Wisconsin Dialysis, Inc.

Pathways to Summer 2007

Note from the Director Exercise: Why do it? Interviews with Two Patient Exercisers Coping with Dietary Restrictions Prescription for Health: Medications to Treat Depression Living Happy no Matter the Hand You're Dealt If you've Got Meaning, You've Got Life! From the Director's Chair: SEX and Kidney Disease What is a Nurse Practitioner? Note from the Director: Living Well With Kidney Disease; It's not just Physical Anastasia Korbitz The entire summer issue of Pathways has been devoted to the many facets of well-being. For those of us who work at Wisconsin Dialysis we not only care about your physical wellness, which includes; your monthly labs, your treatment attendance and your access; we also care about you as a person. We know that to consider your overall well-being, we must consider all areas of your functioning, not just your physical health. We are concerned about how well you cope with your chronic illness and how well you adjust to your new renal diet. We are also concerned that you be involved in some form of physical activity and that your spiritual needs are being met. Finally, we are concerned about your personal and supportive relationships. The Pathways contributing writers took the time to focus their thoughts, expertise and ideas to assist and help you examine your own well-being. Additionally, we are fortunate to have patients offer advice about diet and exercise. For example, we have patient contributors that talked about how they cope with the restrictions of the renal diet, while two additional patients, Ron Wade and Ramona Newton, share their thoughts on exercise and why they do it, even in spite of their disability. There are excellent articles on intimacy and sexuality, use of medications for depression, the importance of a positive attitude and spiritual well-being. Plus, we have two new staff members who have taken the time to introduce themselves and their roles at WDI. Please take the time to consider these thoughtful and helpful articles as you continue to grow, learn and improve your quality of life as a dialysis patient, but more importantly, as a person. Exercise: Why do it? Interviews with Two Patient Exercisers What do dialysis patients have to say about the reasons and benefits of exercise? Read about two WDI patients, Ramona Newton and Ron Wade, who are avid and dedicated exercisers. Ramona Newton: Interviewer: What type of Exercise do you do? Ramona: Weight training. Interviewer: Why weight training? Ramona: Well, I have been doing it since I was 17 years old. I am the oldest with younger brothers. When we were young we bought a weight bench and lifted weights together. I figure I had authority over my brothers, I told them we were going to lift weights and we did. Interviewer: What do you do currently for exercise? Ramona: I lift weights 3 times a week for 2 hours. I prefer to exercise on non-dialysis days. Interviewer: Why do you still exercise? Ramona: I'm a big fan of exercising. I have been doing it all my life. You know, all of life has a rhythm to it. I like the rhythm of exercise, the repetitions and the sounds of the weights. Actually, you don't have to join a gym to find this exercise rhythm; you can find it in everyday things like mopping the floor or doing the laundry. I also exercise for my grandbabies. I want to be able to keep up with them. I have a lot to do and need the energy to do it. Exercise gives me more energy. Interviewer: What are the benefits of exercise for you? Ramona: My mind is clearer. It keeps my stress level down, I sleep better and it really makes me feel good. I think part of the reason my dialysis is going so well is because I do exercise. Interviewer: What would you say to someone who thought you were too disabled to exercise? Ramona: You know when I go to the gym, other people say to me "if you can make it here three times a week with all you deal with, I can make it here too". I have diabetes, I'm partially blind, missing a leg and go to dialysis 3 times a week, but I figure these changes to my body are a part of my life and I just refuse to let that get in my way of what I want to do. Exercise keeps me on the road to healthy living, my numbers (labs) look good and my dialysis is going great. Choosing to exercise with a disability is a frame of mind and it's up to you. Ron Wade: Interviewer: Ron, how long have you exercised regularly? Ron: Pretty much all my life. I used to take my kids to the YMCA when they were kids and I would play handball. I loved handball. But a real turning point for me was when I developed diabetes and lost my younger brother to a heart blockage at the age of 48. Interviewer: Do heart problems run in your family? Ron: Oh yeah, you look at members of my family going way back, and I realized that no one seemed to live past the age of 60 because of failing hearts. I am not sure how it happened, but I ended up attending a cardiac exercise program and I learned a lot about exercise and the cardiovascular system. Interviewer: What do you do for exercise now? Ron: I exercise 3 times a week at a gym. I do ½ hour on a new-step X-trainer recumbent bike with arm motions. And 30 to 40 minutes with free weights and a weight machine. Interviewer: Why do you exercise? Ron: Once you get started, you get hooked on exercise. I loved going to the cardiac rehab center and after that I joined a gym. I like the people and have made friends. Also, it is very important for me to keep my upper body strength because I don't have much of a lower body anymore (Ron is a double amputee with prosthetics). I need my strength to keep me independent. Interviewer: What would you say to someone who said they are too disabled to exercise? Ron: I would say they are just looking for an excuse not to exercise. Everyone, no matter your disability can do something for exercise. There are great machines and people to help you learn how to use them. It is exercise alone that supports the spirits, and keeps the mind in vigor. ~Marcus Tullius Cicero Coping with Dietary Restrictions Ashley Massart, Dietetic Intern Fran Kittell, MS, RD Patients on hemodialysis have many restrictions in their diets that should be followed to maintain good health. Most patients must eat a diet low in potassium, phosphorus, and sodium. Some patients are on fluid restrictions because they retain too much in between dialysis treatments. Also, patients are encouraged to consume more protein-usually twice the amount they needed pre-dialysis. Dairy, a great source of protein, is virtually "off limits" due to the high content of potassium and phosphorus. So how do hemodialysis patients deal with these restrictions? After chatting with a few people, I found that they all have a different attitude towards the restrictions and thus, different coping strategies. Don told me that he eats what he wants and doesn't restrict his diet. He watches his lab values and alters his diet in response to that. Potatoes are one of his favorite foods so he often indulges himself. He says he can tell when his potassium gets too high and if that happens, he lays off of the potatoes. Helen feels that limiting her fluid intake is very difficult. In order to deal with this, Helen came up with some innovative ways to control her fluid intake. She freezes a 12 oz. bottle of water every day and drinks it as it melts. She also puts soda into ice cube trays and freezes it so it takes her longer to "drink" the beverage. This prevents her from going over her fluid restriction for the day. Another thing that helps Helen cope with the dietary restrictions is family support. At family functions, her relatives always ensure they have foods Helen can eat. Mike, who is newer to hemodialysis, feels as though he isn't restricted. He says his wife is a "damn good cook" and makes sure he is getting the foods he needs. Together they have been watching sodium intake for many years and the current restrictions have been a breeze for them to adapt to. "If I'm going to eat something, I'm going to eat something I enjoy," says Mary. She eats what she wants, when she wants it and doesn't pay much attention to the restrictions because she feels she is "doing okay." The one item she does stay away from is potatoes, which is difficult for her, but she is able to do it. Marianne has no problem with the diet because she says she is used to it. She never ate a lot of the restricted items prior to starting dialysis, so she doesn't miss them. For Marianne, this was an easy transition. Family support, a good attitude, will power, and thinking outside the box are all great coping strategies when dealing with hemodialysis dietary restrictions. A lot of people are going through this. Just remember, you're not alone. Prescription for Health: Medications to Treat Depression Kim Holdener, PharmD Depression is a common medical disorder that is caused by an imbalance of neurochemicals in the brain. These neurochemicals allow cells to communicate with each other, among other important brain functions. Symptoms of depression may be different in each person. Common symptoms include feeling sad, loss of interest or pleasure, changes in sleep patterns, changes in appetite or weight, loss of energy, trouble concentrating, thoughts of worthlessness or guilt, and thoughts of suicide or death. Depression occurs more commonly in women, nursing home residents, and people with a wide range of acute and chronic illnesses. There are several methods that can be used to treat depression. The most common treatments are counseling and medications. This article will focus on the most common medications used to treat depression. There are several different types of medications that can be used for depression. In some people they may be more effective when used in combination. Many factors, including the type of depression, the presence of other medical conditions, the possibility of drug interactions, and potential side effects, help determine which medication is most appropriate. Using medications in combination with counseling can be very effective. The effects of most antidepressants take up to four to six weeks to be noticed. It is important to give antidepressants plenty of time to start working before deciding one is not helping. Most people will need medications for at least six to nine months, though some require long-term therapy. The selective serotonin reuptake inhibitors (SSRIs) are a commonly used class of antidepressants. This class includes fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil® and Paxil CR®), citalopram (Celexa®), and escitalopram (Lexapro®). These medications work by increasing the brain levels of the neurochemical serotonin. Compared to many other antidepressants, they have a low number of side effects. Side effects that can occur include jitteriness, agitation, headache, diarrhea, nausea and insomnia. Sexual dysfunction is possible with long-term use. Another class of medications that is commonly used to treat depression is the serotonin norepinephrine reuptake inhibitors (SNRIs). This class includes venlafaxine (Effexor® and Effexor XR®) and duloxetine (Cymbalta®). These medications affect the levels of several different neurochemicals in the brain. SNRIs may be very effective in people who don't respond to other antidepressants. Side effects seen with these medications include nausea, dizziness, insomnia, sedation, constipation, and sexual dysfunction. Two other commonly used antidepressants are bupropion (Wellbutrin®) and mirtazapine (Remeron®). Bupropion alters the levels of many neurochemicals in the brain except serotonin. It may work well for people who have symptoms of fatigue and poor concentration because it has a mild stimulant effect. This medication may increase the risk of seizures in some people. Unlike many other antidepressants, it does not have sexual side effects. Mirtazapine alters the levels of several neurochemicals in the brain including serotonin. The most common side effect with mirtazapine is sedation, which may make it a good choice for someone with insomnia. It is recommended that mirtazapine be taken at bedtime due to this side effect. Sedation is more common with mirtazapine when taken in lower doses. It is also less likely to cause sexual side effects than other antidepressants. There are several strategies that can be used to decrease the potential side effects of antidepressants. These strategies include starting at low doses and gradually tapering up, taking other medications to counter the side effects, taking the medication at different times of the day, and switching to a different medication in the same class or a different class of antidepressants. It is important not to stop taking antidepressants without consulting with your doctor. Many antidepressants need to be stopped by gradually lowering the dose to prevent withdrawal. Talk with your doctor if you think you might be experiencing depression to see if medications or some other form of therapy are appropriate for you. Depression can affect anyone and there is nothing wrong with seeking treatment. Depression will often not get better without some form of therapy. If you are concerned that you may have symptoms of depression ask to speak with your dialysis social worker. Your social worker can help you assess your mood and come up with a plan for treatment. Living Happy no Matter the Hand You're Dealt Anastasia Korbitz, LCSW It is certainly easier for me to give advice than take it and it is easier for me to judge how others should be living when I'm not the one walking around in your shoes. But, for the brief time I have been a social worker in dialysis (7 years) I have learned a thing or two from patients who have done well and those who have not. There's a ton of research out there to tell you how to live well, but the fact is, it comes down to YOU. Social workers can give you all kinds of ideas, some will work and some won't. Or you can join classes that have you laughing to relieve stress, screaming til' you turn red or living in a commune and eating organics. You can get in touch with your inner child, your outer adult or go to pet therapy with your doggie. You can search and search for happiness in spite of your condition, but the best place to start is with YOU. How well do you know who you really are? We go about our days running here and there, meeting the needs of others, putting things on hold waiting for a better time. So, when was the last chance you had to go inside your own thoughts and ask yourself, who am I anyway? What makes me happy? What makes me sad? How do I cope with sad news? I will ask new patients, "What is a goal you have over the next few months and years?" Some patients have no idea. I will then ask "when times are hard, how do you cope?" I get blank stares. "I don't know ", some will say," I just do I guess", is a common response I hear. Having personal goals, even if they seem minor, and understanding how and why you cope are two important things to know about yourself. Since we are humans, we will all experience loss, disappointment and change over the course of our lives, but who are the people who recover and remain the most resilient? It's the folks who know themselves and their capabilities. It's those who can readjust to new circumstances and take control where and when they can. It's those with great attitudes. Think about someone you know that has faced adversity with grace and gusto, what qualities did they have, what can you learn from them? Now, let's get to the deck of cards metaphor. Think about the hand you have been currently dealt. In a card game, where do you usually start, well first you organize the cards in a way that is helpful and meaningful and determine your best strategy, right? Whoops, an unexpected card was taken by the bloke next to you, now what do you do? You come up with a new strategy and so it goes. Taking new cards, eliminating others, out-foxing your opponents, strategizing, reorganizing, and on and on. Think of your life right now and the cards you have been dealt. You can certainly organize your life in a way that is meaningful to you. Do you find comfort from being with others, going to church, exercising? Prioritize these meaningful parts of your life. Are there some things that you need to readjust in your life, strategize, or change? Well, it can be done. You will need to determine what you have control over and what you don't and change your strategy as new life challenges come your way. So what is your strategy with your hand of cards? Are you going to draw another card, discard one that is no longer useful, pass off a card to someone else, or are you going to fold? Hmm..sounds like you will have to continue changing your cards dealt until you have something resembling a winning hand and something you can at least work with! But that's what is great about cards and life in general. Once you know yourself better, you can make some changes. Certainly, the original hand dealt is just a-luck-of-the-draw, but what you do with the cards dealt is up to you. If you've Got Meaning, You've Got Life! Chaplain Penny Andrews I have had the privilege of being around the dialysis and transplant culture for almost 30 years now. And I have noted over the years, and it is still true today, that the resilience and inner strength needed navigating kidney disease requires every bit the courage required to live with a cancer diagnosis. The dialysis stories just aren't out there in the same way. But each day a dialysis patient wakes and moves forward, requires a recommitment to Life and the things that bring meaning to life. This is what is called the spiritual journey. Actually, we are all on this journey. Dialysis or a diagnosis of any kind, calls us to look within and evaluate what is most valuable and meaningful. The more we live aligned with what we call our spiritual "meaning", the more enlivened we feel. As it has been said, spirituality isn't 'a piece of the pie, it is the pie plate.' It's what holds our lives together. For some spirituality is a deep and abiding faith, for some it is not. Spirituality may take its meaning in the realm of family, nature, connections with friends or music. It may be in the form of a God, or it may be some combination of all of it. It is in our essential commitment to this thing we call Life and spending time with what we have identified as meaningful to us. This commitment to a Life of meaning then spills over into all all aspects of spiritual life. It affects our awareness and this affects our choices. Spirituality is what plays into our choosing to have a mindful approach to how we eat; knowing that food is what sustains and nourishes our bodies. Our bodies are the home of our spirit. This attention to nourishing ourselves well in turn improves the overall quality of our lives. Spirituality is the attention we give to being intimate with someone, knowing that our sense of touch is very important to our well-being. This spiritual celebrating of our bodies through touch, however we are able to, can have a profound effect on our Life meaning. How we touch today may differ from the earlier ways of touching, but it can have a wonderful and profound impact whenever two people choose to connect. And attitude, to commit to making one's life as full and rich as possible given any circumstance, changes everything and is also a form of spirituality. Committing to Life in the fullest, knowing that awareness and meaning are the foundation of one's spiritual 'pie plate'. Make each slice of your pie, a sweeter taste, no matter what. .and don't forget, a sense of humor is good for you too.. A car was involved in an accident. As expected, a large crowd gathered. A newspaper reporter, anxious to get his story, could not get near the car. Being a clever sort, he started shouting loudly, "Let me through! Let me through! I am the son of the victim. "The crowd made way for him. Lying in front of the car was a donkey. From the Director's Chair: SEX and Kidney Disease Paul Kellerman, MD Now that I've got your attention, I felt it appropriate to talk about a topic that is very important to most people, given the emphasis on coping and living well in this issue of Pathways. Sex is not only a fact of life, but a very important part of most people's lives. Age is not necessarily a limiting factor, as many people are sexually active their entire lives. Close personal relationships with intimacy, even without active sex, provide important emotional support for all people, particularly in the face of illness. Illness can significantly affect people's sex lives. People with kidney disease undergo changes in their sex hormones, which normally contribute to having a good sex life. Testosterone levels drop, estrogen levels drop, overall energy levels decrease and there is often depression in adjusting to a life on dialysis. More than 50% of men have symptoms of decreased sexual desire, impotence and decreased sperm counts. Women have decreased desire, decreased ovulation and fertility and much higher rates of miscarriage. Women on dialysis rarely carry babies to term but women who are transplanted can often have children if they so desire. The causes of decreased sexual function include uremia (the illness from kidney dysfunction), anemia (low red blood cell counts), certain medications, and other medical conditions that interfere with sexual function, such as diabetes, hardening of the arteries, and depression. Once on dialysis, some patients may do better sexually than prior to starting dialysis , mostly due to dialysis clearing the uremia, but a majority of dialysis patients still have sexual problems. The treatment of sexual dysfunction in men and women is initially the same: making sure patients receive adequate dialysis, correcting the anemia, removing medications that interfere with sexual function, if possible, and treating depression if present. There are also specific treatments available as well. Women may require female hormones such as estrogen or progesterone to undergo normal menstrual cycles and men may require testosterone if their levels are low. Prior to 1998, for men, there were medications that helped with erections, either introduced into the urethra, or with injections. With the introduction of Viagra 9 years ago and similar medications in recent years (such as Cialis and Levitra) that dilate blood vessels and cause erections, these pills are now the primary method of helping men with impotence. These pills must never be used if you are taking nitrates for heart disease (either by patch or pill), for the combination of these medications can drop your blood pressure dangerously low. Also, if you have active heart disease, for example angina, it can be harmful to use these medications. There is very little data on use of these medications in women, but there are some indications that these agents may increase sexual desire and satisfaction in women too. If you are concerned with any sexual problems, please talk initially with whomever you are most comfortable with -- your nurse, social worker or doctor. We help patients deal with this problem all the time. Then, your doctor can discuss your treatment options and individualize the treatment for you. Every heart sings a song, incomplete, until another heart whispers back. Those who wish to sing always find a song. At the touch of a lover, everyone becomes a poet." -Plato What is a Nurse Practitioner? Deb Krembs, MS, APNP-C Hi, my name is Deb Krembs and I am the new Nurse Practitioner working at WDI. Some of you may have already seen me tagging along on dialysis rounds. Hopefully I will soon begin to remember your names without looking at my "cheat sheet". In the meantime, feel free to tell me your name and anything else you want to share. I would also love to know how long you have been on dialysis, and what medical condition led you to dialysis. I have a lot to learn from you and welcome any suggestions you have for me to improve while providing this piece of healthcare for you. Here is some information on what is required to become a certified Nurse Practitioner (NP). Currently, a NP is first required to become a Registered Nurse (RN) with a Bachelor's Degree. After completing the RN exam, graduate school is required to become a NP. The Master's Degree, which generally takes an additional 3 years, includes intensive study in all areas of medicine and pharmacology, followed by a national written exam to become licensed as a NP.] NPs can also study and practice in many different areas of medicine and subspecialties which requires yet another written exam after a minimum number of hours or years in training have occurred within that subspecialty. After being licensed and then certified, we are allowed to write prescriptions, as well as diagnose and treat medical conditions within the boundaries of the work environment. NPs have a collaborative agreement with the physicians in their practice, which means the physicians are available to consult for health problems that are hard to diagnose or treat. Okay, so what will I be doing at WDI? My focus will be to do the weekly rounds on each one of you on dialysis, and to see other patients with chronic kidney disease in the clinic. My subspecialty is Diabetes Management, and in the future I would like to schedule small group classes for patients with diabetes and chronic kidney disease. If I can help with some part of your diabetes management, let me know. I am a firm believer that knowledge is power, and patients need power over chronic medical conditions. "POWER TO THE PATIENTS" will be my motto. Since my office is located at WDI, I am readily available for teaching and/or learning. Have one of the WDI staff page me or call me in my office. I look forward to meeting each one of you and consider it an honor to be involved in your healthcare. And, introducing our new Social Worker.. Hello, my name is Deb Parker and I am a new ½ time Social Worker at WDI. Since my first day of work (May 29), I have learned so much and met so many welcoming people, both patients and staff. I am not new to UW Hospital & Clinics as I worked as a Social Worker in the Hospital Admissions Department for over 10 years. I may have assisted some of you with Disability and Medicaid applications during that time. My office is located off the waiting room (I share it with Helen). I will work primarily with the MWF morning patients, the MARS patients and will cover social work duties as needed. I look forward to meeting and getting to know more of you at WDI.