Never ring the bell!
Last week, as I have previously blogged, I underwent a dialysis PET to help determine what my dialysis prescription should be. The results are back from the lab and might as well be written in Latin. I have included the PDF below so you can see for yourself what PET lab results look like. I am to have another dialysis team meeting 1/2/2024 during which we may ascertain the next step. I’ll keep readers in the loop. For Doug, what do my results suggest to you?
Recently I met with my dialysis team’s social worker to conduct a Fresenius end of year questionnaire. One of the topics covered involved anger and depression. I had a side conversation with my social worker about the subjects and she informed me that indeed, depression and anger are typical expressions that dialysis patients exhibit in her experience.
Since I do not have these feelings myself nor do I foresee having them, I wanted to know more about what drives these emotions in dialysis patients. Am I missing something? I turned to Poe, my AI Assistant for answers. I wrote the following Prompt with the following results. (Poe also provided the lead graphic.)
Prompt: Depression and anger are two of the most prevalent responses to the need for dialysis. What do researchers have to say about this topic?
Assistant Poe
Depression and anger are indeed common emotional responses among individuals who require dialysis treatment. Researchers have extensively studied the psychological impact of dialysis and have shed light on the prevalence, causes, and potential interventions for these emotions. Here are some key findings and perspectives from the research:
Prevalence of depression and anger: Studies have consistently found higher rates of depression and anger among individuals undergoing dialysis compared to the general population. The chronic nature of the treatment, lifestyle changes, and the burden of managing a complex medical condition contribute to these emotional responses.
Causes and contributing factors: The causes of depression and anger in individuals undergoing dialysis are multifaceted. They can include the disruption of daily life and activities, the loss of independence, physical discomfort, financial stress, fear of the future, social isolation, and the impact of chronic illness on the individual’s overall well-being.
Impact on quality of life: Depression and anger can significantly impact the quality of life for individuals on dialysis. They may experience reduced motivation, decreased adherence to treatment, impaired social functioning, and lower overall life satisfaction. These emotional states can also negatively affect physical health outcomes and increase the risk of hospitalization.
Importance of mental health support: Recognizing the psychological challenges faced by individuals on dialysis, researchers emphasize the importance of providing mental health support as an integral part of their care. This can involve interventions such as counseling, psychotherapy, support groups, and education programs aimed at enhancing coping skills and emotional well-being.
Effectiveness of interventions: Several studies have shown that psychological interventions, such as cognitive-behavioral therapy, mindfulness-based techniques, and psychosocial support, can effectively reduce depressive symptoms and anger among individuals on dialysis. These interventions focus on improving emotional regulation, enhancing problem-solving skills, promoting social support, and fostering resilience.
Integrated care approach: Researchers advocate for an integrated care model that addresses both the physical and psychological aspects of dialysis treatment. This involves collaboration between nephrologists, psychologists, social workers, and other healthcare professionals to provide comprehensive support. By addressing emotional well-being alongside medical management, this approach aims to improve overall patient outcomes and quality of life.
It is important to note that the experiences and emotional responses to dialysis can vary among individuals. Therefore, personalized and patient-centered approaches are crucial in addressing depression, anger, and other psychological aspects of care for individuals undergoing dialysis treatment.
The saying “I am never out of the fight” is closely associated with the U.S. Navy SEALs. It encapsulates the unwavering determination, resilience, and mindset that SEALs embody in the face of adversity.
The origins of this motto can be traced back to the legendary Navy SEAL sniper, Lieutenant Commander Mark W. Divine. Divine, a former Navy SEAL himself, popularized the phrase in his book “The Way of the SEAL: Think Like an Elite Warrior to Lead and Succeed.” In the book, Divine emphasizes the importance of mental toughness, perseverance, and an indomitable spirit to overcome challenges and achieve success.
“I am never out of the fight” reflects the SEALs’ commitment to excellence and their refusal to give up under any circumstances. It signifies their readiness to face and overcome obstacles, no matter how daunting or insurmountable they may seem. This mindset is deeply ingrained in the SEAL training and operational ethos, as their missions often involve high-risk situations, where failure is not an option.
The phrase also highlights the SEALs’ ability to adapt and improvise in dynamic and unpredictable environments. It conveys their determination to find alternative solutions, regroup, and continue the fight, even when faced with setbacks or unexpected challenges. It serves as a reminder to maintain focus, stay resilient, and press forward despite the adversities encountered along the way.
Moreover, “I am never out of the fight” embodies the SEALs’ commitment to their teammates and the camaraderie that exists within their ranks. It signifies their dedication to supporting and protecting one another, ensuring that no member is left behind. This unwavering loyalty and sense of brotherhood are crucial elements in the success of their missions and the preservation of their unit cohesion.
Beyond the SEAL community, the saying has resonated with many individuals seeking inspiration and motivation in their personal and professional lives. It has become a symbol of resilience, perseverance, and the refusal to surrender in the face of challenges. The mindset encapsulated by these words serves as a powerful reminder that, no matter the circumstances, one can always find the strength to keep fighting, to keep pushing forward, and to never give up.
In summary, the U.S. Navy SEAL saying “I am never out of the fight” embodies the unwavering determination, resilience, adaptability, and teamwork that defines the SEALs. It serves as a reminder to maintain an indomitable spirit, persist in the face of adversity, and stand together with a shared commitment to mission success.
I am never out of the fight applies equally to those of us on dialysis. Not only am I, Hank Feeser, never our of the fight, I’ll never Ring the Bell. Think about it if you are on dialysis or have other health shortfalls, and read what it means again and again. I am never out of the fight.
The above video was made using three AI tools. First, I used Poe to write the script. Second I used Grammerly (free) to clean up the script. Then I chucked the results into Pictory’s text to video engine with the above results. I did not alter or edit Pictory’s output.
Yesterday I blogged about my having had a PET test (Peritoneal Equilibration Test) early this week but did not go into why and what would be accomplished with the outcome, if anything. This blog attempts to fill in these gaps.
I have previously blogged about algorithms that may be used to calculate ideal mixtures of PD parameters such as amount of fluid used during the PD and dwell times. Turns out, according to my dialysis team, the results provided by the Fresenius app, while adequate, are surpassed by one provided by Baxter. It is this algorithm that my team wishes to use for my particular situation and it requires fresh inputs from a PET. Thus the why.
A PET measures how well your peritoneum (The membrane that lines the abdomen and abdominal cavity.) transports wastes and water. This transport is the essence of PD treatment. How well or poorly your peritoneum works is measured by something named “Transport rate.” Typically, the rate is expressed as a high, average, or low transport rate. Depending on the transport rate, a heuristic for what type of PD is best suited may be determined. See table below from this link:
In the past, my transport level has been Low Average. Based on this, my peritoneum is slow in removing waste but good in water removal (as indicated by my daily micro-filtration numbers which are always greater than 1000 ml.) Based on these results alone, I should be using manual CAPD (Continuous Ambulatory Peritoneal Dialysis) instead of the APD (Automated PD) that I am currently using.
We’ll know soon enough what my new prescription will be as a result of this PET.
Now to some fun stuff. The lead graphic is from a POE bot named “Playground-v2.” This bot generates high quality images based on the user’s most recent prompt. I inputted as a prompt “Picture of a 1932 Ford five window coupe” with the lead graphic resulting. This is the most classic Ford every produced and the golden standard for all hot rodders in the US. See, there is a fun-factor even in dialysis! See this link for everything you ever wanted to know about the 1932 Ford: https://en.wikipedia.org/wiki/1932_Ford
Monday I was informed that my dialysis team wanted to conduct a PET (Peritoneal Equilibration Test) to best determine what my current optimum dialysis prescription is. (See link for more info on PET. The first part of the test required me to conduct a manual introduction of 2000 ml of 2.5 % dialysis fluid Monday night which was to be left in my stomach overnight, followed by a visit to the Fresenisus clinic Tuesday morning for three more manual drains and fills, interspersed with a blood draw and siphoning off of 200 ml of expelled dialysis fluids for lab tests. I should know the results later on in the week depending on how Christmas affects lab schedules.
Since a patient on PD is not often required to do a manual process (we were taught how in our training sessions) a refresher was needed. I found the following video which is included to help those who may be in the same situation as I found myself in. The video spells out in detail every step and precaution involved.
During my quarterly GP visit last week, I briefed my doctor, JP Letellier, MD on the status of my Peritoneal Dialysis including my shortfall in the Kt/V area. He quizzed me about what is behind the numbers which I was unable to provide in any detail. The following blog is in response to his questioning and will be provided to him. I used my AI assistant Poe as indicated below. She did a great job summarizing Kt/V for us.
Prompt: I am calculating Kt/V as I am on Peritoneal Dialysis. I conjecture that it has two components: the first is obtained from Peritoneal Dialysis, and the Second is from any Residual Kidney Function. Write a 500-word or so blog entry about the components of Kt/v and how labs calculate it in a professional medical tone.
Assistant Poe
Title: Understanding Kt/V in Peritoneal Dialysis: Examining the Components and Calculation
Introduction:
Peritoneal Dialysis (PD) is a life-sustaining treatment for patients with end-stage renal disease (ESRD) that helps remove waste products and excess fluid from the body. One crucial parameter used to assess the adequacy of PD is Kt/V, which measures the efficiency of solute clearance during dialysis. Kt/V incorporates two components: the contribution from Peritoneal Dialysis itself and the residual kidney function. In this blog post, we will explore these components and delve into the professional medical perspective of how laboratories calculate Kt/V.
Component 1: Peritoneal Dialysis (Kt):
Peritoneal Dialysis is a process that involves the infusion and drainage of a dialysis solution into the peritoneal cavity. The peritoneal membrane acts as a semipermeable barrier, allowing waste products and excess fluids to diffuse across it. The efficiency of solute removal during PD is represented by the term Kt, where K denotes the dialyzer clearance rate (clearance of solutes) and t represents the duration of the dialysis session.
The dialyzer clearance rate (K) is determined by factors such as the composition of the dialysis solution, the size of the solutes being cleared, and the characteristics of the peritoneal membrane. It is typically measured using the peritoneal equilibration test (PET), which involves measuring the concentrations of solutes in the dialysate and blood at various time points during a dwell period. The rate at which solutes equilibrate between the dialysate and the blood provides an estimate of K.
The duration of the dialysis session (t) refers to the time over which the dialysis solution is dwelling in the peritoneal cavity. Longer dwell times allow for greater clearance of solutes, improving the overall efficiency of Peritoneal Dialysis.
Component 2: Residual Kidney Function (V):
Residual Kidney Function (RKF) refers to the remaining functional capacity of the patient’s own kidneys. Even in patients with advanced renal failure, some degree of kidney function may persist. This residual function plays a significant role in the overall clearance of solutes from the body.
To quantify RKF, laboratory tests are performed to measure parameters such as serum creatinine and urea levels, as well as urine output. These values are then used to estimate the glomerular filtration rate (GFR), which reflects the filtering capacity of the kidneys. The GFR is a vital determinant of the second component of Kt/V, represented by V.
Calculation of Kt/V:
The total Kt/V is obtained by summing the contributions from Peritoneal Dialysis (Kt) and Residual Kidney Function (V). This summation provides a comprehensive measure of the overall clearance of solutes from the body during a given period.
Laboratories utilize various equations to calculate Kt/V, such as the formula developed by Twardowski et al. or the Daugirdas equation. These equations take into account parameters such as the patient’s total body water, ultrafiltration volume, and the measured or estimated GFR.
Conclusion:
Kt/V is a key parameter used to evaluate the adequacy of Peritoneal Dialysis. It incorporates two essential components: the efficiency of Peritoneal Dialysis itself (Kt) and the residual kidney function (V). The calculation of Kt/V involves assessing the dialyzer clearance rate, dwell time, and measurements of residual kidney function.
Accurate determination of Kt/V aids healthcare professionals in optimizing dialysis prescriptions, ensuring adequate solute clearance, and tailoring treatment plans to individual patient needs. By understanding the components and calculation of Kt/V, both patients and healthcare providers can make informed decisions regarding the management of Peritoneal Dialysis therapy.
I then asked Poe about the two methods mentioned above to calculate Kt/V with the following prompt and results:
Prompt: What are the Twardowski and Daugirdas equations for calculating Kt/V?
Assistant Poe
The Twardowski equation and the Daugirdas equation are two commonly used formulas for calculating Kt/V in peritoneal dialysis. Here are the equations:
Kt/V = -ln(R – 0.03) + (4 – 3.5R) × UF/W,
where:
R = D/P ratio of urea,
UF = ultrafiltration volume in liters,
W = patient’s weight in kilograms.
In this equation, the D/P ratio of urea is obtained from the measured concentrations of urea in the dialysate and plasma samples taken during a PET. The ultrafiltration volume represents the volume of fluid removed during the dwell period, and the patient’s weight is used to account for body water distribution.
Kt/V = -ln(R – 0.008 × t) + (4 – 3.5R) × UF/W + 0.03 × t,
where:
R = D/P ratio of urea,
t = dwell time in hours,
UF = ultrafiltration volume in liters,
W = patient’s weight in kilograms.
The Daugirdas equation incorporates the dwell time (t) in addition to the parameters used in the Twardowski equation. The dwell time represents the duration of the dialysis session.
It’s important to note that these equations are just two examples of the many formulas available for calculating Kt/V in peritoneal dialysis. Different centers or regions may use slightly different equations or modifications based on local practices and preferences. Additionally, these equations primarily focus on the clearance of urea, which is a commonly used marker for assessing dialysis adequacy. Other solutes may require additional equations or adjustments for accurate Kt/V calculations. It’s always recommended to consult with a healthcare professional or nephrologist for precise calculations and interpretation of Kt/V values in individual cases.
Last Thursday I blogged (link) about a online calculator for Kt/V that is provided by Fresenius (see link). I tossed it out there for patients to play around with but did not articulate about one very important aspect of the calculation. This blog is to rectify that shortcoming on my part. Thus the “cleanup.”
In the left panel center section you have the option of setting “Residual Kidney Function.” For the example I used, I set it to zero. Since I am still urinating, albeit not that much, it is NOT zero but some positive number, probably for me about 0.3. If you increase this from zero to 0.3 in the left panel, the calculations in the right panel, yields 1.7 on the dial. The dial reading is a combination of what your kidney is producing and what Kt/V is obtained from dialysis itself. There are two components. There’s a label at the bottom of the third panel as “Kidney Weekly Kt/V” and “Peritoneal Kt/V.” Thus the dial is showing both.
Sorry for any confusion. Since Kt/V is so central to our dialysis well being, tomorrow’s blog will dig even deeper into it. The more patients know, the better patients they can become. Certainly that is the goal for all of us, regardless of what ails us.
As part of prep for my annual physical in March 2024, on 12/13/2023 my GP had a set of labs done by Quest Labs here in Granbury,TX. One of the labs we are always interested in is how my Testosterone levels are doing. The lead graphic above shows that they have varied since 2018, and my results yesterday indicated they were above the upper bound at 935 or so. Keep in mind that every two weeks I am injected with a 1 ml Testosterone shot so for me, this is not unexpected. My last shot was Sunday a week ago.
Here’s the rest of the story. In our society, we talk in hushed voices about women and their “hot flashes” and even, God bless us, Hormone Replacement Theory. What we NEVER talk about, even among men in the locker room, so to speak, is men and their testosterone levels. Among men, testosterone is inexplicably tied to their perceived sexual prowess, and any discussion along the lines of lack thereof is taboo. It directly attacks their manhood.
This is tragic in that testosterone in men has many many more functions than growing hair on their chests. It extends further than this to severely impacting those of us (males) on peritoneal dialysis. To help in this area, I turned to my AI assistant Poe with the following Prompt and results. Please read what she has to say, and my comments thereafter. Listen up Fresenius Dialysis Team; you are brought to task therein:
Prompt: Write a 500 word blog in a serious tone on how important testosterone is to male patients on peritoneal dialysis.
Assistant Poe
Title: The Significance of Testosterone for Male Patients on Peritoneal Dialysis
Introduction
Peritoneal dialysis is a life-saving treatment for individuals with end-stage renal disease (ESRD). While it offers numerous benefits, it can also have an impact on hormone levels in the body. Specifically, male patients on peritoneal dialysis may experience a decline in testosterone levels. In this blog post, we will explore the importance of testosterone in male patients and shed light on the significance of managing testosterone levels for those undergoing peritoneal dialysis.
Understanding Testosterone
Testosterone is a hormone primarily associated with male sexual development and reproductive function. However, its influence extends far beyond these realms. It plays a crucial role in regulating bone density, muscle mass, red blood cell production, mood, cognitive function, and overall well-being. Testosterone levels naturally decline with age, but in male patients on peritoneal dialysis, this decline may be accelerated due to various factors.
Testosterone and Peritoneal Dialysis
Peritoneal dialysis involves the use of a catheter to filter waste products and excess fluids from the body. While it is an effective treatment, it can lead to hormonal imbalances. The loss of proteins during dialysis can disrupt the delicate equilibrium of hormones, including testosterone. Additionally, factors such as inflammation, oxidative stress, and the presence of comorbidities can further contribute to decreased testosterone levels in these patients.
Impact on Male Patients
The decline in testosterone levels can have significant consequences for male patients on peritoneal dialysis. Firstly, it can lead to a decrease in muscle mass and strength, resulting in fatigue and reduced physical performance. This can impact the patient’s ability to carry out daily activities, diminish their quality of life, and potentially lead to muscle wasting. Moreover, low testosterone levels may contribute to decreased bone mineral density, increasing the risk of osteoporosis and fractures.
Furthermore, testosterone deficiency can affect mood and cognitive function. Male patients may experience symptoms such as depression, irritability, difficulty concentrating, and reduced motivation. These changes can further hinder their ability to participate in social activities and negatively impact their mental well-being.
Managing Testosterone Levels
Recognizing the importance of testosterone in male patients on peritoneal dialysis, it is crucial to monitor and manage testosterone levels effectively. Regular assessment of hormone levels can help identify deficiencies and guide appropriate interventions. Healthcare professionals may consider various treatment options, including testosterone replacement therapy (TRT).
TRT involves the administration of testosterone to supplement or restore levels in the body. It can be administered through different methods, such as injections, gels, patches, or pellets. However, it is essential to evaluate each patient individually and consider potential risks and benefits before initiating TRT.
In addition to TRT, optimizing lifestyle factors can also play a role in managing testosterone levels. Regular exercise, a balanced diet, stress reduction techniques, and adequate sleep can positively influence hormone production and overall well-being.
Conclusion
Testosterone is a vital hormone for male patients on peritoneal dialysis, as it impacts various aspects of their health and well-being. The decline in testosterone levels associated with this treatment can lead to muscle loss, decreased bone density, mood disturbances, and cognitive impairments. By actively monitoring testosterone levels and implementing appropriate interventions, healthcare professionals can help mitigate these adverse effects. It is crucial to individualize treatment plans and utilize a multidisciplinary approach to optimize the overall health and quality of life for male patients on peritoneal dialysis.
My closing comments for Fresenius Dialysis Team: It appears that monitoring testosterone levels for males is central to the overall care and feeding of your patients. Why has this never been a topic of interest or questioned by team members? What are you going to do about it? It would appear to be as central to a male patients’ well being as phosphorous, potassium or other chemical levels you keep a keen eye on?
A couple of days ago I blogged about finding an algorithm to calculate PD prescriptions. Alas, because of cycle restrictions being 6-12 cycles, it did not apply to me. I searched some more, and found a PD Calculator by Fresenius Medical (link) that does not have these restrictions. All of the following three screen shots are from this calculator with my data inputted.
There are three panels that are viewable on my large desktop computer all at once which is nice. The left, or first panel above is where patient-specific data is entered. Notice there are small “i”s next to most values that explain in detail what the required value is all about; I found them to be helpful. The Transport entry allows you to dynamically change this value and see how it impact values of Kt/V which are displayed in the third panel. Values are mostly self-explanatory otherwise.
The second or center panel provides Estimated Prescription Data to obtain a minimum of a Kt/V of 1.7. In my case, for the values entered in the left panel, it suggests a maximum fill volume of 2.7 L per fill, and 6 exchanges.
The right/last panel is labeled Physician Modeling. I inputted my current prescription of 2.5L per fill 4x fills, and 2 hour dwell and the panel provided an estimated Kt/V value of 1.4 for these parameters. This is very close to the lab-provided value of 1.46 and 1.67 my two most recent readings. To obtain these readings, I had to adjust the Transport input in the left panel to the second highest setting which is more Transport than I recall I am getting from my current PD.
So there it is, a way for patients to play around with their numbers and see how variables are interrelated. Go for it!
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