Henry Feeser's Peritoneal Dialysis (PD) journey

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Dental Health, Diabetes, and Dialysis: The Three Ds

July 25, 2023 / / 0 Comments

Normally one would not associate Dental, Diabetes, and Dialysis in the same sentence or thought process. However, it is an uncontested fact that Diabetes and the need for Dialysis are closely associated with over 40% of dialysis patients also diabetic. Up to now, I had never heard or read any association between the latter two Ds and Dental. I know that often diabetic patients have dental challenges, but the study I’m about to present notes a causality going the other direction, Dental Problems -> Diabetes and further -> Dialysis.

Writing in the July 9 2023 issue of SciTechDaily, the University At Buffalo wrote an article titled “The Surprising Connection Between Chewing and Type 2 Diabetes.” The article is linked here:

With the following Prompt, I asked my AI to condense the article for this blog into 400 words or fewer entries in laymen’s terms. The Prompt and result follow. My closing comments are at the end. The lead graphic is from Bing Illustrator.

Summarize the following article into a 400-word or less entry at laymen’s level for a blog that concentrates on peritoneal dialysis:

ChatGPT:

Mehmet A. Eskan, a researcher from the University at Buffalo, suggests medical professionals treating Type 2 diabetes (T2D) patients should pay attention to their patient’s dental health. Eskan’s recent study, published in PLOS ONE, found a significant link between chewing functionality and blood sugar levels in T2D patients. Essentially, those who could chew well had much lower blood sugar levels than those who couldn’t.

Eskan and his team analyzed data from 94 T2D patients at a clinic in Istanbul, Turkey. They divided the patients into two groups based on their ability to chew – those with a good “occlusal function” (the ability to chew food effectively), and those who couldn’t chew well due to missing or improperly placed teeth. The results were striking: the group with good occlusal function had an average blood sugar level of 7.48, while those who couldn’t chew well had an average blood sugar level almost 27% higher, at 9.42.

Chewing, or mastication, kickstarts the digestion process by stimulating saliva production. It also helps our bodies absorb fiber and other essential nutrients from food, which are important for controlling blood sugar levels. Moreover, chewing well can promote feelings of fullness, helping to prevent overeating – a major risk factor for T2D.

Eskan’s research comes amid growing recognition of the role oral health plays in managing diabetes. In one case, a patient’s blood sugar level dropped dramatically after dental implants and restoration improved their ability to chew. However, the study also showed that factors like Body Mass Index (BMI), sex, smoking status, medications, or infections did not significantly affect the participants’ blood sugar levels.

High blood sugar levels can have serious health consequences, with a 1% increase linked to a 40% rise in the risk of heart disease among diabetic patients. Eskan hopes his research will spur further studies to understand the cause-and-effect relationship between dental health and blood sugar levels better.

So, the next time you sit down for a meal, remember: chewing your food well isn’t just good manners – it could be critical for your health, especially if you’re living with Type 2 diabetes.

My wife often laments that she spends hours cooking a nice meal for us, and given my military background where you are taught to inhale food on the run in uncertain circumstances, it is often gone in five minutes. As a couple, we are working on slowing our food intake down in keeping with the findings of this article.

New Kidney Atlas Breakthrough

July 24, 2023 / / 0 Comments

Isabella Creto wrote in the July 19, 2023 issue of STAT an article titled “The kidney, in all its complexity, is captured in an atlas that could aid disease research.” The source article is here: It is a fairly complex article, so I asked my AI assistant to summarize it in laymen’s terms for us. The Prompt I authored and the ChatGPT result is below followed by another query about how this research applies to those of us on Peritoneal Dialysis. Read on:

Prompt: Summarize the following article to 400 words or less for a blog entry that addresses peritoneal dialysis in layman’s terms:

A team of scientists has developed the most comprehensive model of the human kidney to date, utilizing new techniques and technologies to probe deep inside human cells. This “kidney atlas” is a result of detailed analysis of nearly 100 tissue samples from healthy kidneys, and those with acute or chronic kidney disease. The research, published in Nature, found 51 main cell types, 28 kidney injury states, and 1.2 million “injury neighborhoods” that could be vital for understanding kidney diseases.

The atlas allows scientists to differentiate between “good” and “bad” neighborhoods of cells, with the latter usually falling apart due to dysfunctional cellular interactions. These cell neighborhoods were then compared with data from the Rare Diseases Clinical Research Network to identify which were associated with positive and negative health outcomes.

Kidney disease is a leading cause of death in the U.S., and symptoms often don’t appear until the disease is quite advanced. Once kidney failure occurs, the best treatment is a transplant, but this is not always possible and many patients have to rely on dialysis. The process of dialysis can be strenuous and carries the risk of infections, and only extends life by a few years.

The kidney atlas, which is public and open-source, is hoped to provide the basis for breakthroughs in the treatment of kidney diseases after decades of relatively little progress. It offers a common reference for all scientists, and the international Human Cell Atlas project was also involved in its creation.

There are, however, limitations to the current data, which is focused on mRNA, the step between DNA and the proteins that help cells function. Further study is needed to understand how cellular interaction affects health and disease at the protein level. The ultimate goal is to fully map the human kidney to pave the way for novel therapies for specific kidney diseases.

Prompt: How might this research help those of us on peritoneal dialysis with ESRD?

ChatGPT

This groundbreaking kidney atlas could pave the way for major improvements in the treatment of End-Stage Renal Disease (ESRD) and possibly help those on peritoneal dialysis in several ways:

  1. Understanding Disease Mechanisms: By detailing the numerous cell types, states of kidney injury, and “injury neighborhoods,” the atlas could help researchers understand the precise cellular and molecular events that lead to ESRD. Understanding these mechanisms could lead to the development of new therapeutic strategies or interventions that might slow the progression of the disease or even reverse it.
  2. Identifying New Treatment Targets: The atlas may help identify “bad neighborhoods” of cells that contribute to ESRD progression. These areas could become new targets for medications, potentially leading to more effective treatments for ESRD or therapies to protect the kidneys and delay or prevent the need for dialysis.
  3. Personalized Treatment: The atlas could contribute to personalized medicine, by identifying specific cellular characteristics that differ from patient to patient. Treatments could then be tailored based on the individual’s unique cellular profile, potentially leading to more effective and less harmful therapies.
  4. Biomarker Identification: By comparing healthy and diseased kidneys at the cellular level, researchers could identify new biomarkers that could be used to monitor disease progression or response to treatment. This could lead to earlier detection and intervention, better monitoring of the disease, and adjustment of treatments as needed.
  5. Improving Dialysis: If researchers can pinpoint what makes certain cell neighborhoods “bad” or unhealthy, it may lead to improvements in dialysis techniques, making them more effective or safer. For example, it could lead to the development of dialysis techniques that better mimic the natural filtration process of the kidneys, which could improve patients’ quality of life.

While the potential benefits of this research are exciting, it’s important to remember that translating scientific discoveries into clinical treatments often takes many years. The kidney atlas represents an important step forward, but there is still much work to be done.

So probably not in my lifetime, but it’s heartening to know “their” working on it! The lead graphic is from Bing Illustrator with Prompt: Picture combining atlas with kidney research for blog

Blood Pressure, Cell Phone Use and Dialysis

July 21, 2023 / / 0 Comments

The National Kidney Foundation (NKF) reports that about 15% of Americans, or 37 million people, have chronic kidney disease (CKD). NKF further states that hypertension (high blood pressure) is second only to diabetes in the cause of kidney failure. About 20% of those with hypertension may have CKD. Recently (2023), the U.S. Food and Drug Administration (FDA) highlighted the correlation between hypertension and chronic kidney disease on its website, urging Americans to control their blood pressure in order to reduce their chances for CKD.

I recently ran across an article in SciTechDaily by European Society of Cardiology dated 7/17/2023 titled “An Unexpected Pathway to Hypertension: Your Phone Habits Could Be Putting Your Heart at Risk.” I immediately applied this concept to myself, my triple bypass, hypertension, and subsequent Peritoneal Dialysis. Are we as a global population setting ourselves up for hypertensive-driven health challenges as a result of cell phone use?

I turned to my ChatGPT and instructed it to write a 500-word or less summary of the article. The results follow. Talk less, live longer?

New research published in the European Heart Journal – Digital Health suggests that spending over 30 minutes per week talking on mobile phones may lead to a 12% increased risk of high blood pressure (hypertension). The study, conducted by Professor Xianhui Qin of Southern Medical University, Guangzhou, China, utilized data from the UK Biobank and involved over 200,000 adults aged 37 to 73 years.

Nearly three-quarters of people aged 10 and over globally own a mobile phone, and approximately 1.3 billion adults worldwide suffer from hypertension, a major cause of heart attack, stroke, and premature death. Mobile phones emit low-level radiofrequency energy, previously associated with short-term blood pressure increases. This research exclusively focused on the link between phone call duration and hypertension onset, an area that past studies showed mixed results, possibly due to the inclusion of other mobile phone activities.

The study participants’ information regarding phone usage for calls was collected via self-reported questionnaires, and those who used their phones at least once a week for this purpose were categorized as mobile phone users. The researchers then analyzed the relationship between mobile phone usage and new-onset hypertension, adjusting for factors such as age, sex, BMI, race, medical history, lifestyle, and medication.

The median follow-up period was 12 years, during which 13,984 (7%) participants developed hypertension. A 7% higher hypertension risk was observed in mobile phone users compared to non-users. Individuals spending 30 minutes or more per week on phone calls were found to have a 12% higher likelihood of developing hypertension than those who spent less time. The results were consistent across genders.

Further, the study revealed a positive correlation between phone usage time and hypertension risk, irrespective of participants’ genetic susceptibility to hypertension. The risk was notably high (33% higher) in those with high genetic risk who talked on the phone for at least 30 minutes weekly compared to those with low genetic risk spending less time on the phone. Notably, the study found no significant link between hypertension and years of phone use or usage of hands-free devices or speakerphones.

Prof. Qin advised limiting mobile phone calls to under half an hour per week for heart health preservation until more research confirms these findings.

Proprioception, Dialysis, and You

July 19, 2023 / / 0 Comments

Jen Murphy wrote an article that was in the 7/15/2023 edition of The Wall Street Journal titled “Six Exercises for Better Balance from a Trainer Who Lives on a Paddleboard.” At first blush, you might cast this article out of hand into the trash as not having any application to those of us on dialysis. Nothing could be further from the truth. Dialysis can take the starch out of you, drain your energy, cast you as a shut-in, and all sorts of other degenerating aspects that directly impact something named “Proprioception.” In this blog, I will first define the concept of Proprioception and how it applies to those of us on peritoneal dialysis followed by an excerpt from Murphy’s article on the most simple way for us, regardless of age, or fitness, to improve our proprioception.

First I turned to my AI Assistant with the following prompt and result concerning proprioception:

Prompt: Write a blog entry about how Proprioception applies to those of us who are up in age and on peritoneal dialysis.

ChatGPT

Proprioception refers to the sense of the relative position of one’s own parts of the body and the strength of effort being employed in movement. It is essentially our sense of body awareness and is often described as the “sixth sense”. This is extremely important for all individuals regardless of age, health condition, or treatment modalities.

In the context of aging and peritoneal dialysis, proprioception plays a few significant roles:

  1. Fall Prevention: As we age, our proprioception can decline, increasing the risk of falls. Being on peritoneal dialysis doesn’t directly impact proprioception but can contribute to frailty and general weakness. Falls can be especially harmful to people undergoing dialysis due to weakened immune systems and a greater risk of complications. Thus, maintaining good proprioception can help prevent falls.
  2. Self-Care Tasks: For someone on peritoneal dialysis, maintaining good proprioception can help with the ability to perform self-care tasks, like dialysis exchange, and maintaining independence.
  3. Exercise and Rehabilitation: Proprioceptive exercises, which can include balance training and strength training, can help maintain muscle mass, improve coordination, and improve quality of life. This can be particularly important for people on peritoneal dialysis who may experience muscle wasting.

If you are an older adult on peritoneal dialysis, you might find it beneficial to work with a physical therapist or an occupational therapist. They can provide proprioceptive exercises and balance training, which can improve your safety, independence, and overall well-being. Always remember to consult with your healthcare provider before starting any new exercise regimen.

Murphy notes in her article that “Falls are the leading cause of injury and injury-related death among Americans 65 and older, according to the Centers for Disease Control and Prevention. Research shows our balance begins to decline starting at about age 50. But falling doesn’t have to be an inevitable part of aging.”

In her article, Murphy outlines six exercises to improve balance as a proprioceptive incentive. The first is most applicable to those of us on dialysis and is a doable do. It is named “Single-leg balance” and is illustrated in the lead picture from Bing Illustrator. The following is a quote from this section of the cited WSJ piece:

“

Why:

A 2022 study published in the British Journal of Sports Medicine suggests an inability to balance on one leg for 10 seconds in mid- to later life is linked to a near doubling the risk of death from any cause within the next decade. You can do this simple balance drill while brushing your teeth or watching TV.

How:

Stand with feet hip-width apart. Balance on your right foot as you bring your left foot off the floor. Start with a hover. Eventually, bring the left knee just below hip height. Keep hips square and eyes focused forward on a steady object. If you need assistance, stand near a chair or wall and use your fingertips as a light aid. Hold for 10 to 15 seconds. Complete three reps per leg.

Options:

Increase the challenge by standing on an unstable surface such as a BOSU ball or pillow. Progress to bouncing a tennis ball in front of you and catching it while you remain balanced. Next, try to move the hovering foot in front of you, to the side, and behind you while keeping the hips square. The most advanced progression is performing any of these variations with your eyes closed.”

Summary: We introduced the concept of Proprioception which in laymen’s terms is balance, how and why it declines as we age, how the concept applies to those of us on peritoneal dialysis, and by conducting a simple exercise how we can improve in this area from just about anywhere in our domicile. So get off your butts and stand on one foot for a while. I am.

Chronological Dialysis Activities and eGFR

July 18, 2023 / / 0 Comments

I sense that one of the many bothersome attributes of being associated with dialysis is the timing and sequencing of events leading up to the actual event. It is much like an avalanche; once set in motion it adapts a will of its own. In this blog, I relate the events that preceded and included my journey from chronic kidney failure to being a card-carrying peritoneal dialysis member.

I am going to start off by relating my eGFR readings by date preceding my decision to request dialysis. In the table below, I present the date and corresponding eGFR calculation. As you can see from the table, roughly two years prior to requesting dialysis my eGFR was in the 14-15 range. Just prior to requesting dialysis, it was 7. So for me, I went two years between an eGFR of 15 to dialysis.

DateeGFR Calculation
5/20/2014
8/20/2015
11/17/2015
2/24/2115.7
5/4/2114
8/4/2111
11/9/2111
12/30/2111
3/1/2210
7/7/227
Table Date versus eGFR Reading

Let’s now turn to the events leading up to my actual dialysis. From the table below, note I started Hemo on Saturday, August 20, 2022, followed by Peritoneal Dialysis at home on 9/30/2022.

DateActivity
8/16/2022Felt bad, requested dialysis
8/17/2022Hemo port installed Ft Worth hospital
8/20/20220500 Sat morning started hemo @ Fresenius
9/24/2022Last hemo dialysis
9/26/2022Started PD training and manual PD
9/29/2022Last training and manual PD
9/30/2022First home PD treatment I’m in charge
10/3/2022Local doctor removed hemo catheter in office
9/6/2022PD port in Ft Worth Hospital (out of order)
Chronology PD Journey

A comment on timing based on the above table. Given that my eGFR was slowly decreasing, I took the time to research what PD was all about and watched numerous YouTube videos on the mechanics of using the Liberty Cycler for dialysis. Going into training I was already up to speed on most of the mechanics, techniques, and sanitary requirements. My wife and I purchased the home we currently live in with the foresight that I would be requiring dialysis, and knew from research that vast amounts of dialysis fungibles would be required. We had our master bedroom outfitted and ready for dialysis prior. The home we purchased provides the required storage. Lastly, I successfully completed the training in just four days. This is because of our research prior to dialysis and also because I am a Purdue University-trained engineer used to dealing with “systems.” Dialysis is a system. Fresenius allocates two weeks for training and it is not without precedent to take longer.

I consider myself fortunate to be in the care of nephrologist Dr. T. Turner and the Fresenius Dialysis Team. It is obvious that you really really have to have your ducks in a line to accomplish an aggressive timeline such as I just presented. But I am living proof if you have the opportunity to plan ahead and anticipate it can be done.

Dialysis and Living

July 14, 2023 / / 0 Comments

Even though some on dialysis are of the viewpoint that life is centered on this life-giving requirement, other life-requirements do also happen. This blog is about a couple of “happenings” that recently took place in our space that were of high(er) priority.

Last Saturday evening our septic alarm went off indicating something amiss in our system. Our system is a bastard concoction. Seems our black water sewage system does not have enough fall for proper “flushing” to the main drains in the street. A small holding tank was placed in our yard with a Liberty Series 41 Lift Pump and a pole with a low float switch (turns the pump on and off) and a high float switch that sounds the alarm if the effluent level gets too high.

The alarm has sounded once previously and the bottom float switch was bad. Tried calling around for professionals to fix the problem and of course the soonest anyone could come was Monday. Try shutting down all showers, washing hands while on dialysis, etc let alone no toilet use – just doesn’t work.

Turns out our son has vast experience installing such systems so we called him and he came first thing Sunday morning with a spare float switch in hand. Didn’t need it. The power cord to the pump insulation had failed, effluent had entered the hot wires and totally corroded them in two a length of about two feet. We cut this power cord off and spliced in a completely new cord back to the junction box and sealed it with heat shrink and we are back in business.

The entire ordeal took about three hours from start to finish. Luckily we were working in the shade (we are having 100+ temps here in N. Texas). To preclude this from happening again, I ordered a replacement pump from eBay and it’s due to arrive tomorrow. The current installation has all the wiring hard-wired via a junction box that’s buried in the ground. When I have to replace a component, I’m going to wire in a standard male and female plug to make installation much more straightforward.

On to yesterday. On the way back from helping our son finish up the electrical wiring in his new chicken coup, the temp was 110F. Was starting to take a shower, and my wife came and got me to listen to the compressor unit of our whole house a/c. It was making a screeching noise indicating a bearing going out in the unit’s fan. My wife called the HVAC company we have a maintenance contract with and believe it or not they arrived in less than an hour.

The condenser fan by now had totally crapped out and was not even attempting to turn on. No fan, no a/c and it’s currently 105F or so. My wife would melt without a/c in this weather.

Luckily the repairman had a replacement fan on the truck and affected repair. Bottom line, some $900 later we can again flush toilets and have a/c in the N. Texas sun. Life in this regard is good.

My whole point is that dialysis takes center stage, but, sometimes you have to go with the flow.

Single Injection for Diabetes in Development

July 13, 2023 / / 0 Comments

Emily Mullin wrote on July 10, 2023, Wired in an article titled “A One-Time Shot for Type 2 Diabetes? A Biotech Company Is On It.” The following is a summary of her article. As in the past, I am interested in all things diabetic because #1 I am a diabetic, and #2 47% of us on dialysis are also diabetic.

Fractyl Health, a biotech company based in Massachusetts, is in the early stages of developing a one-time gene therapy treatment for type 2 diabetes and weight control. This therapy could provide an alternative to drugs like Ozempic and Wegovy, which require weekly injections to control blood sugar and body weight.

Currently prescribed medications like Ozempic and Wegovy mimic a human hormone called GLP-1, released in response to eating, which cues the pancreas to produce insulin, regulating blood sugar. These drugs also interact with parts of the brain involved in appetite, signaling fullness and thereby assisting in weight loss. However, these medications can have unpleasant side effects, and their efficacy drops off if a patient misses a dose or discontinues usage after reaching weight-loss goals.

Fractyl’s innovation seeks to solve these problems by delivering a one-time treatment that could have lasting effects for years. The therapy involves introducing an artificial gene to the pancreas that continuously produces the GLP-1 hormone, removing the need for regular injections. The delivery method involves using inactivated viruses to transport the therapeutic gene to the pancreatic cells, leveraging the viruses’ innate ability to deliver genetic material to cells.

While this therapy is currently only in the experimental stage, with tests having been conducted on animals, the initial results show promise. Using mice bred to develop type 2 diabetes, the researchers found that a single infusion of the gene therapy could reduce fasting blood sugar by 70%, compared to a 64% reduction by semaglutide injections. Separate tests also indicated that the therapy reduced body weight in mice by 23%.

The delivery method for this therapy involves an endoscopic procedure with a thin needle attached to a catheter, which is threaded down the throat and into the GI tract. Initial safety tests have been performed on pigs, which have a pancreas anatomically similar to humans, and no adverse side effects were reported.

However, this therapy raises some concerns, particularly around the potential for inflammation in the pancreas and the high cost of gene therapies. Dr. Daniel Drucker, an endocrinologist, and professor of medicine at the University of Toronto, is skeptical about directly injecting therapy into the human pancreas due to its fragility and importance. In addition, existing gene therapies on the market are priced quite high, with treatments for conditions like beta-thalassemia and hemophilia B costing millions.

Maria Escobar Vasco, an endocrinologist and diabetes expert at UT Health San Antonio, acknowledges the potential of the therapy but insists on the need for extensive testing to ascertain its safety. The first human trials are slated for the end of 2024.

In the meantime, other alternatives to injection-based therapies are being explored, including semaglutide in pill form, which may offer more convenience. Whether Fractyl’s gene therapy will result in similar side effects as current drugs is yet to be determined, but if it proves to be effective and safe, it could revolutionize the management of diabetes and weight control.

Monthly Labs & Phosphorus

July 12, 2023 / / 0 Comments

Last week I had my adequacy test along with monthly labs. I noted that my A1c jumped from 5.3 to 6.3, and my phosphorus reading went slightly high rising from 4.8 in June to 5.7 in July.

Explaining my A1c is easy. I was starting to have hypoglycemic events during the night and coupled with higher temps here in North Texas and working outside resulting in lots of sweat I cut back on my insulin from 10 units to 7 at one point. I am gradually increasing my nightly insulin back toward 10 with success thus far. Keep in mind the goal for Type II diabetics is an A1c under 7.0 so I’m still within acceptable range.

My nephrologist and Diatetian were concerned about my Phosphorus increasing and suggested I start chewing a Velphoro, the big brown horse pill that absorbs phosphorus with any large meal, not just breakfast as I had been doing. So that’s what I’m doing now.

With this as a background, I turned to my AI assistant with the following prompt and result to provide us all more insight into just what this Phosphorus thing is all about. Read on ->

w=Write an interesting blog entry about the importance of controlling phosphorus in their diet for a person on peritoneal dialysis

ChatGPT

Title: Phosphorus in Check: The Crucial Role of Dietary Management for Peritoneal Dialysis Patients

While everyone needs a certain amount of phosphorus to maintain their body’s balance and function, those on peritoneal dialysis require a more precise, carefully controlled approach. Phosphorus, an essential mineral found abundantly in many foods, plays an integral part in building strong bones and teeth, aiding muscle function, and maintaining heart rhythm. However, the kidneys often struggle to filter this mineral in individuals with kidney disease, leading to high phosphorus levels in the blood—a condition known as hyperphosphatemia.

When it comes to dialysis, particularly peritoneal dialysis, excess phosphorus in the diet can cause several complications, ranging from calcification of organs and blood vessels to bone disease, heart disease, and even an increased risk of mortality. This makes dietary phosphorus control a key aspect of the healthcare strategy for individuals undergoing this treatment.

A Delicate Balance

The average person typically consumes more phosphorus than the body needs. However, in the case of peritoneal dialysis patients, the inability of their kidneys to remove excess phosphorus necessitates restrictions. While dialysis helps remove some phosphorus, it cannot remove as much as healthy kidneys would. This imbalance may lead to an overabundance of phosphorus in the blood, creating potential health hazards.

Effects of High Phosphorus Levels

One of the most significant health risks is the development of bone disease. Too much phosphorus can lead to lower calcium levels in the blood, stimulating the release of parathyroid hormone (PTH). High PTH levels can cause calcium to be drawn from the bones, weakening them over time—a condition known as renal osteodystrophy.

Additionally, excess phosphorus can bind with calcium in the blood, creating deposits that can stiffen and clog blood vessels—a process known as vascular calcification. This can lead to increased blood pressure and an elevated risk of heart disease, the leading cause of death in individuals with chronic kidney disease.

The Diet Factor

To minimize these risks, it’s essential to control dietary phosphorus. While it’s found in nearly all foods, it’s especially abundant in protein-rich foods like meats, poultry, fish, dairy products, beans, and nuts, as well as processed foods and drinks, which often contain added phosphates.

A dietitian can provide an individualized meal plan to keep phosphorus intake in check. The plan may involve consuming smaller portions of high-phosphorus foods, choosing foods with lower phosphorus-to-protein ratios, or opting for fresh, unprocessed foods. Some people may also need phosphorus binders, medications that help prevent phosphorus absorption.

Understanding the Adequacy Test for Peritoneal Dialysis: Essentials, Implications, and Caveats

July 11, 2023 / / 0 Comments

Every quarter (three months) I have to do a PD Adequacy Test. From my perspective, it involves collecting my urine for 24 hours, and collecting the Cycler drains into separate collection bags rather than draining them to the shower drain. The following morning I take both containers to my Fresenius lab appointment, where my dialysis nurse Cindy also draws blood, and often gives me an injection of this or that. I think I actually am getting more shots than I did in the military. The results of the adequacy test are central to my nephrologist’s input at our next dialysis team meeting, which is always scheduled shortly after this test.

With this as background, I thought readers might be interested in on what underlies the “adequacy test” so I obtained the following from my AI assistant. Read it and you’ll know all you need to know about this dialysis-specific test.

Title: Understanding the Adequacy Test for Peritoneal Dialysis: Essentials, Implications, and Caveats

Peritoneal dialysis (PD) is a life-sustaining treatment for patients suffering from end-stage renal disease (ESRD). PD uses the body’s own peritoneal membrane as a filter to remove waste products and excess fluid from the blood. To ensure the treatment’s effectiveness, an “adequacy” test is routinely performed, a vital assessment tool in managing PD patients. This blog will delve into the details of the PD adequacy test, discussing its significance, interpretation of results, and potential limitations.

What is the Adequacy Test for Peritoneal Dialysis?

Adequacy in the context of peritoneal dialysis refers to how effectively the treatment is cleaning the blood of toxins and maintaining proper fluid balance. The adequacy test measures key parameters like residual kidney function, total urea clearance, and ultrafiltration volume.

The primary focus of the adequacy test is measuring the clearance of a molecule called urea, a waste product produced by the body during protein metabolism. High urea levels indicate the body is not effectively removing waste, signifying suboptimal dialysis.

Why is the Adequacy Test Essential?

The adequacy test is crucial for several reasons:

  • Monitoring Treatment Effectiveness: The test gives healthcare providers a clear understanding of how effectively PD is functioning. It helps clinicians tweak the PD regimen, optimizing dialysis fluid volumes and dwell times to ensure maximum removal of toxins.
  • Preventing Overhydration: By measuring ultrafiltration volume, the test can help detect and prevent overhydration, a common complication in PD patients.
  • Preserving Residual Kidney Function: The adequacy test measures residual kidney function, which plays a critical role in the overall well-being of PD patients. The aim is to preserve this function as long as possible to improve the patient’s quality of life.

Interpreting Adequacy Test Results

The Kt/V is a commonly used index for assessing the adequacy of peritoneal dialysis. It measures the dialytic clearance of urea (K), adjusted for the patient’s total body water (V), and considers the time of dialysis (t).

The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) recommends a target weekly Kt/Vurea of ≥1.7 for adults on continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). This signifies that the volume of blood cleaned of urea over a week should be at least 1.7 times the volume of the patient’s total body water.

Results lower than this threshold may necessitate adjustments in the dialysis prescription to improve urea clearance and maintain an optimal balance of electrolytes and fluids.

Caveats and Limitations

While the adequacy test provides crucial insights into the PD’s effectiveness, it also comes with certain limitations:

  • Urea as a Sole Marker: Urea clearance is an imperfect marker of dialysis adequacy as it doesn’t reflect the removal of larger, potentially more toxic solutes. New research is ongoing to identify additional biomarkers that could be used to assess PD adequacy more comprehensively.
  • Patient Variability: Factors such as age, gender, body size, and residual renal function can influence the required level of dialysis adequacy. Therefore, individualized patient assessment is crucial.
  • Quality of Life: Although dialysis adequacy is important for patient survival, it does not necessarily correlate with the quality of life. Factors such as dialysis-related symptoms, physical function, and mental health also need to be addressed.

Conclusion

The adequacy test for peritoneal dialysis is a critical tool for managing patients with ESRD. It helps gauge the effectiveness of the dialysis regimen and informs necessary adjustments to optimize the patient’s health. However, it is essential to remember that it is only one piece of the larger clinical picture.

Given the caveats and limitations of the PD adequacy test, it should not be used in isolation. Complementary assessments, such as those for nutritional status, inflammation, anemia management, bone-mineral disease, fluid status, and patient-reported outcomes, must also be considered to ensure comprehensive patient care.

Furthermore, communication between the healthcare provider and the patient is vital. The patients should understand the importance of the adequacy test, the implications of the results, and the potential adjustments in the dialysis prescription that may ensue based on the results.

Ongoing research might provide us with more precise markers of dialysis adequacy in the future, which can potentially enhance our ability to individualize and optimize PD therapy for each patient. However, until then, the urea clearance test continues to be a cornerstone of assessing and managing dialysis treatment for ESRD patients.

In conclusion, peritoneal dialysis adequacy testing is a significant part of the treatment plan for patients with end-stage renal disease. It is a tool that helps deliver personalized care and treatment, keeping patients’ unique needs and conditions in mind. However, it is just one aspect of a complex and multifaceted treatment landscape, and ongoing research and development promise to refine and enhance these critical treatment parameters.

New Type 2 Diabetic Shot in Trial

July 10, 2023 / / 0 Comments

Keep in mind that up to 47% of those on dialysis are also diabetics with hypertension coming in second. Thus anything pertaining to diabetes has almost a 50:50 chance of applying to those of us also on dialysis. I am one of this group thus my interest in all things diabetic. I have been treating diabetes for roughly 40 years and have been on dialysis less than one. Thus my sensitivity to advances in the treatment of diabetes.

In a June 24, 2023 article in The New England Journal of Medicine by Julio Rosenstock, MD et al titled “Weekly Codec Versus Daily Glargine U100 in Type 2 Diabetes without Previous Insulin,” research sponsored by Nova Nordisk was reported. Some clarification of terms first. “Week Codec” is a new weekly basal injection under development by Nova. This article reports on a phase of human testing under the rules and regulations of the USA’s FDA. Another definition: a basal injection for Type 2 diabetes is a long-lasting injection. An example of such an injection is Glargine U100 sold under the brand name “Lantus” by Lilly which I inject daily.

As is usual in these trials, the null hypothesis of no difference in paired groupings between those receiving the Weekly Codec and those receiving Lantus was made. The following conclusions are copied directly from the report’s end:

“the findings of the current trial highlight the totality of evidence for glycemic control with icodec. Among persons with long-standing diabetes taking noninsulin glucose-lowering agents including GLP-1 receptor agonists and SGLT-2 inhibitors, those who received icodec were more likely to reach a glycated hemoglobin level (That’s A1C) below 7% than those who received glargine U100, and they spent more time in the target glycemic range and were more likely to reach a glycated hemoglobin level below 7% without clinically significant or severe hypoglycemia (low blood sugar). In this phase 3a trial, we found that once-weekly insulin icodec offered better glycemic control than once-daily insulin glargine U100 in persons with type 2 diabetes who had not previously received insulin.”

While this is but one component of the march by Nova to gain full approval of Weekly icodec for treatment of Type 2 diabetics, it looks like its release in the future looks probably and perhaps we can move from daily injections of Lantus to weekly injections of icodec? I would be for that.

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