I’m a happy camper. Last night no alarms again with the new Cycler! Pulled 1300mL on ultrafiltration. To those not familiar with dialysis, the amount of fluid that the cycler pulls out over what it puts in is called ultrafiltration and is the result of fluids you inputted prior to dialysis. 1.3 liter is a healthy amount to pull out. My weight this morning reflected the increased filtration coming in at 145 pounds of mean and lean maleness.
Another good thing happened yesterday: FedEx showed up and removed my old cycler for return. Yea on this!
Received a call from the doctor’s office that installed my catheter after a referral from my nephrologist to check out potential blockage in my catheter system. Supposed to call back later yesterday afternoon and did not so I’m hanging on this aspect. Always seems to be something hanging.
My wife and I have been planning our six-day trip back to visit her sisters in Indiana, a two-day each-way journey of about 1000 miles. We have decided to put the required bulk items for each dialysis in individual boxes to include: one 5000mL, one 3000mL, a cassette, and a stay.safe plug. In another “carry-on” will be all the other required safety and aseptic supplies required for dialysis. We will also load some drain bags in case the 20-foot drain line on the standard cassette won’t reach a drain in the motel, and an extension cord for power.
Speaking of power, I was browsing through the new cycler manual and saw the power requirements as being 480 watts at 100 volts. Using Watts=voltage times amps, we derive 480/100 = 4.8 amps max the cycler draws. Based on this and lots of other calculations, you would need five 200 Ah batteries which are large and expensive to run a cycler for up to 12 hours. Much better to consider a low-noise Honda 1000 generator instead. They can be converted to run on propane and with the appropriately-sized propane tank, should be capable of lasting an entire dialysis session.
Sunday night’s dialysis was different from any other. Around midnight, the cycler gave out an alarm notification sound and then shut itself off. Almost as to say “Sorry about that.” It was on the first drain cycle at about 1381mL accomplished. I noted this, rolled over and slept in until 0855 Monday morning. I have reported this to my Dialysis Nurse and she has sent in a referral for me to see the surgeon that installed my catheter, Dr. Tan in Forth Worth, TX.
In yesterday’s blog, I posted about my Dialysis Nurse suggesting I may be experiencing a phenomenon in peritoneal dialysis called “Omental Wrap.” This is new to me so I queried a new-to-me AI source called Poe (poe.com) with the following edification results:
Poe Prompt: What is an omental wrap as pertains to slow drainage in peritoneal dialysis patients?
The term “omental wrap” refers to a complication that can occur in peritoneal dialysis (PD) patients, leading to slow or inadequate drainage of dialysis fluid. To understand omental wrap, let’s first briefly review peritoneal dialysis.
Peritoneal dialysis is a renal replacement therapy that involves using the peritoneal membrane, a thin lining that covers the abdominal organs, as a natural filter for waste products and excess fluid in the body. During PD, a sterile dialysis solution is introduced into the peritoneal cavity through a catheter. The peritoneal membrane allows waste products and excess fluid to pass from the bloodstream into the dialysis solution. After a certain dwell time, the fluid is drained out, carrying the waste products with it.
In some cases, the omentum, which is a fold of fatty tissue attached to the stomach and covering the intestines, can wrap around the catheter or form adhesions in the peritoneal cavity. This can hinder the proper flow and drainage of dialysis fluid during the exchange process. The omental tissue can become entangled with the catheter or form scar tissue, creating a physical barrier that impedes the movement of fluid.
When omental wrap occurs, it can result in slower or incomplete drainage of dialysis fluid. This can lead to inadequate dialysis, as the waste products and excess fluid may not be effectively removed from the body. The symptoms may include abdominal pain, bloating, and reduced ultrafiltration (the removal of excess fluid).
An omental wrap is typically managed by adjusting the peritoneal dialysis technique or by performing surgical interventions. The specific approach depends on the severity of the omental wrap and the patient’s individual circumstances. In some cases, the catheter may need to be repositioned or replaced to improve fluid flow. Surgical procedures, such as omentectomy (removal of the omentum) or adhesiolysis (separation of scar tissue), may be required in more severe cases.
It’s important for PD patients experiencing slow drainage or other complications to consult with their healthcare team. They can assess the situation, perform necessary investigations, and recommend appropriate interventions to address omental wrap or other issues affecting peritoneal dialysis efficiency.
Poe Prompt: What are some common symptoms of omental wrap in peritoneal dialysis patients?
Omental wrap in peritoneal dialysis patients can present with various symptoms. Some common symptoms associated with omental wrap include:
Slow or inadequate drainage: Omental wrap can impede the proper flow and drainage of dialysis fluid during exchanges. This can result in slower or incomplete drainage, leading to longer dwell times and inadequate removal of waste products and excess fluid.
Abdominal pain or discomfort: Patients may experience abdominal pain, cramping, or discomfort. The pain can range from mild to severe and may be localized around the catheter exit site or diffuse throughout the abdomen.
Bloating and distension: Omental wrap can cause abdominal bloating and distension due to the accumulation of dialysis fluid in the peritoneal cavity. This can lead to a feeling of fullness and tightness in the abdomen.
Reduced ultrafiltration: Ultrafiltration refers to the removal of excess fluid during peritoneal dialysis. An omental wrap can interfere with fluid removal, causing reduced ultrafiltration. This can result in fluid retention, edema (swelling), and weight gain.
Catheter malfunction or poor dialysis efficiency: Omental wrap can affect the function of the catheter used for peritoneal dialysis. Patients may experience catheter-related issues such as kinking, clogging, or poor dialysis efficiency. These problems can further contribute to inadequate waste product clearance and fluid removal.
It’s important to note that these symptoms can also be associated with other complications or conditions in peritoneal dialysis patients. If you are experiencing any of these symptoms, it’s crucial to consult with your healthcare team for proper evaluation, diagnosis, and management. They will be able to assess your specific situation and recommend appropriate interventions to address the underlying cause.
Last Thursday at 1303 FedEx delivered a new/replacement cycler. The replacement is running software version 3.0.03 062; my old cycler was running 2.9.2 062 so we’re on a much newer software version.
So how’s it going so far? The first night, Thursday, no alarms. The second night Friday, slow drain alarms on the first and second drains happening at approximately 1281 and 800+ mL of the accomplished drain. In preparation for Saturday night, I rerouted my patient line so it goes straight across my stomach and to the cycler without any loops being taped to my stomach. No alarms.
I have informed my Dialysis Nurse of the status and inquired about switching to “Treatment Based” as the new manual suggests on page 60. This is still an open item. In order of action, we are going to keep watching alarms given only one night of no alarms with patient line rerouting. We are going to make sure I’m clear of any stool blockage. I may be referred to the doctor who installed my catheter to see if there are any other internal issues blocking the tip of the catheter called “Omental Wrap.” All of this may culminate in a laparoscopic procedure (keyhole surgery) where the surgeon enters my stomach and looks around to ascertain if all is in order.
In the middle of all of this, I was informed initially by Fresenius that the old cycler would be picked up by FedEx on Tuesday, 8/21/2023. Upon receipt of the new cycler, it DID NOT have return labels in the plastic envelope that it was supposed to. This necessitated a call to Fresenius where NOW the FedEx driver is supposed to pick up the old cycler Monday, 8/20/2023, and have a return label with him/her. Seems that Fresenius has a really hard time getting all their ducks in a line!
As I write Friday’s blog it is approaching noon on Thursday and no replacement cycler has arrived nor have we been contacted by anyone from Fresenius. However, I did manage to achieve other housekeeping chores.
We have been trying to move a brokerage account to our main Schwab account with difficulty. Lots of t’s to cross etc. This morning I journeyed to UPS to send a copy of the monthly statement from the account we desire to close to a Schwab rep to process.
The second gate was the delivery of our golf cart. We bought a refurbed 2019 Club Car to putt around Pecan Plantation. Upon testing on our dead-end street, it crapped out and was trailed back to the dealer. Troubleshooting found that a main electrical connection between the battery and generator had battery acid on it and the interior wire had corroded and opened. This prevented charging the battery and supplying power while the engine attempted to run. The wire was replaced as was the battery. We did another test run with good results.
Yesterday was the supply order date for me to order supplies from Fresenius which I did. We will be in Indiana on vacation on the scheduled delivery date at the end of September so I called support and worked with them for an alternative date. We came up with delivery the first week in October so that’s taken care of.
I also made a call to Fresenius customer service to inquire about cassettes with shorter hookup lines. I had previously read that you could order one with a 10-foot instead of a 20-foot catheter line. My thinking is maybe this will help alleviate the drain alarms I have been plagued with for almost a year. I was informed that the cassette with the 10-foot catheter line only comes with a 10-foot drain line which won’t work for me; I need a 20-foot drain line to reach our master bath shower drain. I was also informed that to receive such a cassette my “prescription” had to be altered by my Dialysis Nurse. I could not just order one on my own. The shorter cassettes do not show up in the Fresenius Patient Portal FYI.
In closing, nada concerning the new cycler delivery supposedly scheduled for today.
Called Fresenius “Tech Support” again Monday AM. Seems like my Cycler is going downhill. In the last seven days, I have experienced 13 alarms on the drain cycle. It seems to be developing a pattern of sorts where it drains 12-1400 mL of “distillate”, then hangs. The time on dialysis reflects this in that instead of 10 hours 30 +/- minutes, it jumps up to over eleven hours.
For the record, the support person, after asking expected questions like the cycler’s serial number and software version, was interested in where the system drains (straight into a shower drain), how long a run this is, had the drain line been modified, the data off the cassette (lot #, etc.), and “how long has this been going on? When I responded at least six months it got her attention and even more when I explained my dialysis team and I had exhausted all other possibilities other than the cycler itself and were in unanimous agreement I needed a new cycler.
I’m supposed to receive a phone call that a new unit is en route (haven’t) and receive it within 24 hours. Not holding my breath but praying!
One of the first phrases I learned in Vietnamese language school before going In-Country was một lần nữa, meaning one more time. It just kinda rolls off the tongue when speaking Vietnamese. In the military, you learn to do lots of things, One More Time. So it is with alarms on my company-issue Liberty Cycler.
Last Wednesday night on the first main drain cycle the cycler hung up and essentially at every “pump” drained only 1 or 2 mL of fluid instead of the normal 12 to 13 mL. I called “tech support” and after over half an hour on the phone, it was agreed that my case would be “escalated.” What this means, in reality, is that a faceless, clueless, and heartless representative of Fresenius would contact my clinic dialysis nurse and deny me cycler replacement. This is exactly what happened. The excuse was that I had not been faithfully calling tech support every time I received alarms and thus they could not justify replacement. Nothing was said nor has it ever been regarding just how many times something like alarms have to be reported before action is taken.
Along the way, Fresenius always comes back to everything which does not include their cycler as being at fault. This incident included questions as to whether my catheter was properly placed and operational/not blocked. Responding to the blocked aspect, the cycler always fills well, and recently I had a manual drain test conducted by my Fresenius team with no abnormalities detected.
So, in consort with my dialysis nurse, we scheduled a xray exam to look inside to see if anything is untoward in my stomach with my catheter system. The full report is below: I’m good so my strategy is to report every burp of the cycler’s drain problems until someone smells the coffee or I die from sleep deprivation.
Exam AR Acute Abdomen Series 08/10/2023
History: Poorly draining PD Catheter
Technique: 5 views of the lumbosacral spine
Comparison: None
Findings: There is moderate curvature of the lumbar spine with convex to the right. Moderate degenerative changes lower thoracic and lumbar spine.
No fractures of dislocation. Large amount of formed stool is seen within the right colon. Curvilinear tube overlying left lower quadrant of the abdomen. There is a larger bore catheter identified with the distal tip overlying the mid aspect of the lumbar spine at the L4 level on the AP view and overlying the area of the LS level on the lateral view.. CT may be more helpful.
Moderate degenerative changes lumbar spine. Mild to moderate degenerative changes of the hip joints bilaterally.
Moderate vascular calcifications of the abdominal aorta and iliac vessels.
Impression:
There is mild to moderate curvature of the lumbar spine with mixed the right.
2. There is a curvilinear catheter seen overlying the left lower quadrant of the abdomen. There is a larger bore catheter is seen overlying the lower mid abdomen. CT may be more helpful for placement if no drainage..
3. There is a moderate to large amount of degenerative changes lumbar spine.
4. Significant amount of stool is seen within the right colon.
For the last five monthly labs, my Hemoglobin readings have exceeded the upper limit of 11 with readings of 11.6, 12.2, 11.4, 12.9, and the last reading of 11.4. My brother-in-law Jerry is currently in the hospital with a reading of 6.0 and is receiving blood transfusions to help alleviate his shortfall. This value indicates the amount of red blood cells in my body. These cells contain iron and carry oxygen from my lungs to the rest of my body. My O2 readings which I take every morning or always 98 or 99.
For most of my life, I have engaged in one form or other of exercise. While in the US Navy, I was required to maintain a high level of physical fitness as “part of my job.” To do this, I ran in 5k, 10k, and 15k races just about every weekend for the better part of four years.
After retirement, I ran in a couple of marathons organized around the Indianapolis 500 race, joined a fitness club to stay in shape to race my Porsche (I did quite well BTW), and even after triple bypass surgery hired a personal trainer for years to continue to work with me on my personal fitness. I’m still, even with dialysis, not a couch potato and can hold my own.
According to several web references, The typical female athlete tested in 2019 had a hemoglobin of 13.6, while the male athlete has an average hemoglobin level of 14.7. Both are well above the levels of anemia and fall into, what is termed, the “optimal” athlete range.
I posit that my higher levels ARE NOT a problem, nor have they been flagged as such by my Dialysis Team, but are a holdover from my more athletic endeavors. Comments?
This falls into the category of “It happened to me and it could happen to you!” So what is this “happening?”
The last time I applied a new Libre 3 sender to the underside of my upper arm, it bleed like a stuck pig, however stuck pigs bleed. It WAS somewhat profusely and went through my sweatshirt and elicited from my wife “What is that?” in an alarming fashion. I knew I was in trouble – again, but NOT WHAT FOR. Keep in mind I have been using the Libre 3 without any such occurrence for months and months.
We cleaned up my underarm area with alcohol swabs but left the expensive new sensor in place. I did not bleed anymore and it has been in place and operating normally ever since.
If it happened to me, it can happen to you also…… Be forewarned.
Glucose control isn’t just a buzzword for those on Peritoneal Dialysis (PD); it’s a vital aspect of managing overall health and wellness. For individuals depending on PD, maintaining the right balance of glucose is about more than just avoiding highs and lows—it plays a critical role in preventing complications and ensuring the effectiveness of the dialysis treatment itself. Thus, anything that aids and abets control is a matter of interest to those of us on PD, especially those who are also diabetic. That includes me.
TIR, or Time in Range, recently has come to the forefront in diabetic care and control. Hayden E. Klein writing in the August 3, 2023 edition of AJMC in an article titled “Why Time in Range Matters for Diabetes Care Beyond A1c” found essentially universal support for the use of CGMs (Continuous Glucose Monitors) to monitor TIR.
The American Diabetes Association (Link here) suggests “The time in range method works with your CGM’s data by looking at the amount of time your blood glucose has been in target range and the times you’ve been high (hyperglycemia) or low (hypoglycemia). Time in range is often depicted as a bar graph showing the percentage of time over a specific amount of time when your blood glucose was low, in range, and high. This data is helpful in finding out which types of foods and what activity level causes your blood glucose to rise and fall.
Most people with type 1 and type 2 diabetes should aim for a time in range of at least 70 percent of readings—meaning 70 percent of readings, you should aim for roughly 17 out of 24 hours each day to be in range (not high or low),”
So what does this look like in real life? Using my Samsung S23 Ultra phone and the Libre 3 app I captured the screen of the CGMS’s home screen showing the preset upper and lower glucose readings (the shaded area around the actual glucose reading line), and after hitting the three bars in the upper left corner and under “Reports” selecting “Time in Ranges” obtained the second graphics.
The first graph with a glucose reading of 131 is about 1 1/2 hr after lunch and is accepted as good. All of my glucose readings for the last 24 hours have been within the set limits. The second graph shows for the last seven days 95% of the time I have been within limits. There is no reason this couldn’t be 100% so I have work to do.
The last graph is included just to give the world an idea of what the weather is like here in the Dallas-Fort Worth area where we live. Pecan Plantation is actually some 40 or so miles SW of DFW.
Sorry to have to report that the modified methodology I am using to close the cover on the Cassette for my Fresenius Liberty Cycler IS NOT precluding alarms. Last Thursday night I have alarms on both the first and second drain cycles so it’s back to the drawing board for me.
I have constructed a table shown below of my August 2 lab results. Below the table are comments about its contents.
What
Aug 2, 2023
Range
For what
Albumin
3.4
=>4.0
Protein in blood
nPCR
0.97
=>1.2
Enough protein
Potassium
4.6
3.5-5.5
Heart & muscles
wKt/V
1.86
=> 2.0
Enough dialysis
Calcium
8.8
8.5-10
Bones & muscles
Phosphorus
5.3
3.0-5.5
Bones & heart
Hemoglobin
11.4
10-11
Red blood cells
Glucose
121
70-160
Energy for cells
Creatinine
7.5
Low
Impacts eGFR
Lab Readings 2 August 2023
From the table above, the big three that my nephrologist keeps on top of, K, Ca, and P (Potassium, Calcium, and Phosphorus) are all within specs, a good thing. I’ll take these readings as a win.
Albumin is always low, along with nPCR. I am working on eating more red meat but that also has the downside of increasing P so I have an additional P-Binder to take with my steak.
The wKt/V reading indicates my dialysis treatment is not quite up to where it should be but higher than what would trigger action.
My glucose reading of 121 is very acceptable in that I had breakfast some one hour before the blood draw for the labs. I’ll take this reading all day every day.
Lastly, for some reason, my Creatinine reading fell almost one full point from last month. Plugging 7.5 into my eGFR app yields an eGFR of 7 for the record. All else being equal, the creatinine test is a measure of how well kidneys are performing their job of filtering waste from the blood. So from this perspective, the drop is a good thing indicating my kidneys are still trying to function. I am also still making urine but not nearly as much as when I drank lots of beer.
