My wife, Linda, received a phone call from our IPN provider, Pentec Health. She was informed that we would receive a shipment of three of their protein-enhanced five-liter dialysis bags today/Tuesday, and four on Friday. Assuming Lowe’s delivers the refrigerator on Tuesday, we should be good. Also, we are to receive a phone call this afternoon at 1330 to bring us up to speed on the IPN gambit.

In doing research on IPN, a basic question arises. To wit, why do I need this? Why am I not getting enough protein via my diet, which lately has seen a large increase in protein-rich foods? What’s going on here?

I turned to Perplexity with the following Prompt and response:

Prompt: Is it possible that peritoneal dialysis reduces body protein to the extent that the patient is weak, gets winded after the slightest exertion, etc.

Peritoneal dialysis (PD) can contribute to significant protein loss, which may lead to muscle wasting, weakness, and fatigue. Here’s a detailed analysis:

Protein Loss in Peritoneal Dialysis

• PD patients lose 5–7 grams of protein daily through dialysate, primarily albumin217.
• This loss occurs because the peritoneum allows serum proteins to leak into the dialysis fluid during exchanges27.

Mechanisms Linking Protein Loss to Weakness

1. Muscle Wasting (Sarcopenia)
   • Chronic protein loss exacerbates protein-energy wasting, reducing muscle mass and strength37.
   • Uremia, inflammation, and hormonal imbalances further accelerate muscle breakdown34.
2. Fatigue and Exertional Limitations
   • Protein depletion impairs muscle repair and energy metabolism, causing fatigue and breathlessness during minimal exertion456.
   • Anemia (common in dialysis) reduces oxygen delivery, worsening fatigue6.
3. Inflammation and Metabolic Dysfunction
   • Chronic inflammation from PD increases catabolism (muscle breakdown)37.
   • Acidosis and insulin resistance further disrupt protein synthesis34.

Contributing Factors

• Fluid Overload: Exacerbates protein loss and inflammation7.
• Inadequate Nutrition: PD patients require 1.3g/kg/day of protein to offset losses1. Failure to meet this accelerates muscle loss.
• Physical Inactivity: A vicious cycle where fatigue reduces activity, further diminishing muscle mass45.

Management Strategies

• Nutritional Intervention: High-protein diets (e.g., eggs, lean meats) to counter losses13.
• Exercise: Resistance training preserves muscle mass and reduces fatigue56.
• Volume Control: Optimizing fluid removal minimizes overhydration-related protein leakage7.

Conclusion

Yes, peritoneal dialysis can deplete body proteins sufficiently to cause weakness and exertional intolerance. This stems from direct protein loss, compounded by inflammation, metabolic dysregulation, and inadequate nutritional compensation. Addressing protein intake, volume status, and physical activity is crucial to mitigate these effects2137.

1. https://www.dpcedcenter.org/wp-content/uploads/2021/02/Protein-and-Dialysis.pdf
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC3082414/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC12005912/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC2582327/
5. https://www.nhs.uk/tests-and-treatments/dialysis/side-effects/
6. https://www.dpcedcenter.org/news-events/news/conquering-dialysis-fatigue/
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC9178188/
8. https://www.sciencedirect.com/science/article/pii/S0085253815324741
9. https://onlinelibrary.wiley.com/doi/10.1111/sdi.13194
10. https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2021.653807/full
11. https://www.mdpi.com/2077-0383/12/7/2670
12. http://www.davita.com/treatment-services/peritoneal-dialysis/protein-and-your-peritoneal-dialysis-diet
13. https://advancingdialysis.org/peritoneal-dialysis/nutritional-status-concerns-for-peritoneal-dialysis-patients/
14. https://www.kidney.org/kidney-topics/getting-more-protein-while-dialysis
15. https://homedialysis.org/news-and-research/blog/547-muscle-stiffness-in-dialysis-patients-tips-to-prevent-and-overcome
16. https://onlinelibrary.wiley.com/doi/10.1155/2014/614846

As I have been blogging about, I am in the throes of entry into the world of IPN. The refrigerator to cool the mixture is due to arrive tomorrow from Lowe’s. We expect to hear soon from Pentec to receive the training they provide for IPN usage. Soon to follow this should be the actual receipt of our weekly allotment of IPN-fused dialysis bags.

In preparation for our IPN gig, I quizzed Perplexity about the nuts and bolts of IPN actual use with the following Prompt and results. Doesn’t seem to be all that complicated after all.

Prompt: What are the nuts and bolts of actually using IPN from Pentec?

The nuts and bolts of actually using IPN (Intraperitoneal Nutrition) from Pentec Health involve several key steps and considerations to ensure safe and effective therapy for peritoneal dialysis patients who need additional protein supplementation:

What is IPN from Pentec?

• IPN is a nutritional therapy that adds protein directly into the peritoneal dialysis fluid (dialysate) by replacing some of the usual dextrose with protein. This helps replenish protein losses that dialysis patients experience and supports nutritional status without requiring oral intake123.

How IPN is Prepared and Delivered

• Pentec Health prepares customized IPN bags based on the patient’s specific dialysis regimen and nutritional needs. A Pentec nurse or pharmacist compounds the sterile bags by adding protein to the patient’s cycler or CAPD bag, removing some dextrose to maintain fluid balance14.
• The IPN bags are shipped weekly to the patient’s home and must be refrigerated between 36-46°F. Pentec provides a refrigerator for storage. Patients are instructed to inspect bags for damage or discoloration immediately upon delivery and before use25.

Administration of IPN

• IPN is typically administered daily at home as a replacement for one of the patient’s regular exchange bags, either manually or via cycler. Patients are trained on how to handle and infuse the bags safely25.
• The IPN bag is usually the first bag on the cycler machine or hung to replace one exchange5.

Monitoring and Clinical Support

• Pentec provides a clinical case manager and registered dietitians who work closely with the patient’s nephrologist and dialysis clinic. They:
  • Confirm patient eligibility and customize the IPN prescription.
  • Monitor nutritional status through labs (e.g., albumin levels) and clinical assessments.
  • Adjust therapy as needed based on patient response.
  • Help manage any side effects, such as dehydration, which can occur if IPN causes additional ultrafiltration14.
• Fluid removal goals during dialysis are adjusted carefully. For example, for IDPN (similar therapy for hemodialysis), 75-80% of the total volume is suggested to be removed; similar judgment applies to IPN fluid management14.

Duration and Goals of Therapy

• The length of IPN therapy varies per individual and depends on nutritional needs and response. Typically, improvements in appetite, strength, and energy are expected within a few months2.
• Once protein levels normalize, clinicians may consider discontinuing or pausing therapy to see if nutrition can be maintained independently1.

Insurance and Financial Considerations

• IPN therapy is covered by many commercial and Medicaid insurance plans. Pentec Health handles billing directly and offers flexible payment options and assistance programs if needed2.

Summary Table of Key Steps in Using Pentec IPN

Step	Description
Prescription	Nephrologist and dietitian determine need; PD nurse completes IPN prescription form with Pentec CCM
Preparation	Pentec compounds sterile, patient-specific IPN bags by adding protein and removing dextrose
Delivery & Storage	Weekly home shipment; refrigerate at 36-46°F; inspect bags for damage or discoloration
Administration	Replace one PD exchange bag daily with IPN bag; use cycler or manual exchange
Monitoring & Support	Regular lab tests (albumin), clinical assessments, therapy adjustments by Pentec clinical team
Side Effect Management	Watch for dehydration or other issues; clinical team intervenes as needed
Duration	Individualized; often several months until nutritional goals met
Insurance & Billing	Pentec handles insurance; offers payment plans and assistance

In essence, using Pentec’s IPN involves a coordinated clinical approach with personalized sterile nutrition bags integrated into the patient’s peritoneal dialysis routine, supported by ongoing clinical monitoring and patient education to optimize nutritional outcomes safely and effectively1245.

1. https://pentechealth.com/idpnipn/
2. https://pentechealth.com/media/hi4hdpco/23pen01008-0124-ipn-patient-brochure.pdf
3. https://pentechealth.com/newsroom/idpn-ipn-nutrition-therapy-for-dialysis-patients-what-s-the-difference/
4. https://pentechealth.com/renal-nutrition-faqs/
5. https://pentechealth.com/media/lxgjflej/23pen01071_ipn-home-therapies.pdf
6. https://pentechealth.com
7. https://pentechealth.com/media/bfolvrox/pentechealth_guide-to-idpn.pdf
8. https://www.pharmko.com/blog/understanding-intraperitoneal-nutrition-ipn-and-its-uses
9. https://pentechealth.com/dialysis-clinics/
10. https://pentechealth.com/media/g0kbui5t/patient-and-hcp-proplete-info-sheets.pdf
11. https://www.pharmko.com/blog/how-ipn-supports-patients-with-severe-malnutrition
12. https://pentechealth.com/clinical-assistance-program/
13. https://www.pharmko.com/blog/how-to-monitor-and-adjust-ipn-for-optimal-patient-outcomes
14. https://pentechealth.com/patient-information/
15. https://pentechealth.com/patient-education/
16. https://www.kidneywi.org/wp-content/uploads/2020/11/How-IDPN-and-IPN-Can-Benefit-Your-Patinets.pdf
17. https://www.reddit.com/r/dietetics/comments/17f4zgj/renal_question_idpn/

This blog follows along with my recent prescription to incorporate more protein in my diet to raise my albumin to acceptable levels. It is currently in the mid-threes, where it should be a minimum of five. I also have the lingering question of cause and effect of protein loss and my current tiredness and general lack of git up and go.

To look into this aspect of our dialysis burden, I turned to Perplexity with the following Prompt and result – spoiler – they go hand in glove:

Prompt: Is it possible that peritoneal dialysis reduces body protein to the extent that the patient is weak, gets winded after the slightest exertion, etc?

Peritoneal dialysis (PD) can contribute to significant protein loss, which may lead to muscle wasting, weakness, and fatigue. Here’s a detailed analysis:

Protein Loss in Peritoneal Dialysis

• PD patients lose 5–7 grams of protein daily through dialysate, primarily albumin217.
• This loss occurs because the peritoneum allows serum proteins to leak into the dialysis fluid during exchanges27.

Mechanisms Linking Protein Loss to Weakness

1. Muscle Wasting (Sarcopenia)
   • Chronic protein loss exacerbates protein-energy wasting, reducing muscle mass and strength37.
   • Uremia, inflammation, and hormonal imbalances further accelerate muscle breakdown34.
2. Fatigue and Exertional Limitations
   • Protein depletion impairs muscle repair and energy metabolism, causing fatigue and breathlessness during minimal exertion456.
   • Anemia (common in dialysis) reduces oxygen delivery, worsening fatigue6.
3. Inflammation and Metabolic Dysfunction
   • Chronic inflammation from PD increases catabolism (muscle breakdown)37.
   • Acidosis and insulin resistance further disrupt protein synthesis34.

Contributing Factors

• Fluid Overload: Exacerbates protein loss and inflammation7.
• Inadequate Nutrition: PD patients require 1.3g/kg/day of protein to offset losses1. Failure to meet this accelerates muscle loss.
• Physical Inactivity: A vicious cycle where fatigue reduces activity, further diminishing muscle mass45.

Management Strategies

• Nutritional Intervention: High-protein diets (e.g., eggs, lean meats) to counter losses13.
• Exercise: Resistance training preserves muscle mass and reduces fatigue56.
• Volume Control: Optimizing fluid removal minimizes overhydration-related protein leakage7.

Conclusion

Yes, peritoneal dialysis can deplete body proteins sufficiently to cause weakness and exertional intolerance. This stems from direct protein loss, compounded by inflammation, metabolic dysregulation, and inadequate nutritional compensation. Addressing protein intake, volume status, and physical activity is crucial to mitigate these effects2137.

1. https://www.dpcedcenter.org/wp-content/uploads/2021/02/Protein-and-Dialysis.pdf
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC3082414/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC12005912/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC2582327/
5. https://www.nhs.uk/tests-and-treatments/dialysis/side-effects/
6. https://www.dpcedcenter.org/news-events/news/conquering-dialysis-fatigue/
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC9178188/
8. https://www.sciencedirect.com/science/article/pii/S0085253815324741
9. https://onlinelibrary.wiley.com/doi/10.1111/sdi.13194
10. https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2021.653807/full
11. https://www.mdpi.com/2077-0383/12/7/2670
12. http://www.davita.com/treatment-services/peritoneal-dialysis/protein-and-your-peritoneal-dialysis-diet
13. https://advancingdialysis.org/peritoneal-dialysis/nutritional-status-concerns-for-peritoneal-dialysis-patients/
14. https://www.kidney.org/kidney-topics/getting-more-protein-while-dialysis
15. https://homedialysis.org/news-and-research/blog/547-muscle-stiffness-in-dialysis-patients-tips-to-prevent-and-overcome
16. https://onlinelibrary.wiley.com/doi/10.1155/2014/614846

My wife and I are in discussions about the new routine we’re about to embark upon, that of IPN. We debated how long it takes for it to take effect, so to speak. Is a day, a week, a month, or longer.

To obtain a definitive answer to this question, I turned to Perplexity with the following Prompt and response. Spoiler – it will take some time.

Prompt: How rapidly does IPN take effect? days, weeks, months?

Intraperitoneal Nutrition (IPN) typically takes several weeks to months to show measurable effects in patients on peritoneal dialysis. Here’s what the evidence and clinical experience indicate:

• Improvements in nutritional markers such as serum albumin and prealbumin—key indicators of protein status and overall nutrition—are generally observed after several months of IPN therapy.
• Positive changes in strength, physical health, and appetite are commonly reported by patients, but these also tend to develop over the course of months rather than days or a few weeks.
• Clinical monitoring is usually performed at least quarterly (every three months), and the goal is often to see an albumin increase to around 4.0 g/dL. The time to reach this target varies, but most patients require ongoing therapy for a minimum of 3 months, with many continuing for longer depending on their response and nutritional needs.
• Incremental improvements—such as a 0.2 g/dL increase in albumin—are considered clinically meaningful and can be seen during this period, with about 70% of patients in one cohort showing such improvements within several months.
• If there is no significant improvement after 3 to 6 months, clinicians may consider discontinuing IPN and exploring alternative interventions.

In summary:
Most patients will not see immediate effects within days; meaningful improvements typically require several weeks to months of consistent IPN therapy. The exact timeline can vary based on the individual’s baseline nutritional status, the degree of malnutrition, and how well they tolerate and absorb the therapy.

As the title suggests, from time to time, I go off the topic of my dialysis journey. Today is no exception. I’m going to relate to you a little of the background from my formative years, the mid-fifties, when I was 15-17, and a sophomore-senior in high school.

Quite often during the time frame suggested, a small group of boys who were also into fast cars would meet in a friend’s garage (Paul Hinton to be exact) where we would discuss cars, girls, drink beer, play poker, and listen to radio station WLAC Nashville. Guys would drop in after dates, with some bringing their female friends with them. All through this, WLAC took front and center. So what’s with WLAC of yore? WLAC was, at the time, at the front of R&B. It brought R&B to the public’s attention and ours. In short, we listened to artists and music long before it reached the airwaves in Springfield, Ohio. WolfMan Jack hadn’t been invented, but WLAC had. Since WLAC played such a pivotal role in my early music listening, it is worth looking back to see where I am now. I quizzed Perplexity with the following Prompt and results. Following at bottom is a clip from Bo Diddley on how he got started. He was one of the artists on WLAC early on. I also inserted a Howlin’ Wolf rendition to give you a flavor of the tunes coming across from WLAC at the time.

Prompt: In the 50s, there was a station in Nashville, WLAC, that played real R&B sponsored by “white rose petroleum jelly” Tell us about this

WLAC and Its Pioneering R&B Broadcasts in the 1950s

WLAC was a Nashville, Tennessee, powerhouse AM radio station (1510 AM) that became legendary in the 1950s for broadcasting rhythm and blues (R&B) music across much of the United States, especially at night when its 50,000-watt clear-channel signal reached up to 28 states, parts of Canada, and the Caribbean. WLAC played a crucial role in introducing Black R&B music to both Black and white audiences during a time of deep segregation and limited access to such music on mainstream radio.

The WLAC R&B Format

• Programming: Starting in the mid-1940s and peaking through the 1950s and 1960s, WLAC’s nighttime airwaves were dominated by a quartet of white DJs—Gene Nobles, John Richbourg (known as “John R.”), Bill “Hoss” Allen, and Herman Grizzard—who played records by Black artists such as Chuck Berry, Fats Domino, Little Richard, Muddy Waters, and Etta James.
• Audience: The station’s management deliberately targeted Black listeners, knowing their signal reached 80% of Black homes in the country at night. However, the shows also attracted a large number of white teenagers, many of whom were hearing authentic R&B for the first time.
• Cultural Impact: WLAC’s broadcasts helped lay the groundwork for the rock and roll explosion, influencing future musicians and helping to bridge racial divides in American popular music.

Sponsorship and “White Rose Petroleum Jelly”

• Advertising Approach: The DJs’ shows were heavily sponsored by products marketed to Black consumers, many of which were sold via mail order and promoted with colorful, sometimes humorous, and often suggestive on-air pitches.
• White Rose Petroleum Jelly: Among the most famous sponsors was “White Rose Petroleum Jelly,” a brand of white petroleum jelly. The DJs would read lively and sometimes double-entendre-filled commercials for this product, joking about its many supposed uses. The playful, sometimes risqué nature of these ads became part of the station’s mystique and appeal, especially among teenagers who felt they were part of a secret, subversive listening club.
• Other Products: Alongside White Rose Petroleum Jelly, the station also advertised products like Royal Crown Hair Pomade and even live baby chicks, all targeting the station’s core late-night audience.

Business Model and Legacy

• Mail-Order Economy: Much of the station’s revenue came from mail-order businesses, such as Randy’s Record Mart, which became the nation’s largest mail-order record seller thanks to WLAC’s reach and influence.
• Social Change: While the DJs and station management profited from Black music and audiences, many Black musicians appreciated the exposure and career opportunities WLAC provided, even as the station’s aggressive product promotion sometimes took advantage of its listeners.
• Enduring Influence: WLAC’s R&B shows were instrumental in breaking down racial barriers in American music, inspiring countless musicians (including Bob Dylan and members of The Band) and helping to usher in the rock and roll era.

“During the hours not sponsored by record shops, WLAC featured a whole slew of wonderful commercials for such things as… ‘live baby chicks,’ ‘Royal Crown Hair Dressing’ and ‘White Rose Petroleum Jelly.’ The disc jockeys used to have a lot of fun mentioning creative uses for that versatile substance, many with double entendre meanings.”

Summary Table: WLAC R&B Era Highlights

Feature	Details
Location	Nashville, Tennessee (not Memphis)
Era	1940s–1970s (peak R&B influence in 1950s–60s)
Signal Reach	50,000 watts; up to 28 states, Canada, Caribbean at night
Key DJs	Gene Nobles, John Richbourg (“John R.”), Bill “Hoss” Allen, Herman Grizzard
Audience	Primarily Black listeners, but also white teenagers across the eastern U.S.
Notable Sponsors	White Rose Petroleum Jelly, Royal Crown Hair Pomade, Randy’s Record Mart, live chicks
Legacy	Broke racial barriers, fueled R&B/rock crossover, influenced generations of musicians

WLAC’s nightly R&B programming, with its iconic product pitches for items like White Rose Petroleum Jelly, stands as a pivotal chapter in American radio and music history, shaping tastes and breaking down social barriers in the mid-20th century.

This past Wednesday, I met with my GP, followed by a monthly meeting with my Dialysis Team. For the meeting with our GP, I had a specific agenda laid out as I did with the Dialysis Team, and took the lead. In both cases, one of the THREE items on our (I say our, because my wife, as my Caregiver, was very involved in setting up the agenda for the meetings) agenda was to review the top three drugs I was taking with the thought in mind to reduce or do away with them.

The drug handout we authored is embedded below:

I am pleased to report that after some discussion, I am no longer taking Januvia for diabetes with the caveat that we’re going to watch my glucose closely. My dialysis doctor stated that the majority of her insulin-taking patients take no oral diabetic medicine. Disposing of hydro… was straightforward. My GP strongly suggested halving my statin medication, while my dialysis doctor was Ok with dropping it. As a result, I’m now taking 1/2 of what I was before the meeting.

As a result of going into the meeting with a plan and our ducks in a row, we dropped two meds altogether and reduced the third by 50%, intending to drop it entirely in the future if my cholesterol and triglyceride readings do not go bananas. A win for all of us.

This past Friday, as scheduled, my wife and I had a one-hour and fifteen-minute phone interview with the social worker representing the VA’s Caregiver Program. I was first up. She interviewed what was obviously a script, and questions at first centered on how I feel, how a normal 24-hour day goes, what my caregiver did to aid and abet my daily activities, etc. It then turned to shades of mental health and suicidal thoughts, and included a question about whether we had a gun or guns in the home. She then talked with my wife, asking about 80% of the same type of questions.

After the interview, she informed us in some detail about what’s coming down the pike. Next up is a video interview by a nurse to go over in more detail health issues, then a panel of representatives from various domains in the VA, and lastly, possibly a home visit. After these activities, we will either be informed by this rep that we were accepted into the program, or receive a detailed letter explaining why we were not. If not, we can either appeal or, if so desired, reapply.

Up to now, the two interfaces with the VA leave the impression that they are pretty much sticking to their script and are not all that interested in anything off script. It’s as though my wife, as my caregiver, could have her finger in the dike of my life, and if this did not fit into a box on their form, they would be indifferent to it.