Wisconsin Dialysis, Inc.

State of the Unit
What are Nephrology Fellows (who are these smart young people)?
Tips from the Chair: Great ideas from One Patient to Another
Prescription for Health: New Medications for Diabetes
I Wish You Enough
Laughter is healing!

State of the Unit
John Hensey, Administrator

Happy New Year! Time seems to keep flying by faster every year. I already feel like 2007 will soon be over! This reminds me that I better get going fast on achieving Wisconsin Dialysis (WDI) goals for the year. Otherwise, we will run out of time before we know it and important changes will be left undone. An easy to understand plan and sense of urgency are key to being successful in business as well as in our personal lives. Delays in making important changes are costly in terms of our quality of life, self satisfaction, time and money.

All WDI patients play a critical role in achieving important quality of care goals for the upcoming year. You and those close to you are best able to act and make decisions in your best interest. Your active involvement will help ensure you receive the best quality care so you can feel your best. You know yourself and your needs better than anyone else. With that in mind, please include the following simple goals as part of your personal plans for 2007:

Learn as much as you can about living well with kidney failure.
Be an educated and active member of your care planning team.
Attend all of your dialysis treatments and always stay for the full treatment.
Make the lifestyle and diet changes prescribed by your health care team. Exercise, eat the right foods and minimize your fluid intake.
Closely track your monthly lab results. Decide to make the personal choices and changes needed to improve your labs.
For hemodialysis patients, get rid of your catheter (if you have one) by scheduling the appointments and procedures needed to place an AV Fistula or Graft. The type of access used for dialysis is a critical part of you feeling your best.
Communicate often with your health care team and listen to and learn from them.

If you act quickly to follow these simple plans and actions, in addition to other instructions from your health care team, you will be helping yourself to a happier and healthier year in 2007. Just ask us if you have questions about any of these goals and we will help you understand. Maximizing your health and happiness are our basic goals as members of your health care team here at WDI.

Three brief items to highlight from the past year include:

WDI staff members provided about 23,500 treatments to almost 300 patients. WDI nurses also provided 615 inpatient treatments at Meriter Hospital.
The overall patient satisfaction score remained high again this year at 3.6 (on a scale of 0-4). I was very proud of WDI staff members when I saw that you rated us highest in the areas of being friendly, helpful and timely in providing your services. All scores on average were higher than 3.0 so we seem to be generally keeping you satisfied here at WDI, but we want to do even better! According to your scores, areas where we need to improve are: a) showing respect for your privacy and dignity, b) minimizing the waiting time past your scheduled start time, c) providing easy telephone access when calling the unit and d) your impression of safety and security while at WDI.
We continue to strongly promote home dialysis for patients who are eligible. If you are interested in a home based dialysis therapy, please talk to your doctor to find out if you qualify.

We take our responsibility to provide top quality patient care very seriously. We will continue working hard every day to deserve your trust. I hope you all have a great 2007!

From the Director’s Chair
What are Nephrology Fellows (who are these smart young people)?
Paul Kellerman, MD

When Wisconsin Dialysis, Inc (WDI) was formed, it was a fusion of a university dialysis unit (UW) and a private hospital dialysis unit (Meriter). Our goals were to bring the “best of both worlds” to form WDI. These goals are spelled out in our Mission Statement, which is posted in the lobby. Besides excellent patient care, one of our missions is education, both of staff as well as physicians.

Having rested my pen for many months, I thought it was time to introduce you to our fellows. You likely have already met one or more of our nephrology fellows rounding with me or another attending physician.

A nephrology fellow is a physician who is learning to become a nephrologist, or kidney doctor. They have already obtained a four-year college degree, gone to medical school for another four years (where they were awarded their M.D.), and have completed a three-year residency in internal medicine, so they are already specialists in internal medicine. When a person finishes their internal medicine residency, they can practice as a general internist taking care of a variety of adult medical problems, or they can go on to a fellowship to subspecialize in taking care of specific organ problems. For example, a cardiologist takes care of diseases of the heart, an endocrinologist takes care of gland disorders, and a nephrologist takes care of kidney diseases.

In their two year program, our fellows learn how to take care of patients with multiple kinds of kidney diseases. They learn to consult on patients in the hospital for both acute and chronic kidney problems, including dialysis issues, as well as learn to manage patients who have had kidney transplants.

In outpatient clinics, they learn to take care of people with chronic kidney disease that are not on dialysis, as well as patients who have had transplants, and patients with severe hypertension. But the primary activity of nephrologists once they go into practice is taking care of dialysis patients in an outpatient dialysis unit.

The University of Wisconsin nephrology fellows spend one month in their first year, and three successive months in their second year at Wisconsin Dialysis, Inc., learning to take care of patients on dialysis. They round with the attending nephrologists in hemodialysis, attend the home dialysis clinic, and also attend the vascular access clinic where they learn about fistulas and grafts. Although they learn from their nephrology attending physicians, the nurses, the social workers, the dietitians, and technicians, their true teachers are YOU, our patients! By caring for your needs while on dialysis, they learn to be the best kidney doctors they can be for their future patients.

So the next time you see those young, enthusiastic doctors rounding on you, please realize they are board-certified internists with great experience, but are learning from you how to be the best possible kidney doctors. And remember, you are their best teachers.

Tips from the Chair: Great ideas from One Patient to Another
Elizabeth Gebhardt, Dietetic Intern
Fran Kittel, RD

Do you find it hard to eat enough protein? Do you forget to take your binders with meals? Living with kidney disease can be very hard, particularly with regards to the diet! Your dietitian may tell you which foods to eat and which foods to limit. Unlike Pinocchio’s good friend Jimminy Cricket, your dietitian cannot be perched atop your shoulder giving advice for every dining situation. Advice from others can be helpful, however, and who better than other patients just like you!

Several patients at Wisconsin Dialysis were interviewed, asking what they have found to be useful in reaching their own goals. Here are a couple of tips from your fellow patients.

Plan ahead! Make a list or a mental picture of your meals ahead of time. This will help you monitor your meal ahead of time.
Keep your binders with you. Carrying a small container of binders attached to your key chain to remind you to take your binders, particularly when eating in a restaurant.
Prioritize! Don't forget to incorporate protein into your diet, even if you don't feel well. Eating enough protein is important for good immune function and longer life! Make sure to eat the protein containing food first, especially you don’t have the greatest of appetites. Talk to your dietitian for new ways to incorporate protein into your diet.
Treat yourself (in moderation)! Find ways to eat foods that you love without going overboard. Look for food samples at grocery stores in order to get a taste of your favorite food. A little taste goes a long way without harming you. Allow a small quantity as a treat, such as dark soda once per week. Just be sure to take binders with it.
Don't do it alone! Create a support system to help you live with kidney disease. Family and friends are great resources, but there are also classes offered at WDI to help you with things like nutrition and mental well-being. In addition to learning helpful information, you can meet others and swap tips for success.
The dietitians are here for you! Talk to your dietitian if you need information or helpful ideas, including ways to help you achieve and maintain healthy protein intake. You dietitian is an important part of your health care team and available to help you whenever you need them, so don't be shy!

Prescription for Health: New Medications for Diabetes
Kim Holdener, PharmD

Diabetes is a growing health concern in the United States. According to the Center for Disease Control, 1.4 million adults were diagnosed with diabetes in 2004. They also reported that the number of new cases of diagnosed diabetes increased by 54 percent from 1997 through 2004. Diabetes is also the number one cause of kidney disease. Forty percent of patients diagnosed with kidney disease developed their kidney disease due to diabetes. There are many new diabetes medications under investigation and several have been approved by the Food & Drug Administration (FDA) in the past couple of years. This article will discuss some of these new medications and whether they are appropriate for patients on dialysis.

Three new types of insulin have become available in the last year. All three are safe for dialysis patients. The first is insulin detemir (Levemir®), which is a long-acting insulin similar to insulin glargine (Lantus®). Insulin detemir can be used in Type 1 (previously known as insulin dependent or juvenile onset) or Type 2 (previously known as insulin independent or adult onset) diabetes. It lasts for around 20 hours in the body and does not have any peaks associated with its blood levels like NPH insulin. It is approved for once- or twice-daily dosing. When used once a day it should be taken at night. It has similar safety and efficacy as insulin glargine and is available in a vial or for use in pen devices such as the Innolet pen or FlexPen.

Insulin glulisine (Apidra®) is a new rapid-acting insulin similar to insulin lispro (Humalog®) and insulin aspart (NovoLog®). Insulin glulisine should be injected 15 minutes before each meal or within 20 minutes after starting a meal. It lowers blood glucose levels more quickly than regular insulin and lasts for a shorter amount of time. The third new type of insulin is inhaled insulin (Exubera®). Inhaled insulin is available as a powder contained in a small capsule that is opened and inhaled using a special inhalation device. Inhaled insulin should be used immediately prior to meals. Its blood glucose lowering effects are similar to the rapid-acting insulins. Some concerns about the long-term effects of inhaled insulin on the lungs are still being studied. Inhaled insulin can not be used in patients who have any lung disease such as asthma or COPD, or in patients who smoke or who quit smoking less than 6 months ago, as these conditions will affect the drug’s absorption.

There are also two new injectable medications for diabetes that are each in a new class of drugs for diabetes. The first one, exenatide (Byetta®), is approved for use in patients who are taking certain types of oral diabetes medications but need more glucose control. It is only approved for Type 2 diabetes. Exenatide is not approved for use in patients with kidney disease on dialysis. Pramlintide (Symlin®) is the other new injectable medication. It is approved for use in patients with Type 1 or Type 2 diabetes in combination with insulin when more glucose control is needed. It will usually lower the amount of insulin that is needed to control blood sugars. The medication can also be used in combination with oral medications. Pramlintide is injected three times a day prior to meals. Pramlintide effects how quickly the stomach empties so it should not be taken at the same time as any oral medications Pramlintide has not been studied in patients on dialysis, so it should be used with caution, if at all, for these people.

The most recent new medication for diabetes is called sitagliptin (Januvia®). This medication is also in a new class of drugs for diabetes and was just approved by the FDA in October. Sitagliptin is only approved for use in patients with Type 2 diabetes, either in combination with certain other oral medications or by itself. It is taken by mouth once daily and can be used in patients on dialysis, although a dosage adjustment is needed. Sitagliptin is not effective for treating Type 1 diabetes and has not been studied for use in combination with insulin.

New diabetes medications are constantly being studied, and may offer hope to patients with difficult to control diabetes.. However, they may not all be appropriate for use in patients on dialysis. The long-term side effects of new drugs are still under investigation after they are released on the market and may be unknown at this time. Ask your pharmacist, doctor or diabetes specialist if you have any questions about these new medications.

I Wish You Enough

Recently I overheard a mother and daughter in their last moments together at the airport. They had announced the departure. Standing near the security gate, they hugged and the mother said, "I love you and I wish you enough".

The daughter replied, "Mom, our life together has been more than enough. Your love is all I ever needed. I wish you enough, too, Mom".

They kissed and the daughter left. The mother walked over to the window where I was seated. Standing there I could see she wanted and needed to cry.

I tried not to intrude on her privacy but she welcomed me in by asking, "Did you ever say good-bye to someone knowing it would be forever?” Yes, I have," I replied.

"Forgive me for asking, but why is this a forever good-bye?”

"I am old and she lives so far away. I have challenges ahead and the reality is - the next trip back will be for my funeral," she said.

"When you were saying good-bye, I heard you say, 'I wish you enough'. May I ask what that means?"

She began to smile. "That's a wish that has been handed down from other generations. My parents used to say it to everyone". She paused a moment and looked up as if trying to remember it in detail and she smiled even more. "When we said, 'I wish you enough', we wanted the other person to have a life filled with just enough good things to sustain them".

Then turning toward me she said, "I wish you enough sun to keep your attitude bright no matter how gray the day may appear. I wish you enough rain to appreciate the sun even more. I wish you enough happiness to keep your spirit alive and everlasting. I wish you enough pain so that even the smallest of joys in life may appear bigger. I wish you enough gain to satisfy your wanting. I wish you enough loss to appreciate all that you possess. I wish you enough hellos to get you through the final good-bye."

She then began to cry and walked away.

They say it takes a minute to find a special person, an hour to appreciate them, a day to love them but then an entire life to forget them.

Laughter is healing!
Penny Andrews, Chaplain

Humor contributes to the health of body, mind and spirit. We are accustomed to thinking about what it does for our mind and spirit, but who’d have guessed that something that feels so good could also be so good for your body? How is this possible? According to the Humor and Health Journal (September/October 1996), humor has been shown to have positive affects on the human body.

Muscle Relaxation – A great belly laugh results in muscle relaxation. While you laugh, the muscles that do not participate in the belly laugh, relax. After you finish laughing, the muscles involved in the laughter start to relax (it benefits in two ways).

Reduction of Stress Hormones - Laughter reduces at least four hormones associated with stress response.

Immune System Enhancement - Clinical studies have shown that humor strengthens the immune system.

Pain Reduction - Humor allows a person to "forget" about pains such as aches, arthritis, etc.

Cardiac Exercise - A belly laugh is equivalent to "an internal jogging." Laughter can provide good cardiac conditioning, especially for those who are unable to perform physical exercises.

Blood Pressure – Women, in particular, seem to derive some benefit.

Respiration - Frequent belly laughter empties your lungs of more air than it takes in resulting in a cleansing effect - similar to deep breathing.

Humor is as individual a fingerprint.

Are you a fan of I love Lucy, Johnny Carson re-runs or a Saturday Night Live humor? Think about the TV shows and movies that tickle your funny bone. Have you seen any of them lately?

Niles Crane of Frasier is one of my favorite television characters. I recently watched a season of reruns on DVD, and it was a delight to be laughing out loud!

Humor is a gold mine in the way it contributes to well-being. It is too often left untapped. There is no time like the present to consciously bring more humor into your life. Perhaps it can be part of your New Year’s resolution.

Go on a mission to discover what tickles you and make it part of your day. You may find that the uplift is contagious and you have funny bones located all over your body! Go on….laugh!