There is a phrase “Screwed up as Hogan’s Goat.” The phrase Hogan’s goat refers to something that is faulty messed up, or stinks like a goat. The phrase is a reference to R.F. Outcault’s seminal newspaper comic Hogan’s Alley, which debuted in 1895. The title of the strip changed to The Yellow Kid the following year.
CVS, a national drug store chain in the US, personifies Hogan’t Goat. Let me explain. A couple of weeks ago my wife and I, using the CVS App, made appointments to receive the fall flu shot, the new COVID shot, and the RSV shot. When we arrived for our appointment, we were told they were out of the RSV shots, it would be $200 each for the COVID shots, but we were OK for the fall flu shot which we both received. We passed on the $200 for each COVID shot as the news had been blaring about them being available and free for those of us on Medicare.
The next day I phoned CVS and asked them WTF was going on with the COVID shots. I was informed, the very next day mind you, that our military insurance, TriCare for Life, was now covering the COVID shots. Like this took place overnight!???
Back to the CVS app where I made appointments for my wife and I to receive both the COVID and RSV shots on Monday, 10/2/2023. I called CVS on 10/1/2023 and they assured us that the shots were and would be available for our appointments. So far everything seems to be working – Until!
Until we turned up at CVS in Granbury for our shots. The pharmacy area looked like Grand Central Station on Friday afternoon at 5 p.m. There were people everywhere. We showed up at 1020 for our 1030 appointment, and at noon, yes 1200, we walked out with shots in our arms, a full hour and forty minutes after showing up for our appointments. Seems that some people like us signed up for appointments online which went into their computer base. Some called in for appointments that went somewhere else. Some just showed up. Some made appointments in person for a later date. All of these inputs were not merged into a time-sensitive file so who knows how the queue was established and managed, or mismanaged as the case may be?
The sad part about the mismanaged mess is I saw no indication that anything was going to be done about their inaptitude to preclude similar situations in the future. Luck for us, we now have our shots until next year rolls around. I think we will wait until our local Pecan Plantation pharmacy has the shots to preclude being part of CVS’s Hoagan’s Goat show again. Caveat Emptor!
We’re back home from a week’s trip to visit with my wife’s sisters in Indiana – Central Indiana to be specific, in and around Lafayette, Indiana, close to Purdue University. To say that time changes things is an understatement. Every time we go back, which is infrequently, we cannot believe how much things have changed – traffic, crowds, people, infrastructure, route changes, etc. Like being in an alien world.
Background: In preparation for our trip back to Indiana, a trip of roughly 1000 miles each way, we divided my PD supplies into 7 boxes; two boxes contained supplies for two nights, four boxes contained supplies for one night, and one box contained cassettes. We divided the trip up so we traveled roughly halfway each night, 486 miles as it turns out. So the night on the road we used a single box, and the three nights in Lafayette we used one double and one single, and coming back one single. Upon our return home, we had a single and a double as backup. This worked out well.
Some lessons learned:
Aseptic procedures take twice as long while traveling and are probably more than twice as important. At home, all your aseptic gear is laid out in an orderly fashion. While traveling it is a mess stuffed into your luggage almost at random, especially after a couple of nights on the road. Anything you can do to organize this area is very lucrative.
I have gained about four pounds traveling for one week. En route, we grabbed what we could mostly while stopped for gas. Once we landed in Lafayette, every interface with my wife’s sisters and their families revolved around food. We were literally eating breakfast, getting up from that, and going directly to a lunch date and after a short break to supper. It was a never-ending parade of food. That’s the way it was and I don’t see any way around such social occasions. It is what it is.
We stayed going and coming in a Hilton Inn Express in Springfield, MO. While in Lafayette, IN we stayed in a Drury Inn. The Hilton was somewhat long in the tooth in comparison with Drury with Drury’s ambiance superior as was their food and in general their welcomeness. I would suggest Drury given the choice by far. Prices for an overnight stay were in the $185 per night for Drury in Lafayette and $134 per night for Holiday Inn. Looks like you get what you pay for.
The largest single expense incurred for our week away from home was the boarding of our Golden Retriever Dickens. He was boarded from Saturday to Saturday at a cost of $600 including tip. We supplied his food. You need to factor this cost into your budget for traveling.
We used whatever route our BMW X5’s GPS suggested we take so we hit several tolls. We have the NTTA automatic toll sticker on our car so we did not have to stop to pay tolls. Interestingly, tolls in Oklahoma were also automatically paid via our sticker. Point to note.
We have lots of “stuff” to contend with in the coming week. Monday we are scheduled for COVID and RSV shots at CVS, assuming they have the shots in hand. On Tuesday I have a dialysis lab and will return the cycles case that Fresenius lent to me for our travels along with a dermatology appointment to remove a Basail Cell cancer from my check. Wednesday I have surgery scheduled to have a look-see at my catheter to ascertain if there is any blockage or placement issues causing my incessant drain alarms.
As the song below attests, “Don’t tell me I’ve nothing to do!”
A commentator on this board and I have been comparing notes on our individual treatments. While this is instructive and interesting, you have to keep in mind that we are each individuals into ourselves and it’s easy to fall into the trap of comparing apples to oranges. The following table depicts differences and similarities in our PD:
My Readings
His Readings
UFiltration
4-800 mL
11-1300 mL
# Cycles
4
5
Dwell
120 minutes
90 minutes
Total Time
10-5 to 11 (Hr-min)
10-5 to 12-15
Comparison table me to him
At first glance, it would appear that “him” is pulling lots more fluid out via PD compared to me as indicated by the comparison of the UFiltration (microfiltration) numbers. But this is misleading. What we don’t know and can’t compare is how much urine each of us is still making via normal kidney function. I still pass a plausible amount of urine naturally; does he? Something else we don’t know is what percentage solution each of us is using. The more concentrated the solution (we have a choice of 1.5, 2.5 and 4.25%), the higher the expected microfiltration.
My prescription has me on dwell for a total of 4 times 120 minutes or 480 minutes, while “him” is on dwell for a total of 5 times 90 minutes or 450 minutes. So I have fluid in my stomach for 30 more minutes, all else being equal. This is where things get a little bit more complex to describe and understand.
There is a concept in peritoneal dialysis called Transport, and Transport is measured by something called PET. To help explain these concepts, I turned to Poe with the following result:
Poe Assistant:
In peritoneal dialysis, the transport level refers to the permeability of the peritoneal membrane to solutes during the dialysis process. The peritoneal membrane acts as a semi-permeable barrier between the blood vessels and the dialysis solution (dialysate) that is infused into the peritoneal cavity. The transport level is determined by the characteristics of the peritoneal membrane, which can vary from person to person. There are three main types of transport levels in peritoneal dialysis:
High Transporters: High transporters have a peritoneal membrane that is highly permeable to solutes. This means that solutes, such as waste products and excess fluid, can easily pass through the membrane from the blood vessels into the dialysate. High transporters may require more frequent or longer dwell times during peritoneal dialysis to adequately remove waste products.
Low Transporters: Low transporters have a peritoneal membrane that is less permeable to solutes. In these individuals, the removal of waste products and excess fluid during peritoneal dialysis may be less efficient. Low transporters may require longer dwell times or more exchanges to achieve adequate dialysis.
Medium Transporters: Medium transporters have a peritoneal membrane with intermediate permeability. Their peritoneal membrane allows for a moderate transfer of solutes between the blood vessels and the dialysate.
The transport level is assessed using a test called the peritoneal equilibration test (PET). This test involves measuring the concentrations of certain solutes in the dialysate at different time points during a dwell period. The results of the PET help determine the transport level of an individual and guide the prescription of peritoneal dialysis.
By tailoring the peritoneal dialysis prescription to an individual’s transport level, healthcare providers can optimize the effectiveness of dialysis treatment and improve patient outcomes.
I have what is considered to be a LOW TRANSPORT peritoneal membrane. Without knowing what “his” transport is, we can’t compare “his” dwell times or total times to mine. If we did, it would be comparing apples to oranges and we don’t want to be guilty of that, do we?
A Michigan Medicine study found that the longer an individual has type 2 diabetes, the more likely they are to exhibit changes in brain structure, such as decreased cortical thickness and gray matter volumes. Despite no discernible difference in cognition between those with and without diabetes, complications like chronic kidney disease and vascular damage in diabetes are linked to these brain changes. They also note that diabetic complications increased the odds of developing a cognitive disorder by 2.45 times in 40 to 60-year-olds.
So what is being implied herein? Type 2 diabetes -> brain changes -> also kidney functions -> plus other externalities -> and cognitive functions, i.e., how well our brain works? We already have cited research in previous blogs associating CKF with diabetes. It is a given. Therefore, if diabetes is adversely affecting cognition, then diabetes leading to CKF also imparts to those on dialysis as a result of CKF as potentially having cognition impacted as a comorbidity.
Impact on Cognitive Function: The impact of kidney disease on cognitive function can manifest in various ways. Studies have shown that individuals with kidney disease may experience:
Slowed Processing Speed: Cognitive processing speed, such as the ability to quickly understand and respond to information, may be impaired in individuals with kidney disease.
Reduced Attention and Concentration: Difficulty focusing, sustaining attention, and maintaining concentration are common cognitive challenges observed in some individuals with kidney disease.
Memory Problems: Kidney disease may affect different aspects of memory, including both short-term memory and long-term memory. This can manifest as forgetfulness, difficulty retaining new information, or trouble recalling past events.
Executive Function Deficits: Executive functions, which include skills like planning, organization, problem-solving, and decision-making, may be compromised in individuals with kidney disease.
Increased Risk of Cognitive Disorders: Research suggests that kidney disease, particularly in the presence of diabetes and its complications, may increase the risk of cognitive disorders such as dementia and Alzheimer’s disease.
Take it on board: It’s bad enough to experience CKF resulting in the need for dialysis. In the presence of diabetes which is highly likely, it is a double-edged sword. Perhaps having a “big brain” before onset is helpful?
Recent research has shed light on the potential benefits of incorporating pomegranate juice into the dietary routine of dialysis patients. Pomegranate juice, renowned for its antioxidant properties and numerous health benefits, may offer a ray of hope by addressing complications and improving overall well-being. In this blog post, with the help of Poe, we will delve into the findings of recent studies and explore how pomegranate juice could be a valuable addition to the lives of dialysis patients.
The Power of Antioxidants: One of the key factors that make pomegranate juice remarkable is its high antioxidant content. Antioxidants play a crucial role in protecting cells from oxidative stress, which is prevalent in chronic kidney disease. By neutralizing harmful free radicals, antioxidants can help alleviate inflammation, reduce cellular damage, and potentially slow down the progression of kidney disease.
Managing Hypertension and Cholesterol Levels: Dialysis patients often struggle with hypertension (high blood pressure) and elevated cholesterol levels, which significantly increase the risk of cardiovascular complications. Pomegranate juice has been found to have beneficial effects on both these factors. Studies suggest that the juice may help lower blood pressure, making it particularly valuable for hypertensive dialysis patients. Additionally, pomegranate juice has shown the potential to reduce LDL (bad) cholesterol levels, promoting cardiovascular health.
Protection Against Infections and Cardiovascular Events: Patients undergoing dialysis are susceptible to infections and cardiovascular events, which can have severe consequences. The preliminary findings of a recent study presented at the American Society of Nephrology’s annual meeting indicate that pomegranate juice could be a preventive measure against these complications. The juice’s antioxidant and anti-inflammatory properties may help boost the immune system, reducing the risk of infections. Furthermore, its ability to improve cardiovascular health may contribute to a lower incidence of cardiovascular events, enhancing the overall well-being of dialysis patients.
Enhancing Nutritional Intake: Dialysis patients often face challenges related to their nutritional status. Incorporating pomegranate juice into their diet can be an effective way to supplement their nutritional intake. Pomegranate juice is a rich source of essential vitamins, minerals, and dietary fiber. It provides vital nutrients that support overall health and can help combat common deficiencies observed in dialysis patients.
Considerations and Precautions: Drinking a controlled amount of pomegranate juice with a safe and monitored potassium content may help reduce the complications that often occur in dialysis patients. It is important to consider the risk involved in potassium overload, especially in chronic kidney disease (CKD) patients with dietary potassium restriction.
Incorporating Pomegranate Juice into Your Routine: If you are a dialysis patient interested in incorporating pomegranate juice into your diet, discuss it with your healthcare team. They can provide guidance on the appropriate amount and frequency of consumption based on your unique circumstances. Freshly squeezed pomegranate juice or commercially available varieties with minimal additives are recommended for optimal health benefits.
Conclusion: The potential health benefits of pomegranate juice for dialysis patients present a promising avenue for improved well-being. From its antioxidant properties to its potential to manage blood pressure, and cholesterol levels, and reduce the risk of complications, pomegranate juice offers a natural and accessible option. However, it is essential to remember that dietary changes should always be made under the guidance of healthcare professionals. By exploring the potential advantages of pomegranate juice and incorporating it into a balanced diet, dialysis patients may take a step towards enhancing their quality of life.
For individuals undergoing dialysis, managing blood pressure becomes a critical aspect of their treatment. The kidneys play a crucial role in regulating blood pressure by controlling fluid balance and producing hormones that help relax blood vessels. When kidney function is compromised, blood pressure can rise significantly, leading to hypertension.
My 100% disability rating with the VA states I have CKF with Hypertension. Keep in mind that hypertension is considered to be the No. 1 risk factor for death globally. It is intuitively obvious (didn’t you love those words in geometry proofs?) that those of us on dialysis have a very imperative need to quickly and accurately track our blood pressure readings.
Recent research has shown that a significant number of off-the-shelf blood pressure devices are providing inaccurate readings due to improper fitment of cuffs. In general, the standard size cuff is too small for the majority of adults resulting in blood pressure readings being higher than they actually are. See the lead graph from the cited research link at paragraph head. Note that small and medium cuffs read much higher than large and xlrge for the author who considers himself to require a larger cuff.
I suggest you read and ponder the cited article, and if you possibly have larger arms and/or suspect your organic blood pressure measuring device is overly stating your true blood pressure, take it to your GP for comparison and possibly obtain a better version. After all, it’s only your life and well-being we’re dealing with here!
In July 2015 during my annual physical, my GP noticed something not quite right with my EKG. He passed me on to a cardiologist who ordered a stress test followed by a dye test that uncovered blockage. Within three days of my GP’s initial prognosis, I was in the ICU recovering from triple bypass surgery. Bear in mind that as a person I did not feel anything to be out of order. I was not overly tired nor did I present, and MDs like to phrase it, any other outward discernable symptoms.
As a result of this history, I have been prescribed baby aspirin by both the cardiologists I have been associated with, one in Corpus Christi, TX, and one here in Granbury, TX where I now live. Other than bruising and marginally thinner blood, I have observed no other effects of taking the prescribed aspirin.
Now to the story. Recent research has found that “taking 100mg of aspirin every day could lower the risk of people aged 65 and over developing type 2 diabetes…” The research also noted previous researchers have found that aspirin use was associated with a significantly increased risk of bleeding, primarily in the gastrointestinal tract. Since CKF is strongly correlated with the presence of diabetes, this finding has merit for those experiencing kidney degradation and/or failure.
I used Poe to construct a 500-word summary of the article cited above which follows:
A recent study suggests that taking a daily dose of 100mg aspirin may reduce the risk of developing type 2 diabetes in individuals aged 65 and older. Led by Professor Sophia Zoungas from Monash University, the study involved over 16,000 participants who were either given aspirin or a placebo. The results indicated that the group taking aspirin experienced a 15% reduction in type 2 diabetes risk and a slower increase in fasting plasma glucose levels. However, the study’s authors emphasize that further research is needed before any changes are made to current clinical guidelines regarding aspirin use in older adults. It’s worth noting that a previous trial called ASPREE, published in 2018, found that taking aspirin led to an increased risk of major bleeding without a reduction in cardiovascular disease incidence. Thus, while the recent findings are interesting, they do not alter the current clinical advice on aspirin use in older individuals.
Starting Sunday and for a week, my wife are I are traveling to Indiana via our BMW X5 to visit with family. She has three sisters living there. This is our first trip since I started Peritoneal Dialysis on 9/30/2023 and we’re probably over preparing in the face of so many unknowns.
One of the first things we accomplished was to borrow from our local Fresenius group the travel case for the Cycler. The picture at lead is of our Cycler with the case to the right of it. It is the HUGE black blob to the right of the picture. I mean as in enormous. It has a large yellow sign on it stating “Medical Device” I assume for shipping on airlines etc.
In addition to our normal luggage for a week’s travel to a foreign land, we will have eight boxes devoted solely to dialysis supplies. Four of the boxes contain one night’s supply of Dialysate ( one 5L and one 3L bag), trash bag, sta-keeper, etc. Two boxes double this up. The strategy here is we will spend one night going and coming on the road (staying over in Springfield, MO) and two nights in Lafayette, IN for a total of four nights. The other boxes with dialysate are backups. We have one box of cassettes, and one box containing all the other supplies required for dialysis such as 2x2s, tape, cleaning liquids, towels, heparin, syringes, etc.
It is going to end up being quite a bit of “stuff” but needed for a week’s trip. Even if we had arranged for dialysate to be shipped to our hotel in Lafayette, we would still need the bulk of supplies to conduct PD on the road. Another thing, each night we use one of the single boxes it is one less box we have to haul in the BMW.
The picture at the end (our golden Dickens had to supervise the taking of the picture) shows where we stand at packing out some 4 days in advance. I will share our traveling experiences when we return. Meanwhile, I have written a week’s worth of blogs which will continue automatically (aren’t computers wonderful) while we journey up to our Nation’s Breadbasket.
In this modern-day world, we all are a function of numbers. Be they income qualifications for SNAP or a home loan, or the amount of taxes on income. We live in a swirl of numbers; how tall we are, what our BMI is, what our blood pressure is, and during the phases of CKF, what our eGFR is.
It seems to me that medical personnel are relying more on numbers and less on the patients as an individual. They spend less time getting to know the patient and more on lab results. Is this a good or bad thing? I don’t really know but I do know that this model of operation by medical personnel, has by its very nature, made patients become more in tune with their numbers, be they biometric or lab-based.
It is conjectured that being human, some patients obsess over their numbers, and this is especially so when small or random changes in their lab results occur. In this setting, I have never had a conversation with medical personnel about how accurate the presented lab results are. What is the margin of error? How repeatable are the results? Do they depend on the time of day taken? Do they vary significantly from lab to lab? Do the lab results in fact measure what they proport to, or are they a proxy? Instead, they are taken prima facia as factual and direct explicit health regimens.
Patients can use philosophical help in dealing with the deluge of lab-produced numbers they are by their very nature forced to live with and by. I turned to my AI assistant, Poe seeking help in this area with the following prompt and results. Hopefully, it will help readers deal with the number onslaught.
Poe Prompt: Increasingly patients are subjected to numbers in their care, especially lab results. This is especially true of those of us on peritoneal dialysis. We live and die by these numbers. It can become an obsession with patients that is not constructive. Write a brief blog entry targeting peritoneal patients and their caregivers on how to deal with pressure from lab numbers.
Assistant Poe
Title: Navigating the Pressure of Lab Numbers: A Guide for Peritoneal Dialysis Patients and Caregivers
Introduction:
Living with peritoneal dialysis brings about a unique set of challenges, and one of them is navigating the pressure that often comes with monitoring lab numbers. While these numbers are crucial indicators of your health, it’s essential to maintain a balanced perspective and avoid becoming obsessed with them. In this blog entry, we’ll discuss some practical strategies for peritoneal dialysis patients and their caregivers to cope with the pressure of lab numbers and promote a healthier mindset.
Understand the Purpose of Lab Numbers:
First and foremost, it’s crucial to understand the purpose and significance of lab numbers. They provide valuable information about your health status and help healthcare professionals make informed decisions about your care. Recognize that these numbers are tools to guide your treatment, and they should not define your self-worth or overall well-being.
Establish Open Communication with Your Healthcare Team:
Developing a strong, communicative relationship with your healthcare team is vital. Regularly discuss your lab results with your healthcare provider and ask questions to gain a better understanding of what each number means for your health. This collaborative approach will foster trust and empower you to actively participate in your own care.
Focus on Trends, Not Isolated Results:
Lab numbers can fluctuate from time to time, and it’s important to remember that isolated results don’t always tell the whole story. Instead of fixating on individual values, pay attention to the trends over time. This will provide a more accurate reflection of your health and help you and your healthcare team make more informed decisions about your treatment plan.
Seek Emotional Support:
Living with the pressure of lab numbers can sometimes lead to anxiety and stress. It’s crucial to seek emotional support from loved ones, support groups, or mental health professionals. Sharing your concerns, fears, and frustrations with others who understand your situation can be immensely helpful in navigating this journey.
Focus on Overall Well-being:
Remember that your overall well-being extends beyond lab numbers. While they are essential, they are just one piece of the puzzle. Maintain a holistic approach to your health by focusing on other aspects such as maintaining a balanced diet, engaging in regular physical activity, managing stress, and getting adequate rest. Taking care of your mental and emotional well-being is equally important.
Celebrate Small Victories:
Lab numbers may not always be perfect, but it’s essential to celebrate the small victories along the way. Recognize and appreciate the progress you make, regardless of whether it matches your ideal expectations. Celebrating achievements, no matter how small can help shift your focus from solely relying on lab numbers and promote a more positive outlook.
Conclusion:
Peritoneal dialysis patients and their caregivers face the pressure of lab numbers, which can sometimes become overwhelming. By understanding the purpose of these numbers, maintaining open communication with your healthcare team, focusing on trends rather than isolated results, seeking emotional support, prioritizing overall well-being, and celebrating small victories, you can navigate this pressure more effectively. Remember, you are more than just the numbers on a lab report, and your well-being is a holistic journey encompassing both physical and emotional aspects.
It may be constructive if readers of this blog have an opportunity to compare lab readings from two different individuals. We are each unto our own, and lab readings follow this discourse. But, if we look at lab readings as “how are we doing vis-a-is “the competition,” perhaps insights are derivable that would not be apparent by just comparison with what labs state are goals.
A respondent to blog posts on this blog and I have developed rapport due to our common interest in peritoneal dialysis employing the Fresenius Liberty Cycler. He recently shared his lab readings and I constructed the table below so our readings may be compared side-by-side and with stated lab goals where established. See the table below and the comments following.
Reading
Him
Me
Goal
Albumin
3.9
3.4
=>4.0
Potassium
4.0
4.2
3.5-5.5
wKt/V
1.87
1.86
=>2.0
Calcium
9.2
8.5
8.5-10
Phosphorus
5.5
5.4
3-5.5
IPTH
206
380
100-720
Hemoglobin
10.2
10.9
10-11
BUN
68
52
Not Established
Creatinine
8.98
7.27
Not Established
Comparison His labs to mine
Pulling out some numbers now. Neither of us are where we should be regarding Albumin. I’m always low regardless of how much red meat I ingest. Low Albumin is a plague for those of us on dialysis.
His Calcium is much better than mine but this could be due to his younger age (74 versus 84.) My IPTH is much higher. IPTH indicates a balance of calcium and phosphorus in our blood. High phosphorous can cause high IPTH which can lead to bone and heart damage.
Both of us are down on wkt/V which measures whether or not we’re getting enough dialysis to adequately clean our blood. However, at least from my dialysis team’s perspective, we are close enough to keep on doing what we are doing without alteration of our dialysis prescription.
For kicks, I calculated eGFR for both of us using my Android App for this purpose. For him I used age = 74 and the Creatinine value of 8.98. His eGFR is 6. For me, I used age = 84 and a Creatinine value of 7.27 and obtained an eGFR of 7. So we’re both in the tank from an eGFR perspective as should be expected since both of us are on PD.
Bottom line: As the table above suggests, although we are two entirely different individuals, our labs don’t really vary that much, given that we are both on dialysis.
