Wednesday was my scheduled day to order supplies. I use the Fresenius-sponsored app to do so. It has a wealth of information about most aspects of PD including providing a Forum where people may post questions and start a thread. I browsed through the threads before placing my supply order, BTW I noted we can now order the extension for the new, shorter cassette, and was confounded by several threads having to do with new PD patients in particular, being extremely depressed to the point of being despondent.

Here are a few of the comments at the start of the threads:

1. New to pd. Few weeks now. Does the feeling alone go away.
2. What motivates you to fight kidney disease every day?
3. …I am so nervous, I have anxiety attacks high bp
4. Dealing with depression… advice?
5. I am having a really tough time right now coping with being on PD. I am experiencing a great amount of stress and grief. I don’t know what to do and I feel like I am on an emotional roller coaster. Is there help?
6. And on and on.

PD presents a problem for many patients. None of the threads were started by a person who was a male. This is not to say in any way that only females are prone to this form of behavior and may just be more apt to voice their perceived woes.

The responses, and there were many, mostly stated in one form or another that families were where patients gathered the most strength from. More often than not, children and/or grandchildren and living for them were the reasons offered to keep on truckin’. While this is all well and good, the question as to what is the root cause of these maladies is not addressed. I turned to Perplexity for research into this area with the following results:

Patients on peritoneal dialysis (PD) often experience symptoms of despondence and depression for several reasons:

1. Chronic illness burden: PD is a treatment for end-stage renal disease (ESRD), a chronic condition that significantly impacts a patient’s physical health and daily life[1]. The ongoing management of ESRD and its complications can lead to feelings of hopelessness and despair.
2. Lifestyle restrictions: PD requires patients to adhere to strict schedules, dietary limitations, and fluid restrictions. These constraints can cause frustration and a sense of loss of control over one’s life[1].
3. Physical symptoms: ESRD and dialysis can cause fatigue, pain, and other physical discomforts that may contribute to depressive symptoms[1].
4. Treatment-related stress: The need for regular dialysis procedures, potential complications, and the constant reminder of illness can increase anxiety and depression[2].
5. Social isolation: PD may limit patients’ ability to participate in social activities or maintain employment, leading to feelings of isolation and loneliness[1].
6. Fear and uncertainty: Concerns about the future, potential complications, and mortality can contribute to anxiety and depressive symptoms[4].
7. Body image issues: PD requires a catheter to be permanently inserted into the abdomen, which may affect self-image and contribute to depression[2].
8. Loss of independence: Reliance on dialysis and potential limitations in daily activities can lead to feelings of helplessness and despondency[5].
9. Biological factors: ESRD and dialysis can cause hormonal imbalances and changes in brain chemistry that may contribute to depression[1].
10. High prevalence: Studies have shown that depression is significantly more common in PD patients compared to the general population, with one study reporting a prevalence of 98.5% among PD patients[1].

It’s important to note that depression in dialysis patients, including those on PD, is often underrecognized and undertreated[1]. Regular screening for depression and providing appropriate psychological support and treatment can help improve the mental health and overall well-being of PD patients.

Citations:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4394933/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9784045/
[3] https://karger.com/kbr/article/41/1/86/185661/The-Level-of-Anxiety-and-Depression-in-Dialysis
[4] https://www.davita.com/education/ckd-life/support/your-emotions-and-chronic-kidney-disease-ckd
[5] https://www.elsevier.es/es-revista-european-journal-psychiatry-431-articulo-depression-cognitive-distortions-in-hemodialysis-S021361632100001X
[6] https://www.researchgate.net/publication/364304306_A_cross-sectional_study_on_assessing_depression_among_hemodialysis_patients
[7] https://health.usnews.com/conditions/mental-health/depression

No one talks much about what a typical day for an active 85-year-old male might look like. This blog relates what I have been up to (yesterday) in a day.

Readers of this blog know that my wife and I live in Pecan Plantation near Granbury, TX near Fort Worth. You also know that we maintain 15 flower beds and a well-kept lawn. Today, the bags of mulch/manure that we ordered from our local greenhouse came in. I first hitched up our trailer, then journed about 20 minutes north where we loaded it up with 60, yes 60 bags of the good stuff. Along with this, we loaded 21 bags of pine bark mulch into our X5.

Upon return home, we had to figure out how to get the trailer back into our single-car garage up over a 2″ or so concrete burm in the floor. I ended up using two clamps to clamp 2x2s to the back of the trailer and pushed it in with our ZTR mower. Meanwhile, I noticed on our local Nextdoor that a fellow resident of Pecan Plantation advertised a free Craftsman 10″ radial arm saw. I jumped on this, contacted him, and made arrangements to pick up the saw later in the afternoon.

Had lunch and left to pick up the saw. It’s heavy. The guy who gave us the saw was nice enough to deliver it to our house on his trailer. It is now in the garage. As you can see from the lead picture, it lacks the wooden table but that can be replaced. Let our son know what we had and it turns out he needs one for his new house construction project so everyone wins.

My typical day will finish off with a shower, doing my manual 2 liters of static fill, supper, a little TV, and then on the Cycler. Wake up in the morning to our loving golden retriever Dickens – lead picture – and repeat.

I have previously blogged about the title above. This blog adds to that blog.

I have received my first box of cassette extensions made necessary by Fresenius unilaterally reducing the length of both the drain and hookup line to 15 feet from 20 feet. As previously stated, in my setup, I require at least 20 feet of drain line to reach the toilet where we drain. With the 20-foot extension, I now have 35 feet of drain line, more than enough.

I tried out the new setup with the extended drain and had no alarms so we made it through the first night, from a drain perspective. But wait. The line to hook up to your catheter has also been reduced to 15 feet. I visited the lab last Friday and my attending nurse related that they have been bombarded with patient complaints about the change. People are having to redo their setups, vacation plans, and on and on as a result. For me, I no longer can reach a toilet to relieve myself if necessary; the line is not long enough to reach. I no longer can reach the desk where I accomplish morning biometrics; the line is not long enough. I can no longer reach the blinds in our master bedroom to open them in the morning; the line is not long enough. I barely have enough line to be able to sleep comfortably; the line is not long enough. You get the picture!

Fresenius screwed up in doing this, especially how they did it. Just like Biden pulling us out of Afghanistan but in this case they didn’t even ask.

As you may ascertain from the above, my lab results from this past Friday are in. I am a happy camper. While my Albumin is still low and out of range, we’ve turned the corner and it’s going up. Keep in mind that Albumin responds slowly to “treatment” such as increasing protein intake so we’re on the right track.

The lab reading for Kt/V is likewise reassuring. Recall that last month due to a much higher reading, I asked that the dwell time of the evening cycler routine be reduced to one hour forty-five minutes from two hours for each of four cycles. This was accomplished and this Kt/V being greater than 2.0 indicates we are OK.

The last result I’m sharing is Creatinine. This value maps to an eGFR of 6. Notice that it has steadily been improving. I asked Perplexity about improving Creatinine for a patient on dialysis with the following result:

For patients on peritoneal dialysis, a decreasing creatinine lab result generally indicates improving kidney function or effective dialysis treatment. Here’s a more detailed explanation:

Interpretation of Decreasing Creatinine Levels

A declining creatinine level in peritoneal dialysis patients can signify:

1. Improved Kidney Function: In some cases, residual kidney function may improve, leading to better creatinine clearance by the patient’s kidneys[1].
2. Effective Dialysis: A decrease in serum creatinine suggests that peritoneal dialysis is effectively removing waste products from the blood[1][3].
3. Adequate Dialysis Dose: It may indicate that the prescribed dialysis regimen is sufficient in clearing creatinine and other uremic toxins[3].

Factors to Consider

While decreasing creatinine is generally positive, it’s important to consider:

• Muscle Mass: Creatinine is a byproduct of muscle metabolism. A decrease could also reflect loss of muscle mass, which is not desirable[1][4].
• Nutritional Status: Poor nutrition can lead to decreased creatinine production, so dietary factors should be evaluated[4].
• Hydration Status: Overhydration can dilute serum creatinine, giving a false impression of improvement[2].

Clinical Significance

Healthcare providers use creatinine levels, along with other markers, to:

• Assess the adequacy of dialysis treatment
• Adjust dialysis prescriptions if needed
• Monitor overall kidney function and health status

Additional Considerations

It’s crucial to interpret creatinine results in conjunction with:

• Other laboratory values (e.g., BUN, electrolytes)
• Clinical symptoms
• Overall health status
• Dialysis parameters (e.g., ultrafiltration volume, dialysate composition)

Healthcare providers will consider all these factors when evaluating the significance of decreasing creatinine levels in peritoneal dialysis patients.

Citations:
[1] https://www.mayoclinic.org/tests-procedures/creatinine-test/about/pac-20384646
[2] https://my.clevelandclinic.org/health/diagnostics/16380-creatinine-clearance-test
[3] https://www.ncbi.nlm.nih.gov/books/NBK544228/
[4] https://www.mountsinai.org/health-library/tests/creatinine-blood-test
[5] https://www.medicalnewstoday.com/articles/322380
[6] https://www.kidney.org/kidney-topics/understanding-your-lab-values-and-other-ckd-health-numbers
[7] https://www.medicalnewstoday.com/articles/319892
[8] https://www.healthline.com/health/low-creatinine

There is a fine line in Diabetic Control for those of us on Peritoneal Dialysis. It’s as though we’re balancing on a knife’s edge. Let me explain. Over more than 40 years of being a Type II diabetic, I have learned that my glucose readings are correlated very closely with my weight, and lately, with exercise. Just a few pounds weight variation can make all the difference in my readings. Tie this to work that approaches being strenuous, especially tied to the heat we experience here in N. Texas in the summer, and my glucose drops.

For the last three nights, my wife has been awakened by my Libre 3 alarm because of low glucose readings. (I can’t hear it because I don’t have my hearing aids in.) Each night she has provided orange juice to remedy the situation and we have managed to go back to sleep. My last five glucose entries into the Cycler for morning biometrics have been 85, 86, 75, 67, and 71. Keep in mind the last three entries are after ingesting a full 8 oz of orange juice during the night.

In response to this, I reduced my intake of insulin to 9 units from 10 units. As I write this blog about an hour after breakfast on Wednesday, Libre 3 indicates my glucose to be 93 and this is after putting a mocum of honey on my cereal. So tonight I intend to drop my insulin dose even more, down to 6 or 7 units.

Why did I titled this blog “Diabetic Contol & PD?” Because, unlike many patients with PD, I have not had any problems to date with weight. If anything, It has been constant in the low 140s pounds. This is still the case even though I have upped my protein intake in an attempt to improve my albumin lab results. There’s always something, isn’t there?

I am, at age 85, at the upper end of life expectancy. This is a fact of life. Being a Purdue PhD, we were taught statistics as a tool to look to the future and as an aid in decision making. I posed a couple of questions to Perplexity, first given I’m 85 what is my life expectancy, and second, given I’m on PD how does this compute? The following provides answers: (Hint: I have already been on some type of dialysis for over two years so I’m beating the odds. I intend to continue to do so!)

An 85-year-old male in the USA has a life expectancy of approximately 5.24 years. This means that, on average, an 85-year-old man can expect to live until around the age of 90. This estimate can vary based on individual health conditions and lifestyle factors. Additionally, there is a 75% chance that an 85-year-old man will survive for at least 2 more years and a 25% chance that he will live for an additional 9 years. These probabilities highlight the variability in life expectancy due to factors such as comorbid conditions and functional status.

For an 85-year-old male on peritoneal dialysis in the USA, life expectancy is notably reduced compared to the general population. Studies indicate that elderly patients on peritoneal dialysis have a mean survival time of around 38.9 months (approximately 3.24 years) with survival rates of 78.8% at 1 year, 66.8% at 2 years, and 50.9% at 3 years after starting dialysis[1]. Another study suggests that elderly patients on chronic peritoneal dialysis have a 5-year survival rate of 30%[2].

Moreover, the life expectancy for seniors aged 85 and older on dialysis is about 2 years on average, compared to 3.5 years for their healthy peers[4]. Factors such as advanced age, comorbid conditions, and episodes of peritonitis significantly impact mortality in these patients[1][2].

Citations:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4449459/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033330/
[3] https://academic.oup.com/ndt/article/27/9/3581/1858404
[4] https://www.griswoldcare.com/blog/pros-and-cons-of-dialysis-in-elderly-adults/
[5] https://www.eurekalert.org/news-releases/836978
[6] https://archive.nytimes.com/newoldage.blogs.nytimes.com/2011/12/29/the-unspoken-diagnosis-old-age/
[7] https://academic.oup.com/biomedgerontology/article/71/9/1171/2605446?login=false
[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822435/

Like many patients on peritoneal dialysis, I am taking a phosphorous binder, for me named Velphoro. I chew at least two of these horse-sized yuk wafers with my breakfast and sometimes with a meaty meal. At present, I receive them via my military pharm, ExpressScripts at about $38.00 for 3 month’s supply.

Saturday I received a postcard-type communication from Fresenius stating that starting 1/1/2025, binders would be covered as part of Medicare (part B.) My RX will be transferred to FreseniusRx from some point on. The cost henceforth should be mapped into my overall PD coverage by Medicare/Tricare for Life. No more $38. To provide background to those, not of the community and question what is this phosphorous thing all about, read on..

Excessive phosphorus levels (hyperphosphatemia) can present several complications for patients on peritoneal dialysis:

Cardiovascular Complications

Hyperphosphatemia is associated with increased cardiovascular morbidity and mortality in peritoneal dialysis patients[1][3]. It contributes to:

• Vascular calcification
• Arterial stiffness
• Increased risk of cardiovascular events

Bone and Mineral Disorders

Too much phosphorus disrupts normal bone and mineral metabolism, leading to:

• Secondary hyperparathyroidism
• Renal osteodystrophy
• Increased risk of bone fractures

Soft Tissue Calcification

Excess phosphorus can cause calcium-phosphate deposits to form in soft tissues throughout the body, including:

• Blood vessels
• Heart valves
• Joints
• Skin

Anemia

Hyperphosphatemia may contribute to anemia in peritoneal dialysis patients by:

• Interfering with erythropoiesis
• Shortening red blood cell survival

Itching

Many peritoneal dialysis patients with high phosphorus levels experience severe itching (pruritus), which can significantly impact quality of life.

Nutritional Issues

Dietary phosphorus restriction, often necessary to control levels, can lead to:

• Protein malnutrition
• Muscle wasting
• Overall poor nutritional status

Proper management of phosphorus levels through dialysis prescription, diet, and medications is crucial for peritoneal dialysis patients to prevent these complications and improve outcomes[2]. Regular monitoring of phosphate clearance and serum levels is important, as peritoneal dialysis may provide less effective phosphorus removal compared to hemodialysis in some patients[4].

Citations:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10386128/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737570/
[3] https://www.nature.com/articles/s41598-020-74412-2
[4] https://academic.oup.com/ndt/article/31/9/1508/1751782
[5] https://www.sciencedirect.com/science/article/pii/S0085253815528755
[6] https://www.mayoclinic.org/tests-procedures/peritoneal-dialysis/about/pac-20384725
[7] https://www.kidneyfund.org/living-kidney-disease/health-problems-caused-kidney-disease/high-phosphorus-hyperphosphatemia
[8] https://www.kidney-international.org/article/S0085-2538%2815%2952875-5/fulltext

Here’s the deal. My supply order arrived as advertised this morning, right in the window advertised. But it was not “my supply order,” but one Fresenius decided. Seems like they are no longer supplying the cassette boxes with 20-foot-long supply and drain lines in a 10-count box. They now supply 14 cassettes with 15-foot-long lines. I need at least a 20-foot drain to reach the toilet where we drain the cycler overnight. Did anyone bother to ask me what I needed? Hell no.

I called Fresenius Supply and was told I now have to order drain line extensions that come 28 to a box. Ok, I can do that, but wait, such drains are not listed as something we as mere patients can order. The voice on the other end of the phone at Fresenius couldn’t believe that we could not order drain extensions, went off the line, came back, and acknowledged that we presently could not order them.

Fresenius is FUBAR. It is obvious they made a business decision to modify cassette packaging. Let’s see. We’ll chop the lines down but increase the number of cassettes per box and charge more. Ok, and if patients need a longer drain line we’ll sell it to them (actually whomever is paying the bill) and make even more money. Not once have I ever been asked my opinion about anything having to do with MY treatment from a supply perspective. Fresenius is acting as if they are a government that always knows what’s best. Some democracy, isn’t it? Makes Hogan’s goat look like a precision machine!