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From The Director's Chair
Prescription for Health
Stay Healthy by Staying Active, Even on Dialysis
Social Work at Your Service
Bon Voyage! How to Plan Travel While on Dialysis
Body, Mind and Soul
Celebrate
From The Director's Chair
Muscle Cramps on Dialysis
Paul Kellerman, MD
As many of you have experienced, muscle cramps are a common complication during dialysis treatments. Cramps occur in 1/3 to 2/3 of all dialysis patients. Patients tend to experience cramps in the lower extremities, but they can occur in the hands, arms and abdominal muscles as well. Although the exact cause is unknown, multiple causes have been proposed, including volume contraction (getting "too dry"), low blood sodium concentration, low body magnesium, and carnitine deficiency. Of these, the first two seem to be the most common. In terms of volume contraction, both getting below your "dry weight" (goal weight at the end of dialysis), as well as rapid removal of large volumes can result in cramps. Low concentrations of sodium in the dialysis bath can also cause cramps by lowering your blood sodium concentration.
Treatment has two components: prevention of cramps from occurring, as well as treatment of cramps when they occur. In terms of prevention, some of these measures are under your control, and some under your care team's control.
What works to prevent cramps?
Minimize weight gains between dialysis - Simply put, restrict your fluids. The more you take in, the more we have to take off to get to your dry weight. The more taken off, the more likely you will get cramps.
Assure your proper dry weight - If your blood pressure is low, you have no edema, and you are cramping, you may need to have your dry weight increased. Your nurse and doctor will work with you to get to the proper dry weight.
Higher dialysate sodium concentration - Sometimes you will hear your nurse or doctor talk about being on a "sodium modeling program" with higher salt in the dialysate. If you are predisposed to cramps, this may help prevent them. Not everyone should be on a program, since the tradeoff of these programs is that you absorb more salt during the procedure, which makes you more thirsty between dialyses, so you tend to drink more fluid and gain more weight (see #1). Also, if your blood pressure tends to run high, the program will only make it that much harder to control your blood pressure to normal levels.
Carnitine deficiency - If you have lots of cramps, your doctor may wish to measure a carnitine level in your blood. If your level is low, you can be given carnitine pills, which may help to prevent cramps.
Quinine sulfate - Some of you already use quinine. One small study showed a benefit of quinine taken at the beginning of dialysis to prevent cramps. Because it is a pill that takes time to absorb, it is best if you take it 1-2 hours prior to dialysis. Like all medicines, it can on occasion have side effects, such as deafness, optic nerve problems, and gastrointestinal symptoms.
Vitamin E - In one study of 29 patients, Vitamin E prevented cramps as well as quinine. There is some recent evidence, though, showing that Vitamin E may increase the chances of heart failure.
What can be done when you get cramps on dialysis?
- Hypertonic saline - In a study of 20 patients with 100 episodes of cramps, hypertonic saline effectively relieved cramps, as did 50% dextrose.
- Mannitol - This has also been shown to be effective for cramps, but we want to avoid giving it at the very end of the dialysis session.
- Massage and moist heat- Sometimes this can provide some comfort.
So in summary, if you have frequent cramps while on dialysis, what do you do? If you gain a lot of fluid, you need to decrease your fluid intake. If you don't have large fluid gains, talk with your doctor about reassessing your dry weight. If adjusting your dry weight does not solve the problem, you may be a candidate for dialysate sodium modeling, carnitine, quinine or Vitamin E.
Above all, we certainly don't want dialysis to "cramp" your lifestyle.
Prescription for Health
What Are the Statins?
Curtis A. Johnson, Pharm.D.
Many people, including dialysis patients, take a medication known as a statin. Some examples of statins include simvastatin (Zocor), atorvastatin (Lipitor ), fluvastatin (Lescol ), and pravastatin (Pravachol ). You may have seen ads for these products on television. Why are these drugs prescribed so much?
The statins have become a primary means of treating abnormalities of lipids (fats) in the blood. We know that certain abnormalities in the fat composition of our blood can put us at risk for heart and blood vessel disease. As a group, dialysis patients are at high risk for the development of this type of disease, so they are often treated with these drugs to reduce that risk. At WDI, we measure the amount of the various types of fat (cholesterol and triglycerides) in the blood once a year.
The National Kidney Foundation has developed guidelines for the treatment of lipid problems in patients with kidney disease. Successful treatment includes certain changes in the way you live your life such as exercise and diet plus the use of medications designed to improve the lipids in the blood. Your care team checks your cholesterol and triglycerides in order to recommend the therapy that is best for you.
As you may know, there is more than one type of cholesterol. The so-called "good" cholesterol is high-density lipoprotein cholesterol (HDL-C). The so-called "bad" cholesterol is low-density lipoprotein cholesterol (LDL-C). The statins are used most often to increase HDL-C and reduce LDL-C.
The statins may also improve the amount of triglycerides, a different type of fat, in the blood. We encourage you to know what your HDL-C, LDL-C and triglyceride numbers are, as these are important to your health. Sometimes, the statins may be prescribed even if the amount of lipids in the blood is normal because the statins may be beneficial for such patients. Statins may also be combined with other medications in order to lower lipid concentrations in the blood. Please feel free to ask your doctor or dietitian about what your lipid numbers are and what your goal should be.
The statins should be taken in the evening in order to get the best effect. Patients are usually prescribed a small dose at first. If the desired effect does not occur, the dose can be increased gradually. As with any medication, there is a risk of certain side effects. The most worrisome are damage to the liver and damage to muscles. At WDI, we routinely utilize laboratory tests to check the health of the liver, even in those patients who do not receive statins. If you develop muscle or joint pain and you are taking a statin, you should report this to a WDI staff member.
Some of the statins may lead to drug interactions if certain other medications are given at the same time. If you see a doctor outside of WDI and you are given a prescription for another medication, you should remind that doctor that you are taking a statin.
If you have any further questions about the statins, their side effects, or possible drug interactions, please ask. We will do everything we can to give you the information you desire.
What is a lipid profile?
It's a group of tests that determine risk or coronary heart disease.
What tests are included?
- Total cholesterol
- HDL (good cholesterol)
- LDL (bad cholesterol)
How is the lipid profile used? It's used to guide your physician in deciding if you are a patient at risk, and if necessary, develop a treatment plan or follow-up.
Stay Healthy by Staying Active, Even on Dialysis
Amy Alvig, Dietetic Intern
You no doubt already know that exercising is important even for those on dialysis! Exercising regularly can help condition muscles, improve strength, assist with balance, and increase energy level. Exercise has also been shown to reduce fatigue, help depression, and help people remain more independent.
The benefits of regular exercise are endless. It can keep your weight under control, increase your good cholesterol (HDL), and lower your total cholesterol and blood pressure. For those with diabetes, exercise can help stabilize blood sugars by improving insulin sensitivity. You sleep more soundly, cope better with stress, tone your muscles, and help soothe bodily aches and pains.
If you are not a seasoned exerciser then start with Baby Steps by increasing your activity level slowly and over time. Think about the activities you already enjoy and take part in those on a regular basis. Some suggestions are household chores such as vacuuming, dusting, and folding laundry. If feasible, you could walk to your dialysis treatments. Stretching activities, water aerobics or dancing around the house to your favorite tunes, while your neighbors watch, are further good suggestions. If you are in a wheelchair consider using hand weights or a large rubber band. Do range of motion or stretching exercises while sitting.
Please consult with your physician before beginning an exercise program. Also, remember to warm up before you start and cool down before you stop and remember those baby steps! However, whatever your limitations, exercise can be fun and can improve your overall health. Remember, any activity is good exercise!
Second Annual Exercise Program
Ann Mader, RDGet ready for June 1st when WDI will officially launch the Second Annual Exercise Program! The article above on exercise gives all of you many good reasons for exercising, and we hope you will consider joining and participating.
Last year 40 participants finished the program. Each participant kept a log as to his or her progress throughout the summer. The program ended with a party at the Old Country Buffet, complete with a meal, presentations and awards on September 9th. Everyone who was able to attend had a wonderful time.
The dietitians, Fran and Ann, will be around to discuss this opportunity with each of you to sign up for the program. Each participant works at his/her own pace with a variety of activities that can qualify. The goal is to increase exercise or activity over the summer so everyone will experience the positive benefits of exercise! So, dust off those exercise shoes or rev up that wheelchair….. it's ready, set, exercise!
Hooray! It's time for WDI Announcements!
Life can be easier with the Easier Support and Education Program. Here is the Program for April and May :
"Let's Talk Transplant 1" - Wednesday, April 13 at 4:30 at WDI Fitchburg
"Gear Up For Exercise" - Wednesday, May 11 at 4:30 at WDI Fitchburg
What would we do without our support staff? April 27th is Administrative Professionals Day. Thank you to Tricia, Kris, Mary, Terri and Jacqui for handling all the special favors, requests, problems, frustrations, deadlines and timelines! We would all be lost without you!
May 6-12 is Nurses Week. With gratitude and thanks WDI recognizes: Lila, Jan, Sharon, Mimi, Helen, Sally, Theresa, Mary, Elaine, Linda, Lesli, Kathleen, Connie, Janiece, Maria, Alane, Michelle, Sandy, Therese, Laura, Kay, Karen, Karl, Carol, Dawn, Claire, Carolyn and Janice.
Social Work at Your Service
It's Coming! Medicare Part D
Helen Rugowski, MSSW
Medicare is gearing up to offer a new prescription drug plan called Medicare Part D, which begins January 1, 2006. While enrollment is optional, this new drug coverage requires every Medicare beneficiary to make a decision this fall. You will be able to enroll beginning November 15, 2005 through May 15, 2006. If a person enrolls after May 15, 2006, you may be subject to a 1% increase in premium for each month you delayed enrolling in Part D. Complete details of the program have not been fully developed, but this article is an introduction to some of the aspects of Part D.
The benefit will be delivered through private insurance companies, pharmacy benefit managers and Medicare Advantage Plans. To participate in Part D the individual needs to enroll in one of the plans offered in the area where they live. You must have Part A and B of Medicare to enroll in Part D.
The basic plan is insurance coverage for prescription drugs and features:
- A monthly premium generally around $37.
- A share of the cost of each prescription after you pay the initial $250 out of pocket.
- Plans can vary in what drugs are covered. The drugs that the plan covers can change during the year. You cannot change plans during the year.
- Plans can vary in which pharmacies the beneficiary can use.
Beneficiaries who already have drug coverage which Medicare determines is at least as good as part D will not need to enroll in Part D and will not have to pay a penalty for deferring enrollment to a later date. At this time it has not been determined which plans will meet this "at least as good as" test.
Beneficiaries with incomes up to 100% of 2005 poverty levels will pay no monthly premium and will pay $1 for generics and $3 for brand name drugs. This group will automatically be enrolled in the low-income subsidy and a part D plan if the beneficiary does not choose a plan.
Medicare beneficiaries whose income is low (but above the 2005 poverty level which is $9,570 for an individual and $12, 830 for a couple) can apply for federal subsidy to cover all or part of the Part D Premium. This low-income benefit is very complex and is the group that should be targeted for assistance.
- Medicare has the goal of beginning to accept applications for subsidy starting July 1, 2005
- The social security administration has the responsibility of determining eligibility for the subsidy assistance.
- There are different levels of assistance depending on income and asset levels.
Additional information can be found at:
Finally, printed materials are located in the wall rack at WDI-Fitchburg. Although WDI social workers have a lot to learn too, feel free to contact Helen Rugowski or Anastasia Korbitz. Let's all take the time to learn as much as we can about Medicare D.
Bon Voyage! How to Plan Travel While on Dialysis
Anastasia Korbitz, LCSW
Whether you are planning a cruise to Hawaii to take hula lessons, hopping on a plane to England to drink tea with the Queen, or driving to the North woods to watch the annual cow patty toss, planning ahead, being flexible and partnering with WDI will make your travel experience like a day at the beach! So where do you start?
- Determine the dates of your travel. Be flexible with your travel dates, as the destination unit may not have your exact requested dates available.
- Planning at least 4-6 weeks in advance, in most case, is a good rule of thumb. Some of the "hot spots", such as the cabin up north during the 4th of July, is a good example of the need to plan ahead.
- Have the address of where you will be staying while on vacation and be prepared to provide this information to WDI.
- If you have a computer, you can locate the dialysis unit closest to where you will be staying (please refer to the table). Otherwise, a staff member can assist you in locating a unit.
- Be prepared to sign a consent form and provide copies of your insurance cards to your WDI social worker or travel coordinator. This information will be needed to inquire about availability.
- Traveling to an unfamiliar unit can be stressful which is all the more reason to call and learn more. Once you have been given the "okay" by the accepting unit, call and speak with their charge nurse or social worker to get the "lowdown" on their policies regarding lidocaine use, linen provisions and visitor policies.
- Educate yourself on your insurance coverage. As a general rule Medicare will pay 80% of dialysis, but only in the US. You may be asked to pay the remaining 20%.
- Once you arrive at your destination, contact your unit to confirm your start date and time. Arrive at the new unit at least 15 minutes before your scheduled time to get yourself acquainted with your "home away from home".
- Most of all enjoy your adventure and be prepared to tell the staff all about your trip when you return. Bon Voyage!
Helpful Websites for the Savvy Traveler
www.dialysisfinder.com: Enter a city, address, zip code or state for a map and listing of dialysis units in the area you are traveling to.
www.globaldialysis.com: includes inter-national listings for places to stay, travel agents, tours, cruises and travel insurance as well as dialysis centers.
www.medicare.gov/dialysis/home.asp: This site lists Medicare approved dialysis facilities in the US. It has a feature allowing you to compare many facilities.
www.nephron.com: Search this site for dialysis units.
Attention PD patients, please discuss your travel plans with your PD nurse. Although most of what has been discussed in this article pertains to you, and you are encouraged to participate in all levels of planning for your travel, your nurse will need to discuss the process of traveling with your PD supplies.
Body, Mind and Soul
Penny Andrews, Chaplain
This is the time of year when the sap runs, crocuses, hyacinths and daffodils bravely show off their beauty, and we feel spring in our hearts again.
This is not the spring of our younger selves-when energy was abundant and even feverish. The spring of adulthood is in part made up of our earlier memories of this time, in part it is the energy that is being generated in nature and most importantly, spring is what we choose to make of it.
Spring is the time for planting seeds. Now is the time to consider what we choose to grow during this season of such vigorous change.
If we look at our lives from the standpoint of Body, Mind, and Soul, which aspects of these would you like to enhance? The summer exercise program is a terrific opportunity to set some goals that can address all three.
Energy may be something you'd like to cultivate at this time. Exercise not only increases your energy, but it can have a positive effect on your spirit and overall outlook on life. Whether one walks, bikes, lifts weights, does yoga, t'ai chi or some personal combination, one participates in spring's call to us.
So go ahead, create intention for yourself in these days of longer light. You'll be pleasantly surprised to see how what you put your attention too is able to grow. Make it something you consider fun and you'll get an extra bonus…. you'll lift your spirits----
Celebrate
Celebrate the budding flowers, the clear blue sky, the deep green forests, the perfect full moon, the twinkling stars-
Celebrate the miracle of a baby, the optimism of children, the laughter of adolescents, the responsibility of adults, the wisdom of elders-
Celebrate the love in our hearts, the spirit in our souls, the health of our bodies-
Celebrate all that binds us together as one.
-Susan Polis Schutz
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