On 11/14/2023 WSJ ran an article by Jen Murphy titled Learning How to Fall Safely with Help From Martial Arts. Research indicates that by far the heavy half of those of us on Peritoneal Dialysis are over 66 putting us at risk for falls because of age if nothing else. Consider the following:
Increased Vulnerability: Patients on peritoneal dialysis often experience health conditions that can compromise their balance, coordination, and muscle strength. These factors contribute to an increased vulnerability to falls.
Bone Health Concerns: Chronic kidney disease, which necessitates peritoneal dialysis, can lead to weakened bones, making individuals more susceptible to fractures and injuries in the event of a fall. Osteoporosis, a condition characterized by low bone density, is prevalent among dialysis patients. The reader may recall that I suffer from Osteoporosis as measured by a recent bone density test and a frequent visitor from NC does also.
Given that a case be made for doing something about falling, what can we do is the thrust of this blog. Seems that research suggests the main tenant of judo and like sports is learning how to fall without hurting oneself as falling is central to the activity. The WSJ article states “Globally, one-third of people 65 and older fall at least once a year, with 5% of these falls resulting in a fracture… Falls are the leading cause of injury and injury-related death among Americans 65 and older….The fear of falling can significantly affect the quality of life…”
I’ll leave it up to the reader to take it from here. What I’m advocating is that maybe, just maybe, learning how to fall, however, you accomplish it, is a good idea. This is especially so for those of us on dialysis, regardless of our age. The video below explains the concept in more detail:
Recently I have come across several articles from the likes of Harvard Medical citing the physical, health, and mental advantages of dog ownership. Even those of us on PD can, with proper adjustments, have a dog in our lives. My wife and I have a 17-month-old Golden Retriever who is a constant delight, entertainment, and “forces” us into exercise of mind and body. His name is Dickens and he always lives up to his name. I walk him every morning, and my wife walks him every evening. In between we take turns going out with him to do his tricks and explore our ever-changing North Texas landscape.
I recently made a short video of pictures of him (lead video) and put it up on YouTube. The video was mashed together using Pictory.AI. It has received, as of this writing, going on 90 views already and hasn’t been up a week. People really like Goldens.
As I have cited numerous times in my blogs, I use poe.com as my ChatGPT/AI go-to source. One of the many special-purpose AI engines it hosts is one that deals with medical issues named DoctorSage. I quizzed this app with the following Prompt and obtained the included results. Dogs are good for us, especially those of us on dialysis.
Prompt: Write a blog entry about the health advantages of dog ownership
DoctorSage
Poe Title: The Health Advantages of Dog Ownership: More Than Just a Furry Friend
Introduction: Dogs have been man’s best friend for centuries, providing companionship, loyalty, and love. But did you know that owning a dog can also have numerous health advantages? From physical to mental well-being, having a canine companion can positively impact our overall health. In this blog entry, we will explore some of the remarkable health benefits that come with dog ownership.
Increased Physical Activity: Owning a dog naturally encourages physical activity, as they require regular exercise. This can be particularly beneficial for those who struggle with motivation or find it challenging to stick to an exercise routine. The following points highlight how dog ownership promotes physical activity:
Regular walks and outdoor activities: Dogs need daily exercise, such as walks, runs, or games of fetch. This encourages their owners to get outside and engage in physical activity. Improved heart health: Consistent exercise, such as walking or jogging with your dog, can reduce the risk of cardiovascular diseases, lower blood pressure, and improve overall heart health. Enhanced Mental Well-being: Dogs provide more than just physical benefits; they also contribute to our mental well-being. Here’s how:
Stress relief: Spending time with a dog has been shown to reduce stress levels and promote relaxation. Petting or cuddling a dog releases endorphins, which are natural mood boosters. Decreased feelings of loneliness: Dogs offer companionship and unconditional love, combating feelings of loneliness and isolation. This is particularly important for individuals living alone or struggling with mental health conditions. Increased social interaction: Dogs are excellent conversation starters and can help facilitate social connections. Taking your dog for walks or visiting dog parks can provide opportunities for socializing with other dog owners. Improved Immunity and Allergy Prevention: While it may seem counterintuitive, owning a dog can actually improve our immune system and protect against allergies. Consider the following points:
Boosted immune system: Studies suggest that children who grow up with dogs have a lower risk of developing allergies and asthma. Exposure to pet dander and microbes from dogs at an early age can help strengthen the immune system. Allergy prevention: Contrary to popular belief, owning a dog may actually reduce the risk of allergies later in life. It is believed that early exposure to pet allergens can help build tolerance and prevent the development of allergies. Conclusion: Owning a dog brings immense joy and companionship, but it also offers a myriad of health advantages. From increased physical activity and enhanced mental well-being to improved immune system function, dogs truly have a positive impact on our overall health. So, if you’ve been contemplating getting a furry friend, remember that along with their wagging tails and wet noses, they also bring a multitude of health benefits into your life.
I thought about naming this post “The Good and the Ugly; No Bad Here” but thought better of it. After viewing numerous ads on Facebook touting their company providing Abbott’s Libre 3 Continuous Glucose Monitor (CGM) as being covered by Medicare subject to some restrictions, I first tried US Med aka the ugly!
But first, a little background: I have been using the newer Libre 3 CGM for a year now, paying for it out of pocket to the tune of $154 to $192 per month. In the past, it has not been covered by Medicare because it required the user to have a smartphone on which to load the associated app to work. This past April Abbott received the OK from the FDA for their associated, stand-alone reader, so now the new package, consisting of the reader and required sender is becoming available and is covered by Medicare.
Back to US Med. Don’t go there. Despite numerous, and I mean numerous follow-ups, they just could not, or would not, get their order to my GP for fulfillment. I was promised by multiple CSRs and Order Fulfillment Reps that I would receive follow-up phone calls but never received one.
The second place I tried, Family Medical Supplies (301-479-3500) was the good and proved to be as different from USMed as the day is night. They immediately provided me with a link to their Intake Form (Link) which I filled out and followed up with a phone call to make certain it went through which it did. I then informed my GP that they would be contacting him for a script. In due course, I received a text from my GP that he had received the fax and replied. I then inquired about some particulars of the order, specifically to make certain I would be receiving the Libre 3 and NOT a Libre 2, and received a text smartly back informing me that it would be a Libre 3, what was in the shipment, when it was scheduled to ship, and when I should receive it.
Disclaimer: I do not and have not had any financial interest of any sort in the companies cited above. If interested, on Medicare, a diabetic and take insulin, check the link embedded above out.
Update: Order arrived Monday, 11/13/2023 as advertised at zero cost to me.
I have received numerous questions about this blog such as “Are people reading it?” etc. and a few about the nuts and bolts of running a blog such as this one. First to the nuts and bolts:
As I write this entry on 11/3/2023, I am running version 6.3.4 of WordPress as a Content Management System. It is an Open Source software that is literally in use by millions of users across the globe. First released on May 27, 2003, the soon-to-be-released version 6.4 (due out 11/7/2023) will be the 48th release. It is an absolutely solid piece of work with which I had had zero, nada, zip issues. It just works.
It costs $32.95 per year to register the domain name feeser.me. I am hosting the site on Dreamhost.com and they provide the resources for WordPress as part of the hosting. I signed up for two-year hosting at something like $99.00.
One of the strongest features of WordPress is since it is open software, there have been literally hundreds of plugins developed by independent developers for it. These include themes, SEO, search, table, and other enhancements. I am running the 23 theme and may try out the new 24 theme when it is released on 11/7/23. I am running a Search Engine Optimization program that provides me insights into who is visiting the site, what they read, for how long, where they came from, and so on. In the following screenshots with comments, I’ll share a small portion of these analytics.
The above screenshot suggests that as of 11/3/2023 there have been 6,576 pages viewed by 1,710 visitors of which 1,635 were unique. This is for a blog that has been up since 1/5/2023 with over 200 entries.
The next screenshot above provides data on the last 30 days during which there were 537 page views by 152 visitors of which 140 were first timers and overall visitors looked at 3.47 pages per visit. The graph further indicates page views on a given date which is indicative of interest in a given subject.
This screenshot depicts the geographical distribution of people are located that are visiting the blog. On the right side is a listing of the most recent visitors, from the United States, Canada, China, Columbia, Singapore, and Israel.
The screenshot above is of that portion of the WordPress analytics that provides a more precise location of visitors by IP address, and physical location of the IP address as you can ascertain.
The last screenshot above provides further analytics on the specifics of the blog entries that visitors landed on.
The above is but a taste of the information that is available to me and others posting their blogs using WordPress. Big Brother is watching!
My wife often tells me that I get the plow in too deep for many readers of this blog who may be at the onset of research into what PD is all about. For that audience, I recently viewed the video embedded below from YouTube that speaks very well to the basics of PD, especially the manual version. For that audience, the video below is for you:
As of September 30, 2023, Fresenius Medical Care treated 341,793 patients in 4,014 dialysis clinics worldwide and had 123,106 employees (headcount) globally, compared to 130,295 employees as of September 30, 2022.
Fresenius Medical Care is the world’s leading provider of products and services for individuals with renal diseases of which around 3.9 million patients worldwide regularly undergo dialysis treatment. Through its network of 4,014 dialysis clinics, Fresenius Medical Care provides dialysis treatments for approximately 342,000 patients around the globe. Fresenius Medical Care is also the leading provider of dialysis products such as dialysis machines or dialyzers. Fresenius Medical Care is listed on the Frankfurt Stock Exchange (FME) and on the New York Stock Exchange (FMS).
All of the above from this link: The lead graphic is from a Bing search on stock FMS.
The bottom line is that FMS is the 100-pound gorilla in the dialysis arena. As a side note, in the recent past, they won a huge contract with the VA to provide dialysis services to veterans. It may be comforting to those on dialysis, regardless of the type, that they appear to be here to stay. Further, Ms Helen Giza, born in 1968, is their CEO @ $3.45 million per year. This is a bit more than my dialysis nurse Cindy makes, even with overtime.
On Thursday, 11/9/2023 I met with my dialysis team: dialysis nurse, social worker, neurologist, and dietician. It went exactly as my dialysis nurse predicted after my last Adequacy Test; the amount of fluid I am to use now has been increased to 2500 mL from 2000mL previously. This was programmed into the thumb drive that is placed into the Liberty Cycler so it is accomplished more or less automatically.
What isn’t accomplished automatically, is my supply storage and ordering it now completely different. Before I was using one 5L and one 3L bag per session (8L total) and now I can use two 5L bags, two 6L bags (I don’t have any), or many other combinations as long as they add to to a minimum of 10 L.
I was also prescribed Lasix which in generic form is Furosemide. It is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease. This can lessen symptoms such as shortness of breath and swelling in your arms, legs, and abdomen.This drug is also used to treat high blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. Furosemide is a “water pill” (diuretic) that causes you to make more urine. This helps your body get rid of extra water and salt. For me, it is being targeted toward making more urine and shortness of breath.
Readers should not come away from this blog thinking that having to change dialysis prescriptions is unique to me. A frequent reader of this blog from Greensboro, NC is experiencing almost exactly the same situations as I have related recently. He is undergoing multiple adequacy tests as adjustments to his fluid amounts and dwell times are being jockeyed in an attempt to ascertain what works best for him. His GP recently recommended a bone density test for him; you may recall that I recently had one and was diagnosed as having osteoporosis, and the vitamins D3 and K2 were indicated.
During my last adequacy test visit, the team social worker had me fill out a Kidney Disease Quality of Life questionnaire. I was provided a summary of this report at this visit which compared me to a large group of Fresenius Medical Care patients who are similar to me, based on gender, age range, and diabetes status. This is an annual requirement on their part. The survey looks at five areas:
Physical Health: How well you think you feel physically.
Emotional/mental health: How well you think you feel mentally and emotionally.
Burden of kidney disease: How much kidney disease interferes with your daily life, causes you frustration, and makes you feel like a burden.
Physical symptoms and problems related to CKD: How bothered you feel by day-to-day physical symptoms or problems caused by dialysis?
Effects of kidney disease: How your daily life is affected by dialysis in terms of fluid/dietary limits on work or travel, feeling dependent stress, your sex life, or your appearance.
I’ve summarized my results in the table below
Attributes
Average Range
Current Score
Past Score 12/2022
Physical health
24.8 to 44.6
55.3
55.3
Emotional/Mental Health
40.3 to 61.3
60.7
60.7
Burden of Kidney Disease
19.1 to 76.5
87.5
93.8
Physical symptoms and problems
63.7 to 94.8
97.9
93.8
Effect of Kidney Disease
50.9 to 94.6
96.9
96.9
Hank Feeser Kidney Disease Quality of Life Survey Nov 2023
As you should ascertain from the foregoing table, I’m hanging in there with the best.
As the title of this blog indicates, my latest (Nov 1, 2023) PD Adequacy Test indicates I am not getting enough PD treatment. In October 2023 my reading was 1.7 and now it’s 1.56 with a downward trend since April 2023 as you may readily ascertain from the graph above.
I have a dialysis team meeting coming up on Friday, 11/9/2023 during which I’m certain changes in my dialysis prescription will result. Such changes could range from increasing the amount of dextrose fluid per exchange that is utilized, to its strength, to the length of dwells, to change of medication such as the diuretic Hydrochlorothiazide I currently am prescribed. As I currently only stock 5L and 3L bags of dextrose, this could have an impact on my supply inventory and consequent supply ordering from Fresenius.
So my wKt/V has changed. Turns out as previously reported, so has a colleague’s in Greensboro, NC. To ascertain what may be causal in this change, I turned to my AI assistant with the Prompt in blue below with the following results for all of our edification:
Title: Understanding Peritoneal Dialysis Adequacy Test Decreases: Causes and Nephrologist’s Response
Introduction:
Peritoneal dialysis (PD) is a vital treatment option for individuals with end-stage renal disease (ESRD). Regular assessment of peritoneal dialysis adequacy is crucial in ensuring the effectiveness of the treatment. However, there are instances when the peritoneal dialysis adequacy test may indicate a decrease in efficiency. In this blog post, we will explore the potential causes behind this decrease and the steps typically taken by nephrologists in response. It is worth noting that your use of the diuretic Hydrochlorothiazide may have some implications in this context.
Causes of Peritoneal Dialysis Adequacy Test Decrease:
Peritoneal Membrane Changes: Over time, the peritoneal membrane, which serves as the dialysis filter, may undergo structural changes. This can lead to a decrease in the efficiency of solute and fluid removal during PD.
Infection or Inflammation: Infections or inflammation of the peritoneum, known as peritonitis, can impair the function of the peritoneal membrane. It can lead to decreased dialysate flow, reduced ultrafiltration, and compromised clearance of waste products.
Catheter Dysfunction: The peritoneal dialysis catheter is responsible for delivering and draining the dialysate. Catheter-related issues such as blockages, malpositioning, or infections can impede the dialysis process and result in inadequate clearance.
Medications: Certain medications, including diuretics like Hydrochlorothiazide, can affect the fluid balance in the body. While diuretics are commonly used to manage fluid overload, excessive diuresis can impact the fluid status required for effective PD.
Nephrologist’s Response:
Comprehensive Assessment: When faced with a decrease in peritoneal dialysis adequacy, nephrologists begin by conducting a thorough assessment of the patient. This includes reviewing medical history, and current medications, and conducting physical exams to identify potential causes.
Evaluation of Peritoneal Membrane Function: Nephrologists may order tests such as a peritoneal equilibration test (PET) to evaluate the transport characteristics of the peritoneal membrane. This helps determine if structural changes in the membrane contribute to the decrease in adequacy.
Infection Management: If peritonitis is suspected, prompt initiation of appropriate antibiotic therapy is crucial. Cultures may be obtained to identify the causative organism and guide treatment. Resolving the infection can improve peritoneal dialysis adequacy.
Catheter Assessment and Intervention: Nephrologists closely evaluate the peritoneal dialysis catheter for any signs of dysfunction or infection. If necessary, interventions such as catheter repositioning, flushing, or replacement may be recommended to restore adequate dialysate flow.
Medication Adjustment: In the case of medications that may impact fluid balance, nephrologists may consider adjusting the dosage or switching to alternative medications. This helps maintain the delicate fluid balance required for effective peritoneal dialysis.
Conclusion:
Peritoneal dialysis adequacy is a crucial aspect of effective renal replacement therapy. The causes of a decrease in adequacy can range from peritoneal membrane changes to medication-related factors. Nephrologists play a vital role in investigating and addressing these issues promptly. By conducting comprehensive assessments and implementing appropriate interventions, they strive to optimize peritoneal dialysis outcomes and improve the overall well-being of their patients. If you have concerns about the adequacy of your peritoneal dialysis, it is important to consult with your nephrologist, who can provide personalized guidance based on your specific situation.
Typically, every quarter, PD patients must undergo what is called an “adequacy test.” My cycle has been accelerated in an effort to ascertain if moving my catheter has helped with my overall dialysis treatment. The test, from my perspective, involves a 24-hour urine collection, collection of all of the drains from my dialysis treatment and, presenting them to the dialysis center for analysis, and using just a 2.5% dextrose solution for treatment.
Based on analysis of all of this, one of the measurements the lab provides is depicted in the lead graphic, wKt/V, which indicates if we’re getting enough dialysis. From this, my nephrologist decides if I’m OK as is, need a stronger dialysis solution, or more cycle time on the Liberty Cycler. Of course, it could go the other way and improve, but this hasn’t happened lately for me. From the foregoing, you should take away that adequacy testing is a most important part of PD and should not be taken lightly.
For comparison, a frequent visitor to this blog from Greensboro, NC’s wKt/V is 1.47. His doctor prescribed more dialysis. He was doing five cycles of 2 liters each but now is doing five cycles of 2.3 liters each.
Since adequacy testing is so important and central to keeping peritoneal dialysis on track, readers of this blog should have a more complete understanding of just what adequacy testing is. I fired up my AI Assistant Poe and, with the prompt in the graphic below, obtained the following results to further your understanding.
Introduction: Living with a chronic kidney disease and undergoing peritoneal dialysis (PD) can be challenging, but advancements in medical technology have significantly improved the quality of life for patients. One critical aspect of PD care is the regular adequacy test, which plays a crucial role in ensuring effective and efficient dialysis treatment. In this blog post, we will explore the need for adequacy testing, explain what it involves, and highlight its importance for peritoneal dialysis patients.
Understanding Adequacy Testing: Adequacy testing is a procedure performed regularly, typically every quarter, to evaluate the effectiveness of peritoneal dialysis treatment. It assesses how well the patient’s body is being cleared of waste products and excess fluid, as well as the overall health of the peritoneal membrane, which acts as the filter during dialysis. The test measures parameters such as urea clearance, creatinine clearance, and ultrafiltration volume to determine the efficiency of the treatment.
Why is Adequacy Testing Important?
Optimal Waste Removal: Adequacy testing helps ensure that waste products, toxins, and excess fluid are adequately removed from the body. This is crucial for maintaining the overall health and well-being of peritoneal dialysis patients. Proper waste removal helps prevent complications associated with the buildup of toxins, such as cardiovascular problems, anemia, and bone diseases.
Monitoring Peritoneal Membrane Function: The peritoneal membrane is a vital component in the peritoneal dialysis process. Adequacy testing allows healthcare professionals to assess the health and function of this membrane. It helps identify any abnormalities or changes that may affect the efficiency of dialysis treatment. Early detection of membrane dysfunction enables healthcare providers to make necessary adjustments to the treatment plan, ensuring optimal dialysis outcomes.
Individualized Treatment Optimization: Adequacy testing provides valuable information about a patient’s specific dialysis needs. The results help healthcare providers determine the adequacy of the current treatment regimen and make appropriate adjustments. These adjustments may include changes in dialysis solution prescription, dwell time, or the number of exchanges to maximize the efficiency of waste removal and fluid balance tailored to the patient’s unique requirements.
Prevention of Complications: Regular adequacy testing aids in the early detection of potential complications. By closely monitoring parameters such as urea and creatinine clearance, healthcare professionals can identify issues such as peritonitis (infection of the peritoneal membrane) or inadequate clearance, which can lead to inadequate dialysis. Timely intervention can prevent the progression of complications and improve patient outcomes.
The Adequacy Testing Procedure: Adequacy testing involves several components, including blood tests, urine collection, and dialysate collection. During the procedure, blood samples are taken to measure various parameters that indicate the efficiency of waste removal. Urine samples may also be collected to evaluate residual kidney function. Additionally, dialysate samples are collected to assess the amount of waste removal during peritoneal dialysis.
The Importance of Active Patient Participation: Patients play a vital role in ensuring the accuracy and effectiveness of adequacy testing. It is essential to follow healthcare provider instructions regarding diet, medication, and fluid intake leading up to the test. Maintaining accurate records of dialysis exchanges and symptoms experienced between treatments can provide valuable information for healthcare professionals during the assessment process.
Conclusion: Adequacy testing is a crucial aspect of peritoneal dialysis care. By evaluating the efficiency of waste removal and assessing peritoneal membrane function it helps healthcare providers optimize treatment plans and prevent complications. Regular testing allows for personalized adjustments to the dialysis regimen, ensuring patients receive the most effective treatment tailored to their unique needs. As a peritoneal dialysis patient, active participation in the adequacy testing process empowers you to take charge of your health and maximize the benefits of this life-sustaining therapy.
In yesterday’s blog, I demonstrated how to calculate the percentage strength of a dialysis mixture given an assortment of input fluids of various dextrose percentages. In today’s blog, we are going to consider the question: Given that I am using mixtures of 2.125% and 1.72% dextrose strength and that this strength is a factor in determining how much fluid (ultrafiltration) is removed during peritoneal dialysis, what is the difference, if any, in ultrafiltration between the nights when I use a 1.5% 5-liter with a 2.5% 3-liter fluid, as compared with alternative nights when I use a 2.5% 5-liter with a 1.5% 3-liter?
The hypothesis in this case is that there is no difference in the means of the two groups of observed ultrafiltration samples. This is the NULL hypothesis. A paired samples t-test based on a “matched-pairs sample” is the appropriate statistical methodology in this case (trust me!) A t-test is a type of statistical analysis used to compare the averages of two groups and determine whether the differences between them are more likely to arise from random chance.
Although I have never used my AI assistant Poe to conduct statistical analysis previously, I knew it could do so. So first, I asked Poe what format it wanted to receive data in with the following results:
To perform a t-test, you must provide the data for two groups or samples. Each group should consist of numerical values that you want to compare. Here’s an example of how you can input the data for a t-test:
Group 1: [1, 2, 3, 4, 5] Group 2: [2, 4, 6, 8, 10]
In this example, we have two groups: Group 1 and Group 2. Group 1 contains the values [1, 2, 3, 4, 5], and Group 2 contains the values [2, 4, 6, 8, 10]. These are just sample values, and you should replace them with your own data.
I then inputted my recorded ultrafiltration data from my log sheet, using only the 18 data points since my catheter was repositioned. Group 1 is the lower percentage group, and Group 2 is the higher percentage Group. Poe responded with the following:
To perform a paired t-test on the given data, we’ll compare the paired observations between Group 1 and Group 2. Here are the two groups of data:
I then informed Poe that I desired to have a 95% confidence level in the results, which corresponds to a p-value of 0.05, and the following resulted:
Given a significance level 0.05, we compare the calculated t-value (-1.46) with the critical t-value from the t-distribution table with 8 degrees of freedom.
Since the t-value does not fall within the critical region (beyond the critical value), we fail to reject the null hypothesis. This means that we do not have sufficient evidence to conclude that there is a significant difference between Group 1 and Group 2.
In other words, at a significance level of 0.05, the null hypothesis is supported, suggesting that there is no significant difference between the means of the paired observations in Group 1 and Group 2.
The bottom line for those of you whose eyes glazed over at the first mention of statistics is that I am obtaining the statistically same ultrafiltration whether using the 2.215% or 1.72% solution. It makes no difference in the amount of fluid we are pulling off. QED
