There is much more to being a successful Dialysis patient, parent and/or partner than finishing nightly dialysis. Those of us on Dialysis tend to get wrapped up in ourselves, in the process of dialysis, in its needs and yes, confining and conflicting requirements. We forget that there are people out there who are normal, or at least they should be, who are having other life’s experiences that float their boats.
We sometimes overlook the fact that Dialysis is but one, an important one, but just one aspect of our lives. As a diabetic, I must keep a high level of diabetic control. Yesterday I visited with my eye doctor for a diabetic retinopathy exam. Do this once a year. I’m fine. No change. We have to keep a steady pull on all aspects of our life. We have to start every day with the USNavy Seal’s credo, and make our beds.
The neatest thing that took place at our N. Texas home yesterday was that the Egyptian Goose that laid eggs in the guttering over our master bedroom roof coached her six little ducklings down off the roof and she went quacking, along with her male mate, across the street, through the ditch, and off into the golf course to seek water.
Life does go on, even if you are are Dialysis……. Live it, own it.
The purpose of this blog is to vent my frustration with the medical community and its support group, pharmacies.
Since late March, I have been trying to get a prescription for the Freestyle Libre 3 filled by the pharmacy required to be used by my insurance company, ExpressScripts. As you know from the lead to this blog, I am a retired Naval Officer and ExpressScripts (ES) is our “pharmacy.”
In good faith, my GP honored my request and sent a script in to ES. ES acknowledged receipt of the script, and within a day or so, my tracking app on my phone informed me that something called prior authorization was required, and they had contacted my prescribing MD. A couple of days later, the app informed me that all was good and they were “Working” on filling the script. Then I was informed that everything was canceled. I called ES and was informed that everything was on track and shipping would occur by 4/14/23. Then my app informed me that everything had been canceled. On 4/11/23, I again called ES and was informed that my GP had been faxed a “Critical Criteria” form to fill out and submit, and had not done so in the few days ES allocated, so the script had been unilaterally canceled by ES. Called the GP’s office, and of course, they had not received and/or were unaware of this Critical Criteria form.
The Libre3 lasts for but 14 days. Usually, a script for a year is prescribed for pills, with three months’ worth, or in this case, 6 Libre3 is delivered once every three months. Instead, my out-of-pocket would be every two weeks instead of the same cost for a three-month supply. Another screwup.
Another unsatisfactory situation with ES is their two-factor authentication process. They require a username and password to log in, then send back a six-digit number via email for the second authentication. Sounds good in theory, except the 15-minute timer on completing the second step often times out before receipt of the code. Regardless, who has time to stare at a screen waiting seemingly forever for a stupid code?
Yet another hindrance to goodwill is having to talk to a stupid computer when you call ES. Trying to bust out of the Ai’s scripting is daunting. I’m certain management is patting themselves for all the money they’re saving on CS calls, but they should get on the other end of the phone call and experience how frustrating it is when your call does not meet their canned expectations. Bummer!
As I write this, I await a call from the GP to resolve this dilemma.
Update. No callback. Called the GP script person again, and we agreed that she would send in a new script to ES for a year’s supply of Libre 3 every three months. That’s the latest. Stand by as the saga continues.
Yesterday afternoon at 1:34 PM CDT, I received a call from a 781-699-5405 number. Area code maps to Boston. A Google search on the number resulted in Fresenius numbers. Their corporate office in Waltham, MA, is 781-699-9000. The female voice on the other end of the call inquired about the “dialysis problems” I was having, and the thrust of her call seemed to be whether I could complete my nightly dialysis treatment. I attempted to fill her in on what has been happening, and her response was had I discussed the matter with my dialysis nurse?
This is insulting! I assured her I had discussed the matter with my entire team and anyone else who would stand still long enough for me to relate, including our Golden Retriever Dickens. She was disinterested in anything else, which was obvious when I attempted to explain my interfaces with tech support. All the call managed to do was piss me off!
How did someone from Corporate know that I have been having severe problems with drains on their Liberty Cycler – and I’m NOT the only one! While I have blogged about it, anyone with a slight amount of brain cells from reading the blog would know the full history of my drain problems. If corporate had troubled themselves to reach out to my local Fresenius facility (if they can find me, they could find them), they would have received an in-depth briefing. I have exchanged emails with corporate about the new cycler, and believe I included my contact info therein. Perhaps this is the source of the phone call?
Whatever it is, a phone call out of the blue from corporate that even hinted I have not been in close contact with my local Fresenius Dialysis Team on this, and ANY aspect of my treatment is an insult to both the people who support my treatment and me. I’m so close to the team, that they even know the color of the skivvies I wear.
On March 19, 2023, I wrote a blog titled “Impact of dialysis on marriage: Does dialysis correlate with divorce?”My research found at least five areas directly impact marriage+dialysis; 2. Emotional Impact and 5. Intimacy & sexual health. Anything we can do and/or embrace for improvements in these two areas should/could lead to a more optimum dialysis experience – without the expenditure of much time and/or money on our part in this instance.
-I recently read an interesting article by Dr. Cortney Warren “If you use any of these 9 phrases every day, ‘your relationship is more successful’ than most”Dr. Cortney S. Warren, PhD, is a board-certified psychologist and author of “Letting Go of Your Ex.” She specializes in marriages, love addiction, and breakups, and received her clinical training at Harvard Medical School. She has written almost 50 peer-reviewed journal articles and delivered more than 75 presentations on the psychology of relationships. Follow her on Twitter @DrCortneyWarren, according to the article which is linked here.
It is so important that readers of this blog can take on the full impact of Dr. Warren’s wisdom, that I am including verbatim the bulk of the text from the article for your edification. From here on in the blog is a direct quote from the article by Dr. Warren linked above. The lead graphic is also from the article for full attribution. These are the nine phrases to incorporate into your daily interfaces with your partner.
1. “I appreciate your effort.”
It’s tempting to become overly focused on things you don’t like about your partner and to point them out at every chance you get.
But it’s important to highlight the good in their actions. Happy couples express gratitude for each other’s efforts. It’s a great way to make everyone feel valued.
Similar phrases:
“I appreciate that you work so hard to support our family.”
“I’m grateful you take the kids to school because it helps me get things done in the morning.”
2. “I like you.”
The healthiest couples don’t just love each other, they like each other, too. Loving someone is an intense feeling of affection; liking is about seeing them for who they are and acknowledging the attributes you enjoy about them.
Similar phrases:
“I like that you are so passionate about staying healthy.”
“I like how devoted you are to your hobbies.”
3. “Help me better understand this.”
We all have different upbringings, vulnerabilities, values, and beliefs that shape how we think relationships should work.
If your partner reacts to a situation in a way you don’t understand, telling them that you want to know them better is key to resolving conflict and bonding at a deeper level.
Similar phrases:
“I don’t know why this is so upsetting to you. Please help me see your perspective.”
“I want to work through this together, and I need to understand you better to do that.”
4. “I’m listening…”
Disagreements are inevitable, but it’s important to still support each other through active listening.
You have to be willing to suspend your desire to be “right” or to get your point across — long enough to hear and empathize with your partner’s perspective.
Similar phrases:
“I’ll stop talking now and really try to listen to your point of view.”
“I want to hear your side of things, even if we ultimately disagree.”
5. “I’m sorry.”
When things don’t go right or as planned, healthy couples know that both partners play a part in the situation.
Taking responsibility for our role in those conflicts — and genuinely apologizing — is critical to repairing rifts.
Similar phrases:
“I didn’t communicate my feelings in a respectful way to you, and I’m sorry for that.”
“I didn’t like the way you acted last night, but I also need to apologize for lashing out.”
6. “I forgive you. Can you forgive me?”
Forgiveness is hard. It requires being vulnerable, letting go of something that caused you pain, and changing your feelings toward your partner.
But studies have shown that couples who practice forgiveness are more likely to enjoy longer, more satisfying relationships.
Similar phrases:
“I know we can’t change the past, so I’m actively trying to let it go and move forward.”
“I made a mistake and I’m trying to forgive myself. I hope you can forgive me, too.”
7. “I am committed to you.”
Being in a relationship is a choice. Reassuring your partner that you’re still choosing to be with them and to work through challenges will help create a sense of safety and stability.
Similar phrases:
“Even when times are tough, I still choose to be with you.”
“I’m here, and I want to make this work with you. We’re a team.”
8. “Let’s have some fun!”
If you can find humor (or playfully tease each other) during tense moments, your relationship might be stronger than you think.
The happiest couples are able to break tension and recalibrate the mood by finding room for an authentic smile, silly banter or a lighthearted joke.
Similar phrases:
“We should get some fresh air. Want to do something fun today?”
“I know I’m a lot sometimes. Let’s take a breather from the tough topics and watch a comedy.”
9. “I love you.”
This one is simple but always worth reminding. Verbally expressing your romantic love for one another keeps the relationship alive. And when you say it, make sure you truly mean it.
The past week I had my monthly and quarterly meeting with my Dialysis Nurse. I collected a 24-hour urine sample – yes, still making some yellow fluid, and four collection bags for discharge from the Cycler wherein only 2.5 solutions were used. All the typical attributes of my dialysis health were checked – she listened to my heart, inspected my feet – some swelling, drew a blood sample, injected me with iron, and asked me a battery of questions, plus provided me with the Fresenius monthly educational packet. Took about 30 minutes and after collecting the bag of replacement dialysis support items provided by Fresenius – tape, and soap this cycle, I was on my way. As usual, the following day preliminary lab results were available via the Fresenius Patient Hub, and the following day detailed lab results were available. My detailed lab results in PDF format are available below for your download and/or viewing.
There is no concise or easy way to present a graphical representation of some of the lab results. I’m going to list 11 results followed by a screen capture of the same from the PatientHub. You can cycle down and visually ascertain what’s going on. I am not upset by any results. I would like to explain what’s going on with A1c. I started gaining weight and as I result I noticed via my CGM that my morning glucose reading was rising, not bad, in the 120+ range, but still up from my normal 90-110 range. I know that I am extremely sensitive to weight gain from a diabetic control perspective. I increased my Lantus by one unit to 9 from 8 as a result. This brought my morning/fasting glucose back down – it was 94 this morning and explains the full one-point drop in A1c.
Second comment, my Creatinine at 6.60 is up from 6.27 in the last lab. Inputting age=84, Gender=M into my eGFR app yielded an eGFR of 8 which it has consistently been over many months. You can refer back to the eGFR graphical analysis I blogged about a couple of days ago for an additional check.
Last comment: Note that my Hemoglobin at 11.6 continues to be high from the stated goal of 10-11. I would think that more red blood cells are good but intend to discuss this with my nephrologist meeting scheduled for later this week. BTW, Fresenius provided me with a full box of high protein bars at my lab meetup also. Thanks to them for this.
Fresenius hosts a Patient’s Hub through which many aspects of Dialysis support are provided. Examples are the ability to order supplies monthly, daily input dialysis info from the night before, and a forum for supported members to post and respond to other inputs from fellow dialysis patients. Recently, a rlbecker posted what is quoted below. After this input, I included a few of my own. These are inputs to improve the Fresenius experience from a user’s perspective.
I am a newbie. Only on PD for 4 months. But I have some thoughts on potential improvement of the experience which are in the details below.
1. Catheter insertion.
If we need an x-ray to see where the catheter is, something is broken. The surgeon knows where it is placed right after the surgery. In addition to saying “everything went well” and prescribing pain medications afterwards, he/she should show on a diagram the angle of the catheter and the depth of the insertion. Even better, the surgeon should ask the patient how he/she sleeps (back, side, stomach) before the surgery, to guide the process for the best outcome.
2. Modem power.
The cycler cord is 10 feet long, but the cord on the modem is a couple feet less. This makes it difficult to manage the cords from the cycler to the wall. If both were the same length, one could tape the cords together to make a less cumbersome attachment. Even better, just like amplifiers, tuners, etc., the cycler could provide a through power outlet on the back for plugging in the modem (which could have a very short cord), eliminating one cord from the cycler to the wall.
3. Display on the cycler.
At this point, you have two options: always on; and on for x minutes, then off. There are times when you just want to see where things are in the process, so you tap on the display to see, and are then burdened with an additional period of light in the darkness of the bedroom. Since the sensors are already there and programmable, why not treat the light like the infamous “clapper” from TV ads: one tap to turn the light on, two taps to turn it back off?
4. Treatment complete.
When treatment is complete, why not turn on the light with that screen showing? One should not have to wonder whether or not the cycler has done its thing and you can get up and do the aseptic disconnection.
5. Helpful chart for new patients.
Setting up can seem a little daunting in the beginning. I am suggesting a chart to help demystify the process. On the chart, columns would be: display, time, you must do, and you can do. Rows will contain the displays that appear on the cycler as you go from step to step. As the cycler is going through its various setup steps, you could see what you can do in parallel and how much time you have to do that before the cycler will be ready for you to review and press next. This could shorten the time required to set up the cycler in the beginning while one is learning.
End Quote:
Hank’s comments follow:
H1: Several technology companies have virtual assistants that are now ingrained into users’ fabric. Apple has Siri. Google has Google Assistant. Amazon has Alexa. Fresenius should incorporate technology into the Cycler so that patients can query the Cycler while at a distance and/or in bed. For example, they could inquire how many more minutes the cycler has on dwell, drain, or where in the total treatment. Instead of getting up to quell a drain alarm, they could reset it from bed and, in response, reposition their bodies, etc. They could verbally enter parameters into the Cycler upon completion of dialysis instead of getting down on their knees to enter the same digitally – the old fashion way, BTW.
H2: Excessive non-recyclable debris must be disposed of after a Dialysis course. There are the boxes in which the dialysate is delivered. There are plastic wrappers from dialysate bags and the bags themselves. There is the cassette to be disposed of. And more odds and ends. This adds up to a 64 Galleon trash can just about filled every week. Certainly, German engineers can do better than this.
H3: Why do we even have an external modem at all? Most newer appliances are connected to the IOT (Internet of Things), including television sets. Using current technology, all of the hardware to gather data should be housed within the cycler.
H4: And speaking of data gathering, why, if I am inputting data into the Cycler every morning after my dialysis? There is a USB Thumb Drive that is also gathering data that I am required to “Sneaker Net” to my monthly meeting with my Dialysis Nurse. Why, when I call Tech support, do I have to go through countless screens of data and verbally provide the same to tech support before they even attempt to address the problem(s) that initiated my call? Shouldn’t such data already be in the system via the modem?
H5: My initial loadout of dialysate in no way matched the initial prescription my Nephrologist ordered. So I’m stuck with thirty-plus boxes of 2.5 dialysates that I have to eliminate since Fresenius has a policy of not accepting boxes of dialysate to return once they pass the patient’s portal.
There is an article in the 4/3/2023 issue of CNN Health by Madeline Holcombe titled “These 5 rules for good sleep may also impact the development of asthma, experts say.” “Bad sleep quality and quantity may put you at greater risk for developing asthma, according to a new study” the study concludes. It is linked here: The picture above is from the cited article.
That got me thinking about what other ailments might be lurking in the background related to lack of sleep caused by the Fresenius Cycler Drain Alarms for which Fresenius may be found to be culpable. This line of thinking springs from my dealings with the Veteran Administration and Agent Orange. In my instance, a primary prima facia fact is that I served boots on the ground in Vietnam. Given so, I was exposed to Agent Orange. I subsequently developed Type II diabetes which became my primary ailment from such exposure. As documented herein, up to 40% or more diabetes patients become Dialysis patients. Dialysis is secondary to diabetes in the VA way of thinking. The same logic probably follows herein, but I am NOT (thank God) a lawyer!
So we have the Fresenius Liberty Cycler interrupting sleep (Primary) and “causing” what possible other “secondary” ailments among Peritoneal Dialysis patients?
So doing what I am trained to do, I asked my able AI for assistance in this manner, in this case, openai.com’s GPT-3.5. The Prompt I used is listed below, followed by the AI output I edited and a few short conclusion comments.
Prompt: It is a well-established fact from users that the Fresenius Liberty Cycler interrupts sleep because of alarms on the drain cycle. Interruption of sleep can lead to a lack of sleep on the part of the dialysis patient. A recent article in CNN suggested that lack of sleep can lead to asthma. What other ailments could be secondary to lack sleep possibly caused by drain alarms on the Liberty Cycler?
Many potential health problems can result from a lack of sleep caused by interruptions, such as those caused by the alarms on the Fresenius Liberty Cycler during dialysis treatment. Here are a few examples:
Cardiovascular disease: Lack of sleep has been linked to an increased risk of heart disease, stroke, and other cardiovascular problems. Interruptions in sleep caused by alarms on the dialysis machine could exacerbate these risks in dialysis patients who are already at a higher risk for cardiovascular problems.
Diabetes: Poor sleep has been linked to insulin resistance and impaired glucose tolerance, key risk factors for diabetes. Dialysis patients with diabetes may be at a higher risk for complications related to their condition if they are not getting enough sleep.
Depression and anxiety: Sleep deprivation has been linked to depression and anxiety in many studies. Dialysis patients already dealing with the stress of their condition may be particularly vulnerable to these mental health problems if they cannot get enough sleep.
Immune system problems: Lack of sleep has weakened the immune system, making it harder for the body to fight infections and other health problems. Dialysis patients already dealing with weakened immune systems due to their condition may be particularly vulnerable to infections if they are not getting enough sleep.
Cognitive problems: Sleep deprivation can lead to problems such as difficulty concentrating, memory problems, and impaired decision-making. Dialysis patients not getting enough sleep may have trouble managing their treatment regimen or other aspects of their daily life.
This looks like a real pickle for PD patients using the Liberty Cycler. On the one hand, the Cycler is totally supporting their very life. On the other hand, it CAN be related to other life-threatening medical challenges. In this case, it boils down to the lesser of all evils. I’m sticking with the Cycler and holding on to the sincere hope that Fresenius rolls out the new and improved version in my lifetime.
A couple of days ago I related my long journey to being currently on dialysis. I 100% attribute this requirement to my earlier ailment, diabetes. One aspect I did not relate to is that my grandmother on my mother’s side of the family was diabetic, my mother was diabetic, and our two sons were/are diabetic. This is somewhat moot “proof” that it can be inherited and runs in families. It does not, however in any aspect, remove the burden of where we are, a diabetic on dialysis. This association got me thinking about the importance of really really recognizing the strong tie between being diabetic and its impact on the future statistical probability of needing/requiring Dialysis.Then, I turned to my silent partner in crime, my faithful AI assistant openai.com running gpt-4 with the following prompt, and the subsequent result is included below.
First, a couple of comments. I firmly believe I stayed on Metformin too long, seriously impacting my kidneys. At no time was there any appearance of coordination and/or teamwork or communication between doctors involved in my treatment? I’m sorry to state that to this day it is obvious that such teamwork is lacking. Doctors live in silos from which they rarely seem to leave. Over time my doctors hammered my Hypertension without explaining in any detail the ramifications and/or if/then/else of not keeping it within bounds, which seemed to be ever-changing over time. As soon as an individual’s eGFR passes the 60 wicket regardless of what’s going on with hypertension and A1c, a team should take over and hold the patient by the hand to preclude to the extent possible the need for Dialysis. You draw your own conclusions from the essay below.
GPT-4 Prompt: From a statistical perspective, what is the relationship between diabetes and the subsequent need to go on dialysis? Use citations and include references in at least a 2000-word essay written at a freshman college level.
Introduction
Diabetes is a global health concern that affects millions of people. It is a group of metabolic disorders characterized by high blood sugar levels over an extended period. Type 1 and type 2 diabetes are the most common forms, with type 2 diabetes accounting for about 90% of cases. Diabetes can cause various complications, including kidney disease, cardiovascular disease, and neuropathy. One severe complication is diabetic nephropathy, which may lead to end-stage renal disease (ESRD) and dialysis needs. This essay explores the statistical relationship between diabetes and subsequent dialysis needs by examining relevant literature and studies.
Diabetes and kidney disease: the pathophysiology
Diabetic nephropathy, a leading cause of kidney disease, develops in about 40% of individuals with diabetes (Gheith et al., 2016). High blood sugar levels cause damage to the blood vessels in the kidneys, impairing their ability to filter waste and excess fluids. Over time, this damage accumulates, leading to kidney disease and, eventually, kidney failure.
Kidney disease can be categorized into five stages based on the glomerular filtration rate (GFR), a measure of kidney function. Stage 1 represents the least severe stage, while stage 5, or ESRD, is the most severe, often necessitating dialysis or a kidney transplant. Diabetes increases the risk of developing kidney disease and progressing to ESRD (Afkarian et al., 2013).
Prevalence of diabetes and kidney disease
The prevalence of diabetes has been increasing worldwide, with the International Diabetes Federation (IDF) estimating that 537 million adults will have diabetes in 2021 (IDF Diabetes Atlas, 2021). The number is projected to reach 643 million by 2030 (IDF Diabetes Atlas, 2021). The global prevalence of diabetic nephropathy was estimated at 6.9% in 2020 (Thomas et al., 2020).
Kidney disease is a significant public health concern, affecting more than 850 million people worldwide (Liyanage et al., 2015). Among individuals with ESRD, diabetes is the leading cause, accounting for 44% of cases in the United States (USRDS, 2020). In Europe, diabetes is responsible for 25% of ESRD cases, with variations between countries (ERA-EDTA, 2019).
Diabetes and the Risk of Dialysis
Diabetic nephropathy progresses more rapidly in individuals with poor glycemic control, high blood pressure, and genetic predisposition (Tuttle et al., 2014). Studies have reported that the risk of developing ESRD in individuals with diabetes is 12-25 times higher than in those without diabetes (Afkarian et al., 2013; de Boer et al., 2011).
A study by Afkarian et al. (2013) investigated the risk of ESRD in a cohort of 10,483 individuals with type 1 diabetes and 9,697 individuals with type 2 diabetes. The cumulative incidence of ESRD at 20 years was 3.3% for type 1 diabetes and 1.7% for type 2 diabetes. The study also found that the risk of ESRD increased with the duration of diabetes and higher levels of baseline glycated hemoglobin (A1C), a marker of long-term blood sugar control.
Another study by de Boer et al. (2011) assessed the risk of ESRD in 1,746 individuals with type 1 diabetes and 4,507 individuals with type 2 diabetes. The cumulative incidence of ESRD at 20 years was 2.2% for type 1 diabetes and 1.8% for type 2 diabetes. The study demonstrated that higher baseline A1C levels and longer diabetes duration were associated with increased risks of ESRD, emphasizing the importance of proper blood sugar management.
Factors influencing the need for dialysis in diabetic patients
Several factors can increase the likelihood of diabetic patients requiring dialysis. These factors include:
a. Glycemic control: Maintaining optimal blood sugar levels is critical in delaying the progression of diabetic nephropathy and reducing the risk of ESRD (Ismail-Beigi et al., 2010). Improved glycemic control has been shown to reduce the risk of microvascular complications, including kidney disease, in both type 1 and type 2 diabetes (DCCT/EDIC Study Research Group, 2005; ADVANCE Collaborative Group, 2008).
b. Blood pressure control: High blood pressure is a significant risk factor for the progression of diabetic nephropathy (Molitch et al., 2015). Strict blood pressure control, particularly with medications such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), can slow kidney disease progression and reduce the risk of ESRD in diabetic patients (Lewis et al., 1993; Brenner et al., 2001).
c. Albuminuria: Elevated albumin levels in the urine (albuminuria) are an early sign of kidney damage in diabetic patients. Reducing albuminuria through blood sugar and blood pressure control can delay the progression of kidney disease (Wanner et al., 2016).
d. Lifestyle factors: Adopting a healthy lifestyle, including regular exercise, a balanced diet, and maintaining a healthy weight, can help control blood sugar levels and reduce the risk of kidney disease in diabetic patients (ADA, 2021).
Strategies to reduce the need for dialysis in diabetic patients
Efforts to minimize the risk of dialysis in diabetic patients include:
a. Early detection and monitoring: Regular screening for kidney disease in diabetic patients can facilitate early intervention and slow the progression of kidney disease (ADA, 2021).
b. Integrated care: A multidisciplinary approach that involves primary care providers, endocrinologists, nephrologists, and other healthcare professionals can optimize diabetes management and reduce the risk of complications (ADA, 2021).
c. Patient education: Empowering patients with knowledge about diabetes management, self-monitoring of blood sugar, and healthy lifestyle choices can improve treatment adherence and reduce the risk of kidney disease (Funnell et al., 2010).
Conclusion
Diabetes is a significant risk factor for kidney disease and the subsequent need for dialysis. The relationship between diabetes and dialysis is influenced by glycemic control, blood pressure management, and albuminuria. Early detection, proper management of diabetes, and lifestyle modifications can reduce the risk of kidney disease progression and the need for dialysis in diabetic patients. Continued research and public health initiatives aimed at preventing diabetes, optimizing diabetes management, and raising awareness about kidney disease are essential in addressing this global health challenge.
References
ADA. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Suppl. 1), S1-S232.
ADVANCE Collaborative Group. (2008). Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. New England Journal of Medicine, 358(24), 2560-2572.
Afkarian, M., Sachs, M. C., Kestenbaum, B., Hirsch, I. B., Tuttle, K. R., Himmelfarb, J., & de Boer, I. H. (2013). Kidney disease and increased mortality risk in type 2 diabetes. Journal of the American Society of Nephrology, 24(2), 302-308.
Brenner, B. M., Cooper, M. E., de Zeeuw, D., Keane, W. F., Mitch, W. E., Parving, H. H., … & Shahinfar, S. (2001). Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. New England Journal of Medicine, 345(12), 861-869.
DCCT/EDIC Study Research Group. (2005). Sustained effect of intensive treatment of type 1 diabetes mellitus on the development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) study. Journal of the American Medical Association, 290(16), 2159-2167.
de Boer, I. H., Rue, T. C., Hall, Y. N., Heagerty, P. J., Weiss, N. S., & Himmelfarb, J. (2011). Temporal trends in the prevalence of diabetic kidney disease in the United States. Journal of the American Medical Association, 305(24), 2532-2539.
Funnell, M. M., Brown, T. L., Childs, B. P., Haas, L. B., Hosey, G. M., Jensen, B., … & Weiss, M. A. (2010). National Standards for Diabetes Self-Management Education. Diabetes Care, 33(Suppl. 1), S89-S96.
Gheith, O., Farouk, N., Nampoory, N., Halim, M. A., & Al-Otaibi, T. (2016). Diabetic kidney disease: worldwide difference of prevalence and risk factors. Journal of Nephropharmacology, 5(1), 49-56.
Ismail-Beigi, F., Craven, T., Banerji, M. A., Basile, J., Calles, J., Cohen, R. M., … & ACCORD Trial Group. (2010). Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. The Lancet, 376(9739), 419-430.
Lewis, E. J., Hunsicker, L. G., Bain, R. P., & Rohde, R. D. (1993). The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. New England Journal of Medicine, 329(20), 1456-1462.
Liyanage, T., Ninomiya, T., Jha, V., Neal, B., Patrice, H. M., Okpechi, I., … & Perkovic, V. (2015). Worldwide access to treatment for end-stage kidney disease: a systematic review. The Lancet, 5(9981), 1975-1982.
Molitch, M. E., Adler, A. I., Flyvbjerg, A., Nelson, R. G., So, W. Y., Wanner, C., … & Wheeler, D. C. (2015). Diabetic kidney disease: a clinical update from Kidney Disease: Improving Global Outcomes. Kidney International, 87(1), 20-30.
Thomas, M. C., Brownlee, M., Susztak, K., Sharma, K., Jandeleit-Dahm, K. A., Zoungas, S., … & Cooper, M. E. (2020). Diabetic kidney disease. Nature Reviews Disease Primers, 6(1), 1-28.
Tuttle, K. R., Bakris, G. L., Bilous, R. W., Chiang, J. L., de Boer, I. H., Goldstein-Fuchs, J., … & Molitch, M. E. (2014). Diabetic kidney disease: a report from an ADA Consensus Conference. Diabetes Care, 37(10), 2864-2883.
USRDS. (2020). United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD.
Wanner, C., Inzucchi, S. E., Lachin, J. M., Fitchett, D., von Eynatten, M., Mattheus, M., … & EMPA-REG OUTCOME Investigators. (2016). Empagliflozin and progression of kidney disease in type 2 diabetes. New England Journal of Medicine, 375(4), 323-334.
One of the things that is suggested while on Dialysis is to keep your brain active. Obviously, this can take on many forms. For me, I have become more than just interested in the field of Artificial Intelligence (AI) and in fact, am using it to support this blog. When I do so I generally refer to its use as my “AI Assistant.” Another path I am pursuing is taking online courses to bring me up to speed on the newest technologies in my former area of expertise, Electrical Engineering (EE). I am currently enrolled in a course with TheGreatCourses.com titled Electrical Engineering for Everyone that provides an introduction to all things that do just that. The online course started off with a brief introduction to how EE has impacted and changed since its inception. Bear with me, we’ll get to where I’m going with this shortly. The lead to the course, without any formatting, follows from the course:
Built on Maxwell’s equations, the field of electrical engineering has experienced four distinct revolutions in the past 150 years, each of which increased our knowledge of the world around us, improved the quality of life for masses of people, and led to the opportunity for further discoveries. Revolution One brought the transmission of electrical energy with wires, which provided electric power to homes and businesses and produced the telegraph and telephone. Revolution Two brought the transmission of electric energy without wires. This phase started with radio, which led to television, satellites, and other forms of wireless communications. Revolution Three occurred when we learned to control electrons with transistors, which led to electronics and photonics. And Revolution Four produced computers and communication systems to create intelligent applications, including brain-controlled prosthetics, self-driving cars, and advanced robotics.
This is all well and good, but I got to wondering how AI might be used to improve the delivery, understanding, and retention of these concepts by the interested party. This harkens back to my tenure as a university lecturer and professor. So here’s what I did. First I plugged the “script” above into Designs.Ai’s video engine, and came up with the video presentation embedded below. I uploaded static pictures of the phases from the internet; I found what Designs selected on their own to be OK but not anywhere optimum. Even then I managed to use the same picture for the third and fourth eras of EE.
So that’s one AI take on jazzing up otherwise dull text. I tried a second named Avatarbuilder.com. It uses AI to produce a figure dictating the text. You can change figures, backgrounds, dress, etc. to suit your needs. The video from this AI-assisted presentation tool is embedded below. I like the first one best for university-level presentations. Minds sharp = successful Dialysis.
Every morning I have to read my glucose level off of my Libre 3 Continuous Glucose Monitor and enter the reading into the Cycler’s “fitals” screen. Other than of interest to me, it was 99 this morning, no one from my team ever comments on this or how in general my diabetic control is doing. I would like to think this is because we are on track and doing an OK job with diabetic control. At the present time, my A1C is in the 6.2 range where it more or less stays. It has been as low as 5.4 and as high as 6.7. I don’t remember how long it has been, years since it has ever been over 7. That did get me thinking about how important, especially to those who are on dialysis, it is to maintain tight diabetic control. Thus this blog with the help of my AI assistant offer the following treatise on diabetic control and dialysis.
Introduction
Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels, resulting from defects in insulin secretion, insulin action, or both. In 2021, the International Diabetes Federation estimated that over 537 million adults worldwide had diabetes, and this number is projected to rise to 643 million by 2030 (IDF Diabetes Atlas, 2021). Poorly managed diabetes can lead to numerous long-term complications, including diabetic kidney disease (DKD), which is the leading cause of the end-stage renal disease (ESRD) requiring dialysis (Afkarian et al., 2016).
Dialysis is a life-sustaining treatment for patients with ESRD that serves to remove waste products and excess fluid from the body when the kidneys can no longer perform this function effectively. However, managing diabetes and dialysis simultaneously presents a unique set of challenges. This blog will discuss the importance of optimal diabetic control for patients on dialysis, focusing on the effects on patient outcomes, cardiovascular risks, and quality of life, as well as exploring potential strategies for achieving optimal control.
Effects on Patient Outcomes
Optimal diabetes control is crucial for patients on dialysis, as it has been shown to improve patient outcomes. A study by Williams et al. (2012) found that among diabetic patients on hemodialysis, those with poor glycemic control (HbA1c ≥ 8%) had significantly higher mortality rates compared to those with good glycemic control (HbA1c < 7%). Furthermore, Ricks et al. (2012) reported that in a cohort of 24,875 diabetic patients undergoing dialysis, each 1% increase in HbA1c was associated with a 14% increase in the risk of all-cause mortality. These findings suggest that appropriate diabetic control is essential for improving survival rates among patients undergoing dialysis.
Cardiovascular Risks
Patients with diabetes and ESRD are at an increased risk of cardiovascular complications. According to the United States Renal Data System (USRDS, 2020), cardiovascular disease accounts for approximately 50% of deaths in ESRD patients, with diabetes being a major contributing factor. Optimizing diabetic control can help reduce cardiovascular risk in patients on dialysis. For example, a study by Shurraw et al. (2011) found that a 1% reduction in HbA1c was associated with a 15% decrease in the risk of myocardial infarction and a 17% decrease in the risk of stroke among diabetic patients on hemodialysis.
Moreover, patients with diabetes and ESRD often have other cardiovascular risk factors, such as hypertension and dyslipidemia, which can be exacerbated by poor glycemic control (Charytan et al., 2020). Thus, optimal management of diabetes in conjunction with other risk factors is essential to minimize cardiovascular morbidity and mortality in patients on dialysis.
Quality of Life
Diabetes and dialysis can both negatively impact the quality of life (QOL) of patients. However, studies have shown that improved glycemic control is associated with better QOL scores. A study by Kalantar-Zadeh et al. (2012) found that among diabetic patients on hemodialysis, those with better glycemic control (HbA1c < 7%) had significantly higher QOL scores compared to those with poor glycemic control (HbA1c ≥ 8%). Additionally, optimal diabetes management can help prevent or slow the progression of other diabetes-related complications, such as neuropathy and retinopathy, which can further enhance patients’ QOL (ADA, 2021).
Strategies for Achieving Optimal Diabetic Control
Achieving optimal diabetic control in patients on dialysis requires a comprehensive approach, encompassing medical management, lifestyle modifications, and patient education.
4.1. Medical Management
Medical management of diabetes in patients on dialysis requires close monitoring of blood glucose levels and appropriate adjustments to the patient’s diabetes medication regimen. Insulin therapy is the most commonly used treatment for patients with diabetes on dialysis, as oral antidiabetic medications are often contraindicated or require dose adjustments due to impaired renal function (Molitch, 2019). In addition, continuous glucose monitoring (CGM) systems can be a valuable tool for patients on dialysis, as they provide real-time information on glucose levels, allowing for more accurate adjustments of insulin doses (Buse et al., 2020).
4.2. Lifestyle Modifications
Lifestyle modifications, including diet and exercise, are essential components of diabetes management for patients on dialysis. A tailored meal plan, developed in consultation with a registered dietitian, can help patients manage their blood glucose levels while also adhering to their dialysis-specific dietary restrictions (Kovesdy & Kalantar-Zadeh, 2016). Regular physical activity, as recommended by the American Diabetes Association (ADA, 2021), can also help improve glycemic control, cardiovascular health, and overall well-being.
4.3. Patient Education
Patient education is a critical component of diabetes management for patients on dialysis. It is essential for patients to understand the importance of regular blood glucose monitoring, medication adherence, and lifestyle modifications to achieve optimal glycemic control. Collaborative, patient-centered educational programs, such as the Chronic Kidney Disease Self-Management Program (CKD-SMP), have been shown to improve diabetes knowledge and self-care behaviors in patients with ESRD (Chen et al., 2018).
While the importance of optimal diabetic control in dialysis patients is well-established, there are several challenges that healthcare professionals and patients may encounter in achieving this goal. This section will discuss some of these challenges, as well as potential future directions for improving diabetic management in this population.
Challenges and Future Directions in Diabetic Control for Dialysis Patients
5.1. Challenges in Diabetic Control
One challenge in managing diabetes for patients on dialysis is the complexity of their medical regimen. In addition to managing their diabetes medications and insulin therapy, patients must also adhere to dialysis-specific dietary restrictions and fluid intake limitations, which can make maintaining optimal glycemic control more difficult (Kovesdy & Kalantar-Zadeh, 2016).
Another challenge is the increased risk of hypoglycemia in patients undergoing dialysis. Dialysis can cause fluctuations in blood glucose levels, and insulin requirements may change due to the removal of glucose and insulin during the dialysis process (Molitch, 2019). As a result, patients on dialysis are at a higher risk of hypoglycemia, which can be life-threatening if not promptly recognized and treated (ADA, 2021).
5.2. Future Directions
To address these challenges and improve diabetes management in patients on dialysis, research is ongoing to develop new therapeutic options and strategies. For example, novel glucose-lowering medications, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, are being investigated for their potential use in patients with ESRD (Molitch, 2019). SGLT2 inhibitors have been shown to reduce the risk of cardiovascular events and slow the progression of kidney disease in patients with type 2 diabetes (Zinman et al., 2015), and ongoing studies are evaluating their safety and efficacy in patients on dialysis (ClinicalTrials.gov, NCT03819153).
Additionally, advances in technology may help improve diabetes management for dialysis patients. For instance, the development of closed-loop insulin delivery systems, also known as artificial pancreas devices, may offer an effective solution for managing blood glucose levels in this population (Bally et al., 2017). These systems combine continuous glucose monitoring with automated insulin delivery, allowing for precise adjustments of insulin doses based on real-time glucose levels, which may help reduce the risk of hypoglycemia and improve overall glycemic control.
Conclusion
In conclusion, optimal diabetic control is of utmost importance for patients on dialysis, as it can significantly improve patient outcomes, reduce cardiovascular risks, and enhance the quality of life. Achieving optimal glycemic control requires a comprehensive approach, including medical management, lifestyle modifications, and patient education. Healthcare professionals and patients must work collaboratively to develop individualized treatment plans that address the unique challenges of managing diabetes and dialysis concurrently.
References
ADA. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Supplement 1), S1-S232.
Afkarian, M., Sachs, M. C., Kestenbaum, B., Hirsch, I. B., Tuttle, K. R., Himmelfarb, J., & de Boer, I. H. (2016). Kidney disease and increased mortality risk in type 2 diabetes. Journal of the American Society of Nephrology, 27(2), 486-495.
Buse, J. B., Wexler, D. J., Tsapas, A., Rossing, P., Mingrone, G., Mathieu, C., … & Consoli, A. (2020). 2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 43(2), 487-493.
Charytan, D., Solomon, S. D., Ivanovich, P., Remuzzi, G., Cooper, M. E., McGill, J. B., … & Parving, H. H. (2020). Efficacy and safety of losartan in diabetic patients with or without chronic kidney disease: a post hoc analysis of the
Reduction of Endpoints in Non-Insulin-Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan trial. Nephrology Dialysis Transplantation, 35(11), 1935-1944.
Chen, S. H., Tsai, Y. F., Sun, C. Y., Wu, I. W., Lee, C. C., & Wu, M. S. (2018). The impact of self-management support on the progression of chronic kidney disease—a prospective randomized controlled trial. Nephrology Dialysis Transplantation, 33(11), 1976-1982.
Kalantar-Zadeh, K., Kopple, J. D., Regidor, D. L., Jing, J., Shinaberger, C. S., Aronovitz, J., … & Kovesdy, C. P. (2012). A1C and survival in maintenance hemodialysis patients. Diabetes Care, 35(5), 1043-1051.
Kovesdy, C. P., & Kalantar-Zadeh, K. (2016). Why is protein-energy wasting associated with mortality in chronic kidney disease? Seminars in Nephrology, 36(1), 3-16.
Molitch, M. E. (2019). Management of diabetes in patients with chronic kidney disease. Diabetes Spectrum, 32(3), 211-216.
Ricks, J., Molnar, M. Z., Kovesdy, C. P., Shah, A., Nissenson, A. R., Williams, M., & Kalantar-Zadeh, K. (2012). Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study. Diabetes, 61(3), 708-715.
Shurraw, S., Majumdar, S. R., Thadhani, R., Wiebe, N., & Tonelli, M. (2011). Glycemic control and the risk of death in 1,484 patients receiving maintenance hemodialysis. American Journal of Kidney Diseases, 57(4), 549-556.
USRDS. (2020). United States Renal Data System 2020 Annual Data Report: Epidemiology of kidney disease in the United States. American Journal of Kidney Diseases, 77(1), A7-A8.
Williams, M. E., Lacson, E., Teng, M., Ofsthun, N., & Lazarus, J. M. (2012). Hemodialyzed type I and type II diabetic patients in the US: Characteristics, glycemic control, and survival. Kidney International, 72(5), 629-637.
