Tuesday, May 7, 2019

The Dialysis Patient and His Monthly Laboratory Tests



     
As a new patient before, I was not familiar with the significance of the results of my monthly laboratory tests. Our Nephrologist read my result and if she tells me that a certain value on my test is high or low, I just obey what she tells me to avoid and not to do and buy the medicines that are in the prescription. Now that I have been undergoing dialysis for almost eight years, I know the importance of the correct interpretation of my laboratory results. We have many laboratory tests every second week of the month. Before we are hooked on the dialysis machine, the nurses take a specific amount of our blood which they then put in two test tubes to be sent to the Outpatient Laboratory for the following tests: Complete Blood Count (CBC), Pre-dialysis: Creatinine, Blood Urea Nitrogen (BUN), Inorganic Phosphorus, Calcium, Potassium, Albumin, Sodium, and Blood Uric Acid (BUA). Post -dialysis: Creatinine and BUN.

        Why the so many tests. Now I know that CBC is done to monitor the value of Hemoglobin, Red Blood Cell (RBC), White Blood Cell (WBC) and other components of my blood. Hemoglobin value of a dialysis patient usually does not reach the normal value of a normal person which is 12 - 14. If the patient reaches a value of more than 12, the doctor will advise him to inject Erythropoietin for once a week. Injection of the synthetic hormone is stopped if the value is 13 or more. This is done to prevent too much viscosity or thickness of the blood of the patient that might result to stroke or heart attack. If the value is below 11, this means that production of RBCs is very low and the injection should be done twice or thrice a week depending on how low is the Hemoglobin. Hemoglobin combined with Iron help in the distribution of Oxygen in the tissues of the body through the Red Blood Cells. Erythropoietin is a hormone that helps in the production of RBC and is normally secreted or produced by the kidneys of a normal person. If the kidneys are damaged, the production of Erythropoietin stops. That is why synthetic Erythropoietin injection was developed to replace the natural Erythropoietin of a dialysis patient. It took many years of study and research to develop this synthetic hormone which is derived from cloning the gene for Erythropoietin. Low level of Hemoglobin and RBC results to muscle weakness and fatigue and will strain the heart while the patient is on dialysis. A blood transfusion is necessary to bring the Hemoglobin count to at least 9 or 10 up to 11 which is better. Anemic patients who practice too much physical exertion or rigorous exercises are exposing their heart to too much stress making the heart to compensate resulting to Cardio-Megally or enlargement of the heart.

       I know now that a high value of White Blood Cell (WBC) indicates an infection somewhere in my body that needs to be detected in order for the doctors to determine what type of anti-biotic they will prescribe me. A low WBC count indicates a viral infection or other diseases like Leukemia or cancer. It can also be caused by Rheumatoid Arthritis and other auto-immune diseases.

        Low and high Platelet count indicate an infection or disease. High platelet count could result to stroke or heart attack and low platelet count results in skin bruising and bleeding since it is the Platelet that is responsible in blood clotting.

      I know now that monitoring my blood Phosphorus level is important because high level of Phosphorus leads to increased mortality in dialysis patients because Phosphorus binds with Calcium in the blood to form Calcium Phosphate crystals which accumulate in the organ tissues including the heart, muscles and joints resulting to cardio-vascular disease and painful inflammation especially when the patient has undergone many years of dialysis. These crystals are mostly deposited in the lower limbs causing the skin to itch that the patient cannot avoid scratching his skin which result to small lacerations that expose it to bacteria that cause infection called Cellulitis which make the patient prone to Sepsis (blood infection) if left untreated with anti-biotic. Sepsis is a serious condition which leads to morbidity and death. Taking too much anti-biotics is bad for the liver. When the liver is damage, death of the dialysis patient will surely come next. Low level of Phosphorus among dialysis patients is very rare because Phosphorus in foods eaten by the patients accumulate in the blood since it is the kidney that excretes excess Phosphorus. Dialysis patients have damaged kidneys and excess Phosphorus has no way to get out of the body. Thus, it binds with Calcium and gets deposited in muscles, tissues and joints of the patient. Small amount of Phosphorus is removed by dialysis but most of the Phosphorus is in the tissues of the dialysis patient and hard to remove. Hyper-Phosphatemia or excess Serum Phosphate is treated with phosphate binders. To prevent additional phosphorus from entering the blood stream phosphate binders are taken by the patient after each meal. Effective phosphate binders are: Calcium Carbonate and Sevelamer Carbonate. Calcium binds with Phosphorus during digestion of foods in the intestine and is excreted or removed together with other bodily waste. Sevelamer acts like a sponge that absorbs Phosphorus and is also removed together with other bodily waste. The dialysis patient should still avoid eating foods high in Phosphorus since the phosphate binders cannot bind all the Phosphorus that he have eaten.

           As mentioned above, excess Phosphorus binds with Calcium. In this way, the level of Calcium in the blood is also monitored because high amount of Calcium causes Calcification and is detrimental to the: tissues of the organs and muscles and joints. Low level of Calcium however, results to Hypo-Calcemia which causes the bone to become weak and brittle. That is why Calcium Carbonate is prescribed to patients with low level of Calcium.

       Monitoring the Potassium level in the blood is also necessary because very high level of 7 and above can cause the heart beat to stop that will kill the patient. Death Row prisoners about to be executed are given overdose of Potassium that will cause painless death. Injured and sick animals are put to death by high dose of potassium. Low level of Potassium (Hypo-Kalemia) causes muscle weakness and fatigue, muscle cramps and twitching and irregular heartbeat. Just like Phosphorus, Potassium is accumulated in the blood of dialysis patients because of their impaired kidneys. Excess Potassium is removed by regular dialysis but some patients eat foods that are high in Potassium two or more days before dialysis. That is why Potassium builds up to dangerous level in the blood before they are dialyzed.

        Level of Albumin in the blood is monitored regularly since the dialysis patient is on low protein diet which makes the Albumin level to fall down. Serum Albumin is responsible for maintaining the volume of the blood. Low level of Serum Albumin results to less blood volume and the excess water in the blood is deposited in the muscles and body cavities including the cavity around the heart. This makes the heart exert more effort resulting to stress and eventual heart damage if not remedied. Low level of Albumin also results to leaking body nutrients out of the blood vessels depriving the muscles and organs of vitamins and minerals. This also results to Edema or swelling of the legs and Ascite (accumulation of water in the cavity of the stomach or abdomen which can lead to shortness of breath and peritoneal cavity infection). Some patients eat salty foods and as a result they feel very thirsty and drink a lot of water. Excess water is then stored in the cavity of the abdomen; more so if their Albumin count is low due to kidney and other disease like that of the liver. Low level of Albumin is corrected by ingestion of the dialysis patient of two to three egg whites per day. Egg yolk contains high amount of Phosphorus and Cholesterol and should be avoided.

       The amount of serum sodium is also monitored regularly. High value of sodium (above 145) can cause high blood pressure and Edema which could lead to stroke and heart attack. Excess water in the body of a dialysis patient is also harder to remove during dialysis if the sodium concentration in the blood is high. This strains the heart and creates a feeling of discomfort during dialysis. The patient is advised to lessen sodium intake and drink small amount of water in order to stabilize the sodium level and the excess water removed by regular dialysis of two to three times per week. Three times per week is the recommended dialysis session but dialysis patients limit it to one to two times per week due to financial constraints. Low level of Serum Sodium (below 135) is also bad for the dialysis patient because this could lead to hypo-tension (low blood pressure) and painful cramps during dialysis. Very low blood pressure could result to dizziness, shortness of breath, restlessness, seizures and coma.

        I know now that monitoring the Blood Uric Acid (BUA) is also important since this indicates whether the patient is prone to painful inflammations like Gout and Arthritis. Purine (the derivative of Uric Acid) is present in most fruits like oranges and berries. Foods high in Uric Acid are beans, meat and internal organs. Uric Acid is a crystalline substance which is the product of Nitrogenous Metabolism (digestion) and if it accumulates in high quantity in the blood of the dialysis patient could lead to painful swollen joints. Excess Uric Acid is removed by the normal kidney but dialysis patients have damaged kidneys, that is why Uric Acid accumulates in the blood. Some Uric Acid is removed by dialysis but some patients eat foods with high amount of Uric Acid two to three days before dialysis and that is why excess Uric Acid is accumulated before they are dialyzed. Excess Uric Acid is also treated with Allo-Purinol.

          Before a patient is diagnosed by the doctor of having kidney disease, his blood sample is taken for CBC, Creatinine and Blood Urea Nitrogen (BUN) tests. The laboratory tests would indicate if he is Anemic, with high value of Creatinine and BUN which clearly indicate kidney damage. Creatinine test indicate if the kidneys are functioning normally or are partially or totally damaged. A value of Creatinine of 2 to 3 means the patient has Chronic Kidney Failure and dialysis is not yet prescribed by the doctor. Creatinine value of 4-5 means there is substantial damage to the kidneys and dialysis of once a week is advised by the doctor. Values of more than 6-10 indicates major Chronic Kidney Disease (CKD) and values of more than 11 indicate End Stage Kidney Disease (ESKD) and two to three times dialysis sessions per week is needed. High BUN indicates that the blood is high in nitrogenous wastes that are accumulated because of kidney damage. Normal kidneys filter out these wastes. A clear example of this is when a normal person eats large amount of protein or meat, the by-product of protein digestion or metabolism is Urea and other nitrogenous wastes and is efficiently remove regularly 24/7 by the normal kidneys. It is noted that the urine of that normal person has a strong pungent smell like Ammonia. If the kidneys are impaired, these nitrogenous wastes including Urea is accumulated in the blood of the dialysis patient and can only be removed by dialysis. Large amount of Urea and other nitrogenous wastes in the blood results to the condition of Uremia (the blood becomes acidic and toxic). Serious Uremia affects the brain function of patients resulting to anxiety, restlessness and confusion. If left untreated, uremic patients suffers brain damage and eventually die.

       Levels of Serum Creatinine and BUN are monitored regularly by the doctor to find out if the degree of damage to the kidneys is improving or has worsened. Pre-dialysis (before dialysis) and Post-dialysis (after dialysis) value of Creatinine and BUN is taken so the doctor will see if the dialysis patient is dialyzed sufficiently or efficiently. High value of BUN and Creatinine even after dialysis indicates insufficient dialysis due to the type of dialyzer, length of time and frequency of dialysis and the Blood Flow Rate (BFR) of the dialysis machine. Faster BFR means more volume of blood passing the dialyzer is cleaned. This is limited though due to the condition of the patient if he has a serious heart problem or his blood pressure is too high or too low. Dialysis patients with minor heart problem can tolerate up to 300 ml per minute BFR. The type of the dialyzer also affects the efficiency of dialysis. High Flux Dialyzer (HFD) cleans more efficiently compared to the Low Flux Dialyzer. High Flux Dialyzer is not tolerated at high BFR by some patients with heart condition. If dialysis is insufficient and not efficient, it means that more toxins are retained in the blood that could increase the risk of morbidity and mortality among dialysis patients.

          The above tests are only the monthly laboratory tests of dialysis patients. Other laboratory tests are done depending on the condition and symptoms experienced by the patient to confirm if complications from dialysis is present. It is very important to fully understand the interpretation and meaning(s) of the results of these tests to guide the patient in dealing with his disease. This also will give the patient a positive outlook in life for him to be disciplined to resist temptations from: eating excess foods that could aggravate his condition, give him courage and hope to face challenges, pain and uncertainties that will come his way.

        

        




Sunday, April 28, 2019

Life Before and During Dialysis


   
     In my almost eight years of undergoing dialysis, I have seen many of my co-patients become sicker and most of them eventually died. On what I have observed, their condition happened because they do not know much of the important facts of what dialysis is and they lack the right attitude or outlook in life while having dialysis. They are used to living their lives before having dialysis and they are unaware that life during dialysis has a big difference with what they love to do before dialysis. Like a patient who loves to jog early in the morning and do rigorous biking afterwards resulting to thirst and fatigue. Being a normal person before, he loves to drink very cold water and then take a cold shower immediately and nothing serious happened. This continued even when he is already on dialysis and then one day after drinking cold water and taking a shower he suffered shortness of breath until he can barely breath and was rushed to the emergency room of the hospital. His condition was very serious that the attending physician decided to perform intubation (put a rubbery tube into his throat up to his lungs) to allow him to breath. The tube remained in his lungs until his condition stabilized. He is lucky because he was able to survive such ordeal to tell to his fellow dialysis patients of his experience. Others were not lucky though because they suffered heart attack and died. He could be unaware that as a dialysis patient his Hemoglobin and Red Blood Cell count is below the normal value. In short, he is Anemic. He is also suffering from hyper-tension and this is seriously aggravated when he drank very cold water (this will make the arteries and vein shrink) and he was not completely rested from physical exertion. High blood pressure of more than 200/110 is a very dangerous condition especially to a dialysis patient. It could result to a stroke or heart attack and excess water that he drank will be forced into his lungs that makes breathing very difficult considering also that he has Anemia and distribution of oxygen to his heart and lungs is not normal.

     Other patients have a negative attitude or outlook in life. As if they have accepted defeat from their sickness to the point that they do not care anymore of what will happen to them as long as they are able to do what they want to do including eating too much food that will make them more sick. "You will still die even if you do not eat and drink too much. It will be better to enjoy life while we still live." This is what other patients say and seem to be proud of telling to their fellow dialysis patients. This proves that foods are very "addictive" since the patients do not mind dying as long as they can eat what they love to eat. They live to eat and not eat properly in order to live longer.

    Dialysis requires knowledge of the patient about his disease through research and personal experience. He also should have discipline to avoid as much as possible not to be tempted to eat and drink too much.  He should be patient, learn how to endure pain, have courage and hope that he will survive the challenges of dialysis and to live longer to be with his family and also be able to share to other dialysis patients his experience and knowledge so that they will also be motivated to adapt a positive outlook in life despite their condition.

     I have realized that a Vision Mission Statement for our association of dialysis patients is necessary for us dialysis patients to serve as a covenant while we still live. Vision and Mission Statement should be understood word for word and be instilled in the mind and heart. It should be internalized deeply on a day to day basis so that it will not be easily forgotten. Below is the Vision Mission Statement that I have made:

Vision: All dialysis patients in Bohol are dialyzed comfortably, sufficiently and efficiently in various hospitals in Bohol with ample benefits from the government and other charitable institutions; and they are well educated about their disease through seminars, forums, discussions among members and brochures about kidney failure and dialysis.

Mission: To have a network with hospitals, Government and Non-Government Institutions for the: putting up of more dialysis centers with more dialysis machines, formulation and implementation of educational programs on kidney failure and dialysis and ensure that logistics and financial requirements are met accordingly. For this, an Inter-Agency Task Group will be organized; and,

As a result of the efforts made by the above Inter-Agency Task Group, the members of Bohol Association of Hemo-Dialysis Patients and Watchers will have the qualities of a good dialysis patient who is well educated about dialysis, disciplined, patient, resilient to endure pain and challenges, courageous and hopeful that he will live longer and be still with value to his family and other members of the community.

     It would be heart-warming if the above VM Statement would be realized since kidney disease is on the rise and more and more patients are undergoing dialysis treatment. It is time that dialysis patients should have one belief that: Life does not end during dialysis and they should be strong to face challenges and accept them as they come and still have a positive outlook in life and be joyful despite a life of pain and uncertainty. 
                                          
                                     








Wednesday, January 2, 2019

ANSWERED PRAYERS


     
    A new era has dawned on Gov. Celestino Gallares Memorial Hospital (GCGMH) highlighted by: a newly constructed modern Hemo-Dialysis Center comparable to those of Cebu and Manila, a new high rise building, new hospital equipment, continuing construction of the Pharmacy, Blood Bank, Rehabilitation Center, Emergency facility and the newly built Malasakit Center. Medical services have greatly improved breaking the stigma that government service equates poor service. Behind all these developments is a type of aggressive but proactive management implemented by the new Medical Center Chief in the person of Dr. Mutya Kismet T. Macuno. Truly, Dr. Macuno is God sent especially for us dialysis patients who have experienced the worst condition before. The old Hemo-Dialysis Unit (HDU) was located in a small room with ten not well known brand of dialysis machines placed side by side very near each other. Admitted patients have dialysis together with the regular outpatients such that risk of infection or contamination is high. The room has poor ventilation and noisy with not so disciplined HDU Staff. The old HDU is right beside a huge electric generator creating a fire hazard in case of power overload. It is also beside the hospital’s morgue. Dialysis patients and their watchers in the waiting area are used to seeing dead patients in stretcher wheeled on the dirty hallway.

     In contrast to the old HDU, the new HDU started operation in July, 2018 is located in front of the hospital which is newly painted with appropriate combination of suiting colors, it has 15 brand new German made Fresenius dialysis machines placed not so close to each other, very clean comfort room, well lighted and with sufficient number of big split-type air-conditioners, state of the art water filtration facility, readily available oxygen outlets on the wall per patient and most of all; it has newly trained dialysis staff with two doctors on an eight hour shift. We are also very blessed because we do not have to pay for our dialysis. We are covered by 90 dialysis sessions per year under PHILHEALTH on a no balance billing scheme. Upon exhaustion of our PHILHEALTH benefits our dialysis expenses are automatically charged to the PDAF and Medical Assistance Fund (MAF) provided by the DOH, Governor and Congressmen of Bohol. Our monthly laboratory tests expenses are also charged to the PDAP/MAF. Depending on funds availability, part of our maintenance medicines expenses are also charged to the MAF. 

     As a gesture of gratitude, I have written a letter (copy printed below) to Dr. Macuno for all that she has done for us dialysis patients and to all the patients of GCGMH:


July 11, 2018


Dr. Mutya Kismet T. Macuno MD FPPS, FPSNbM, MDM

Medical Center Chief II

GCGMH, Tagbilaran City


Dear Madam:


After so many years of longing for a new relocation site of our old HDU, finally our dreams are fulfilled by an angel who knows what we feel and what we need and that is you. In behalf of the Bohol Association of Hemo-Dialysis Patients and Watchers (BOASHEPAWA) we would like to express our heartfelt gratitude to you for everything that you have done for us. You are truly a child of God who knows how to take care of His people.


Having a new site for the HDU is one of the major objectives of our association. I have written Dr. Arcay some letters regarding this but he seemed to be having difficulty accomplishing our request then. For your information, our other objectives that we have fulfilled are the following:


1.      Our 2nd Board Resolution was about the putting up of the provincial office of the Phillipine Charity Sweepstake Office (PCSO); and thru the intervention of Gov. Chatto our request was granted;


2.      Our next request was on the extension of PHILHEALTH’s 45 dialysis sessions per year to 90 sessions per year. The granting of our request was facilitated by Cong. Relampagos thru his relative who is a ranking officer of PHILHEALTH;


3.      Then, the request to Sec. Butch Abad on financial assistance coming from taxes from vice such as cigarette, liquor and gambling thru Cong. Relampagos. This could be the result of funds coming from Congressmen and the Medical Assistance Fund; and,


4.      Also, our association was able to give financial assistance to the family of our members who died (P1,000.00 pesos for directors / officers and P500.00 pesos for regular members).


Our current objective is to have a gathering probably on a beach to know more of each other, exchange experiences and insights about dialysis; and have an election afterwards.


You have done so much for us, but if you could extend an accreditation of our association in the future or refer a forum on dialysis, then, we could not ask for more.


Thank you very much and regards.


Very truly yours,


SIGNED:

BUEN T. DOMINGO

Chairman, BOASHEPAWA


     When I became a regular dialysis patient of GCGMH in October, 2011, I saw the need of putting up an association of dialysis patients with a legal personality (registered with the SEC) for us to be able to express our needs, privileges / rights and to legally solicit financial assistance for our dialysis needs. Also, I thought that it would not be difficult for me to do the organizing since I was an Area Development Officer of the UCPB-CIIF Finance and Development Corporation and I have experience in Community Development by organizing Small Coconut Farmers Organizations. I immediately organized a core group despite some negative feedback by the patients and nurses who were opposed to an association of dialysis patients (maybe they were “burned” by their previous experiences in organizations). I prepared the basic requirements and went to the provincial office of the SEC. I lost count of the number of times I went back to the office of SEC in Bohol to comply with the additional requirements or amendments in our documents since the SEC is very meticulous in screening applicant organization for registration. I have to go to the National Office of SEC in Manila to personally submit our registration documents to facilitate its approval despite my physical condition. I have water in my lungs due to previous Pneumonia infection and high blood pressure. I was gasping for air with my wife when we were crossing the overpass in Ortigas. At last on May 9, 2013, our association of dialysis patients and watchers was registered with the SEC with Registration Number: CN 201326623.


     Having dialysis before is very difficult since there was no provincial office of the PCSO. The patients themselves or their close relatives have to go to the National Office of PCSO in Manila just to get a 20 thousand pesos per three months financial assistance for the cost of dialysis. The 45 dialysis sessions per year of PHILHEALTH before was not enough to cover our dialysis cost for a year. They have to ride a ship to go to Manila and wait for many hours in a long line at the PCSO office only to get a net of 16 thousand pesos not considering the health risk of the patients. So we are grateful when our request for the putting up of the provincial office of the PCSO was granted. Also, we have to individually solicit funds from politicians and NGOs. During the period from November to December, many of the indigent patients have to undergo dialysis for once a week only instead of the regular twice a week due to lack of funds.


     We learned that having an association is effective in lobbying for our dialysis needs, so we passed a Board Resolution requesting the PHILHEALTH to extend its assistance of 45 dialysis sessions per year to 90 dialysis sessions per year. We provided copies of our request to Congressmen and post it in the social media joining other dialysis patients associations with the same request. At last, our plea was considered by PHILHEALTH and the 90 dialysis sessions per year was finally approved.  


     We also saw the opportunity of getting financial assistance from the government through the Sin Taxes (taxes obtained from cigarettes, alcohol and gambling), so we passed a Board Resolution requesting the then Budget Secretary, Butch Abad, to allot some funds for dialysis assistance. We wrote the Congressmen of Bohol to do the same from their Priority Development Fund or PDAF.

We are very grateful, when the Congressmen started allocating funds directly to the GCGMH and the DOH has implemented their Medical Assistance Program for the hospital. From then on and with Dr. Macuno at the helm as Chief of the Hospital, we do not have a problem regarding our dialysis needs.


     Many thanks for our prayers that have been heard. Merry Christmas and a happy prosperous New Year to everyone.