Saturday, June 28, 2014

Do's and Don'ts of Dialysis Patients

Fluid Intake:

     The first thing that a dialysis patient should not do is to drink too much water especially when his/her urine output is low or very low because this could cause edema (swelling) of the legs and other body parts. The worst that a dialysis patient can get from drinking too much water is pulmonary edema wherein water could enter the lung cavity resulting to difficulty in breathing and high blood pressure. If the situation becomes serious the lung could not anymore function properly and the last resort for the doctor is intubation (putting a tube in the trachea of the patient to facilitate breathing with the help of a manual/mechanical pump). Too much water volume of the blood strain the heart as it tries to pump the excess water and it could result to enlargement of the heart or heart failure. The question is how much water is too much? For dialysis patients with low or very low urine output they should drink not more than one liter per day or preferably less.
     To avoid drinking too much water, the dialysis patient should try licking small ice stick to quench his/her thirst. Water molecules in ice have already expanded and less water is contained in a certain volume compared to its liquid state. The dialysis patients should also avoid eating watery fruits like water melon, mango, banana, avocado, pineapple, oranges and papaya. The water content in these fruits is high and could contribute to the increase in the water intake of the patient. Eating too much cooked rice also contain high amount of water. The dialysis patient should sip small amount of water from the glass or mug and he/she should avoid frequent drinking of coffee or soft drinks. The patient should avoid salty foods as salt could cause water retention and will aggravate edema. The patient should avoid sipping too much soup as this may contain too much salt and water. The dialysis patient should eat fruit with less water content like apple. The patient should regularly monitor his/her blood pressure as well as his/her blood sodium. Low blood sodium value result to low blood pressure and prone to painful cramps. High blood sodium value result to high blood pressure because of constriction of the blood vessels that could strain the heart resulting to either stroke, coma and death. 
High Phosphorous Toxicity:

     The second thing that a dialysis patient should watch for is Phosphorous. This mineral is found in almost all the foods that we eat and too much phosphorous in the body of the patient is dangerous because it is very toxic and could cause weakening of the bones or osteoporosis. Phosphorous may also deplete the amount of Calcium in the blood. Phosphorous binds with Calcium in the body that forms abrasive calcium phosphate crystals which finds its way in the skin causing it to itch and rupture with constant scratching. Cracks in the skin could be infected causing Cellulitis (painful infection of the skin and if left untreated it becomes life threatening as it may reach the bloodstream) which is treated with strong anti-biotics that could harm the liver. Always remember that it is the liver that replaces the function of the kidneys in breaking down and excreting harmful chemicals. Calcium phosphate crystals are also deposited between soft tissues and joints causing pain and weakness. Calcification of organs such as the heart leads to heart disease and eventual death of the patient. To control Phosphorous, the dialysis patient should take at most 1,500 mg of calcium carbonate per day depending on how high is your phosphorous level. These can be taken either before, during and after eating. Calcium binds with Phosphorous in eaten foods in the digestive tract and excreted together with the stool. The other effective Phosphate binder is Sevelamer which is expensive (P80-P100 per tablet). This acts as a sponge and absorb the phosphorous in food in the stomach and also excreted with the stool. This tablet can be taken either before, during and after meals; but not more than 30 minutes after eating. The patient should monitor his/her serum or blood Calcium and Phosphorous level. Too much Calcium in the blood causes kidney stones or harmful deposits in the heart and artery. The patient should also avoid foods rich in Phosphorous like dairy product, chocolate, beans and nuts. Red meats are also rich in Phosphorous.

Hyper - Kalemia or High Serum Potassium:

     The third important element that a dialysis patient should watch for is Potassium. Too much Potassium in the blood is also dangerous because it could stop the beating of the heart causing heart attack and possible death of the patient. Potassium Chloride is used in jail inmates with death sentence to execute and kill them. Overdose of Potassium is less painful compared to electric execution. Foods rich in Potassium are: banana, avocado, papaya, mango, pineapple, oranges, potato, tomato, squash and other green leafy vegetables. The dialysis patient could eat small amounts of these foods only but not on a regular basis as Potassium could accumulate in the blood before dialysis. Patients who suffered Myocardial Infarction or heart attack (injury of heart muscle due to lack of oxygen) have high Potassium level in the blood and should undergo regular dialysis. Foods rich in Potassium supplements such as catsup should also be avoided.

Cholesterol level:

    The dialysis patient should properly choose the fat he/she eats. Foods rich in cholesterol and uric acid should be avoided such as: fatty meats like pork, beef and chicken skin. Processed coconut oil and other vegetable oil are also rich in cholesterol. Cholesterol is deposited in the arteries and veins causing blockage which result to high blood pressure, stroke and heart attack. Fats that are allowed are corn oil, canola oil, and olive oil. They are rich in omega fatty acid which is good for the heart. As the usual practice, patients should consume only small amount of the cholesterol rich oils found in foods such as fried vegetables and fish but should avoid eating, potato fries, milk shakes and ice cream for they contain more harmful fats per serving. The patient should monitor on a regular basis his/her cholesterol level or triglycerides so he/she can take the proper medicine if the level is high. 

Blood Uric Acid (BUA):

Dialysis patient should avoid eating too much of fish with no scales such as tuna and animal organs because it contains high amount of uric acid. Uric acid causes gout and arthritis and helps in the formation of hard kidney stones. The derivative of uric acid which is purine is rich in animal organs, some type of fish,  bean and nuts, some green leafy vegetables and fruits.

Uremia or too much toxic wastes in the blood:

     The dialysis patient should eat moderate amount of red meat such as pork and beef. Eating too much animal protein could lead to uremia (high level of nitrogenous waste in the blood) which if left untreated will lead to confusion, convulsion, excessive vomiting, coma and even death.

Monthly Laboratory Tests: 

     One of the most important routine or practice that a dialysis patient should do is to check his blood count especially the hemoglobin for it indicates if the patient should be transfused with blood or not. Almost all of dialysis patients are anemic and have below normal level of hemoglobin. This is because it is the normal kidney that produces erythropoietin (helps in the production of hemoglobin in the blood). Once the kidneys are damaged, production of erythropoietin is affected and the same is true for hemoglobin and the red blood cells, thus causing anemia. To maintain acceptable values of hemoglobin, the dialysis patient should inject synthetic erythropoietin alpha or beta two to three times per week at hemoglobin value of ten or below while only once or twice a week for hemoglobin value of more than 10 but not to exceed 12. If the hemoglobin is high, 13 and above, the patient is at risk of having a stroke because erythropoietin has a tendency to thicken the blood. The patient should stop injecting erythropoietin. Optimum hemoglobin value is at 11. For erythropoietin to be effective, the patient should take organic iron supplements. Iron and hemoglobin help in the distribution of oxygen in cells and tissues. Regular monthly or bi-weekly monitoring of the hemoglobin is very important to prevent the patient having blood transfusion which increases his/her risk of acquiring hepatitis infection. Patient infected with hepatitis is not anymore accepted in some dialysis centers/clinics with no isolated machine for hepatitis patients. Also, patients with very low hemoglobin cannot be dialyzed since he/she can strain his/her heart and may die while dialyzing. Patients should check their iron in their blood every three months.

The Dialysis Access:

     The dialysis access (it is where the dialysis needles are inserted or connected) of the patient is very important since it is the connection of the patient and the dialysis machine. Without the access, there is no way for the patient to be dialyzed and he/she is in danger of becoming uremic and will die if his/her blood is not cleaned. New dialysis patients have their access either on the neck, wrist or thigh. Few patients have a functioning fistula (artery and vein joined together to make the vein large enough for needle insertion) before the onset of dialysis. Proper care of the dialysis access is very important to prevent infection which could lead to sepsis (severe infection of the blood). This is done by regular cleaning using povidine iodine (Betadine) solution and anti-biotic ointment. Symptoms of infected access are shivering (feeling very cold) and fever during dialysis. The fistula that is infected with cellulitis means it can not be used during dialysis such that a new emergency dialysis access should be inserted either in the neck or thigh.

Heart Care: 

   Dialysis patients should also take care of their heart by having chest x_ray and 2D Echo- cardiogram once in a while or when you feel pain or something not ordinary in your chest or experiencing difficulty in breathing. In dialysis, it is the heart that always compensates when you have low hemoglobin and RBC, high blood pressure, too much fluid in the blood or lungs, fast flow rate of the dialysis machine and when too much fluid is taken from your body and you are already dehydrated. The patient should feel if his/her heart is already stressed and should tell the nurse to lower the blood flow rate of the dialysis machine or lower the set goal of fluid to be taken. The most important is for the patient to discipline himself/herself to avoid drinking too much fluid and eating the right foods in their allowed quantity.

Prevention of infection:

      Dialysis patients usually have a compromised immune system or they are prone to infections like pneumonia. When the patient has a persistent cough with yellow phlegm for two to three weeks, this is a sign that he/she has a lung infection and should have an x-ray to confirm the diagnosis. Early detection and treatment is ideal to prevent complications such as sepsis (an infection of the blood). A monthly Complete Blood Count (CBC) or urinalysis will also help in the early diagnosis of infection(s). To prevent lung infection, the patient should wear a face mask while in the dialysis room especially if in-patients and out-patients have their dialysis at the same time (big hospitals have separate dialysis rooms for in-patients and out-patients). Wearing a face mask while in dialysis is important since some virus and bacteria is present in the air or they are lodged in air-con filters and dislodged into the air later. In-patients are also exposed to hospital acquired infections that are already immune to some anti-biotics and are difficult to treat. The patient should also wear a face mask if he/she is with many people like movie-houses, mall and other gatherings.

Important Remarks:

     The dialysis patient should develop his/her discipline of the mind and body by proper and regular (but not strenuous) exercises such as stretching, bending and brisk walking. This enhances proper disposition and keep the body healthy (with sufficient dialysis of two or more dialysis sessions per week). The patient should also grow in spirit to enhance awareness and acceptance and make him/her always hopeful that there is still life during dialysis. He/she should firmly believe that with God nothing is impossible and he will be cured of his disease. Of course this should be done with less expectations. With proper discipline the dialysis patient should realize that following his/her diet is not difficult if he/she believes that one should eat to live and not live to eat.


Friday, June 20, 2014

Political Will

Political Will

       I laud the effort of the government and the private sector to clean up the “esteros” or waterways of Metro Manila including the Pasig River. This is not an easy task considering the manpower and logistics requirement of the project. But the most important part of this clean up drive is the relocation of squatters along the waterways. It is the squatters along these waterways who throw their garbage and dirt such that any clean up drive would be futile if they are allowed to stay. I know there are laws about the construction of residential structures near the waterways to ensure accessibility, flood control, sanitation and safety of the people residing in the area. Maintenance of these waterways is part of the Urban plan. The question is why did the government allowed these squatters to start living in these critical areas? There should have been a strong effort in the part of the administration to clear up the initial squatters so other squatters who plan to construct houses along the waterways would have been discouraged. Allowing them could not have been for humanitarian purposes because the squatters are in danger of being washed out by floods. Could it be that the government officials are too busy implementing “priority” projects that they have overlooked the importance of clearing squatters along the waterways from the start? Were the squatters allowed because the politicians are aware that these squatters could also be used for political means because they can easily be swayed and manipulated during elections, rallies and “other” purposes? The laws are in place but it seems that the government lacks the political will to properly implement these enacted laws. If only city / municipal ordinances and policies are strictly executed consistently for many years, this mess could have been avoided. The people sense these laxity in implementing rules and penalties such that they easily become violators themselves. Other people imitate the wrong practices until it becomes habitual. Why are Filipinos working abroad don’t throw their garbage anywhere? It is because they avoid being fined by the authorities who implement the laws strictly and they have seen that it has been the norm of the people to properly dispose of their garbage.
     It needs political will to get rid of the malpractices such as: “kumpadre” system, “I’ll scratch your back and you scratch mine”, “It is whom you know and not what you know”, “Kotong”, “extortion”, “any kind of fixing in government agencies”, “orchestrated corruption in government agencies” and so on. It needs unblemished integrity and rock solid commitment with unwavering passion on the part of the president and his cabinet members and their staff to reshape the values believed by the people as reflected by the current system. This is a big task but not impossible to achieve as shown by the on-going trial on the PDAF scam which is an example of the small steps taken by the government leading to this purpose. But this effort will again be hampered by the change of administration in 2016. This is a wait and see situation on who will win the election. If in case the candidate of the opposition wins then another set of priorities will be formulated and scrapping of projects or initiatives started by the past administration is expected. Even if the candidate of the present administration wins, we cannot be sure if he will continue what has been started. How many years have passed by since the formation of the first commonwealth and it seems that our system is still running in circles. The poor remains poor and their number is increasing, health care is still struggling, the educational system especially in elementary and high school are still DDUs (Depressed, Deprived and Underserved), college education is almost only for the moneyed, jobs are not sufficient to accommodate new graduates, general services needs improvement. Priority on these areas is not so much compared to projects on priority areas such as: construction of big national and provincial roads, mining, logging, airports, piers, commercial buildings, communication facilities, factories, condominiums, malls and hotels. All of these priority projects are geared towards enhancing or supporting the economy which suits the needs of the multi-nationals and local businessmen. A positive increase in the Gross Domestic Product (GDP) is an indication of “good weather” for investors. Businessmen rakes in big profits while only small amounts of the fruits of economic development trickle down to the masses.

     A system whether it is political or economic will continue to survive if all its components are properly maintained. Sectors that are not well taken care of will reach a critical level sooner or later and God forbids that the equilibrium will be breached.


Thursday, June 19, 2014

Hope With All your Heart And Soul


 I once came across a shared line in Facebook which read like this: "Hope but don't expect". At first I found it hard to fully comprehend the meaning of this because how can you hope for something without expecting it to come true. Even others say that when you pray for something, you should consider it done. A 100 percent expectation. Later on after repeatedly thinking on this I realized that hoping without expecting too much is possible. Hope is like faith which is believing without seeing, hearing and touching. You believe and trust in it. Hope is like a spring that never runs out of pure water. It is hope that motivates a person to keep moving on. They say that we should not lose hope while we are still alive. Persons hope for many things, to mention some: "I hope that you will be a good guy"; "I hope that peace will reign in our country"; "I hope corruption in the government will cease". If you have huge expectations that these will happen and it did not, then somehow you will be hurt. It is the failed expectations that cause broken marriages, broken relationship with a son or a daughter or a friend. It may even be the cause of wars and political misunderstanding. It is the cause of disagreement between a father and his son if he expects his son to be a doctor and unfortunately the son is not inclined to studying medicine and he pursues fine arts instead thereby disappointing his father. This leads to frustration when a father expects his son to follow his footsteps in military training but finding later on that his son is gay and interested in fashion instead. It is heart breaking when you expect your best friend to be with you even in the worst times but left you to protect his personal interest. It is degrading for a father who is well respected in the community such that he has high expectations for his family to be God fearing and with high moral values but only to find out one day that her daughter is pregnant and her boyfriend left her for another girl. There are many more examples, I could only mention a few.
     For me, I do not stop hoping. Day by day I hope and visualize that I will be cured of my disease. I am hoping that my kidney cells will regenerate and the normal function of my kidneys will be restored. In my case my kidney disease is already in end stage and what I hope for seems impossible to come true but I will continue to hope. Nothing is impossible with God! There are many things that I hope for but I am not expecting too much. If it will not be granted then fine with me.
     I am not a regular viewer of "telenovela" but  this can happen or is happening to some men and women. What I am talking about is the just concluded television series "The Legal Wife". Because of Monica's high expectations for her husband Adrian, she was deeply hurt when she found him having an affair with another woman who even got pregnant. Monica cannot forgive and accept back her husband because he did not live up to her expectations. Does this indicate that she only married Adrian because she saw in him that he is faithful and will give his whole life to him? Did she overlooked that Adrian is also human who is also prone to commit mistakes? If this is true then it can be deduced that she only love the good traits of Adrian and not his whole self. Her love is very conditional: "I love you only if you are..."; but when you love without too much expectations, you will not get frustrated or depressed. You can only hope with your whole heart and soul and forgive or smile when things don't come out as you expected it to be!


Wednesday, June 4, 2014

Understanding Hemo-dialysis

      As the days, months and years pass by I gradually witness the unfolding of the realities and processes of hemo-dialysis. Now I know that the word dialysis came from the greek words: "dialusis" which means dissolution, "dia" meaning through, and "lysis" means loosening or splitting. Dialysis is done to patients with either acute, chronic and end-stage renal or kidney failure to remove excess nitrogenous waste, mineral salts and water. There are mainly two types of dialysis: the hemo (blood) dialysis and the peritoneal (abdominal cavity) dialysis. Hemo-dialysis involves a dialysis machine and is recommended to patients with considerably healthy heart and liver while those with ailing heart, peritoneal dialysis is advised. With my almost three years of experience, I come to understand how the dialysis machine works and how it affects my body. The dialysis machine is a wonderful piece of machinery originally designed by Dr. Willem Kolff, a Dutch physician in 1943. Through the years with constant researches, tests and adjustments it evolved into state of the art machinery which is safer and really suits the need of dialysis patients.
      Before a patient undergoes dialysis, the bloodline (long tube where blood flows) and dialyzer (this is the filter where the blood passes through and cleaned while in contact with the dialysate or dializing solution) are primed with Normal Saline Solution (NSS) or suero in Tagalog to clean and make it sure that it passes the conditions that are set by the machine. Then while priming, the patient is prepared by sitting him/her on a "lazy boy chair" or laid comfortably on a cushioned bed whichever his/her choice. The nurse take the blood pressure of the patient to determine if dialysis will push through or not (patients with very high or low blood pressure cannot be dialyzed until his/her BP normalizes or comes back within acceptable range. If the BP is okay, the nurse inserts the Cannula (dialysis) needles. Other dialysis centers have local anesthesia to dull the pain of insertion of big needles in the vein or fistula (artery and vein joined together to make the vein larger to make it possible to insert the needles for dialysis). For new patients that do not have a fistula, their dialysis access is either through the neck, wrist and thigh. This has less pain compared to venous insertions of needles. After the needles are inserted and the machine is ready for dialysis, the patient is "hooked" or connected to the dialysis machine. First, the Cannula needle which is inserted into the artery or fistula is connected to the bloodline and blood rushes within the tube into the dialyzer, filling it and into the other end of the bloodline where the venous Cannula needle is connected and blood is returned to the body. Blood flow is accomplished by a rotating external mechanical pump which squeezes the tube of the bloodline forcing blood through the tube. The faster the pump rotates, the faster the flow of blood but at the initial phase of dialysis the normal flow rate should be 180 ml or cc per minute or lower depending on the condition of the patient's health and his/her dialysis access if the flow of blood in the vein is strong or weak. Then a regular or low dose of Heparin (an anti-coagulant to prevent blood clot) is injected into the bloodline. If the patient is bleeding due to her period or other wound, no Heparin is injected and clotting is prevented by regular flushing with Normal Saline Solution (NSS) or suero in Tagalog. After the patient is connected to the machine, it is advisable for the nurse to take a second reading of the patient's BP to see if it is still normal. Some patients experience hypo-tension after they are hooked on the machine due to the amount of blood circulating outside the patient’s body which is about 237 ml or cc.  If the patient’s BP is still normal, dialysis continues for two or four hours depending on the recommendation of the doctor. Dialysis period for first timers is only two hours to acquaint the patient’s body to hemo-dialysis.
     The dialysis machine is a complex machine that combines modern computing and medical science into one. The machine “knows” if the pH(acidity or alkalinity), concentration, amount and temperature of the dialysate (dialyzing solution) are not right by sounding an alarm. The dialysate is composed of an acid and base or electrolytes that are separately contained in one gallon plastic containers. The one with the red cap is the acid and the one with the blue cap is the bicarbonate or base. In solution they contain physiological (in equilibrium or equal quantity in the dialysate and the patient’s blood, these electrolytes are consistent with the normal functioning of the patient) amounts of potassium, calcium, glucose, sodium and other minerals and water. The machine also monitors the arterial and venous pressure of the blood in the bloodline. If the pressure is either too high or too low, the machine automatically sounds an alarm or even stops the blood flow if necessary. It can also detect air bubbles in the blood line and blood leak in the dialyzer and will also sound the alarm. During power interruption or brownouts, the machine automatically draws power from its own Uninterrupted Power Supply (UPS) and will sound an alarm.
     Once the patient is connected to the machine, the nurse checks for the arterial and venous pressure readings if they are not high or too low and record them in the patient's chart. The nurse also checks if air bubbles are trapped properly in the air trap of the bloodline. If everything is okay, the nurse monitors the patient’s BP every hour or as needed. Dialysis or cleaning the patient’s blood is accomplished by the dialyzer and the dialysate. The blood flow into the dialyzer downward while the dialysate in the opposite direction. Through the process of diffusion (movement of molecules in a solution is from higher concentration to lower concentration) the nitrogenous waste and excess mineral salts in the patient’s blood is drawn out through the semi-permeable membrane of the dialyzer into the dialysate. The faster the flow of blood and dialysate, the blood is more cleaned. Now, the question is: why do the blood and other proteins in the blood are not drawn out into the dialisate together with the waste? That is because the dialyzer is made up of fine fibers and openings in the membrane are so small that it limits the passage of larger particles of blood such as RBC, WBC, proteins. Thus, it prevents blood loss that may result to hypo-tension. Another question that arises is how does excess water from the patient’s blood taken out from the body through the dialyzer? This is accomplished by the process of reverse osmosis (movement of water molecules is from lower to higher concentration of water). The amount of water circulating in the dialyzer is lower compared to the amount of water circulating in the dialysate. Diffusion and osmosis are enhanced by a negative pressure in the dialysate compartment of the dialyzer. A negative pressure exerts a pulling action of the fluids in a tube while a positive pressure push the fluid in the tube. The dialysis machine can be set at the prescribed volume of water to be taken from the patient’s body at a specific time period by increasing or decreasing the pressure. Too much water taken from the body could result to painful cramps, temporary hearing loss and hypo-tension. My practice is when I feel that my toes are twitching or my leg muscle starts to contract or there is pressure in my ear, it is a sign that excess water has been taken from my body and I would stop the flow of ultra-filtrated water in the dialysate while cleaning of my blood continues. The normal practice of nurses is to flush the bloodline with NSS. When the prescribed time of dialysis is reached, the nurse terminate the dialysis session by returning the patient’s blood in the bloodline and inject erythropoietin intra-venous(into the bloodline  or subcutaneous(below the skin) depending on the patient’s decision. Swimming in pools or sea water in beaches is discouraged for hemo-dialysis patients to prevent infections through the punctured wound in the skin where the needles were inserted.
     During my first year in dialysis I experienced high blood pressure. Even with the hypertensive drugs prescribed by the physician at the Regional Hospital, my BP is not lower than 150/90. During dialysis, my BP will shoot up to 200/110 and I would feel pain at the back of my neck and I experienced severe headache. I would take sub-lingual dose of Clonidine or Catapres and my BP will go down near normal values. As a result of my hypertensive condition, water entered the cavity of my left lung and found it hard to breathe especially when walking or lying flat while I slept. I was diagnosed as having pneumonia and enlargement of the heart. When I went to Manila for a vacation, I had my dialysis in the Capitol Dialysis Center near the Capitol Medical Center where my daughter is a pediatric staff nurse. I had bouts of hypertension and cramps during dialysis so their physician prescribed me oral maintenance dose of Catapres(Clonidine) 75 mg 3 times per day aside from my maintenance medicine of Olmesartan 40 mg. once a day and Amlodipine 5 two times per day. I took Clonidine 75 mg. only two times per day since I monitored regularly my BP with my digital BP reader. To my amazement my BP returned to normal value and the water has left my lungs. Now I take the Clonidine 75 mg once a day or every other day.
     I have learned that it is very important for the patient to fully understand what dialysis is all about and he/she should observe what are the factors affecting his/her body functions. The number one factor is fluid control especially for end-stage patients whose urine output is low or very low. This is also the cause of water in the lungs if there is too much water in the blood. This also affects the heart since the volume of blood is above normal values. Excess water is also deposited in the abdominal cavity and the legs. The patient should stick close to his/her diet especially avoiding salty foods that can cause water retention. Too much intake of animal protein will significantly increase the nitrogenous wastes in the blood and will cause uremia that can affect the patient’s heart and brain. During this condition, the body compensates by triggering the patient to vomit constantly until his/her esophagus is so irritated that he/she vomits blood. Excess intake of animal protein also causes the dark pigmentation in the skin of the patient. Intake of food rich in uric acid or purines causes painful gout and arthritis. Phosphorous in the blood is also removed by dialysis but the bulk of it is located in the tissues and almost all the food that we eat contain some phosphorous. With damaged kidneys, excess Phosphorus is not efficiently removed through urination so there is a danger of build-up of Phosphorous in the blood which is dangerous. This mineral will bind with calcium in the blood and will deplete the calcium that causes hypocalcemia that can result to weakening of the bones and osteoporosis. To counteract this, the patient should take at most 1500 mg of calcium carbonate per day depending on the Calcium level to replenish the calcium in the blood. Calcium also binds with phosphorous in the food taken in by the patient and excess phosphorous will not enter the bloodstream and instead will go through the digestive tract and excreted with the feces. Other phosphate binder such as Sevelamer is very expensive but very effective if taken in the right dose and timing. Monthly monitoring of the chemistry and uric acid content of the blood is recommended aside from other monthly laboratory tests. The hemoglobin level in the blood will indicate if the patient is advisable to have blood transfusion. A hemoglobin level of seven or lower is already critical and the patient is not advised to have dialysis unless he/she can have blood transfusion during dialysis. At very low level of hemoglobin, the patient can strain his/her heart during dialysis since it is the hemoglobin together with iron that helps distribute oxygen in the body cells. My practice is if my hemoglobin level is below 10, I would inject 4,000 units of erythropoietin alpha twice or three times per week to elevate my hemoglobin back to 10 or 11. Too much erythropoietin could cause high blood pressure due to the thickening of the blood. At a hemoglobin value of 10.8 to 11 or more, the dose of erythropoietin is at once a week. Blood transfusion is discouraged by the physician unless it is really needed by the patient to prevent Hepatitis infection. Erythropoietin should be combined with a daily dose of ferrous gluconate or other organic iron supplements to be effective. Dialysis patients should not eat too much fat in their diet since it could contain cholesterol that blocks arteries and veins resulting to stroke and heart attack. So it is also advisable to regularly monitor the cholesterol level in the patient’s blood. Too much fat also causes fatty liver which could affect its function. Remember that without the kidneys, it is the liver that performs the function of breaking down harmful chemicals and substances that are supposed to be excreted by the kidneys. Drinking alcohol is also not advisable since it can harm the liver. If the above practices are followed religiously, I can vouch for the efficiency of dialysis of at least twice a week and the survival period of the patient can be prolonged to a maximum of twenty years!
     Headaches and high blood pressure during dialysis especially of new patients can also be caused by Dialysis Disequilibrium Syndrome (DDS). In theory, DDS results when the blood waste, Blood Urea Nitrogen (BUN) level in the patient’s blood is abruptly or drastically brought down by aggressive hemodialysis (fast blood flow rate). My practice now is I would start my dialysis at a blood flow rate of 180 ml per minute and after one half to one hour my blood flow rate should be 250 ml per minute for two to three hours. At the fourth hour of my dialysis my blood flow rate should be lowered to 200 ml per minute. One half hour before I am through with my dialysis, my blood flow rate should be back at 180 ml per minute. This would allow the gradual removal of nitrogenous waste in my blood at the same time allowing my heart to cope up easily with my dialysis. My maximum blood flow rate is only 250 ml per minute because of my heart condition which is already enlarged but is not yet failing. Other patients can tolerate a blood flow rate of more than 300 ml per minute.  The BUN shoots up when the patient has eaten a large amount of animal protein for two or three or more days. Three times or more dialysis per week is recommended for patients with very high level of BUN and suffering from Uremia and this is also true for diabetic patients. Most patients have two times dialysis per week due to the high cost of dialysis especially in private hospitals and dialysis centers. The ideal frequency of dialysis is three times or more per week.
     I hope that I could learn more from the processes of hemo-dialysis so I can share more learning with other dialysis patients. God willing, I can accomplish this task. We praise and thank you Lord God almighty!