Is this really true? Almost all of my patients have their sodium go up after dialysis (although they are hyponatremic to begin with).
Daily weights helps with the volume status, and they get home BP cuffs and instructions. It takes a Dialysis Nurse - not me - two months to do the training for HD (only a month for peritoneal), step by step and with lots of return demos and follow up phone calls. By the time I take over, the clients know more about dialysis than I do. (I know very little; it’s never been my field, although I would like to become proficient if the opportunity ever presents itself.) And they still have phone contact with their Dialysis Nurse as long as they need it.
'sWhat they tell me. Heh. Maybe that’s why they end up with higher sodiums, maybe it’s not working as well as they think. Or maybe their sodium is just up because you’ve taken off the excess fluid? Again, don’t know much about dialysis, sorry if that’s idiotic.
Yeah, if insulin fails, what happens next is more commonly referred to as “death.” At our current level of technology, that is.
There are pumps, and there are CGMSs, and there’s one or two pumps out there where they have the pump controller and CGMS receiver in one unit, but none of them are integrated to the point where the pump automatically uses the CGMS data for dosing insulin. No CGMS out there is stand-alone, either; they all require finger stick glucose readings to calibrate. And none of them are accurate enough that the manufacturers recommend dosing based on their results; they all back away from that promise and say to double-check with finger stick glucose readings. I’m not saying that people don’t do it, but it’s not recommended.
I have a pump, and I have a CGMS, and I like 'em both. But the CGMS is not at all foolproof to the point where I’d trust it to act on its own in regards to insulin. It’s accurate enough that I use it to see trends, and it alerts me when I go high or low, but I don’t trust it enough not to double check what it’s telling me before I do anything based on the info it gives me.
Case in point: a couple days ago, 4+ hours after I ate anything, sitting at my desk doing nothing, the CGMS decided that my blood glucose went from around 100 to over 200 in the span of about 15 minutes. That simply doesn’t happen. Finger stick said I was right around 100. Had that thing been integrated with a pump, I’d’ve been in a world of hurt for a few hours after it corrected that imaginary spike. And that’s why I’m saying that the technology is not quite there for something like this to be controlling our imaginary blood-sugar-filter-machine.
My current experience is that nowdays, most pumps are ‘CGM capable’, even the Omnipod, which is a very simple pump. The ‘fully integrated’ or ‘closed loop’ system is in development, and has been trialed in children with good results. That’s an ‘artificial pancreas’, not a pump/CGM. The current ADA recommendation is for pumps and CGMs at the current level of tech, which admittedly is developing extremely rapidly. Insurance companies are also becoming better about paying for pump/CGM equipment; the ADA position paper on the treatment of type 1 was meant, in part, to hurry that along.
The ADA is also trying to officially discourage the use of the term ‘Juvenile Diabetes’ as inaccurate. The point being that there are many more adults with type 1 than there are children, and the disease (as either LADA or MODY, can certainly occur in adults, and does a lot more often than we used to think. Your own experience is a good example.)
Most of the type 1 people I talk to as part of my job would not be in favor of having an artificial pancreas. They like using the pump, and they like having the control over the dosing themselves. I even talk to a few who don’t want a pump at all, or who have had bad experiences with them. And the current pump tech is not at all friendly for people with vision problems, which is a big issue that needs fixing.
When they finally get the artificial pancreas tech up and out there, I think it will change things dramatically for a lot of people, but will also have its own set of issues. It’s going to be exciting to watch.
What do you mean by a pump being “CGM Capable”?
Rather than just being a computer-controlled pump which dispenses insulin, they are able to store periodic blood glucose levels (continuous glucose monitoring). Seeing the track show when your blood sugar goes up (say, every night at 2 am) allows you to program the monitor to nudge the insulin up a little bit at 2 am, to see if you can make the spike go away.
This is confusing to me - you’re describing a CGMS plus a pump, unless you mean that the pump automatically will adjust itself according to CGMS data? I didn’t think any pump/CGMS offered that capability yet, nor is CGMS accuracy to the point where you can do that.
Artificial pancreases, which combine an insulin pump, a glucagon pump (which will raise blood sugar if it goes low) and a CGMS are in development and look pretty damn cool. But I don’t think that’s what we’re talking about here.
The MedTronic version that I read a pamphlet for had the pump, which looked like a bulky pager and clipped to the belt, and the monitor, which looked like a refrigerator magnet, about the size of a quarter. The monitor got poked into the skin on the belly, and the pump went in somewhere else. The pump just follows its programmed schedule and squirts a tiny bit of insulin under the skin every once in a while. The monitor checked serum glucose levels every 15 minutes and transmitted the info via wifi to the pump. You could bring up a little graph on the pump showing the last N hours of glucose levels. All changes to the amount of insulin pumped, and when, were manually programmed into the pump.
The pamphlet seemed to indicate that finger-sticks would be a thing of the past, but somebody mentioned upthread that the reliability isn’t there yet, and the remote monitor was just there to give you a WAG baseline for what your levels might be like between meals or overnight. The writers of the pamphlet may have been trying to get me to buy their product…
My cousin did home PD for a while before he had his transplant (he inherited a disease - IDK what it’s called - from his mother, who died before she had a chance to get a transplant). He had a machine that he hooked himself up to 6 nights a week, and was still able to work full time, look after his kids, etc.
Home PD is also done for children. A special dialysate is drained into the abdomen, allowed to dwell for an hour or so, and then drained out. It should be done 3 or 4 times a day, but often isn’t.
I’ve read about home HD being done more frequently in the 1960s and 1970s, when the procedure was new anyway, than it is now.
By CGM capable, I mean that the pump has the capability to integrate with the CGM and can be used with or without a CGM physically attached to the pump or connected to the pump by bluetooth. The pump receives the reading from the CGM and can suggest an action, which the pump user can choose to approve, modify, or ignore. Many pumps are also programmed to do this with a glucometer. For example, the Omnipod pump has no controls (or very few) on the pump at all; the pump controller is a bluetoothed remote that has an Accucheck Freestyle glucometer built in. (Losing the remote is a common problem that I’ve helped a lot of the people I work with troubleshoot).
There’s a somewhat outdated and incomplete listing of insulin pumps and their capabilities on the ADA website HERE . The ADA does consumer guides of meters, pumps, and other items in January each year. The new one will be out soon, and I’m excited to see what’s new, as the field is advancing so rapidly it can be hard to keep up with! The best thing that could happen now would be the resolution of the real time and accuracy issues between CGMs and meters. That would help a lot and move things one step closer to systems that don’t need intervention.
Of course, the stem cell research that’s ongoing could render a lot of this unnecessary. And that would not be a bad thing.
I guess what confused me on this is that really only one pump - the Minimeds - are a little bit integrated with the CGMS. The Omnipod is in no way integrated with a CGMS, and neither are any but the Minimed that I know of, and the Minimed’s integration is more or less limited to displaying the CGMS graph and (on one model) automatically suspending insulin deliveries in hypoglycemic situations.
Nobody yet is dosing insulin based on CGMS input. I wish the technology was at the point where they could, but not yet! Soon, hopefully. The artificial pancreases look very, very cool, can’t wait for them to be ready for prime time.