Yesterday I received a call from my dialysis nurse. She informed me that my nephrologist had reviewed my most recent lab report and wanted to make some changes. She is concerned about my Hemoglobin being so high (14.5) which has a lab range of 14-18. Mine is too high for someone on PD. Secondly, my iron is in the over 800 range and the lab range is 22-322. I have been taking OTC iron supplements which I was instructed to stop. Additionally, she wants labs on my B12 for which I have been taking an injection every two weeks. On top of that, in question is if I should continue testosterone injections which I currently take every two weeks.
As you can ascertain from the above, there are lots of moving parts. See graph below:
The results from my Adequacy Test (more on this nomenclature later on) and my labs in general are in. As you can view in the lead graphic, my Kt/V, captured by the Urea Index, has significantly increased to 2.29, or as my local Fresenius clinic would report, 2.3 rounding the number to one decimal place. While on the surface this would appear to be “good,” to me it raises the question “How much Kt/V is “enough?” or “What value is medically indicated?”
This is where “medicine” is all over the place. Let me explain. The Nurse practitioner who recently visited with me last week stated the “government’s” criteria is 1.4 or better. My local Fresenius clinic sets a minimum of 1.7 as do several other entities. From the graph above, you can see the lab sets a minimum of 2.0 with no upper bound as do several other entities. I have to live with the environment where I am so as long as I am above 1.7 I may have discussions with my team, and if I’m above 2.0 get atta boys. But this still begs the issue of how much is enough.
My copious research turned up this statement: “The updated January 2020 ISPD guidelines reflect the changes mentioned above including a shift in terminology used to describe the proper amount of dialysis attained from “adequate” to “goal directed,” including multiple aspects to meet optimal “goal directed” care, including residual kidney function, nutritional status, and patients’ sense of well-being and satisfaction with their treatment. The effect of the burden of time spent fulfilling their dialysis prescription on their ability to carry out normal day-to-day tasks and their psychosocial status are now included as important factors in assessing if dialysis prescriptions are adequate. Finally, it is now mentioned that there is no specific target for clearance to meet to ensure PD prescriptions are satisfactory (15). … Finally, we have seen a growth in the field of nephrology in which the term “adequacy” has developed from a synonym for clearance of a single small solute to a term for a holistic assessment of the patient. We have learned that in PD, there is such a thing as too much of a good thing.Link to source for quotes above.
OK, so instead of “Adequacy Tests” we should be goal-directed based on patients’ input. It still begs a response to the question “How much Kt/V is enough? which we may attack through the question “What harm, if any, results from higher Kt/V?” I turned to Perplexity with this question with the following results:
For peritoneal dialysis patients, what is really good kt/v
Answer
For peritoneal dialysis patients, a Kt/V of 1.7 or higher per week is generally considered good. This target value has been recommended by guidelines from organizations like the International Society for Peritoneal Dialysis (ISPD) and the Kidney Disease Outcome Quality Initiative (K/DOQI). However, it’s important to note that the relationship between Kt/V and clinical outcomes is not straightforward. Some studies have shown that achieving higher Kt/V values may not necessarily lead to better survival rates. The ISPD in 2020 stated that there was a lack of high-quality evidence to prove the impact of Kt/V on survival and mortality, and reaching Kt/V > 1.70 may not bring additional survival advantages. Recent research suggests that the Kt/V reach rate – the percentage of Kt/V measurements that reach the target threshold – may be a more representative index to assess clinical status. Patients who consistently achieve the target Kt/V (3/3 times) or intermittently achieve it (1/3 or 2/3 times) have been shown to have better clinical outcomes than those who never reach the target. Ultimately, while a Kt/V of 1.7 or higher is considered good, it’s essential to consider other factors such as how the patient feels, their overall health status, and their residual kidney function when assessing dialysis adequacy.
Rather than ask “How high should Kt/V be,” perhaps we should ask Perplexity another question “What are the risks associated with higher Kt/V targets in PD patients?”
Answer
While higher Kt/V targets are often considered beneficial for peritoneal dialysis (PD) patients, there are some potential risks and considerations associated with pursuing higher Kt/V values:
Increased peritoneal exposure: Achieving higher Kt/V may require more frequent exchanges or larger volumes of dialysate, which can lead to increased exposure of the peritoneal membrane to glucose and other potentially harmful substances.
Peritoneal membrane damage: Over time, excessive exposure to dialysis solutions can cause structural and functional changes in the peritoneal membrane, potentially leading to ultrafiltration failure.
Loss of residual renal function: Aggressive pursuit of higher Kt/V targets might inadvertently accelerate the decline of residual kidney function, which is crucial for PD patients’ overall health and survival.
Diminishing returns: Studies have shown that achieving Kt/V values above 1.7 may not provide additional survival benefits. This suggests that there might be a point of diminishing returns where the risks outweigh the potential benefits.
Quality of life impact: More frequent or longer dialysis sessions to achieve higher Kt/V targets can negatively affect a patient’s quality of life and daily activities.
Increased risk of complications: More intensive dialysis regimens may increase the risk of peritonitis, exit-site infections, or mechanical complications related to the PD catheter.
Nutritional issues: Overzealous removal of uremic toxins might lead to the loss of essential nutrients, potentially affecting the patient’s nutritional status.
It’s important to note that the relationship between Kt/V and clinical outcomes is complex, and individual patient factors should be considered when determining optimal dialysis prescriptions.
One of the most important measurements accomplished in a PD patient’s monthly labs is the phosphorus finding. My dialysis team looks at all of the results, but concentrates on Kt/V, calcium, A1C, potassium, and phosphorous, at least seemingly. Since my past phosphorous reading was too high, I have been concentrating on getting it back down. As part of this effort, I asked Perplexity what foods I should be avoiding with the following results. Read and Heed! (The lead picture from Poe is its rendition of the element Phosphorous.)
For patients on peritoneal dialysis, it’s important to limit phosphorus intake as the treatment may not remove enough phosphorus from the body. Here are some high-phosphorus foods to avoid or limit:
Dairy products: Milk, cheese, yogurt, ice cream, and pudding
Processed and packaged foods: Lunch meats, canned iced teas, and bottled beverages with phosphate additives
Cola and dark sodas
Nuts and peanut butter
Dried beans and lentils
Whole grains: Brown rice, oat bran muffins
Chocolate and caramel candies
Organ meats: Liver, sweetbreads
Fish roe and sardines
Beer and ale
Processed meats: Hot dogs, bacon, sausage
Pizza
When reading food labels, look for ingredients containing “phos” to identify hidden phosphorus additives. Choose alternatives like rice milk, almond milk, white rice, and fresh fruits and vegetables. It’s crucial to work with a kidney dietitian to develop a personalized meal plan that balances nutrient needs while controlling phosphorus levels.
One of the most often questions patients new to peritoneal dialysis have is “What is involved in the stowing of the many parts required to conduct dialysis?” In that yesterday we received our monthly bits and bobs supply from Fresenius, I thought it might be lucrative to video just what the situation entails. See below:
Yesterday Michelle from KidneyLink conducted her interface with my wife and me for about an hour. It was productive time spent and we plan on continuing with the annual visits in the future. She went over in detail all my meds and found two that were not on my medication list. One was D3 an OTC I’m taking on the advice of my GP and the consent of my Nepro; the other was a prescription cream that I use for dry skin mainly as a result of diabetes. The bottom line of the visit is that she found me, and us by association, the “us” including my wife as my caregiver, to be at the top of the game-so to speak. She said she had many 55-year-old patients in much worse shape than I am. In particular, she commented very positively about my weight and blood pressure.
If your dialysis provider has something like KidneyLInk, I suggest you consider engaging with them. I found the video below which explains better the thrust of this service.
I have been steadily commenting on the yard work my wife and I are engaged in. To strike home what is involved, I made the video below so you can see for yourself. For those on peritoneal dialysis, YOU CAN still accomplish things if you set your mind to it. At 85, I’m still truckin’ in the extreme heat of North Texas.
I have a somewhat busy medical week ahead plus plans to continue working on our flower beds. Tuesday I start an Adequacy Test in preparation for labs Wednesday. Also Tuesday a rep from Kidney Link is scheduled to visit our home and conduct an overall, 10,000-foot appraisal of my overall medical care. I’m a little bit dubious of the efficacy of such an audit but we will see.
Wednesday we are scheduled for a supply delivery from Fresenius. I will only have one day (one box) of 1.5% six liters left which is running it close. Also have the labs and have to lug in the night before fluids which at 12,800 mL are heavy. The same day my wife has her first appointment with my GP as a concierge patient. She kept running into having to wait hours for a given appointment and was not able to make timely appointments otherwise. With the concierge doctor, while it costs extra, we get appointments mostly on the same day, with minimal wait times, like 5 minutes. I have the doctor’s private cell phone number and email for prompt communication.
This month I made my supply order online using the PatientHub App just like many many months in the past. Everything went as expected. About a week later, I received an email from Fresenius telling me to submit my supply order. I checked my PatientHub App and it showed my order pending. I then called the Fresenius Order desk to inquire what my order status was. After a ten-minute hold, I was informed that indeed my order had been placed. I then inquired as to what the problem was and was informed that a software update has glitches in it which they are working on.
I took this opportunity to inquire why my previous order for cassettes wasn’t filled. I was told their records indicate none were ordered when in fact I DID order four boxes. I then inquired why Fresenius’ order software does not flag accounts such as mine where I have been putting in more or less consistent orders for fungibles such as cassettes for years. Their system must be written in COBOL and manned by COBOL-aged personnel because this basic system analysis was above the pay grade of the supply person who answers the phone at Fresenius. On top of this, I sensed no interest in improving their system either.
Buyer beware. The Fresenius “System” can bite you!
The 6/22-23, 2024 Review section of WSJ had an interview with Usher. In it, he provided his A to Z advice on life. His “R” was Read, learn, study about everything important in your life.” This struck home to me as deeply applying to those of us on dialysis. Our dialysis is very very important to our lives, so his admonishment fits. I turn to Poe with the following Prompt and results which are very insightful. Read on:
Prompt: Develop a 500-word blog post on the importance of continuing to “read, learn, and study everything important to your life” for peritoneal dialysis patients:
Title: The Lifelong Learning Mindset for Peritoneal Dialysis Patients
As a peritoneal dialysis patient, it’s easy to get stuck in a routine – performing your dialysis exchanges, taking your medications, and seeing your doctors for regular checkups. While maintaining that necessary routine is critical, it’s also important to adopt a mindset of lifelong learning. Continuing to read, learn, and study everything important to managing your health and quality of life can make a tremendous difference.
Peritoneal dialysis is a complex treatment, and there is always more to understand about how it works, how to optimize your dialysis regimen, and how to cope with the challenges it presents. By actively seeking out new information, you can become a true expert in your care. Read medical journals, attend educational seminars, and join online support communities to learn the latest developments in peritoneal dialysis research and best practices.
But it’s not just about the medical and technical aspects of dialysis. It’s also crucial to continuously educate yourself on the broader health, lifestyle, and psychosocial factors that impact your well-being as a dialysis patient. Learn about the role of nutrition, exercise, stress management, and mental health in managing your condition. Discover new hobbies, activities, and social connections that can enrich your life. Understand your legal rights and financial assistance options.
The more you know, the more empowered you’ll be to make informed decisions about your care, to advocate for yourself, and to achieve the best possible outcomes. Peritoneal dialysis patients who take a proactive, curious approach to learning tend to experience improved clinical results, greater treatment satisfaction, and a stronger sense of control over their health.
Of course, the learning process doesn’t stop once you’ve mastered the basics. As your needs and circumstances change over time, you’ll need to continually adapt and expand your knowledge. New dialysis technologies, medications, and clinical guidelines are always emerging. Your own physical, emotional, and social needs will evolve. Embrace this ongoing journey of discovery – it’s all part of being a savvy, engaged patient.
Remember, you are the expert on your own body and your own life. No one knows your unique situation better than you do. By nurturing your natural curiosity and committing to lifelong learning, you’ll be better equipped to navigate the ups and downs of peritoneal dialysis, collaborate effectively with your healthcare team, and optimize your health and quality of life. So keep reading, keep learning, and keep seeking out new information that can make a difference for you. Your continued growth and education is a true investment in your well-being.
Some of you may recall we have a golden retriever named Dickens. He just turned two and continues to be a constant companion and delight to my wife and I. I only wish that more people could experience the warm and loving feelings that go along with associating with a golden. With this thought in mind, I turned to Poe and inquired about the advantages to someone on peritoneal dialysis in having a golden. This is what Poe had to say about it; pretty interesting. BTW, the lead graphic is of Dickens in the morning where he hangs out while we are having breakfast.
For those living with kidney disease and undergoing peritoneal dialysis, the daily routine of managing this treatment can often feel isolating and draining. However, many patients have found a unexpected source of comfort, companionship, and even medical benefits through an unlikely companion – the golden retriever.
Golden retrievers are well-known for their gentle, affectionate temperament and their innate desire to please their human companions. These traits make them particularly well-suited as service and therapy dogs, and increasingly, peritoneal dialysis patients are discovering the advantages of inviting one of these furry friends into their homes.
Reduced Stress and Anxiety Undergoing dialysis can be an immensely stressful experience, both physically and emotionally. The constant monitoring of fluid levels, the disruption to daily routines, and the worry about long-term health can take a significant toll. Studies have shown that interacting with dogs can dramatically reduce stress and anxiety levels, thanks to the calming effect of petting a soft, furry animal and the release of feel-good hormones like oxytocin.
For peritoneal dialysis patients, having a golden retriever nearby during treatments can provide a welcome distraction and a source of comfort. The dog’s presence and unconditional love can help ease the mental strain of the dialysis process, allowing patients to feel more relaxed and focused on their well-being.
Improved Mobility and Exercise Peritoneal dialysis patients are often advised to maintain an active lifestyle to support their overall health. However, the fatigue and physical limitations associated with kidney disease can make it challenging to incorporate sufficient exercise into their daily routines.
This is where a golden retriever can make a big difference. These energetic pups require regular walks and playtime, which can encourage their owners to get up and move around more frequently. Even gentle strolls around the neighborhood or light games of fetch can translate to meaningful physical activity for dialysis patients, helping to build strength, improve cardiovascular health, and promote better sleep.
Enhanced Social Connections Kidney disease and dialysis can be incredibly isolating experiences, as patients may feel self-conscious about their condition or find it difficult to maintain social connections. Golden retrievers, with their friendly demeanor and eagerness to interact with people, can serve as social catalysts, helping their owners to meet new people and engage with their community.
Whether it’s striking up conversations with fellow dog owners at the park, joining a local pet-centric social group, or simply attracting the attention of passersby who want to give the dog some affection, a golden retriever can open up a world of new social opportunities for peritoneal dialysis patients. This increased sense of belonging and support can have a profoundly positive impact on mental health and overall well-being.
In conclusion, for peritoneal dialysis patients, a golden retriever can be far more than just a beloved pet – they can be a faithful companion, a therapeutic ally, and a gateway to a healthier, more connected life. By providing comfort, motivation, and social engagement, these furry friends can make a remarkable difference in the daily experiences of those managing kidney disease.
