It’s been an interesting week from many perspectives. (Graphic above from Designs.AI’s Illustrator. It reminds me of my Dialysis nurse for some reason.)
Our Granddaughter, who lives in the Seattle area, visited
I got tangled up in ExpressScripts bureaucratic nightmare.
My Fresenius Liberty Cycler continues, on a random basis, to illicit drain alarms and, this week, one fill alarm. For the past 15 nights, seven have had no alarms (47%), and eight have had alarms (53%). Disregarding the fourth and last drain, when I am always up and moving about, 15X3=45 possible drain alarms, of which I have experienced 10, or 10/45=22%. So more than half of the time I go to bed, my sleep is interrupted by Cycler alarms. Remember that Fresenius’ tech support is oblivious to this fact, telling me to shut off the alarms as a “fix.” What BS!
I can’t seem to articulate to my GP’s script person that I want all scripts written for a 90-day supply. Why is this so difficult to understand?
At one point, our Fresenius stock was up $5.00 per share from our by-in price. Not too shabby.
My GP script person sent a prescription to CVS for a Libre 3. But it was sent in for three, not six, covering 90 days, more or less. My CVS app shows they have been working on it since 4/13/2023. Why is it that I can buy direct from HealthWarehouse.com, which I am, and receive Libre 3s like clockwork, but the large government-contracted agencies cannot? What’s wrong with this picture?
I have a normal monthly meeting next Thursday with my Dialysis Team. I’ll share my going-in discussion points with you next week.
Our goose eggs hatched with six little ones that have been seen paddling around in our local ponds. Life does go on, even on Dialysis!
I used AI to generate the feeser.me ad is shown below, which I then posted to Facebook and Linkedin. Enjoy what AI can do for you if you can 🙂
I asked Craiyon.com to generate a picture of ChatGPT to insert in this blog. Below is what was provided. My Prompt was “picture of chatgpt.”
The most often question I receive other than “How’s it going?” pertaining to Peritoneal Dialysis, is how long does it normally last which is code for how long can I expect to live given I’m on dialysis. Trying to explain to the layman the differences between PD and Hemo quite often cause their eyes to gloss over. This blog is aimed at those one PD and/or interested in PD and answers the question “What determines how long one can expect, all else being equal, to be able to be on PD? And then what?”
First the “Then what.” At the point where it becomes obvious from quarterly lab visits that PD is not hacking it, the nephrologist should encourage the patient to get set up for Hemo as a treatment of last resort. When PD is no longer viable, Hemo is the go-to treatment. Yes, to me it appears to be going backward, but hey, it beats the hell out of being without breath and a beating heart six feet under!
As the following from my trusty ChatGPT assistant will show, PD Transport Rate and Status of the Peritoneum are determining factors in how long a patient has a chance of using PD. Shown first is the Prompt I used to quiz the AI front end, and then the result. Pretty interesting and adds context to the PD longevity question. Here goes.
Model: Default (GPT-3.5)
Prompt to ChatGPT: Consider yourself to be a trained and experienced Nephrologist. Discuss in explicit detail the longevity of Peritoneal Dialysis as relates to 1. Transport Rate and 2. Status of Peritoneum. Write in explicit concise and understandable English at the MBA level terminology in at least a 2000-word essay with citations and an end reference list.
Introduction
Peritoneal dialysis (PD) is a form of renal replacement therapy used in the treatment of end-stage renal disease (ESRD). This therapy uses the peritoneum, a thin membrane that lines the abdominal cavity, as a semipermeable membrane to remove waste products and excess fluids from the body. Unlike hemodialysis, which uses an external machine to filter blood, PD allows the patient to perform the therapy at home with the help of a catheter inserted into the abdomen.
The longevity of PD as a form of renal replacement therapy depends on several factors, including the transport rate and the status of the peritoneum. In this essay, we will discuss each of these factors in detail, along with their impact on the longevity of PD.
Transport Rate
The transport rate refers to the rate at which solutes move across the peritoneal membrane during PD. There are three types of transport rates: high, high-average, and low average. The transport rate is determined by measuring the rate at which glucose, a solute used in PD, is absorbed by the peritoneal membrane.
High transporters have a peritoneal glucose absorption rate of more than 0.81 mmol/L/h. High-average transporters have a peritoneal glucose absorption rate between 0.60 and 0.81 mmol/L/h, and low-average transporters have a peritoneal glucose absorption rate of fewer than 0.60 mmol/L/h.
The transport rate has a significant impact on the longevity of PD. High transporters have been shown to have a higher risk of technique failure and a shorter PD duration compared to low transporters. In a study of 360 patients, high transporters had a median PD duration of 17 months, while low transporters had a median PD duration of 37 months.
The reason for this difference in PD duration is thought to be due to the increased exposure of high transporters to glucose, which can lead to peritoneal fibrosis and membrane damage. This damage can lead to a decline in ultrafiltration capacity and an increased risk of infection, both of which can contribute to technique failure and the need to switch to another form of renal replacement therapy.
In addition to the transport rate, other factors such as age, diabetes, and the presence of cardiovascular disease can also impact the longevity of PD. Older patients, those with diabetes, and those with cardiovascular disease have been shown to have a shorter PD duration compared to younger patients without these comorbidities.
Status of Peritoneum
The status of the peritoneum is another factor that can impact the longevity of PD. The peritoneal membrane is a dynamic structure that can undergo changes over time, including thickening, fibrosis, and neovascularization. These changes can impact the function of the peritoneum and lead to a decline in ultrafiltration capacity and an increased risk of infection.
Several factors can contribute to peritoneal membrane damage, including long-term exposure to glucose, infection, and exposure to other toxins. Infection is a particularly important risk factor for peritoneal membrane damage, as it can lead to the development of peritonitis, a serious complication of PD that can lead to technique failure and the need to switch to another form of renal replacement therapy.
Peritoneal membrane damage can be assessed using imaging techniques such as peritoneal scintigraphy, which can measure the peritoneal thickness and blood flow. These assessments can be useful in predicting the longevity of PD and identifying patients who may be at higher risk of technique failure.
Several interventions can be used to protect the peritoneal membrane and prolong the longevity of PD. These include the use of biocompatible dialysis solutions, which have been shown to reduce peritoneal membrane damage and improve patient outcomes. Biocompatible solutions have a lower concentration of glucose and other osmotically active solutes, which can reduce peritoneal fibrosis and inflammation.
In addition to biocompatible solutions, the use of intermittent peritoneal dialysis (IPD) has also been shown to improve peritoneal membrane function and prolong the longevity of PD. IPD involves performing short, frequent exchanges of dialysis solution, which can reduce the exposure of the peritoneal membrane to glucose and other toxins.
Other interventions that may help to protect the peritoneal membrane and prolong the longevity of PD include the use of low-GDP dialysis solutions, which have a lower concentration of glucose degradation products, and the use of agents that can reduce oxidative stress and inflammation.
Conclusion
In conclusion, the longevity of PD as a form of renal replacement therapy depends on several factors, including the transport rate and the status of the peritoneum. High transporters and patients with peritoneal membrane damage are at higher risk of technique failure and may require a switch to another form of renal replacement therapy.
However, interventions such as the use of biocompatible solutions, intermittent peritoneal dialysis, and low-GDP dialysis solutions can help to protect the peritoneal membrane and prolong the longevity of PD.
It is important for nephrologists to carefully monitor the transport rate and status of the peritoneum in patients undergoing PD and to make appropriate interventions to protect the peritoneal membrane and ensure the best possible outcomes for their patients.
References:
Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. 2010;30(4):393-423.
Lameire NH, Van Biesen W, Vanholder R. The longevity of peritoneal dialysis: still an open question? Kidney Int Suppl. 2008;(108):S45-51.
Davies SJ. Longitudinal relationship between solute transport and ultrafiltration capacity in peritoneal dialysis patients. Kidney Int. 2005;67(1):237-242.
Holmes CJ, Patel PR, Perez J, et al. Peritoneal dialysis: recent advancements and future challenges. Int J Nephrol Renovasc Dis. 2019;12:223-233.
Dong J, Yuan Z, Zhang L, et al. Effects of different glucose concentrations in dialysate on peritoneal membrane function in peritoneal dialysis patients: a systematic review and meta-analysis. PLoS One. 2017;12(1):e0170535.
Krediet RT. Biocompatible peritoneal dialysis solutions: do they exist? Contrib Nephrol. 2011;173:99-107.
Peppelenbosch A, van Kuijk WH, Bouvy ND, et al. The effect of peritoneal dialysis fluid containing low glucose degradation product on peritoneal transport and markers of peritoneal damage. Kidney Int. 2004;66(3):1047-1053.
Bright and early this morning, almost at 0800, I received a direct real person phone call from a pharmacist at ExpressScripts. He attempted to explain why the script for a Libre 3 Continuous Glucose Monitor from my GP was not being filled by them. The reason he stated, was that ExpressScripts does not yet carry the Libre 3; they could however fill a script for a Libre2. Hummmm?
I attempted to relate that I received a letter from ExpressScripts stating that the reason they refused to fill the order was that my GP was just that, a GP and not a diabetic specialist. He apologized and stated that was not correct. When I told him I was buying Libre 3s directly from an online supplier, not a problem but at an out-of-pocket cost of over $200 per month he essentially wished me luck.
Keep what’s going on here in perspective. ExpressScripts’ contract with the government started in January 2023 and runs through 2029. It has value in the billions of dollars and serves over 9.6 million active-duty service members, their family members, and retirees.
Yesterday I received a letter (included at bottom of this blog as a PDF) whose logic totally escapes me. My request for Tricare to provide me with CGMs to aid in the treatment of my diabetes was turned down BECAUSE the script came from my GP, not an endocrinologist or diabetes management expert. Seems that they maintain that such people are “experienced in the management of insulin-dependent diabetics…and familiar with the operation and reports necessary for proper management of continuous glucose monitoring systems.”
The logic in this approach is totally counter to the PR the manufacturer, Abbott advertises as to how simple the CGM is to deploy and use. What operation and reports are they speaking of?
This appears to me to be just another instance of bureaucratic BS hiding behind obfuscation.
Over the weekend I received a couple of robo-calls from ExpressScripts. Recall I am having a go at them attempting to have Continuour Glucose Monitors covered. The calls asked me if I wanted to continue to wait on my doctor to get back to them on some unnamed prescription which I assume to be CGMs. Same set of scripts they told my GP rep they would not cover? What is the logic in this?
Second continuing sage is that for the last 12 days, I have had exactly five nights without any alarms. Recall this is after Fresenius tech support told me to solve the problem of nightly alarms on their Liberty Cycler to shut them off which I did. So much for their wisdom when 58% of the time I’m still experiencing alarms.
How would you like to have to get up out of bed with a line sticking out of your gut to assuage an incessant screaming of an alarm?
Yesterday was an eventful day for me, but not in a good way. Started at the breakfast table with a call from ExpressScripts (recall my military-provided pharmacy) stating that they needed to talk to my GP about two related items concerning my recent request for the Libre 3 CGM to help with my diabetic control. First, they had to confirm that no drug interaction was present. How a device that measures glucose interacts with medication is beyond my Ph.D. understanding. Second, they wanted to confirm insurance coverage. Get this: ES, which administers the military’s pharmacy program, wanted to know if the government’s pharmacy program (Tricare for Life) covered CGMs. This also escapes any logic known to humans.
So I called my GP and explained the situation to them, and they assured me they would contact ES and resolve the problem. I left home and traveled about an hour north to where our son is building an ICF (Integrated Concrete Form) home to help him install temporary electrical service in the basement/ground floor of the building where they will live until the upper stories are completed. We went to Mineral Wells, TX, for a TexMex lunch, during which I received another RoboCall from ES. This time ES stated that they had not received any contact from my GP, and if they did not hear back by the end of the business day, they would unilaterally cancel the CGM script.
I went back to calling my GP’s office, where luckily, I got hold of the nurse who had been handling my requests previously. We reviewed all past conversations with her office, by now at least five, and again she assured me she would contact ES and resolve the matter and get back to me.
Get back to me she did with the news that the ES insurance would not cover CGMs for me. So here I am, a 100%+++ retired USN Naval Officer who served at the pleasure of the President of the United States and, while doing was subjected to Agent Orange and, as a result, is on Dialysis. They denied coverage for a CGM to aid in the exact diabetes that they, the US Government, were directly instrumental in subjected me to conditions where the probability of becoming diabetic was greatly exacerbated.
The “logic” of all of this escapes me. I’ll cool my jets and see what is under the next rock. Meanwhile, my GP will contact CVS to ascertain if they will accept Tricare coverage for CGMs for me. Stay tuned. I’m certain the saga will continue.
The purpose of this blog is to vent my frustration with the medical community and its support group, pharmacies.
Since late March, I have been trying to get a prescription for the Freestyle Libre 3 filled by the pharmacy required to be used by my insurance company, ExpressScripts. As you know from the lead to this blog, I am a retired Naval Officer and ExpressScripts (ES) is our “pharmacy.”
In good faith, my GP honored my request and sent a script in to ES. ES acknowledged receipt of the script, and within a day or so, my tracking app on my phone informed me that something called prior authorization was required, and they had contacted my prescribing MD. A couple of days later, the app informed me that all was good and they were “Working” on filling the script. Then I was informed that everything was canceled. I called ES and was informed that everything was on track and shipping would occur by 4/14/23. Then my app informed me that everything had been canceled. On 4/11/23, I again called ES and was informed that my GP had been faxed a “Critical Criteria” form to fill out and submit, and had not done so in the few days ES allocated, so the script had been unilaterally canceled by ES. Called the GP’s office, and of course, they had not received and/or were unaware of this Critical Criteria form.
The Libre3 lasts for but 14 days. Usually, a script for a year is prescribed for pills, with three months’ worth, or in this case, 6 Libre3 is delivered once every three months. Instead, my out-of-pocket would be every two weeks instead of the same cost for a three-month supply. Another screwup.
Another unsatisfactory situation with ES is their two-factor authentication process. They require a username and password to log in, then send back a six-digit number via email for the second authentication. Sounds good in theory, except the 15-minute timer on completing the second step often times out before receipt of the code. Regardless, who has time to stare at a screen waiting seemingly forever for a stupid code?
Yet another hindrance to goodwill is having to talk to a stupid computer when you call ES. Trying to bust out of the Ai’s scripting is daunting. I’m certain management is patting themselves for all the money they’re saving on CS calls, but they should get on the other end of the phone call and experience how frustrating it is when your call does not meet their canned expectations. Bummer!
As I write this, I await a call from the GP to resolve this dilemma.
Update. No callback. Called the GP script person again, and we agreed that she would send in a new script to ES for a year’s supply of Libre 3 every three months. That’s the latest. Stand by as the saga continues.
Yesterday afternoon at 1:34 PM CDT, I received a call from a 781-699-5405 number. Area code maps to Boston. A Google search on the number resulted in Fresenius numbers. Their corporate office in Waltham, MA, is 781-699-9000. The female voice on the other end of the call inquired about the “dialysis problems” I was having, and the thrust of her call seemed to be whether I could complete my nightly dialysis treatment. I attempted to fill her in on what has been happening, and her response was had I discussed the matter with my dialysis nurse?
This is insulting! I assured her I had discussed the matter with my entire team and anyone else who would stand still long enough for me to relate, including our Golden Retriever Dickens. She was disinterested in anything else, which was obvious when I attempted to explain my interfaces with tech support. All the call managed to do was piss me off!
How did someone from Corporate know that I have been having severe problems with drains on their Liberty Cycler – and I’m NOT the only one! While I have blogged about it, anyone with a slight amount of brain cells from reading the blog would know the full history of my drain problems. If corporate had troubled themselves to reach out to my local Fresenius facility (if they can find me, they could find them), they would have received an in-depth briefing. I have exchanged emails with corporate about the new cycler, and believe I included my contact info therein. Perhaps this is the source of the phone call?
Whatever it is, a phone call out of the blue from corporate that even hinted I have not been in close contact with my local Fresenius Dialysis Team on this, and ANY aspect of my treatment is an insult to both the people who support my treatment and me. I’m so close to the team, that they even know the color of the skivvies I wear.
On March 19, 2023, I wrote a blog titled “Impact of dialysis on marriage: Does dialysis correlate with divorce?”My research found at least five areas directly impact marriage+dialysis; 2. Emotional Impact and 5. Intimacy & sexual health. Anything we can do and/or embrace for improvements in these two areas should/could lead to a more optimum dialysis experience – without the expenditure of much time and/or money on our part in this instance.
-I recently read an interesting article by Dr. Cortney Warren “If you use any of these 9 phrases every day, ‘your relationship is more successful’ than most”Dr. Cortney S. Warren, PhD, is a board-certified psychologist and author of “Letting Go of Your Ex.” She specializes in marriages, love addiction, and breakups, and received her clinical training at Harvard Medical School. She has written almost 50 peer-reviewed journal articles and delivered more than 75 presentations on the psychology of relationships. Follow her on Twitter @DrCortneyWarren, according to the article which is linked here.
It is so important that readers of this blog can take on the full impact of Dr. Warren’s wisdom, that I am including verbatim the bulk of the text from the article for your edification. From here on in the blog is a direct quote from the article by Dr. Warren linked above. The lead graphic is also from the article for full attribution. These are the nine phrases to incorporate into your daily interfaces with your partner.
1. “I appreciate your effort.”
It’s tempting to become overly focused on things you don’t like about your partner and to point them out at every chance you get.
But it’s important to highlight the good in their actions. Happy couples express gratitude for each other’s efforts. It’s a great way to make everyone feel valued.
Similar phrases:
“I appreciate that you work so hard to support our family.”
“I’m grateful you take the kids to school because it helps me get things done in the morning.”
2. “I like you.”
The healthiest couples don’t just love each other, they like each other, too. Loving someone is an intense feeling of affection; liking is about seeing them for who they are and acknowledging the attributes you enjoy about them.
Similar phrases:
“I like that you are so passionate about staying healthy.”
“I like how devoted you are to your hobbies.”
3. “Help me better understand this.”
We all have different upbringings, vulnerabilities, values, and beliefs that shape how we think relationships should work.
If your partner reacts to a situation in a way you don’t understand, telling them that you want to know them better is key to resolving conflict and bonding at a deeper level.
Similar phrases:
“I don’t know why this is so upsetting to you. Please help me see your perspective.”
“I want to work through this together, and I need to understand you better to do that.”
4. “I’m listening…”
Disagreements are inevitable, but it’s important to still support each other through active listening.
You have to be willing to suspend your desire to be “right” or to get your point across — long enough to hear and empathize with your partner’s perspective.
Similar phrases:
“I’ll stop talking now and really try to listen to your point of view.”
“I want to hear your side of things, even if we ultimately disagree.”
5. “I’m sorry.”
When things don’t go right or as planned, healthy couples know that both partners play a part in the situation.
Taking responsibility for our role in those conflicts — and genuinely apologizing — is critical to repairing rifts.
Similar phrases:
“I didn’t communicate my feelings in a respectful way to you, and I’m sorry for that.”
“I didn’t like the way you acted last night, but I also need to apologize for lashing out.”
6. “I forgive you. Can you forgive me?”
Forgiveness is hard. It requires being vulnerable, letting go of something that caused you pain, and changing your feelings toward your partner.
But studies have shown that couples who practice forgiveness are more likely to enjoy longer, more satisfying relationships.
Similar phrases:
“I know we can’t change the past, so I’m actively trying to let it go and move forward.”
“I made a mistake and I’m trying to forgive myself. I hope you can forgive me, too.”
7. “I am committed to you.”
Being in a relationship is a choice. Reassuring your partner that you’re still choosing to be with them and to work through challenges will help create a sense of safety and stability.
Similar phrases:
“Even when times are tough, I still choose to be with you.”
“I’m here, and I want to make this work with you. We’re a team.”
8. “Let’s have some fun!”
If you can find humor (or playfully tease each other) during tense moments, your relationship might be stronger than you think.
The happiest couples are able to break tension and recalibrate the mood by finding room for an authentic smile, silly banter or a lighthearted joke.
Similar phrases:
“We should get some fresh air. Want to do something fun today?”
“I know I’m a lot sometimes. Let’s take a breather from the tough topics and watch a comedy.”
9. “I love you.”
This one is simple but always worth reminding. Verbally expressing your romantic love for one another keeps the relationship alive. And when you say it, make sure you truly mean it.
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.
