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!

Six of the last seventeen nights I have experienced cycler alarms. But I am not alarmed no pun intended. In each case, I had the cycler line kinked under my body. By merely shifting my body and straightening out the line, the alarms cleared.

My wife has noticed that where supplies are delivered by Fresenius which are scheduled for today BTW over time the carts they use and the load on them has started to stretch and hump up our hallway and bedroom where we store dialysis disposables. The wheels on their cart are small, on the order of six inches or less which by necessity places lots of weight on a small area creating enormous pressure on the carpet and underlayment. She wants to get new carpeting but we have come up with a solution to this problem.

Our running toilet of yesterday has been solved – at a cost of $150.00 for a plumber. Here’s the deal. The toiler started running from time to time. Our son installed a new flapper value. The toilet continues to leak down after flushing. I installed a new flapper valve and a seat. The toilet continued to lead down. The plumber came, and installed a new flapper which fixed the problem. What is the difference – the flapper valves we were using were plastic and somewhat ridged; his was rubber and more flexible. For this knowledge $150. Go figure.

My peritoneal dialysis treatment is boring, in the groove, doing what it is designed to do – keeping me alive. What more can I say? My weight hasn’t varied by more than 1.5 lbs for weeks. My glucose is right in there. My BP this morning, without drugs keep in mind, was 103/70. The only exciting thing going on this week in the PD world is supply delivery on Wednesday.

For those of you experiencing difficulty my condolences. Right now PD is a piece of cake with added protein.