The past week I had my monthly and quarterly meeting with my Dialysis Nurse. I collected a 24-hour urine sample – yes, still making some yellow fluid, and four collection bags for discharge from the Cycler wherein only 2.5 solutions were used. All the typical attributes of my dialysis health were checked – she listened to my heart, inspected my feet – some swelling, drew a blood sample, injected me with iron, and asked me a battery of questions, plus provided me with the Fresenius monthly educational packet. Took about 30 minutes and after collecting the bag of replacement dialysis support items provided by Fresenius – tape, and soap this cycle, I was on my way. As usual, the following day preliminary lab results were available via the Fresenius Patient Hub, and the following day detailed lab results were available. My detailed lab results in PDF format are available below for your download and/or viewing.
There is no concise or easy way to present a graphical representation of some of the lab results. I’m going to list 11 results followed by a screen capture of the same from the PatientHub. You can cycle down and visually ascertain what’s going on. I am not upset by any results. I would like to explain what’s going on with A1c. I started gaining weight and as I result I noticed via my CGM that my morning glucose reading was rising, not bad, in the 120+ range, but still up from my normal 90-110 range. I know that I am extremely sensitive to weight gain from a diabetic control perspective. I increased my Lantus by one unit to 9 from 8 as a result. This brought my morning/fasting glucose back down – it was 94 this morning and explains the full one-point drop in A1c.
Second comment, my Creatinine at 6.60 is up from 6.27 in the last lab. Inputting age=84, Gender=M into my eGFR app yielded an eGFR of 8 which it has consistently been over many months. You can refer back to the eGFR graphical analysis I blogged about a couple of days ago for an additional check.
Last comment: Note that my Hemoglobin at 11.6 continues to be high from the stated goal of 10-11. I would think that more red blood cells are good but intend to discuss this with my nephrologist meeting scheduled for later this week. BTW, Fresenius provided me with a full box of high protein bars at my lab meetup also. Thanks to them for this.
Fresenius hosts a Patient’s Hub through which many aspects of Dialysis support are provided. Examples are the ability to order supplies monthly, daily input dialysis info from the night before, and a forum for supported members to post and respond to other inputs from fellow dialysis patients. Recently, a rlbecker posted what is quoted below. After this input, I included a few of my own. These are inputs to improve the Fresenius experience from a user’s perspective.
I am a newbie. Only on PD for 4 months. But I have some thoughts on potential improvement of the experience which are in the details below.
1. Catheter insertion.
If we need an x-ray to see where the catheter is, something is broken. The surgeon knows where it is placed right after the surgery. In addition to saying “everything went well” and prescribing pain medications afterwards, he/she should show on a diagram the angle of the catheter and the depth of the insertion. Even better, the surgeon should ask the patient how he/she sleeps (back, side, stomach) before the surgery, to guide the process for the best outcome.
2. Modem power.
The cycler cord is 10 feet long, but the cord on the modem is a couple feet less. This makes it difficult to manage the cords from the cycler to the wall. If both were the same length, one could tape the cords together to make a less cumbersome attachment. Even better, just like amplifiers, tuners, etc., the cycler could provide a through power outlet on the back for plugging in the modem (which could have a very short cord), eliminating one cord from the cycler to the wall.
3. Display on the cycler.
At this point, you have two options: always on; and on for x minutes, then off. There are times when you just want to see where things are in the process, so you tap on the display to see, and are then burdened with an additional period of light in the darkness of the bedroom. Since the sensors are already there and programmable, why not treat the light like the infamous “clapper” from TV ads: one tap to turn the light on, two taps to turn it back off?
4. Treatment complete.
When treatment is complete, why not turn on the light with that screen showing? One should not have to wonder whether or not the cycler has done its thing and you can get up and do the aseptic disconnection.
5. Helpful chart for new patients.
Setting up can seem a little daunting in the beginning. I am suggesting a chart to help demystify the process. On the chart, columns would be: display, time, you must do, and you can do. Rows will contain the displays that appear on the cycler as you go from step to step. As the cycler is going through its various setup steps, you could see what you can do in parallel and how much time you have to do that before the cycler will be ready for you to review and press next. This could shorten the time required to set up the cycler in the beginning while one is learning.
End Quote:
Hank’s comments follow:
H1: Several technology companies have virtual assistants that are now ingrained into users’ fabric. Apple has Siri. Google has Google Assistant. Amazon has Alexa. Fresenius should incorporate technology into the Cycler so that patients can query the Cycler while at a distance and/or in bed. For example, they could inquire how many more minutes the cycler has on dwell, drain, or where in the total treatment. Instead of getting up to quell a drain alarm, they could reset it from bed and, in response, reposition their bodies, etc. They could verbally enter parameters into the Cycler upon completion of dialysis instead of getting down on their knees to enter the same digitally – the old fashion way, BTW.
H2: Excessive non-recyclable debris must be disposed of after a Dialysis course. There are the boxes in which the dialysate is delivered. There are plastic wrappers from dialysate bags and the bags themselves. There is the cassette to be disposed of. And more odds and ends. This adds up to a 64 Galleon trash can just about filled every week. Certainly, German engineers can do better than this.
H3: Why do we even have an external modem at all? Most newer appliances are connected to the IOT (Internet of Things), including television sets. Using current technology, all of the hardware to gather data should be housed within the cycler.
H4: And speaking of data gathering, why, if I am inputting data into the Cycler every morning after my dialysis? There is a USB Thumb Drive that is also gathering data that I am required to “Sneaker Net” to my monthly meeting with my Dialysis Nurse. Why, when I call Tech support, do I have to go through countless screens of data and verbally provide the same to tech support before they even attempt to address the problem(s) that initiated my call? Shouldn’t such data already be in the system via the modem?
H5: My initial loadout of dialysate in no way matched the initial prescription my Nephrologist ordered. So I’m stuck with thirty-plus boxes of 2.5 dialysates that I have to eliminate since Fresenius has a policy of not accepting boxes of dialysate to return once they pass the patient’s portal.
There is an article in the 4/3/2023 issue of CNN Health by Madeline Holcombe titled “These 5 rules for good sleep may also impact the development of asthma, experts say.” “Bad sleep quality and quantity may put you at greater risk for developing asthma, according to a new study” the study concludes. It is linked here: The picture above is from the cited article.
That got me thinking about what other ailments might be lurking in the background related to lack of sleep caused by the Fresenius Cycler Drain Alarms for which Fresenius may be found to be culpable. This line of thinking springs from my dealings with the Veteran Administration and Agent Orange. In my instance, a primary prima facia fact is that I served boots on the ground in Vietnam. Given so, I was exposed to Agent Orange. I subsequently developed Type II diabetes which became my primary ailment from such exposure. As documented herein, up to 40% or more diabetes patients become Dialysis patients. Dialysis is secondary to diabetes in the VA way of thinking. The same logic probably follows herein, but I am NOT (thank God) a lawyer!
So we have the Fresenius Liberty Cycler interrupting sleep (Primary) and “causing” what possible other “secondary” ailments among Peritoneal Dialysis patients?
So doing what I am trained to do, I asked my able AI for assistance in this manner, in this case, openai.com’s GPT-3.5. The Prompt I used is listed below, followed by the AI output I edited and a few short conclusion comments.
Prompt: It is a well-established fact from users that the Fresenius Liberty Cycler interrupts sleep because of alarms on the drain cycle. Interruption of sleep can lead to a lack of sleep on the part of the dialysis patient. A recent article in CNN suggested that lack of sleep can lead to asthma. What other ailments could be secondary to lack sleep possibly caused by drain alarms on the Liberty Cycler?
Many potential health problems can result from a lack of sleep caused by interruptions, such as those caused by the alarms on the Fresenius Liberty Cycler during dialysis treatment. Here are a few examples:
Cardiovascular disease: Lack of sleep has been linked to an increased risk of heart disease, stroke, and other cardiovascular problems. Interruptions in sleep caused by alarms on the dialysis machine could exacerbate these risks in dialysis patients who are already at a higher risk for cardiovascular problems.
Diabetes: Poor sleep has been linked to insulin resistance and impaired glucose tolerance, key risk factors for diabetes. Dialysis patients with diabetes may be at a higher risk for complications related to their condition if they are not getting enough sleep.
Depression and anxiety: Sleep deprivation has been linked to depression and anxiety in many studies. Dialysis patients already dealing with the stress of their condition may be particularly vulnerable to these mental health problems if they cannot get enough sleep.
Immune system problems: Lack of sleep has weakened the immune system, making it harder for the body to fight infections and other health problems. Dialysis patients already dealing with weakened immune systems due to their condition may be particularly vulnerable to infections if they are not getting enough sleep.
Cognitive problems: Sleep deprivation can lead to problems such as difficulty concentrating, memory problems, and impaired decision-making. Dialysis patients not getting enough sleep may have trouble managing their treatment regimen or other aspects of their daily life.
This looks like a real pickle for PD patients using the Liberty Cycler. On the one hand, the Cycler is totally supporting their very life. On the other hand, it CAN be related to other life-threatening medical challenges. In this case, it boils down to the lesser of all evils. I’m sticking with the Cycler and holding on to the sincere hope that Fresenius rolls out the new and improved version in my lifetime.
A couple of days ago I related my long journey to being currently on dialysis. I 100% attribute this requirement to my earlier ailment, diabetes. One aspect I did not relate to is that my grandmother on my mother’s side of the family was diabetic, my mother was diabetic, and our two sons were/are diabetic. This is somewhat moot “proof” that it can be inherited and runs in families. It does not, however in any aspect, remove the burden of where we are, a diabetic on dialysis. This association got me thinking about the importance of really really recognizing the strong tie between being diabetic and its impact on the future statistical probability of needing/requiring Dialysis.Then, I turned to my silent partner in crime, my faithful AI assistant openai.com running gpt-4 with the following prompt, and the subsequent result is included below.
First, a couple of comments. I firmly believe I stayed on Metformin too long, seriously impacting my kidneys. At no time was there any appearance of coordination and/or teamwork or communication between doctors involved in my treatment? I’m sorry to state that to this day it is obvious that such teamwork is lacking. Doctors live in silos from which they rarely seem to leave. Over time my doctors hammered my Hypertension without explaining in any detail the ramifications and/or if/then/else of not keeping it within bounds, which seemed to be ever-changing over time. As soon as an individual’s eGFR passes the 60 wicket regardless of what’s going on with hypertension and A1c, a team should take over and hold the patient by the hand to preclude to the extent possible the need for Dialysis. You draw your own conclusions from the essay below.
GPT-4 Prompt: From a statistical perspective, what is the relationship between diabetes and the subsequent need to go on dialysis? Use citations and include references in at least a 2000-word essay written at a freshman college level.
Introduction
Diabetes is a global health concern that affects millions of people. It is a group of metabolic disorders characterized by high blood sugar levels over an extended period. Type 1 and type 2 diabetes are the most common forms, with type 2 diabetes accounting for about 90% of cases. Diabetes can cause various complications, including kidney disease, cardiovascular disease, and neuropathy. One severe complication is diabetic nephropathy, which may lead to end-stage renal disease (ESRD) and dialysis needs. This essay explores the statistical relationship between diabetes and subsequent dialysis needs by examining relevant literature and studies.
Diabetes and kidney disease: the pathophysiology
Diabetic nephropathy, a leading cause of kidney disease, develops in about 40% of individuals with diabetes (Gheith et al., 2016). High blood sugar levels cause damage to the blood vessels in the kidneys, impairing their ability to filter waste and excess fluids. Over time, this damage accumulates, leading to kidney disease and, eventually, kidney failure.
Kidney disease can be categorized into five stages based on the glomerular filtration rate (GFR), a measure of kidney function. Stage 1 represents the least severe stage, while stage 5, or ESRD, is the most severe, often necessitating dialysis or a kidney transplant. Diabetes increases the risk of developing kidney disease and progressing to ESRD (Afkarian et al., 2013).
Prevalence of diabetes and kidney disease
The prevalence of diabetes has been increasing worldwide, with the International Diabetes Federation (IDF) estimating that 537 million adults will have diabetes in 2021 (IDF Diabetes Atlas, 2021). The number is projected to reach 643 million by 2030 (IDF Diabetes Atlas, 2021). The global prevalence of diabetic nephropathy was estimated at 6.9% in 2020 (Thomas et al., 2020).
Kidney disease is a significant public health concern, affecting more than 850 million people worldwide (Liyanage et al., 2015). Among individuals with ESRD, diabetes is the leading cause, accounting for 44% of cases in the United States (USRDS, 2020). In Europe, diabetes is responsible for 25% of ESRD cases, with variations between countries (ERA-EDTA, 2019).
Diabetes and the Risk of Dialysis
Diabetic nephropathy progresses more rapidly in individuals with poor glycemic control, high blood pressure, and genetic predisposition (Tuttle et al., 2014). Studies have reported that the risk of developing ESRD in individuals with diabetes is 12-25 times higher than in those without diabetes (Afkarian et al., 2013; de Boer et al., 2011).
A study by Afkarian et al. (2013) investigated the risk of ESRD in a cohort of 10,483 individuals with type 1 diabetes and 9,697 individuals with type 2 diabetes. The cumulative incidence of ESRD at 20 years was 3.3% for type 1 diabetes and 1.7% for type 2 diabetes. The study also found that the risk of ESRD increased with the duration of diabetes and higher levels of baseline glycated hemoglobin (A1C), a marker of long-term blood sugar control.
Another study by de Boer et al. (2011) assessed the risk of ESRD in 1,746 individuals with type 1 diabetes and 4,507 individuals with type 2 diabetes. The cumulative incidence of ESRD at 20 years was 2.2% for type 1 diabetes and 1.8% for type 2 diabetes. The study demonstrated that higher baseline A1C levels and longer diabetes duration were associated with increased risks of ESRD, emphasizing the importance of proper blood sugar management.
Factors influencing the need for dialysis in diabetic patients
Several factors can increase the likelihood of diabetic patients requiring dialysis. These factors include:
a. Glycemic control: Maintaining optimal blood sugar levels is critical in delaying the progression of diabetic nephropathy and reducing the risk of ESRD (Ismail-Beigi et al., 2010). Improved glycemic control has been shown to reduce the risk of microvascular complications, including kidney disease, in both type 1 and type 2 diabetes (DCCT/EDIC Study Research Group, 2005; ADVANCE Collaborative Group, 2008).
b. Blood pressure control: High blood pressure is a significant risk factor for the progression of diabetic nephropathy (Molitch et al., 2015). Strict blood pressure control, particularly with medications such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), can slow kidney disease progression and reduce the risk of ESRD in diabetic patients (Lewis et al., 1993; Brenner et al., 2001).
c. Albuminuria: Elevated albumin levels in the urine (albuminuria) are an early sign of kidney damage in diabetic patients. Reducing albuminuria through blood sugar and blood pressure control can delay the progression of kidney disease (Wanner et al., 2016).
d. Lifestyle factors: Adopting a healthy lifestyle, including regular exercise, a balanced diet, and maintaining a healthy weight, can help control blood sugar levels and reduce the risk of kidney disease in diabetic patients (ADA, 2021).
Strategies to reduce the need for dialysis in diabetic patients
Efforts to minimize the risk of dialysis in diabetic patients include:
a. Early detection and monitoring: Regular screening for kidney disease in diabetic patients can facilitate early intervention and slow the progression of kidney disease (ADA, 2021).
b. Integrated care: A multidisciplinary approach that involves primary care providers, endocrinologists, nephrologists, and other healthcare professionals can optimize diabetes management and reduce the risk of complications (ADA, 2021).
c. Patient education: Empowering patients with knowledge about diabetes management, self-monitoring of blood sugar, and healthy lifestyle choices can improve treatment adherence and reduce the risk of kidney disease (Funnell et al., 2010).
Conclusion
Diabetes is a significant risk factor for kidney disease and the subsequent need for dialysis. The relationship between diabetes and dialysis is influenced by glycemic control, blood pressure management, and albuminuria. Early detection, proper management of diabetes, and lifestyle modifications can reduce the risk of kidney disease progression and the need for dialysis in diabetic patients. Continued research and public health initiatives aimed at preventing diabetes, optimizing diabetes management, and raising awareness about kidney disease are essential in addressing this global health challenge.
References
ADA. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Suppl. 1), S1-S232.
ADVANCE Collaborative Group. (2008). Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. New England Journal of Medicine, 358(24), 2560-2572.
Afkarian, M., Sachs, M. C., Kestenbaum, B., Hirsch, I. B., Tuttle, K. R., Himmelfarb, J., & de Boer, I. H. (2013). Kidney disease and increased mortality risk in type 2 diabetes. Journal of the American Society of Nephrology, 24(2), 302-308.
Brenner, B. M., Cooper, M. E., de Zeeuw, D., Keane, W. F., Mitch, W. E., Parving, H. H., … & Shahinfar, S. (2001). Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. New England Journal of Medicine, 345(12), 861-869.
DCCT/EDIC Study Research Group. (2005). Sustained effect of intensive treatment of type 1 diabetes mellitus on the development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) study. Journal of the American Medical Association, 290(16), 2159-2167.
de Boer, I. H., Rue, T. C., Hall, Y. N., Heagerty, P. J., Weiss, N. S., & Himmelfarb, J. (2011). Temporal trends in the prevalence of diabetic kidney disease in the United States. Journal of the American Medical Association, 305(24), 2532-2539.
Funnell, M. M., Brown, T. L., Childs, B. P., Haas, L. B., Hosey, G. M., Jensen, B., … & Weiss, M. A. (2010). National Standards for Diabetes Self-Management Education. Diabetes Care, 33(Suppl. 1), S89-S96.
Gheith, O., Farouk, N., Nampoory, N., Halim, M. A., & Al-Otaibi, T. (2016). Diabetic kidney disease: worldwide difference of prevalence and risk factors. Journal of Nephropharmacology, 5(1), 49-56.
Ismail-Beigi, F., Craven, T., Banerji, M. A., Basile, J., Calles, J., Cohen, R. M., … & ACCORD Trial Group. (2010). Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. The Lancet, 376(9739), 419-430.
Lewis, E. J., Hunsicker, L. G., Bain, R. P., & Rohde, R. D. (1993). The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. New England Journal of Medicine, 329(20), 1456-1462.
Liyanage, T., Ninomiya, T., Jha, V., Neal, B., Patrice, H. M., Okpechi, I., … & Perkovic, V. (2015). Worldwide access to treatment for end-stage kidney disease: a systematic review. The Lancet, 5(9981), 1975-1982.
Molitch, M. E., Adler, A. I., Flyvbjerg, A., Nelson, R. G., So, W. Y., Wanner, C., … & Wheeler, D. C. (2015). Diabetic kidney disease: a clinical update from Kidney Disease: Improving Global Outcomes. Kidney International, 87(1), 20-30.
Thomas, M. C., Brownlee, M., Susztak, K., Sharma, K., Jandeleit-Dahm, K. A., Zoungas, S., … & Cooper, M. E. (2020). Diabetic kidney disease. Nature Reviews Disease Primers, 6(1), 1-28.
Tuttle, K. R., Bakris, G. L., Bilous, R. W., Chiang, J. L., de Boer, I. H., Goldstein-Fuchs, J., … & Molitch, M. E. (2014). Diabetic kidney disease: a report from an ADA Consensus Conference. Diabetes Care, 37(10), 2864-2883.
USRDS. (2020). United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD.
Wanner, C., Inzucchi, S. E., Lachin, J. M., Fitchett, D., von Eynatten, M., Mattheus, M., … & EMPA-REG OUTCOME Investigators. (2016). Empagliflozin and progression of kidney disease in type 2 diabetes. New England Journal of Medicine, 375(4), 323-334.
One of the things that is suggested while on Dialysis is to keep your brain active. Obviously, this can take on many forms. For me, I have become more than just interested in the field of Artificial Intelligence (AI) and in fact, am using it to support this blog. When I do so I generally refer to its use as my “AI Assistant.” Another path I am pursuing is taking online courses to bring me up to speed on the newest technologies in my former area of expertise, Electrical Engineering (EE). I am currently enrolled in a course with TheGreatCourses.com titled Electrical Engineering for Everyone that provides an introduction to all things that do just that. The online course started off with a brief introduction to how EE has impacted and changed since its inception. Bear with me, we’ll get to where I’m going with this shortly. The lead to the course, without any formatting, follows from the course:
Built on Maxwell’s equations, the field of electrical engineering has experienced four distinct revolutions in the past 150 years, each of which increased our knowledge of the world around us, improved the quality of life for masses of people, and led to the opportunity for further discoveries. Revolution One brought the transmission of electrical energy with wires, which provided electric power to homes and businesses and produced the telegraph and telephone. Revolution Two brought the transmission of electric energy without wires. This phase started with radio, which led to television, satellites, and other forms of wireless communications. Revolution Three occurred when we learned to control electrons with transistors, which led to electronics and photonics. And Revolution Four produced computers and communication systems to create intelligent applications, including brain-controlled prosthetics, self-driving cars, and advanced robotics.
This is all well and good, but I got to wondering how AI might be used to improve the delivery, understanding, and retention of these concepts by the interested party. This harkens back to my tenure as a university lecturer and professor. So here’s what I did. First I plugged the “script” above into Designs.Ai’s video engine, and came up with the video presentation embedded below. I uploaded static pictures of the phases from the internet; I found what Designs selected on their own to be OK but not anywhere optimum. Even then I managed to use the same picture for the third and fourth eras of EE.
So that’s one AI take on jazzing up otherwise dull text. I tried a second named Avatarbuilder.com. It uses AI to produce a figure dictating the text. You can change figures, backgrounds, dress, etc. to suit your needs. The video from this AI-assisted presentation tool is embedded below. I like the first one best for university-level presentations. Minds sharp = successful Dialysis.
Every morning I have to read my glucose level off of my Libre 3 Continuous Glucose Monitor and enter the reading into the Cycler’s “fitals” screen. Other than of interest to me, it was 99 this morning, no one from my team ever comments on this or how in general my diabetic control is doing. I would like to think this is because we are on track and doing an OK job with diabetic control. At the present time, my A1C is in the 6.2 range where it more or less stays. It has been as low as 5.4 and as high as 6.7. I don’t remember how long it has been, years since it has ever been over 7. That did get me thinking about how important, especially to those who are on dialysis, it is to maintain tight diabetic control. Thus this blog with the help of my AI assistant offer the following treatise on diabetic control and dialysis.
Introduction
Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels, resulting from defects in insulin secretion, insulin action, or both. In 2021, the International Diabetes Federation estimated that over 537 million adults worldwide had diabetes, and this number is projected to rise to 643 million by 2030 (IDF Diabetes Atlas, 2021). Poorly managed diabetes can lead to numerous long-term complications, including diabetic kidney disease (DKD), which is the leading cause of the end-stage renal disease (ESRD) requiring dialysis (Afkarian et al., 2016).
Dialysis is a life-sustaining treatment for patients with ESRD that serves to remove waste products and excess fluid from the body when the kidneys can no longer perform this function effectively. However, managing diabetes and dialysis simultaneously presents a unique set of challenges. This blog will discuss the importance of optimal diabetic control for patients on dialysis, focusing on the effects on patient outcomes, cardiovascular risks, and quality of life, as well as exploring potential strategies for achieving optimal control.
Effects on Patient Outcomes
Optimal diabetes control is crucial for patients on dialysis, as it has been shown to improve patient outcomes. A study by Williams et al. (2012) found that among diabetic patients on hemodialysis, those with poor glycemic control (HbA1c ≥ 8%) had significantly higher mortality rates compared to those with good glycemic control (HbA1c < 7%). Furthermore, Ricks et al. (2012) reported that in a cohort of 24,875 diabetic patients undergoing dialysis, each 1% increase in HbA1c was associated with a 14% increase in the risk of all-cause mortality. These findings suggest that appropriate diabetic control is essential for improving survival rates among patients undergoing dialysis.
Cardiovascular Risks
Patients with diabetes and ESRD are at an increased risk of cardiovascular complications. According to the United States Renal Data System (USRDS, 2020), cardiovascular disease accounts for approximately 50% of deaths in ESRD patients, with diabetes being a major contributing factor. Optimizing diabetic control can help reduce cardiovascular risk in patients on dialysis. For example, a study by Shurraw et al. (2011) found that a 1% reduction in HbA1c was associated with a 15% decrease in the risk of myocardial infarction and a 17% decrease in the risk of stroke among diabetic patients on hemodialysis.
Moreover, patients with diabetes and ESRD often have other cardiovascular risk factors, such as hypertension and dyslipidemia, which can be exacerbated by poor glycemic control (Charytan et al., 2020). Thus, optimal management of diabetes in conjunction with other risk factors is essential to minimize cardiovascular morbidity and mortality in patients on dialysis.
Quality of Life
Diabetes and dialysis can both negatively impact the quality of life (QOL) of patients. However, studies have shown that improved glycemic control is associated with better QOL scores. A study by Kalantar-Zadeh et al. (2012) found that among diabetic patients on hemodialysis, those with better glycemic control (HbA1c < 7%) had significantly higher QOL scores compared to those with poor glycemic control (HbA1c ≥ 8%). Additionally, optimal diabetes management can help prevent or slow the progression of other diabetes-related complications, such as neuropathy and retinopathy, which can further enhance patients’ QOL (ADA, 2021).
Strategies for Achieving Optimal Diabetic Control
Achieving optimal diabetic control in patients on dialysis requires a comprehensive approach, encompassing medical management, lifestyle modifications, and patient education.
4.1. Medical Management
Medical management of diabetes in patients on dialysis requires close monitoring of blood glucose levels and appropriate adjustments to the patient’s diabetes medication regimen. Insulin therapy is the most commonly used treatment for patients with diabetes on dialysis, as oral antidiabetic medications are often contraindicated or require dose adjustments due to impaired renal function (Molitch, 2019). In addition, continuous glucose monitoring (CGM) systems can be a valuable tool for patients on dialysis, as they provide real-time information on glucose levels, allowing for more accurate adjustments of insulin doses (Buse et al., 2020).
4.2. Lifestyle Modifications
Lifestyle modifications, including diet and exercise, are essential components of diabetes management for patients on dialysis. A tailored meal plan, developed in consultation with a registered dietitian, can help patients manage their blood glucose levels while also adhering to their dialysis-specific dietary restrictions (Kovesdy & Kalantar-Zadeh, 2016). Regular physical activity, as recommended by the American Diabetes Association (ADA, 2021), can also help improve glycemic control, cardiovascular health, and overall well-being.
4.3. Patient Education
Patient education is a critical component of diabetes management for patients on dialysis. It is essential for patients to understand the importance of regular blood glucose monitoring, medication adherence, and lifestyle modifications to achieve optimal glycemic control. Collaborative, patient-centered educational programs, such as the Chronic Kidney Disease Self-Management Program (CKD-SMP), have been shown to improve diabetes knowledge and self-care behaviors in patients with ESRD (Chen et al., 2018).
While the importance of optimal diabetic control in dialysis patients is well-established, there are several challenges that healthcare professionals and patients may encounter in achieving this goal. This section will discuss some of these challenges, as well as potential future directions for improving diabetic management in this population.
Challenges and Future Directions in Diabetic Control for Dialysis Patients
5.1. Challenges in Diabetic Control
One challenge in managing diabetes for patients on dialysis is the complexity of their medical regimen. In addition to managing their diabetes medications and insulin therapy, patients must also adhere to dialysis-specific dietary restrictions and fluid intake limitations, which can make maintaining optimal glycemic control more difficult (Kovesdy & Kalantar-Zadeh, 2016).
Another challenge is the increased risk of hypoglycemia in patients undergoing dialysis. Dialysis can cause fluctuations in blood glucose levels, and insulin requirements may change due to the removal of glucose and insulin during the dialysis process (Molitch, 2019). As a result, patients on dialysis are at a higher risk of hypoglycemia, which can be life-threatening if not promptly recognized and treated (ADA, 2021).
5.2. Future Directions
To address these challenges and improve diabetes management in patients on dialysis, research is ongoing to develop new therapeutic options and strategies. For example, novel glucose-lowering medications, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, are being investigated for their potential use in patients with ESRD (Molitch, 2019). SGLT2 inhibitors have been shown to reduce the risk of cardiovascular events and slow the progression of kidney disease in patients with type 2 diabetes (Zinman et al., 2015), and ongoing studies are evaluating their safety and efficacy in patients on dialysis (ClinicalTrials.gov, NCT03819153).
Additionally, advances in technology may help improve diabetes management for dialysis patients. For instance, the development of closed-loop insulin delivery systems, also known as artificial pancreas devices, may offer an effective solution for managing blood glucose levels in this population (Bally et al., 2017). These systems combine continuous glucose monitoring with automated insulin delivery, allowing for precise adjustments of insulin doses based on real-time glucose levels, which may help reduce the risk of hypoglycemia and improve overall glycemic control.
Conclusion
In conclusion, optimal diabetic control is of utmost importance for patients on dialysis, as it can significantly improve patient outcomes, reduce cardiovascular risks, and enhance the quality of life. Achieving optimal glycemic control requires a comprehensive approach, including medical management, lifestyle modifications, and patient education. Healthcare professionals and patients must work collaboratively to develop individualized treatment plans that address the unique challenges of managing diabetes and dialysis concurrently.
References
ADA. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Supplement 1), S1-S232.
Afkarian, M., Sachs, M. C., Kestenbaum, B., Hirsch, I. B., Tuttle, K. R., Himmelfarb, J., & de Boer, I. H. (2016). Kidney disease and increased mortality risk in type 2 diabetes. Journal of the American Society of Nephrology, 27(2), 486-495.
Buse, J. B., Wexler, D. J., Tsapas, A., Rossing, P., Mingrone, G., Mathieu, C., … & Consoli, A. (2020). 2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 43(2), 487-493.
Charytan, D., Solomon, S. D., Ivanovich, P., Remuzzi, G., Cooper, M. E., McGill, J. B., … & Parving, H. H. (2020). Efficacy and safety of losartan in diabetic patients with or without chronic kidney disease: a post hoc analysis of the
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My eGFR is currently bouncing between 8 and 9. How did I get here is a long story that started over sixty years ago when I was on the Rivers in Vietnam and subjected to Agent Orange. I started with Type II diabetes alone which lasted about ten years. Then my eGFR reached the low sixties, and I was sent to a Urologist who stated I would die of something other than Kidney Failure. This was in the early nineties. Progressively, but slowly, my eGFR coasted slowly downward. At no time would my diabetes be considered anything but “under control.” However, my meds changed and or increased over time to keep this control. At one point I was taking 2500 mg of Metformin, 1000 morning and night, and 500 at lunch. As a result of our moving to Corpus Christi, TX from Central Indiana I started with a new nephrologist who noted my eGFR was in the 30 range and immediately took me off of Metformin. This took place in about 2015 in the same time frame that I had a triple bypass. Absent Metformin, I started taking Lantus Insulin and have bounced around from 8 to 12 units ever since taking one injection in the evening before bed. In August my eGFR cratered in the 5-6 range, and I started on Dialysis, first hemo (it really sucks to the nth degree) then switched over to Peritoneal Dialysis as soon as possible.
Below is a graphical representation of eGFR versus Creatinine with the variable age shown as a family of curves obtained from this link:
As a result of this journey, I because very interested and sensitive to this measurement named eGFR which both my previous and current nephrologist seemed to deem as the Gold Standard in kidney functioning. Just like my GPs throughout my diabetic history have held A1C to be the standard checkpoint for diabetic control. As an engineer, I’ve always wondered why someone hasn’t displayed the relationship between creatinine and other variables in the equation that calculates eGFR. Keep in mind the “e” in eGFR stands for “estimated.
” While several government entities I have dealt with demanded/required that eGFR be calculated by an MD, some apps and websites do so painlessly. It is an exercise for the reader to sort these out for themselves. Referring to the graph above, I am currently 84, with a Creatinine value consistently in the over 6 range. Transferring these values to the graph results in an eGFR value along the 80 age curve to be in the 8 range. Easy-peasy.
For individuals interested in or currently on dialysis, it is crucial to understand the relationship between estimated Glomerular Filtration Rate (eGFR) and creatinine. The remainder of this blog will provide a comprehensive overview of these two critical measures, their interrelationship, and their importance for dialysis patients.
eGFR: A Key Measure of Kidney Function
eGFR, or estimated glomerular filtration rate, is a calculation used to evaluate kidney function. It measures the rate at which the kidneys filter waste and excess fluids from the blood (in mL/min/1.73 m2). The calculation takes into account factors such as age, sex, race, and serum creatinine level. A lower eGFR indicates decreased kidney function, with levels below 15 mL/min/1.73 m2 considered kidney failure.
Creatinine: A Waste Product Indicative of Kidney Function
Creatinine is a waste product generated through normal muscle metabolism. Healthy kidneys efficiently filter creatinine from the blood, excreting it in urine. Therefore, elevated blood creatinine levels can be indicative of reduced kidney function. Creatinine levels are typically measured in mg/dL; normal ranges vary depending on age, sex, and muscle mass.
The Relationship Between eGFR and Creatinine
Creatinine levels and eGFR are inversely related. As creatinine levels increase, eGFR decreases, indicating reduced kidney function. Conversely, lower creatinine levels correspond to a higher eGFR and better kidney function. Monitoring eGFR and creatinine levels can provide valuable insights into kidney health and inform treatment decisions, including dialysis.
Importance of eGFR and Creatinine for Dialysis Patients
For dialysis patients or those considering dialysis, understanding eGFR and creatinine levels is essential for several reasons:
A. Monitoring Kidney Function: Regularly tracking eGFR and creatinine can help assess the progression of kidney disease, allowing healthcare providers to adjust treatment plans accordingly.
B. Determining Dialysis Timing: eGFR and creatinine levels play a crucial role in determining when dialysis should be initiated. Generally, dialysis is considered when eGFR falls below 15 mL/min/1.73 m2 or when symptoms of uremia (waste buildup in the blood) become evident.
C. Evaluating Dialysis Effectiveness: Dialysis aims to remove excess waste, including creatinine, from the blood. Comparing pre- and post-dialysis creatinine levels can help assess the effectiveness of dialysis sessions and identify the need for adjustments.
D. Adjusting Medications: Kidney function impacts drug metabolism and excretion. Monitoring eGFR and creatinine levels can help healthcare providers adjust medication dosages to ensure safety and efficacy for dialysis patients.
Conclusion:
Understanding the relationship between eGFR and creatinine is crucial for individuals on or considering dialysis. Monitoring these measures helps assess kidney function, informs treatment decisions, and ensures the effectiveness of dialysis therapy. Regular communication with healthcare providers is vital in managing kidney disease and optimizing overall health for dialysis patients.
Last night’s Cycler performance did not fail us; it did however fail. I received the same drain alarm on the cycle 1 drain as during the previous night’s usage. The above Cycler screenshot of detailed “My Records” shows cycle 0 had a drain as predicted yesterday. Going down the columns, All cycle fill volumes, as are the times, are reasonable. The dwell time, supposed to be 120 minutes/2 hrs, is inconsistent. Why was cycle 1 133 minutes? Regarding drains, note that the first three drains left fluid in my gut, thus the negative UF (Ultra Filtration, negative indicates fluid left it, positive taken out) readings. Note especially the last drain of 3178 taking 29 minutes. I was up and moving around during this drain, probably resulting in it being quite large and positive. Something is not right in Dialysisville.
From cited article
In a March 22, 2023 article in SciTechDaily linked here, there was an interesting research report titled “Stay Sharp: Healthy Lifestyle Linked to Slower Memory Decline in Older Adults”
The researchers found that each individual healthy behavior (healthy diet, regular exercise, active social contact, cognitive activity, non-smoking, and never drinking alcohol) was associated with a slower-than-average decline in memory over ten years after accounting for other health, economic, and social factors. A healthy diet, cognitive activity, and physical exercise strongly affected slowing memory decline.
Since cognitive impairment is of central concern to dialysis patients, the research strongly suggests eating right, using your brain, and doing physical exercise. However, we all know this, right? Getting it done is another matter.
Picture from TIME article below.
The second research article I recently read has to do with the Widowhood Effect. With the widowhood effect, older adults grieving a spouse’s death have an increased mortality risk compared to those whose spouses are living. This effect has even been documented by researchers. A 2013 study that appeared in the Journal of Public Health showed that people had a 66% higher risk of dying within the first 90 days of losing their spouse. This discovery held true for both men and women.
An article on March 22, 2023, in Time BY HALEY WEISS titled “Losing a Spouse Makes Men 70% More Likely to Die Within a Year,” found that Gender and Age were two of the most influential risk factors for the widowhood effect. So if you are on Dialysis and want to beat the odds of dying within 4.5 years of going on the treatment, take good care of your spouse else you are a dead duck.
By the way, our goose is still in her nest in one of our gutters. Many people are interested in her activities up and down our street.
Data from last night’s Cycler performance – screenshot
Recall from yesterday’s blog that Fresenius Tech Support recommended turning off alarms to solve my cycler throwing alarms consistently during most night’s cycler use. With alarms off, last night on drain one I received another alarm, this one with the Stop Button flashing and a warning not to stop the patient’s drain or something like that. I was 3/4 asleep on my feet. After pressing the OK button, and staying on my feet upright, the drain proceeded until about 1700 mL had been drained, at which point I got back in bed.
Referring to the screenshot at the blog top, fill times are pretty much right on the 10-minute spec. Dwell times, except the last one, are NOT on the 120-minute spec. Drain volumes are all over the place – disregard the Cycle 0 327 drain, that was left over from yesterday’s cycle. So we have drains of 1944, 1516, 1965, and 2217. Drain time of 36, 17, 25, and 20 where only the last meets spec of 20. Disregarding the 327 Cycle 0, we had UF (fluid left in gut) of -57, -485, -37, and + 292, for a net of -287mL. This is over a cup (236.6 mL) of fluid left. I expect when I hook up to the cycler tonight that drain 0, that is upon startup, there will be a drain of at least this amount.
Add to the above that my weight was up another pound to 154 this morning leads me to the conclusion that all is not right in my Fresenius-lead treatment at this point. I have passed this data on to my Team Nurse and we’ll have to see what falls out. The alarm panel is at the blog’s end.
CGM: Had a call this morning from my pharmacy ExpressScripts about another matter, and at the conversation close asked about the status of my Freestyle Libre 3 order. I was told that it had been approved and should ship somewhere around April 4, 2023. Until such time as I have firm shipping info, I’m not going to cancel my out-of-pocket order which is prudent given we ARE dealing with government resources!
VA: I happened to check the status of my request to the VA to up my kidney failure to 100% from 80% due to the fact that I am now on Dialysis. I saw that it had been approved and that the rating package with info on how they arrived at their decision was in the mail. I received the package and was informed that the monthly disability payment had been increased which I did not ask for or anticipate. Turns out that since with the new rating of 100% for being on Dialysis, and the fact that I have another non-related rating of at least 60% (actually have a triple-bypass at 60% plus a host of others), I now fall under Special Monthly Compensation tables which resulted in the unanticipated increase. Blind squirrels etc.
As stated in my blog entry last Friday, yesterday (Monday), I called Fresenius Tech Support concerning the seemingly continuous throwing of drain alarms by my Liberty Cycler. We spent over 20 minutes with the tech rep requesting data from various cycler screens. As of the phone call, the cycler was throwing drain alarms for exactly 50% of the evening dialysis treatments. Let me explain this so those not acquainted with the cycler have a little more insight into what I’m talking about.
The Cycler is a computer-controlled pumping device that controls the three phases of my evening dialysis treatment. After turning on and plugging my catheter into the cycler, it first checks to see if any fluid is left in my stomach cavity and if so pumps it out. It defaults to 50mL or more of such fluid. If there previously had been a “good” drain, the machine can’t remove at least 50mL of fluid so guess what, yes, it throws an alarm. You have to manually bypass this phase to move on.
From here on what takes place depends on what your nephrologist has ordered. From me, I am on 8000 mL total fluids, pumped in and out of my stomach lining 2000mL at a time, for four cycles total. So initially 2000mL is pumped in – called “fill,” which is left in my lining for two hours – called dwell, then pumped out – called a drain. Each fill is supposed to take 10 minutes, and each drain is 20 minutes. If you add up the total fill times 4×10=40 minutes and drain 4×20 = 80 minutes, you have 120 minutes or two hours ideally spent on fill and drain, plus 4×2 hrs = 8 hrs total dwell. So altogether, 10 hours in an ideal world. My best time is 10 hrs 11 minutes, and the worst is right at 11 hours. The problem is with the drain. For me, as previously stated, 50% or more of the time my system has problems with drains. Is it me, the cycler, or God knows?
On the me vector, I have been doing EVERYTHING my team has suggested. We tested my plumbing, and everything is working properly. I am on my second cycler; I have read that some patients have gone through more than 10 with drain problems. The internet is full of complaints by patients concerning drain problems with the Fresenius Cycler. The PR fluff Fresenius has released on their new cycler touts improvement in this area which is moot acknowledgment on their part of the cycler’s intrinsic problems with the current cycler. I guess other than the cycler, it’s in God’s bailiwick.
This morning I received a call from my Dialysis Team Nurse who had been contacted by Fresenius Tech Support. The bottom line is this: Tech Support’s solution to grossly excessive alarms is to turn them off. I was directed to a section in the Cycler manual called “Flow Alerts” wherein it states that if both flow alert and flow alert sound are set to “NO” the sound will not occur, but the cycler will display an alarm when you are draining or filling slowly. So I fired up my Cycler, went to the proper panel, and turned off the flow alert, defaulting the sound to N/A. Note the differences between what the manual stated needed to be accomplished and what took place on my Cycler.
Regardless, the alarm is now off, and we’ll soon know what effect this “fix” has. I’m going to watch what happens to the overall time I’m on the cycler. I suspect it will increase, perhaps drastically, because I’m not getting up to increase the drain flow as I have in the past. We’ll see, and I’ll report back.
CGM: Last week I had a conversation with my online pharmacy, ExpressScripts about an unrelated matter. Upon conclusion of this call, I inquired about their provision of Libre3 CGMs. I was assured that they either have them or will provide them when presented with a valid prescription by my doctor. I call my GP who sent them a script yesterday. My ExpressScripts app notified me they had received a script to fill. Today I received notification from ExpressScripts that a “Prior Authorization Required” has to be in place before they can ship my CGM order. My benefits plan must be approved through prior authorization to ensure my plan covers this medicine.
It looks like governmental red tape is taking over. Meanwhile, I’m paying $204.xx out-of-pocket for the Libre 3. I’ll keep you posted.
