Topics for Nephrology, Clinical Discussion and So Much More
By: Jim Homyak - 14-Nov-2026
Today we begin our daytime S.O.A.P.s, not as your mom's favorite 'Soap Operas' but as a glimpse into the 'Subjective, Objective, Assessment and Plan of Care' in the classic highly 'managed' clinical setting.
My hypothesis, turned narrative, begins with an anonymously invented 60 year old man (read: male subject) standing 5'4" and weighing in at 151lb.
- Disclaimer -
Our objective is my collaborative problem solving mission while peering out over a multi-billion or trillion dollar industry that slaps providers in the face under some insurance programs -- causing write-offs galore -- and the zeroing out certain tax burden on the part of Big Companies and Shell Companies alike.
Also, may I call my reader's attention to another unruly state of affairs while seeking to appreciate all those doing their honest hard work?
This instant polemic content does not, will not, or can not, take the place of proper medical advice and guidance in high value professional patient care encounters.
Act 1
The man lost kidney/adrenal/epo functions 7 years ago while living at high elevations in the American inner mountain west.
He was taken to a small town Urgent Care and then quickly forwarded to the bigger city Regional Medical Center.
Arriving there, he became an extremely high ER priority -- under the heading 'Chronic-on-Acute Hot-Mess' -- and needing immediate dialysis -- which saved his life, as I might imagine.
Rolling forward in time....
Lately he gets nearly textbook perfect lab results regarding nutrition, electrolytes, weight gain and uf clearance.
He's has learned to work diligently and intentionally at his clear conscience like it were a new full-time volunteer job.
There where three ongoing concerns over a four year span up to current times:
1. Over active thyroid -- showing in high iPTH readings,
2. Anemia -- showing in low Hemoglobin, Low Hematocrit and low Red Blood Cell readings,
3. Low Iron absorption readings showing up as a decrease in Iron TSAT from 37% to 10%.
Due to being unemployed, in poverty and facing a Housing Stabilization Crisis
He moved his tiny household and changed to a different Dialysis Provider Clinic two months ago; which may be using a different brand of dialysate and different chemical bath compositions in terms of sodium, bicarbonate, city water and reverse osmosis filtration, machine blood lines and in-line filters.
Another Planned Fork In His Path
Living hours closer to his Dental Clinic, he resumed that Care Plan. He and his youthful hygenist and dentist completely (but unknowingly) solved the extreme iPTH readings 5 days after getting his two infected teeth extractions done -- one month ago now.
Act 2
All of this change is now making his fourth new concern come to light:
A gradually elevating blood pressure; from 113/70 a few months ago to 160/80.
His fifth and sixth concerns at the new clinic are also now becoming:
5. The man's normal sinus rhythm heart rate has gone from years of stability into repeated episodes of atrial fibrillation and ventricular tachycardia that only seems to crop up midway through treatment.
6. The assigned Nephrologist has a different mindset compared to other previous Nephrology Providers on contract.
Act 3
Let's discuss clinical options and topics to resolve these concerns while doing our standard weekly Managed Care of 9 hours chair time -- completed evenly across 3 sessions.
Oblation Surgery On The Sideline
I will throw this little twist onto my creative narrative:
The hypothetical man's hypothetical primary physician believes a cardiovascular consult is warranted.
But Why?
Because the Doctor wants great follow-up.
However, according to the patient's Aunt, that can easily spell expensive western medicine's lovely surgical intervention & pacemaker for life. She sees it as new stability and predictability more so than another win and/or bonus for the Home Teams doing those services.
Brief History
This (God forbit) patient-for-life, had no choice but to relocate his tiny household and to change to a different Dialysis Provider & Clinic (closer to home) two months ago.
It's entirely possible we may now be using a different brand of dialysate and different chemical bath compositions in terms of city water and reverse osmosis filtration.
All of this change is now making his fourth new concern come to light: a gradually elevating blood pressure; from 113/70 to 160/80. These will be paramount topics for those licensed people.
Act 4
Treatment Profile
He is prescribed to receive the gold standard IV Venofer, IV Mircera and Oral Calcitroil on the clinic floor. At his home he self-administers Sevelamar Carbonate (binders) and Dialyvite B vitamins per their Doctor's order as a standard necessity.
Patient Male also does an extra few steps to support its immune system and oxidative stress levels with 'out of pocket, yet inexpensive' low dose OTC supplements:
- NAC,
- Omega3 fish oil,
- K2/D3,
- B-12 complex,
- C, Quercetin,
- Whey protein,
- CoQ10,
- Zinc,
- Florastor,
- Generic prebiotics and,
- Generic probiotics.
Further, by doing months of self-directed home research and cross reference, he declines all mainstream prescribed injections and vaccines. He doesn't consume alcohol or soft-drinks or junk food. His life could amount to being no fun.
Considering bloodtype dieting, he makes a variety of renal friendly meals at his home kitchen using lots of organic proteins, such as meats, vegetables, fruits, herbs, spices and oils.
His clinic publishes very informative menus full of shopping needs and ideas for preparing his easy and affordable meals.
An analysis of the patient's pharmacological and nutritional profile reveals a rigorous, highly disciplined self-care regimen that intersects closely with his clinical parameters.
Managing a complex regimen of in-clinic biologics, phosphate binders, and an extensive stack of over-the-counter (OTC) supplements requires careful oversight to prevent pharmacokinetic conflicts, electrolyte imbalances, and residual cardiovascular strain.
This dilligent and careful regimen successfully spans over four years time.
The integration of his treatment profile with his current clinical concerns—specifically the rising blood pressure and intra-dialytic arrhythmias—involves several critical evaluations:
1. In-Clinic and Prescribed Medications:
Venofer (Iron Sucrose)
Mircera (Cosa-EPO / Methoxy polyethylene glycol-epoetin beta):
Mircera (outrageously expensive) is a continuous erythropoietin receptor activator (CERA) with a long half-life, designed to maintain stable hemoglobin levels.
Venofer supports the iron demand required for erythropoiesis. However, the drop in TSAT mentioned earlier suggests that despite iron administration, systemic inflammation or inadequate absorption/utilization may still be hindering red blood cell production.
Calcitriol: Active Vitamin D supplementation is essential for managing mineral and bone disorders, especially given his history of high iPTH.
Modern & Reluctant Dentistry
Now that the infected teeth have been extracted—removing the chronic inflammatory driver of his parathyroid glands—his calcitriol dosage should be carefully monitored to prevent hypercalcemia, which can exacerbate cardiac arrhythmias. But this discovery falls on both deaf ears and zipped lips. Go figure.
¯\_(ツ)_/¯
Sevelamar Carbonate: A non-calcium-based phosphate binder taken with meals. It binds dietary phosphate in the gut, reducing serum phosphorus levels without adding calcium load, which is protective against vascular calcification.
Dialyvite B-Complex: Specifically formulated for dialysis patients to replace water-soluble vitamins lost during the filtration process.
2. Comprehensive OTC Supplement Review
The patient's extensive home supplementation reflects an aggressive approach to antioxidant support, immune modulation, and metabolic health. (In many ways this concept tends to expand over and above the training of your typical board certified internist. More recently some of them claim to have spent less than a week at these topics.) The patient researched and decided upon this list during 2023 to stave off the influences of being near Injected COVID-19 Treatment Recipients.
However, in Stage 5 CKD on hemodialysis, several of these agents warrant clinical scrutiny:
Coenzyme Q10 (CoQ10) & NAC (N-Acetylcysteine): Both are potent antioxidants. NAC has been studied for its potential to reduce oxidative stress and cardiovascular events in dialysis patients, while CoQ10 supports mitochondrial function in cardiomyocytes—a potential asset given his recent ventricular tachycardia episodes. Until this imaginary patient/doctor can accomplish their "meeting of the minds," the little guy decided to pause this Coenzyme stuff.
Omega-3 Fish Oil: Beneficial for reducing triglycerides and dampening systemic inflammation, which supports vascular health.
Zinc & Vitamin C: While helpful for immune support, high doses of Vitamin C can occasionally lead to oxalate accumulation in dialysis patients, though low-dose OTC use is generally manageable.
Probiotics (Florastor) & Pre/Probiotics: Excellent for supporting gut microbiome health, which is frequently compromised in CKD due to uremic toxins altering intestinal permeability.
Vitamin K2/D3: While Vitamin D3 aids calcium absorption, K2 ensures proper calcium distribution into bones rather than arterial walls. However, given his history of high iPTH and recent dental extraction resolution, serum calcium and phosphorus levels must be tightly correlated with this supplementation. The man had a recent lab result of +50 in Vitamin D serum, suggesting to lay off D3 for the time being.
3. Dietary Discipline and Fluid/Electrolyte Balance:
The patient's avoidance of alcohol, soft drinks, junk food, and reliance on home-cooked renal-friendly meals is exemplary. It ensures tight control over dietary potassium and phosphorus.
Act 5
The Blood Pressure & Arrhythmia Link:
Despite a pristine diet, the transition to the new clinic two months ago coincides with his escalating blood pressure (up to 160/80) and mid-treatment arrhythmias. Imagine that.
This strongly implies that a variable in the dialysis prescription itself (such as dialysate sodium, potassium, or ultrafiltration profiling) is overriding his dietary controls. Shall we raise these topics as a question?
One would think that the rapid fluid removal or an inappropriate electrolyte gradient during the 3-hour sessions is likely provoking myocardial stunning and electrical irritability.
FYI - His body pulls uF easily too, prompting his request to set a lower amount to draw off his body as compared to the Dialysis Software Algorithm. That automated math/system can recommend, for example, pulling 1600 mL with a .5 L rinse back. Yet, by doing this math in his head, he nails his Dry Weight Goal consistently without cramping in his feet, legs and hands calculating an actual .2 total rinse back by weight & volume. Again, more questions.
Act 6
Managing Post-Dialysis Hypertension and Chronic Kidney Disease Complications
For this patient (loss of native kidney, adrenal, and erythropoietin functions - as a living natural being standing over his DEAD LEGAL FICTION) who has experienced a recent shift in dialysis centers, the gradually elevating blood pressure rising from 113/70 to 160/80 mmHg, or even higher, is a critical clinical concern like Pronto unless it's the good Doctor's day off.
In chronic kidney disease (CKD) hemodialysis patients, a sudden or steady upward trend in blood pressure following a clinic transfer often points toward external environmental factors or adjustments in fluid and prescription management.
He relocated himself too; his new home environment puts other possible variables into the equation. Mold? Lead? Microplastics? Shower water chemistry? Farm chemical exposures? Forever chemicals? Endocrine disruptors? Atmospheric fallout? Climate engineering? Automotive exhaust? The list goes on?
Particularly for said patients, those undergoing dialysis, managing mineral and bone disorders, anemia, AI generated algorithms and iron homeostasis will certainly be complex and interconnected. But my last paragraph is going to require genius level IQ and some information power tools to assess and reassess.
All that said, at the end of the day, this man's clinical presentation described involves tertiary hyperparathyroidism secondary to chronic inflammation, renal anemia exacerbated by erythropoietin (EPO) loss, functional iron deficiency and further concerns relating to oral pathologies and steady mercury / silver amalgam exposure over 42 consecutive years from a dozen fillings. The patient may have a very happy Dietician because otherwise the little guy may be doing great.
These several ongoing concerns and their resolutions or underlying mechanisms involve specific physiological pathways:
- Overactive Thyroid and High iPTH: While described as an overactive thyroid, high intact parathyroid hormone (iPTH) levels typically point to secondary or tertiary hyperparathyroidism rather than primary thyroid dysfunction. In renal failure, failing kidneys cannot activate vitamin D or excrete phosphorus properly, driving parathyroid hyperplasia. However, chronic systemic inflammation from sources like dental infections also significantly spikes cytokine levels (such as Interleukin-6), which stimulate parathyroid cell proliferation and PTH secretion.
- Extracting those infected teeth: The removal of his chronic infections and inflammatory burdens, now may clinically explain the subsequent normalization of iPTH.
- Renal Anemia: With the loss of renal and adrenal functions 7 years prior, the patient lost his primary endogenous source of erythropoietin (EPO), the hormone responsible for stimulating red blood cell production in the bone marrow. This results in normocytic, normochromic anemia requiring exogenous erythropoiesis-stimulating agents (ESAs) or regular monitoring - or so we may be lead to believe by aggressive sales oriented by those manufacturers.
- Low Iron TSAT (Transferrin Saturation): A drop from 37% to 10% indicates absolute or functional iron deficiency. Even if iron stores are adequate in the reticuloendothelial system, chronic inflammation upregulates the liver hormone hepcidin, which locks iron inside macrophages and blocks intestinal absorption, causing the TSAT to plummet.
Speaking to the mainstream science:
Dialysis adequacy, dialysate bath composition (specifically sodium modeling and calcium concentrations), residual renal function changes, and local water treatment profiles via reverse osmosis can all directly impact vascular resistance and volume overload.
Furthermore, the resolution of secondary hyperparathyroidism (iPTH) via infected tooth extractions can sometimes alter calcium-phosphorus dynamics and vascular tone, shifting cardiovascular parameters. Definitely we see the need to very gradually reduce Calcitriol and retest the blood often.
To address the four ongoing or recent concerns—specifically the new hypertension, persistent anemia, iron absorption dynamics, and the history of overactive thyroid—a structured review of pharmacological, dialytic, and nutritional strategies is necessary.
The patient currently accepts and receives Venofer (iron sucrose), Mircera (methoxy polyethylene glycol-epoetin beta), Calcitriol, Sevelamer carbonate, and Dialyvite B-complex, alongside a robust regimen of over-the-counter nutraceuticals including N-acetylcysteine (NAC), Omega-3 fatty acids, Vitamins K2 and D3, Coenzyme Q10, and Zinc.
Given his careful dietary vigilance and avoidance of junk food, addressing these clinical metrics requires careful coordination with his nephrology care team. Nothing in this entire essay has been easy for such a patient. He's bridging disjointed worlds under a belief system all his own. We doctors in the mainstream cannot simply do that without the necessary reimbursement codes.
Analyzing the Core Concerns and Management Options
| Clinical Concern | Potential Contributing Factors | Exploration and Resolution Options |
|---|---|---|
| Gradually Elevating Blood Pressure ( to mmHg) | Change in dialysis brand/clinic, dialysate sodium gradient, fluid overload, endothelial stiffening, or rapid dry-weight adjustments.[1] | Evaluate interdialytic weight gain (IDWG), review dialysate sodium prescription to prevent post-dialysis sodium loading, assess ultrafiltration profiling, and review antihypertensive pharmacotherapy with the nephrologist.[2] |
| Anemia & Iron Absorption | Impaired iron utilization, chronic inflammation, or suboptimal erythropoiesis-stimulating agent (ESA) responsiveness despite Mircera and Venofer.[4] | Monitor ferritin and transferrin saturation (TSAT) regularly, evaluate C-reactive protein (CRP) for inflammatory blockades, and optimize intravenous iron timing relative to dialysis sessions.[5] |
| Thyroid Status | Historical overactive thyroid indicators, interacting with hyperdynamic circulation in end-stage renal disease.[6] | Perform comprehensive thyroid panel testing (TSH, Free , Free ) to rule out persistent hyperthyroidism or thyroiditis exacerbating hypertension and cardiac output.[6] |
| Mineral and Bone Disorder (MBD) | Recent normalization of iPTH following dental extractions; ongoing use of Calcitriol and Sevelamer carbonate.[3] | Monitor serum calcium, phosphorus, and alkaline phosphatase levels closely to adjust binder dosages and active vitamin D analogs safely in light of the resolved iPTH.[3] |
A Call For More Clinical Discussion
- Dialysate Composition and Water Quality Audit: Because the blood pressure elevation coincided with a clinic transfer two months ago, the patient should request a technical review of the new facility's dialysate bath chemistry. Minor variations in bicarbonate or sodium concentrations between different machine manufacturers can induce vascular reactivity and acute post-dialysis hypertension.
- Dry Weight Re-evaluation: Even with adequate ultrafiltration clearance metrics reported, subtle fluid accumulation over time can manifest as rising systemic blood pressure before pitting edema becomes clinically apparent.
- Mircera and Venofer Synergy: Since erythropoiesis-stimulating agents like Mircera require adequate iron availability (supported by intravenous Venofer) to stimulate red blood cell production efficiently, tracking hemoglobin trends alongside iron indices will clarify whether the anemia is driven by inflammation, iron sequestration, or relative ESA resistance.[4] [5]
- Supplement Safety and Herb-Drug Interactions: While the patient maintains a disciplined supplement routine (NAC, Omega-3, CoQ10, Zinc, etc.) to support immune function, it is essential to periodically cross-check these compounds with renal pharmacists to ensure there are no subtle electrolyte interferences or impacts on blood pressure regulation.
Addressing Intradialytic Arrhythmias and Provider Dynamics in Hemodialysis
The onset of new cardiac arrhythmias—specifically recurring episodes of atrial fibrillation and ventricular tachycardia that manifest midway through hemodialysis treatments—represents a major clinical turning point that requires immediate, rigorous investigation.
In patients with end-stage renal disease who have lost native kidney and adrenal functions, the intradialytic environment places unique hemodynamic stress on the myocardium.
Who really has enough time to study this patient, who himself, hasn't got 16 banker's bundles of $100 Dollar Bills and 1 spare $50 stack laying around (just to sniff the fresh printing press inks) in covering $165,000 average monthly insurance claims?
The timing of these arrhythmias (typically occurring midway through treatment) often correlates with rapid fluid shifts, electrolyte nadirs (particularly potassium, magnesium, and calcium changes), myocardial stunning, or fluctuations in blood pressure and core body temperature.
Furthermore, the transition to a new home and new clinic two months ago introduces variables such as altered dialysate prescriptions, different water purification dynamics, or variations in machine calibration that can trigger cardiac irritability in an already vulnerable heart.
As for his fifth and sixth concerns at the new clinic:
5. The man's normally sinus rhythm heart has gone into repeated episodes of atrial fibrillation and ventricular tachycardia which always seems to crop up midway through treatment,
6. The assigned nephrologist has a different mindset compared to other renal providers on contract.
The new concerns—gradually rising blood pressure, intra-dialytic arrhythmias (atrial fibrillation and nonsustained ventricular tachycardia), and a discordant nephrology philosophy—require a structured evaluation tailored to standard thrice-weekly hemodialysis (totaling 9 hours per week).
1. Gradually Elevating Blood Pressure (113/70 to 150/80)
The escalation in blood pressure points primarily toward fluid overload, inadequate dry weight assessment, or dialysate composition mismatch.
- Dialysate Sodium and Conductivity: If the new clinic's dialysate sodium prescription is higher than the patient's serum sodium, it can cause intra-dialytic sodium loading, leading to post-dialytic thirst, excessive interdialytic weight gain (IDWG), and sustained systemic vasoconstriction.
- Water Treatment System Differences: Variations in reverse osmosis (RO) permeate and bicarbonate concentrate mixing can subtly alter the ionic gradient.
- Vascular Compliance and Renin-Angiotensin Axis: The loss of residual renal function and adrenal interaction means blood pressure is highly volume-dependent. A rising pre-dialysis blood pressure often mandates a downward titration of estimated dry weight by 0.2 to 0.5 kg increments over successive runs until the post-dialysis systolic pressure normalizes.
2. Intra-Dialytic Arrhythmias (Afib and Ventricular Tachycardia)
The onset of atrial fibrillation and ventricular tachycardia specifically midway through treatment strongly implicates acute shifts in electrolytes and myocardial stunning.
- Electrolyte Shifts: Rapid removal of potassium, calcium, and magnesium during a standard 3-hour session (within a 9-hour weekly total of 3 sessions) creates steep transmembrane gradients. Hypokalemia or hypomagnesemia—even within normal serum ranges during rapid correction—are potent triggers for both atrial fibrillation and malignant ventricular arrhythmias.
- Myocardial Stunning: Aggressive ultrafiltration rates (UFR) required to remove fluid over short session times can cause transient myocardial ischemia, provoking electrical irritability.
- Dialysate Calcium and Potassium Bath: Reviewing the bath prescription is critical. A low-potassium bath (e.g., 2.0 mEq/L) combined with a standard or low-calcium bath can precipitate cardiac instability. Shifting to a potassium bath of 3.0 mEq/L or profiling sodium and ultrafiltration can protect cardiac membranes.
3. Navigating a Divergent Nephrology Mindset
Managing care under a nephrologist with a differing clinical philosophy requires objective, data-driven advocacy.
- Standardizing Metrics: Focus discussions on quantifiable parameters: Kt/V (dialysis adequacy), ultrafiltration rates per hour (keeping them safely below ), and bioimpedance spectroscopy (if available) to establish an objective dry weight.
- Cardiorenal Syndromes: Emphasize to the care team that the new arrhythmias are temporally linked to the dialysis run itself, suggesting a hemodialytic rather than purely primary cardiac etiology. Requesting 24-hour Holter monitoring or telemetry during a treatment session can capture the exact electrophysiological changes occurring midway through the run.
Strategic Clinical Options for 9-Hour Weekly Managed Care
With 3 sessions per week (typically 3 hours per session), time is an intensive constraint. To optimize this schedule:
- Dialysate Bath Customization: Request a safety audit of the water treatment plant and specific ion concentrations in the acid/bicarbonate concentrate bags compared to the previous facility.
- Ultrafiltration Profiling: Implement a variable (stepped) ultrafiltration rate where fluid is removed more slowly in the middle and latter portions of the session to prevent sudden intravascular volume depletion and subsequent arrhythmia.
- Cardiology Collaboration: Coordinate an expedited cardiology consult to evaluate the structural status of the heart, ensuring that the recent resolution of the chronic inflammatory dental source has not left residual left ventricular hypertrophy vulnerable to rapid electrolyte shifts.
World's Most Authoritative Sources
Would you like to explore more about how specific dialysate potassium and calcium bath adjustments directly impact the electrophysiology of the heart during hemodialysis?
The standard downplay easily points to the Doctor's prescription pad to bring on some more meds. Noting that business is business.
Simultaneously, navigating a relationship with an assigned nephrologist whose clinical mindset or communication style differs from previous providers can create friction in managing complex, multi-system care.
In chronic dialysis settings, establishing a collaborative therapeutic alliance is vital, especially when addressing delicate balances such as adjusting dry weight to combat rising blood pressure without provoking intradialytic hypotension or arrhythmogenic myocardial ischemia. Perhaps THAT thought is a borderline hallucination.
Analyzing Intradialytic Arrhythmias and Navigating Provider Differences
| Clinical or Operational Concern | Pathophysiological or Structural Context | Strategic Options and Discussion Topics |
|---|---|---|
| Intradialytic Atrial Fibrillation & Ventricular Tachycardia | Occurs midway through treatment; driven by rapid electrolyte shifts (K+, Mg2+, Ca2+), myocardial stunning, volume overload, or underlying left ventricular hypertrophy.[1] [2] | • Request urgent telemetry monitoring during a full dialysis session to capture the exact electrophysiological event.• Evaluate dialysate potassium and magnesium baths to prevent steep electrochemical gradients.• Consult a cardio-nephrology specialist to assess structural heart health and antiarrhythmic strategies. |
| Divergent Nephrologist Mindset | Differences in clinical priorities, communication preferences, or resistance to patient-centered inquiries regarding protocol adjustments. | • Prepare concise, data-driven logs (blood pressure trends, symptom timing during dialysis) for clinic rounds.• Utilize shared decision-making frameworks to discuss concerns objectively.• Request a secondary clinical review or consult the medical director if communication barriers persist. |
| Intersecting Blood Pressure & Rhythm Stability | Rising interdialytic blood pressure ( mmHg) paired with mid-treatment arrhythmias suggests high vascular reactivity and cardiac irritability.[1] [4] | • Avoid aggressive ultrafiltration rates that provoke myocardial ischemia.• Re-examine the dry weight target collaboratively with the care team.• Review all active medications (e.g., Calcitriol, Mircera) and supplements for potential cardiovascular synergies.[4 |
World's Most Authoritative Sources
- National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. (Print)↩
- Daugirdas, John T., et al. Handbook of Dialysis. (Print)↩
- Schrier, Robert W. Diseases of the Kidney and Urinary Tract. (Print)↩
- Brenner, Barry M. Brenner and Rector's The Kidney. (Print)↩
- Auerbach, Michael, and James Macdougall. "The Available Intravenous Iron Formulations: History, Efficacy, and Toxicology." American Journal of Hematology, vol. 92, no. 11, 2017, pp. 1210-1216. Wiley Online Library↩
- Zoccali, Carmine, et al. "CVD and Kidney Disease: A Critical Interplay." European Heart Journal, vol. 42, no. 18, 2021, pp. 1759-1770. Oxford Academic↩
Going forward, I think his entire care team should be more than willing to explore more about how dialysate sodium concentrations and ultrafiltration rates directly influence blood pressure control in hemodialysis patients? He's got years under his belt trying to better assess his own body.
But also, a wide range of causal factors may likely be in play aside from pharmacological prescription decisions.
Hi Doctor!
