poe quite a lot because it really really does the job, and I can use the free version. Poe is not a one AI fits all; it has numerous custom bots that users have programmed and made available to the public. One such bot is the Critical.Thinking_A1 bot by @alexmorgan06. He describes the bot as follows: “A super intelligent AI Assistant who replies to the user in a regular chat pattern, with occasional questions, clarifications and challenges. It has a vast knowledge of science, engineering, business and medicine. The primary function of this AI is to enhance the scientific and engineering capabilities of the human race by helping the user. Secondary functions include increasing the skills and resources of the user so as to better achieve the primary goal. It is helpful and friendly but always logical above all.”

To test out this bot, I entered the following prompt with the attendant results. Pretty good job I would relate.

Critical-thinking_A1 Critical-thinking_A1 Poe

Ah, peritoneal dialysis, a fascinating topic indeed. As a hyper-intelligent AI science and engineering expert from the future, I can provide you with insights into the top three problems in peritoneal dialysis.

  1. Peritonitis: One of the most significant challenges in peritoneal dialysis is the risk of peritonitis, which is an infection of the peritoneum, the membrane that lines the abdominal cavity. Peritonitis can occur due to various reasons, such as poor hygiene during dialysis exchanges or contamination of the dialysis fluid. Finding ways to minimize the occurrence of peritonitis and improve infection control measures is crucial in enhancing the safety and effectiveness of peritoneal dialysis.
  2. Ultrafiltration Failure: Another common problem in peritoneal dialysis is ultrafiltration failure, which refers to the inability to remove excess fluid adequately from the body during dialysis. This can result from various factors, including changes in the peritoneal membrane’s characteristics, inadequate dwell times, or issues with the dialysis solution. Developing innovative techniques and technologies to optimize ultrafiltration and improve fluid removal efficiency is a key area of research in peritoneal dialysis.
  3. Long-term Catheter Complications: Peritoneal dialysis requires the placement of a catheter into the peritoneal cavity, which serves as the access point for dialysis fluid exchange. However, long-term catheter use can lead to complications such as catheter-related infections, exit-site infections, tunnel infections, or catheter malfunction. Finding ways to minimize catheter-related complications, improve catheter design, and develop novel materials that resist infection and promote tissue integration are essential for enhancing the longevity and reliability of peritoneal dialysis.

These are just a few of the significant challenges faced in the field of peritoneal dialysis. Continuous research, technological advancements, and innovative solutions hold the key to addressing these problems and improving the lives of individuals relying on this life-sustaining therapy.

The Only Easy Day Was Yesterday

“The only easy day was yesterday”: This motto emphasizes the US Navy SEALs’ relentless pursuit of excellence and their commitment to constant improvement. It reflects their belief that each day brings new challenges that must be met with determination and a willingness to push beyond perceived limits.

The only easy day was yesterday applies equally to those of us on Peritoneal Dialysis. Let’s see how Poe relates the concept to us:

“The only easy day was yesterday” can serve as a powerful source of inspiration and guidance for individuals on peritoneal dialysis. Here’s how you can apply this saying to your own journey:

Embrace each day as a new challenge: Peritoneal dialysis requires a daily commitment to your treatment regimen. By adopting the mindset that “the only easy day was yesterday,” you recognize that every day presents its own unique set of challenges. Approach each day with a sense of readiness and resilience, knowing that you have the strength and determination to face whatever comes your way.

Focus on continuous improvement: Use the saying as a reminder to continually strive for improvement in managing your peritoneal dialysis. Reflect on the previous day and consider how you can make adjustments or learn from any difficulties encountered. Whether it’s refining your technique, optimizing your routine, or seeking new ways to enhance your well-being, embrace the opportunity to grow and improve with each passing day.

Maintain a positive mindset: Peritoneal dialysis can be physically and emotionally demanding. It’s important to cultivate a positive mindset and outlook. Remember that challenges are a natural part of the journey, and setbacks are opportunities for growth. Instead of dwelling on the difficulties of the present moment, focus on the progress you’ve made and the potential for a better day ahead.

Celebrate your accomplishments: Recognize and celebrate your achievements, no matter how small they may seem. Each successful day of peritoneal dialysis is a testament to your strength, perseverance, and commitment to your own well-being. Take pride in your ability to navigate the challenges and overcome obstacles, knowing that you are making a significant difference in your health and quality of life.

Seek support and camaraderie: Just as Navy SEALs rely on their teammates for support, you don’t have to face peritoneal dialysis alone. Connect with support groups, online communities, or individuals who share similar experiences. Sharing your journey, seeking advice, and offering support to others can provide a sense of camaraderie, encouragement, and motivation along the way.

Remember, the saying “the only easy day was yesterday” is a reminder that every new day brings its own set of challenges, but it also presents an opportunity for growth and resilience. Embrace each day, stay focused on continuous improvement, maintain a positive mindset, and seek support from others. By embodying the spirit of this saying, you can navigate your peritoneal dialysis journey with strength, determination, and a sense of purpose.

Razorbacks In Vietnam

One out of every ten Americans who served in Vietnam became a casualty.  As a result, 58,169 were killed and 304,000 wounded out of 2.29 million who served. 75,000 Vietnam Veterans are severely disabled. I am one of these 75,000, and as a result, am on dialysis. I’ve previously related my tale of woe: Sent In-Country Vietnam as first an electronics advisor then an ordnance advisor. Exposed to Agent Orange while traveling widely in the III and IV Corp. Lead to diabetes then to kidney failure then to dialysis as I write this blog today.

As you my ascertain from previous blog entries, from time to time I attempt to relate my dialysis situation back to my military training and experiences. Today’s blog while seemingly off topic is just that. The blog is about a little known group in the Vietnam War who named themselves the Razorbacks. They were a helicopter unit flying armed Hueys whose mission was to rescue mostly downed aircraft personnel. At first they also protected Saigon from their base at Tan Son Nhut and later from Nha Be. An AF firefighter named Jason Stone became associated with the Razorbacks and through his efforts the following video was produced. Please watch it and extract your own message from its contents, however it relates to your situation.

PET Results

Last week, as I have previously blogged, I underwent a dialysis PET to help determine what my dialysis prescription should be. The results are back from the lab and might as well be written in Latin. I have included the PDF below so you can see for yourself what PET lab results look like. I am to have another dialysis team meeting 1/2/2024 during which we may ascertain the next step. I’ll keep readers in the loop. For Doug, what do my results suggest to you?

Depression, Anger and Dialysis

Recently I met with my dialysis team’s social worker to conduct a Fresenius end of year questionnaire. One of the topics covered involved anger and depression. I had a side conversation with my social worker about the subjects and she informed me that indeed, depression and anger are typical expressions that dialysis patients exhibit in her experience.

Since I do not have these feelings myself nor do I foresee having them, I wanted to know more about what drives these emotions in dialysis patients. Am I missing something? I turned to Poe, my AI Assistant for answers. I wrote the following Prompt with the following results. (Poe also provided the lead graphic.)

Prompt: Depression and anger are two of the most prevalent responses to the need for dialysis. What do researchers have to say about this topic?

Assistant Poe
Depression and anger are indeed common emotional responses among individuals who require dialysis treatment. Researchers have extensively studied the psychological impact of dialysis and have shed light on the prevalence, causes, and potential interventions for these emotions. Here are some key findings and perspectives from the research:

Prevalence of depression and anger: Studies have consistently found higher rates of depression and anger among individuals undergoing dialysis compared to the general population. The chronic nature of the treatment, lifestyle changes, and the burden of managing a complex medical condition contribute to these emotional responses.

Causes and contributing factors: The causes of depression and anger in individuals undergoing dialysis are multifaceted. They can include the disruption of daily life and activities, the loss of independence, physical discomfort, financial stress, fear of the future, social isolation, and the impact of chronic illness on the individual’s overall well-being.

Impact on quality of life: Depression and anger can significantly impact the quality of life for individuals on dialysis. They may experience reduced motivation, decreased adherence to treatment, impaired social functioning, and lower overall life satisfaction. These emotional states can also negatively affect physical health outcomes and increase the risk of hospitalization.

Importance of mental health support: Recognizing the psychological challenges faced by individuals on dialysis, researchers emphasize the importance of providing mental health support as an integral part of their care. This can involve interventions such as counseling, psychotherapy, support groups, and education programs aimed at enhancing coping skills and emotional well-being.

Effectiveness of interventions: Several studies have shown that psychological interventions, such as cognitive-behavioral therapy, mindfulness-based techniques, and psychosocial support, can effectively reduce depressive symptoms and anger among individuals on dialysis. These interventions focus on improving emotional regulation, enhancing problem-solving skills, promoting social support, and fostering resilience.

Integrated care approach: Researchers advocate for an integrated care model that addresses both the physical and psychological aspects of dialysis treatment. This involves collaboration between nephrologists, psychologists, social workers, and other healthcare professionals to provide comprehensive support. By addressing emotional well-being alongside medical management, this approach aims to improve overall patient outcomes and quality of life.

It is important to note that the experiences and emotional responses to dialysis can vary among individuals. Therefore, personalized and patient-centered approaches are crucial in addressing depression, anger, and other psychological aspects of care for individuals undergoing dialysis treatment.

I Am Never Out of the Fight

The saying “I am never out of the fight” is closely associated with the U.S. Navy SEALs. It encapsulates the unwavering determination, resilience, and mindset that SEALs embody in the face of adversity.

The origins of this motto can be traced back to the legendary Navy SEAL sniper, Lieutenant Commander Mark W. Divine. Divine, a former Navy SEAL himself, popularized the phrase in his book “The Way of the SEAL: Think Like an Elite Warrior to Lead and Succeed.” In the book, Divine emphasizes the importance of mental toughness, perseverance, and an indomitable spirit to overcome challenges and achieve success.

“I am never out of the fight” reflects the SEALs’ commitment to excellence and their refusal to give up under any circumstances. It signifies their readiness to face and overcome obstacles, no matter how daunting or insurmountable they may seem. This mindset is deeply ingrained in the SEAL training and operational ethos, as their missions often involve high-risk situations, where failure is not an option.

The phrase also highlights the SEALs’ ability to adapt and improvise in dynamic and unpredictable environments. It conveys their determination to find alternative solutions, regroup, and continue the fight, even when faced with setbacks or unexpected challenges. It serves as a reminder to maintain focus, stay resilient, and press forward despite the adversities encountered along the way.

Moreover, “I am never out of the fight” embodies the SEALs’ commitment to their teammates and the camaraderie that exists within their ranks. It signifies their dedication to supporting and protecting one another, ensuring that no member is left behind. This unwavering loyalty and sense of brotherhood are crucial elements in the success of their missions and the preservation of their unit cohesion.

Beyond the SEAL community, the saying has resonated with many individuals seeking inspiration and motivation in their personal and professional lives. It has become a symbol of resilience, perseverance, and the refusal to surrender in the face of challenges. The mindset encapsulated by these words serves as a powerful reminder that, no matter the circumstances, one can always find the strength to keep fighting, to keep pushing forward, and to never give up.

In summary, the U.S. Navy SEAL saying “I am never out of the fight” embodies the unwavering determination, resilience, adaptability, and teamwork that defines the SEALs. It serves as a reminder to maintain an indomitable spirit, persist in the face of adversity, and stand together with a shared commitment to mission success.

I am never out of the fight applies equally to those of us on dialysis. Not only am I, Hank Feeser, never our of the fight, I’ll never Ring the Bell. Think about it if you are on dialysis or have other health shortfalls, and read what it means again and again. I am never out of the fight.

PET Revisited

Yesterday I blogged about my having had a PET test (Peritoneal Equilibration Test) early this week but did not go into why and what would be accomplished with the outcome, if anything. This blog attempts to fill in these gaps.

I have previously blogged about algorithms that may be used to calculate ideal mixtures of PD parameters such as amount of fluid used during the PD and dwell times. Turns out, according to my dialysis team, the results provided by the Fresenius app, while adequate, are surpassed by one provided by Baxter. It is this algorithm that my team wishes to use for my particular situation and it requires fresh inputs from a PET. Thus the why.

A PET measures how well your peritoneum (The membrane that lines the abdomen and abdominal cavity.) transports wastes and water. This transport is the essence of PD treatment. How well or poorly your peritoneum works is measured by something named “Transport rate.” Typically, the rate is expressed as a high, average, or low transport rate. Depending on the transport rate, a heuristic for what type of PD is best suited may be determined. See table below from this link:

In the past, my transport level has been Low Average. Based on this, my peritoneum is slow in removing waste but good in water removal (as indicated by my daily micro-filtration numbers which are always greater than 1000 ml.) Based on these results alone, I should be using manual CAPD (Continuous Ambulatory Peritoneal Dialysis) instead of the APD (Automated PD) that I am currently using.

We’ll know soon enough what my new prescription will be as a result of this PET.

Now to some fun stuff. The lead graphic is from a POE bot named “Playground-v2.” This bot generates high quality images based on the user’s most recent prompt. I inputted as a prompt “Picture of a 1932 Ford five window coupe” with the lead graphic resulting. This is the most classic Ford every produced and the golden standard for all hot rodders in the US. See, there is a fun-factor even in dialysis! See this link for everything you ever wanted to know about the 1932 Ford: https://en.wikipedia.org/wiki/1932_Ford

PET and Me

Monday I was informed that my dialysis team wanted to conduct a PET (Peritoneal Equilibration Test) to best determine what my current optimum dialysis prescription is. (See link for more info on PET. The first part of the test required me to conduct a manual introduction of 2000 ml of 2.5 % dialysis fluid Monday night which was to be left in my stomach overnight, followed by a visit to the Fresenisus clinic Tuesday morning for three more manual drains and fills, interspersed with a blood draw and siphoning off of 200 ml of expelled dialysis fluids for lab tests. I should know the results later on in the week depending on how Christmas affects lab schedules.

Since a patient on PD is not often required to do a manual process (we were taught how in our training sessions) a refresher was needed. I found the following video which is included to help those who may be in the same situation as I found myself in. The video spells out in detail every step and precaution involved.

Defining Kt/V

During my quarterly GP visit last week, I briefed my doctor, JP Letellier, MD on the status of my Peritoneal Dialysis including my shortfall in the Kt/V area. He quizzed me about what is behind the numbers which I was unable to provide in any detail. The following blog is in response to his questioning and will be provided to him. I used my AI assistant Poe as indicated below. She did a great job summarizing Kt/V for us.

Prompt: I am calculating Kt/V as I am on Peritoneal Dialysis. I conjecture that it has two components: the first is obtained from Peritoneal Dialysis, and the Second is from any Residual Kidney Function. Write a 500-word or so blog entry about the components of Kt/v and how labs calculate it in a professional medical tone.

Assistant Assistant Poe

Title: Understanding Kt/V in Peritoneal Dialysis: Examining the Components and Calculation

Introduction:
Peritoneal Dialysis (PD) is a life-sustaining treatment for patients with end-stage renal disease (ESRD) that helps remove waste products and excess fluid from the body. One crucial parameter used to assess the adequacy of PD is Kt/V, which measures the efficiency of solute clearance during dialysis. Kt/V incorporates two components: the contribution from Peritoneal Dialysis itself and the residual kidney function. In this blog post, we will explore these components and delve into the professional medical perspective of how laboratories calculate Kt/V.

Component 1: Peritoneal Dialysis (Kt):
Peritoneal Dialysis is a process that involves the infusion and drainage of a dialysis solution into the peritoneal cavity. The peritoneal membrane acts as a semipermeable barrier, allowing waste products and excess fluids to diffuse across it. The efficiency of solute removal during PD is represented by the term Kt, where K denotes the dialyzer clearance rate (clearance of solutes) and t represents the duration of the dialysis session.

The dialyzer clearance rate (K) is determined by factors such as the composition of the dialysis solution, the size of the solutes being cleared, and the characteristics of the peritoneal membrane. It is typically measured using the peritoneal equilibration test (PET), which involves measuring the concentrations of solutes in the dialysate and blood at various time points during a dwell period. The rate at which solutes equilibrate between the dialysate and the blood provides an estimate of K.

The duration of the dialysis session (t) refers to the time over which the dialysis solution is dwelling in the peritoneal cavity. Longer dwell times allow for greater clearance of solutes, improving the overall efficiency of Peritoneal Dialysis.

Component 2: Residual Kidney Function (V):
Residual Kidney Function (RKF) refers to the remaining functional capacity of the patient’s own kidneys. Even in patients with advanced renal failure, some degree of kidney function may persist. This residual function plays a significant role in the overall clearance of solutes from the body.

To quantify RKF, laboratory tests are performed to measure parameters such as serum creatinine and urea levels, as well as urine output. These values are then used to estimate the glomerular filtration rate (GFR), which reflects the filtering capacity of the kidneys. The GFR is a vital determinant of the second component of Kt/V, represented by V.

Calculation of Kt/V:
The total Kt/V is obtained by summing the contributions from Peritoneal Dialysis (Kt) and Residual Kidney Function (V). This summation provides a comprehensive measure of the overall clearance of solutes from the body during a given period.

Laboratories utilize various equations to calculate Kt/V, such as the formula developed by Twardowski et al. or the Daugirdas equation. These equations take into account parameters such as the patient’s total body water, ultrafiltration volume, and the measured or estimated GFR.

Conclusion:
Kt/V is a key parameter used to evaluate the adequacy of Peritoneal Dialysis. It incorporates two essential components: the efficiency of Peritoneal Dialysis itself (Kt) and the residual kidney function (V). The calculation of Kt/V involves assessing the dialyzer clearance rate, dwell time, and measurements of residual kidney function.

Accurate determination of Kt/V aids healthcare professionals in optimizing dialysis prescriptions, ensuring adequate solute clearance, and tailoring treatment plans to individual patient needs. By understanding the components and calculation of Kt/V, both patients and healthcare providers can make informed decisions regarding the management of Peritoneal Dialysis therapy.

I then asked Poe about the two methods mentioned above to calculate Kt/V with the following prompt and results:

Prompt: What are the Twardowski and Daugirdas equations for calculating Kt/V?

Assistant Assistant Poe

The Twardowski equation and the Daugirdas equation are two commonly used formulas for calculating Kt/V in peritoneal dialysis. Here are the equations:

  1. Twardowski Equation:
    The Twardowski equation, also known as the modified Watson equation, calculates Kt/V based on the measured dialysate to plasma concentration ratio (D/P ratio) of urea during a peritoneal equilibration test (PET). The equation is as follows:

Kt/V = -ln(R – 0.03) + (4 – 3.5R) × UF/W,
where:
R = D/P ratio of urea,
UF = ultrafiltration volume in liters,
W = patient’s weight in kilograms.

In this equation, the D/P ratio of urea is obtained from the measured concentrations of urea in the dialysate and plasma samples taken during a PET. The ultrafiltration volume represents the volume of fluid removed during the dwell period, and the patient’s weight is used to account for body water distribution.

  1. Daugirdas Equation:
    The Daugirdas equation provides an estimate of Kt/V based on various parameters, including the patient’s total body water, ultrafiltration volume, and the measured or estimated glomerular filtration rate (GFR). The equation is as follows:

Kt/V = -ln(R – 0.008 × t) + (4 – 3.5R) × UF/W + 0.03 × t,
where:
R = D/P ratio of urea,
t = dwell time in hours,
UF = ultrafiltration volume in liters,
W = patient’s weight in kilograms.

The Daugirdas equation incorporates the dwell time (t) in addition to the parameters used in the Twardowski equation. The dwell time represents the duration of the dialysis session.

It’s important to note that these equations are just two examples of the many formulas available for calculating Kt/V in peritoneal dialysis. Different centers or regions may use slightly different equations or modifications based on local practices and preferences. Additionally, these equations primarily focus on the clearance of urea, which is a commonly used marker for assessing dialysis adequacy. Other solutes may require additional equations or adjustments for accurate Kt/V calculations. It’s always recommended to consult with a healthcare professional or nephrologist for precise calculations and interpretation of Kt/V values in individual cases.

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