I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: Diet and Recipes => Topic started by: kristina on March 10, 2009, 04:49:54 AM
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Dear friends, I would again appreciate your comments: my kidney-function fluctuates between 9%-12% and I feel poorly. I read that end-stage kidney failure patients drink as much liquid (teas, etc) as possible, every 10 minutes a sip, up to 4 litres a day, to stay clear of dialysis for as long as possible. The weight of people drinking such an amount of liquid was not given. My weight is 59-60kg and I wonder if I drink 4 litres of liquid a day would I be overdoing it and rather harm my kidneys instead of keeping them going for as long as possible before dialysis? I weigh myself every morning, check through my weight if there is any water-build-up and it still works well. Thanks, Kristina. E-mail: schmidt56@yahoo.co.uk
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Dear friends, I would again appreciate your comments: my kidney-function fluctuates between 9%-12% and I feel poorly. I read that end-stage kidney failure patients drink as much liquid (teas, etc) as possible, every 10 minutes a sip, up to 4 litres a day, to stay clear of dialysis for as long as possible. The weight of people drinking such an amount of liquid was not given. My weight is 59-60kg and I wonder if I drink 4 litres of liquid a day would I be overdoing it and rather harm my kidneys instead of keeping them going for as long as possible before dialysis? I weigh myself every morning, check through my weight if there is any water-build-up and it still works well. Thanks, Kristina. E-mail: schmidt56@yahoo.co.uk
Never heard anything like that to be honest. When I was at those levels (and not on Dialysis) my doc just told me to eat/drink as per normal (well avoid salt and that sort of thing). I am not sure that deliberately drinking large amounts of liquids, specially stuff like tea, coffee, soft drinks etc - all with stuff in them the kidneys have to filter - is such a smart idea - I mean if your kidneys are failing pushing them to do more doesn't seem so smart. Flushing with water might aid a small amount, but I honestly have never heard of that sort of form of staving off dialysis. Still i guess if it works for you then why not.. though personally I would run this theory by the neph. Your own situation may contra-indicate that sort of approach for reasons you hadn't thought of. I hope you keep off dialysis for as long as possible :)
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Monitor your ankles. If they get swollen (or disappear) then your kidneys are not working well enough to get rid of all the fluid. Don't eat salty foods so you won't be thirsty. You can try drinking lots of water but I think to drink as you are thirsty would be fine.
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my doctor did not put me on a fluid restriction until I started dialysis and as long as I was urinating there was not limit - but thing changed- after awhile on dialysis my urine output got very low - I am on 50 ounces a day -- that counts jello or anything that will melt at room temperature -
I never follow it --- I live in Texas and it can get so hot and humid - the doctor has never said that I gain too much in between treatments -
honestly, I wish I would have been told to drink that much --- except for the fact that I was teaching school, it would have been wonderful
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My kidney fucntion is 15% and my neph tells me to drink lots of water to stay hydrated. If I don't drink enough water, I do feel effects of nausea more.
I drink about 5 to 6 tall 16 ounce glasses of water per day. Luckily, I don't retain much water in my ankles, though I do notice it in my face and abdomen.
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Thank you very much for your thoughts, I am so glad that I asked the forum because logic tells us it is better to take great care of our fragile kidneys instead of putting great pressure on them by drinking 4 litres of liquid a day. That seems a little harsh on kidneys who just about try to hang on. It is just that I have read this information, was not quite sure about its logic and as there has not been much research done into this, I thought it a good idea to ask the forum about logical experiences. Thank you.
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With a GFR of 9-12 you should be on dialysis now. Talk to your nephrologist.
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With a GFR of 9-12 you should be on dialysis now. Talk to your nephrologist.
Dear Wallyz, sorry that I did not make myself clear: to drink up to 4 litres of liquid a day was suggested by a nephrologist in a medical paper. In another medical paper another nephrologist suggests that patients in end-stage kidney failure should measure their "output", add 600ml to the amount & they should drink exactly such an amount of liquid per day. Another medical article suggests that patients in end-stage renal failure before dilaysis can eat and drink what they like. I got a little confused and dizzy reading these contradicting medical suggestions & I wondered how other patients are dealing with such contradicting medical advice? Which option do they choose? Another riddle is the fact that apart from my high Creatinine of 436 (during an influenza without any antibiotics because of my severe drug-intolerance) and my fragility, nothing would indicate my end-stage renal failure: my BP is perfectly under control with 120/70, I check it at home regularly, my weight has not increased, my “output” reflects exactly my “input”, and because I suffer from a very rare form of MCTD/SLE, my hope is that by supporting my kidneys the best I possibly can with diet and the least stressful fluid-input etc, I give my kidneys the best possible chance to “hang on” for as long as possible, this might give me a chance to be lucky and find a specialist who can tell me what precisely is going on to cause my kidney failure – and maybe...
Dear Walllyz, please excuse my asking but could you please explain me your startling logo? Are you a dog-handler or looking after strayed dogs? Please excuse my asking, but English is not my first language and your logo startles me a little. Thank you from Kristina.
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Dear Wallyz, sorry that I did not make myself clear: to drink up to 4 litres of liquid a day was suggested by a nephrologist in a medical paper. In another medical paper another nephrologist suggests that patients in end-stage kidney failure should measure their "output", add 600ml to the amount & they should drink exactly such an amount of liquid per day. Another medical article suggests that patients in end-stage renal failure before dilaysis can eat and drink what they like. I got a little confused and dizzy reading these contradicting medical suggestions & I wondered how other patients are dealing with such contradicting medical advice? Which option do they choose? Another riddle is the fact that apart from
I believe the confusion you are seeing is because the "measure output and add 600ml thing is almost certainly a suggestion for those *ON DIALYSIS* - down here we use a figure of 500ml plus output for a *recommended* daily amount of intake. For instance I output around 100-200ml a day, so in theory I'm supposed to keep it to about 700ml max. What I do in practice is I keep to 2kg (2000ml) between treatments, so that means I go around 1l or so a day. The 500ml (or 600 if you prefer - not THAT much difference) is derived from the usual fluid loss through sweating and what the body absorbs naturally.
So you're trying to corelate two different suggestions for two different situations (one pre-dialysis, and one during)- of course that will cause confusion!
btw you think a 436 creat is hight? LOL. Mine last week was measured as 1000!
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Dear Wallyz, sorry that I did not make myself clear: to drink up to 4 litres of liquid a day was suggested by a nephrologist in a medical paper. In another medical paper another nephrologist suggests that patients in end-stage kidney failure should measure their "output", add 600ml to the amount & they should drink exactly such an amount of liquid per day. Another medical article suggests that patients in end-stage renal failure before dilaysis can eat and drink what they like. I got a little confused and dizzy reading these contradicting medical suggestions & I wondered how other patients are dealing with such contradicting medical advice? Which option do they choose? Another riddle is the fact that apart from
I believe the confusion you are seeing is because the "measure output and add 600ml thing is almost certainly a suggestion for those *ON DIALYSIS* - down here we use a figure of 500ml plus output for a *recommended* daily amount of intake. For instance I output around 100-200ml a day, so in theory I'm supposed to keep it to about 700ml max. What I do in practice is I keep to 2kg (2000ml) between treatments, so that means I go around 1l or so a day. The 500ml (or 600 if you prefer - not THAT much difference) is derived from the usual fluid loss through sweating and what the body absorbs naturally.
So you're trying to corelate two different suggestions for two different situations (one pre-dialysis, and one during)- of course that will cause confusion!
btw you think a 436 creat is hight? LOL. Mine last week was measured as 1000!
I still cannot find the original article but found my notes about it and they gave an example that if you drink 2 litres you should add ~600ml and drink that amount of liquid next day, because - according to the article - that should be the amount of liquid the kidneys still feel comfortable with "to work through". BP & weight should be checked daily and signs of water-retension should be observed. That is what the article said.
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I only get to drink 400 everyday and it's really hard to control. I cheated loads of time and I know it pressurise my heart but is there any topic that can teach me to overcome my fluid problems. I feel like getting a heart disease really soon if I keep doing it.
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I still cannot find the original article but found my notes about it and they gave an example that if you drink 2 litres you should add ~600ml and drink that amount of liquid next day, because - according to the article - that should be the amount of liquid the kidneys still feel comfortable with "to work through". BP & weight should be checked daily and signs of water-retension should be observed. That is what the article said.
I think this just continues to confuse the issue.
I am talking about rules for those on dialysis - specifically hemo dialysis (because PD is different, and I guess nightly hemo also - because there is little need for fluid restrictions for those folks). However for those of us doing the usual 3x/week hemo sessions the basic rule of thumb is whatever your OUTPUT is (note, not what you drink, but what you output) per day PLUS 500ml to cover natural loss via sweat etc. The idea is only to really replace what you put out to minimise the stress on the heart and lungs from creating fluid overload - which is very serious.
Of course you also have to be careful to not become dehydrated as this can cause it's own bad consequences. Unfortunately it is a somewhat delicate balance - even more so because the dry weight which such things are taken from as a base is pretty much an educated guestimate anyway....
fluids are the hardest thing to deal with in terms of dialysis for me - without doubt.
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I only get to drink 400 everyday and it's really hard to control. I cheated loads of time and I know it pressurise my heart but is there any topic that can teach me to overcome my fluid problems. I feel like getting a heart disease really soon if I keep doing it.
Kidney disease does put stress on your heart. Having a fluid restriction is hard. I chewed lots of gum.
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I only get to drink 400 everyday and it's really hard to control. I cheated loads of time and I know it pressurise my heart but is there any topic that can teach me to overcome my fluid problems. I feel like getting a heart disease really soon if I keep doing it.
Try to be very very careful about how much sodium or salty foods you eat and you will probably find it a bit easier to keep your fluids down.. Not easy though, I know.
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Remember, the amount of fluid allowed varies depending on whether you are on dialysis or pre-dialysis. I think Kristina is still pre-dialysis and her fluid intake should be higher. I am pre-dialysis and I know that I absolutely must keep well hydrated to combat toxin build-up. We should all watch sodium intake regardless. I drink at least 3 litres of water a day and rarely drink anything else (except for 1 cup of coffee in the morning and the occasional glass of red wine). All that, and I'm still thirsty, so I chew gum and suck on mints. Of course, your nephrologist is the best guide for what is right for you and your particular medical condition.
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Oh GOD! To be able to drink 3 litres a day!! Ahhhhhhhhhhhhhhh. Without doubt, for me the hardest part of being on dialysis is the fluid restriction. People often ask if I'm 'allowed' to drink alcohol (I used to love a glass or 7 or bubbly) and it's hard to explain that yes, I can actually drink alcohol, but when you're on a litre a day fluid restriction, you don't go wasting it drinking alcohol. The days of stitting with my mates drinking a few bevvies has gone - that would be my whole day's worth in one sitting ha ha. But anyway, back to the topic! Just don't do anything without talking to your own neph!
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I have heard that there are some nephrologists recommending their PKD patients drink at least 4 liters of water a day (more if you are a larger person). This is because it's not known to harm, bar a few conditions, and because of the current clinical trials going on which are looking at blocking the action of vasopressin (anti-diuretic hormone) to stop its direct involvement in cyst growth. It worked on mice pretty well. So there is a trial on using Tolvaptan to do that and a couple recruiting to get people to drink a lot of water to minimise output of vasopressin. My doctor said it was OK for me to do it so I do drink about 4-5 litres a day. I don't notice any water retention. I guess it is something you'd have to discuss with a cluey nephrologist.
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Hallo, Sunny,
Yes, I am pre-dialysis like yourself.
Why should my fluid-intake be higher?
Is it not dependent on the weight/size of the person?
Or is it independent?
I weigh 59kg and I am medium-build
and the amount of liquid I drink per day is
what my kidneys manage without difficulty
and without water-retention.
You say you drink at least 3 litres of water a day,
plus 1 cup of coffee and the occasional glass of red wine,
what is your weight and size?
I am only asking because there seems
so much contradicting information
and I try to find an answer and
keep my kidneys happy for as long as possible.
Thank you.
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I could drink huge amounts pre-dialysis because I still peed a lot although the urine was basically liquid without removing the toxins etc. After ten months back on D I was only peeing about a third of a cup a day. This is a very individual issue and does not depend on the size of a person. Some people retain fluids pre-D, some do not. BP, and salt intake and many other factors are hugely variable from one person to the next. Even on D, fluid restrictions will vary because people's stages of ESRD and function vary. Weighing yourself every morning is a good way to figure out if you're holding on to fluids because it's not always as obvious as swollen ankles or puffy eyes. If there's one thing we MUST realise, it's that there's simply no such thing as universal "rules" in all this stuff. There are guidelines and such but the range of individual differences between kidney patients is about as great as the range of differences within the "normal" population. Also PD is different than hemo, pre-D is different than D and one year on D is different than 10 years on D.
I think Richard already said all this so I apologize for the repetition.
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Thank you, Monrein,
Please don't apologize! You see,
for "us beginners" it is so important
to comprehend the maze of information
and as everyone explains things differently,
there is a chance for us beginners,
to understand the real issue much better.
Thanks again.
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Oh GOD! To be able to drink 3 litres a day!! Ahhhhhhhhhhhhhhh. Without doubt, for me the hardest part of being on dialysis is the fluid restriction. People often ask if I'm 'allowed' to drink alcohol (I used to love a glass or 7 or bubbly) and it's hard to explain that yes, I can actually drink alcohol, but when you're on a litre a day fluid restriction, you don't go wasting it drinking alcohol. The days of stitting with my mates drinking a few bevvies has gone - that would be my whole day's worth in one sitting ha ha. But anyway, back to the topic! Just don't do anything without talking to your own neph!
oh man I am so there with this!!!
It's funny the numbers of people who, when I explain I am on fluid restrictions, seem to assume it is only about booze... "So you can't have a lot of beer?" umm.. no I can't have a lot of ANYTHING! It usually takes two or three goes to explain it's ALL fluid.. and even stuff that you wouldn't consider "fluid" like ice cream, custard, and all that.
Yeah I would SOOO love to be able to drink 3L of water a day!! I don't think people really realise how much they drink(this is not a bad thing, btw) until you have to give it up. Without a doubt this is the hardest thing for me.. specially when workmates on a Friday want to go for after-work drinks... I have one if I'm doing well with the fluids and that's my limit, and that's not a drink - that's a bloody tease!! :rofl;
I think we need to be VERY CLEAR about the difference between pre-dialysis and during-dialysis fluid restrictions because that can seem very confusing. For me, pre-dialysis I drank pretty much anything and everything. I was told to check for fluid retention and all that but it was never an issue for me, and I was always drinking 2-3L of just water a day (not including tea/coffee/soft drinks oh and beer :) )and those were good, good days!! I miss them!!! :rofl;
The message to check with your neph before changing anything like this is SO important!!
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My limit is 400ml a day :/ that's all :(
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Ouch. 400ml!!! I'm allowed 1 litre. First time I've felt like that's a huge amount. How do you do it? That's only two drinks! Do they make you include yoghurt/breakfast cereal milk etc in that?
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Indeed! 400ml would be well... very difficult to imagine how to keep to that. However having said that humans are amazing in what we can get used to and come to consider normal. Prior to dialysis I couldn't possibly imagine keeping to 1L or less of fluid a day!! I drank 2-3L just in water let alone tea, coffee other drinks!! The prospect was one of the most difficult i ever faced. I guess it's a matter of will power - I imagine I could meet that limit pretty much, but it's not something I ever want to test!
My hat goes off to you.
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Hallo, Maxridex,
Please tell me why are you so restricted with your fluid-intake?
And how do you regulate this minimun on intake every day?
Do you have a glass with 400ml liquid standing and every hour or so
you allow yourself to take a little sip?
And why is Hanify allowed one liter of liquid per day?
Is it connected with the fact that the kidneys of Hanify
are functioning a little better than the kidneys of Maxridex
despite the fact that both are on dialysis?
Or is it connected with different methods of dialysis?
I am still pre-dialysis and I am still puzzled.
Thank you for your answers. Kristina.
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For those with no kidney function left, some centers may determine the daily fluid intake (gain) by using the dry-weight of the person and how many hours per treatment on the hemodialysis machine.
This is one formula that may be used: 10 ml per kilogram of body weight per hour.
It is about how much fluid can be removed by hemodialysis per hour without causing major side effects.
So if you weigh 60 kg, that's 600ml per hour you can remove. If your're on only 2 hours per treatment, that's a total of 1.2 kg you can gain. If you're on four hours, your total fluid gain can be 2.4 kg.
There is a more conservative formula that regardless of body size, one should not remove more than about 400 ml per hour because that is about the same rate at which fluid shifts from the tissues to the bloodstream.
http://www.nocturnaldialysis.org/lowbp.htm
8)
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Thanks Zach for making it so very clear.
I shall bear this in mind because it will help me
when the time comes. Thanks again!
Kristina.
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Also Kristina, I am on PD which is much kinder re the fluid. When I was on haemo I had to be much more careful. On PD, although you still have a restriction, it's not such a big deal if you go over - you can just re-jig the dialysis you do and take a bit more fluid off over the day.
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Thanks again, Hanify.
I am very grateful that this point is kindly
explained by several people because
the turmoil which goes on in the mind
during the pre-dialysis stage, when one is
panicky, frightened and fears the future
seems to prevent one from thinking cool
and logically, and so the comments given
are very helpful and bring back a structure
to a mind that is disturbed
by the prospects ahead.
Thanks again.
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Do you know if you're going to do haemo or PD? I have done both, but never home haemo. Don't be too scared - it's kind of one of those things that, once you start you do get used to. After a while you can't imagine what you did with all your time before. It does become part of your day, and is definitely better than feeling sick!
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Zach - thanks - that's interesting reading. Because I run a profile I commonly take off 800-900ml in a half an hour block at the start of a treatment (UFR of 1500-1800) under profile six. I do this because say I have to take off 2.4l over a 5 hour treatment (as was today's setting) I get the majority of it off in the first 3 or so hours. My body seems to tollerate the higher UF pull earlier on and I have no problems. We did a refill study the other week and you could see it graphed on the machine and in the "breaks" (when the UFR resets to 100 for 30 mins) I often would refill to 90% which was just fine.
I ound when I did not use a profile and would run at say 480 UFR for the whole treatment by the last hour I would often start to crash or cramp and it was really bothering me. Using the profile has really helped me in that regard - but I know it's not for everyone. Half the nurses in my unit don't believe in it, but I've been doing it for 18 months now and I think even most of them are convinced that for me at least it works.. so they don't give me grief anymore when I want it set (though these days they mostly let me set it myself :) ).
Kristina, the fluid limits are set with two goals in mind (I am now talking about hemo dialysis):
1. Carrying too much fluid is bad for the heart and lungs and can in extreme cases of fluid overload cause breathing problems, heart problems and other severe problems.
2. As Zach suggested, there's a "healthy" amount of fluid dialysis can remove per hour. Because Dialysis sessions are limited to say a max of 5 hours in center (obviously home patients can do runs of 8) that means the total amount of fluid you can safely pull out of a person is going to be less. I know in my unit they WILL NOT take more than 5L off in any one treatment (so that will be 1000ml/hour for 5 hours). I have seen patients come in 7 or 8kg over. They told me of one person once that came in 10kg fluid overloaded (!) scary. More likely than not patients having to take that much off will suffer from pulling so much and cramp or "crash" (low BP, feel faiint, etc.. it is not fun) and of course if you only take off say 5L and someone is 7kg over, then they will leave still carrying 2 litres extra fluid.. and that's not good either.
I was always educated that the "normal" or "ideal" (stupid terms, I think) fluid gain between in-center treatments should be no more than 2kg. With treatments every other day that works out to around 1L(kg of fluid) per day. I can usually keep it to around there though weekends with the extra day are much harder, and requires some will power. Everyone is different though. I find the most I can tolerate being removed in a session is around 3.2-3.5 litres. The most I've ever taken off was 4.1. Some guys in my unit usually always come in 3.5 or so over and they are OK so everyone's experience differs.
I know this is a confusing topic!!! I do think it is something that is important to manage correctly. I'd rather go without now and keep my body in an "OK" state for the hopefully future time when I can down 3 large iced coffees in a row (and then probably puke!! :rofl;)
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Thanks Richard and Hanify for this valuable information.
I haven't yet decided which type of Dialysis to go for.
But let me thank you for this valuable information about the
"fluid-business", it seems a little confusing at the moment,
but no doubt this information will be valuable
when I come to the Dialysis itself and I really appreciate all the replies.
At the moment it seems all rather frightening
but having all this information to refer to
is extremely important to me
as, I am sure,
it is for other pre-Dialysis patients
who read this.
Thanks again!
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Well, speaking for myself (which is all any of us can do) I find PD with a cycler machine at night extremely easy. I mean it. It took a while to get used to being attached to a machine at night, but the dialysis itself is easy. It means I do one 'exchange' during the day (not for long though), and I could do that anywahere. If I wanted to go out after school with my mates I'd take it with me, and do it in a toilet, or my car. It only takes about 40mins, then you're away. I've travelled with my machine to the US and Australia, and am planning to go to Samoa in August. There's issues with your body image - the tube, and the fluid etc, but I much prefer that to doing haemo in centre.
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Thank you, Hanify to let me know,
I shall look into that!
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My Wife Maria chose H.D. in centre. She has been on Dialysis for just over 2 years now.
The original decision was made between the two of us, (because Dialysis affects me as well as her).
The major deciding factor was this-:
IF (god forbid) anything went wrong , then there would be qualified staff on hand to deal with it.
Secondly to that,Maria decided that it was much easier to hide a fistula than a tube, plus at the time there was a major
outbreak of Peritonitis,which, after all she had been through, wasn`t appealing. On top of that, Maria has Goodpastures Syndrome,
a NASTY disease, which basicaly means that your own body is attacking itself (Kidneys and Lungs). Anyway, I digress, the choise?
is yours . P.D. is good for some but not for others and vice versa. You must weigh up the pros and cons of all methods of Dialysis, and hopefully you will find the one you are happy with. Whatever you choose, may it give you a long and active life,
Tony
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You are very kind, Celtic Warrior.
Thanks for you advise and good wishes.
All the best to you both!
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Hanify I would love to do PD/cycler and/or home hemo.. but I love alone and I don't have manual dexterity(spelling?) to handle the needles or the PD stuff - I discussed it with the PD nurse prior to dialysis and we agreed that it wouldn't be a good idea given how easy it is to screw it up and cause an infection or something... so sort of like CW's wife I like in center the staff are awesome (and it is quite social too in a funny way) and I know if anything bad happens they will take good care of me.
I realise doing PD and/or home hemo would be much easier on me with the fluid restrictions and all that, but it's not a realistic option for me. That's OK I am fairly happy with where I am at.
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Thank you for replying and I wish you all the best. I have talked it over with my husband and he feels the same that it would be safer if I would be in a centre. I also feel from the answers that it might be a character thing as well, that some people handle the "do it yourself home-dialysis" and others find it unapproachable. At the moment I feel home-dialysis is not for me. Thanks again for your kind answers.
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The most important thing is that you are making the decision that suits you. It looks like you are too. Once you're an old hat at dialysis it's always possible to change at a later date. Good luck with it all.
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Thanks again! Mind you, my husband and I
are still studying all aspects of Dialysis and
it is great to be able to ask questions here.
That really helps a lot!
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Feel free to pm me or send an email if you want to ask any more detailed questions about PD. We're all here to help in the only way we really can - with our advice.
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Thanks Hanify for the kind offer.
Please feel free to send me an e-mail if
I can assist you with anything.
I do hope your treatment is going alright.
Best wishes from Kristina.
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At the risk of being way off-base because cats are cats and people are people, I will share Harry's story. Harry is my cat and his kidneys are failing. As this has progressed, he pees more and more in his body's attempt to wash out the toxins. I now see him drink frequently from his waterbowl, something I never saw before.
In his body's attempt to remove the toxins, he runs the risk of dehydration and even electrolyte loss. The vet has put him on subcutaneous fluids every other day to help compensate for the lost fluids and electrolytes (apparently a point is reached where the animal cannot drink enough to make up for the loss).
Do humans go through the same process (the body trying to wash out the toxins?) and might this be why a predialysis STILL PEEING kidney patient would be encouraged to drink a lot?
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I feel very sad for Harry just reading that - how horrible.
I don't know that humans are like that although yes I do recall being told to drink water to flush the kidneys as much as possible prior to starting dialysis - but I was also told to keep a watch on my ankles and other areas to look out for fluid retention and obviously if that happened to stop drinking and do something about it. Luckily that never happened to me.
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That's how my kidney failure progressed. After being diagnosed, I was predialysis for almost a year and a half, and that entire time I was peeing enough to keep my dehydrated. I'd wake up thirsty and have to drink a ton of water. My kidneys finally started giving out this year, as far as fluid excretion goes. Now I finally have to rely on PD ultrafiltration each night.
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As far as my liquid-intake is concerned, I have tailored it to my requirements.
Maybe, other people would drink less, or more, than myself.
So, again, like diet, liquid intake is perhaps tailored to the individual and their needs.
Kind regards from Kristina.